Hepatologist Consultation in Low-Risk MASLD

This clinical decision article explores whether a hepatologist consultation is warranted for a 58 year old woman with low-risk metabolic dysfunction associated steatotic liver disease (MASLD). The patient has obesity, hypertension, hyperlipidemia, and poorly controlled diabetes (HbA1c 7.5%), but her Fibrosis 4 index score of 1.20 suggests low risk of advanced fibrosis. Two expert perspectives are presented:

1. Against Referral (Dr. Carr): Argues that primary care management is sufficient given the low hepatic risk (1% 10-year liver complication rate) and emphasizes prioritizing cardiovascular risk reduction. Recommends serial Fibrosis 4 monitoring and metabolic optimization via dietitian and endocrinologist referrals.

2. For Referral (Dr. Abdelmalek): Highlights the patient’s high risk profile (postmenopausal, diabetes, ALT >5× ULN) and potential for undetected fibrosis. Advocates for hepatologist evaluation to rule out competing diagnoses (e.g., autoimmune hepatitis) and access to emerging MASH therapies.

The debate underscores the balance between conservative management and early specialist intervention in low-risk MASLD.

This clinical decision article explores whether a hepatologist consultation is warranted for a 58 year old woman with low-risk metabolic dysfunction associated steatotic liver disease (MASLD). The patient has obesity, hypertension, hyperlipidemia, and poorly controlled diabetes (HbA1c 7.5%), but her Fibrosis 4 index score of 1.20 suggests low risk of advanced fibrosis. Two expert perspectives are presented:

1. Against Referral (Dr. Carr): Argues that primary care management is sufficient given the low hepatic risk (1% 10-year liver complication rate) and emphasizes prioritizing cardiovascular risk reduction. Recommends serial Fibrosis 4 monitoring and metabolic optimization via dietitian and endocrinologist referrals.

2. For Referral (Dr. Abdelmalek): Highlights the patient’s high risk profile (postmenopausal, diabetes, ALT >5× ULN) and potential for undetected fibrosis. Advocates for hepatologist evaluation to rule out competing diagnoses (e.g., autoimmune hepatitis) and access to emerging MASH therapies.

The debate underscores the balance between conservative management and early specialist intervention in low-risk MASLD.