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Metabolic dysfunction-associated steatohepatitis — Clinical Guidelines

Overview

Metabolic dysfunction-associated steatohepatitis (MASH) is a prevalent liver condition linked to metabolic syndrome, characterized by hepatic steatosis, inflammation, and potential fibrosis, contributing to significant morbidity including cirrhosis and hepatocellular carcinoma 1 3.

Diagnosis

Noninvasive Tests: Use of noninvasive tests (NITs) such as fibrosis-4 index, enhanced liver fibrosis (ELF) tests, and 2D-SWE ultrasound for assessing fibrosis 2 7.

AI Integration: Emerging role of artificial intelligence in enhancing diagnostic accuracy and therapeutic approaches 1.

Histological Evaluation: Liver biopsy remains definitive for diagnosing MASH and assessing fibrosis severity, particularly in pediatric populations 6.

Management

First-Line Treatments: Lifestyle modifications including diet and exercise are foundational 3.

Pharmacological Agents:

- GLP-1 Receptor Agonists: Show promise in improving MASH and reducing liver fibrosis (e.g., semaglutide, liraglutide) 5. - Comparative Efficacy: Network meta-analysis suggests varying efficacy among pharmacological agents; specific rankings depend on clinical context 4.

Referral Patterns: Early referral to gastroenterology specialists for advanced fibrosis risk assessment is recommended 11.

Special Populations

Pediatrics: Increasing prevalence noted; severity of MASH and fibrosis assessed via liver biopsy 6.

Elderly: Specific management guidelines are evolving but emphasize risk stratification and multidisciplinary care 8.

Comorbidities: Management often requires collaboration between hepatology and cardiology due to systemic metabolic impacts 10.

Key Recommendations

Utilize noninvasive tests for early risk stratification and timely specialist referral in patients with suspected MASH (Evidence: Moderate 2 7).

Consider glucagon-like peptide-1 receptor agonists as part of pharmacological management to improve MASH and reduce liver fibrosis (Evidence: Strong 5).

Implement multidisciplinary approaches involving gastroenterology and cardiology for comprehensive care, especially in patients with systemic metabolic dysfunction (Evidence: Expert opinion 10).

Regularly assess pediatric patients with metabolic dysfunction for MASH severity through liver biopsy to guide intervention (Evidence: Moderate 6).

Early referral to gastroenterology specialists is crucial for patients at risk of advanced fibrosis (Evidence: Moderate 11).

References

1 Hernández-Almonacid PG, Marín-Quintero X. Artificial intelligence in metabolic dysfunction-associated steatotic liver disease: Transforming diagnosis and therapeutic approaches. World journal of gastroenterology 2026. link 2 Kamada Y, Sumida Y, Takahashi H, Ishiba H, Kawanaka M, Tada T et al.. Noninvasive strategies for metabolic dysfunction-associated steatotic liver disease assessment and referral in Japan. World journal of gastroenterology 2026. link 3 Lam BP, Bartholomew J, Bau S, Gilles H, Keller A, Moore A et al.. Focused Recommendations for the Management of Metabolic Dysfunction-Associated Steatohepatitis (MASH) by Advanced Practice Providers in the United States. Journal of clinical gastroenterology 2025. link 4 Souza M, Al-Sharif L, Antunes VLJ, Huang DQ, Loomba R. Comparison of pharmacological therapies in metabolic dysfunction-associated steatohepatitis for fibrosis regression and MASH resolution: Systematic review and network meta-analysis. Hepatology (Baltimore, Md.) 2025. link 5 Mantovani A, Morandin R, Fiorio V, Lando MG, Stefan N, Tilg H et al.. Glucagon-Like Peptide-1 Receptor Agonists Improve MASH and Liver Fibrosis: A Meta-Analysis of Randomised Controlled Trials. Liver international : official journal of the International Association for the Study of the Liver 2025. link 6 Souza M, Khalil SM, de Oliveira FD. Meta-analysis: Histological severity of biopsy-proven metabolic dysfunction-associated steatotic liver disease in pediatric patients. Journal of pediatric gastroenterology and nutrition 2025. link 7 Indre MG, Leucuta DC, Lupsor-Platon M, Turco L, Ferri S, Hashim A et al.. Diagnostic accuracy of 2D-SWE ultrasound for liver fibrosis assessment in MASLD: A multilevel random effects model meta-analysis. Hepatology (Baltimore, Md.) 2025. link 8 Mandorfer M, Semmler G, Aigner E, Bräuer A, Maria Brix J, Clodi M et al.. Austrian multisociety consensus on metabolic dysfunction-associated steatotic liver disease : Austrian Society of Gastroenterology and Hepatology (ÖGGH), Austrian Society of Diabetology (ÖDG), Austrian Society of Obesity (ÖAG). Wiener klinische Wochenschrift 2025. link 9 Wong W. Aging from adipose accumulation of antibodies. Science signaling 2024. link 10 Raggi P, Milic J, Manicardi M, Cinque F, Swain MG, Sebastiani G et al.. Metabolic dysfunction-associated steatotic liver disease: An opportunity for collaboration between cardiology and hepatology. Atherosclerosis 2024. link 11 Bobo JFG, Keith BA, Marsden J, Zhang J, Schreiner AD. Patterns of gastroenterology specialty referral for primary care patients with metabolic dysfunction-associated steatotic liver disease. The American journal of the medical sciences 2024. link

Metabolic dysfunction-associated steatohepatitis