# A Systematic Review and Meta-Analysis on the Diagnostic Test Accuracy of Hepatorenal Index in Pediatric Metabolic Dysfunction-Associated Steatotic Liver Disease

## TL;DR

This study evaluates the hepatorenal index as a noninvasive tool for diagnosing fatty liver disease in children, finding it helpful but not definitive.

## Contribution

The study provides the first meta-analysis of hepatorenal index diagnostic accuracy in pediatric metabolic dysfunction-associated steatotic liver disease.

## Key findings

- The hepatorenal index has a pooled sensitivity of 90% and specificity of 84% for detecting pediatric MASLD.
- The area under the curve for HRI diagnostic accuracy is 0.91, indicating strong performance.
- HRI lacks sufficient discriminatory power to confirm or exclude MASLD definitively in children.

## Abstract

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is increasingly prevalent in children. However, reliable noninvasive diagnostic tools remain limited. The hepatorenal index (HRI) has been proposed as a quantitative ultrasound method to assess hepatic steatosis. This study aims to evaluate the diagnostic accuracy of HRI in detecting pediatric MASLD. Methods: A systematic review and meta-analysis were conducted on 13 September 2025, following PRISMA-DTA guidelines, with the protocol registered in PROSPERO (CRD420251146939). MEDLINE, PubMed, Cochrane Library, ScienceDirect, and Google Scholar were searched. Studies that assessed HRI against reference standards (MRI-PDFF or liver biopsy) in pediatric MASLD were included. Pooled diagnostic parameters were estimated using a bivariate random-effects model, with heterogeneity evaluated by I2 statistics and publication bias by funnel plot asymmetry. Results: Four studies involving 194 pediatric patients (47.9% MASLD), mostly male (57.7%), met the inclusion criteria. The suggested HRI cut-off varies from ≥1.215 to 1.99. The pooled sensitivity and specificity were 90% (95% CI 70–97) and 84% (95% CI 73–92), respectively, with an AUC of 0.91 (95% CI 0.88–0.93). Positive and negative likelihood ratios were 6 and 0.12, corresponding to post-test probabilities of 32% and 1%, respectively. No significant publication bias or heterogeneity was detected. Conclusions: Although HRI demonstrates strong diagnostic performance, it currently lacks sufficient discriminatory power to definitively confirm or exclude MASLD in pediatric populations and should therefore be regarded as a supportive rather than definitive diagnostic tool pending further high-quality validation studies.