Cirrhosis Regression After Metabolic Bariatric Surgery in Patients With Compensated MASH Cirrhosis

OBJECTIVE: To evaluate histologic cirrhosis regression after metabolic bariatric surgery (MBS) in patients with compensated metabolic dysfunction-associated steatohepatitis (MASH) cirrhosis. SUMMARY BACKGROUND DATA: Cirrhosis in MASH has traditionally been considered irreversible. Although MBS improves steatohepatitis and fibrosis in noncirrhotic MASH, its impact on established cirrhosis remains uncertain. METHODS: This retrospective study included adults with biopsy-proven compensated MASH cirrhosis who underwent MBS at Cleveland Clinic from 2004 to 2024 and had paired baseline and follow-up liver biopsies. The primary outcome was regression from NASH Clinical Research Network (NASH CRN) stage 4 to stage 3 or lower. Fibrosis was also assessed using modified Ishak staging and the Beijing classification. RESULTS: Thirty patients were included; 22 (73%) were female, median age was 54.2 years, and median baseline body mass index was 43.7 kg/m². The median (IQR) biopsy interval was 6.2 (2.0-9.2) years, median body weight reduction was 31.8 (21.4-40.4) kg, and median total weight loss was 23.9% (18.0%-30.5%). Cirrhosis regression occurred in 33% of patients using NASH CRN staging and in 40% using modified Ishak staging. Regressive fibrosis features were identified in 60% of patients using the Beijing classification. Significant improvements were also observed in steatosis, lobular inflammation, and hepatocyte ballooning. CONCLUSIONS: MBS was associated with histologic cirrhosis regression in a substantial proportion of patients with biopsy-proven compensated MASH cirrhosis. More detailed histologic frameworks identified additional fibrosis improvement and regressive remodeling, suggesting that compensated MASH cirrhosis may be reversible after sustained metabolic intervention.