All issues › Volume 1, Issue 2, September – October 2026
From Aminotransferases to Target-Specific Testing: A Biochemical Framework for Non-Invasive Assessment of Metabolic Dysfunction-Associated Steatotic Liver Disease
Assistant Professor, Department of Biochemistry (Government Aided), Kongunadu Arts and Science College (Autonomous), Bharathiar University, Coimbatore, Tamil Nadu, India
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) is common, clinically silent in many individuals and biochemically heterogeneous. The principal laboratory error is not simply choosing an imperfect biomarker; it is asking one measurement to answer the wrong biological question. Alanine aminotransferase and aspartate aminotransferase reflect hepatocellular stress, whereas FIB-4 combines age, aminotransferases and platelet count to triage advanced fibrosis; the Enhanced Liver Fibrosis (ELF) test and PRO-C3 interrogate extracellular-matrix turnover; and cytokeratin-18, NIS4 and related panels target cell death or fibrotic steatohepatitis. This critical review synthesizes international guidance, systematic reviews, validation studies and Indian evidence published through 3 September 2026. Evidence was organized by intended use: detection of steatosis, identification of metabolic dysfunction-associated steatohepatitis (MASH), exclusion or confirmation of advanced fibrosis, prediction of outcome and longitudinal monitoring. Routine aminotransferases cannot exclude clinically important disease, and the positive predictive value of any fibrosis test depends strongly on prevalence and referral setting. FIB-4 remains suitable as a low-cost first-line rule-out tool, but age, acute illness, thrombocytopenia and type 2 diabetes alter its performance. ELF and PRO-C3 add mechanistic information about matrix remodeling, yet thresholds, extrahepatic collagen turnover and pre-analytical effects require attention. CK-18 and emerging multi-omic panels are biologically attractive but are not interchangeable with validated fibrosis pathways. The review proposes TARGET-MASLD: Target the biological condition, Anchor interpretation to pre-test risk, Rule out with a validated routine score, Gate second-line testing, Examine discordance and analytical quality, and Trend results under comparable conditions. This framework converts biomarker selection from a catalogue of assays into a decision-linked biochemical strategy suited to resource-variable settings, including India.
Keywords: MASLD, MASH, non-invasive tests, FIB-4, Enhanced Liver Fibrosis test, PRO-C3, cytokeratin-18, clinical biochemistry
How to cite
Santhoshkumar, M. (2026). From Aminotransferases to Target-Specific Testing: A Biochemical Framework for Non-Invasive Assessment of Metabolic Dysfunction-Associated Steatotic Liver Disease. Imaginex International Journal of Interdisciplinary Research and Reviews, 1(2), 1–12.