ABSTRACT Background articles were screened by two independent reviewers against pre‐specified inclusion and exclusion criteria. Results Twenty‐nine studies were included in the review: 12 with paired liver biopsies, 2 progression to cirrhosis, 13 progression to decompensation, 2 portal hypertension in F3 fibrosis and 13 on HCC in F3 fibrosis. Rates of progression on paired biopsies were 16%–30% over varied follow‐up. Varices were found in 16% of patients with F3 fibrosis and rates of non‐cirrhotic HCC varied from 37%–75%. Pooled univariate HR for F3 progression and F4 progression to major adverse liver outcomes (MALO) were 8.15 (95% CI 3.42–19.43) and 38.16 (95% CI 11.58–125.76), respectively. Conclusions Progression to cirrhosis and decompensation events occurs in a significant proportion of patients with F3 fibrosis in MASLD. There is evidence of portal hypertension and HCC developing in F3 MASLD. Further work to identify risk groups, including those at risk of rapid progression to guide future clinical management is urgently required given the prognostic inflection of decompensated disease.
Barrett et al. (2026) studied this question.