Metabolic dysfunction-associated steatotic liver disease (MASLD)
1. What is MASLD?
MASLD is a chronic metabolic liver condition defined by hepatic fat accumulation in the absence of significant alcohol consumption and in the presence of at least one feature of metabolic dysfunction. This term replaces the previous definition of NAFLD (non-alcoholic fatty liver disease), in accordance with the international consensus (AASLD, EASL, ALEH, APASL, 2023).
2. Etiology and risk factors
MASLD develops in the context of metabolic dysregulation, including:
- Abdominal obesity
- Insulin resistance
- Type 2 diabetes mellitus
- Dyslipidemia (↑triglycerides, LDL; ↓HDL)
- Hypertension
- Genetic predisposition
- Sedentary lifestyle and poor diet
3. Classification
- MASLD without inflammation (simple steatosis)
- MASH – with steatohepatitis, ballooning, and fibrosis
- Hepatic fibrosis (F0–F4)
- Cirrhosis secondary to MASH
- Hepatocellular carcinoma (HCC) – may occur even without cirrhosis
4. Clinical features
- Asymptomatic in 70–80% of cases
- May present with fatigue, right upper quadrant discomfort
- Often detected via elevated ALT and AST
- Transaminases may remain normal, especially in MASH
5. Diagnostics
Initial workup:
- Abdominal ultrasound (limited with BMI >30)
- Liver enzymes: ALT, AST, GGT, ALP, bilirubin
- HOMA-IR, lipid profile, glucose
Non-invasive fibrosis assessment:
Elastography (FibroScan)
FibroTest, FIB-4, NAFLD fibrosis score
MR elastography (if uncertainty remains)
Liver biopsy – gold standard for confirming MASH and fibrosis stage
6. Treatment (AASLD/EASL recommendations)
1. Lifestyle modification (first-line):
- ≥7–10% weight reduction
- Mediterranean, DASH, or low-glycemic index diet
- ≥150 minutes/week of aerobic physical activity
2. Pharmacotherapy (for MASH or fibrosis ≥F2).
- Pioglitazone (especially in T2DM)
- GLP-1 receptor agonists: semaglutide, liraglutide
7. Complications
- Progressive liver fibrosis
- Cirrhosis and portal hypertension
- Hepatocellular carcinoma
- Increased cardiovascular risk
- MASLD-associated mortality exceeds liver-specific complications
8. When to consult a doctor
- Elevated liver enzymes on blood tests
- Presence of metabolic risk factors (obesity, diabetes, dyslipidemia)
- Steatosis on ultrasound or CT
- Planned consultation with a gastroenterologist/hepatologist when MASLD is diagnosed