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Indices & scales

METAVIR — the liver fibrosis scale

A liver fibrosis staging scale from F0 to F4

Five stages of liver fibrosis from healthy tissue to cirrhosis

METAVIR is a histological scale used to grade liver fibrosis in chronic liver diseases, primarily in hepatitis C and fatty liver disease. The stage of scarring is denoted by the letter F (from F0 to F4), and the severity of inflammation — the "activity" — by the letter A (from A0 to A3).

What the scale assesses

METAVIR describes the liver along two independent axes. The first is fibrosis (F): the accumulation of scar (connective) tissue, which is triggered when damaged hepatocytes activate the hepatic stellate cells. The second is activity (A): the severity of necroinflammation, that is, how actively the damage is proceeding right now. Early fibrosis stages are potentially reversible, late ones (cirrhosis) practically not.

How the stage is determined

Historically the "gold standard" was a liver biopsy, but it has a limitation: because fibrosis is uneven, the sampling error reaches 40%. So today the stage is increasingly assessed non-invasively: by elastometry (FibroScan measures liver stiffness in kilopascals) and by calculated blood indices such as FIB-4 and FibroTest. The combination of FibroScan and FibroTest allows a biopsy to be avoided in most patients with chronic hepatitis C.

Reference ranges

METAVIR fibrosis stages (histology):

F0no fibrosis
F1portal fibrosis without septa
F2portal fibrosis with a few septa
F3numerous septa (bridging fibrosis) without cirrhosis
F4cirrhosis
Important: Fibrosis ≥ F2 is usually considered clinically significant, and ≥ F3 advanced. Activity (necroinflammation) is coded separately: A0 — none, A1 — minimal, A2 — moderate, A3 — marked.

Calculate using this marker

Calculators where METAVIR is used directly:

FIB-4 (Liver Fibrosis) A first-line check for liver scarring, adjusted for age Open FibroTest A non-invasive estimate of fibrosis stage — an alternative to biopsy Open Liver Steatosis Score (LSS) A calculated alternative to elastography: fibrosis likelihood from blood tests Open

Frequently asked questions

Is a biopsy required to determine the METAVIR stage?

No. The biopsy was long the reference standard but has a notable sampling error. Today the stage is often assessed non-invasively — by liver stiffness on FibroScan and by blood indices (FIB-4, FibroTest). Biopsy is reserved for uncertain cases.

How does F2 differ from F4?

F2 is portal fibrosis with a few septa: this is already significant fibrosis, at which treatment is usually started. F4 is cirrhosis: diffuse scarring with irreversible remodeling of the tissue and a risk of complications.

Related terms

Liver fibrosis Scarring of the liver — the replacement of healthy tissue by connective tissue Cirrhosis The extreme stage of liver fibrosis with irreversible tissue restructuring Hepatocyte The main working cell of the liver Elastometry Measuring liver stiffness by instrumental methods Liver stiffness The firmness of liver tissue; it rises as scarring (fibrosis) progresses NAFLD / MAFLD Non-alcoholic (metabolically associated) fatty liver disease NASH Non-alcoholic steatohepatitis — the inflammatory form of fatty liver disease ALT (alanine aminotransferase) A liver enzyme; a marker of liver-cell damage

Sources

  1. Wikipedia — Liver biopsy (METAVIR scoring)
  2. Wikipedia — Transient elastography (FibroScan)
  3. StatPearls (NCBI) — Hepatitis C
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This content is educational and does not replace consultation with a physician. Reference ranges may vary depending on the laboratory and method — rely on the ranges stated on your own test report.
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