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CPE-005 · synthetic case LIVER-FX-12
ALT falling while platelets fall
Known fatty liver, ALT now normal and platelets down to 140.
Purpose: Known fatty liver, ALT now normal and platelets down to 140.
Inputs the engine received
Liver tests and imaging
- Hepatic steatosis documented
- Yes
- AST
- 27 U/L
- ALT
- 24 U/L
- Platelets
- 140 ×10⁹/L
Patient
- Age
- 59 years
- Sex
- Female
- Alcohol intake
- 0 g/day
Cardiometabolic criteria
- BMI
- 33 kg/m²
- Type 2 diabetes
- Yes
Other liver disease and context
- Hepatitis B and C testing already done
- Yes
Cirrhosis, decompensation and trends
- ALT falling or newly normal
- Yes
- Platelets falling
- Yes
What the engine reports
In steatotic liver disease this pattern can mean advancing fibrosis rather than improvement. Recalculate FIB-4 and consider elastography; do not reassure on ALT alone.
Detected clinical pattern
Pattern Meeting the 2023 MASLD Criteria
Steatosis with 2 cardiometabolic criterion/criteria and alcohol in range. Fibrosis risk by non-invasive tests: indeterminate.
- Alcohol: Alcohol 0 g/day · MASLD range
- Fibrosis risk: Fibrosis risk · indeterminate
Why this pattern was identified
- MASLD criteria. Steatosis is documented and 2 cardiometabolic criterion/criteria are met (BMI 33; type 2 diabetes).
Calculations
- FIB-4
- 2.32
Lower cutoff 1.3; high above 2.67.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Recalculate FIB-4 and consider elastography.
- 2Assess cardiovascular risk: it is the leading cause of death in MASLD.
Evidence and rule trace · 6 rules
LV-FIB-01FIB-4 and its stratum
Inputs: FIB-4 2.32 · cutoff 1.3
Indeterminate: second-line test needed.
LV-01MASLD criteria met
Inputs: steatosis documented · 2 cardiometabolic criterion/criteria: BMI 33; type 2 diabetes · alcohol in MASLD range
Pattern meeting the 2023 MASLD criteria.
LV-CV-01Cardiovascular risk assessment
Inputs: MASLD criteria met
Formal cardiovascular risk assessment is part of the work-up.
LV-FIB-04ALT normalizing with falling platelets
Inputs: steatotic liver disease known · ALT falling or newly normal · platelets falling
Falling ALT with falling platelets can mean advancing fibrosis.
Evidence
- EV-AASLD-2023 · Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835.
- EV-DELPHI-2023 · Rinella ME, Lazarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023;78(6):1966-1986.
- EV-MCPHERSON-2017 · McPherson S, Hardy T, Dufour JF, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol. 2017;112(5):740-751.
Physician adjudication required. Clinical decision support for physician review. This output classifies steatotic liver disease under the 2023 nomenclature and stratifies fibrosis risk. It does not stage fibrosis by itself, diagnose a cause, or recommend a drug. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Fibrosis risk by non-invasive tests
✓ Low
FIB-4 <1.3 (<2.0 from 65), stiffness <8 kPa
● Indeterminate
Needs a second-line test
○ High
FIB-4 >2.67, stiffness ≥12 kPa or ELF ≥9.8
Liver tests and imaging
Patient
A standard US drink is about 14 g.
Cardiometabolic criteria
Other liver disease and context
Cirrhosis, decompensation and trends
More liver cases
LIVER-FX-01
Steatosis with metabolic risk and a low FIB-4
A 52-year-old man with fatty liver on ultrasound, BMI 31 and triglycerides 190.
LIVER-FX-02
Type 2 diabetes, no imaging yet
A 58-year-old with diabetes and normal enzymes: the screening question.
LIVER-FX-03
Indeterminate FIB-4
FIB-4 of 2.0 in a 56-year-old with steatosis.
LIVER-FX-04
High FIB-4
FIB-4 above 5 in a 63-year-old man with low platelets.
LIVER-FX-05
FIB-4 of 1.65 at age 70
Low risk under the age-adjusted cutoff of 2.0.
LIVER-FX-06
Stiffness 14 kPa with a low FIB-4
Discordant tests: the elastography result prevails as a warning.
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