Screening MASH Upstream: Building a Practical, Scalable Algorithm for the Real World

In 'Screening MASH Upstream: Building a Practical, Scalable Algorithm for the Real World,’ Nadege Gunn, MD delves into the following critical question:

1. There is growing interest in screening for MASH further upstream. What would a practical, scalable screening algorithm look like in your view, and what are the limitations of that approach?

Gunn outlined a tiered, scalable MASH screening algorithm anchored by the FIB-4 score as the recommended first-step tool across multiple guidelines from the liver, gastrointestinal, endocrine, and cardiology communities. It is a simple calculation using AST, ALT, platelets, and age that yields an actionable number, with a result of 1.3 or higher signaling potential at-risk fibrosis and the need for further evaluation, and that can be performed universally regardless of clinical setting or geographic location. She also described the second tier of the algorithm for patients with abnormal FIB-4 results, noting that elastography is a preferred next step where available, providing quantification of both liver stiffness and fat content, while the Enhanced Liver Fibrosis test offers a validated blood-based alternative for settings where elastography is not accessible. Gunn further clarified that an abnormal secondary test should prompt referral to a hepatologist or gastroenterologist experienced in MASH for definitive diagnosis and care linkage, while acknowledging that patients with early disease and no competing processes can often be managed effectively in the primary care setting, reinforcing that the FIB-4 remains the cornerstone of any population-based screening strategy precisely because of its scalability.

Throughout the conversation, the experts provide a comprehensive reflection on the field and the factors that may shape how clinicians approach care moving forward.

Our next episode, 'Risk Stratification and Weight Loss as Therapy: A Hepatologist's Framework for Managing MASH Progression,' further explores obesity and MASH with Nadege Gunn, highlighting the clinical and metabolic risk factors she uses to stratify patients most likely to experience fibrosis progression, and what the evidence tells us about the relationship between meaningful weight loss and hepatic outcomes.