Non-invasive tests of fibrosis in the management of MASLD: revolutionising diagnosis, progression and regression monitoring

With the recent conditional approval of resmetirom by the US Food and Drug Administration, the treatment of metabolic dysfunction-associated steatotic liver disease (MASLD) has potentially entered a new era, requiring a comprehensive understanding of the strengths and weaknesses of non-invasive tests (NITs) for diagnosing and monitoring MASLD-related fibrosis. This article focuses on F2/F3 liver fibrosis and summarises the current application status of NITs, including serum biomarkers, imaging methods and their combined use in the management of MASLD. The article highlights the application of NITs in several areas, including diagnosis and baseline stratification, monitoring progression of fibrosis, prediction of liver-related clinical events, as well as assessment of disease regression, remission and long-term liver-related outcomes. Furthermore, we compare the advantages and limitations of NITs and propose practical strategies for integrating them into clinical practice. Additionally, we highlight the main challenges currently faced in the application of these NITs and potential future research avenues. We suggest that future studies prioritise the validation of NITs across diverse ethnic populations. We believe it essential to explore the role of NITs in dynamic monitoring and integration of multiomics technologies, artificial intelligence and personalised risk models to improve diagnostic accuracy and treatment planning.