Author：Professor Jiangao Fan
Editor's Note: On June 7, 2024, at 5:30 PM in Milan, Italy, the European Association for the Study of the Liver (EASL), the European Association for the Study of Diabetes (EASD), and the European Association for the Study of Obesity (EASO) jointly released the latest Clinical Practice Guidelines for the management of Metabolic Associated Fatty Liver Disease (MASLD) at the EASL 2024 Annual Meeting. The guidelines cover a wide range of topics from the use of non-invasive diagnostic tools to treatment strategies, emphasizing the importance of treating obesity and diabetes and multidisciplinary collaboration in the management of MASLD. These guidelines have been simultaneously published online in the official journals of EASL, EASD, and EASO, such as the Journal of Hepatology.Background
Metabolic Associated Fatty Liver Disease (MASLD), previously known as Non-Alcoholic Fatty Liver Disease (NAFLD), is defined as fatty liver disease (FLD) occurring in the presence of one or more cardiovascular metabolic risk factors without excessive alcohol intake. The disease spectrum of MASLD includes simple hepatic steatosis, metabolic associated steatohepatitis (MASH, previously known as NASH), liver fibrosis, cirrhosis, and MASH-related hepatocellular carcinoma (HCC). This guideline update provides a series of scientific statements and recommendations for the definition, prevention, screening, diagnosis, and treatment of MASLD.
Diagnostic and Screening Recommendations
For individuals with type 2 diabetes (T2D), metabolically unhealthy obesity, or persistently elevated serum liver enzymes, non-invasive tests such as the fibrosis-4 (FIB-4) index should be used for screening and monitoring liver fibrosis, and individuals suspected of having advanced liver fibrosis should be promptly referred to a liver specialist.
The new guidelines strongly recommend non-invasive liver fibrosis screening for individuals with cardiovascular metabolic risk factors, abnormal liver enzyme levels, or imaging evidence of liver steatosis. Blood-based biomarker scores (e.g., FIB-4) and imaging techniques (e.g., transient elastography) are recommended as part of a stratified non-invasive assessment strategy to rule out or confirm the presence of advanced fibrosis, which helps predict liver-related clinical outcomes.
Treatment Strategy Recommendations
1. Lifestyle Changes:
The guidelines emphasize the importance of lifestyle changes for overweight and obese individuals, including weight loss, improved diet quality, increased physical activity, and avoidance of alcohol. These measures are recommended for all MASLD patients, and normal-weight MASLD patients should also be advised to prevent obesity.
2. Recommendations Beyond Lifestyle Changes:
For non-cirrhotic MASH patients, the guidelines conditionally recommend using new drugs like Resmetirom, which have shown improvements in fatty liver inflammation and fibrosis in clinical trials. It is noted that Resmetirom may be considered for adults with MASH and significant liver fibrosis (F2 and F3) when approved and indicated by local authorities, showing histological efficacy and acceptable safety and tolerance. However, this medication is not currently recommended for MASH-related cirrhosis patients.
For MASLD adults, the guidelines suggest active management of comorbidities and liver-related complications, including the use of GLP-1 receptor agonists (e.g., Semaglutide, Tirzepatide) for T2D or obesity when necessary. Weight-loss metabolic surgery is also an option for MASLD patients with obesity.
Metabolic Surgery:
For MASLD patients with obesity, the guidelines recommend considering laparoscopic metabolic surgery when indicated, as it can provide long-term liver benefits, including T2D remission, cardiovascular risk reduction, and lower cancer incidence. Endoscopic metabolic surgery is considered promising but needs further validation as a targeted therapy for MASH.
Liver Transplantation and Management of End-Stage Liver Disease:
For MASH-related cirrhosis patients, the guidelines propose comprehensive management of cardiovascular metabolic comorbidities to optimize pre- and post-liver transplant risk assessment and management. Management includes adjusting metabolic medications (e.g., statins, GLP-1 receptor agonists for Child-Pugh A patients, metformin, and SGLT-2 inhibitors for Child-Pugh B patients), nutritional assessment and intervention, monitoring clinically significant portal hypertension and HCC, and considering liver transplantation in cases of decompensated cirrhosis.
Additionally, MASLD patients awaiting liver transplantation should adjust their diet and lifestyle to maintain muscle mass, reduce the risk of sarcopenia, and carefully use medications affecting liver and kidney function.
Summary
The latest MASLD management guidelines provide a comprehensive set of practical tools and valuable recommendations for clinicians to diagnose and manage FLD patients. Through early identification, risk assessment, and multidisciplinary treatment strategies, the guidelines aim to improve clinical outcomes for MASLD patients. By adopting non-invasive diagnostic techniques, personalized treatment plans, and interdisciplinary collaboration, these guidelines bring new hope and direction for MASLD management.
