BACKGROUND AND AIMS:The role of shear wave elastography (SWE) in two-step MASLD risk stratification remains unclear. We compared SWE with vibration-controlled transient elastography (VCTE) using American Gastroenterological Association (AGA) and European Association for the Study of the Liver (EASL) algorithms. APPROACH AND RESULTS:Patients with MASLD who underwent both VCTE and SWE during the same session between 2019 and 2025 were included. Risk stratification was performed using AGA-based and EASL-based two-step approaches. The primary endpoint was liver-related events (LREs). Among 2817 patients, the AGA-SWE algorithm classified 2196, 140, and 481 patients as low-risk, intermediate-risk, and high-risk, respectively. Using the AGA-SWE algorithm, both intermediate-risk and high-risk groups showed increased risks of LREs compared with the low-risk group [subdistribution hazard ratio (sHR) 7.60 and 9.86, respectively]. The EASL-SWE algorithm also stratified LRE risk relative to the low-risk group, with higher sHRs observed for the intermediate-low, intermediate-high, and high-risk groups (sHR 2.99, 10.83, and 18.87, respectively). The integrated time-dependent area under the curve through 60 months was 0.770 [95% confidence interval (CI): 0.709, 0.827] and 0.775 (95% CI: 0.712, 0.835) for AGA-SWE and AGA-VCTE, respectively, and 0.804 (95% CI: 0.753, 0.849) and 0.805 (95% CI: 0.750, 0.852) for EASL-SWE and EASL-VCTE, respectively, with no significant differences between SWE and VCTE in either algorithm. No significant net reclassification improvement was observed between SWE-based and VCTE-based AGA algorithms. SWE and VCTE demonstrated a strong correlation (Spearman ρ = 0.713, 95% CI: 0.691-0.735, p <0.001). CONCLUSIONS:SWE-based two-step risk stratification showed similar predictive performance to VCTE-based models for predicting LREs in MASLD, although these findings do not establish formal equivalence.
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