Originally published by our sister publication Gastroenterology & Endoscopy News
WASHINGTON—Despite the prevalence of chronic and progressive liver diseases among U.S. adults, awareness of the conditions remains woefully low, not just in the general population but among physicians. At The Liver Meeting 2025, researchers presented studies revealing gaps in care and missed opportunities for treatment.
“Patients are aware of diabetes, heart health, cholesterol, but it seems no one talks about liver disease. And it’s not just the patients. Primary care physicians don’t usually screen their patients for MASLD,” said Jameel Alp, MD, an internal medicine resident at the University of Minnesota, in Minneapolis. Dr. Alp and his co-investigators sought to examine nationwide awareness of MASLD, “because there were no prior studies discussing it.”
Using data from the National Health and Nutrition Examination Survey from 2017 to 2023, the investigators identified adults for whom body mass index and vibration-controlled transient elastography data were available. “Through that population, we were able to identify if they had MASLD. We followed the current criteria for the diagnosis of MASLD, the diagnosis of MASH, and the proportion of those eligible for resmetirom,” Dr. Alp said.
The initial analysis included 13,188 individuals, projecting to a total of 219 million people. Before and after the COVID-19 pandemic, the prevalence of MASLD-related compensated advanced chronic liver disease (cACLD) increased from 3.7% to 5.4% (P=0.02), and the proportion deemed eligible for resmetirom (Rezdiffra, Madrigal) increased from 13.4% to 15.7% (abstract 2014).
Estimates show that “about 3.7% of U.S. adults [had] MASLD-related [cACLD] in the pre-pandemic era,” Dr. Alp said. “Yet only 8.5% of those individuals were aware they had advanced liver disease, meaning more than nine out of 10 had no idea. That level of unawareness was really quite shocking.”
While the awareness of the disease in those with MASLD-related cACLD increased to 20.4% in the post-pandemic era, cACLD patients are at a high risk for complications and, therefore, not eligible for resmetirom. In those who were eligible for the drug, awareness fell from 12.6% to 10.3%.
“If they’re not aware, they’re not going to seek care and they’re not going to get the medication,” Dr. Alp said. “This type of disease is one of the silent killers, and we have a lot of work to do to increase the awareness of MASLD in the general population, in primary care physicians, and even in some GI physicians.”
Ashwani Singal, MD, MS, a transplant hepatologist and professor of medicine at the University of Louisville, in Kentucky, told Gastroenterology & Endoscopy News that the findings are clinically more relevant now that there are FDA-approved treatments for MASH.
“What we do not understand is the reason for these findings. The increasing severity of the disease over time can be explained by lack of focused attention to MASH patients during the COVID-19 pandemic,” Dr. Singal explained. “It will be interesting to see whether the metabolic comorbidities have also increased since that time. Clearly, more awareness and education are needed in the primary care setting, with interventions to identify high-risk patients and refer them to specialists for management.”
Not Enough Referrals
A retrospective review presented by Rahul Sandella, MD, a resident at the University of Chicago Medicine, found that patients with MASLD or MASH are not receiving needed referrals to hepatology for treatment.
“Often, patients with MASH present to hepatology in advanced stages. We wanted to see what we can do to improve on how soon they get screened and evaluated,” Dr. Sandella said, explaining that his team hopes to investigate current care pathways and referral patterns to describe screening, diagnosis, and treatment of MASLD and MASH in the ambulatory care setting.
The retrospective review of patients seen in 35 ambulatory care clinics between 2021 and 2025 included 56,552 patients; 73% (41,525) were considered at low risk for fibrosis based on their Fibrosis-4 Index (FIB-4) scores, while 20% (11,292) and 7% (3,735) were considered intermediate and high risk, respectively (abstract 2013).
Across all three categories, between 11% and 12% were referred to a hepatologist. “When we look at those who were actually seen by hepatology, about 18% of those with high risk for fibrosis were seen, compared against 5% in the low-risk group,” Dr. Sandella said. “Still, 18% is lower than we would have anticipated or perhaps wanted for patients in a high-risk category.”
Looking for factors associated with referral to hepatology, metabolic characteristics such as diabetes and obesity didn’t appear to play a role, but race did. “About 33% of white patients with high risk for liver fibrosis were referred to or seen by hepatology, compared with 20% of Black patients with high risk for fibrosis,” Dr. Sandella said.
Outpatient subspecialty also was a factor. Patients with a high risk for fibrosis were most likely to be referred to hepatology, seen by hepatology, or referred for further liver stiffness testing when seen by gastroenterology, at 73%. Only 39% of high-risk patients seen by endocrinology—and between 22% and 24% of those seen by family medicine, internal medicine, or cardiology—received a referral.
“Patients who are at high risk for fibrosis based on FIB-4 testing do not seem to be getting the appropriate referrals and screening tests to evaluate for their stage of fibrosis. This presents an opportunity to identify and treat these patients earlier. We’re working to see how we can intervene without overwhelming the primary care doctors who have a lot on their plate otherwise,” Dr. Sandella said. “I’m looking forward to seeing how we can work together.”
Dr. Singal commented that the study addresses an important gap in the care pathway for referral of MASLD patients to specialty care, noting that the study’s strengths include its large sample size and multiple settings.
“It was an interesting observation that Black patients were less likely to be referred than white patients, and it’s unclear whether this is a true referral issue or if patients are not going to specialists despite being referred,” he stated.
“It is very likely that primary care providers and other specialties are unaware of the use of FIB-4,” Dr. Singal added. “This can be overcome by building calculation of FIB-4 into clinical documentation and referring if a patient’s FIB-4 is above 2.67, thus considered at intermediate to high risk for fibrosis.”
—Monica J. Smith
Drs. Alp and Sandella reported no relevant financial disclosures. Dr. Singal is a member of the Gastroenterology & Endoscopy News editorial board.