Curation log — MASLD¶

Newest entries first. Every content-changing session appends an entry: date, what changed, what was searched, follow-ups for next time. See CLAUDE.md.

2026-11-01 — periodic literature sweep (Codex; independent auditor pending)¶

Window and searches. Publications from 2026-10-25 through 2026-11-01 inclusive, with a second PubMed Entrez-date pass to catch newly indexed records. Live E-utilities ESearch/EFetch covered the old/new-vocabulary union (MASLD OR MASH OR NAFLD OR NASH OR "steatotic liver disease" OR "fatty liver" OR steatohepatitis) in title/abstract. Thirteen topic searches covered definitions/alcohol, burden, mechanisms/genetics, non-invasive assessment/histology, natural history/cirrhosis, lifestyle, surgery, thyromimetics, incretins, other drugs, extrahepatic/HCC outcomes, special populations, and guidelines/patient experience, plus the broad union. Every topic and the union had a parallel "Cochrane Database Syst Rev"[jour] query on both date fields: all 28 dated CDSR queries returned zero. The broad publication-date search returned 328 records and the Entrez-date search 254; the combined topic/union retrieval held 467 distinct PMIDs. These are database hits, not eligible studies. Four additional targeted PubMed follow-ups checked AZD2693, rapirosiran, EASL targeted-therapy guidance and WHO policy implementation. Exact queries, translations, IDs, Europe PMC records and registry checks are in the sweep manifest.

Beyond PubMed. Europe PMC REST ran the same 13-topic plus broad sweep using FIRST_PDATE:[2026-10-25 TO 2026-11-01]; its broad query returned 113 records. Non-PMID results included preprints, acronym noise and a PMC counterpart of a PubMed record; none warranted a DOI-only addition. Europe PMC core metadata was checked for selected records' full-text availability. Its full-text XML endpoint supplied the All of Us paper even though the search metadata had not supplied its PMC link; the cohort includes mixed/uncertain aetiologies and is not a population estimate of confirmed MASLD. OpenAlex DOI lookups sought full-text routes for LITMUS and Baveno VIII. The Baveno publisher and three institutional routes returned 403; LITMUS publisher returned 403 and the repository landing page supplied no text. No detailed new thresholds or diagnostic-performance estimates were inferred. Crossref was queried without a personal email; every added paper, and inherited citations on modified lines, passed both PubMed publication-type and Crossref updated-by checks. Unpaywall was skipped because LIFEBANK_CONTACT_EMAIL is unset.

Trials. ClinicalTrials.gov v2 re-fetched all 68 NCT IDs present in this condition's Markdown. Against the previous manifest, no tracked study changed overall status, enrolment or primary-completion date. The important change is AZD2693 phase 2 (NCT05809934): results were first posted 2026-10-28. NASH resolution without fibrosis worsening occurred in 4/73 (25 mg), 1/69 (50 mg), and 5/74 (placebo); neither dose was superior (P=0.783 and 0.116). Fibrosis improvement without NASH worsening was 12/73, 6/69 and 8/74 (P=0.320 and 0.693). ALT >3×ULN was tabulated in 18/73, 33/69 and 10/74; these are laboratory abnormalities, not adjudicated drug-induced liver injury. Registry enrolment remains 220 while the flow/outcome/safety groups total 216; the discrepancy is preserved. The results are registry-submitted, not a peer-reviewed phase 2 report: live AZD2693[Title/Abstract] still returned only the phase 1 publication. MAESTRO-NASH OUTCOMES (NCT05500222), MAESTRO-NASH (NCT03900429) and ESSENCE (NCT04822181) still have no posted registry results. The two LIVERAGE records (NCT06632444 and NCT06632457) were updated 2026-10-28 and remain recruiting without results.

Non-US registries and access limits. ISRCTN REST returned all 96 records for the vocabulary query after setting limit=1000 (the default returns only ten). One was updated in the window, ISRCTN17863382, the cross-aetiology PROMISE cirrhosis/FMT trial; it supplied no new MASLD-specific efficacy result. The WHO ICTRP homepage returned 200, but the actual vocabulary query returned 403, so no completed WHO search is claimed. An AZD2693 CTIS search page returned 200 but no structured trial result was extracted. ChiCTR, CTRI and EudraCT were not separately searched. Cochrane Library/CENTRAL was not searched (403). SciELO and the LILACS search endpoint were inaccessible (403; LILACS homepage was a maintenance page). No absence of Latin American or MENA evidence is inferred, including for OQ-7.

Guidelines, burden and patient organisations. Checked the AASLD MASLD guidance listing, NICE NG49, KASL and ALEH; attempted EASL/APASL index routes returned 404, supplemented by targeted web/PubMed searches. Checked WHO's WHA79 governing-body resolution list and SLD resolution directly, as well as WHO GHO and IHME GBD portals. Four documents warranted catalogue entries: Taiwan GEST–TASL–TMASO MASLD/obesity position statement (PMID 42922180), Madrid Declaration (PMID 42929259), Baveno VIII (PMID 42624290), and the 29 September EASL–EASD–EASO targeted-therapy guidance (PMID 42805503). The latter predates the window and was missing from this condition; Baveno VIII surfaced through its November issue date despite earlier online publication. Detailed recommendations remain pending full-text appraisal. The original Spanish Madrid declaration was retrieved, but a declaration calling for national policy is not evidence that such a policy has been implemented. The registry's old assertion that no guideline adopted obesity-adjusted portal-hypertension models is now marked [unverified] pending Baveno VIII appraisal. The GBD 2023 MASLD burden paper (PMID 41990758), also earlier than the window and missing from the bibliography, was catalogued without importing abstract estimates into the statistics tables. No new dated burden statistic survived table-level triage.

American Liver Foundation pages were blocked on direct retrieval; its ECHO listing was search-result verified but is professional education, not new patient-experience evidence. Retrieved Global Liver Institute and ELPA news, the ELPA prevention-village and MASLD policy-event pages; checked Liver UK routes (404/403). No dated new MASLD patient-organisation source warranted an addition. The NIDDK treatment page was retrieved and remains last reviewed April 2021, with its outdated statement that no medicines are approved. No patient-voice synthesis was changed.

Triage and changes. Added 11 bibliography records, four cited only for document identity/scope on wiki/guidelines.md and seven bibliography-only: LITMUS (PMID 42956772), Global NAFLD/MASLD Registry symptom burden (PMID 42925568), prospective DM-FibroScan outcomes (PMID 42935238), All of Us implementation (PMID 42920888), miricorilant phase 1b (PMID 42929711), HERALD/ALG-055009 (PMID 42648297; November issue, earlier online), and the older GBD analysis. No landmark deep note. Most retrieved papers were preclinical, off-topic, routine reviews or small surrogate/association studies and received no entry. An Expression of Concern notice was excluded; its target is not in this condition's bibliography.

Updated wiki/genetics.md, wiki/clinical-trials-landscape.md and STATISTICS.md with the posted AZD2693 results and denominators; updated wiki/guidelines.md and guidelines/REGISTRY.md with the four documents. OQ-3 now separates target engagement from demonstrated histological benefit; OQ-39 flags the new LITMUS report for reassessment of its older analyte/biopsy conclusion without importing abstract-only performance figures. INDEX.md and bibliography counts were reconciled: 393 bibliography records, 373 wiki-cited; 59 guideline-registry rows; 13 curated and nine draft wiki pages. Every edited content page has last-curated: 2026-11-01; the three edited wiki pages and edited reference layers are draft. No page was promoted. The log and the manifest are the remaining changes; no other condition was touched.

Validation and handoff. Re-fetched all PMIDs appearing on added/modified citation lines; checked both retraction sources, bibliography uniqueness/coverage, registry-table figures, page metadata and local links. This is a consistency check, not the independent audit. No publishing, deployment or git command was run, as requested. Author: Codex; auditor: pending, must be a different engine.

Next sweep. Seek the AZD2693 phase 2 manuscript/protocol analysis to explain low histological response, ALT abnormalities and the 220/216 denominator difference; continue MAESTRO-NASH OUTCOMES and ESSENCE monitoring and the rapirosiran discrepancy. Obtain full text for LITMUS, Baveno VIII, EASL targeted-therapy guidance, Taiwan position statement and the GBD analysis before replacing detailed recommendations/statistics; check the newly retrieved G-MASLD erratum against the regional-accuracy figures. Reattempt PEth, fazpilodemab and aMAP full texts (this session re-fetched their PubMed records, but established no new full-text route; PEth BMJ returned 403). Track actual WHA79.4 implementation reports and national NCD strategies, using the governing-body list rather than generic WHO home-page probes. Recheck NIDDK and regional/non-US registry access. Regional transportability conclusions remain bounded by unavailable SciELO/LILACS searches.

2026-10-25 — periodic literature sweep (Claude; auditor pending)¶

Window and sources. Publications from 2026-10-18 through 2026-10-25. PubMed E-utilities ESearch/ESummary/EFetch ran live on the union (MASLD OR MASH OR NAFLD OR NASH OR "steatotic liver disease" OR "fatty liver" OR steatohepatitis)[Title/Abstract]. Each query ran twice: once on [Date - Publication], which gave 78 broad hits, and once on [Date - Entrez], which gave 138. The second run catches records indexed this week that carry a later issue date. The two runs together held 144 unique PMIDs. Thirteen topic queries each had a parallel "Cochrane Database Syst Rev"[jour] filter. Every Cochrane filter returned 0 on both date fields, so no CDSR review appeared in the window. Exact queries, translations and IDs are in the sweep manifest. All counts are database hits, not eligible studies.

Europe PMC REST (FIRST_PDATE 2026-10-18 to 2026-10-25) returned:

Query	Hits
Broad	79
Not in MEDLINE	24
Preprints	18
CDSR journal	0

Most preprint and non-MEDLINE hits were acronym noise, such as "Nash equilibria". One linafexor-plus-semaglutide medRxiv preprint was seen and not added, because it is not peer reviewed. Europe PMC was also used to establish full-text availability.

Retraction checks covered every added record, in both PubMed publication types and Crossref updated-by. Neither showed a retraction or expression of concern. One gap: Crossref returned HTTP 404 for the DOI of PMID 42900157, which appears not yet to be registered, so only its PubMed check was completed. Unpaywall was skipped because LIFEBANK_CONTACT_EMAIL is unset, and no email was sent to Crossref.

Trials. ClinicalTrials.gov v2 re-fetched all 66 NCT IDs this condition cites, plus NCT04171765 and NCT07338331. No cited trial posted results. Across the whole union, no study had results first posted in the window. One material change: NCT06419374 (pegozafermin in compensated MASH cirrhosis) raised its estimated enrolment from 762 to 1,800, with primary completion 2028-06-30, in an update posted 2026-10-23.

The outcome-trial watch is unchanged:

Trial	Status	Results posted	Notes
NCT05500222 (MAESTRO-NASH OUTCOMES)	active, not recruiting	no	primary completion 2026-12
NCT03900429 (MAESTRO-NASH)	active, not recruiting	no
NCT04822181 (ESSENCE)	active, not recruiting	no
NCT05809934 (AZD2693)	completed	no
NCT04565717	terminated	—	enrolment 6
NCT06168383 (simedeutirom)	completed	no

Union snapshot: 2,089 total, 184 interventional recruiting, 115 phase 3 interventional and 18 phase 3 recruiting. On 2026-10-18 the same counts were 2,084, 185, 115 and 18.

Other registries: - ISRCTN API: 98 MASLD-vocabulary records. Two were updated in the window, ISRCTN13789886 (bimekizumab in psoriatic disease) and ISRCTN68931598 (INT-747 in PBC). Neither is in this corpus. - WHO ICTRP: the portal returned 200 but is JS-driven, so no search was completed. - ChiCTR, CTRI and EudraCT: not queried.

Blocked and probed sources. - Blocked: Cochrane Library/CENTRAL (HTTP 403), SciELO (HTTP 403), LILACS (timed out). None of them was searched, and no claim is made about absent regional evidence. - Society and patient-organisation probes: AASLD 200, NICE NG49 200, ELPA 200, EASL CPG URL 404, American Liver Foundation 403, Global Liver Institute 403. No new dated society guideline was found. - The NIDDK treatment page was retrieved 2026-10-25. It is still "Last Reviewed April 2021" and still says "No medicines have been approved to treat NAFLD—either NAFL or NASH".

The most important find was not in the window. The full text of a new awareness letter (PMID 42900157) refers to a 2026 World Health Assembly resolution. It was verified at source: WHA79.4, "Steatotic liver disease: a missing piece in the global noncommunicable disease response", adopted 22 May 2026, following Executive Board resolution EB158.R1 of 3 February 2026. Both PDFs were read from apps.who.int. This condition had no record of either, although the 2026-10-11 and 2026-10-18 sweeps both probed WHO pages. The miss is a gap in the probes, not a fault of the window. WHA79.4 is a policy resolution with no clinical thresholds. It does date the claim, cited on two pages from the 2022 public-health consensus (PMID 34707258), that the disease is absent from international NCD strategies.

Triage. Of 144 PubMed records, most were preclinical or off-topic. What survived:

Wiki edits: - Jamialahmadi 2026 (PMID 42907524, Nat Genet; full text read): - 60-locus MRI-PDFF GWAS in 71,488 people; SNP heritability 25%. - Polygenic score, highest vs lowest decile: cirrhosis OR 2.71, HCC OR 7.47. - Limits: European ancestry only, and only 14 of the 31 new loci were Bonferroni-supported in clinical MASLD. - Added to genetics.md (heritability and PRS tables) and noted in OQ-3. - Xu 2026 (PMID 42904608, Liver Int; abstract only): - aMAP in 156,406 UK Biobank participants with SLD: C-index 0.80. - A refined cut-off (>64) picked out a subgroup with 15-year HCC incidence of 3.08–5.35%. - Added to the surveillance-stratifier table in masld-related-hepatocellular-carcinoma.md and noted in OQ-5. - Sanyal 2026 (PMID 42892346, NCT04171765; abstract plus registry, full text unreachable): - Fazpilodemab phase 2: 46 randomised, 23 biopsied, terminated "due to strategic business reasons". - The authors draw no efficacy conclusion. - Added as a row in other-pharmacotherapy.md. - Shumbayawonda 2026 (PMID 42911297, RADIcAL-1 EQ-5D; full text read): - Each 80-ms rise in cT1: anxiety/depression OR 1.29 (1.01–1.61), utility 0.023 lower. - No difference between trial arms. - Added to the quality-of-life section of patient-experience-and-advocacy.md and to patient-voice/sources.md. - White 2026 (PMID 42900157, research letter; full text read): - 1,000 at-risk US adults, February 2026: 13% recognised "MASLD" and 60% "fatty liver disease". - Added to the awareness section of patient-experience-and-advocacy.md, to that page's portal open question, to OQ-16 and to patient-voice/sources.md. - WHA79.4: - New row and per-document note in literature/guidelines/REGISTRY.md, plus a watch-list row for the first biennial implementation report. - Added to the documents table and the "who owns the patient" paragraph of guidelines.md, and to the awareness section of patient-experience-and-advocacy.md. - NCT06419374: enrolment corrected in clinical-trials-landscape.md and noted in STATISTICS.md §12.

Bibliography only: - Torgersen 2026, SLD and HCC or decompensation by HIV status, VACS (PMID 42898815). - Fan 2026, California chronic-liver-disease hospitalisation burden (PMID 42892919). Its MASLD-specific figures are not in the abstract, so nothing went into STATISTICS.md. - Abdel Monem 2026, a single-arm SGLT2-inhibitor meta-analysis (PMID 42914763). - Hamed 2026, aspirin vs dapagliflozin, n=80 (PMID 42900372). Its registry, NCT07338331, was posted after the listed primary completion and names three agents, while the report describes two arms. - Zhao 2026, eHealth lifestyle meta-analysis (PMID 42893986). - Luo 2026, phenotyping systems and lifestyle response (PMID 42918741). - Kim 2026, accelerometer-measured physical activity and cardiovascular mortality (PMID 42893825).

Seen and not added: - An erratum (PMID 42900895) to an ELF meta-analysis this condition does not cite. - A JAMA Insights on paediatric MASLD (PMID 42905722) with no abstract. - A JAMA news feature (PMID 42912403).

No landmark note was written.

Statuses. - other-pharmacotherapy.md and masld-related-hepatocellular-carcinoma.md went from curated to draft, because their new rows rest on abstracts. - genetics.md and clinical-trials-landscape.md were already draft. - guidelines.md and patient-experience-and-advocacy.md were kept curated. Every added sentence was checked against a primary full text read in this session: the WHA79.4 PDF and the Europe PMC full texts of PMIDs 42911297 and 42900157. Pre-existing content on those pages was not re-verified, and the auditor should confirm or demote. - INDEX.md: the page-status column was out of step with the frontmatter for six pages, four of them from earlier sessions. It now matches. The registry count was corrected from 52 to 54 rows.

What changed. - Wiki pages: wiki/genetics.md, wiki/masld-related-hepatocellular-carcinoma.md, wiki/other-pharmacotherapy.md, wiki/clinical-trials-landscape.md, wiki/guidelines.md, wiki/patient-experience-and-advocacy.md. - Literature layer: literature/BIBLIOGRAPHY.md (12 records; total 382, of which 369 are wiki-cited, recounted against the pages), literature/guidelines/REGISTRY.md, literature/statistics/STATISTICS.md §12, literature/patient-voice/sources.md. - Also: OPEN-QUESTIONS.md (OQ-3, OQ-5 and OQ-16 sharpened; no absence query re-run), INDEX.md, this log, and literature/sweeps/2026-10-25.json.

Next sweep. - Check MAESTRO-NASH OUTCOMES (NCT05500222), whose primary completion is 2026-12. - Look for a full-text route to the fazpilodemab and aMAP papers, and verify the abstract figures against their tables. - Watch for the first WHA79.4 implementation report, and for any national NCD strategy that names SLD. - Re-check the NIDDK page. - Recheck PEth (PMID 42850047). - Watch for the AZD2693 publication and the rapirosiran enrolment discrepancy. - Find a probe that would have caught WHA79.4 in time. WHO governing-body resolution lists are not covered by any current sweep step. - Any regional transportability claim still needs SciELO/LILACS access.

Provenance. Every PMID in this entry and in the edits came from a live PubMed E-utilities query in this session. Every NCT ID came from the ClinicalTrials.gov v2 API in this session. The WHO documents were retrieved from apps.who.int on 2026-10-25. Author: Claude. Auditor: pending — must be a different engine.

2026-10-18 — periodic literature sweep (Grok; auditor pending)¶

Window and sources. Publications dated 2026-10-07 through 2026-10-18 inclusive. Live PubMed E-utilities ESearch/ESummary/EFetch on the old/new-name union (MASLD[Title/Abstract] OR MASH[Title/Abstract] OR NAFLD[Title/Abstract] OR NASH[Title/Abstract] OR "steatotic liver disease"[Title/Abstract]). The broad fielded query returned 150 records (3 already in the bibliography; 147 new). Twelve topic searches plus Cochrane-journal filters on each, a CDSR union, and three follow-up queries (PEth; AZD2693/rapirosiran/ALN-HSD/ALN-PNP; MAESTRO-NASH/ESSENCE/clinical outcomes). Every Cochrane-journal filter in the window returned 0. Exact queries, translations, IDs and NCT checks are in the sweep manifest. These are database hit counts, not eligible-study counts.

Europe PMC REST: broad FIRST_PDATE window 233 hits (100 returned); nomenclature 96; guidelines 90; CDSR journal 0; SRC:PPR preprints 21. Free-text acronym matches included unrelated material. Crossref updated-by was checked for every record added; PubMed publication types were checked for Retracted Publication / Expression of Concern. Unpaywall was skipped because LIFEBANK_CONTACT_EMAIL is unset; no personal email was sent to Crossref.

Trial and other-source checks. ClinicalTrials.gov v2 returned all 65 NCT records already cited by this condition, plus NCT06168383 (simedeutirom phase 2b). Union snapshot 2026-10-18: 2,084 total, 185 interventional recruiting, 115 phase 3 interventional, 18 phase 3 recruiting (was 2,056 / 181 / 112 / 17 on 2026-09-02). filter.studyType=INTERVENTIONAL returns HTTP 400 on this API; counts used query.term AREA[] syntax. Outcome-trial watch: NCT05500222, NCT03900429 and NCT04822181 remain without posted results (ESSENCE last updated 2026-10-13, still ACTIVE_NOT_RECRUITING). NCT05809934 still completed, no results posted. NCT04565717 still terminated, actual enrolment 6. NCT06168383 completed (n=186 actual) with no registry results section. Recruiting-status updates inside the window (NCT06215716, NCT06528314, NCT06632444, NCT06632457, NCT05519475, NCT07165028) did not post results.

ISRCTN REST API: 0 records lastUpdated 2026-10-07 to 2026-10-18 for MASLD/NAFLD/NASH/MASH. WHO ICTRP portal returned HTTP 200 but is JS-driven; no programmatic search was completed. ChiCTR and CTRI homepages returned 200; no structured query was possible. Cochrane Library cochranelibrary.com HTTP 403. SciELO HTTP 403. LILACS timed out. No absence claim about Latin American regional literature is made.

Society/guideline/patient-org probes: AASLD, EASL, NICE NG49, APASL, ALEH, KASL, GBD, WHO GHO, American Liver Foundation, Global Liver Institute, ELPA, Liver UK returned 200. ADA Standards HTTP 403. NICE NG49 remains titled MASLD (already catalogued 2026-09-02); no new dated society guideline survived triage. NIDDK NAFLD/NASH treatment page still last reviewed April 2021 and still states "No medicines have been approved to treat NAFLD—either NAFL or NASH" (retrieved 2026-10-18).

Triage. One Expression of Concern in the window (PMID 42872615, Afonso necroptosis paper) is not in this condition's corpus. The PEth paper (PMID 42850047) still has no PubMed abstract; findings not inferred. VK2809/VOYAGE absence re-run: 9 records, still no peer-reviewed VOYAGE phase 2b efficacy report. AZD2693 title/abstract search still returns only PMID 39798707.

Survived:

Xue 2026 (PMID 42887516, NCT06168383) — simedeutirom (HSK31679) 52-week Chinese phase 2b, MASH improvement without fibrosis worsening 37% (80 mg) and 30% (160 mg) vs 10% placebo. Wiki: resmetirom-and-thyromimetics.md, clinical-trials-landscape.md. Primary endpoint is not the FDA co-primary pair.
Anouti 2026 (PMID 42869334) — UNOS 19,756 MASH recipients, 12.3% lean; waitlist transplant sHR 0.94; 1-year mortality HR 1.33. Wiki: lean-masld.md.
Bibliography only: Park 2026 nationwide SLD-subtype mortality (PMID 42880865); Samala 2026 saroglitazar PCOS+MASLD liver-fat RCT (PMID 42879243); Ng 2026 statins in cACLD (PMID 42873450). None yet warrants a wiki claim.

No landmark literature/notes/ addition. OPEN-QUESTIONS.md and literature/guidelines/REGISTRY.md unchanged. No new patient-voice source.

What changed. wiki/resmetirom-and-thyromimetics.md (curated → draft); wiki/lean-masld.md (curated → draft); wiki/clinical-trials-landscape.md (already draft; registry snapshot and simedeutirom row); literature/BIBLIOGRAPHY.md (5 records; total 370 / 364 wiki-cited); literature/statistics/STATISTICS.md §13.13; this log; literature/sweeps/2026-10-18.json.

Next sweep. Recheck PEth full text (PMID 42850047); watch MAESTRO-NASH OUTCOMES (primary completion still December 2026), ESSENCE, AZD2693 phase 2 publication, rapirosiran enrolment discrepancy; whether simedeutirom enters phase 3; NIDDK public page still asserting no approved medicines. Any regional transportability claim still needs SciELO/LILACS access.

Provenance. Every PMID written in this entry was retrieved from a live PubMed E-utilities query in this session. Every NCT ID was retrieved from the ClinicalTrials.gov v2 API in this session. Added records were checked against PubMed publication types and Crossref updated-by; none carried a retraction. Author: Grok. Auditor: pending — must be a different engine.

2026-10-07 — dot D9's absence claim was false; the two head-to-head comparisons added (Claude)¶

What prompted this. The novelty gate assessed D9 with three engines. All three returned pre-empted. Verdicts: novelty/masld/D9-{claude,codex,grok}.md.

What was wrong¶

D9 claimed metabolic surgery and incretin therapy "have never been compared, and only one has outcome data". Both halves are false, and the papers were cited nowhere in this repository:

Stupalkowska 2026 (PMID 41969188) — TriNetX, MASLD with type 2 diabetes, 2018–2023, surgery vs semaglutide. Major adverse liver outcomes HR 1.63 (95% CI 1.12–2.37), driven by Roux-en-Y (2.01, 1.26–3.20) and not sleeve (0.97, 0.52–1.78); new cirrhosis 0.46 (0.29–0.73) after excluding pre-existing cirrhosis; MACE 0.51 (0.38–0.67); heart failure 0.41 (0.27–0.62); obesity-associated cancer 0.56 (0.34–0.92); all-cause mortality no overall difference but Roux-en-Y 1.64 (1.01–2.67).
Wu 2025 (PMID 40668509) — TriNetX, MASLD with obesity, 6,199 propensity-matched pairs, tirzepatide vs bariatric metabolic surgery. Composite of death/MACE/MAKE/MALO HR 0.47 (0.36–0.61) favouring tirzepatide; all-cause mortality 0.36 (0.21–0.63); MAKE 0.32 (0.21–0.49); MALO 0.32 (0.22–0.48).
Grok additionally noted that GLP-1 receptor agonists have their own published liver-outcome literature, so "only one has outcome data" was independently wrong.

What changed¶

D9 rewritten. Its Dot B now carries both comparisons with their effect sizes, and the junction states plainly that the original claim was false and is corrected, leaving the narrower residual: both comparisons are retrospective EHR cohorts whose hepatic direction contradicts the single-arm surgical literature in Dot A, neither enrols biopsy-confirmed fibrotic MASH, and neither separates early post-operative decompensation from long-term benefit. NCT06374875 randomises the comparison in advanced MASH (n≈120) but reports histology only.
Both papers added to literature/BIBLIOGRAPHY.md under bariatric and metabolic surgery, in a dated block recording how they were found.
wiki/bariatric-and-metabolic-surgery.md — new paragraph in "Comparison with drug therapy" reporting both comparisons and the unresolved contrast with SPLENDOR; the open-question bullet claiming "no completed head-to-head trial exists" corrected to distinguish randomised trial from the comparisons that do exist; two references added. Demoted curated → draft.
wiki/glp1-and-incretin-therapy.md — new paragraphs in "Observational evidence on hard hepatic outcomes" covering both, with the extra confounding caveat that routing to surgery versus a drug differs in ways an EHR cannot capture; two references added. Demoted curated → draft.

Searched. No new literature searches; this applies verdicts already on disk. Both PMIDs re-fetched live here and both DOIs checked against Crossref.

Next time. The procedure-specific split — hepatic harm in gastric bypass, absent in sleeve — is consistent across both comparisons and aligns with the bypass-predominant alcohol-use-disorder risk already on the surgery page. That is a mechanistic thread worth a dedicated look, and it bears directly on dot D16, which the gate rated the strongest surviving candidate in this condition.

Provenance. Every PMID written in this entry and in the rows above was retrieved from a live PubMed E-utilities query in this session, and every one was checked for retraction against both the PubMed publication types and the Crossref updated-by field (per the new SOURCES.md rule). All were clean.

Audit status. These edits were authored by Claude Opus 5, which also ran the gate that found the defects. A different engine must therefore audit them before any demoted page returns to curated — a model does not mark its own homework (CLAUDE.md, "Audit").

2026-09-02 — independent audit of Claude depth pass (Codex)¶

Authorship and audit independence. Claude authored the additions in the depth pass immediately below. Codex independently audited them against live PubMed E-utilities and ClinicalTrials.gov v2 records, then made only corrections needed for claim fidelity, provenance, reference closure and status.

Result¶

Re-fetched all 93 PubMed records attributed to the depth pass: 90 page-level additions, two additions to the patient-evidence layer (PMIDs: 37024220 and 39701123), and the literature-only 2026 EASL guidance record (PMID 42617506). All 93 resolved in the same-session E-utilities responses; author, title, journal and year metadata matched after the corrections recorded below.
Re-fetched all 64 NCT IDs present at the start of this audit from the ClinicalTrials.gov v2 API. The care-pathway correction added NCT06671886, also fetched live, bringing the current wiki total to 65.
Re-ran the exact ClinicalTrials.gov condition union (MASLD OR NAFLD OR MASH OR NASH OR "steatotic liver disease"): 2,056 total studies, 181 recruiting interventional studies, 112 phase 3 interventional studies, and 17 recruiting phase 3 interventional studies. The current-count table and linked statistics artifact now use these union counts.
Checked page bodies against page reference lists and literature/BIBLIOGRAPHY.md. Three missing page-reference entries were restored (PMIDs: 39283612, 35677499 and 40467095); final closure is zero missing body-to-reference or reference-to-bibliography PMIDs.
Promoted 20 pages to status: curated. genetics.md and clinical-trials-landscape.md remain draft because PMID 40581300 and NCT04565717 disagree materially on rapirosiran enrolment.

Was the added “depth” evidence or padding?¶

It was predominantly genuine evidence expansion, but not entirely. The immediately preceding independent audit recorded 274 distinct wiki-cited records; Claude's pass added 93 and produced 367, so the depth-pass log's stated baseline of 259 was stale. This audit removed eight citations that served only as publication-existence or review padding (PMIDs: 40759197, 32890594, 35165400, 31337282, 39690310, 37584065, 35899384 and 39136211) and added the corrective care-pathway protocol (PMID 40325466). The final wiki corpus is 360 distinct records: 16.36 records/page, versus 16.68 immediately before this audit and 12.45 before Claude's depth pass. The audited depth pass therefore remains a net expansion of 86 substantive records over its true 274-record baseline.

Corrections made¶

Bounded PEth misclassification to the selected at-risk cohort rather than generalising 39% to all MASLD cohorts; labelled epidemiological and mechanistic explanations as hypotheses where the cited designs were not causal.
Corrected overstatements in the genetics, microbiome, glycaemic-control, GLP-1, surgery, cirrhosis, HCC, pregnancy and guideline sections. In particular, statistical interaction was not translated into a simple multiplicative biological relation, Mendelian randomisation was not treated as automatically free of confounding, and observational adjustment was not described as proof of independence.
Corrected the resmetirom qFibrosis category error: the 24.4-percentage-point result concerns categorical qFibrosis stage, not a continuous-score change. The page also now exposes an additional source-internal inconsistency in PMID 40577015: its abstract says lower discontinuation improves cost-effectiveness while reporting a no-discontinuation ICER of $318,740/QALY versus $140,134/QALY in the base case.
Corrected trial provenance: the dapagliflozin study began in 2018 under NASH-era terminology and was described as MASH in its 2025 report; SPECCIAL and the pregnancy cohort are explicitly identified as retrospective MASLD classifications.
Corrected the LITMUS summary, FGF21 recruiting arithmetic and current registry totals. A newly asserted absence of a randomised care pathway was false: live retrieval found the MCCP cluster-randomised protocol (PMID 40325466; NCT06671886), now cited with its process endpoint and not misrepresented as a completed outcome result.
Corrected bibliography tags for guidance/review records and recalculated coverage: 360 distinct wiki records plus 15 literature-only records equals 375 across wiki and supporting literature.

Exact absence-search audit¶

Every PubMed audit search used the old/new-name union U = (MASLD[Title/Abstract] OR NAFLD[Title/Abstract] OR MASH[Title/Abstract] OR NASH[Title/Abstract] OR "steatotic liver disease"[Title/Abstract]). Exact claim-directed searches included:

Question tested	Exact construction after `U AND`	Result
Published VOYAGE efficacy	`(VK2809[Title/Abstract] OR VK-2809[Title/Abstract] OR VOYAGE[Title/Abstract])`	8; no peer-reviewed VOYAGE phase 2b efficacy report
Dapagliflozin incorporated into guidance	`dapagliflozin AND (guideline OR guidance OR consensus OR recommendation)`	8; none cited the 2025 histology trial as guidance
Obstetric or liver guidance naming pregnancy risk	`(pregnancy OR obstetric OR antenatal) AND (guideline OR guidance OR consensus OR recommendation)`	70; no retrieved guideline identified MASLD as an obstetric risk factor
Randomised non-cirrhotic HCC surveillance	`("hepatocellular carcinoma" OR HCC) AND ("non-cirrhotic" OR precirrhotic) AND surveillance AND (randomized OR randomised OR trial)`	16; no eligible surveillance trial
Formally qualified biomarker	`("biomarker qualification" OR "qualified biomarker")`	2; no qualified MASLD biomarker identified
Randomised clinical care pathway	`("clinical care pathway" OR "care pathway") AND (randomized OR randomised OR trial) AND (outcome OR implementation)`	3; found PMID 40325466, so the asserted absence was retracted
Contemporary paired-biopsy sampling study	`("liver biopsy" OR histology) AND (paired OR sampling OR reproducibility) AND (modern OR contemporary OR prospective)`	466; no eligible modern paired-core remeasurement identified after screening

Two exact ClinicalTrials.gov combinations were also tested under the full condition union: resmetirom AND semaglutide and sequential non-invasive AND clinical outcomes; both returned zero studies. Broad searches that could not support a defensible absence were not used as proof: claims were either bounded to “not retrieved,” converted to open questions, or removed.

Discrepancies deliberately preserved¶

PMID 25935633 reports 193/619 as 33.2%; the page retains the published percentage and the calculated 31.2%.
PMID 37040843 reports 63 studies while its geographic components sum to 64; no invalid fraction was reconstructed.
PMID 40581300 reports rapirosiran Parts A/B n=58/n=46, whereas NCT04565717 reports terminated with actual enrolment 6; both values remain side by side and the two affected pages remain draft.

2026-09-02 — depth pass (Claude). Widening the evidence base, page by page.¶

Why this pass ran. The condition was structurally complete but sourced narrowly: 133 lines and 21 citations per page across 22 pages, and — the measure that mattered — only 12 distinct PubMed records per page across the whole condition, against reference conditions running 15–24. The problem was not page length; it was that the pages recycled one shared pool of 259 records. Lengthening them with the same references would have made the ratio worse. The brief was therefore to bring in records this condition did not previously cite, sourced to each page's own topic.

What changed, in numbers¶

Measure	Before	After
Total wiki lines	2,941	3,581
Mean lines per page	133	163
Mean citations per page	21	25.5
Distinct verified records per page	12	17
Distinct records cited by pages	259	367
Records in `BIBLIOGRAPHY.md`	274	368 (93 added)
Open questions	30 (18 Tier 1 / 12 Tier 2)	43 (23 / 20)
Dots not yet connected	12	19
Guidelines catalogued	47	52
Documented statistical conflicts	12	21

All 22 pages were extended; none was rewritten and no verified content was deleted. Every page is status: draft and awaits re-audit by a different engine.

Search discipline¶

Every search unioned old and new vocabulary — (MASLD OR NAFLD OR MASH OR NASH OR "steatotic liver disease") or a topic-appropriate equivalent containing both naming systems. Roughly 45 distinct PubMed E-utilities searches were run (esearch + esummary + efetch), plus three ClinicalTrials.gov v2 API queries. Every one of the 93 new PMIDs was retrieved by live query in this session and its author list, journal, year, volume, pages and abstract read via efetch before being written. Two citations were caught mid-pass where a detail had been supplied from memory rather than from the record (an author list and a page number) and were corrected against efetch output before the file was finalised; the working rule for the remainder of the pass was that nothing goes into a reference line that did not come from the fetched record.

The three disclosed source-internal discrepancies were preserved¶

Verified present and unaltered at the end of the pass:

PMID 25935633 — 193/619 stated as 33.2% where the quotient is 31.2%; both shown deliberately.
PMID 37040843 — 63 studies whose geographic components sum to 64; the "62 of 63" calculation is still explicitly refused in epidemiology-and-burden.md and in STATISTICS.md conflict 7.
Rapirosiran — enrolment differs between PMID 40581300 and NCT04565717; both numbers retained side by side in genetics.md and clinical-trials-landscape.md.

What was deepened, page by page¶

overview.md (42→45 records) — added a fifth organising fact: the category is unstable in two directions (39.0% of self-report-classified MASLD has PEth in the MetALD/ALD range; clustering splits MASLD into liver-specific and cardiometabolic types; unstaged MASLD is null for mortality against a metabolically matched comparator).
nomenclature-and-definitions.md (25→28) — quantified alcohol misclassification with the Odense PEth cohort; added the data-driven two-cluster subtype analysis.
epidemiology-and-burden.md (27→30) — the GBD DALY paradox (3.67M DALYs against 75M for T2D, no significant change in 30 years) and its attribution explanation; the Indian meta-analysis (38.6% adults, with hospital-vs-community and obese-vs-non-obese splits).
pathogenesis.md (23→26) — the DAG–PKC-ε versus ceramide/DES1 question as a genuine unresolved mechanism, and the intestinal nicotine → AMPKα → SMPD3 → ceramide pathway with its nicotine-degrading commensal.
genetics.md (16→20) — the rare-variant map (CIDEB, MTARC1, GPAM), the multi-ancestry cirrhosis GWAS with its PNPLA3×exposure interaction, and clonal haematopoiesis as a somatic liver-risk factor.
noninvasive-assessment.md (21→25) — the age-specificity collapse of FIB-4 (35% at ≥65) with re-derived thresholds, the five-cohort population-screening failure (43% of LSM ≥8 kPa have normal FIB-4), and the superlearner ceiling on routine-variable models.
histology-and-biopsy.md (13→20) — a new section on sampling variability (41% ≥1-stage discordance between paired cores) and on trial-dataset reader reliability (κ 0.366–0.396 for the licensing endpoints; power >90%→40%). This corrected a stale absence: the page previously asserted no contemporary paired-sampling study existed; Ratziu 2005 and 2007 do, and the correction is stated explicitly on the page.
natural-history-and-fibrosis-progression.md (19→22) — the metabolically-matched mortality null, and the MASLD/MetALD/ALD outcome ordering from a 24-cohort meta-analysis and UK Biobank.
lifestyle-and-weight-loss.md (10→15) — MEDINA contradicting DIRECT-PLUS, exercise-modality dissociation, and the coffee dose–response (fibrosis-specific, not incidence).
resmetirom-and-thyromimetics.md (9→20) — quantified thyroid-status association, the phase 2 open-label extension, qFibrosis digital pathology, the two contradictory cost-effectiveness models, real-world access data, a second network meta-analysis with a different podium, and HSK31679's microbiome-dependent mechanism.
glp1-and-incretin-therapy.md (14→19) — four target-trial emulations on hard hepatic outcomes with a consistent within-class ordering, and lean-mass loss quantified at ~25% of weight lost.
bariatric-and-metabolic-surgery.md (8→12) — SPECCIAL (metabolic surgery in compensated MASH cirrhosis), which closed a stale absence on the page, and the alcohol-use-disorder hazard quantified across SOS and Danish registers with a possible incretin mitigation.
other-pharmacotherapy.md (19→23) — the dapagliflozin randomised histological trial, two empagliflozin liver-fat trials, and ATLAS (combination therapy, all arms negative on the primary endpoint).
cirrhosis-and-decompensation.md (19→22) — Baveno VII's MASLD-with-obesity failure (rule-in PPV 0.67) and its correction, plus spleen stiffness closing the grey zone.
masld-related-hepatocellular-carcinoma.md (15→20) — chemoprevention (statins, aspirin, metformin) and both sides of the immunotherapy controversy, including two prospective atezolizumab–bevacizumab cohorts that contradict the survival penalty.
cardiovascular-and-extrahepatic-outcomes.md (29→32) — the causality question stated properly (more atherosclerosis, not more asCVD mortality; only mixed hyperlipidaemia survives MR), cT1-versus-PDFF discrimination, and the HFpEF phenotype.
masld-and-type-2-diabetes.md (23→27) — glycaemic control slowing fibrosis progression but not liver events, lanifibranor's clamp study, and MASLD in type 1 diabetes with its twelve-fold modality spread.
lean-masld.md (9→16) — the cardiovascular contradiction laid out in full with seven studies on three sides, and the design split that explains it.
guidelines.md (33→39) — KASL 2025, AISF 2026 (STEPS-MASH), INASL 2023 (the resource-stratification objection) and the NICE summary, plus the guidance lag behind the dapagliflozin trial.
clinical-trials-landscape.md (25→28) — LITMUS biomarker head-to-head and its regulatory-qualification experience, ESSENCE baseline characteristics, and re-queried registry counts (17 recruiting phase 3 studies against 111 registered).
patient-experience-and-advocacy.md (17→20) — economic and PRO burden, the liver–brain axis as a mechanism for the cognitive complaints patients report, and the depression discordance between meta-analysis and Mendelian randomisation.
red-flags-and-safety-concerns.md (46→52) — herbal and dietary supplement injury (20% of US hepatotoxicity; turmeric with HLA-B*35:01) and a new pregnancy section (preterm-birth aOR 3.41, independent of obesity, with no severity gradient).

What was deliberately left alone¶

No page was rewritten or restructured. Section order, TL;DRs and existing tables were kept; new material was inserted as new sections or as clearly-marked extensions.
No verified content was removed, and no existing citation was dropped.
The three disclosed source discrepancies (above) were not touched.
literature/notes/ and literature/patient-voice/ were not modified. The seven landmark notes still cover the seven landmark papers; none of the 93 new records is landmark in the sense the notes require (practice-changing or field-opening), so adding notes would have diluted the criterion. The patient-voice layer's organisation and source verification is dated 2026-09-02 and was re-verified in the audit; nothing in this pass changed its ethics-governed content.
WHATS-NEW.md was not regenerated. It is a generated file (tools/build_recency.py), and regenerating it writes a cache into tools/ and a cross-condition file at the repository root — both outside this pass's permitted scope. It is therefore stale by 93 papers and should be regenerated in the next session that is allowed to run repository tooling.
pathogenesis.md remains the shortest page (126 lines). It was extended where a genuine open mechanism existed and not padded further; its density per line is already the highest in the condition.

One repair to record honestly¶

While editing cirrhosis-and-decompensation.md, a scripted insertion truncated the file, destroying its ## Related pages section and References 1–19. References 1–19 were restored verbatim from the file content read earlier in the same session, and re-verified against the in-page inline citations. The ## Related pages section was reconstructed, not restored: its ten links point to canonical filenames that all resolve, and each carries a one-line description written in this pass rather than the original wording. Nothing else on the page was affected, and no citation was lost. A re-auditor should treat that section as new text.

Absence claims re-run in this pass¶

Claim	Outcome
"No contemporary paired-sampling study of biopsy variability" (`histology-and-biopsy.md`)	False. Ratziu 2005 (PMID 15940625) and 2007 (PMID 17767466) exist; page corrected, and the residual open question narrowed to whether sampling error has been re-measured with modern cores
"Surgery untested in MASH cirrhosis" (`bariatric-and-metabolic-surgery.md`)	Superseded. SPECCIAL (PMID 39870816) reports 15-year hepatic outcomes; page updated, remaining gap is decompensated cirrhosis and randomisation
"No phase 3 result for any other THR-β agonist" (`resmetirom-and-thyromimetics.md`)	Still true. Re-run 2026-09-02 as `(VK2809 OR VK-2809 OR VOYAGE) AND liver` (74 records) and `VK2809 AND (NASH OR NAFLD OR MASLD OR MASH)` (8 records); no peer-reviewed VOYAGE efficacy report retrieved
"No guideline cites the dapagliflozin trial" (`guidelines.md`, OQ-33)	True as of 2026-09-02 across the 52 documents in the registry
"No obstetric or hepatology guideline names MASLD as an antenatal risk factor" (`red-flags-and-safety-concerns.md`, OQ-36)	True as of 2026-09-02

For the next session¶

Re-audit this pass with a different engine. 93 records were added across all 22 pages; none has been independently checked. The reconstructed ## Related pages section in cirrhosis-and-decompensation.md is new text and should be read as such.
Re-check the two citations corrected mid-pass (PMID 31337282 author list; PMID 41066138 article number) against the live records.
Consider whether any of the 93 new records deserves a literature/notes/ deep note. The strongest candidates are Davison 2020 (PMID 32610115) for what it implies about the entire MASH failure literature, Torp 2025 (PMID 40945520) for what it implies about every cohort in this condition, and Raverdy 2024 (PMID 39653777) if the two-cluster result replicates.
STATISTICS.md §13.12 and clinical-trials-landscape.md hold ClinicalTrials.gov counts from 2026-09-02 and are a single-date snapshot.
Regenerate WHATS-NEW.md with python3 tools/build_recency.py masld — it is stale by the 93 papers added here, several of which are 2026 publications that would move the recency buckets.
The pathogenesis.md mechanism sections remain the place where a further pass would have the most room, specifically on human tissue evidence for the DAG-versus-ceramide question (OQ-40).

2026-09-02 — Independent audit (Codex auditor; Claude author)¶

Scope and result. Independently audited all 22 wiki pages and all 14 literature artifacts authored by Claude. Re-extracted the edited corpus and verified 288 unique PubMed records through live PubMed E-utilities and 62 unique NCT records through live ClinicalTrials.gov v2 API records in this session; all identifiers resolved. Checked 1,267 claim-linked identifier occurrences (966 in wiki bodies and 301 in literature artifacts, excluding bibliography/registry catalogue repetitions) and 2,225 total PMID/NCT occurrences including reference lists and catalogues. Re-ran the stated PubMed absence searches, the ClinicalTrials.gov condition/status counts, and 16 public URLs. Wiki-to-bibliography closure is 274/274; no wiki-body PMID lacks a page reference.

Promotion result: 0 curated, 22 draft. No page was promoted. clinical-trials-landscape.md and genetics.md retain an unresolved publication–registry enrollment discrepancy for rapirosiran (PMID 40581300 versus NCT04565717). epidemiology-and-burden.md and the statistics artifact retain a source-internal study-count inconsistency in PMID 37040843. The Angulo landmark note retains a source-internal arithmetic inconsistency (PMID 25935633). Three patient-voice records have no PubMed abstract/full text available in this audit (PMIDs: 28624648, 33497764, 42525136), so their findings remain unsummarised. In addition, most pages remain below the requested reference density and/or 150-line floor. Those are substantive curation limitations, not identifier failures.

Errors found and fixed¶

Area	Error in authored material	Audit correction
Cirrhosis	Claimed four cited randomised cirrhosis trials although the three cited PMIDs support three cirrhosis RCTs	Corrected four to three
Recompensation	Claimed MASLD-specific recompensation had not been reported	Added the 344-person SLD cohort: 18.6% overall, 17.7% MASLD; retained observational/causal limitation (PMID 42467948)
MELD 3.0	Claimed no evaluation in MASLD/MASH	Added the 44,037-candidate registry study and its up/down-categorisation and outcome estimates (PMID 41284513)
Cirrhosis surgery	Claimed no randomised cirrhosis trial	Added recruiting NCT07058155 and completed observational NCT03753438; bounded the gap to no completed RCT
Surgery vs incretin	Claimed no head-to-head trial	Added recruiting NCT06374875; bounded the gap to no completed comparison
Bariatric procedures	Left procedure comparison as wholly unanswered	Added the 16-study sleeve-versus-bypass meta-analysis and its limitations (PMID 42420150)
Hard outcomes	Called metabolic surgery the only intervention with hard hepatic-outcome data	Reworded to the strongest dedicated observational major-adverse-liver-outcome analysis; stated non-randomised design
Pivotal endpoints	Claimed every pivotal trial uses only histological surrogates	Distinguished accelerated-approval histology readouts from phase 3/confirmatory trials with primary or later clinical composites
Combination therapy	Claimed only one registered combination trial	Added published semaglutide/cilofexor/firsocostat phase 2 (PMID 35439567), NCT07570810, and retained the narrower absence of resmetirom-plus-semaglutide
Rapirosiran	Presented publication enrollment and registry as if concordant	Explicitly retained the paper's Parts A/B n=58/n=46 against the registry's terminated/actual n=6 discrepancy; did not force reconciliation
Diabetes therapy	Claimed no randomised glucose-lowering comparison with hepatic endpoints	Added luseogliflozin plus semaglutide trial, including nonsignificant full-analysis comparisons (PMID 42605535)
Diabetes directionality	Claimed no genetic-instrument separation	Added three Mendelian/shared-genetics analyses and their non-identical directional results (PMIDs: 37223039, 37931882, 39690818)
Alcohol misclassification	Claimed objective misclassification was unquantified	Added PEth studies (PMIDs: 40517819, 40228582); retained lean-specific PEth-plus-genetics gap
Statin underuse	Claimed prescribing gaps had not been quantified	Added 6,055-person study: 33% untreated when indicated in MASLD versus 19% without MASLD (PMID 41861677)
Sequential NITs	Claimed no prospective false-negative measurement	Added prospective n=186 FIB-4/ELF/MRE/biopsy study: FIB-4 sensitivity 57%, 43% excluded from second-line testing, concurrent sensitivity 87%/specificity 64% (PMID 42566274)
Guideline implementation	Claimed implementation had not been measured	Added 207-officer pre/post training study; bounded remaining gap to durable practice and patient outcomes (PMID 41845319)
Patient voice	Claimed interview evidence was US/high-income only and omitted new studies	Added 25-adult lived-experience study and 16-person Nanjing study (PMIDs: 42651339, 42529177); corrected geographic coverage and study-type counts
Organisations	Retained transient 403/failure claims	Live retry verified American Liver Foundation and GLI, British Liver Trust redirected to Liver UK, and ELPA resolved at its current official domain `elpa.eu`
Epidemiology	Stated “62 of 63” despite source counts summing to 64	Removed invalid fraction and documented PMID 37040843's internal inconsistency
Angulo arithmetic	Repeated 193/619 as 33.2% without comment	Preserved the abstract's statement but flagged that the quotient is 31.2% (PMID 25935633)
Resmetirom NNT	Said fibrosis-improvement NNT about 8–9	Corrected to about 9–10 from 11.7- and 10.0-point absolute differences
Prognostic wording	Generalised that NITs “match or beat” biopsy and “double as” cardiovascular tools	Bounded to selected prognostic cohorts and stated that liver tools are not validated individual cardiovascular calculators
Search count	Retained 203 records for the surrogate search	Live exact re-run returned 204; updated the dated count
Reference closure	Three guideline citations appeared in the body without page-reference entries	Added PMIDs: 27053230, 38852583 and 38869512 to the reference list

Remaining flags¶

Rapirosiran enrollment remains unresolved between PMID 40581300 and NCT04565717; affected pages remain draft.
PMID 37040843 reports 63 studies but geographic components totaling 64; no fraction was reconstructed.
PMID 25935633 reports 193/619 as 33.2%; both the published statement and calculated 31.2% are shown.
PMIDs: 28624648, 33497764 and 42525136 still lack an abstract in PubMed; no findings were inferred.
No completed positive phase 3 cirrhosis trial, randomised clinical-outcome NIT pathway trial, resmetirom-plus-semaglutide trial, or before/after patient-experience study of the nomenclature change was identified in the dated live searches.
The bibliography now contains 274 wiki-cited papers; 14 additional unique records occur in literature-only artifacts, for 288 PubMed records across the condition.

Verification evidence¶

PubMed final extraction: 288 requested; all 288 present in the live E-utilities response.
ClinicalTrials.gov: all 62 current NCT IDs covered by same-session live v2 API records; no API errors in the original 58-record run, and all four newly cited records were retrieved live.
Exact condition registry snapshot re-run: 2,011 total studies, 178 interventional/recruiting, 110 phase 3.
All 274 wiki PMIDs occur in BIBLIOGRAPHY.md; no body citation is missing from its page's References section.
Final status count: 22 draft; 0 curated. CONDITIONS-ROADMAP.md was not touched.

2026-09-02 — Full build (Claude)¶

Built the condition from the seeded scaffold: 22 wiki pages, 2,919 lines, 272 verified records (259 cited by pages), the complete literature layer, a rewritten OPEN-QUESTIONS.md and an updated INDEX.md. Every page left at status: draft. No page promoted; the auditor must be a different engine.

What was written¶

All 22 pages in the canonical plan, none skipped: overview, nomenclature-and-definitions, epidemiology-and-burden, pathogenesis, genetics, noninvasive-assessment, histology-and-biopsy, natural-history-and-fibrosis-progression, lifestyle-and-weight-loss, resmetirom-and-thyromimetics, glp1-and-incretin-therapy, bariatric-and-metabolic-surgery, other-pharmacotherapy, cirrhosis-and-decompensation, masld-related-hepatocellular-carcinoma, cardiovascular-and-extrahepatic-outcomes, masld-and-type-2-diabetes, lean-masld, guidelines, clinical-trials-landscape, red-flags-and-safety-concerns, patient-experience-and-advocacy. Pages run 98–175 lines with 7–44 unique PMIDs each (deduplicated total 259).

Literature layer: BIBLIOGRAPHY.md (259 papers in 21 topic sections, generated from the pages so it is complete by construction, each line carrying tags and citing pages); notes/ (7 landmark notes — Rinella 2023, Angulo 2015, Romeo 2008, Abul-Husn 2018, Vilar-Gomez 2015, Harrison 2024, Sanyal 2025, with DOIs verified against PubMed articleids); guidelines/REGISTRY.md (47 catalogued documents, supersession chains, 7 named disagreements, watch list); statistics/STATISTICS.md (12 sections, 12 documented conflicts); patient-voice/ (README with method and ethics, organizations, themes, sources).

OPEN-QUESTIONS.md rewritten: 18 Tier 1 and 12 Tier 2 questions with stable IDs, plus a 12-row "Dots not yet connected" table. OQ-1 to OQ-5 carry forward from the seed with sharpened scope; OQ-6 to OQ-30 are new.

Anchor re-verification¶

All 13 anchor records resolved at scoping were re-fetched from live PubMed. All 13 matched on first author, year, journal, volume, issue, pages and title. None required correction.

Searches run (live PubMed E-utilities, 2026-09-02)¶

Roughly 60 topic searches, every one unioning both vocabularies. Scoping counts re-confirmed: the union query (MASLD OR NAFLD OR MASH OR NASH OR "steatotic liver disease") returned 78,992 records against 50,200 for the new name alone. Topic searches covered: nomenclature and MetALD (3,044); global epidemiology (1,081); NHANES prevalence (7,925); de novo lipogenesis, lipotoxicity, stellate cells, macrophages, microbiome (1,685–6,565 by facet); PNPLA3 (1,316), other variants and GWAS (1,023), heritability; FIB-4 and elastography (5,784 area), blood panels, sequential pathways (932); histology scoring, sampling variability (32), AI pathology (559); paired-biopsy natural history (259) and fibrosis-stage outcomes (203); lifestyle (3,895), exercise (907), Mediterranean diet and fructose (2,225); resmetirom and THR-β (513); GLP-1 and incretins (1,231); bariatric surgery (1,210); pioglitazone and vitamin E (1,317); failed agents (1,161); FGF21 (636); statins, SGLT2, metformin (1,053); cirrhosis and cACLD (138); transplant (281); HCC (5,216); cardiovascular (5,908); extrahepatic and CKD (1,300); type 2 diabetes (4,936); lean (2,043); guidelines (461 by publication type, 1,161 by phrase); alcohol boundary (2,611); drug-induced liver injury (1,166); stigma and quality of life (1,168); qualitative and lived experience (133); paediatric (4,916); omics (4,837); screening cost-effectiveness (577).

ClinicalTrials.gov v2 API, same date: 2,011 studies for the condition union; 178 interventional and recruiting; 110 phase 3. Individual NCT records for MAESTRO-NASH, ESSENCE, the FGF21 and incretin phase 3 programmes, the genotype-directed siRNA and antisense trials, and the terminated and withdrawn programmes were each retrieved and are cited with status, enrolment and dates.

Direct HTTP retrieval, same date: 13 patient organisations and public health portals verified; 2 recorded as unverifiable (see below).

Citation integrity¶

Every PMID in every page was extracted programmatically and re-fetched through PubMed esummary; the bibliography is generated from that verified metadata, so no citation in this condition was written from memory. Approximately 25 volume/issue/page errors introduced during drafting were caught by this pass and corrected before the pages were finalised. Two invented article-locator strings (e186418, e135197, for J Clin Invest records with no pages field) were caught and removed.

One asserted absence was checked and found false¶

The patient-experience page initially stated that no substantial interview-based qualitative literature existed, on the basis of a broad search (stigma OR "quality of life" OR "patient-reported outcomes" OR qualitative, 1,168 records dominated by instrument work). A targeted re-run — ("qualitative study" OR "semi-structured interview" OR "focus group" OR "lived experience" OR "illness perception"), 133 records — surfaced six interview and focus-group studies. The page was rewritten, the claim retracted, and the whole episode recorded in OQ-16 and in patient-voice/sources.md as a worked example of why an absence found under one search formulation is not an absence.

The corrected material changed the page's conclusions substantively: non-cirrhotic MASH is not experienced as asymptomatic (fatigue 18/23, right-upper-quadrant pain 14/23 in concept-elicitation interviews, PMID 33336323); diagnosis is preceded by misdiagnosis and followed by an information vacuum (PMID 38780312); and a second patient survey found 79.7% did not consider "fatty" stigmatising while 85.1% found "alcohol" in a disease name stigmatising, concluding that the MASLD change "does not seem warranted, at least if stigma is the main concern" (PMID 40337974) — a minority position against a multisociety consensus, recorded as such.

Scoping decisions taken during the build¶

Border with hepatocellular carcinoma held. masld-related-hepatocellular-carcinoma.md covers only what is distinctive in this setting — pre-cirrhotic occurrence, halved surveillance uptake, the attribution problem, and reduced immunotherapy responsiveness — and explicitly defers staging, treatment allocation and transplant criteria to conditions/hepatocellular-carcinoma/. Tan 2022 found no significant difference in treatment allocation between NAFLD-related and other HCC, which supports the border rather than straining it.
Border with type 2 diabetes held. masld-and-type-2-diabetes.md covers the bidirectional epidemiology and case-finding; glycaemic management is deferred.
NAFLD/NASH provenance stated throughout. Every trial and cohort is described by the criteria it actually enrolled under. No study population was relabelled MASLD retrospectively.
Two published confidence intervals that do not contain their point estimates (extrahepatic-cancer and liver-specific mortality in PMID 38521116) were reproduced as published and flagged, rather than silently corrected. Flagged again here for the auditor.
The Ha 2022 sarcopenia record (PMID 35347595) is an editorial, not the primary study its title suggests; it is cited as commentary and labelled as such.
The APASL 2020 MAFLD guideline (PMID 33006093) is indexed in PubMed as an editorial, not a practice guideline, despite its content and title; the registry records both facts.
259 of the 272 verified records are cited by a wiki page; the remaining 13 are guideline and consensus documents catalogued only in the registry. Both counts are stated where they are used.
Two patient organisations could not be verified — the American Liver Foundation (HTTP 403) and ELPA (connection failed). Both are widely referenced and neither is cited anywhere in this condition, because this repository does not cite pages it did not retrieve.

What could not be verified, and what remains open¶

No full text was retrieved for Avery 2017 (PMID 28624648), Alem 2021 (PMID 33497764) or Berg 2026 (PMID 42525136) — all carry no abstract in the PubMed record. They are listed in patient-voice/sources.md with their findings not summarised.
The AZD2693 phase 2 (NCT05809934, n=220, completed 2025-07-14) has no retrieved publication; the trial is cited from the registry with its status and dates, and the phase 1 programme from Armisen 2025.
NICE NG49 was verified by page title only; its recommendation content was not extracted and is not quoted.

Follow-ups for the auditor¶

Re-fetch every one of the 259 PMIDs and check claim-to-source correspondence, especially the numbers in STATISTICS.md §5, §8 and §9, which are the densest.
Re-run every asserted absence in OPEN-QUESTIONS.md with at least two search formulations. The base rate observed in this build is that one in one checked was wrong.
Verify the two flagged confidence intervals from PMID 38521116 against the full text.
Re-attempt the American Liver Foundation and ELPA sites, and re-verify all 13 organisation URLs — sites move.
Re-run the ClinicalTrials.gov queries; §12 of STATISTICS.md and the whole of clinical-trials-landscape.md are a single-date snapshot.
Check whether MAESTRO-NASH OUTCOMES (NCT05500222) has reported — its primary completion was December 2026, so it may have read out.
Look specifically for a published AZD2693 phase 2 result.
Only then consider promoting pages to curated, and only those where every citation resolved and matched.

Follow-ups for the next sweep¶

Watch the four outcome trials in the registry watch list; any readout changes resmetirom-and-thyromimetics.md, glp1-and-incretin-therapy.md, clinical-trials-landscape.md and OQ-1 simultaneously.
The qualitative literature is small enough that a handful of new studies would materially change patient-voice/themes.md.
The NIDDK public page (last reviewed April 2021) still states no medicines are approved; worth re-checking whether it has been updated, as it is the clearest measurable instance of public-facing lag.

2026-09-02 — Seeded (Claude)¶

Created the scaffold: INDEX.md with a 22-page plan (20 topical + 2 standing house pages) and a 13-record anchor table, a seed OPEN-QUESTIONS.md, this log, and the empty wiki/ and literature/ layers. No wiki pages written.

Searches run (live PubMed E-utilities, 2026-09-02). Scoping: metabolic dysfunction-associated steatotic liver disease OR MASLD 50,200; nonalcoholic fatty liver disease OR NAFLD 51,746; nonalcoholic steatohepatitis OR MASH 53,007. Per-page topic counts in INDEX.md, including epidemiology 11,395, type 2 diabetes 6,262, noninvasive fibrosis 5,784, HCC 5,271, cardiovascular 1,484, bariatric surgery 1,346, GLP-1 1,332, genetics 1,206, pathogenesis 644, resmetirom/THR-beta 434, histology 427, lifestyle 263, cirrhosis outcomes 239, lean 100, nomenclature 9.

Query-hygiene note. Four initial topic queries were malformed by unparenthesised OR; NASH AND resmetirom OR thyroid hormone receptor returned 16,427 rather than 434. Re-run parenthesised and marked † in INDEX.md.

Anchor records resolved live: 13, listed in INDEX.md.

Scoping decisions. The defining problem here is not size but vocabulary: the 2023 multisociety renaming split the literature across NAFLD/NASH and MASLD/MASH, with overlapping but non-identical definitions. Two binding rules are written into INDEX.md — every search must union the old and new vocabulary, and a study conducted under NAFLD/NASH criteria must be described as such rather than silently relabelled. An asserted absence found under one vocabulary is not an absence. Borders: this condition owns the liver disease to cirrhosis; the tumour stays with hepatocellular-carcinoma, with one dedicated page for what is distinctive about HCC arising in MASLD (notably pre-cirrhotic occurrence, which breaks surveillance assumptions).

Flagged for the build pass. Anchors must be re-verified. No anchor yet for EASL guidance, PIVENS/TONIC, diagnostic-accuracy studies for FIB-4 and elastography, bariatric histological cohorts, transplant outcomes, the MetALD alcohol boundary, or patient-organisation material.

Follow-ups. Build with tools/build-condition.sh masld; auditor must differ from the writer.

2026-10-07 — independent audit of Claude Opus 5's D9 and two wiki-page edits (Codex, auditor)¶

Records and checks. Re-fetched all 32 distinct PMIDs cited on the two edited pages and D9 through live PubMed E-utilities, plus all 13 NCT registrations cited on those pages/D9 through ClinicalTrials.gov v2. Every PMID's publication types and DOI's Crossref updated-by field was checked. No retraction or expression of concern was flagged. Crossref lists an erratum, not a retraction, for the previously cited pemvidutide trial (PMID 39002641). The added bibliography entries match the retrieved Stupalkowska and Wu records; their citations are substantive, not padding.

Figures and correction. The new comparisons' specified numbers, directions, intervals and populations resolve: Stupalkowska surgery-versus-semaglutide MALO HR 1.63 (1.12–2.37), bypass 2.01 (1.26–3.20), sleeve 0.97 (0.52–1.78), new cirrhosis 0.46 (0.29–0.73), MACE 0.51 (0.38–0.67), bypass all-cause mortality 1.64 (1.01–2.67); Wu tirzepatide-versus-surgery composite HR 0.47 (0.36–0.61) and MALO 0.32 (0.22–0.48) in 6,199 matched pairs. None failed. NCT06374875 is recruiting, with estimated enrollment 120 and biopsy fibrosis improvement as primary outcome. The original "never compared" assertion was false.

Overcorrection and edits. Claude described these active-drug comparisons as contradicting SPLENDOR's surgery-versus-nonsurgical-care effect, and called SPLENDOR single-arm, although it had a nonsurgical comparator. Populations and MALO definitions differ; the hazard ratios are not competing estimates of one effect. The stated bypass-versus-sleeve pattern comes from Stupalkowska, not both comparisons, and does not establish an alcohol mechanism. Corrected D9, both added wiki sections, the surgery-page question and the bibliography preface. Preserved the genuine within-study tension between fewer new cirrhosis diagnoses and more decompensation/transplant events.

Page status and judgement. Both pages remain draft: the added paragraphs are now source-faithful and useful, but this pass did not resolve every older full-text-dependent claim on either dense page, so curated would overstate verification. The four-condition correction is reliable on the existence and reported estimates of direct comparisons, with causal interpretation and hard-outcome reconciliation still open. A future page-wide verification can decide promotion.

2026-10-08 — correction of dot row D14, which misstated its own evidence (Claude Opus 5, author)¶

Why. The novelty gate returned narrowed unanimously on D14 (all three engines), and the row's missing-junction claim — "No negative MASH trial has been re-analysed with reader and sampling unreliability modelled" — is false as written.

What was wrong. Three faults, all in the row's handling of records it already cited. (1) PMID 32610115 is itself a multi-reader re-read of a completed drug trial, so reader-side reanalysis had already been done; the row cited it as evidence of the problem while overlooking that it is also a partial solution. Separately, ATLAS biopsies have been retrospectively AI-rescored (PMID 39112795, Nat Med 2024), which enlarged the treatment–placebo histological signal. (2) The ">90% → 40%" power collapse is a simulation, not an observed estimate, and was stated as fact. (3) Two of the four trials listed as failures are only partly negative: obeticholic acid met its prespecified interim fibrosis endpoint (23% vs 12%, P=0.0002; PMID 31813633) and cenicriviroc missed NAS improvement but improved fibrosis (20% vs 10%, P=0.02; PMID 28833331).

What the row now says. The residual gap is narrower and checkable: no joint, treatment-arm-specific model of reader disagreement and independent-core sampling error has been fitted inside a randomised MASH trial. Sampling discordance (PMID 15940625) has only ever been measured in a separate observational cohort.

Provenance of this pass. Every PMID written into the row was re-fetched live from PubMed in this session (E-utilities via the bio-research PubMed tool), its publication types inspected for Retracted Publication / Expression of Concern, and its DOI checked against Crossref's updated-by field. Twenty records were checked across the three conditions corrected today; none carried a retraction, withdrawal or expression of concern. No identifier was carried over from the gate verdict files on trust: those were written in an earlier session, and SOURCES.md's prime rule binds the session that writes the claim.

Author: Claude Opus 5. Auditor: pending — must be a different engine.

2026-10-08 — independent audit of Claude Opus 5's D14 correction (Codex, auditor)¶

Live records re-fetched. PubMed E-utilities: row PMIDs 32610115, 15940625, 32147362, 33169409, 31813633, 28833331, 39112795; search candidates 35090960, 38467661, 36704465, 42196715, 41848630, 41825098, 41810432, 41180689, 41127419, 39961300, 39945523, 39612947, 39496972, 38879176, 38126958, 37879461, 37195431, 36503204, 33460786, 31600834, 30744560, 30128694, 29222917, 15800431. All seven row records exist and match the cited papers. Their PubMed publication types show no retraction or expression of concern; each row paper's actual PubMed-listed DOI was resolved through Crossref and its updated-by field checked. None has a retraction or expression of concern; PMID 31813633 has two errata. Full text of PMIDs 28833331 and 39112795 was retrieved through Europe PMC.

Searches re-run, live PubMed ESearch, 2026-10-08 (exact terms; counts are database hits, not eligible studies).

Query	Count
`(MASLD OR MASH OR NAFLD OR NASH OR "steatotic liver disease") AND (biopsy OR histolog*) AND ("reader variability" OR "inter-reader" OR interobserver OR misclassification) AND ("sampling error" OR "sampling variability") AND (trial OR randomized)`	0
`(MASLD OR MASH OR NAFLD OR NASH) AND (ATLAS OR STELLAR OR EMMINENCE OR cenicriviroc OR selonsertib) AND ("sampling error" OR "sampling variability" OR "reader variability" OR interobserver OR misclassification OR "digital pathology")`	6
`(MASLD OR MASH OR NAFLD OR NASH) AND ("Cochrane Database Syst Rev"[jour]) AND (biopsy OR histolog*) AND (variability OR reliability OR sampling)`	4
`(MASLD OR MASH OR NAFLD OR NASH) AND ("reader variability" OR interobserver) AND ("paired cores" OR "sampling variability") AND (randomized OR trial OR treatment)`	0
`(MASLD OR NAFLD OR MASH OR NASH OR "steatotic liver disease") AND ("reader variability" OR "interobserver variability" OR "inter-reader") AND (trial OR treatment)`	21

Corrections. Confirmed the κ values and that the >90% to 40% power loss is simulated, not observed; the 41% discordance came from 51 paired-core patients outside a drug trial. Confirmed STELLAR and ATLAS primary failures and obeticholic acid's successful prespecified interim fibrosis endpoint (25 mg 23% vs placebo 12%, P=0.0002). Cenicriviroc's 20% vs 10%, P=0.02 fibrosis difference is secondary and nominal: its full-text protocol controls type I error through a step-down sequence beginning with the primary NAS endpoint, which failed. Removed the implication that the secondary endpoint was formally met. ATLAS AI rescoring enlarged placebo-adjusted response rates, but the fibrosis endpoint remained nonsignificant (AI P=0.152, central reader P=0.196); the continuous fibrosis P=0.02 comparison was limited to primary-endpoint responders. Replaced the broad signal claim with those qualifications and made the residual absence explicitly PubMed-dated. The four additional records from the six-hit trial query and the 21-hit broader reader query were screened at abstract level; none contained the proposed joint reader-plus-independent-core treatment-arm model; this is a bounded search result, not proof of universal nonexistence.

2026-10-11 — periodic literature sweep (Codex; auditor pending)¶

Window and sources. Searched publications dated 2026-10-07 through 2026-10-11 inclusive. Live PubMed E-utilities ESearch/EFetch covered the old/new terminology union (MASLD OR MASH OR NAFLD OR NASH OR "steatotic liver disease") in title/abstract, with 12 major-topic searches spanning definitions/alcohol, burden, mechanisms/genetics, diagnosis/histology, natural history, lifestyle/surgery, resmetirom, incretins, other drugs, extrahepatic/HCC outcomes, special populations and guidelines/patient experience. The broad fielded query returned 48 records. Each topic had a parallel PubMed query restricted to "Cochrane Database Syst Rev"[jour]; all 12 returned zero dated records. A 12-topic Europe PMC REST sweep plus a broad query returned 72 broad-query records, including PMC/preprint entries without PMIDs; free-text acronym matches included unrelated material. The exact queries, PubMed translations, returned IDs and 65 per-record ClinicalTrials.gov checks are in the sweep manifest. These are database hit counts, not eligible-study counts.

Trial and other-source checks. ClinicalTrials.gov v2 returned all 65 NCT records already cited by this condition. Only NCT05519475 and NCT07165028 had updates posted within the window (both 2026-10-08); both still read RECRUITING, neither posted a results section. Targeted searches checked AASLD, EASL, ADA, NICE and Asian/Latin American society guidance pages; WHO/health-data burden sources; and the American Liver Foundation, Global Liver Institute and European Liver Patients' Association material. No dated society guideline, new registry/burden estimate, or patient-experience source survived triage. The ELPA October screening tour overlapped the window, but its event listing did not supply new MASLD-specific patient-experience evidence. The WHO ICTRP portal returned HTTP 403 and ISRCTN search redirected to a holding page, so neither yielded a usable non-US registry sweep. Cochrane Library/CENTRAL, SciELO and LILACS each returned HTTP 403; none was searched. In particular, no absence of Latin American regional evidence is inferred. Unpaywall was skipped because LIFEBANK_CONTACT_EMAIL is unset; no personal email was sent to Crossref.

Triage and edits. Three papers received bibliography lines only: a weight-change/genetic-risk cohort analysis (PMID 42854771), a ketohexokinase-inhibition crossover trial (PMID 42844400), and a European care-model survey (PMID 42850141). Each PMID was returned by live E-utilities and each paper's PubMed publication types and DOI's Crossref updated-by field showed no retraction or expression of concern. None yet warrants a wiki claim, deep note, guideline entry, statistics entry or change to an open question. The prospective PEth biomarker paper (PMID 42850047) has no PubMed abstract, and publisher full text was inaccessible; no findings were inferred or cited. No other screened record survived triage. Thus only literature/BIBLIOGRAPHY.md, this log and the legal-path search manifest changed; wiki pages, OPEN-QUESTIONS.md, literature/guidelines/REGISTRY.md, literature/statistics/STATISTICS.md and patient-voice files did not.

Next sweep. Recheck the PEth full text and assess whether it changes alcohol-classification questions; monitor the three catalogued studies for replication or outcome evidence before promoting them into wiki claims; continue watching the cited outcome trials for actual results, the rapirosiran publication–registry enrolment discrepancy, and non-US registry access. Any regional transportability claim still needs SciELO/LILACS access or a clearly bounded alternative search.