Metabolic-associated steatotic liver disease (MASLD): how I evolved my approach to diagnosis and staging

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide, with high morbidity and mortality rates. An early diagnosis, in primary care, seems paramount, especially in the high-risk patients with type 2 diabetes and/or obesity. As we discuss in this review, the diagnosis and staging of MASLD has extensively evolved during recent years, especially with the introduction of non-invasive tests (NITs) into management. According to current guidelines, a multitier diagnostic system is implemented in primary care in high-risk groups: the first step includes a non-patented blood test, such as Fibrosis-4 index (FIB-4), followed by an imaging modality (such as transient elastography) or a test based on collagen formation (such as enhanced liver fibrosis (ELF) test). In a specialty setting, several NITs for the diagnosis of steatosis, steatohepatitis and fibrosis, as well as for the prediction of clinical outcomes, have been developed and validated—with various performances—aiming to replace liver biopsy and to guide management decisions. However, NITs have certain limitations, particularly when applied to the general population. Further research is needed to refine and validate both existing and novel biomarkers to reliably guide stage and prognostication in this cohort.