Up to 5 million adults in Romania may have MASLD. Experts propose a national pathway for early detection

Approximately 4.5–5.1 million adults in Romania may have metabolic dysfunction-associated steatotic liver disease (MASLD), while between 225,000 and 410,000 may have the progressive form, MASH, associated with significant fibrosis. A new multidisciplinary consensus document proposes ten directions for prevention, identification of at-risk patients and the organization of a national care pathway.

The paper, entitled “Metabolic Dysfunction-associated Steatotic Liver Disease in Romania: A Multidisciplinary Position Paper on Prevalence, Clinical Spectrum, Prevention, Screening and Management”, was published in August 2026 in the Journal of Gastrointestinal and Liver Diseases and brings together the recommendations developed during the third Romanian Forum of Metabolic Hepatology, held in Bucharest in March 2026.

The initiative was coordinated by the Romanian Society of Gastroenterology and Hepatology (SRGH) and the Romanian Association for Liver Diseases (RoALD), with the participation of specialists in gastroenterology and hepatology, family medicine, diabetology, endocrinology, cardiology, nephrology, pulmonology, ENT, transfusion medicine and public health, as well as patient representatives.

MASLD may affect 30–33% of adults in Romania

The authors estimate that the prevalence of MASLD in Romania is around 30–33% of the adult population, a proportion comparable with European estimates. Applied to Romania’s adult population, this prevalence would correspond to approximately 4.5–5.1 million people.

It is important, however, that most people with MASLD will not develop severe liver disease. The document distinguishes between simple steatosis, with a low risk of progression, and the progressive phenotype represented by metabolic dysfunction-associated steatohepatitis – MASH – accompanied by fibrosis.

According to the estimates presented by the authors, approximately 225,000–410,000 adults in Romania may have MASH with significant F2–F4 fibrosis, a category associated with an increased risk of cirrhosis, hepatocellular carcinoma, liver transplantation and liver-related mortality.

Fibrosis stage is considered one of the most important predictors of prognosis. For this reason, the authors argue that healthcare resources should be concentrated particularly on identifying people at risk of progression rather than on extensively investigating all individuals with hepatic steatosis.

Screening the entire population is not recommended

One of the main recommendations of the document is that MASLD screening in the general population is neither feasible nor recommended, given the very high prevalence of low-risk forms.

Instead, the authors propose a case-finding strategy aimed at identifying moderate or severe fibrosis – F2–F4 – in groups with a higher probability of progression.

People who should be considered for evaluation include patients with:

• type 2 diabetes;
• obesity;
• metabolic syndrome;
• persistently elevated transaminases;
• steatosis identified on imaging;
• obesity associated with other medical complications;
• a family history of metabolic syndrome or cryptogenic cirrhosis.

FIB-4 proposed as the first test for identifying at-risk patients

For these categories, the Romanian consensus proposes a two-step algorithm. The first tier should use the FIB-4 index, a non-invasive tool calculated on the basis of the patient’s age, AST and ALT levels, and platelet count.

The advantage of FIB-4 is that it relies on widely available investigations and can therefore be used in family medicine, diabetology and other specialties that frequently care for patients with metabolic risk.

According to the proposed algorithm, a FIB-4 value below 1.3 generally indicates low risk, while a threshold of 2.0 is used in people over the age of 65. Patients considered low risk would be reassessed at intervals of 1–3 years, depending on their clinical profile.

The authors caution, however, that FIB-4 is a triage tool, not a definitive diagnostic test. Some patients with low values may still have significant fibrosis, particularly in the presence of diabetes or obesity.

Second tier: elastography and other non-invasive tests

Patients whose first assessment indicates intermediate or high risk should proceed to a second level of investigation in gastroenterology and hepatology centres.

The document mentions vibration-controlled transient elastography – VCTE/FibroScan –, shear-wave elastography, ARFI, magnetic resonance elastography and the ELF test among the tools that can be used for further fibrosis assessment.

In the proposed algorithm, liver stiffness below 8 kPa indicates a low risk of advanced fibrosis, values between 8 and 12 kPa require clinical interpretation and, where appropriate, further testing, while values of at least 12 kPa warrant specialist management.

The authors suggest that elastography could be concentrated in regional centres, while FIB-4 could serve as an initial tool widely used in primary care and in specialties managing patients with metabolic risk.

MASLD is not only a liver disease

Another central message of the consensus is that MASLD should be regarded as part of a cardio-reno-hepato-metabolic spectrum rather than as an isolated liver condition.

The disease is frequently associated with type 2 diabetes, obesity, dyslipidaemia, hypertension, chronic kidney disease, obstructive sleep apnoea and cardiovascular disease.

In most people with MASLD, cardiovascular disease is the main cause of mortality. Liver-related mortality, however, rises sharply as fibrosis progresses towards cirrhosis.

For this reason, the document proposes collaboration among family physicians, gastroenterologists and hepatologists, diabetologists, endocrinologists, cardiologists, nephrologists, pulmonologists and obesity specialists, with bidirectional screening for associated diseases.

Alcohol and metabolic risk may act together

The consensus also adopts the new international terminology for steatotic liver diseases, which includes the MetALD category – the situation in which metabolic dysfunction and alcohol consumption simultaneously contribute to liver injury.

The authors emphasise that the effects of alcohol and cardiometabolic risk factors can potentiate one another and recommend systematic assessment of current and past alcohol consumption in people with steatotic liver disease.

The document cites an annual consumption of approximately 12.3–12.6 litres of pure alcohol per capita in Romania, above the OECD average of 8.5 litres, and considers reducing alcohol consumption an important component of the national strategy for liver disease.

Ten recommendations for Romania

The position paper summarises ten consensus directions for organizing MASLD prevention and care in Romania:

1. recognising chronic liver disease as a major medical and socio-economic burden and developing a coordinated strategy for prevention and early diagnosis;
2. adopting the new international SLD, MASLD, MASH and MetALD nomenclature in clinical practice, education, coding and reimbursement mechanisms;
3. developing a national MASLD registry and structured, reimbursed pathways for identifying at-risk patients;
4. distinguishing between low-risk simple steatosis and MASH associated with fibrosis, the form responsible for most liver-related complications;
5. systematically assessing the interaction between metabolic factors and alcohol consumption;
6. integrating MASLD into non-communicable disease strategies and into a cardio-reno-hepato-metabolic model of care;
7. using a two-step strategy for fibrosis detection, with FIB-4 initially and elastography or other non-invasive tests in selected patients;
8. developing a multidisciplinary model and a cross-specialty consensus on prescribing and monitoring relevant therapies;
9. creating a national clinical pathway establishing the responsibilities of primary, secondary and tertiary care;
10. developing a National MASLD Action Plan with objectives, responsibilities, deadlines and measurable indicators.

Authors propose a National MASLD Action Plan

The final recommendation is also the most extensive from a health policy perspective. SRGH and RoALD call for the development of a National MASLD Action Plan in the context of the recognition of steatotic liver diseases within the global non-communicable disease agenda.

The proposed plan would include routine calculation of FIB-4 in family medicine and metabolic specialties, integration into electronic medical records, expanded access to elastography and reimbursement of this investigation for at-risk populations.

Other objectives include the creation of a national MASLD registry, integration of the condition into national cardiovascular and cancer plans, development of policies addressing harmful alcohol consumption and monitoring patients’ quality of life.

First EU-approved therapy for certain forms of MASH

The document also addresses the recent change in the therapeutic landscape. Resmetirom (Rezdiffra) received conditional marketing authorisation in the European Union in August 2025 for adults with non-cirrhotic MASH and moderate-to-advanced F2–F3 fibrosis, in combination with diet and physical exercise.

The authors consider that the availability of an approved liver-targeted therapy for this category of patients makes it even more important to have a pathway through which eligible individuals can be identified before cirrhosis develops.

Romania among European countries with a high liver disease mortality burden

The need for an early detection strategy is amplified by the burden of liver disease in Romania. The document cites an age-standardised mortality rate from cirrhosis and other chronic liver diseases of 55.6 deaths per 100,000 population in 2021, one of the highest in Europe.

The authors estimate between 4,000 and 8,000 deaths annually associated with chronic liver disease, but underline that the absence of a national MASLD registry and systematic reporting by aetiology makes it impossible to precisely quantify the contribution of MASLD and MASH to cirrhosis, liver cancer, transplantation needs and liver-related mortality in Romania.

From late diagnosis to early identification of risk

The practical message of the consensus is that the tools needed to identify at-risk patients already exist. Romania’s challenge is to organize them into a coherent, accessible and funded pathway.

Instead of a model in which liver disease is identified after advanced fibrosis or complications have already developed, the authors propose that patients with diabetes, obesity and other metabolic risk factors should be stratified early, starting in family medicine and in the specialties they already attend.

In their conclusions, the specialists state that the current limitations are no longer primarily related to the absence of diagnostic or therapeutic tools. Non-invasive tests for fibrosis assessment are available, internationally validated algorithms exist, and the emergence of targeted therapies creates the possibility of intervention before advanced stages develop. Turning these tools into a functional system, however, requires collaboration among professional societies, the Ministry of Health, CNAS, primary care, the specialties involved and patient organisations.