Metabolic Dysfunction–Associated Steatotic Liver Disease: Diagnosis and Management

Metabolic dysfunction–associated steatotic liver disease (MASLD; formerly nonalcoholic fatty liver disease) is an increasingly common cause of chronic liver disease. It is fatty infiltration of the liver with at least one cardiometabolic risk factor, without a secondary cause and no or low alcohol use. People with MASLD and other risk factors (eg, diabetes, obesity) are at higher risk for long-term adverse outcomes, including cirrhosis and hepatocellular carcinoma. Screening for advanced fibrosis involves two-step sequential noninvasive testing. Clinicians should risk stratify using the Fibrosis-4 index. Secondary risk assessment with vibration-controlled transient elastography or ultrasound-based methods is needed in people with indeterminate or high-risk Fibrosis-4 scores. Monitoring and management of earlier stages of the MASLD spectrum in primary care may reduce the risk of adverse outcomes and maximize care before specialist referral. Patients should be counseled on lifestyle interventions (eg, at least 5% weight loss for people with overweight or obesity, healthy diet, at least 150 minutes of moderate aerobic physical activity per week) to improve steatosis and lower cardiovascular risk. Additional lifestyle recommendations include smoking cessation, limited alcohol intake in people with no or mild fibrosis, and no alcohol for those with more significant fibrosis. Semaglutide and resmetirom are approved by the US Food and Drug Administration for treatment of metabolic dysfunction– associated steatohepatitis in patients with moderate or severe fibrosis.