Time to Screen for Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): Insights From a Single-Center...

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common cause of chronic liver disease worldwide and is strongly associated with obesity and type 2 diabetes. However, many patients remain undiagnosed in primary care because liver enzyme levels are often normal despite the presence of clinically significant fibrosis. Current international guidelines recommend the use of noninvasive fibrosis scores, such as the fibrosis-4 (FIB-4) index, for risk stratification. Importantly, this study focuses on individuals with normal liver enzymes who are at risk of MASLD rather than those with an established diagnosis, positioning FIB-4 as a pragmatic screening tool to identify high-risk patients in primary care settings.

This study aimed to evaluate fibrosis risk among high-risk primary care patients with normal liver biochemistry and to assess referral patterns to gastroenterology services. This study provides the first real-world evidence from Saudi Arabia evaluating noninvasive fibrosis risk stratification in a primary care population with normal liver enzymes.

This retrospective observational study used electronic medical record data from primary care clinics within a large tertiary healthcare system in Saudi Arabia between January 2021 and December 2024. Adult patients (n = 200) with metabolic risk factors, including obesity and type 2 diabetes, with no previous diagnosis of liver disease and normal liver enzyme levels were included. FIB-4 scores were calculated using routinely available laboratory parameters to stratify patients into low, intermediate, and high fibrosis risk categories.

A notable proportion of patients with normal liver enzymes demonstrated intermediate or high fibrosis risk based on FIB-4 scores. Referral rates to gastroenterology services were low, suggesting missed opportunities for early detection. Integrating FIB-4 into routine primary care pathways may improve early identification and referral of patients at risk of advanced fibrosis in MASLD.

These findings highlight the importance of proactive screening in high-risk individuals, even when liver enzymes are normal, as reliance on biochemistry alone may overlook clinically significant fibrosis; incorporating tools such as FIB-4 and the AST:ALT ratio can facilitate earlier identification and timely intervention.