Metabolic Dysfunction–Associated Steatotic Liver Disease

Metabolic dysfunction–associated steatotic liver disease (MASLD) is a complex disease closely related to obesity and other cardiometabolic processes. It affects millions worldwide and is on track to markedly increase cases of end-stage liver disease requiring transplantation as well as cases of hepatocellular carcinoma in the coming years. Noninvasive assessments such as the Fibrosis-4 index are useful tools for identifying those at risk of clinically significant fibrosis and cirrhosis caused by MASLD. Other noninvasive tests, including liver stiffness measured with transient elastography, help to stratify risk, guide therapy, and inform surveillance and prognosis. Weight loss is the cornerstone of treatment for MASLD. The condition can progress to metabolic dysfunction–associated steatohepatitis (MASH), characterized by stage F2 or F3 fibrosis, and ultimately cirrhosis (stage F4 fibrosis). For patients with MASH who have comorbid obesity, bariatric surgery or pharmacologic approaches to weight loss should be considered. Progression to advanced fibrosis and cirrhosis (stage F3 or F4) is slow and depends on multiple factors. Screening for hepatocellular carcinoma with abdominal ultrasonography and alpha-fetoprotein testing every 6 months is indicated in patients with MASH-related cirrhosis.