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Enhanced Liver Fibrosis (ELF) Score

A blood score made from three proteins linked to liver scarring. It helps estimate the risk of advanced scarring and of liver problems getting worse.

AI-verified against cited sources. Awaiting expert reviewAlso called ELFLOINC 88055-9

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What it is

The Enhanced Liver Fibrosis (ELF) test measures three substances that your body releases as scar tissue forms and is remodeled: hyaluronic acid, a protein fragment called PIIINP, and TIMP-1. The lab combines them into one score using the test maker's formula. The score has no units. A higher score goes with more scarring activity in the liver.

Why it matters

Liver scarring (fibrosis) can build for years without symptoms, and how far it has gone shapes future liver risk. In the US the ELF test is approved as a prognostic test, to estimate the risk of liver-related problems in people who have or may have advanced scarring. It is also used as a blood-based second step after a FIB-4 result, particularly when an elastography scan is not available.

If it’s low

A low score does not point to a problem. A score below 7.7 makes advanced scarring less likely, though no single test can rule it out completely.

Common causes

  • No scarring or only mild scarring in the liver

What can help

  • Ask how often your clinician would like to recheck, based on your risk factors

If it’s high

A higher ELF score goes with a greater chance of advanced scarring and of liver problems getting worse. A score of 9.8 or higher is the usual point for higher risk, and 11.3 or higher is the highest-risk group. A higher score is not a diagnosis, and your clinician will read it with your history and other tests.

Common causes

  • A blood draw soon after a meal, which can raise some of the proteins in the score (seen in a small study of people with type 2 diabetes)
  • Male sex (healthy men score slightly higher than women) and age, which both influence the score
  • Other conditions with active inflammation or tissue remodeling, which can raise these proteins
  • Scarring from fatty liver disease
  • Scarring from long-term alcohol-related liver disease
  • Scarring from chronic viral hepatitis

What can help

  • Ask whether the test should be repeated after an overnight fast
  • Ask about a follow-up such as an elastography scan (for example FibroScan) and how it fits with your FIB-4 result
  • Talk with your clinician about weight, physical activity and alcohol, which affect fatty liver disease

Usual ranges

What labs print as the reference range, by who was tested. Ranges differ a little between labs, so the range on your own report is the one your result is judged against.

The usual range depends on sex. Choose women or men to see the one that applies.

Standardized ELF thresholds (Day 2019; AASLD 2023)

  • Lower likelihood of advanced fibrosisbelow 7.7 score
  • Indeterminate7.7 to under 9.8 score
  • Higher risk of progression9.8 to under 11.3 score
  • Highest-risk group11.3 and above score

What can affect your result

  • Eating before the test (fasting is preferred)
  • Sex: healthy men score slightly higher than healthy women
  • Age
  • Time of day: slightly higher in the afternoon in healthy adults
  • Biotin supplements taken in the 12 hours before the draw (Mayo's instruction)
  • Other inflammatory or tissue-remodeling conditions
  • Mayo asks that you take no multivitamins or supplements containing biotin (vitamin B7, including hair, skin and nail products) for 12 hours before the draw.
  • A meal can raise two of the three proteins in the score (hyaluronic acid and PIIINP), at least in people with type 2 diabetes, so a fasting sample is preferred (Khoo 2012).
  • Mayo asks for the serum to be separated and transferred to a plastic vial within 2 hours of collection.
  • Age and sex both shift the score, so results are read with your age and sex in mind.

A fasting morning draw is best. Healthy adults had slightly higher scores in the afternoon than in the morning (Lichtinghagen 2013). ELF follows scarring that builds over years, so it is not meant for frequent rechecks.

When to talk to a clinician

There is no urgent ELF value. Talk with a clinician about a score of 9.8 or higher so they can decide on follow-up. Get prompt care for yellow skin or eyes, vomiting blood, black or tarry stools, a swollen belly, or new confusion or drowsiness, and call 911 or your local emergency number if these are severe.

Questions you could ask

  • How does my ELF score fit with my FIB-4 and my other liver tests?
  • Which of my health conditions or habits matter most for my liver?
  • Does my score change what follow-up I need?
  • Should I also have an elastography scan?
  • Could a recent meal or a biotin supplement have affected the result?
  • When should this be rechecked, given my health conditions?

Questions people ask

What do the numbers 7.7, 9.8 and 11.3 mean?

They are the usual decision points. Below 7.7, advanced scarring is less likely. From 7.7 to just under 9.8 the result is indeterminate. From 9.8 up, the risk of progression is higher, and 11.3 or higher is the highest-risk group. Some labs use slightly different points, so check your own report.

Is ELF the same as a FibroScan?

No. ELF is a blood test that measures three scarring-related proteins. FibroScan is an ultrasound-based scan that measures how stiff the liver is. Clinicians sometimes use one after the other, and the two do not always agree.

Why was ELF ordered after my FIB-4?

AASLD guidance suggests a second test, such as ELF or elastography, when a FIB-4 result is 1.3 or higher. FIB-4 is a first-step estimate, and ELF adds more information.

Show the science and sources

For clinicians and researchers

ELF combines serum hyaluronic acid (HA), N-terminal propeptide of type III procollagen (PIIINP) and tissue inhibitor of metalloproteinase 1 (TIMP-1), measured by direct chemiluminescent immunoassay and reported as a unitless score from a manufacturer algorithm. In 400 healthy controls on the ADVIA Centaur, Lichtinghagen et al. reported reference values of 6.7 to 9.8 (men 7.0 to 9.9, women 6.6 to 9.3), slightly higher in the afternoon, with age a notable influence. Standardized thresholds from a Delphi panel (Day 2019) are 7.7 (about 85% sensitivity for fibrosis), 9.8 and 11.3 (97% specific for cirrhosis); relative to a score below 7.7, hazard ratios for a liver-related outcome at 5 years were 21 for 9.8 to below 11.3 and 71 for 11.3 or higher. AASLD 2023 lists ELF 9.8 or higher to identify advanced fibrosis and below 7.7 to rule it out, says ELF 11.3 or higher predicts liver-related events and is approved for that purpose, and treats other cut-offs as expert opinion. Mayo Clinic Laboratories reports 9.20 or higher as the diagnostic cut-off for stage 2 or greater fibrosis and 11.30 or higher as the prognostic cut-off, so lab-specific decision points differ. Results are not interchangeable with elastography or with FIB-4, which uses different inputs.

LOINC 88055-9 (primary). Specimen: serum.

Sources

  1. Enhanced Liver Fibrosis (ELF), Serum (Test ID ELF), Mayo Clinic Laboratories
  2. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease, Hepatology (AASLD) (2023)
  3. Derivation and Performance of Standardized Enhanced Liver Fibrosis (ELF) Test Thresholds for the Detection and Prognosis of Liver Fibrosis, Journal of Applied Laboratory Medicine (2019)
  4. The Enhanced Liver Fibrosis (ELF) score: normal values, influence factors and proposed cut-off values, Journal of Hepatology (2013)
  5. Elevation of alanine transaminase and markers of liver fibrosis after a mixed meal challenge in individuals with type 2 diabetes, Digestive Diseases and Sciences (2012)
  6. LOINC 88055-9 (NLM Clinical Tables), National Library of Medicine

AI-verified against cited sources. Awaiting expert review. Last reviewed 2026-10-03. How we build and check these pages.

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