Liver Biopsy in Metabolic-Associated Steatotic Liver Disease: Accuracy, Challenges, and Alternatives

Metabolic-associated steatotic liver disease (MASLD) is a common medical condition that can progress to metabolic-associated steatohepatitis (MASH) and advanced fibrosis, leading to severe outcomes. Liver biopsy continues to be the diagnostic gold standard; however, its accuracy and clinical utility in MASLD are subject to debate. Biopsy is also invasive and carries procedural risks. This contemporary narrative review examines the limitations of liver biopsy in MASLD and explores noninvasive alternatives. Our findings indicate that the diagnostic reliability of liver biopsy is limited by sampling error and by variability in tissue adequacy. Interobserver variability further adds to challenges in histological interpretation. Demographic factors and comorbid conditions significantly contribute to the misclassification of disease severity. Among well-established noninvasive tests, transient elastography and magnetic resonance elastography (MRE) assess larger liver volume and demonstrate dependable accuracy in detecting fibrosis, though both have implicit limitations. In conclusion, liver biopsy remains paramount in select clinical cases. Although current guidelines recommend noninvasive tests as first-line assessment tools in MASLD and MASH, no single approach is suitable for all patients. Future evaluation strategies should prioritize patient-centered assessments accounting for the multifactorial nature of MASLD.