Advances in the non-invasive assessment of metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects approximately 30% of adults worldwide. Liver biopsy remains the reference standard but is unsuitable for population-wide screening due to its invasiveness and cost. This review summarizes recent advances in non-invasive tests (NITs) for MASLD and proposes a conceptual three-tier framework to guide clinical practice. First-tier serum biomarker scores enable low-cost initial risk stratification in primary care. Second-tier imaging elastography techniques provide objective quantification of liver stiffness and steatosis for fibrosis staging. Third-tier emerging artificial intelligence (AI) and multi-modal integration models remain investigational but hold promise for precise subtyping. Despite substantial progress, challenges persist in accessibility, standardization, and cost-effectiveness. With the recent Food and Drug Administration (FDA) approvals of resmetirom and semaglutide for metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced fibrosis (F2-F3), and the acceptance of vibration-controlled transient elastography (VCTE) as a surrogate endpoint, NITs have become essential for patient selection, treatment monitoring, and longitudinal disease management. Future directions include multi-omics integration and AI-empowered clinical decision support, enabling a shift toward personalized, metabolic-driven care.