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Assess your risk of developing liver fibrosis

Liver Fibrosis Testing

Fibrosis-4 (FIB-4) Index and Enhanced Liver Fibrosis (ELF™) Score are used to screen for liver fibrosis in non-alcoholic fatty liver disease (NAFLD) patients. Screening is essential for treating patients with fatty liver disease and associated risks, like obesity, Type 2 diabetes, hypertension, and high cholesterol. Fibrosis markers can help determine if referral to a specialist is needed.

How is the test performed?

Blood Sample


Liver fibrosis occurs when there are excessive amounts of scar tissue built up in the liver due to repetitive or long-lasting injury or inflammation. Most types of chronic liver disease can eventually cause fibrosis. Unlike healthy liver cells, scar tissue cells cannot repair themselves. Because of this, fibrosis can reduce overall liver function.

The most common causes of liver fibrosis in North America are:

  • chronic alcohol abuse
  • viral hepatitis C or B
  • non-alcoholic fatty liver disease (NAFLD)
  • non-alcoholic steatohepatitis (NASH), a subtype of NAFLD

NAFLD and NASH tend to develop in people who drink little to no alcohol, but do have excess weight, diabetes, or prediabetes and high levels of fat and cholesterol circulating in the blood. Doctors refer to the latter condition as metabolic syndrome. NASH can lead to liver cirrhosis if left untreated.

Liver fibrosis in its mild to moderate stages doesn’t usually cause symptoms until more of the liver is damaged. That’s why if you have any of the risk factors above, like type 2 diabetes, your health care provider may do regular blood tests to monitor the health of your liver to better manage the condition.

The Fibrosis-4 (FIB-4) Index and the Enhanced Liver Fibrosis (ELFTM) score are two available non-invasive options for liver fibrosis screening that are particularly useful for patients who have NAFLD/NASH. Both tests are simple, accurate methods that use blood samples to assess the risk of developing advanced liver fibrosis.

Fibrosis-4 (FIB-4) Index*

The FIB-4 index is a simple, accurate, non-invasive, liver fibrosis test index that is calculated from other test results and age. The calculated score can act as a ‘red flag’ for early identification of NAFLD patients at high risk of developing advanced liver fibrosis. It is also a potential alternative to liver biopsy for the screening and managing of patients with liver disease. The American Association of Clinical Endocrinology (AACE) guidelines recommends ordering the FIB-4 index as the preferred test for the screening for clinically significant fibrosis in NAFLD patients.

*Please note that currently, the FIB-4 Index is only available in Ontario

Enhanced Liver Fibrosis (ELF) Score*

The Enhanced Liver Fibrosis (ELF™) Score is also a simple, accurate, non-invasive blood test that calculates a score to measure advanced liver fibrosis. It is used with other laboratory findings and clinical tests in patients with advanced fibrosis due to NASH to assess the likelihood of their disease progressing to cirrhosis. According to the AACE guidelines, ELF™ is recommended as a follow up test in high-risk patients with intermediate or elevated FIB-4 results.

*Please note that currently, the ELF™ Score is only available in Ontario but will be available in British Columbia soon

If you have the risk factors for development of NAFLD, like Type 2 diabetes, obesity, metabolic syndrome, elevated liver enzymes, hypertension, and high cholesterol, you should speak to your health care provider about liver fibrosis testing with a simple blood test like the FIB-4 Index or ELF™ before being referred to a liver specialist.

Your health care provider may order the FIB-4 and/or ELF™ if tests done for other reasons point to a liver problem or if you have an abnormal liver enzyme test. Because liver fibrosis in the early stages typically causes no symptoms, early screening of patients in high-risk groups is recommended.

Testing is completed by LifeLabs at a Patient Service Centre or via our mobile lab service (available in select cities) through a simple blood sample. You will require a completed and signed test requisition from your health care provider.

You can order ELF™ score in Ontario here.

Please note:

The FIB-4 and ELF™ are currently available at LifeLabs’ locations in Ontario only.

Test results for both FIB-4 and ELF™ will be provided directly to your health care provider for discussion with you. The FIB-4 report will indicate your risk of developing advanced liver fibrosis. The ELF score will indicate your risk of disease progression to fibrosis and cirrhosis. Your health care provider will interpret the results of one or both tests along with your medical history, clinical presentation, and other findings, and may recommend further testing and follow up with a liver specialist.


Given the high prevalence of NAFLD, patient management by specialists is not feasible. As such, screening for increased risk of advanced fibrosis is essential for triaging NAFLD patients for specialist care and better management. To this end, LifeLabs has introduced the Fibrosis-4 (FIB-4) index and the Enhanced Liver Fibrosis (ELF) score.

Fibrosis-4 (FIB-4) Index*

The FIB-4 index is a simple and inexpensive marker that is calculated from aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count and age. Recently, the American Association of Clinical Endocrinology (AACE) recommended using FIB-4 as the preferred initial test to assess the risk of fibrosis in NAFLD patients. A FIB-4 score of <1.30 showed high negative predictive value for the identification of advanced fibrosis, whereas a score of >2.67 showed high positive predictive value. Importantly, using FIB-4 index with these threshold values was estimated to save 78% of liver biopsies in the cases evaluated.

*Please note that currently, the FIB-4 Index is only available in Ontario

Enhanced Liver Fibrosis (ELF™) Score*

The ELF™ Score is also a simple, accurate, non-invasive blood test that measures the levels of tissue inhibitor of metalloproteinases 1, amino-terminal propeptide of type III procollagen, and hyaluronic acid. ELF™ is used to estimate the rate of liver extracellular matrix metabolism which reflects the severity of liver fibrosis and the risk of progression to cirrhosis and other liver-related clinical events.
The AACE recently recommended ELF™ as a second level test for the screening of liver fibrosis in high-risk patients with intermediate or high FIB-4 index results. FIB-4 together with ELF™ can be used in a two-step pathway in primary care to assess the risk of severe liver fibrosis and for risk stratification and triaging of patients for specialist care. Using both tests in this way was shown to significantly reduce the number of unnecessary biopsies.

In absence of FIB-4, patients with persistently elevated ALT or AST levels and/or indeterminate or high-risk ELF™ Scores can be referred to a gastroenterologist or hepatologist for further assessment. Results should always be interpreted in conjunction with the patient’s medical history, clinical presentation, and other findings.

*Please note that the ELF™ Score is not currently available in BC but will be introduced later this year

FIB-4 Index

To order the FIB-4 Index in Ontario, please select ALT/SGPT and CBC and write ‘FIB-4, FIB-4 index, FIB-4 score, fibrosis index or fibrosis score’ and AST/SGOT in the ‘Other Tests’ section of the standard Ontario MOH requisition.

Please note:

  • The FIB-4 index is a patient paid test
  • AST is only insured under the Ontario Health Insurance Plan (OHIP) when ordered by or on the advice of a physician with expertise in hepatic disorders – it is a patient pay test in all other instances
  • CBC and ALT are both insured tests under OHIP
  • The FIB-4 Index is not currently available in British Columbia

Patients can make an appointment at a LifeLabs Patient Service Centre (PSC) in Ontario for their blood draw. Patients must present the FIB-4 Index requisition signed by a physician or health care provider at the time of testing.

ELF™ Score

To order the ELF™ Score, please write ‘Enhanced Liver Fibrosis Score’ or ‘ELF Score’ in the ‘Other Tests’ section of the standard Ontario MOH requisition

Please note:

  • The ELF™ Score is an uninsured test in Ontario
  • The ELF™ Score is not currently available in BC but will be introduced later this year

Patients can make an appointment at a LifeLabs Patient Service Centre (PSC) for their blood draw. Patients must present the ELF™ Score requisition signed by a physician or healthcare provider at the time of testing.

FIB-4 Index and ELF™ Score are both currently uninsured tests and our currently only available in Ontario.

The FIB-4 Index is $12*

The ELFTM Score is $275

Payment may be made by the patient when the blood sample is taken at one of our Patient Service Centres. For convenience, Visa, Mastercard and Debit Cards are accepted.

The ELF™ Score can also be ordered through the LifeLabs online store by clicking here

Patients are encouraged to check with their private healthcare insurer to see if coverage is provided.

*Please note that the cost of the FIB-4 index is in addition to the cost of the AST test and will also be charged to the patient as it is also uninsured

The test turnaround time for FIB-4 in Ontario is 1 day from specimen drop off.

The test turnaround time for ELFTM Score is 7 to 8 business days in both Ontario and BC.

We have a wealth of medical experts available to support you in interpreting test results. Consults with our experts are available upon request. Request medical consultation.

The FIB-4 index and/or ELF™ Score can both be scheduled directly by the patient at any of our Patient Service Centres in Ontario.

For both tests, the patient must have a requisition form completed by a physician or health care provider.

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