Editorial: MASLD In Primary Care—Risk-Stratification as the First Step to Treatment

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with significant hepatic and extrahepatic clinical outcomes, including mortality [1, 2]. Notably, a subgroup with MASLD has a pronounced increase in risk of liver-related events, earning the name “at-risk metabolic dysfunction-associated steatohepatitis (MASH)” [3-5], and understandably deemed to be most likely to benefit from clinical interventions. However, the silence of MASLD until progression to liver failure challenges the timely identification of at-risk MASH. The conditionally FDA-approved pharmacotherapy, currently indicated only for individuals with “non-cirrhotic at-risk MASH”, has compelled us to switch from passive identification to active risk-stratification to find individuals at risk for MASLD with advanced fibrosis. In individuals with cardiometabolic risk factors, AASLD recommends FIB-4-guided risk-stratification, with referral to gastroenterology for individuals at high risk, or second-tier testing with the Enhanced Liver Fibrosis (ELF) test or transient elastography for intermediate risk and continued cardiometabolic optimization for those at low risk for advanced fibrosis.

In the current issue, Adams et al. examine the prevalence of probable at-risk MASH (using Fibrosis NASH Index (FNI)) and FIB-4 index-defined risk for advanced fibrosis among individuals with metabolic risk factors in primary care practices in Victoria, Australia, using two large linked data repositories—Primary Care Audit, Teaching and Research Open Network (PATRON) (de-identified electronic medical records) and Victorian Admitted Episodes Dataset (VAED) [6]. Of the third with metabolic dysfunction, the authors identified that one in five (4.3%) were at high-risk of advanced fibrosis and one in six (18%) were at intermediate-risk and would need additional risk-stratification. Nearly a quarter (24.3%) of those with metabolic dysfunction, and half with type-2 diabetes had at-risk MASH. We see comparable estimates of at-risk MASH (13.6%) and cirrhosis (5.6%) in individuals with type-2 diabetes in the U.S. [7], and advanced fibrosis (3.3%) from pooled studies [8]. Importantly, the authors found a strikingly high burden of probable at-risk MASH (25% vs. 15.5%) and high-risk for advanced fibrosis (5.4% vs. 4.4%) among individuals living in index of relative socioeconomic disadvantage (IRSD)-determined areas with the worst socio-economic disadvantage, compared to those living in areas with the least socio-economic disadvantage [6]. This finding is consistent with emerging evidence linking food insecurity, limited access to healthy foods, and neighbourhood-level deprivation with MASLD outcomes [9, 10].

Taken together, MASLD is a major public health burden that disproportionately affects individuals facing socio-economic disadvantage. Adams et al.'s paper reinforces that primary care is the key initial setting for identifying individuals at risk for MASLD with significant liver disease. In the absence of a structured risk-stratification pathway, a large proportion of patients are likely to remain undiagnosed and therefore untreated. The study observations should prompt consideration of socio-economic vulnerability as a guide for resource allocation at the healthcare system level, as well as in the design and implementation of risk-stratification frameworks for MASLD by medical societies. The current study underscores the need for collaboration between gastroenterology and primary care and endocrinology to facilitate risk-stratification of patients with cardiometabolic risk factors, thereby improving identification of MASLD with significant liver disease and ensuring timely treatment.

Niharika Samala: writing – original draft, conceptualization, supervision, writing – review and editing.

The author has nothing to report.

This article is linked to Adams et al. papers. To view this article, visit https://doi.org/10.1111/apt.70750.

The author has nothing to report.