Rethinking fatty liver (MASLD): comorbidities and team care

Summary: The authors estimate that fatty liver disease (MASLD) affects 35 to 40% of adults worldwide. Whether complications arise in liver, heart and kidneys depends not only on liver scarring but also on how many and which metabolic disorders come on top. Type 2 diabetes and high blood pressure weigh most. British experts therefore call for treating MASLD as a whole-body metabolic disease and moving care into multidisciplinary teams in the community.

State of the evidence: The paper was accepted on 21 May 2025 and published on 29 May 2025. It presents studies up to 2024 and 2025. No systematic literature search is described. This article was written on 17 October 2026; newer studies are not included.

What is it about?

MASLD (metabolic dysfunction-associated steatotic liver disease, formerly NAFLD) means fat in the liver plus at least one of five metabolic risk factors of the metabolic syndrome: overweight, abnormal blood sugar or type 2 diabetes, high blood pressure, high blood fats (triglycerides) and low HDL cholesterol. Some people have just one of these, others all five. The authors ask what this means for risk and care.

How was it studied?

The text is a perspective article by Bilson, Cuthbertson and Byrne from southern England and Liverpool, not a new study. It draws on published cohorts and reviews and derives proposals for care.

What does the paper show?

• More risk factors, more complications: In a large cohort of more than 270,000 people with fatty liver, the risk of liver cancer or cirrhosis rose to 1.33, 1.61 and 2.03 times with two, three and four metabolic factors. In people with type 2 diabetes, the risk of major liver complications rose from 1.55 times (two factors) to 4.09 times (six factors).
• Kidney risk rises too: With fatty liver and five metabolic factors, chronic kidney disease was about 5.8 times as common as in people without fatty liver and without any metabolic factor.
• Two factors weigh most: Type 2 diabetes and high blood pressure had the strongest influence on liver, cardiovascular and kidney complications in several studies.
• Who is at risk? People with fatty liver and all metabolic factors carry the highest risk of vascular complications. Genes also play a role: there is evidence for a more liver-predominant and a more heart-predominant type.
• Alcohol counts: Even moderate intake can worsen the disease; with advanced fibrosis or cirrhosis, alcohol should be avoided completely.
• Earlier testing and new medicines: A fibrosis test (FIB-4) can be run as a reflex test during diabetes check-ups. In type 2 diabetes, SGLT2 inhibitors, GLP-1 and dual GLP-1/GIP receptor agonists should enter treatment earlier, because they can lower liver fat, weight and several risk factors at once.
• Care in the community: Family practices, nurses, diet and exercise specialists and experts in diabetes, heart, kidney and liver should work together, including through monthly virtual case reviews. The specialist centre mainly handles cancer surveillance, checks for varices in the gullet and advanced cirrhosis.

Where are the limits?

• This is a perspective, not a systematic review or study; the authors chose the evidence.
• The cohorts presented are observational data and cannot prove cause and effect.
• How much metabolic disorder and liver scarring each contribute to complications is still unclear, according to the authors.
• Whether fibrosis screening for everyone is cost-effective is not proven.
• The proposals refer mainly to the British health system.

What does this mean for me?

The evidence describes groups and says nothing about your personal risk. It does show that with fatty liver it pays to watch blood sugar, blood pressure, blood fats and weight together, not only liver tests. If you have diabetes or high blood pressure, you can ask your family doctor to assess your risk of liver fibrosis. Discuss with your doctor which tests and treatments make sense for you.

This article does not replace medical advice.

Source and notes

• Citation: Bilson J, Cuthbertson DJ, Byrne CD. Evolving models of care in patients with metabolic dysfunction-associated steatotic liver disease, recognising its population burden and the impact of metabolic dysfunction on incident rates of hepatic and extrahepatic outcomes. Metab Target Organ Damage 2025;5:27. DOI: 10.20517/mtod.2025.28. Open access (CC BY 4.0).
• Study type: Perspective article.
• Funding: None.
• Conflicts of interest: Josh Bilson is a junior editorial board member and Christopher Byrne honorary editor-in-chief of the journal; both state they were not involved in the editorial process. Daniel Cuthbertson reports no conflicts of interest.