What is the diagnosis and treatment for Metabolic Associated Steatohepatitis Liver Disease (MASLD)?

From the Guidelines

The diagnosis and treatment of Metabolic Associated Steatohepatitis Liver Disease (MASLD) should prioritize lifestyle modification, including weight loss, dietary changes, and physical exercise, as well as optimal management of comorbidities, with consideration of pharmacological treatments such as incretin-based therapies and resmetirom for non-cirrhotic patients with significant liver fibrosis. The management of MASLD is multifaceted, involving the identification of individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes or obesity with additional metabolic risk factors 1. A stepwise approach using blood-based scores, such as the fibrosis-4 index (FIB-4), and imaging techniques like transient elastography, is suitable for ruling out or confirming advanced fibrosis, which is predictive of liver-related outcomes 1. Key aspects of lifestyle modification include:

• Weight loss of 7-10% of body weight through caloric restriction and regular exercise
• Adoption of a Mediterranean diet rich in fruits, vegetables, whole grains, olive oil, and lean proteins
• Physical activity of at least 150 minutes of moderate-intensity exercise weekly For patients with more advanced disease or those unable to achieve adequate weight loss, medication options may include:
• Incretin-based therapies (e.g., semaglutide, tirzepatide) for type 2 diabetes or obesity
• Resmetirom for non-cirrhotic patients with significant liver fibrosis (stage ≥2), if locally approved and dependent on the label Bariatric surgery is also an option for individuals with MASLD and obesity who have not responded to lifestyle interventions 1. Regular monitoring of liver enzymes, imaging, and in some cases, liver biopsy, is necessary to track disease progression and adjust treatment strategies as needed 1. The goal of these interventions is to prevent the progression of MASLD to more severe forms, such as non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma, by addressing underlying metabolic health and insulin resistance 1. In the context of liver transplantation for MASLD-related cirrhosis, a multidisciplinary approach is crucial for managing metabolic risk factors, preventing recurrent or de novo MASH, and optimizing immunosuppressive regimens to minimize metabolic complications 1.

From the Research

Diagnosis of Metabolic Associated Steatohepatitis Liver Disease (MASLD)

• The diagnosis of MASLD involves identifying the presence of liver inflammation, hepatocyte damage, and liver fibrosis, which can lead to cirrhosis 2, 3, 4.
• Non-invasive tests can be used to assess the risk of liver-related complications and identify patients with severe MASLD who require specialist care 4.
• The diagnosis of MASLD is often associated with metabolic syndrome, and patients with MASLD are at a greater risk of developing cardiovascular diseases (CVD) 2, 3, 5.

Treatment of Metabolic Associated Steatohepatitis Liver Disease (MASLD)

• Lifestyle intervention, including diet change and physical activity, is the cornerstone of the management of patients with MASLD, with a focus on weight loss and healthier behaviors 4, 5.
• No pharmacological agent has been approved for the treatment of MASLD, but novel anti-hyperglycemic drugs and medications used for the treatment of diabetes and other metabolic conditions may be beneficial 2, 4, 5.
• Recent advances in MASLD genetics have led to the development of potential treatments, including gene-targeted RNA therapies, and the first pharmacologic therapy has been approved for the treatment of MASLD 6.
• A multidisciplinary approach to treatment, including continuity of care, is essential for managing patients with MASLD and reducing the risk of liver-related and cardiovascular complications 5.

Management of Cardiovascular Risk in MASLD

• Cardiovascular disease risk must be properly assessed and managed in patients with MASLD, as CVD is the leading cause of mortality in these patients 2, 3, 4.
• The management of cardiovascular risk in MASLD involves addressing lipid metabolism disorders and lipotoxicity, which are common pathophysiological mechanisms in MASLD and CVD 2, 3.
• Emerging epidemiological evidence suggests a high concordance rate between NAFLD and MASLD definitions, and patients with MASLD are at an increased risk of developing CVD and malignant complications 3.