MASLD
Metabolic-Dysfunction Associate Steatotic Liver Disease
Type 2 Diabetes
Pre-diabetes
Obesity
with ≥ CV factors
* Exclude secondary causes of steatosis or ↑ ALT
Calculate FIB-4 (Fibrosis-4 Index for Liver Fibrosis)
200,000 cell/µL = 200 × 10⁹/L
* Use with caution for patients younger than 35 or older than 65 years, as the score is less reliable in these age groups.
FIB-4 ≥ 1.3
Liver stiffness measurement (LSM) or enhanced liver fibrosis test (ELF)
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OR
An LSM (liver stiffness measurement) value of less than 8.0 kPa has a strong negative predictive value, indicating a low likelihood of advanced fibrosis (stages F3 to F4).
Conversely, if the LSM is 8.0 kPa or higher, there is an increased risk of advanced fibrosis (≥F3–F4), and individuals in this category should be referred to a hepatologist for further evaluation.
Individuals with an ELF score below 9.8 are considered at low risk for adverse liver outcomes. Those with an ELF score of 9.8 or higher are deemed at high risk for having MASH with advanced liver fibrosis (≥F3–F4) and are therefore at risk for adverse liver outcomes.
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Specialists may order additional tests to assess fibrosis risk in patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASH). These tests include magnetic resonance elastography (MRE), which is known for its excellent performance, especially in detecting early stages of fibrosis, as well as multiparametric iron-corrected T1 mapping (cT1) and patented blood-based fibrosis biomarkers. Although a liver biopsy is considered the gold standard for diagnosing MASH, its use is generally at the discretion of the specialist within an interprofessional team. This is due to the high costs and potential morbidity associated with the procedure.
MASLD with
Individualize care, targeting the following:
• Adoption of a healthy lifestyle
• Weight loss (if indicated)
• Optimal diabetes management
• Cardiovascular risk reduction
• Need for metabolic surgery (as recommended by guidelines)
Obesity
Pharmacotherapy
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Diabetes
Parmacotherapy
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MASH
Parmacotherapy
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References
American Diabetes Association Professional Practice Committee; 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2025. Diabetes Care 1 January 2025; 48 (Supplement_1): S59–S85.