Title : Severity of hepatic steatosis as a predictor of clinical outcomes in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)
Abstract:
Introduction: Metabolic dysfunction–associated steatotic liver disease (MASLD) has become the most prevalent chronic liver disease worldwide, affecting approximately 25-30% of the adult population. As the hepatic manifestation of systemic metabolic dysfunction, MASLD is strongly associated with obesity, insulin resistance, and type 2 diabetes mellitus. The disease encompasses a clinical spectrum ranging from simple steatosis to steatohepatitis, progressive fibrosis, cirrhosis, and hepatocellular carcinoma. Although liver fibrosis is recognized as the strongest independent predictor of clinical outcomes, the prognostic role of hepatic steatosis severity remains incompletely defined.
Methods: A narrative literature review was conducted using a structured search strategy in PubMed, SciELO, and LILACS databases, including studies published between January 2014 and December 2024. Eligible studies included prospective and retrospective longitudinal studies, clinical trials, meta-analyses, and international clinical guidelines that stratified hepatic steatosis into mild (<33%), moderate (34-66%), and severe (>66%) categories. Studies correlating steatosis severity with clinically relevant outcomes such as fibrosis progression, cirrhosis, hepatocellular carcinoma, and cardiovascular events were included. Case reports, studies with fewer than 50 participants, and studies lacking objective diagnostic stratification were excluded. In total, 38 studies met the inclusion criteria.
Results: The analyzed evidence demonstrated a progressive association between increasing steatosis severity and worse clinical outcomes. Moderate steatosis was associated with approximately a twofold increased risk of fibrosis progression, whereas severe steatosis was linked to nearly a threefold higher risk and a greater incidence of hepatocellular carcinoma. Additionally, individuals with MASLD showed a 50-60% higher risk of major cardiovascular events compared with individuals without the disease. Sequential noninvasive strategies, particularly the use of the FIB-4 score followed by liver elastography, demonstrated high diagnostic accuracy for prognostic stratification.
Conclusion: Higher grades of hepatic steatosis are associated with progressively increased hepatic and cardiovascular risk. Although liver fibrosis remains the main independent determinant of prognosis, the severity of steatosis may represent an important early marker for risk stratification and timely metabolic intervention in patients with MASLD.
