Key points
- Baveno VII "rule of five" for liver stiffness: 10, 15, 20, 25 kPa.
- Liver cancer surveillance: ultrasound (± AFP) every 6 months in cirrhosis.
- Carry on statins, diabetes care and weight management in compensated disease.
- Approved MASH drugs are not yet licensed for cirrhosis.
For the evidence, graded recommendations, a case and self-test questions, read Module 5: Caring for MASLD cirrhosis.
1Liver stiffness: the rule of five
| LSM (VCTE) | Meaning |
|---|---|
| <10 kPa | Compensated advanced chronic liver disease (cACLD) unlikely |
| 10–15 kPa | Suggestive of cACLD |
| >15 kPa | Highly suggestive of cACLD |
| ≤15 kPa + platelets ≥150 | Rules out clinically significant portal hypertension (CSPH) |
| <20 kPa + platelets >150 | Screening endoscopy for varices can be skipped |
| ≥25 kPa | Rules in CSPH (less reliable in obese MASLD) |
2Other essentials
- Non-selective beta-blocker (carvedilol preferred) if CSPH, to prevent decompensation.
- Vaccinate against hepatitis A and B if not immune.
- Watch for sarcopenia; avoid long fasts and give enough protein.
- Refer for liver transplant assessment after a first decompensation.
3Advanced fibrosis without cirrhosis (F3)
Liver cancer can occur in MASLD before cirrhosis. EASL advises surveillance at F3 only after an individual risk assessment, and the global consensus individualises it for all non-cirrhotic patients. The Saudi 2026 consensus is more active: its text advises 6-monthly surveillance once non-invasive tests suggest F3 or worse (for example FIB-4 above 2.67 or stiffness above 12 kPa).
Related topics
References
- de Franchis R, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022;76:959–74. doi:10.1016/j.jhep.2021.12.022
- EASL–EASD–EASO Clinical Practice Guidelines on the management of MASLD. J Hepatol 2024;81:492–542. doi:10.1016/j.jhep.2024.04.031
- Rinella ME, et al. AASLD Practice Guidance on the clinical assessment and management of NAFLD. Hepatology 2023;77:1797–835. doi:10.1097/HEP.0000000000000323
- Younossi ZM, et al. Global consensus recommendations for MASLD and MASH. Gastroenterology 2025;169(5):1017–32. doi:10.1053/j.gastro.2025.02.044
- Abaalkhail F, et al. MASLD management in Saudi Arabia: a modified Delphi-based adaptation of international standards. Saudi J Gastroenterol 2026;32(2):104–20. doi:10.4103/sjg.sjg_199_25
- EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis – 2021 update. J Hepatol 2021;75:659–89. doi:10.1016/j.jhep.2021.05.025
How to cite this page
Desoky M. MASLD cirrhosis: key care. Metabolic Liver Academy quick reference, version 1.0. Updated 2026-10-03. Available from: https://drmahmouddesoky.github.io/metabolic-liver-academy/ref/cirrhosis.html
A summary of published guidelines for healthcare professionals. It does not replace clinical judgement, the full guidelines or local drug labels. Disclaimer.