Meta‐analysis: Histological severity of biopsy‐proven metabolic dysfunction‐associated steatotic liver disease in pediatric patients

Abstract The burden of metabolic dysfunction‐associated steatotic liver disease (MASLD) is increasing in children and adolescents. However, the severity of disease at diagnosis by liver biopsy remains uncertain and has not been systematically evaluated. We conducted a systematic review and meta‐analysis to determine the prevalence of metabolic dysfunction‐associated steatohepatitis (MASH), significant and advanced fibrosis in this population. PubMed and Embase databases were systematically searched (from inception to September 17, 2024) for studies reporting liver histology in pediatric patients (≤21 years) with biopsy‐proven MASLD. Meta‐analysis of proportions was performed using a generalized linear mixed model with Clopper‐Pearson intervals to obtain pooled prevalence estimates. Of 4761 records identified, we included 35 studies with 5898 pediatric patients with biopsy‐proven MASLD (33.4% girls; mean age 12.6 years). The pooled prevalences of MASH, significant fibrosis (defined as ≥F2) and advanced fibrosis (defined as ≥F3) based on histology were 59.95% ( n = 18 studies, 95% confidence interval [CI]: 46.89–71.73, I ² = 97%), 30.53% ( n = 26 studies, 95% CI: 22.32–40.20, I ² = 94%), and 11.77% ( n = 28 studies, 95% CI: 8.10–16.80, I ² = 89%), respectively. Subgroup analyses showed higher prevalence of advanced fibrosis in studies with <100 patients compared to larger studies. Meta‐regressions did not show an influence of age, sex, and body mass index on the prevalences. Sensitivity analyses did not modify these results. Pediatric patients have considerable severity of MASLD at diagnosis by liver biopsy. Developing effective screening and risk stratification strategies for this group is urgently needed.