 At this time, liver biopsy remains the gold standard for staging the severity of liver damage in NAFLD and all other types of chronic liver disease.2 This biopsy is traditionally performed percutaneously with or without ultrasound guidance. Needle entry for biopsy is typically into the right lobe below the diaphragm between the ribs in the right mid-axillary line. Alternatively, this may be done by an anterior approach into the left lobe. However, there are potential limitations with percutaneous biopsy including sampling error19,20 which may not be representative of the hepatic architecture and complications pain, bleeding and puncture of another organ, not obtaining liver tissue. Due to anatomical considerations, some patients are not even candidates for liver biopsy by the percutaneous approach. In this case, biopsy may be performed by the transjugular method. This technique involves use of conscious sedation followed by needle access of the jugular vein. A wire is then passed through the heart and into a branch of a hepatic vein to guide a needle biopsy of the liver. Similar to percutaneous biopsy, this procedure is safe when performed by experienced operators. However, complications including neck hematoma, hepatic arteriovenous fistula, liver capsular puncture, intraperitoneal hemorrhage and death have been reported by this technique.21,22 Regardless of the approach, liver biopsy incurs monetary cost, including fees for the facility, equipment, hepatologist and pathologist, as well as for processing the tissue sample itself. On the other hand, the expense of a liver biopsy is roughly equivalent to that of magnetic resonance imaging MRI, which is the most sensitive radiologic test for quantifying liver fat,fat; an MRI is inferior to biopsy for detecting liver inflammation and fibrosis.23 