The Madrid Declaration on metabolic dysfunction-associated steatotic liver disease (MASLD). Innovation, equity, and transformation of the health-system response to the metabolic disease challenge of the 21st century.

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide and one of the most clinically important manifestations of systemic metabolic dysfunction. Rather than a condition confined to the liver, MASLD represents an early marker of risk within the cardio-hepato-renal-metabolic continuum and an opportunity to intervene before irreversible organ damage becomes established. The Madrid Declaration on MASLD emerged from the meeting 'Innovation and Equity in the Management of MASLD', held on 4 March 2026 at the headquarters of the Spanish General Medical Council, with the endorsement of the Council and several scientific societies. In line with resolution WHA79.4, adopted by the Seventy-ninth World Health Assembly in May 2026, the Declaration sets out a ten-point framework for a health-system and policy response commensurate with the scale of the challenge. It calls for MASLD to be recognised as a public health priority and explicitly integrated into national strategies for noncommunicable diseases. Key proposals include early detection and risk stratification using non-invasive tools in primary care, supported by stepwise referral pathways that ensure an effective clinical response after detection. The Declaration further advocates value-based care and risk-proportionate interventions, reserving specialist care for people at greatest risk of progression and currently authorised disease-specific pharmacotherapies for appropriately selected patients with non-cirrhotic MASH and F2-F3 fibrosis. Equity is positioned as a structural principle of care, alongside stigma-free communication, integrated multidisciplinary models of care, and transparent evaluation against verifiable targets. The Declaration calls on policymakers, institutions, scientific societies, health professionals, and civil society to act in a coordinated and evidence-based manner.