Recently the name of this disease has been changed to ‘Rog’. Metabolism Disease-related steatotic liver disease (MASLD). M.A.S.L.D. The presence of fat in the liver detected on any imaging modality (usually liver ultrasonography) and the presence of any one of five cardio-metabolic criteria:
body mass index ≥ 24 kg/m2 or WC > 90 cm (M) 80 cm (F), defined as BMI subgroup;
fasting serum glucose ≥ 5.6 mmol/L or 2-hour postload glucose level ≥7.8 mmol/L or HbA1c ≥5.7 % or diagnosis of DM or treatment for DM, defined as DM subgroup;
blood pressure ≥130/85 mmHg or specific antihypertension treatment, defined as the HT subgroup;
Plasma triglycerides ≥1.70 mmol/L or lipid-lowering treatment, defined as the TG subgroup;
Plasma HDL ≤1.0 (M) and ≤1.3 mmol/L (F) or lipid-lowering treatment, defined as HDL subgroup.
While the corollary for NASH has been retained as Metabolic Disease Associated Steatohepatitis (MASH) to reflect its importance as a pathophysiological condition and its impact on the general population, an entity “Metabolic Disease Associated-Alcohol Induced Liver Disease (Met-ALD)” describes MASH These changes highlight issues such as the term ‘fatty’ being considered a stigmatizing term that prevents patients from seeking appropriate medical help when needed; and, how metabolic dysfunction/inability is directly related to adverse outcomes associated with disease, treatment, and management.
Symptoms and identification
MAFLD, including MASH, is often asymptomatic. If symptoms do occur, they may include fatigue, malaise, and pain or discomfort in the upper right part of the abdomen, where the liver is located. These symptoms are vague and can easily be overlooked, increasing the likelihood of the disease being asymptomatic.
As MASH progresses, particularly when it leads to cirrhosis (severe scarring of the liver), more noticeable symptoms may develop.
These may include the following:
Itchy skin
swelling of the abdomen (ascites)
Difficulty in breathing
Swelling in the legs
spider-like blood vessels just below the skin surface
Enlarged spleen
Red Palms
Yellowing of the skin and eyes (jaundice)
MASH often goes undiagnosed until routine blood tests detect abnormal liver enzymes or imaging studies show fatty liver. The most definitive way to diagnose MASH is through a liver biopsy, in which a small sample of liver tissue is examined for signs of fat, inflammation, and damage. However, this method is invasive, expensive, and unsuitable for routine monitoring.
Recent advances have led to the development of non-invasive imaging biomarkers that can predict the severity of liver steatosis and fibrosis. These imaging techniques such as FibroScan, MRI and ultrasound-based methods offer promising alternatives to liver biopsy, although they have yet to be universally adopted as standard diagnostic tools.
Risk factors for MASH
The risk factors are primarily cardio-metabolic factors. The main factor inducing all these metabolic diseases (diabetes, hypertension, high cholesterol) is insulin resistance and mitochondrial dysfunction. A disordered gut microbiome may also play a role in the development of MASH. Obesity around the abdomen is also a significant risk factor. However, MASH can also be observed in lean individuals (LEAN MASH) indicating the diverse and complex mechanisms behind this disorder. Hypertension, metabolic syndrome, polycystic ovary syndrome (PCOS), and certain genetic predispositions may also contribute to the high prevalence of MAFLD in the general population.
Treatment and Management
To manage MASH, focus on making lifestyle changes to improve liver health. Losing weight through healthy eating, exercise, and positive behavior changes can help. Studies have shown that even a modest weight loss of 7-10% can significantly improve liver condition by reducing fat, inflammation, and scarring.
Changing your diet is important to control 2MASH. Eating less saturated fat, refined carbohydrates and added sugar, as well as eating more fruits, vegetables, whole grains and healthy fats such as omega-3 fatty acids, can help reduce liver fat and inflammation. Regular physical activity, such as aerobic and resistance exercise, improves the body’s response to insulin and helps with weight loss.
Research is ongoing into medications for MASH, particularly for people who do not respond to lifestyle changes or who have liver scarring. These medications improve the way the body uses insulin, processes fats, reduces stress, and reduces inflammation. However, these medications are at best supportive. The most reliable treatment option is to change the body’s metabolic state by adopting lifestyle and dietary habits that work toward reducing metabolic risk.
In severe cases, such as when MASH progresses to cirrhosis, a condition in which liver function is compromised, liver transplantation is the only curative option.
conclusion
MASH is a significant liver disease that is highly prevalent, almost at epidemic levels. More importantly, it can lead to serious health problems if left untreated. Early identification and intervention is crucial to prevent progression to cirrhosis and liver failure. While lifestyle changes are essential for treatment, ongoing research into drug therapies offers the possibility of more effective management options in the future. However, a deeper understanding of the disease and its causative factors can result in taking proactive steps to mitigate them. Since the effectiveness of these steps (lifestyle modifications) is only through long-term sustainability, it is imperative to adopt these practices as habits and maintain them rather than looking at them through the narrow lens of a short-term ‘cure’.
(Article courtesy: Dr. Harshvardhan Rao B, Senior Consultant – Department of Medical Gastroenterology, Ramaiah Memorial Hospital)
