Artificial Intelligence for Fibrosis Diagnosis in Metabolic-Dysfunction-Associated Steatotic Liver Disease: A Systematic Review

<b>Background/Objectives</b>: Artificial intelligence (AI) is an emerging technology for diagnosing liver fibrosis in Metabolic-Dysfunction-Associated Steatotic Liver Disease (MASLD), but a comprehensive synthesis of its performance is lacking. This systematic review (SR) aimed to evaluate the current evidence of AI models for diagnosing or staging liver fibrosis in patients with MASLD compared to conventional diagnostic tools. <b>Methods</b>: A comprehensive search was conducted in PubMed, Scopus, Web of Science, ScienceDirect, Embase, LILACS, IEEE Series, and Association for Computing Machinery (ACM). Primary studies applying AI to diagnose fibrosis in adults with MASLD were included. Risk of bias was assessed using the QUADAS-2 tool, and methodological reporting was evaluated according to the MINimum Information for Medical AI Reporting (MINIMAR) guideline. A narrative synthesis was performed, grouping studies by data type (clinical/laboratory vs. imaging) and summarizing diagnostic performance and clinical application. A frequency-based analysis was applied to identify the most recurrent predictive features, and an analysis of the AI architecture and application was reported. The review was registered in PROSPERO (CRD420251035919). <b>Results</b>: Twenty-one studies were included, encompassing 19,221 patients and 5237 images. Across studies, AI models consistently outperformed non-invasive scores such as Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Score (NFS). The most frequent predictive variables were identified. Despite an overall low risk of bias, methodological transparency and external validation were limited. <b>Conclusions</b>: AI is feasible for the non-invasive diagnosis of liver fibrosis in MASLD, demonstrating superior accuracy to standard clinical scores. Broader clinical application is limited by the lack of external validation and high heterogeneity among the studies. Prospective validation in diverse, multicenter cohorts is essential before AI can be integrated into routine clinical practice.