Global Consensus Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease and Steatohepatitis

Background & Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH) are associated with adverse clinical outcomes, impaired health-related quality of life, and significant economic burden. The growing burden of MASLD and MASH has led to the publication of a large number of MASLD/MASH guidelines by national and international societies. However, important differences among the recommendations have created confusion, contributing to a low implementation rate and suboptimal management of MASLD and MASH. Creating a consensus recommendation has become more important since the approval of a selective agonist of thyroid hormone β receptor (resmetirom) for MASH treatment in the United States. We built a consensus among the most recently published recommendations for MASLD/MASH. Methods: A comprehensive search for MASLD and MASH guidelines, guidance documents, or similar publications from January 2018 to January 2025 using PubMed, Embase, Web of Science, and society websites was conducted. Each selected document was assessed across 8 specific domains with 145 variables. Variables with <50% concordance were used for the Delphi statement development. A supermajority threshold of 67% was set for statement acceptance. Results: There were 61 documents published from 2018 through January 2025. Four rounds of Delphi were conducted: 46 statements were generated for Round 1, 32 statements for Round 2, 16 statements for Round 3, and 8 statements for Round 4, whereby 100% of statements achieved a greater than 90% agreement. All final consensus recommendations were summarized in tables and algorithms. Conclusions: Our study provides an extensive set of recommendations generated based on a comprehensive review of the most recent MASLD/MASH guidelines and a consensus-building process.