Evidence-based clinical practice guidelines for metabolic dysfunction-associated steatotic liver disease (MASLD) 2026
JSGE/JSH (hepatology) · 2026 · Japan
Source and licence
- Authors
- Norio Akuta, Tomomi Kogiso, Kenichi Ikejima et al.
- Title
- Evidence-based clinical practice guidelines for metabolic dysfunction-associated steatotic liver disease (MASLD) 2026
- Journal
- Journal of Gastroenterology, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13219138
Licence statement of the original publication
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Open the original publication →Full text on Europe PMC
Recommendations
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Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as the most prevalent chronic liver disease worldwide, with an increasing number of patients progressing to cirrhosis and hepatocellular carcinoma (HCC). Early identification of individuals at high risk for advanced fibrosis is essential for preventing liver-related events and improving long-term outcomes. This guideline summarizes current evidence and provides practical recommendations for the diagnosis, risk stratification, and management of MASLD in clinical practice. These recommendations were developed through systematic evaluation of the literature and expert consensus. Diagnostic approaches, including noninvasive fibrosis assessment tools, imaging, biochemical testing, and indications for referral to gastroenterology/hepatology specialists, were reviewed. Advanced fibrosis is the major determinant of liver-related morbidity and mortality in MASLD. The Fibrosis-4 (FIB-4) index is a widely accessible and reliable first-line noninvasive tool for fibrosis risk stratification. Patients with elevated FIB-4 values or clinical features suggestive of progressive liver injury should undergo secondary assessment with elastography and be referred to a specialist when appropriate. Liver biopsy is not routinely required for the diagnosis of MASLD but remains essential for establishing a definitive diagnosis of at-risk metabolic dysfunction-associated steatohepatitis (MASH), assessing inflammatory activity, resolving discrepancies between noninvasive tests, and differentiating MASLD from other chronic liver diseases. Lifestyle modification remains the foundation of management, with pharmacological therapy considered for patients with a high likelihood of at-risk MASH. MASLD represents a heterogeneous disease spectrum in which advanced fibrosis is the key prognostic factor. These guideline recommendations aim to standardize clinical practice and support evidence-based management of MASLD in Japan.
Supplementary Information: The online version contains supplementary material available at 10.1007/s00535-026-02408-2.
Contents of the original publication
The section headings of the original.
- Introduction
- Concept and definition of metabolic dysfunction-associated steatotic liver disease (MASLD)
- Diagnostic flowchart for SLD
- Epidemiology
- BQ. Is the risk of liver-related events increased in MASLD?
- BQ. Is there an increased risk of non-liver-related events in MASLD?
- Clinically significant differences between MASLD and MetALD
- Pathogenesis and genomic background
- FRQ. How do genetic factors contribute to MASLD development and progression?
- Diagnosis and risk stratification by noninvasive liver disease assessment
- CQ. Are biomarkers and scoring systems useful for diagnosing and assessing fibrosis and inflammation in MASLD? (Table 3)
- CQ. Are noninvasive steatosis diagnostic methods useful for diagnosing SLD?
- CQ. Is hepatic fat quantification useful for predicting progression of liver disease?
- CQ. Is ultrasound elastography useful for diagnosing fibrosis in MASLD?
- CQ. Is magnetic resonance elastography (MRE) useful for diagnosing fibrosis in MASLD?
- Risk stratification and follow-up flowchart for high-risk liver disease
- BQ. Is a liver biopsy required for the diagnosis of MASLD?
- Criteria for gastroenterological consultation in patients with MASLD
- FRQ. What is the appropriate screening method for liver cirrhosis and liver cancer due to MASLD?
- Follow-up and management of CVD and extrahepatic malignancies
- Treatment
- Pharmacological treatments
- CQ. Are glucagon-like peptide-1 receptor agonists (GLP-1RA) effective for MASLD?
- CQ. Are glucose-dependent insulinotropic polypeptide (GIP)/GLP-1RA effective for MASLD?
- CQ. Are sodium–glucose cotransporter 2 (SGLT2) inhibitors effective for MASLD?
- CQ. Is pioglitazone effective for MASLD?
- CQ. Are lipid metabolism-modifying agents effective for MASLD?
- CQ. Is vitamin E effective for MASLD?
- Surgical treatment
- Comprehensive management
- Other candidate drugs
- FRQ. Is resmetirom effective for MASH?
- Appendix
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