Primary care evaluation and fibrosis risk assessment of metabolic dysfunction-associated steatotic liver disease: a narrative review

Purpose: This review presents a practical approach to diagnosing and evaluating metabolic dysfunction-associated steatotic liver disease (MASLD) in primary care, emphasizing identification of patients at risk of advanced fibrosis who require further assessment or specialist referral.Current concepts: MASLD has replaced the term nonalcoholic fatty liver disease by incorporating cardiometabolic risk factors as positive diagnostic criteria, while still requiring assessment of alcohol consumption and alternative causes of steatosis. MASLD is often detected incidentally during health examinations or evaluation of mildly elevated aminotransferases. Normal aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels do not exclude clinically significant disease. Because liver fibrosis, rather than steatosis severity, is the principal determinant of long-term liver-related outcomes, risk stratification with noninvasive tests is essential. The fibrosis-4 index (FIB-4), calculated from age, AST, ALT, and platelet count, is the most accessible first-line tool in primary care. A FIB-4 value