Key points
- Low risk: repeat FIB-4 every 1–2 years with diabetes or several risk factors, every 2–3 years otherwise.
- Indeterminate: repeat second-line test in about a year, or refer.
- High risk (LSM ≥12 kPa, ELF ≥9.8): hepatology.
- Any sign of cirrhosis or decompensation: urgent referral.
For the evidence, graded recommendations, a case and self-test questions, read Module 1: Assessing liver fibrosis in MASLD.
1Refer to hepatology if
- LSM ≥12 kPa or ELF ≥9.8, or FIB-4 ≥2.67 without access to a second test.
- Clinical, lab or imaging signs of cirrhosis.
- Doubt about the diagnosis or another liver disease suspected.
- Candidate for MASH drug treatment.
- ALT persistently above 3 times normal.
2Red flags: same-day care
- Jaundice, confusion, vomiting blood or black stools, rapid abdominal swelling.
3Every visit
- Weight and waist, blood pressure.
- Diabetes and lipid control.
- Alcohol and smoking.
- Review new medicines for liver effects.
Related topics
References
- 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
- 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
- Kanwal F, et al. Clinical care pathway for the risk stratification and management of patients with NAFLD (AGA). Gastroenterology 2021;161:1657–69. doi:10.1053/j.gastro.2021.07.049
- 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
How to cite this page
Desoky M. Follow-up and referral. Metabolic Liver Academy quick reference, version 1.0. Updated 2026-10-03. Available from: https://drmahmouddesoky.github.io/metabolic-liver-academy/ref/follow-up.html
A summary of published guidelines for healthcare professionals. It does not replace clinical judgement, the full guidelines or local drug labels. Disclaimer.