KEY MESSAGES
1. Tiered Fibrosis Screening:
Screen high‑risk groups such as type 2 diabetes, obesity, abnormal platelets or splenomegaly using a two‑tier approach. Start with FIB‑4 in primary care, then confirm with elastography (FibroScan or ultrasound elastography) to detect advanced fibrosis early.
2. Ultrasound Isn’t Enough:
A “normal” ultrasound cannot rule out fibrosis or compensated cirrhosis. Rely instead on non‑invasive fibrosis tools: liver stiffness <8 kPa rules out advanced fibrosis, and CAP ≥288 dB/m indicates steatosis. Repeat testing when results are inconsistent to ensure accurate MASLD assessment and early detection of progressive liver disease.
3. Cardio‑Metabolic MASLD Management:
Manage MASLD beyond the liver by aggressively treating cardiovascular risk with statins (even with mild ALT rise), promoting daily physical activity and a Mediterranean‑style diet, reducing sugars and saturated fats, and considering semaglutide in F2–F3 for histologic benefit and cardio‑metabolic gains. This integrated approach improves long‑term outcomes in metabolic liver disease.
4. Smart Cirrhosis Stratification:
In compensated cirrhosis, use liver stiffness and platelets annually to gauge portal hypertension. Skip endoscopy when LS <20 kPa with normal platelets, prefer carvedilol to prevent decompensation (titrate low, effective ceiling ~12.5 mg), and use spleen stiffness (~≥40 kPa) to refine gray‑zone decisions. This structured approach enhances cirrhosis management in routine clinical practice.
5. Genetic Steatosis Red Flags:
Watch for genetic red flags: very low untreated LDL (<55 mg/dL / 1.4 mmol/L) with steatosis suggests APOB mutations, which markedly raise cirrhosis/HCC risk. Confirm with imaging/elastography and family assessment to guide close follow‑up. Early recognition is essential for high‑risk MASLD patients.
