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Guidelines

The catalogue of documents lives in literature/guidelines/REGISTRY.md. This page synthesises what they recommend and where they conflict.

TL;DR — There is now more agreement than there was, and one 2025 Delphi across 61 guideline documents published 2018–January 2025 was built specifically because "important differences among the recommendations have created confusion, contributing to a low implementation rate"; four rounds produced statements with >90% agreement (Younossi 2025, PMID 40222485). The convergent core is: FIB-4 first, elastography or ELF second, biopsy only for discordance or competing diagnoses; lifestyle for everyone; and — since 2024–2025 — resmetirom or semaglutide for non-cirrhotic MASH with F2–F3. An updated 2026 consensus of 40 international experts sets the operative thresholds: treat at liver stiffness 10–20 kPa or ELF 9.2–11.3 after excluding cirrhosis, do not use upfront combination therapy, and define one-year response as ≥30% reduction in liver stiffness or ≥0.5-point reduction in ELF (Younossi 2026, PMID 41950980). Real disagreements persist on three questions: whether to screen the general population (no society says yes; the ADA says yes within diabetes), which vocabulary to use (APASL and the Chinese guideline use MAFLD, AASLD/EASL/ALEH use MASLD), and who owns the patient — hepatology, endocrinology, or primary care.

The current documents

Body Year Region Vocabulary Citation
AASLD Practice Guidance 2023 USA NAFLD (readable as MASLD per companion) Rinella 2023, PMID 36727674; Kanwal 2024, PMID 38445559
AASLD update on semaglutide Nov 2025 USA MASLD/MASH Bansal 2026, PMID 41201884
EASL–EASD–EASO CPG 2024 Europe MASLD PMID 38851997 (executive summary PMID 38869512; Obes Facts co-publication PMID 38852583)
APASL CPG 2025 Asia-Pacific MAFLD Eslam 2025, PMID 40016576
ALEH Latin American working group 2025 Latin America MASLD Diaz 2025, PMID 40089151
Japanese evidence-based CPG 2026 Japan MASLD Akuta 2026, PMID 42120590
Spanish multidisciplinary CPG 2025 Spain metabolic hepatic steatosis Romero-Gómez 2025, PMID 40221023
Chinese guideline (v2024) 2024 China MAFLD Fan 2024, PMID 39544247
ADA consensus report 2025 USA (diabetes) MASLD Cusi 2025, PMID 40434108
AACE CPG (AASLD co-sponsored) 2022 USA (primary care/endocrinology) NAFLD Cusi 2022, PMID 35569886
AGA Clinical Care Pathway 2021 USA NAFLD Kanwal 2021, PMID 34602251
AGA Update, non-invasive biomarkers 2023 USA NAFLD Wattacheril 2023, PMID 37542503
AGA Update, lifestyle modification 2021 USA NAFLD Younossi 2021, PMID 33307021
AGA Update, lean individuals 2022 USA NAFLD Long 2022, PMID 35842345
Global consensus (Delphi over 61 documents) 2025 international MASLD Younossi 2025, PMID 40222485
Updated global consensus (40 experts) 2026 international MASLD Younossi 2026, PMID 41950980
AHA scientific statement 2022 USA (cardiology) NAFLD Duell 2022, PMID 35418240
MetALD expert position statement 2025 international MetALD Arab 2025, PMID 39608457
Global public health consensus 2022 international NAFLD Lazarus 2022, PMID 34707258
Superseded: EASL–EASD–EASO CPG 2016 Europe NAFLD PMID 27062661 (Diabetologia PMID 27053230) → superseded by PMID 38851997
Superseded: AASLD Practice Guidance 2018 USA NAFLD Chalasani 2018, PMID 28714183 → superseded by PMID 36727674

Where they agree

Diagnosis and stratification. Every current document endorses a sequential, non-invasive approach with FIB-4 first. The 2026 updated consensus states it explicitly: FIB-4 as first-line, then VCTE or ELF for secondary stratification (PMID 41950980). The Japanese guideline says the same and adds that biopsy "is not routinely required for the diagnosis of MASLD but remains essential for establishing a definitive diagnosis of at-risk MASH, assessing inflammatory activity, resolving discrepancies between non-invasive tests, and differentiating MASLD from other chronic liver diseases" (PMID 42120590). ALEH specifies ultrasonography as the initial steatosis screen on accessibility grounds, with FIB-4 for fibrosis risk and VCTE or ELF for further evaluation (PMID 40089151). The Spanish Delphi reached near-unanimity on sequential non-invasive indices followed by transient elastography (PMID 40221023).

Advanced fibrosis is the target. The Japanese guideline puts it plainly: advanced fibrosis is the major determinant of liver-related morbidity and mortality, and MASLD is a heterogeneous spectrum in which fibrosis is the key prognostic factor (PMID 42120590).

Lifestyle first, for everyone. ALEH advises a Mediterranean diet for all patients with a 7–10% weight-loss target in those with excess weight, complete alcohol abstinence with significant fibrosis, and smoking cessation regardless of stage (PMID 40089151). AASLD's semaglutide update states lifestyle modification "remains the cornerstone" alongside drug therapy (PMID 41201884). The Spanish guideline reached consensus on Mediterranean diet plus exercise improving steatosis, steatohepatitis and fibrosis (PMID 40221023).

Drug therapy for non-cirrhotic F2–F3. The 2026 consensus supports resmetirom or semaglutide at LSM 10–20 kPa or ELF 9.2–11.3 after excluding cirrhosis; selection is by shared decision-making, individualised to the cardiometabolic profile; upfront combination therapy is not recommended; and one-year response is ≥30% LSM reduction or ≥0.5-point ELF reduction (PMID 41950980). AASLD's semaglutide update gives near-identical selection thresholds (VCTE 8–15 kPa, MRE 3.1–4.4 kPa, ELF 9.2–10.5), a defined grey zone (VCTE 15–20 kPa, MRE 4.4–5, ELF 10.5–11.3) requiring cirrhosis exclusion by a second test or imaging or platelets <150,000/mm³, and states that resmetirom plus semaglutide has not been studied (PMID 41201884).

Cardiovascular risk must be managed. ALEH calls routine cardiovascular risk assessment and diabetes prevention "crucial for all patients" (PMID 40089151); AACE frames management as promoting cardiometabolic health and reducing cardiovascular risk (PMID 35569886); the AHA statement names atherosclerotic cardiovascular disease the principal cause of death (PMID 35418240).

Where they disagree

0. Four more documents, and the national-guidance layer

The table above is dominated by the large international societies. Four further documents are in current use and each takes a position the big documents do not.

Document Position that differs
KASL 2025 (Sohn 2025, PMID 39967303) — Korean Association for the Study of the Liver clinical practice guidelines for MASLD A full national guideline written directly to the 2023 MASLD nomenclature, in a country whose registry cohorts supply much of the observational drug evidence used elsewhere in this knowledge base (other pharmacotherapy)
AISF 2026 (PMID 41864758) — Italian practice guidance on pharmacological treatment Publishes a named operational framework for drug therapy — STEPS-MASH — covering identification, selection and monitoring of patients eligible for resmetirom or semaglutide, with discussion of high-risk and broader metabolic populations
INASL 2023 (Duseja 2023, PMID 36950481) — Indian National Association for Study of the Liver guidance States plainly that existing international guidelines "fail to capture the entire landscape of NAFLD in India" and are "often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure"; retains the NAFLD term deliberately, arguing the nomenclature debate "is creating undue confusion among clinical practitioners"
NICE 2016 (Glen 2016, PMID 27605111) — UK national guidance summary Predates both the rename and every approved drug

INASL makes the resource-stratification objection explicit (PMID 36950481), which matters in a country with a pooled adult NAFLD prevalence estimate of 38.6% (PMID 35677499; see epidemiology and burden). The documents also span a decade, from NICE 2016 and NASPGHAN 2017 to AISF and global guidance in 2026, so recommendations differ partly by publication date as well as health system.

1. Screening

Position Body
Screen within diabetes: fibrosis screening as a new standard of care in prediabetes and T2D, especially with obesity ADA 2025, PMID 40434108
Case-find in primary care and endocrinology; identify persons at risk to prevent cirrhosis AACE 2022, PMID 35569886
Early detection in T2D — the strongest-consensus item in the Spanish Delphi Romero-Gómez 2025, PMID 40221023
Do not routinely screen lean individuals in the general population; consider it above age 40 with T2D AGA 2022, PMID 35842345
No society recommends unselected general-population screening —

The disagreement is less about direction than about how strongly to phrase it, and no body has trial evidence for a screening programme with clinical endpoints. Population screening for liver fibrosis has been argued for in the literature (Ginès 2022, PMID 34537988) but has not entered guidance.

2. Vocabulary

APASL's 2025 guideline is written for MAFLD (PMID 40016576), as is the 2024 Chinese guideline (PMID 39544247), while AASLD, EASL, ALEH and the global consensus documents use MASLD. Because the definitions differ — MAFLD does not exclude concurrent liver disease and does not require the same alcohol threshold — this is not a stylistic difference: it changes the population a recommendation applies to. See nomenclature and definitions.

3. Ownership of the patient

Model Body
Hepatology-anchored with referral in AASLD, EASL, APASL
Endocrinology and primary care as the point of identification AACE 2022 (AASLD co-sponsored), PMID 35569886; AGA Clinical Care Pathway, PMID 34602251
Diabetes care as the screening venue, with liver health tracked like retinopathy and nephropathy ADA 2025, PMID 40434108
Explicit multidisciplinary referral protocols agreed per health area Spanish CPG 2025, PMID 40221023
Public-health response beyond clinical services altogether Lazarus 2022, PMID 34707258

The Spanish guideline is the only one to make inter-level referral protocols an explicit consensus recommendation, and Lazarus's global public-health consensus is the only document to observe that "health system and public health responses to NAFLD have been weak and fragmented" and that the disease is "absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity" (PMID 34707258).

4. Which drug, and for whom

ALEH recommends tailoring pharmacotherapy by steatohepatitis, fibrosis, excess weight and diabetes, listing resmetirom, incretin-based therapies, pioglitazone and SGLT2 inhibitors (PMID 40089151). AACE, writing in 2022 before any approval, recommended lifestyle, weight-loss medication (particularly GLP-1 receptor agonists), bariatric surgery, and pioglitazone or GLP-1 receptor agonists for T2D with NASH (PMID 35569886). The 2026 global consensus restricts the recommendation to resmetirom or semaglutide with explicit thresholds and defers to shared decision-making (PMID 41950980). AISF 2026 sits between them, building a structured selection-and-monitoring framework (STEPS-MASH) around resmetirom and semaglutide specifically while extending its scope beyond high-risk populations (PMID 41864758). Pioglitazone therefore appears in Latin American and endocrinology guidance and not in the newest hepatology consensus — the sharpest current divergence on treatment.

A new trial postdates much of this guidance. SGLT2 inhibitors appear in ALEH's list on observational grounds (PMID 40089151); dapagliflozin has since met all three histological endpoints in a randomised trial (other pharmacotherapy, PMID 40467095). An exact PubMed re-run on 2026-09-02 — ((MASLD OR NAFLD OR MASH OR NASH OR "steatotic liver disease") AND dapagliflozin AND (guideline OR guidance OR consensus OR recommendation)) — returned 8 records, none a guideline citing the histology trial.

5. HCC surveillance in advanced fibrosis without cirrhosis

ALEH advises HCC screening for all cirrhotic patients "with consideration given to those with advanced fibrosis based on individual risk" (PMID 40089151); AGA advises considering surveillance for patients whose non-invasive tests suggest F3 or F4 (PMID 37542503). Neither extends to non-cirrhotic MASLD generally, which is where a large minority of MASLD-related HCC arises — see MASLD-related hepatocellular carcinoma.

What guidance does not yet cover

  • Cirrhosis. No approved drug and no positive trial; guidance handles it by exclusion criteria (PMIDs: 41201884, 39038768). See cirrhosis and decompensation.
  • Children. An international multidisciplinary consensus on paediatric MAFLD exists (Zhang 2024, PMID 38677287) and NASPGHAN published a paediatric NAFLD guideline in 2017 (Vos 2017, PMID 28107283); no drug is approved paediatrically.
  • MetALD. Covered by a position statement rather than a guideline, recommending alcohol quantification by validated questionnaire and biomarker (PMID 39608457).
  • Genotype. AGA states current evidence is inadequate for routine genetic testing even in lean disease (PMID 35842345); no guideline incorporates genotype into stratification despite the evidence in genetics.

Open questions

  • Should guidelines be resource-stratified? INASL explicitly states that international guidance is difficult to implement in its setting for reasons of health infrastructure and sociocultural context (PMID 36950481), in a country with a high pooled prevalence estimate (PMID 35677499). The retrieved international documents did not supply a fully specified low-resource pathway; this comparison should not be read as proof that none exists.
  • How long does guidance take to absorb a positive randomised trial? Dapagliflozin met all three histological endpoints in 2025 (PMID 40467095) and appears in none of the guidelines retrieved on 2026-09-02, while resmetirom and semaglutide entered guidance within months of approval. Whether the difference is approval status, sponsorship or specialty ownership has not been examined.
  • Why is implementation low? The 2025 Delphi was commissioned because inter-guideline differences "contributed to a low implementation rate and suboptimal management" (PMID 40222485). A 2026 pre/post training study in 207 medical officers in Chhattisgarh increased mean guideline knowledge from 2.86 to 3.89 but left knowledge modest and did not measure longitudinal practice or patient outcomes (Kaushal 2026, PMID 41845319). Thus implementation education has been measured; durable practice change and clinical outcomes remain the dated evidence gap.
  • Should the two vocabularies be reconciled? APASL and Chinese guidance use MAFLD, everyone else MASLD, and the populations differ measurably (PMID 38293788). No body has proposed a reconciliation procedure.
  • Is the F2–F3 treatment window the right one? It comes from the trials' entry criteria, not from a risk analysis; ANTICIPATE-NASH data suggest some F3 patients carry less event risk than some F4 patients and vice versa (cirrhosis and decompensation) (Aceituno 2026, PMID 41212130).
  • Does the ≥30% LSM / ≥0.5 ELF response definition predict outcomes? It is a consensus construction (PMID 41950980) supported by observational serial-elastography data (Lin 2024, PMID 38512249), not by a trial in which response-guided management was randomised.
  • Should pioglitazone be in the hepatology algorithm? It is in Latin American and endocrinology guidance and absent from the 2026 hepatology consensus, despite the strongest randomised histological effect in T2D (other pharmacotherapy).

References

  1. Younossi ZM, Zelber-Sagi S, Lazarus JV, et al. Global Consensus Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease and Steatohepatitis. Gastroenterology. 2025;169(5):1017-1032.e2. PMID 40222485
  2. Younossi ZM, Kalligeros M, Wong VW, et al. Updated Global Consensus Recommendations for Risk Stratification, Treatment Initiation, and Response Monitoring in Metabolic Dysfunction-Associated Steatotic Liver Disease. Clin Gastroenterol Hepatol. 2026;24(9):2333-2347. PMID 41950980
  3. Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835. PMID 36727674
  4. Kanwal F, Neuschwander-Tetri BA, Loomba R, et al. Metabolic dysfunction-associated steatotic liver disease: Update and impact of new nomenclature on the AASLD practice guidance on nonalcoholic fatty liver disease. Hepatology. 2024;79(5):1212-1219. PMID 38445559
  5. Bansal MB, Patton H, Morgan TR, et al. Semaglutide therapy for metabolic dysfunction-associated steatohepatitis: November 2025 updates to AASLD Practice Guidance. Hepatology. 2026;83(5):1326-1340. PMID 41201884
  6. European Association for the Study of the Liver (EASL), EASD, EASO. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol. 2024;81(3):492-542. PMID 38851997
  7. Eslam M, Fan JG, Yu ML, et al. The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease. Hepatol Int. 2025;19(2):261-301. PMID 40016576
  8. Diaz LA, Arab JP, Idalsoaga F, et al. Updated recommendations for the management of metabolic dysfunction-associated steatotic liver disease (MASLD) by the Latin American working group. Ann Hepatol. 2025;30(2):101903. PMID 40089151
  9. Akuta N, Kogiso T, Ikejima K, et al. Evidence-based clinical practice guidelines for metabolic dysfunction-associated steatotic liver disease (MASLD) 2026. J Gastroenterol. 2026;61(6):693-710. PMID 42120590
  10. Romero-Gómez M, Escalada J, Noguerol M, et al. Multidisciplinary clinical practice guideline on the management of metabolic hepatic steatosis. Gastroenterol Hepatol. 2025;48(8):502442. PMID 40221023
  11. Fan JG, Xu XY, Yang RX, et al. Guideline for the Prevention and Treatment of Metabolic Dysfunction-associated Fatty Liver Disease (Version 2024). J Clin Transl Hepatol. 2024;12(11):955-974. PMID 39544247
  12. Cusi K, Abdelmalek MF, Apovian CM, et al. Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in People With Diabetes: The Need for Screening and Early Intervention. A Consensus Report of the American Diabetes Association. Diabetes Care. 2025;48(7):1057-1082. PMID 40434108
  13. Cusi K, Isaacs S, Barb D, et al. American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings. Endocr Pract. 2022;28(5):528-562. PMID 35569886
  14. Kanwal F, Shubrook JH, Adams LA, et al. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2021;161(5):1657-1669. PMID 34602251
  15. Wattacheril JJ, Abdelmalek MF, Lim JK, et al. AGA Clinical Practice Update on the Role of Noninvasive Biomarkers in the Evaluation and Management of Nonalcoholic Fatty Liver Disease: Expert Review. Gastroenterology. 2023;165(4):1080-1088. PMID 37542503
  16. Younossi ZM, Corey KE, Lim JK. AGA Clinical Practice Update on Lifestyle Modification Using Diet and Exercise to Achieve Weight Loss in the Management of Nonalcoholic Fatty Liver Disease: Expert Review. Gastroenterology. 2021;160(3):912-918. PMID 33307021
  17. Long MT, Noureddin M, Lim JK. AGA Clinical Practice Update: Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Lean Individuals: Expert Review. Gastroenterology. 2022;163(3):764-774.e1. PMID 35842345
  18. Duell PB, Welty FK, Miller M, et al. Nonalcoholic Fatty Liver Disease and Cardiovascular Risk: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol. 2022;42(6):e168-e185. PMID 35418240
  19. Arab JP, Díaz LA, Rehm J, et al. Metabolic dysfunction and alcohol-related liver disease (MetALD): Position statement by an expert panel on alcohol-related liver disease. J Hepatol. 2025;82(4):744-756. PMID 39608457
  20. Lazarus JV, Mark HE, Anstee QM, et al. Advancing the global public health agenda for NAFLD: a consensus statement. Nat Rev Gastroenterol Hepatol. 2022;19(1):60-78. PMID 34707258
  21. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67(1):328-357. PMID 28714183
  22. European Association for the Study of the Liver (EASL), EASD, EASO. EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64(6):1388-402. PMID 27062661
  23. Zhang L, El-Shabrawi M, Baur LA, et al. An international multidisciplinary consensus on pediatric metabolic dysfunction-associated fatty liver disease. Med. 2024;5(7):797-815.e2. PMID 38677287
  24. Vos MB, Abrams SH, Barlow SE, et al. NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017;64(2):319-334. PMID 28107283
  25. Ginès P, Castera L, Lammert F, et al. Population screening for liver fibrosis: Toward early diagnosis and intervention for chronic liver diseases. Hepatology. 2022;75(1):219-228. PMID 34537988
  26. Noureddin M, Charlton MR, Harrison SA, et al. Expert Panel Recommendations: Practical Clinical Applications for Initiating and Monitoring Resmetirom in Patients With MASH/NASH and Moderate to Noncirrhotic Advanced Fibrosis. Clin Gastroenterol Hepatol. 2024;22(12):2367-2377. PMID 39038768
  27. Aceituno L, Bañares J, Pons M, et al. The ANTICIPATE-NASH Models Stratify Better the Risk of Clinical Events Than Histology in MASLD Patients With Advanced Chronic Liver Disease. Gastroenterology. 2026;170(2):385-394. PMID 41212130
  28. Lin H, Lee HW, Yip TC, et al. Vibration-Controlled Transient Elastography Scores to Predict Liver-Related Events in Steatotic Liver Disease. JAMA. 2024;331(15):1287-1297. PMID 38512249
  29. Song R, Li Z, Zhang Y, et al. Comparison of NAFLD, MAFLD and MASLD characteristics and mortality outcomes in United States adults. Liver Int. 2024;44(4):1051-1060. PMID 38293788
  30. European Association for the Study of the Liver, EASD, EASO. Executive summary of the EASL-EASD-EASO Clinical Practice Guidelines on the management of MASLD. Diabetologia. 2024;67(11):2375-2392. PMID 38869512
  31. European Association for the Study of the Liver, EASD, EASO. EASL-EASD-EASO Clinical Practice Guidelines on the management of MASLD. Obes Facts. 2024;17(4):374-444. PMID 38852583
  32. European Association for the Study of the Liver, EASD, EASO. EASL-EASD-EASO Clinical Practice Guidelines for the management of NAFLD. Diabetologia. 2016;59(6):1121-1140. PMID 27053230
  33. Kaushal K, et al. From Policy to Practice: Knowledge gaps and training outcomes related to MASLD guidelines among medical officers in Chhattisgarh, India. BMC Health Serv Res. 2026;26(1):579. PMID 41845319
  34. Sohn W, Lee YS, Kim SS, et al. KASL clinical practice guidelines for the management of metabolic dysfunction-associated steatotic liver disease 2025. Clin Mol Hepatol. 2025;31(Suppl):S1-S31. PMID 39967303
  35. Associazione Italiana per lo Studio del Fegato (AISF). AISF practice guidance on pharmacological treatment of metabolic-dysfunction associated steatotic liver disease and steatohepatitis (MASLD/MASH): A 2026 Update. Dig Liver Dis. 2026;58(5):599-607. PMID 41864758
  36. Duseja A, Singh SP, De A, et al. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol. 2023;13(2):273-302. PMID 36950481
  37. Glen J, Floros L, Day C, et al. Non-alcoholic fatty liver disease (NAFLD): summary of NICE guidance. BMJ. 2016;354:i4428. PMID 27605111
  38. Shalimar, Elhence A, Bansal B, et al. Prevalence of Non-alcoholic Fatty Liver Disease in India: A Systematic Review and Meta-analysis. J Clin Exp Hepatol. 2022;12(3):818-829. PMID 35677499
  39. Lin J, Huang Y, Xu B, et al. Effect of dapagliflozin on metabolic dysfunction-associated steatohepatitis: multicentre, double blind, randomised, placebo controlled trial. BMJ. 2025;389:e083735. PMID 40467095