Metabolic Dysfunction-Associated Steatohepatitis Diagnosis and Management in Germany: Insights From an Expert Consensus Panel

Abstract

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a major cause of chronic liver disease. Metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of MASLD, can lead to fibrosis and cirrhosis. The incidence and burden of MASH in Germany are expected to double by 2030, while diagnostic and management challenges persist. Expert consensus on diagnostic strategies and treatment modalities in MASLD and MASH is required.

Objectives: The panel aimed to gather insights and consensus on the diagnostic pathway and current treatment modalities for MASH in Germany.

Methods: A three-round web-based survey, integrating Delphi panel methodology with a standard survey, was conducted from February to May 2024 to reach consensus on predefined questions. The survey involved 12 gastroenterology, diabetology and/or hepatology specialists in Germany.

Results: The Delphi panel revealed that ~75% of MASH patients in Germany remain undiagnosed. Non-invasive measures, such as fibrosis scores (values from clinical and imaging tests to assess fibrosis), liver enzyme tests and liver stiffness measurement, were primary methods for diagnosing and monitoring MASH patients. Lifestyle modifications were the primary management strategy, given the absence of approved pharmacological treatments for MASH. The panel also highlighted significant challenges in managing MASH, including the lack of approved medications and the difficulty in sustaining lifestyle changes.

Conclusions: The survey underscores the substantial underdiagnosis of MASH and the reliance on non-invasive diagnostic methods in Germany. The lack of approved treatments necessitates a focus on lifestyle modifications and comorbidity management. The Delphi panel's insights call for enhanced screening, early detection and standardised algorithms to improve patient outcomes.

Keywords: MASH; MASLD; NAFLD; NASH; non‐invasive tests.

FIGURE 1

Flow chart presenting the process of the Delphi method with experts participating anonymously in three rounds of survey. Results were prepared by Cencora for the respective next round and results were provided in interim and final report(s).

FIGURE 2

Pie chart showing the average proportions of referral routes of MASH patients to experts' clinics or offices: 62.5% general practitioners (primary care), 18.3% endocrinologists, 17.1% gastroenterologists/hepatologists and 2.1% others.

FIGURE 3

Pie chart showing the estimated fibrosis stages of patients with MASLD including MASH in experts' clinics/practices: 50.8% in stages F0 to F1, 18.3% in F2, 12.5% in F3, 11.3% in F4 compensated and 7.1% in F4 decompensated.

FIGURE 4

Visualisation of the importance of selected approaches (a) to diagnose MASH patients in clinical practice; bar chart showing fibrosis scores, liver enzyme tests, other serological tests and LSM by VCTE as the most important approaches (100%) (b) to monitor MASH patients in clinical practice; bar chart showing fibrosis scores, liver enzyme tests, other serological tests and LSM by VCTE as the most important approaches (100%). Fibrosis scores: NAFLD fibrosis score, FibroTest, BARD‐Score, FIB4 Index, Enhanced Liver Fibrosis (ELF) panel; Imaging procedures: computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, proton magnetic resonance spectroscopy; liver enzyme tests: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), γ‐glutamyltransferase (GGT); other serological tests: INR ratio, serum albumin, total bilirubin, platelets, serological tests that show absence of hepatitis; steatosis and activity scores: SteatoTest, ActiTest; biopsy evaluation scores: NAFLD Activity score (NAS), Steatosis Activity and Fibrosis (SAF) score.