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Metabolic dysfunction-associated steatotic liver disease

Key sources
The following summarized guidelines for the evaluation and management of metabolic dysfunction-associated steatotic liver disease are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2023), the American Gastroenterological Association (AGA 2023; 2022; 2021), the United European Gastroenterology (UEG/ESPEN 2023), the American Diabetes Association (ADA 2023), the European Association for the Study of the Liver (EASL 2023), the American Association of Clinical Endocrinologists (AACE/AASLD 2022), the Expert Committee on NAFLD (ECON/NASPGHAN 2017), the European Association for the Study of Obesity (EASO/EASD/EASL 2016), and the American College of Endocrinology (ACE/AACE 2016).


1.Screening and diagnosis

Indications for screening, adult patients, AASLD
Do not obtain general population-based screening for NAFLD.
Screen for advanced fibrosis in patients at high-risk, such as patients with T2DM, medically complicated obesity, family history of cirrhosis, or more than mild alcohol consumption.
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  • Indications for screening (pediatric patients)

  • Indications for screening (family relatives)

2.Classification and risk stratification

Noninvasive assessment of fibrosis
As per AASLD 2023 guidelines:
Obtain primary risk assessment with FIB-4 index in all patients with hepatic steatosis or clinically suspected NAFLD based on the presence of obesity and metabolic risk factors.
Repeat primary risk assessment with FIB-4 index every 1-2 years in patients with prediabetes, T2DM, or ≥ 2 metabolic risk factors (or imaging evidence of hepatic steatosis).

3.Diagnostic investigations

Initial evaluation: as per AASLD 2023 guidelines, do not obtain an ultrasound to identify hepatic steatosis due to low sensitivity across the NAFLD spectrum, although standard ultrasound can detect hepatic steatosis. Consider using a controlled attenuation parameter as a point-of-care technique to identify steatosis.
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  • Transient elastography

  • MRS

  • Serum biomarkers

  • Genetic testing

  • Nutritional assessment

  • Screening for comorbidities

4.Diagnostic procedures

Liver biopsy: as per AGA 2023 guidelines, consider performing a liver biopsy in patients with indeterminate or discordant noninvasive test results, conflict with other clinical, laboratory, or radiologic findings, or suspected alternative etiologies for liver disease.

5.Medical management

General principles: as per AASLD 2023 guidelines, recognize that there are currently no FDA-approved medications for the treatment of NAFLD. Consider initiating drugs approved to treat associated comorbidities with potential benefit in NAFLD in the appropriate clinical setting.

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  • Glucose-lowering agents

  • Bile acids

  • Other agents

  • Management of comorbidities

6.Nonpharmacologic interventions

Dietary modifications: as per AASLD 2023 guidelines, advise a diet leading to a caloric deficit in patients with NAFLD with overweight or obesity. Encourage diets with limited carbohydrates and saturated fat and enriched with high fiber and unsaturated fats (such as the Mediterranean diet) when possible due to their additional cardiovascular benefits.

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  • Weight loss

  • Protein intake

  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Omega-3 fatty acids

  • Vitamin E

  • Probiotics

7.Therapeutic procedures

Intragastric balloon: consider placing a transient endoscopic gastric balloon for nonoperative management in selected patients with NASH without portal hypertension.

8.Surgical interventions

Bariatric surgery: as per AASLD 2023 guidelines, consider performing bariatric surgery as a therapeutic option in patients meeting the criteria for metabolic weight loss surgery, as it effectively resolves NAFLD or NASH in most patients without cirrhosis and reduces mortality from CVD and malignancy.

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  • Liver transplantation (indications)

  • Liver transplantation (pre-transplant evaluation)

  • Liver transplantation (pre-transplant management)

9.Specific circumstances

Lean patients, screening
Do not obtain routine screening for NAFLD in lean persons in the general population.
Consider obtaining screening for NAFLD in > 40 years old patients with T2DM.

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  • Lean patients (diagnosis)

  • Lean patients (differential diagnosis)

  • Lean patients (risk stratification)

  • Lean patients (noninvasive assessment of fibrosis)

  • Lean patients (imaging)

  • Lean patients (liver biopsy)

  • Lean patients (genetic testing)

  • Lean patients (lifestyle modifications)

  • Lean patients (vitamin E)

  • Lean patients (glucose-lowering agents)

  • Lean patients (serial clinical assessment)

  • Lean patients (surveillance for HCC)

  • Pediatric patients (screening)

  • Pediatric patients (diagnosis)

  • Pediatric patients (management)

  • Pediatric patients (follow-up)

  • Pregnant patients (pre-conception care)

  • Pregnant patients (management during pregnancy)

  • Pregnant patients (breastfeeding)

10.Follow-up and surveillance

Indications for referral: as per AASLD 2023 guidelines, refer patients with suspected advanced NASH or discordant noninvasive tests to a specialist for evaluation, management, and/or further diagnostic evaluation.

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  • Serial clinical assessment

  • Serial laboratory and imaging assessment

  • Surveillance for HCC