What monitoring is needed for a patient with Metabolic Abnormalities and Skeletal Changes associated with Lipodystrophy (MASLD), particularly one with a history of HIV?

Monitoring for MASLD

All patients with MASLD require systematic monitoring of metabolic comorbidities at initial diagnosis and regular follow-up intervals, with fibrosis risk stratification determining the intensity and frequency of hepatic surveillance.

Initial Assessment and Baseline Monitoring

At diagnosis, comprehensive evaluation must include:

• Laboratory testing for metabolic comorbidities including type 2 diabetes, dyslipidemia, hypertension, kidney disease, sleep apnea, and polycystic ovary syndrome 1
• Cardiovascular risk assessment as cardiovascular events represent a major cause of mortality in MASLD 1
• Physical examination focused on metabolic parameters and signs of advanced liver disease 1
• Insulin resistance assessment using HOMA-IR or oral glucose tolerance test-derived estimates in patients without established type 2 diabetes 1

Fibrosis Risk Stratification and Monitoring Frequency

The monitoring approach is fundamentally determined by fibrosis stage:

Low-Risk Patients (FIB-4 <1.3)

• Re-assess FIB-4 annually (≤1 year intervals) 1
• Re-assess FIB-4 every 1-3 years for ongoing risk stratification 1
• Intensified management of comorbidities with lifestyle interventions 1
• No hepatocellular carcinoma surveillance is recommended for non-cirrhotic MASLD without severe fibrosis (fibrosis stage <F3) 1

Intermediate-Risk Patients (FIB-4 1.3-2.67)

• Second-tier testing with liver elastography (VCTE with threshold <8.0 kPa vs ≥8.0 kPa) or alternative tests like ELF 1
• Hepatology referral if VCTE ≥8.0 kPa or other evidence of advanced fibrosis 1
• Diagnostic work-up and management plan for liver-related outcomes 1

High-Risk Patients (FIB-4 >2.67 or F3 Fibrosis)

• Immediate hepatology referral for specialized management 1
• Hepatocellular carcinoma surveillance may be considered based on individual risk assessment in F3 fibrosis 1
• Multidisciplinary team management of comorbidities 1

Hepatocellular Carcinoma Surveillance in Cirrhosis

For patients with MASLD-related cirrhosis:

• Mandatory hepatocellular carcinoma monitoring programs should be implemented 1
• Ultrasound combined with alpha-fetoprotein (AFP) measurement every 6 months, as ultrasound alone has low sensitivity in MASLD-related cirrhosis with obesity 1
• Cross-sectional MRI imaging in selected high-risk patients with persistent poor ultrasound visualization 1
• Risk stratification tools to optimize monitoring strategies for higher-risk individuals 1

Portal Hypertension Monitoring in Advanced Disease

For patients with compensated advanced chronic liver disease:

• VCTE ≤15 kPa plus platelet count ≥150×10⁹/L can rule out clinically significant portal hypertension 1
• Upper gastrointestinal endoscopy is required when LSM ≥20 kPa and/or platelet count <150×10⁹/L to screen for varices 1
• Non-selective beta-blockers should be initiated if clinically significant portal hypertension is present, unless contraindicated 1

Important caveat: The LSM threshold of ≥25 kPa to rule in clinically significant portal hypertension applies only to non-obese patients (BMI <30 kg/m²); obesity confounds LSM interpretation 1

Treatment Response Monitoring

When pharmacological treatment is initiated:

• ALT improvement by ≥17 U/L correlates with histologic response, though lack of ALT response should be interpreted cautiously as many patients improve histologically without ALT normalization 1
• VCTE stiffness reduction >30% may indicate clinically meaningful improvement (coefficient of variation ~30%) 1
• MRI-PDFF changes have been associated with histologic response 1
• Liver stiffness measurement improvements typically require ≥1 year, so more frequent monitoring may be less helpful 1

Extrahepatic Cancer Screening

• Participation in extrahepatic cancer screening according to current guidelines is strongly recommended, given obesity and type 2 diabetes as shared risk factors for malignancies 1

Common Pitfalls to Avoid

Do not rely solely on liver enzymes (ALT/AST) for fibrosis detection—non-invasive scores and elastography have superior diagnostic accuracy 1. Do not perform routine hepatocellular carcinoma surveillance in non-cirrhotic patients without F3 fibrosis, as this represents low-value care 1. Do not use standard LSM thresholds in obese patients without considering the confounding effect of obesity on measurements 1.