Introduction: Global rise in obesity and metabolic syndrome has increased incidence of metabolic dysfunction–associated steatotic liver disease (MASLD). Owing to its high prevalence and the emergence of new therapies, noninvasive tests (NITs) for liver fibrosis are becoming more widely used.

Objectives: The aim of this study was to analyze and compare NIT performance in identifying fibrosis of grade F2 or greater in patients with MASLD confirmed on liver biopsy.

Patients and methods: This study was a retrospective analysis of 134 patients. The accuracy of 9 NITs in identifying significant fibrosis was assessed, and new thresholds were proposed using the Youden index.

Results: The group with fibrosis grade F2 or greater (n = 52) was older (P = 0.002), had higher body mass index (P <0.001), lower platelet count (P <0.001), total cholesterol (P = 0.005) and albumin levels (P = 0.02), and higher aspartate aminotransferase activity (P = 0.003) and international normalized ratio (P = 0.02) than the group without significant fibrosis (n = 82). Areas under the receiver operating characteristic curve above 0.8 were obtained for the nonalcoholic fatty liver disease fibrosis score (0.818), Fibroscan (0.805), Hepamet score (0.803), and aspartate aminotransferase / alanine aminotransferase ratio (0.802). The highest sensitivity and negative predictive value were obtained for the Fibrosis‑4 and Hepamet score. The new optimal thresholds were lower than those previously presented in the literature, which was associated with an increase in the NIT sensitivity and negative predictive value.

Conclusions: NITs for assessing liver fibrosis are useful for identifying patients with significant fibrosis, but lower thresholds should be considered. The Hepamet score might be considered an alternative tool to the Fibrosis‑4 score in ruling out significant fibrosis in clinical practice.