Reliable Monitoring of Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease Using Imaging: A Systematic Literature Review and Meta-Analysis on Measurement Repeatability

As treatments for patients with metabolic dysfunction-associated steatotic liver disease (MASLD) emerge, patient eligibility assessment and monitoring is increasingly important. To assess the reliability of non-invasive imaging technologies in MASLD, we systematically reviewed the literature for studies on technical repeatability. PubMed Central and MEDLINE were searched (2015-2025) for studies in MASLD that examined the repeatability of: magnetic resonance (MR)-derived iron-corrected T1 (cT1), liver fat content (LFC) and elastography (MRE); ultrasound-based vibration controlled transient elastography liver stiffness measurement (VCTE LSM), controlled attenuation parameter (CAP) and shear wave elastography (SWE). The relative repeatability coefficient (%RC) for same-day (%RC SD ) or different-day (%RC DD ) repeat tests were summarized, and available data pooled using random-effects-meta-analysis. Our search identified 19 studies including 1,040 individuals (mean age 45 years; 43% female). The pooled random-effects average %RC DD was 7% for cT1, 12% for LFC, 22% for MRE, 73% for VCTE LSM, and 26% for CAP, with a median interval of 14 days between repeat scans. %RC SD values were consistently lower across all tests. In the context of MASLD monitoring, the %RC DD for MRE and VCTE LSM overlapped with previously reported thresholds for clinically-meaningful change for treatment responders (15% and 30%, respectively). In contrast, the %RCs for cT1 and LFC were below established thresholds for clinically-meaningful change (9% and 30%, respectively). This systematic review and meta-analysis showed that cT1 and LFC are more reliable in detecting change in liver health in people living with MASLD-MASH, compared to liver stiffness. Liver stiffness measurements are less suited to monitoring individual patients.