External Validation and Comparisons of Hepatic Steatosis Index (HSI), Dallas Steatosis Index (DSI), and Triglyceride-Glucose (TyG) Index for the Diagnosis of Steatotic Liver Disease (SLD) in Thai Individuals with Cardiometabolic Risk
Abstract
Objective: Individuals with cardiometabolic risk are a target population for steatotic liver disease (SLD) screening. Fatty Liver Index is a widely accepted noninvasive score to identify SLD; however, it relies on parameters that are often unavailable in general. We aimed to validate and compare the diagnostic performances of the hepatic steatosis index (HSI), Dallas steatosis index (DSI), and triglyceride-glucose index (TyG) for detecting steatotic liver disease (SLD) in Thai individuals with cardiometabolic risk and to evaluate advanced fibrosis risk according to SLD subclassifications.
Material and Methods: This cross-sectional study analyzed adults with >1 cardiometabolic risk who underwent abdominal ultrasonography (USG) at a university hospital between 2019 and 2023. The diagnostic performances of HSI, DSI, and TyG were evaluated using the area under the receiver operating characteristic curve (AUROC).
Results: Among 5,388 eligible individuals, the prevalence of SLD was 49.4%. DSI demonstrated the highest performance (AUROC: 0.813, 95% confidence interval[CI]: 0.801–0.824), surpassing HSI (AUROC: 0.795, p-value<0.001) and TyG (AUROC: 0.729, p-value<0.001). A DSI cutoff <0.2 yielded 84.4% (95%CI:83.2-85.7%) sensitivity for ruling out SLD, whereas a cutoff >0.5 provided 92.5% (95%CI:91.6-93.4%) specificity for ruling in disease. Among 1,355 participants with available alcohol data, the proportion of individuals at high risk of advanced fibrosis (FIB-4 >2.67) was notably higher in the metabolic- and alcohol-associated liver disease (10.7%) and alcohol-associated liver disease (8.1%) groups than in the metabolic dysfunction-associated steatotic liver disease group (1.5%).
Conclusion: DSI outperforms HSI and TyG for detecting SLD and can serve as an effective screening tool in primary care settings without USG.
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Lee CM, Yoon EL, Kim M, Kang BK, Cho S, Nah EH, et al. Prevalence, distribution, and hepatic fibrosis burden of the different subtypes of steatotic liver disease in primary care settings. Hepatology 2024;79:1393-400. doi. 10.1097/HEP.0000000000000664.
Riazi K, Azhari H, Charette JH, Underwood FE, King JA, Afshar EE, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022;7:851-61. doi. 10.1016/S2468-1253(22)00165-0.
Younossi ZM, Razavi H, Sherman M, Allen AM, Anstee QM, Cusi K, et al. Addressing the high and rising global burden of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH): from the growing prevalence to payors’ perspective. Aliment Pharmacol Ther 2025;61:1467-78. doi. 10.1111/apt.70020.
Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, Abdelmalek MF, Caldwell S, Barb D, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77:1797-835. doi. 10.1097/HEP.0000000000000323.
Wang S, Toy M, Hang Pham TT, So S. Causes and trends in liver disease and hepatocellular carcinoma among men and women who received liver transplants in the U.S., 2010-2019. PLoS One 2020;15:e0239393. doi.10.1371/journal.pone.0239393.
Palma-Lara I, Ortiz-López MG, Bonilla-Delgado J, Pérez-Escobar J, Godínez-Aguilar R, Luévano-Contreras C, et al. A landscape of liver cirrhosis and transplantation in Mexico: changing leading causes and transplant as response. Ann Hepatol 2025;30:101562. doi. 10.1016/j.aohep.2024.101562.
Wong VWS, Zelber-Sagi S, Cusi K, Carrieri P, Wright E, Crespo J, et al. Management of NAFLD in primary care settings. Liver Int 2022;42:2377-89. doi. 10.1111/liv.15404.
Eslam M, Fan JG, Yu ML, Wong VWS, Cua IH, Liu CJ, et al. The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease. Hepatol Int 2025;19:261-301. doi. 10.1007/s12072-024-10774-3.
Sripongpun P, Kim WR, Mannalithara A, Charu V, Vidovszky A, Asch S, et al. The steatosis-associated fibrosis estimator (SAFE) score: a tool to detect low-risk NAFLD in primary care. Hepatology 2023;77:256-67. doi. 10.1002/hep.32545.
European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024;81:492-542. doi. 10.1016/j.jhep.2024.04.031.
Said A, Gagovic V, Malecki K, Givens ML, Nieto FJ. Primary care practitioners survey of non-alcoholic fatty liver disease. Ann Hepatol 2013;12:758-65. doi. 10.1016/S1665-2681(19)31317-1.
Bedogni G, Bellentani S, Miglioli L, Masutti F, Passalacqua M, Castiglione A, et al. The Fatty Liver Index: a simple and accurate predictor of hepatic steatosis in the general population. BMC Gastroenterol 2006;6:33. doi.10.1186/1471-230X-6-33.
Foschi FG, Conti F, Domenicali M, Giacomoni P, Borghi A, Bevilacqua V, et al. External validation of surrogate indices of fatty liver in the general population: the Bagnacavallo study. J Clin Med 2021;10:520. doi.10.3390/jcm10030520.
Yang BL, Wu WC, Fang KC, Wang YC, Huo TI, Huang YH, et al. External validation of fatty liver index for identifying ultrasonographic fatty liver in a large-scale cross-sectional study in Taiwan. PLoS One 2015;10:e0120443. doi.10.1371/journal.pone.0120443.
Koehler EM, Schouten JNL, Hansen BE, Hofman A, Stricker BH, Janssen HLA. External validation of the fatty liver index for identifying nonalcoholic fatty liver disease in a population-based study. Clin Gastroenterol Hepatol 2013;11:1201-4. doi. 10.1016/j.cgh.2012.12.031.
Nomura T, Ono M, Kobayashi K, Akaiwa Y, Ayaki M, Ogi T, et al. Validation of fatty liver index as a predictor of hepatic steatosis in Asian populations: impact of alcohol consumption and sex. Hepatol Res 2023;53:968-77. doi. 10.1111/hepr.13935.
McHenry S, Park Y, Browning JD, Sayuk G, Davidson NO. Dallas Steatosis Index identifies patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2020;18:2073-80.e7. doi.10.1016/j.cgh.2020.01.020.
Lee JH, Kim D, Kim HJ, Lee CH, Yang JI, Kim W, et al. Hepatic steatosis index: a simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis 2010;42:503-8. doi.10.1016/j.dld.2009.08.002.
Fedchuk L, Nascimbeni F, Pais R, Charlotte F, Housset C, Ratziu V. Performance and limitations of steatosis biomarkers in patients with nonalcoholic fatty liver disease. Aliment Pharmacol Ther 2014;40:1209-22. doi.10.1111/apt.12963.
Sono S, Kaewdech A, Wongsawanon C, Varanuntakul T, Jarupanich T, Sritanabutr N, et al. Metabolic dysfunction-associated fatty liver disease (MAFLD) in the adult population attending a health check-up program in Thailand: prevalence and fibrosis status. Sci Rep 2025;15:21429. doi. 10.1038/s41598-025-06874-1.
Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology 2023;78:1966-86. doi.10.1097/HEP.0000000000000520.
Guerrero-Romero F, Simental-Mendía LE, González-Ortiz M, Martínez-Abundis E, Ramos-Zavala MG, Hernández-González SO, et al. The product of triglycerides and glucose, a simple measure of insulin sensitivity: comparison with the euglycemic-hyperinsulinemic clamp. J Clin Endocrinol Metab 2010;95:3347-51. doi. 10.1210/jc.2010-0288.
Sterling RK, Lissen E, Clumeck N, Sola R, Correa MC, Montaner J, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology 2006;43:1317-25. doi. 10.1002/hep.21178.
Miwa T, Tajirika S, Imamura N, Adachi M, Horita R, Hanai T, et al. Prevalence of steatotic liver disease based on a new nomenclature in the Japanese population: a health check-up-based cross-sectional study. J Clin Med 2024;13:1158. doi. 10.3390/jcm13041158.
Liu S, Wan H, Yang L, Shen J, Qi X. High prevalence of steatotic liver disease and fibrosis in the general population: a large prospective study in China. J Hepatol 2025;82:e23-5. doi. 10.1016/j.jhep.2024.07.026.
Miwa T, Tajirika S, Imamura N, Adachi M, Horita R, Hanai T, et al. Usefulness of health check-up-based indices in identifying metabolic dysfunction-associated steatotic liver disease. JGH Open 2024;8:e13110. doi. 10.1002/jgh3.13110.
Lee J, Han CI, Lee DY, Sung PS, Bae SH, Yang H. Performance of non-invasive indices for discrimination of metabolic dysfunction-associated steatotic liver disease in young adults. Gut Liver 2025;19:116-25. doi. 10.5009/gnl240323.
DiBattista JV, Burkholder DA, Lok AS, Chen VL. Accuracy of non-invasive indices for diagnosing hepatic steatosis compared to imaging in a real-world cohort. Dig Dis Sci 2022;67:5300-8. doi. 10.1007/s10620-022-07415-w.
McHenry S, Park Y, Davidson NO. Validation of the Dallas Steatosis Index to predict nonalcoholic fatty liver disease in the UK Biobank population. Clin Gastroenterol Hepatol 2022;20:2638-40. doi. 10.1016/j.cgh.2021.05.035.
Sripongpun P, Kaewdech A, Udompap P, Kim WR. Characteristics and long-term mortality of individuals with MASLD, MetALD, and ALD, and the utility of SAFE score. JHEP Rep 2024;6:101127. doi. 10.1016/j.jhepr.2024.101127.
Lee BP, Dodge JL, Terrault NA. National prevalence estimates for steatotic liver disease and subclassifications using consensus nomenclature. Hepatology 2024;79:666-73. doi.10.1002/hep.32678.
Schneider CV, Schneider KM, Raptis A, Huang H, Trautwein C, Loomba R. Prevalence of at-risk MASH, MetALD and alcohol-associated steatotic liver disease in the general population. Aliment Pharmacol Ther 2024;59:1271-81. doi. 10.1111/apt.17395.
Lei Y, Zhu Y, Ni W, Shi J, Seto WK, Li J. Impact of alcohol consumption on the development and progression of metabolic dysfunction-associated steatotic liver disease. Aliment Pharmacol Ther 2025;62:680-91. doi. 10.1111/apt.17380.
Marti-Aguado D, Calleja JL, Vilar-Gomez E, Iruzubieta P, Rodríguez-Duque JC, Del Barrio M, et al. Low-to-moderate alcohol consumption is associated with increased fibrosis in individuals with metabolic dysfunction-associated steatotic liver disease. J Hepatol 2024;81:930-40. doi. 10.1016/j.jhep.2024.06.012.
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