Background Metabolic-associated fatty liver disease (MAFLD), a highly prevalent chronic liver disease globally, has cirrhosis as its severe progressive outcome, which seriously threatens patient health. Non-invasive scoring indices are widely used in clinical practice due to their convenience; however, there is currently no clear evidence for their value in assessing cirrhosis risk in MAFLD patients or their efficacy in evaluating hepatitis B virus (HBV) infection.

Objective To investigate the associations between non-invasive indices such as the AST-to-platelet ratio index (APRI) and fibrosis-4 index (FIB-4), etal. and the prevalence status of cirrhosis in patients with metabolic-associated fatty liver disease (MAFLD), and identify related factors and the modifying effect of chronic hepatitis B virus (HBV) infection.

Methods Patients diagnosed with MAFLD who were admitted to the Fifth Medical Center of PLA General Hospital from January 2023 to July 2024 were enrolled. General clinical data, laboratory indicators, imaging parameters, and non-invasive scoring results of the patients were collected. Univariate and multivariate logistic regression analyses were performed to identify independent factors associated with liver cirrhosis. Stratified analysis was conducted to explore the effect modification of chronic HBV infection. The diagnostic efficacy of APRI, FIB-4, liver stiffness measurement (LSM), and ultrasound attenuation parameter (UAP) was compared using receiver operating characteristic (ROC) curves.

Results Totally 435 patients were included in the analysis, comprising 261 males (60%) and 174 females (40%), with a mean age of 49.5 years. There were 166 cases with cirrhosis and 269 cases without cirrhosis. Significant differences were observed between the two groups in gender, age, chronic HBV infection, platelet levels, and liver fibrosis-related indicators (FIB-4, APRI, and LSM) (all P < 0.05). Multivariate logistic regression analysis showed that in the model incorporating APRI, age ≥60 years (OR=3.216), male gender (OR=2.397), chronic HBV infection (OR=2.450), and LSM ≥12.0 kPa (OR=9.183) were independently associated with prevalent cirrhosis (all P < 0.01), while APRI showed no significant association with cirrhosis (P > 0.05). In the model incorporating FIB-4, FIB-4 ≥2.67 was strongly associated with prevalent cirrhosis (OR=32.005, P < 0.001), and a significant interaction effect was observed between chronic HBV infection and FIB-4 (P < 0.05). ROC curve analysis revealed that the area under the curve (AUC) of FIB-4 for diagnosing cirrhosis was significantly higher than that of APRI in the overall population (0.735 vs 0.658, P < 0.001). In the subgroup without HBV infection, the superiority of FIB-4's AUC was more pronounced (0.855 vs 0.740, P < 0.001). However, in the subgroup with HBV co-infection, the diagnostic efficacy of both indicators decreased, and no significant difference was found between them (P=0.061).

Conclusion The diagnostic efficacy of FIB-4 for cirrhosis in MAFLD patients is superior to that of APRI. The status of chronic HBV infection significantly affects the diagnostic value of FIB-4 through an interaction effect. In the absence of HBV infection, FIB-4 demonstrates better risk identification performance and can serve as a preferred indicator for the non-invasive clinical assessment of cirrhosis risk in MAFLD patients.