Noninvasive prediction of clinically significant portal hypertension in metabolic dysfunction-associated steatotic liver disease compared to other chronic liver diseases

Figure 1 Noninvasive diagnosis of metabolic dysfunction-associated steatotic liver disease. ¹If the fibrosis-4 (FIB-4) score is < 1.3 or FibroScan liver stiffness measurement (LSM) is < 8 kPa, patients can be followed in the primary care setting and reassessed periodically. Patients without prediabetes/type 2 diabetes mellitus (T2DM) and 1 metabolic risk factor have a low risk for disease progression and can be reassessed every 2–3 years. Patients with prediabetes/T2DM or 2 or more metabolic risk factors are at higher risk for disease progression, and more frequent FIB-4 monitoring (e.g., every 1–2 years) should be considered. Direct referral to gastroenterology or hepatology should be considered in those with aminotransferases persistently (> 6 months) above normal to exclude other causes of liver disease or when FIB-4 score > 2.67. ²Patients at all stages of metabolic dysfunction-associated steatotic liver disease (MASLD) should be counseled on lifestyle modifications, and those with F2 and F3 fibrosis (or FibroScan LSM 10-19.9 kPa) should be considered for treatment with resmetirom. Hepatic steatosis is defined as one of these: (1) > 5% macrovesicular steatosis on liver biopsy; (2) Magnetic resonance elastography-proton density fat fraction > 5.5%; and (3) FibroScan controlled attenuation parameter > 288 dB/minute. Cardiometabolic risk factors (at least one of these along with hepatic steatosis defines MASLD with: (1) Body mass index 25 kg/m² or waist circumference > 94 cm/> 80 cm (male/female); (2) Fasting serum glucose ≥ 100 mg/dL or hemoglobin A1c ≥ 5.7% or on treatment for T2DM; (3) Blood pressure ≥ 130/85 mmHg or on treatment with antihypertensive drugs; (4) Plasma triglyceride ≥ 150 mg/dL or on lipid-lowering treatment; and (5) Plasma high-density lipoprotein ≥ 40 mg/dL (50 mg/dL in females) or on lipid-lowering treatment). ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; FIB-4: Fibrosis-4; GI: Gastroenterology; LSM: Liver stiffness measurement; MASLD: Metabolic dysfunction associated steatotic liver disease; MRE-PDFF: Magnetic resonance elastography-proton density fat fraction; VCTE: Vibration controlled transient elastography.