Metabolic dysfunction-associated steatotic liver disease management in Saudi Arabia: A modified Delphi-based adaptation of international standards

The reclassification of nonalcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated steatotic liver disease (MASLD) marks a significant shift in understanding liver disease, particularly in Saudi Arabia, where metabolic disorders are highly prevalent. This study aimed to develop expert consensus recommendations for early detection, specialist referral, and management of MASLD/metabolic dysfunction-associated steatohepatitis (MASH) in Saudi Arabia. A modified Delphi process was used to establish consensus among an expert panel of 15 multidisciplinary specialists, including hepatologists, endocrinologists, gastroenterologists, and primary care physicians. The panel addressed six key areas: terminology and epidemiology, screening, risk categories, hepatocellular carcinoma surveillance, first-line treatment, and advanced therapeutic options. A literature review spanning January 2011 to May 2024 informed evidence-based recommendations, assessed using the Grading of Recommendations, Assessment, Development, and Evaluation criteria. The consensus established screening criteria for high-risk groups, emphasizing noninvasive tests (NITs) such as Fibrosis-4 (FIB-4), enhanced liver fibrosis (ELF) score, and magnetic resonance elastography (MRE). Risk stratification thresholds were defined: FIB-4 ≥2.67, liver stiffness measurement (LSM) >12 kPa, and MRE >5.0 kPa indicate advanced fibrosis requiring specialist referral. Treatment recommendations emphasized a multidisciplinary approach, incorporating lifestyle modifications, pharmacotherapy (including glucagon-like peptide-1 receptor agonists [GLP-1 RA], sodium-glucose cotransporter-2 [SGLT2] inhibitors, and pioglitazone), and surgical interventions when appropriate. Bariatric surgery was recommended for eligible patients with noncirrhotic MASLD. This consensus provides evidence-based guidance for MASLD/MASH management in Saudi Arabia, highlighting early detection through NITs, risk-stratified care pathways, and multidisciplinary treatment strategies essential for improving patient outcomes in the region.