Screening for Fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease: Evidence, Challenges, and the Role of Imaging-From the <i>AJR</i> Special Series on Screening.

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects 40% of the world's population. Despite an association with increased cardiovascular morbidity, MASLD usually does not lead to liver-related adverse outcomes until fibrosis develops. MASLD with clinically significant fibrosis (histologic fibrosis stage ≤2) is associated with poorer prognosis and helps guide management, including specialty care referral. Among adults with MASLD, those with noncirrhotic clinically significant fibrosis (stage 2 or 3) may be eligible for pharmacotherapy to prevent progression to cirrhosis; those with advanced fibrosis (stage ≤3) usually require intensive monitoring; and those with cirrhosis (stage 4) may require additional supportive therapy and surveillance for gastroesophageal varices or primary liver cancer. Professional societies now recommend selective screening of high-risk patients to detect MASLD with clinically significant or advanced fibrosis. While guideline details vary, the screening population generally includes those with diabetes, other cardiometabolic factors, or incidentally detected steatosis. Screening begins with blood-based tests; second-line assessment, possibly including noninvasive imaging, seeks to verify MASLD with clinically significant or advanced fibrosis, stratify risk, and inform management. This Special Series Review describes current and best practices for screening adults to detect and stratify MASLD, focusing on imaging's critical and evolving role in addressing this public health challenge.