Understanding MASLD & MASH -Global NASH/MASH Council Recommendations (Sept 2025)

on September 20, 2025

Understanding MASLD & MASH

Understanding MASLD & MASH

An Educational Guide Based on the Global NASH/MASH Council Recommendations (Sept 2025)

Created by Dr. Sharad Maheshwari, imagingsimplified@gmail.com

1. Identify At-Risk Patients

Type 2 Diabetes Mellitus
Obesity with ≥1 cardiometabolic risk factor
Persistently elevated liver enzymes (ALT/AST) for over 6 months
Incidental finding of steatosis (fatty liver) on an imaging scan

2. Rule Out Other Causes

It's important to exclude other conditions that can affect the liver:

Viral Hepatitis (HBsAg, Anti-HCV)
Excessive Alcohol Use (AUDIT / markers)
Autoimmune diseases, Wilson's, or Hemochromatosis if features are atypical

3. Initial Risk Check: FIB-4

The FIB-4 score estimates liver fibrosis risk from a blood test.

Low Risk: Score <1.3 (<65 yrs) or <2.0 (≥65 yrs). Recommended action is lifestyle advice and follow-up.

Higher Risk: Score above cut-off. Proceed to advanced testing.

4. Advanced Scan: VCTE

VCTE (e.g., FibroScan®) measures liver stiffness (LSM) in kilopascals (kPa).

< 8 kPa: Low risk. Lifestyle advice + repeat in 2-3 yrs.
8-10 kPa: Indeterminate. Consider specialist review or MRE.
≥ 10 kPa: Advanced fibrosis risk. Evaluate for MASH.

5. Confirm & Stage Diagnosis

For high-risk patients (LSM ≥10 kPa), further confirmation may include:

MR Elastography (MRE): A highly accurate imaging test.
Serum Biomarkers: Advanced blood tests (ELF, Pro-C3).
Liver Biopsy: Only if diagnosis is unclear or results conflict.

6. Management Pathways

Lifestyle (All Patients)

Weight loss of ≥7-10%
Mediterranean or calorie-restricted diet
Aerobic + resistance exercise

Pharmacotherapy (Select Patients)

Resmetirom: For MASH with F2-F3 fibrosis.
GLP-1 Agonists: Especially with T2DM/obesity.
Pioglitazone: Option for biopsy-proven MASH with T2DM.

7. Advanced Disease Care

For patients with cirrhosis (LSM ≥20 kPa or biopsy-proven):

HCC Surveillance: Ultrasound every 6 months to screen for liver cancer.
Variceal Screening: Endoscopy to check for large veins in the esophagus.
Manage complications of portal hypertension.

8. Follow-up Schedule

Low Risk: Repeat tests every 2-3 years.
Intermediate/High Risk: Repeat non-invasive tests every 12-18 months.
On Resmetirom: Labs at 3, 6, 12 months and annual elastography.

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Indian Radiology & India-Specific Notes

Ultrasound elastography (like VCTE/FibroScan) is key for staging fibrosis—a critical step beyond just detecting fat on routine scans.
The IRIA's initiative on preventive imaging encourages screening for diseases like MASLD to catch them early and assess risk properly.
Asian BMI cutoffs are lower (Overweight ≥23, Obese ≥25).
VCTE is the practical backbone due to limited access to MRE/ELF.
Drug accessibility and cost are key factors, with GLP-1 RAs often more available.

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