Thiele et al. [14] found that AST:ALT had a Negative Predictive Value of 91% in a large biopsy-paired study and it may be that AST:ALT ratio could be used as a simple direct fibrosis test in addition to ELF in the assessment of advanced liver fibrosis in ArLD in a manner analogous to the combination of FIB4 and ELF in NAFLD [21] but this would require validation. This evidence concerns the gene GPT and metabolic dysfunction-associated steatotic liver disease.