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Liver· Chapter 21

Steatotic Liver Disease

MASLD per the Rinella criteria, MetALD versus alcohol-associated bands, FIB-4 and FibroScan thresholds for staging, resmetirom (Rezdiffra) approval scope, the GLP-1 and dual-incretin trials in MASH, severe alcoholic hepatitis (STOPAH), early liver transplantation criteria, and HCC surveillance once cirrhosis lands.

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What this chapter covers

  • Section 21.1: MASLD nomenclature and cardiometabolic criteria

    The 2023 multi-society Delphi consensus retired the NAFLD and NASH labels in favor of a positive, mechanism-anchored nomenclature that names what the disease is rather than what it is not.

  • Section 21.2: MASLD pathophysiology, lean MASLD, cryptogenic cirrhosis

    MASLD is fundamentally a disease of insulin resistance with genetic susceptibility layered on top, and the histologic phenotype reflects the failure of the hepatocyte to keep up with a steady oversupply of fatty acids.

  • Section 21.3: Noninvasive fibrosis assessment in MASLD

    The clinical question in any MASLD patient is not whether there is steatosis but whether there is advanced fibrosis, because fibrosis stage is what predicts liver-related mortality.

  • Section 21.4: Lifestyle and bariatric surgery

    Lifestyle modification is the only intervention with histologic-improvement evidence across the MASLD spectrum, and the dose-response of weight loss to liver outcomes is one of the few precise numbers in hepatology.

  • Section 21.5: MASLD pharmacotherapy

    The MASLD pharmacotherapy field changed dramatically in March 2024 when resmetirom became the first FDA-approved drug for MASH.

  • Section 21.6: Alcohol-associated liver disease spectrum

    Alcohol-associated liver disease is a continuum from steatosis through alcoholic steatohepatitis to fibrosis to cirrhosis, with each stage carrying a different reversibility profile and a different management implication.

  • Section 21.7: Severe alcoholic hepatitis and STOPAH

    Severe alcoholic hepatitis is the acute clinical syndrome that sits on top of underlying ALD and that demands a structured diagnosis and a structured management.

  • Section 21.8: Early liver transplantation for severe AH

    Severe alcoholic hepatitis that does not respond to corticosteroids carries a 6-month mortality of 70 to 80 percent without further intervention, and the historical answer to that mortality was that liver transplantation was not an option until the patient demonstrated 6 months of abstinence.

Podcast episodes

  1. 01

    MASLD: Diagnosis Through Pharmacotherapy

    MASLD from the cardiometabolic-criteria positive diagnosis through pharmacotherapy: lean disease and cryptogenic cirrhosis as the same entity, noninvasive fibrosis assessment, lifestyle and bariatric surgery, and the new drugs including resmetirom.

  2. 02

    Associated Liver Disease and Early Transplant

    The spectrum from steatosis to alcoholic hepatitis to cirrhosis, severe alcoholic hepatitis identified by the Maddrey function or MELD with prednisolone after infection is excluded, the day-seven Lille response decision, and early transplant for selected patients.