Brief Overview: According to UpToDate, “Metabolic dysfunction-associated steatotic liver disease (MASLD; previously termed nonalcoholic fatty liver disease [NAFLD]) refers to liver steatosis in patients with at least one metabolic risk factor (eg, obesity, diabetes mellitus, dyslipidemia, hypertension). MASLD may progress to cirrhosis.” MASLD occurs when there is fat build up in the liver.
Prevalence: The prevalence of MASLD is estimated to be 30% worldwide.
Etiology: The etiology is not exactly known, but insulin resistance is believed to be a leading factor.
Risk Factors:
- Male
- Obesity
- HTN
- Dyslipidemia
- Type 2 DM
- Family history, genetics
- Certain medications: amiodarone, glucocorticoids, methotrexate, tamoxifen
Commonly Associated Conditions:
- HTN
- Dyslipidemia
- Diabetes
- Overweight, obesity
- Metabolic syndrome
- Atherosclerotic heart disease, arrythmias, heart failure
- PCOS
- Obstructive sleep apnea (OSA)
- Chronic Kidney Disease (CKD)
- History of cholecystectomy
Common Medications:
- No medications have been approved to treat MASLD, but there are some medications used for a targeted approach:
- Resmetirom – for patients with MASH and fibrosis stage F2 or F3 who do not achieve sustained weight loss. This is still being studied
- Vitamin E – for patients with biopsy-proven MASH and fibrosis stage 2 or greater without diabetes. Do not take Vitamin E unless directed to do so by your healthcare provider.
- Pioglitazone in patients with biopsy-proven MASH and diabetes
- Weight loss medication, if indicated – GLP-1 (semaglutide, liraglutide)
- Atorvastatin – needs more study
- Omega-3 fatty acids – needs more study
Common Labs, Imaging, and Tests:
- CMP, CBC, PT/INR, HgbA1c, lipid panel, Hepatitis B screening, Hep C screening, iron studies, AMA, IgG, ceruloplasmin, AAT, tTG-IgA, liver studies
- FibroScan
- Abdominal imaging – ultrasound, CT, MRI
- Liver biopsy
- Elastography, serum fibrosis markers
Common Symptoms:
- Typically, asymptomatic
- Fatigue, malaise
- Vague right upper abdominal discomfort
Common Treatments:
- Medications (see above)
- Weight loss, if indicated
- Bariatric surgery, if indicated
- Management of any associated conditions
Physical Findings:
- Typically, normal physical exam
- Hepatomegaly may be present
Potential Complications and Contraindications:
- Patients with more than 1 metabolic factor are at an increased risk for progression to MASH
- Risk for advanced fibrosis
- May progress to cirrhosis
- Hepatocellular carcinoma
- Increased risk of developing cancer (including breast cancer, colorectal cancer)
- Increased risk of developing diabetes
- Increased risk for cardiovascular disease
General Health and Lifestyle Guidance:
- Avoid alcohol
- Engage in exercise as recommended by your healthcare provider
- Work with your healthcare provider/dietician to maintain a healthy diet
- Work with your healthcare provider to achieve and maintain control of any associated conditions
- Stay up to date on all age-appropriate vaccinations (Hep A, Hep B, flu vaccine, pneumonia vaccine, Tdap, shingles vaccine, etc.). Talk to your healthcare provider about what vaccines are recommended for you.
- Talk to your healthcare provider before taking any OTC supplements or vitamins
Suggested Questions to Ask Patients:
- Have you been told you have fatty liver or elevated liver enzymes?
- Are you working on weight loss or managing diabetes or cholesterol?
- What is your current diet and exercise routine like?
- Do you use alcohol or supplements regularly?
- Have you ever had imaging or tests to evaluate your liver?
Suggested Talking Points:
- Make sure to go to all follow-up appointments and complete all lab work and imaging tests as directed by your healthcare provider
- Weight loss is typically the mainstay of treatment for MASLD. Consider working with a dietician if this is available to you.
Sources:
- UpToDate
- Cleveland Clinic
- Johns Hopkins Medicine