Enhanced Liver Fibrosis (ELF)™ Test

CPT: 0014M
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  • ELF
  • Fatty Liver Disease
  • Nonalcoholic Fatty Liver Disease
  • Nonalcoholic Steatohepatitis
  • Noninvasive Liver Biopsy

Expected Turnaround Time

3 - 6 days

Specimen Requirements




2.5 mL

Minimum Volume

1 mL


Gel-barrier tube or red-top tube


Complete clot formation should take place before centrifugation. Serum should be physically separated from cells as soon as possible with a maximum limit of two hours from the time of collection.

Storage Instructions


Stability Requirements



Room temperature

48 hours (stability provided by manufacturer or literature reference)


7 days (stability provided by manufacturer or literature reference)


≤ -20°C for up to 12 months (stability provided by manufacturer or literature reference)

Freeze/thaw cycles

Stable x4 (stability provided by manufacturer or literature reference)

Causes for Rejection

Plasma sample; hemolyzed sample. Heterophilic antibodies in human serum can react with reagent immunoglobulins and interfere with immunoassays.

Test Details


The Enhanced Liver Fibrosis (ELF™) blood test is a simple, accurate, non-invasive test that provides a simple, unitless numeric score that is generated via an algorithm for use in advanced liver fibrosis. It is indicated as a prognostic marker in conjunction with other laboratory findings and clinical assessments in patients with advanced fibrosis (F3 or F4) due to non-hepatitis (NASH) to assess the likelihood of progression to cirrhosis and liver-related clinical events.1 Because ELF™ uses a blood sample rather than a biopsy, it can be used routinely for the same patient over time.


Currently, there are no clear screening guidelines for Non-Alcoholic Fatty Liver Disease (NAFLD). The joint EASL-EASD-EASO guideline reviewed the accuracy of a few serum markers including NFS, FIB-4, and ELF™ test for significant and advanced fibrosis, suggesting that "non-invasive tests may be confidently used for first-line risk stratification to exclude severe disease." The NICE (National Institute for Health and Care Excellence) guideline on assessment and management of NAFLD recommended ELF™ as an accurate biomarker and the most cost-effective test to detect advanced fibrosis.2

Analysis of multiple prevalences showed that using the ELF™ test at a threshold of 10.51 in primary care settings with disease prevalence of 5-10% leads to a very low PPV (0.26 and 0.43, respectively). However, the test can lead to PPV exceeding 0.80 in a high-prevalence setting only (>40%). Yet, at this threshold, the summary estimate of sensitivity in detecting advanced fibrosis, at 0.50, is well below the 1.00 mentioned in the NICE guideline.3 This may question the validity of the NICE recommendation, to "explain to people with an ELF™ score below 10.51 that they are unlikely to have advanced liver fibrosis."2

Although the available research is too limited to address biomarker accuracy in ruling out significant and advanced fibrosis in patients with NAFLD among the general population, the estimations based on one study suggest that the ELF™ test has a high NPV when the prevalence is lower than 30%.3 This highlights the value of the ELF™ test as a first-line test to exclude advanced fibrosis in the primary care setting and hence to avoid further evaluation of specialists.

However, it is important to note that the high sensitivity of the test (>0.90) comes at the expense of limited specificity (0.30), which, given the low prevalence, means there will be a substantial number of false positive results. This needs to be considered, especially when the test is going to be applied in a clinical setting with low prevalence of the disease, as the large number of false positive results might lead patients to have unnecessary invasive and expensive procedures, like biopsy.

ELF scores may be influenced by age and gender. Even in an apparently healthy cohort of individuals, a small proportion showed ELF scores beyond the 9.8 cut-off value, emphasizing that lower values need to be interpreted with caution.4


The ELF™ test consists of three fully automated, two-site sandwich immunoassays using direct chemiluminometric technology. The component assays use two monoclonal mouse antibodies: The first antibody is an acridinium ester-labeled antibody. The second antibody is a biotin-labeled antibody. The solid phase contains streptavidin-coated paramagnetic particles. The ELF™ score is derived from an algorithm that combines PIIINP, TIMP-1, and HA. ELF™ is a trademark of Siemens Healthcare Diagnostics.

Reference Interval

ELF™ Score Interpretation:

Risk cut-offs to assess the likelihood of progression to cirrhosis and liver-related clinical events within 3.9 years following baseline ELF score (IQR: 14.0-22.4 months):5

Lower risk


Mid risk


Higher risk


Note: The ELF™ Score is a unitless numerical value.

Additional Information

The Enhanced Liver Fibrosis (ELF™) test measures three direct markers of liver fibrosis: hyaluronic acid (HA), Type III procollagen peptide (PIIINP), and tissue inhibitor of matrix metalloproteinase 1 (TIMP-1). HA is a glycosaminoglycan that is produced by hepatic stellate cells, PIIINP is a marker of early fibrogenesis and inflammation, and TIMP-1 is the circulating inhibitor of MMP enzymes that can enhance fibrogenesis. Together, these assays measure qualitative and quantitative changes in the extracellular matrix (ECM). The ECM refers to a set of macromolecules that comprise the extracellular scaffolding of the liver. Some ECM markers reflect fibrogenesis and others reflect fibrosis regression, allowing for a dynamic evaluation of ECM activity.

The ELF™ score is derived from an algorithm that combines for HA, PIIINP, and TIMP-1.


1. Day J, Patel P, Parkes J, Rosenberg W. Derivation and performance of standardized Enhanced Liver Fibrosis (ELF) test thresholds for the detection and prognosis of liver fibrosis. J Appl Lab Med. 2019 Mar;3(5):815-826.31639756
2. National Guideline Centre (UK). Non-Alcoholic Fatty Liver Disease: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2016 Jul.27441333
3. Vali Y, Lee J, Boursier J, et al. Enhanced liver fibrosis test for the non-invasive diagnosis of fibrosis in patients with NAFLD: A systematic review and meta-analysis. J Hepatol. 2020 Aug;73(2):252-262.32275982
4. Lichtinghagen R, Pietsch D, Bantel H, Manns MP, Brand K, Bahr MJ. The Enhanced Liver Fibrosis (ELF) score: normal values, influence factors and proposed cut-off values. J Hepatol. 2013 Aug;59(2):236-242.23523583
5. Harrison SA, Wong VW, Okanoue T, et al. Selonsertib for patients with bridging fibrosis or compensated cirrhosis due to NASH: Results from randomized phase III STELLAR trials. J Hepatol. 2020 Jul;73(1):26-39.32147362


Harrison SA, Abdelmalek MF, Diehl AM, et al. Prospective validation of the Enhanced Liver Fibrosis (ELF) test for the prediction of disease progression in patients with nonalcoholic steatohepatitis (NASH) and advanced fibrosis. Poster 2122 presented at AASLD: The Liver Meeting 2017, October 20-24, 2017, Washington, DC.


Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
550659 Enhanced Liver Fibrosis (ELF) 88055-9 550661 ELF(TM) Score 48795-9
Reflex Table for ELF(TM) Score
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 000000

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