Metabolic dysfunction-associated steatohepatitis in the real world: clinical burden, disease progression, and risk stratification with non-invasive tests

Metabolic dysfunction-associated steatohepatitis (MASH) increases risk of liver-related outcomes, yet comorbidities and mortality patterns remain unclear. Using Optum Market Clarity, we identified adults with MASH and assessed associations of comorbidities and noninvasive tests with liver outcomes and mortality via Fine-Gray models. 18,710 patients were identified (73.5% without cirrhosis, 9.0% with compensated cirrhosis (CC), 17.8% with decompensated cirrhosis, DC). The mortality rate was 0.82, 3.50, and 11.28 per 100 person-years (PY) for the non-cirrhosis, CC and DC subgroups, respectively. Among those without cirrhosis, progression to cirrhosis occurred at a rate of 5.71 per 100 PY. A FIB-4 score > 2.67 vs. ≤ 2.67 was associated with a seven-fold increase in mortality risk (adjusted hazard ratio [aHR] = 7.06; 95% confidence interval [CI] = 6.37–7.83). Elevated AST levels (> 40 U/L vs. ≤40 U/L; aHR = 1.38, 95% CI = 1.24–1.53) and living with ≥ 3 comorbidities (vs. none; HR:1.93, 95% CI 1.47–2.54) were also associated with increased mortality. Our findings highlight the impact of MASH on patients and show how accessible noninvasive tests can identify those at highest risk, empowering timely care at every stage.