2024 EASL-EASD-EASO Clinical Practice Guidelines for MASLD Management: Screening & Evaluation

Risk Factors: 

• Steatosis alone is not linked to liver-related outcomes, but liver fibrosis stage and consistently elevated liver enzymes are.
• Type 2 diabetes (T2D) and obesity, especially abdominal obesity, significantly influence MASLD progression, including fibrosis and hepatocellular carcinoma.
• Men over 50, postmenopausal women, and those with multiple cardiometabolic risk factors face a higher risk of fibrosis and cirrhosis.
• Evidence shows alcohol and metabolic risks independently and synergistically influence chronic liver disease progression. Moderate alcohol consumption’s health benefits are inconsistent, especially in those with cardiometabolic risks.
• Alcohol Intake Documentation: All SLD patients should have their alcohol consumption history documented using validated tools or biomarkers. 

Screening:

• Steatotic liver disease (SLD) screening in the general population is not recommended.
• Healthcare providers should consider case-finding for MASLD with fibrosis in patients with cardiometabolic risks, abnormal liver enzymes, or hepatic steatosis signs.
• Screening for early fibrosis and appropriate management may prevent cirrhosis and its complications.

Prevention:

• Non-pharmacological preventive measures should be advised to prevent MASLD and its complications, including hepatocellular carcinoma, especially in high-risk groups.
• Those with SLD, particularly moderate to high alcohol consumers, should avoid alcohol entirely.

Evaluation:

• In adults with MASLD, non-invasive tests, combining blood tests with imaging, are recommended for detecting fibrosis due to their higher accuracy compared to liver enzyme tests. 
• A multi-step diagnostic approach should be used, beginning with a non-patented blood-based score, followed by imaging if necessary.
• Use blood biomarker scores and elastography to rule out advanced fibrosis. Elastography is particularly effective for predicting advanced fibrosis.
• Non-invasive methods are unable to evaluate key microscopic features of MASLD, such as ballooning or lobular inflammation. 
• A liver biopsy is generally not needed for managing MASLD but remains essential for a definitive diagnosis of steatohepatitis and for ruling out other liver diseases.
• Non-invasive biomarkers (e.g., FIB-4, ELF) and liver stiffness measurements (e.g., VCTE, MRE) are effective in detecting advanced fibrosis, with predictive values depending on the cut-off values and fibrosis prevalence in the population. 
• Sequential non-invasive assessments can help rule out fibrosis progression in adults with MASLD.

Genetic Testing:

• •Specialists may consider genetic risk profiling (e.g., PNPLA3 variant, polygenic risk scores) for personalized risk stratification. However, this approach requires validation in larger studies.
• Genetic risk variants can be used in clinical research to stratify disease progression risk and sub-phenotype MASLD.
• Referral for genetic evaluation may be considered for those with a strong family history of severe liver disease or early severe phenotype presentation, especially when metabolic triggers are absent.

Metabolic Abnormalities Assessment:

• • Clinicians should assess comorbidities (e.g., T2D, dyslipidemia, hypertension) and cardiovascular risk in MASLD patients.
• • Regular laboratory tests and physical exams for related comorbidities are advised at the initial MASLD diagnosis and during follow-up.
• • MASLD patients should be encouraged to participate in extrahepatic cancer screening, particularly due to obesity and T2D.
• • Insulin resistance assessment (e.g., HOMA-IR) may be considered for diagnosing metabolic dysfunction in MASLD patients without T2D.

Hepatocellular carcinoma (HCC) Surveillance:

• Surveillance for HCC is not currently recommended in MASLD or MASH patients without severe fibrosis.
• HCC screening may be considered in MASLD or MASH patients with severe fibrosis based on individual risk assessments.
• HCC monitoring programs should be implemented for those with MASLD-related cirrhosis, with risk stratification optimizing surveillance strategies.

Source: Tack F, Horn P, Wong VWS, et al. Diabetologia. 2024 Jun.