Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A State-of-the-Art Review

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the latest term for steatotic liver disease associated with metabolic syndrome. MASLD is the most common cause of chronic liver disease and is the leading cause of liver-related morbidity and mortality. It is important that all stakeholders be involved in tackling the public health threat of obesity and obesity-related diseases, including MASLD. A simple and clear assessment and referral pathway using non-invasive tests is essential to ensure that patients with severe MASLD are identified and referred to specialist care, while patients with less severe disease remain in primary care, where they are best managed. While lifestyle intervention is the cornerstone of the management of patients with MASLD, cardiovascular disease risk must be properly assessed and managed because cardiovascular disease is the leading cause of mortality. No pharmacological agent has been approved for the treatment of MASLD, but novel anti-hyperglycemic drugs appear to have benefit. Medications used for the treatment of diabetes and other metabolic conditions may need to be adjusted as liver disease progresses to cirrhosis, especially decompensated cirrhosis. Based on non-invasive tests, the concepts of compensated advanced chronic liver disease and clinically significant portal hypertension provide a practical approach to stratifying patients according to the risk of liver-related complications and can help manage such patients. Finally, prevention and management of sarcopenia should be considered in the management of patients with MASLD.

Keywords: Liver cirrhosis; Non-alcoholic fatty liver disease; Portal hypertension.

Figure 1

A simple and clear assessment and referral pathway is essential in streamlining the management of patients with metabolic dysfunction-associated steatotic liver disease, and this depends on available resources and local practice in terms of the defined role between primary and specialist care providers.^, *For patients ≥ 65 years old, fibrosis-4 index cut-off 2.0 (instead of 1.3) may be used to improve specificity; ^†Sensitivity and negative predictive value > 90%; ^‡Patients should be considered for referral to specialist care if they have persistently elevated serum aminotransferase level and/or if the cause of elevated serum aminotransferase level is uncertain; ^§Specificity and positive predictive value > 90%. cACLD, compensated advanced chronic liver disease; CSPH, clinically significant portal hypertension; HCC, hepatocellular carcinoma.