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Summary   Background  Blood tests of liver injury are less well validated in non‐alcoholic fatty liver disease ( NAFLD ) than in patients with chronic viral hepatitis.    Aims  To improve the validation of three blood tests used in  NAFLD  patients, FibroTest for fibrosis staging, SteatoTest for steatosis grading and ActiTest for inflammation activity grading.    Methods  We pre‐included new  NAFLD  patients with biopsy and blood tests from a single‐centre cohort (FibroFrance) and from the multicentre  FLIP  consortium. Contemporaneous biopsies were blindly assessed using the new steatosis, activity and fibrosis ( SAF ) score, which provides a reliable and reproducible diagnosis and grading/staging of the three elementary features of  NAFLD  (steatosis, inflammatory activity) and fibrosis with reduced interobserver variability. We used nonbinary‐ ROC  (NonBin AUROC ) as the main endpoint to prevent spectrum effect and multiple testing.    Results  A total of 600 patients with reliable tests and biopsies were included. The mean NonBin AUROC s (95%  CI ) of tests were all significant ( P  < 0.0001): 0.878 (0.864–0.892) for FibroTest and fibrosis stages, 0.846 (0.830–0.862) for ActiTest and activity grades, and 0.822 (0.804–0.840) for SteatoTest and steatosis grades. FibroTest had a higher NonBin AUROC  than  BARD  (0.836; 0.820–0.852;  P  = 0.0001),  FIB 4 (0.845; 0.829–0.861;  P  = 0.007) but not significantly different than the  NAFLD  score (0.866; 0.850–0.882;  P  = 0.26). FibroTest had a significant difference in median values between adjacent stage F2 and stage F1 contrarily to  BARD ,  FIB 4 and  NAFLD  scores (Bonferroni test  P  < 0.05).    Conclusions  In patients with  NAFLD , SteatoTest, ActiTest and FibroTest are non‐invasive tests that offer an alternative to biopsy, and they correlate with the simple grading/staging of the  SAF  scoring system across the three elementary features of  NAFLD : steatosis, inflammatory activity and fibrosis.

Diagnostic performance of FibroTest, SteatoTest and ActiTest in patients with NAFLD using the SAF score as histological reference