Metabolic dysfunction‑associated fatty liver disease (MAFLD) is a leading chronic liver disease in China, yet primary care capacity remains limited. To address this, the first national Guidelines for Diagnosis and Management of MAFLD in Primary Care (2025) were developed by a multidisciplinary group. The guidelines offer evidence‑based recommendations for screening, diagnosis, treatment, referral, and follow‑up, aiming to improve long‑term outcomes and strengthen primary care’s role in chronic liver disease management.
Introduction
MAFLD affects nearly one‑third of adults globally and ranges from simple steatosis to MASH, fibrosis, cirrhosis, and HCC. It is closely linked to metabolic syndrome, T2DM, CKD, and CVD. With China’s tiered healthcare reforms, primary care is central to chronic disease management. These guidelines, using the GRADE system, provide 13 strong and 2 weak recommendations.
Epidemiology and Natural History
Global MAFLD prevalence is ~32.4%; in China it is ~29.7%. Prevalence increases with age and is higher in men, but post‑menopausal women catch up. MAFLD is strongly associated with obesity, T2DM, dyslipidaemia, and hypertension. In T2DM patients, MAFLD, MASH, significant fibrosis, and advanced fibrosis affect 65%, 32%, 36%, and 15%, respectively. MAFLD can coexist with chronic hepatitis B or alcoholic liver disease. Leading causes of death are CVD and extrahepatic cancers. HCC incidence rises from 1.25 per 1,000 person‑years overall to 14.46 in those with advanced fibrosis/cirrhosis.
Screening, Diagnosis, and Evaluation
Key recommendations: (1) Ultrasound screening for those with ≥1 metabolic component or persistent transaminase elevation (1A). (2) Diagnosis requires imaging/histological steatosis, ≥1 metabolic component, and exclusion of significant alcohol intake and other causes (1A). (3) Regular surveillance for fibrosis, HCC, and comorbidities (1A). (4) FIB‑4 is first‑line for fibrosis risk; FIB‑4 ≥1.3 (or ≥2.0 if >65) warrants transient elastography (1A). (5) Use China ASCVD risk chart for CVD assessment (1A).
Diagnostic criteria include five metabolic components (obesity, hypertension, hyperglycaemia, hypertriglyceridaemia, low HDL‑C). Other causes must be excluded. Fibrosis assessment: Low risk (FIB‑4 <1.3) → primary care; intermediate/high → elastography; LSM >12 kPa → refer. CVD risk integrates age, smoking, family history, and ASCVD stratification.
Treatment Strategies
Lifestyle is cornerstone (1A): reduce 500–1000 kcal/day, with target intakes 1200–1400 (men) and 1000–1200 (women) kcal/day, protein ≥1.2 g/kg/day. Structured diets and ≥150 min/week moderate exercise are recommended. Weight loss: ≥5% for overweight/obese; if BMI >28 and lifestyle fails, consider GLP‑1 RA or orlistat; bariatric surgery for non‑cirrhotic patients (1A).
Glucose‑lowering (1A): In MAFLD with T2DM, prioritise GLP‑1 RA, SGLT2 inhibitors, or pioglitazone for hepatic/cardiovascular benefits. Insulin is preferred in decompensated cirrhosis.
Antihypertensives (1A): Long‑acting agents, with RAS inhibitors preferred for added hepatic benefits. Lipid‑lowering (1A): Statins are first‑line; do not withhold for MAFLD or mild transaminase elevation. Add ezetimibe or PCSK9 inhibitors if needed; fibrates when triglycerides >5.6 mmol/L.
Hepatoprotective drugs are indicated for active injury or high risk. Agents include vitamin E (300 mg/day, validated in China), silymarin, polyene phosphatidylcholine, bicyclol, glycyrrhizin, glutathione, S‑adenosylmethionine, and UDCA. TCM (1B) may be used as adjunctive therapy in primary care, following relevant guidelines.
Referral and Follow‑up
Referral criteria (1A): cirrhosis/lesions on ultrasound; FIB‑4 >2.67 (or intermediate with no elastography); LSM >12 kPa; persistent transaminase/bilirubin elevation; high/very high ASCVD risk. Mild cases with low fibrosis and low‑moderate CVD risk can stay in primary care.
Follow‑up: All patients: liver/renal function, glucose, lipids every 3–6 months; ultrasound and carotid ultrasound every 6–12 months; FIB‑4/elastography annually. Those with T2DM or ≥2 metabolic risks: FIB‑4/LSM every 1–2 years; others every 2–3 years. Cirrhosis patients: AFP and variceal screening every 6–12 months.
Establishing Fatty Liver Clinics
Primary care institutions should establish dedicated clinics with basic equipment, ultrasound, and ideally elastography. Staffing requires at least one trained general practitioner, supported by nurses, dietitians, and TCM practitioners. Clear two‑way referral and multidisciplinary coordination are essential.
Conclusions
These guidelines offer a practical framework for primary care in MAFLD screening, management, and follow‑up. Primary care should enhance health education, lifestyle guidance, and self‑management support. Early detection and standardised care can slow progression and reduce complications. Collaboration with specialists and integration with other NCD programmes are key. Updates will follow as new evidence emerges.
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The study was recently published in the Journal of Clinical and Translational Hepatology .
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Journal of Clinical and Translational Hepatology
Guidelines for Diagnosis and Management of Metabolic Dysfunction-associated Fatty Liver Disease in Primary Care (2025)