Metabolic dysfunction-associated steatotic liver disease — Rapid

Synopsis

Identify metabolic dysfunction-associated steatotic liver disease, stratify fibrosis rather than relying on enzymes, and reduce liver and cardiovascular risk through coordinated care.

MASLD describes hepatic steatosis in a person with cardiometabolic risk after other major causes are assessed; metabolic and alcohol-related injury can coexist.
Type 2 diabetes, central adiposity, dyslipidaemia, hypertension, obstructive sleep apnoea and polycystic ovary syndrome increase risk, but lean people can also develop advanced disease.
Normal ALT does not exclude steatohepatitis or advanced fibrosis, and the degree of ultrasound brightness does not stage scarring.

Key red flags

Possible advanced fibrosis

Thrombocytopenia, splenomegaly, low albumin, prolonged INR, palmar erythema or a high non-invasive fibrosis result suggests portal hypertension or cirrhosis even when ALT is normal.

Investigation priorities

Metabolic and alcohol assessmentFirst step

Establish cardiometabolic drivers and identify combined aetiology.

FIB-4 or local first-line scoreFirst line

Provide inexpensive initial fibrosis triage in commissioned two-step pathways.

Management branches

DetectionIncidental steatosis or abnormal ALT

Imaging-detected fat, persistent transaminitis or high-risk metabolic disease.

Confirm metabolic risk, quantify alcohol and review medicines, viral exposure, family history and features of autoimmune or inherited disease; examine for chronic liver signs.
Obtain a complete liver panel, blood count, metabolic measures and recommended aetiology screen rather than assuming every raised ALT in obesity is MASLD.

Key medicines

Statin therapyChoose intensity and dose from the current NICE cardiovascular-risk and lipid pathway.

GLP-1 receptor agonist or dual incretin therapyUse only for an approved diabetes or weight-management indication and titrate by protocol.

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