Liver pathways
This document provides a national clinical pathway for the diagnosis, assessment, management, and referral of Metabolic Dysfunction Associated Liver Disease (MASLD) and Met-ALD in Scotland. It outlines criteria for primary and secondary care, including fibrosis assessment, lifestyle advice, and the integration of liver screening and diagnostic tools. This pathway is intended for professional use; it is NOT for use by members of the public. It is not replacement for advice from your usual healthcare professional.
MASLD and Met-ALD definitions:
- MASLD is the updated term for Non-Alcohol Related Fatty Liver Disease, occurring mainly in overweight or obese individuals with metabolic dysfunction features;
- Met-ALD applies to those exceeding recommended alcohol intake but below pure Alcohol-related Liver Disease thresholds.
Metabolic dysfunction criteria:
- Impaired Glucose Tolerance* (IGT) or Type II DM
- BP > 130/85 mmHg or antihypertensive therapy
- Plasma triglycerides ≥ 1.70 mmol/L or lipid lowering therapy
- HDL cholesterol ≤ 1.0 (male) or 1.3 mmol/L (female)
Diagnosis in primary care: MASLD diagnosis requires:
- typical liver function test abnormalities (mildly elevated ALT/AST and often GGT),
- negative non-invasive liver screens for other causes
- alcohol consumption within ≤14 units/week;
Met-ALD is diagnosed when alcohol intake is >14 but below sex-specific upper limits defining alcohol related liver disease (ArLD).
Liver screen and investigation: (see appendix 1)
A standard liver screen should exclude
- viral hepatitis
- haemochromatosis
- autoimmune liver disease
Ultrasound in primary care:
Only required if
- elevated alkaline phosphatase or
- high risk of cirrhosis (FIB-4 > 3.25)
Fibrosis assessment:
The FIB-4 score is used to assess fibrosis risk, with thresholds adjusted for age;
- scores below 1.3 (or 2.0 if ≥65 years) indicate low risk
- elevated scores warrant further testing with ELF where available or referral for further fibrosis assessment
- FIB-4 is not reliable under age 35.
Referral criteria:
Referral to secondary care is recommended for
- patients under 35
- Age 35–65 with FIB-4 >1.3
- ≥65 with FIB-4 >2.0
- Where ELF testing is available use to further risk stratify those <35 or with elevated FIB-4, referring if ≥9.8.
At all times consider co-morbidities and frailty when deciding to refer
- Lifestyle advice: Emphasise sustainable long-term changes including
- 10% body weight loss to resolve steatosis and improve fibrosis
- calorie deficit guidance
- alcohol reduction or abstinence especially with elevated fibrosis risk
- encouragement of regular exercise per WHO guidelines
- referral to weight loss programs where available
Screening for and management of cardiovascular risk :
Cardiovascular disease is the primary cause of death amongst patients with MASLD/Met-ALD.
Secondary care assessment process:
Includes nurse-led evaluation of
- BMI
- medical and alcohol history
- medication review
- completion of liver screen (if not completed in Primary care)
- diabetes screening
- updated labs
- Fibroscan to guide diagnosis and management
Secondary care management:
Uses liver stiffness measurement (LSM) to stratify risk; This is most commonly via Fibroscan but other methods are available (see Appendix 2)
Fibroscan
- LSM <10 kPa allows discharge
- 10–15 kPa suggests monitoring and lifestyle intervention, or drug therapy as it becomes available
- LSM >15 kPa indicates probable cirrhosis requiring specialist follow-up, with considerations for portal hypertension and surveillance. Consider pharmacological treatments as these become available.
