Liver Disease Clinical Practice Guidelines (EASL, 2021)

European Association for the Study of the Liver

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 01, 2021

Guidelines for noninvasive tests for evaluation of liver disease severity and prognosis were published in June 2021 by the European Association for Study of the Liver (EASL) in Journal of Hepatology.[1]

General population

Non-invasive fibrosis tests are recommended for ruling out rather than diagnosing advanced fibrosis in low-prevalence populations.

Non-invasive fibrosis tests should be preferentially used in patients at risk of advanced liver fibrosis and not in unselected general populations.

Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and platelet count should be part of the routine investigations in patients with suspected liver disease.

Alcohol-related liver disease

In patients with alcoholic liver disease (ALD), liver stiffness measurement (LSM) by transient elastography (TE) <8 kPa is recommended to rule-out advanced fibrosis in clinical practice.

In patients at risk of ALD, LSM by TE ≥ 12–15 kPa is recommended to rule-in advanced fibrosis.

LSM by TE should be repeated after at least 1 week of alcohol abstinence or reduced drinking in patients with elevated liver stiffness and biochemical evidence of hepatic inflammation.

Hepatitis C virus post-SVR/post-antiviral therapy

Non-invasive scores and LSM by TE and other elastography methods are not accurate in detecting fibrosis regression after sustained virological response (SVR) in hepatitis C virus (HCV) patients diagnosed with compensated advanced chronic liver disease (cACLD) prior to antiviral therapy.

Non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) 

Non-invasive scores are not recommended for the diagnosis of steatosis in clinical practice.

Conventional ultrasound is recommended as a first-line tool for the diagnosis of steatosis in clinical practice.

Cholestatic and autoimmune liver disease

LSM by TE is the best surrogate marker for ruling in severe fibrosis/cACLD and should be used for this purpose using a cut-off of 10 kPa in patients with primary biliary cholangitis (PBC).

LSM by TE above 9.5 kPa can be used to support the diagnosis of advanced fibrosis in compensated patients with normal bilirubin and without high-grade stenosis in patients with primary sclerosing cholangitis (PSC).

Compensated advanced chronic liver disease and portal hypertension

cACLD should be diagnosed using second-line tests (patented serum tests or elastography).

LSM by TE should be used to rule-out and diagnose cACLD using the following cut-offs: <8–10 kPa to rule-out and >12–15 kPa to rule-in.

For more information, go to Alcoholic Hepatitis, Hepatitis C, and Fatty Liver.


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