Metabolic dysfunction-associated steatotic liver disease (MASLD) involves accumulation of fat in the liver and may progress to liver inflammation and scarring (fibrosis). MASLD is the most common chronic liver disease worldwide. It affects 30% to 40% of adults in the general population, 60% to 70% of people with type II diabetes, and 70% to 80% of those with obesity, defined as a body mass index (BMI) of 30 or higher (or 25 or higher for Asian people).
The main risk factors for MASLD are obesity and type II diabetes. Other risk factors include prediabetes (elevated blood sugar levels without a diagnosis of diabetes), older age, male sex, certain genetic variants, and postmenopausal status. Behavioral risk factors include having a sedentary lifestyle, smoking, consuming alcohol, drinking sugar-sweetened beverages, and eating diets high in saturated fats, sugars, and processed foods. Although most people with MASLD have no symptoms, some may feel tired or have pain or discomfort in the upper right side of their abdomen. Those with MASLD often have high blood lipid levels (especially triglycerides), low high-density lipoprotein (HDL) cholesterol, elevated blood glucose, and high blood pressure.
About 15% to 40% of individuals with MASLD will develop metabolic dysfunction-associated steatohepatitis (MASH) which is a more severe form of MASLD that involves liver inflammation and can cause liver fibrosis, cirrhosis, liver cancer, and liver failure. They are also at increased risk of developing cardiovascular disease (the leading cause of death in this patient population) and certain non-liver cancers (esophageal, stomach, pancreas, colon, rectal, breast, and gynecological cancers) and have an increased risk of death compared to people without MASLD.
MASLD is diagnosed by detection of fat accumulation in the liver, typically with ultrasound imaging, along with at least one of the following five risk factors: excess abdominal fat or obesity, prediabetes or type II diabetes, high blood pressure, high blood triglycerides, and low HDL cholesterol in individuals without substantial alcohol consumption and no other known causes of fatty liver. A scoring system used to assess the likelihood of liver fibrosis in patients with MASLD (fibrosis-4 index) includes factors such as age and blood test results. Based on this score, patients at high risk of liver fibrosis may undergo noninvasive imaging called vibration-controlled transient elastography the determine the amount of liver fibrosis.
Behavioral modifications are first-line treatment for MASLD and include eating a low-carbohydrate, low-fat, and low-calorie diet; avoiding alcohol; and getting at least 150 minutes of moderate-intensity exercise or at least 75 minutes of vigorous exercise weekly. Weight loss of greater than 7% to 10% in patients with MASLD has been associated with decreased liver fat, inflammation, and fibrosis. The FDA has approved two medications (resmetirom and semaglutide) for adults with MASH who have moderate to advanced liver fibrosis without cirrhosis. Bariatric surgery may also be considered for people with MASLD and moderate to severe obesity, especially if behavioral modifications and medications for obesity have not produced adequate weight loss.
For more information go to the website of the American College of Gastroenterology at www.gi.org
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