Steatotic liver disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 6 Apr 2025

Last updated: 27 Jun 2024

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the most common causes of chronic liver disease in the developed world.

It is a spectrum of disease, ranging from hepatic fat accumulation without inflammation to steatohepatitis, fibrosis, cirrhosis, and end-stage liver disease.

MASLD is considered the hepatic manifestation of metabolic syndrome and is associated with obesity, dyslipidemia, and type 2 diabetes mellitus.

The diagnosis of MASLD is based on exclusion of other etiologies of steatotic liver disease, such as alcohol use, and supportive laboratory tests and imaging. Liver biopsy and histology is the gold standard for diagnosis, and is performed for patients at higher risk of fibrosis or steatohepatitis.

Lifestyle modification, including weight loss, physical activity, and dietary changes, is the first-line therapy. There are no licensed drug treatments, although use of pioglitazone or vitamin E may be considered for selected patients.

Definition

Steatotic liver disease (SLD) is an overarching term to encompass the various etiologies of steatosis.[1] To more accurately reflect the pathogenesis of fatty liver, a new nomenclature has been suggested.[1][2]

Metabolic dysfunction-associated steatotic liver disease (MASLD) previously known as nonalcoholic fatty liver disease (NAFLD), is the evidence of SLD (imaging or histologic) in the absence of secondary causes of hepatic fat accumulation, such as significant alcohol consumption.[1][3] Pure MASLD encompasses patients with SLD and at least one of five cardiometabolic risk factors. MetALD describes those with MASLD who consume greater amounts of alcohol per week (140-350 g/week for females and 210-420 g/week for males) and have SLD and cardiometabolic risk factors.[1][2]

MASLD can be categorized as metabolic dysfunction-associated steatotic liver (MASL), previously known as nonalcoholic fatty liver (NAFL), or metabolic dysfunction-associated steatohepatitis (MASH), previously known as nonalcoholic steatohepatitis (NASH), depending on histologic features. MASL is the presence of SLD without evidence of hepatocellular injury in the form of hepatocyte ballooning. MASH is the presence of SLD and inflammation with hepatocyte injury (e.g., ballooning), with or without fibrosis.[3] This distinction is important for prognosis because MASH may progress to cirrhosis and liver failure. The risk of MASL progressing to cirrhosis or liver failure is minimal.[3]

This topic focuses on MASLD. See also Alcohol-related liver disease.

History and exam

Key diagnostic factors

absence of significant alcohol use
mild abnormality in liver function tests
truncal obesity

Full details

Other diagnostic factors

fatigue and malaise
right upper quadrant abdominal discomfort
hepatosplenomegaly
signs of chronic liver disease

Full details

Risk factors

obesity
insulin resistance or diabetes
dyslipidemia
hypertension
metabolic syndrome
rapid weight loss
medications
total parenteral nutrition (TPN)
diseases associated with SLD

Full details

Diagnostic tests

1st tests to order

serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
total bilirubin
alkaline phosphatase
gamma glutamyl transferase
CBC
metabolic panel
lipid panel
prothrombin time and INR
serum albumin
autoimmune liver disease screen
iron studies
hepatitis B surface antigen, surface antibody, and core antibody
hepatitis C virus antibody
alpha-1 antitrypsin level and phenotype
liver ultrasound

Full details

Tests to consider

fasting insulin
homeostatic model assessment (HOMA) calculation
abdominal MRI
elastography
liver biopsy
ceruloplasmin
HFE gene mutation testing
anti-M2 mitochondrial antibody

Full details

Emerging tests

cytokeratin-18 fragments

Treatment algorithm

ONGOING

without end-stage liver disease

end-stage liver disease

Contributors

Authors

Shahid M. Malik, MD

Clinical Associate Professor of Medicine

Division of Gastroenterology, Hepatology and Nutrition

Department of Medicine

Program Director, Transplant Hepatology Fellowship Program

Starzl Transplantation Institute

University of Pittsburgh Medical Center

Pittsburgh

Disclosures

SMM declares that he has no competing interests.

Kapil B. Chopra, MD, FACP, FAASLD, AGAF

Professor of Medicine

Medical Director of Comprehensive Liver Program and Liver Pancreas Institute

University of Pittsburgh School of Medicine

University of Pittsburgh Medical Center

Pittsburgh

Disclosures

KBC declares that he has no competing interests.

Acknowledgements

Dr Shahid M. Malik and Dr Kapil B. Chopra would like to gratefully acknowledge Dr Rachel Zhuang, a previous contribution to this topic.

Disclosures

RZ declares no competing interests.

Peer reviewers

Philip Newsome, PhD, FRCPE

Senior Lecturer in Hepatology & Honorary Consultant Physician

Liver Research Group

Institute of Biomedical Research

The Medical School

University of Birmingham

Birmingham

Disclosures

PN declares that he has no competing interests.

Stephen A. Harrison, MD, LTC, MC

Chief of Hepatology

Department of Medicine

Gastroenterology & Hepatology Service

Brooke Army Medical Center

Fort Sam Houston

Associate Professor of Medicine

University of Texas Health Science Center

Houston

Disclosures

SAH is an author of a reference cited in this topic.

Robert D. Goldin, MBCHB, MD, FRCPath

Reader in Liver and GI Pathology

Imperial College at St. Mary's

London

Disclosures

RDG declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023 May 1;77(5):1797-835.Full text Abstract

Vos MB, Abrams SH, Barlow SE, et al. NASPGHAN clinical practice guideline for the diagnosis and treatment of nonalcoholic fatty liver disease in children: recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017 Feb;64(2):319-34.Full text Abstract

European Association for the Study of the Liver; European Association for the Study of Diabetes; European Association for the Study of Obesity. EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016 Jun;64(6):1388-402.Full text Abstract

Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017 Jan;112(1):18-35.Full text Abstract

LaBrecque DR, Abbas Z, Anania F, et al; World Gastroenterology Association. World Gastroenterology Organisation global guidelines: nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. J Clin Gastroenterol. 2014 Jul;48(6):467-73.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Alcohol-related liver disease
- Cryptogenic cirrhosis
- Autoimmune hepatitis
More Differentials
Guidelines
- AASLD practice guideline on imaging-based non-invasive liver disease assessments of hepatic fibrosis and steatosis
- AASLD practice guideline on non-invasive liver disease assessments of portal hypertension
More Guidelines
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Steatotic liver disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

without end-stage liver disease

end-stage liver disease

Contributors

Authors

Shahid M. Malik, MD

Disclosures

Kapil B. Chopra, MD, FACP, FAASLD, AGAF

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Philip Newsome, PhD, FRCPE

Disclosures

Stephen A. Harrison, MD, LTC, MC

Disclosures

Robert D. Goldin, MBCHB, MD, FRCPath

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice