Ultrasound hepatic elastography: A non-invasive indicator of insulin resistance in the pediatric population: A systematic review

Abstract

BACKGROUND Insulin resistance (IR) plays a pivotal role in the pathogenesis of metabolic dysfunction-associated steatotic liver disease. While non-invasive imaging methods are increasingly used in pediatrics, the extent to which hepatic elastography reflects IR in children remains unclear. AIM To evaluate the association between ultrasound-based hepatic elastography parameters and clinical indices of IR in the pediatric population. METHODS A systematic search of PubMed, Scopus, and Web of Science databases was conducted through October 2025. Studies assessing correlations between elastography parameters - controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) - and IR indices were included. Data were pooled using random-effects meta-analysis with correlation coefficients (r ) as the primary effect size. Subgroup and sensitivity analyses examined differences by IR index, cohort characteristics, and elastography modality. RESULTS Sixteen studies, encompassing 2,032 children and adolescents, were included. The pooled correlation between hepatic elastography (CAP/LSM) and IR indices was r = 0.44 (95% confidence interval: 0.38-0.50; I 2 = 72%), indicating a moderate positive association. The strongest correlations were observed for adipose tissue IR (r = 0.65) and the metabolic score for IR (r = 0.49), surpassing simpler indices such as homeostatic model assessment of IR. CAP correlated moderately with early steatosis (r = 0.30-0.40), whereas LSM showed stronger associations with advanced fibrosis and systemic IR (r = 0.50-0.65). Heterogeneity was mainly attributed to differences in disease severity and measurement methods. CONCLUSION Ultrasound-based hepatic elastography provides a reliable, non-invasive surrogate for systemic metabolic dysfunction in pediatric metabolic dysfunction-associated steatotic liver disease. CAP reflects early, reversible hepatic fat accumulation, while LSM reflects more advanced fibrosis and systemic IR, and identifies fibrotic progression driven by chronic IR. The strongest associations with adipose tissue-IR and metabolic score-IR highlight the systemic, multisite nature of pediatric IR. Elastography thus holds promise as an integrated biomarker for IR severity, early risk stratification, and therapeutic monitoring in children and adolescents with metabolic risk factors.