Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR–MASH score
Distinguishing metabolic dysfunction-associated steatohepatitis (MASH) from simple steatosis is clinically important because MASH is associated with faster disease progression and increased mortality, yet definitive diagnosis still relies on liver biopsy. Existing non-invasive tests primarily assess fibrosis and are less effective at capturing the steatohepatitis component itself.
This prospective multicentre study developed and externally validated MR–MASH, an MRI-derived biomarker designed specifically to identify MASH. The study included 317 patients with biopsy-proven MASLD, divided into a derivation cohort (n=194) and an independent validation cohort (n=123) acquired across different centres, MRI protocols and manufacturers.
MR–MASH combines two readily obtainable MRI-derived measures—proton density fat fraction (PDFF) and waist circumference, normalized by height. It achieved an AUC of 0.88 in the derivation cohort and 0.86 in external validation. Using two thresholds, the score provided 91% sensitivity for ruling out MASH and 87% specificity for ruling it in in the validation cohort.
Importantly, MR–MASH focuses on disease activity rather than fibrosis, addressing a limitation of many existing non-invasive biomarkers. When used as a second-line test after FIB-4 or transient elastography, it achieved PPVs of 83–84% for MASH, and its diagnostic performance was significantly higher than the FAST score.
The study therefore provides a simple, externally validated MRI-based approach for identifying MASH without biopsy, with potential applications in patient stratification, clinical-trial recruitment and treatment monitoring. Its reproducibility across geographically distinct cohorts and different MRI protocols strengthens its potential for broader clinical implementation.
Marti-Aguado D, Arnouk J, Liang JX, Lara-Romero C, Behari J, Furlan A, Jimenez-Pastor A, Ten-Esteve A, Alfaro-Cervello C, Bauza M, Gallen-Peris A, Gimeno-Torres M, Merino-Murgui V, Perez-Girbes A, Benlloch S, Pérez-Rojas J, Puglia V, Ferrández-Izquierdo A, Aguilera V, Giesteira B, França M, Monton C, Escudero-García D, Alberich-Bayarri Á, Serra MA, Bataller R, Romero-Gomez M, Marti-Bonmati L. Development and validation of an image biomarker to identify metabolic dysfunction associated steatohepatitis: MR-MASH score. Liver Int. 2024 Jan;44(1):202-213. doi: 10.1111/liv.15766. Epub 2023 Oct 30. Erratum in: Liver Int. 2025 Apr;45(4):e16190. doi: 10.1111/liv.16190. PMID: 37904633.