MRI in MASLD: technical foundations and guideline-based applications

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a major global health burden and fibrosis stage remains the principal determinant of liver-related and overall outcomes. As management increasingly relies on non-invasive risk stratification and treatment monitoring, MRI has become an important quantitative platform for liver assessment. This narrative review summarises the technical foundations and guideline-based applications of MRI in MASLD. MRI proton density fat fraction quantifies hepatic steatosis, magnetic resonance elastography measures liver stiffness as a marker of fibrosis and corrected T1 provides information on fibroinflammatory activity. MRI-based composite models, including magnetic resonance elastography combined with the fibrosis-4 index and MRI-aspartate aminotransferase score, integrate imaging and biochemical biomarkers for risk assessment. Current international guidelines generally recommend a stepwise pathway beginning with high-risk case-finding and blood-based fibrosis assessment, followed by elastography or other imaging-based tests when indicated. MRI is not routinely recommended for universal first-line screening but may add value in indeterminate or discordant cases, suspected advanced fibrosis or at-risk metabolic dysfunction-associated steatohepatitis, treatment selection and longitudinal monitoring. By integrating technical evidence with recommendations from major international societies, this review provides a practical framework for the use of MRI across the MASLD care pathway.