Metabolic dysfunction–associated steatotic liver disease assessment and management: Clinical practice guidance from the Canadian Association for the Study of the Liver

Abstract

Metabolic dysfunction–associated steatotic liver disease (MASLD) is a leading and increasingly prevalent cause of chronic liver disease, cirrhosis, hepatocellular carcinoma, and liver transplantation in Canada. This Canadian Association for the Study of the Liver clinical practice guidance provides pragmatic recommendations for MASLD assessment and management across Canadian health care settings. Guidance statements were developed by a multidisciplinary national steering committee using the best available evidence, targeted literature review, expert consensus, and a modified Delphi process. This document summarizes Canadian epidemiology and natural history, nomenclature, identification of populations at increased risk, screening and advanced fibrosis risk stratification, federal and provincial health policy, remote and community care delivery, and management across the MASLD disease spectrum. MASLD screening is recommended for adults with type 2 diabetes mellitus, obesity, cardiometabolic risk factors, hepatic steatosis, family history of MASLD cirrhosis, or persistently abnormal liver tests. A stepwise approach for at-risk populations, using simple blood-based tests, such as FIB-4, followed by imaging elastography or Enhanced Liver Fibrosis score, to rule advanced fibrosis in or out is appropriate. For children with MASLD, a multidisciplinary approach to management is recommended and should include lifestyle counselling, cardiometabolic risk reduction, treatment of obesity and type 2 diabetes mellitus, and approved therapy for non-cirrhotic MASLD as appropriate. The guidance also highlights gaps in Canadian population-level data in disease surveillance; Indigenous, ethnic-diverse, and equity-deserving cohorts; natural history, prevalence, and risk stratification for pediatric MASLD; epidemiology of MetALD; and varying provincial access to non-invasive tests and multidisciplinary care for persons with MASLD.