Assessment and management of portal hypertension in patients with MASLD: advances and caveats.

Introduction: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly gaining relevance both as a public health issue and a clinical challenge. The development of portal hypertension in MASLD challenges traditional paradigm that it arises only in the context of cirrhosis.

Areas covered: This review explores the understanding of portal hypertension in MASLD, addressing recent advances in pathophysiology, diagnosis, and potential therapeutic approaches. Particular attention is given to studies that highlight non-cirrhotic contributors to increased portal pressure. Pathogenic mechanisms, as well as advances in noninvasive diagnostic tools are discussed, focusing on their utility in identifying early hemodynamic changes and stratifying the risk of clinical complications. A comprehensive literature search was conducted using PubMed and major databases, including studies published up to April 2025.

Expert opinion: The future of MASLD management lies in early detection, improved noninvasive risk stratification, and personalized treatment strategies. Advances in technology and artificial intelligence will likely enhance diagnostic precision while ongoing research into molecular mechanisms and portal hypertension may enable earlier and effective therapeutic interventions.