MASH eligibility tests: study findings

A 2026 multicentre Italian cohort study shows why non-invasive tests should not be treated as a final answer to MASH treatment eligibility. Among 897 adults with MASLD, 22.5% met the study's AASLD-based eligibility definition and 12.7% met an expert-panel-derived definition. Only 86 people met both definitions, while 144 were classified differently^[1]. The result is about how proposed criteria sort patients, not proof that one individual should or should not receive a medicine.

The study's key message is practical: tests that avoid biopsy can help organise risk assessment, but different thresholds can identify meaningfully different groups. In the subgroup with a biopsy close to referral, the classifications only partly aligned with histologically confirmed F2 to F3 fibrosis^[1]. That uncertainty matters as pharmacological options for metabolic dysfunction-associated steatohepatitis, or MASH, develop.

What the researchers compared

The investigators retrospectively included patients from four Italian referral centres. Their AASLD-based definition used liver stiffness measurement of 8 to 15 kPa and no cirrhosis. The expert-panel-derived definition used liver stiffness of 10 to 19.9 kPa, platelet count of at least 140 × 10^9/L, and no cirrhosis^[1]. These are research definitions applied to a cohort, not instructions for readers to interpret a FibroScan result on their own.

The difference is not cosmetic. A threshold changes who is counted as potentially eligible. Type 2 diabetes and obesity were independently associated with eligibility under both definitions, but the two approaches did not produce the same list of people. This is one reason clinical pathways use an overall assessment, including history, laboratory values, imaging and the possibility of referral, instead of a single number in isolation^[1].

Why biopsy remains an imperfect reference point

Liver biopsy can provide histological information, but it is invasive and is not available or appropriate for every person. The study included 175 participants with biopsy within three months of first referral. Of 73 patients with histological F2 to F3 fibrosis, 35, or 47.9%, did not meet the AASLD criteria and 49, or 67.1%, did not meet the expert-panel-derived criteria^[1]. This does not prove that biopsy is always required. It shows that the non-invasive rules examined did not perfectly reproduce the biopsy subgroup's fibrosis classification.

The authors describe the cohort as real-world referral-centre data, which is useful but also limits generalisation. Referral populations can differ from people identified in primary care. The retrospective design also means the analysis cannot establish which threshold produces better patient outcomes. It is a comparison of classification strategies, not a trial of a treatment pathway.

Where semaglutide fits in the discussion

The paper's keywords include semaglutide and resmetirom because MASH pharmacotherapy makes patient selection more consequential. That does not mean a non-invasive test alone determines access to semaglutide or any other medicine. Indications, approvals and local practice evolve, and a qualified liver or metabolic-care team must interpret results in context.

For background, our semaglutide guide explains the molecule's broader evidence base, and the tirzepatide overview provides context on a related incretin medicine. Readers should also check the relevant regulatory information, since medicine status and authorised indications can differ across jurisdictions.

What this study does and does not establish

The analysis establishes that two proposed non-invasive eligibility approaches classified a substantial number of patients differently in this cohort. It also shows partial alignment with F2 to F3 fibrosis among the biopsy subgroup. It does not establish a preferred universal cut-off, a diagnosis for a reader, or a treatment recommendation. People excluded by either rule may still need further assessment.

A useful patient-facing question is not "Which number gets me a drug?" but "What does this result mean alongside my symptoms, metabolic health, liver history and other testing?" That framing leaves room for uncertainty and supports a proper conversation with a clinician. It also helps prevent a screening result from becoming an online self-diagnosis.

What we do not yet know

Prospective studies need to test whether refined non-invasive pathways improve treatment allocation and outcomes. The present analysis cannot settle how often a biopsy is needed, how thresholds should vary by setting, or how these criteria perform in populations outside Italian referral centres. As MASH treatment options and guidance change, eligibility strategies will need ongoing validation. A future pathway also needs to show whether it reduces missed advanced fibrosis without directing unnecessary specialist referrals, whether patients understand what an indeterminate result means, and whether the process is feasible in busy primary-care settings with equitable access to follow-up and clear communication in different languages.

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