Management of metabolic dysfunction-associated steatotic liver disease (MASLD)-An expert consensus statement from Indian diabetologists' perspective

Abstract

In India, the increasing prevalence of diabetes and obesity poses a significant threat towards a surge in the incidence of metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD). Concomitant with the evolving guidelines, there is a need to direct and spread awareness among practicing diabetologists to identify and screen high-risk individuals for MASLD for timely management. Its asymptomatic nature and the evolving guidelines on diagnosis have hindered the precise estimates of MASLD in the high-risk group of individuals in a clinical setting. Therefore, an expert panel of diabetologists from India convened to review, discuss and document the approach towards screening, diagnosis and management of MASLD. Serum biomarkers, simple non-invasive tools and imaging techniques could direct the risk stratification of the patients. Early lifestyle interventions including weight loss and exercise are beneficial. The pharmacological landscape of drugs directed to insulin resistance, lipid metabolism, oxidative stress, inflammation, apoptosis and fibrogenesis pathways for the management of MASLD is expanding. In summary, the consensus statements are expected to serve as a useful guide in the screening and management of MASLD in the region and to direct a well-planned study design that could enhance the scientific value of these statements.

Keywords: India; diabetologist; metabolic dysfunction‐associated steatotic liver disease; prognosis scoring; risk stratification; screening; serum biomarkers; transient elastography; type 2 diabetes mellitus.

FIGURE 1

Timelines and the evolution of nomenclature from non‐alcoholic fatty liver disease (NAFLD) and management of metabolic dysfunction–associated steatotic liver disease (MASLD). AASLD, American Association for the Study of Liver Diseases; EASL, European Association for the Study of the Liver.

FIGURE 2

Global prevalence estimates of metabolic dysfunction–associated steatotic liver disease (MASLD). The percentages provided indicate the prevalence of MASLD in the corresponding regions.

FIGURE 3

Pathophysiology of metabolic dysfunction–associated steatotic liver disease (MASLD). ECM, extracellular matrix; ER, endoplasmic reticulum; HCC, hepatocellular carcinoma; NAFLD, non‐alcoholic fatty liver disease; NASH, non‐alcoholic steatohepatitis; ROS, reactive oxygen species; T2DM, type 2 diabetes mellitus. Source: Reproduced from Wang Y, Fleishman JS, Li T, Li Y, Ren Z, Chen J, Ding M. Pharmacological therapy of metabolic dysfunction–associated steatotic liver disease‐driven hepatocellular carcinoma. Front Pharmacol. 2024;14:1336216. doi: 10.3389/fphar.2023.1336216.

FIGURE 4

Risk stratification and diagnosis algorithm of metabolic dysfunction–associated steatotic liver disease (MASLD). ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; cT1, liver multi‐scan; CVD, cardiovascular disease; ELF, enhanced liver fibrosis test™; FIB‐4, fibrosis‐4 index; kPa, kilopascals; LSM, liver stiffness measurement; MRE, magnetic resonance elastography; NAFLD, non‐alcoholic fatty liver disease; PNPLA3, patatin‐like phospholipase domain‐containing 3; T2D, type 2 diabetes. Source: Reprinted with permission from Cusi K, Isaacs S, Barb D, et al. American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Non‐alcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co‐Sponsored by the American Association for the Study of Liver Diseases (AASLD). Endocr Pract. 2022;28(5):528–562. Doi: 10.1016/j.eprac.2022.03.010.

FIGURE 5

(A) Screening criteria for metabolic dysfunction–associated steatotic liver disease (MASLD). (B) Cardiometabolic criteria for Asian Indian adults. ALD, alcohol‐related liver disease; BMI, body mass index; BP, blood pressure; DILI, drug‐induced liver injury; F, female; HbA1c, glycated haemoglobin; HDL, high‐density lipoprotein; M, male; MetALD, metabolic dysfunction and alcohol‐related liver disease; SLD, steatotic liver disease; WC, waist circumference. Source: (a) Reprinted with permission from Rinella ME, Lazarus JV, Ratziu V, et al. NAFLD Nomenclature consensus group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023;78(6):1966–1986. Doi: 10.1097/HEP.0000000000000520. Epub 2023 Jun 24.