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Survival rates for pediatric acute lymphoblastic leukemia (ALL) have markedly improved; however, survivors remain at risk of long-term hepatic complications, including progressive fibrosis related to chemotherapy and prior viral infections. The objective of this study is to evaluate hepatic fibrosis in pediatric ALL survivors using a sequential non-invasive algorithm combining transient elastography (TE) and enhanced liver fibrosis (ELF) score. This comparative cross-sectional study included 159 pediatric ALL survivors who had completed therapy at least 2 years earlier and 99 age- and sex-matched healthy controls from two Egyptian oncology centers. Liver fibrosis was assessed using TE and serum biomarkers for calculation of the ELF score. The mean age at diagnosis was 6.9 ± 2.7 years, and at assessment, 11.1 ± 2.7 years. Hepatitis C virus (HCV) prevalence declined significantly from 75% during treatment to 5% at enrollment following antiviral therapy (p < 0.001). Fibrosis was detected in 75% of survivors by TE, predominantly moderate (F2) fibrosis. Combined TE/ELF assessment identified advanced fibrosis (≥ F3) in 6% of patients, while most survivors had mild-to-moderate fibrosis. Mean ELF score was significantly higher in survivors than controls (9.3 ± 1.2 vs. 4.5 ± 1.03, p < 0.0001). Agreement between TE and ELF was fair (Cohen's κ = 0.34-0.39). HCV-positive survivors had significantly higher ELF scores than HCV-negative peers.Conclusion: Persistent hepatic fibrosis in pediatric ALL survivors was observed predominantly among patients with current or previous HCV exposure. A combined TE/ELF approach represents an effective non-invasive strategy for early detection and monitoring.