Review of care pathways for fatty liver (MASLD): how dangerous liver scarring is found early

In short: A new review pooled nine studies with 8,551 people in total. It shows that simple blood tests plus an ultrasound-based liver stiffness scan can find people with advanced liver scarring. But only about half of those referred by their family doctor actually make it to the liver specialist ¹.

Status of the evidence: The study’s literature search was completed on 19 January 2026 and published in Liver International (accepted 4 March 2026; included studies date from 2019 to 2025). Article written on 4 October 2026. Newer studies are not covered.

What is this about?

Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD) is the most common chronic liver disease worldwide. Its global prevalence rose from 25.3% to 38.2%. Among people with type 2 diabetes it is 60 to 80%. In most people fatty liver stays mild. In roughly 12 to 40% it turns into inflammation (MASH), and some develop scar tissue (fibrosis) and eventually cirrhosis. This often goes unnoticed for years because there are no symptoms ¹.

The challenge: not everyone with fatty liver needs a specialist, but nobody with advanced scarring should be missed. A “care pathway” is a fixed sequence that defines who gets tested, when, and when they are sent on.

What does such a pathway look like?

Most pathways use two steps:

1. FIB-4: A score calculated from age, two liver blood values and platelet count. It costs almost nothing because the values are part of routine blood work.
2. Liver stiffness (e.g. FibroScan): A painless ultrasound-based test that measures how firm the liver is. Only people flagged in step one get it.

People who are unremarkable in both steps stay with their family doctor. Those flagged are referred to a liver specialist (hepatology). The review found four studies using one step and five using two steps. They came from seven countries, with 162 to 2,206 participants each ¹.

What did the studies find?

• Pathways find people at risk. Risk assessment improved in every study. One UK study cut unnecessary referrals by 81%.
• The effort is manageable. Depending on the study, 8 to 89 people had to be tested to find one person with advanced scarring. For one referral it was only 2 to 19.
• Many do not arrive. At each step, more people are lost. In three studies only about half of those referred visited the specialist, and in one only a third (33.3%).

Where are the limits?

The studies are hard to compare. Each defined “advanced scarring” and its cut-offs differently. Six of nine studies had no comparison group. Hardly any checked whether people who stayed with their family doctor actually had scarring after all. Also, normal liver enzymes do not rule out advanced scarring. In one survey, 70% of primary care doctors said they would only refer people with abnormal liver values ¹.

What does this mean for me?

If you have type 2 diabetes, severe overweight or other metabolic risks, ask your family doctor about your FIB-4 score. It can usually be calculated from existing blood values. If you are referred, go to the appointment. This is where most people are lost. Large European studies (GRIP on MASH with 10,000 and LiverScreen with 30,000 participants) are now testing how pathways work best in everyday practice ¹.

This article does not replace medical advice.