Antipass A, et al. - As outcomes of bariatric and metabolic surgery in patients with non-alcoholic fatty liver disease (NAFLD) are dependent on the severity of the liver disease, ie, improvement of NAFLD in most patients but increased risks of fulminant hepatic failure and/or bleeding varices in patients with more advanced cirrhosis, researchers here examined the role, effectiveness and limitations of liver function assessment and risk scores to screen NAFLD patients at risk of liver fibrosis prior to bariatric and metabolic surgery. They conducted retrospective data review of 392 patients [114 males (29%) and 278 females (71%)] who visited the bariatric medical clinic for consideration into bariatric surgery from January to July 2018. Division of the patient cohort was done into a low-risk and high-risk group based on Aspartate Transaminase/Alanine Transaminase (AST/ALT) ratio of < 1 or > 1, respectively. Analysis suggest the poor indicative value of absolute values of liver enzymes for the risk of liver fibrosis. Suitable screening tools identified were AST/ALT ratio, Fib 4 or NAFLD scores, with each risk score seeming to pick out a certain phenotype of patients based on age, BMI or individual values of ALT, AST or platelet count. In some cases, lack of agreement was observed between FIB-4 scores and NAFLD scores when ruling outpatients at high risk of liver fibrosis. For decreasing the risk of liver-related complications following bariatric and metabolic surgery, meticulous screening of patients at risk of liver fibrosis is essential.