Metabolic Dysfunction Associated Steatohepatitis (MASLD) (Holt, 2/25/2026)

A recording of this presentation is available HERE.

Deep gratitude to Dr. Will Holt, CPMC Hepatologist, who drove to SSRRH from Piedmont at the literal crack of dawn to teach us about Metabolic Dysfunction Associated Steatohepatitis (MASLD) and Alcohol-Associated Liver Disease (AASLD) and then changed hats to spend the morning with our residency leadership as a faculty leader for graduate medical education within Sutter. 

His talk was fantastic! I recommend you watch it.

For those of you who prefer to read, the highlights:

First, MASLD

• We all known that the prevalence of obesity and diabetes have both skyrocketed over the last several decades-- nearing 50% in some regions of our country. 
• 
• Along with these metabolic issues, comes MASLD-- world prevalence is estimated to be 29.8% lowest rates for those of African descent (thought to be both genetic and food access/lifestyle related)
• Risk factors for MASLD include age >50, high BMI and DM2
  
• MASLD is a risk factor for death
• Assume that people are high risk (>50, high elevated BMI, DM2) have MASLD>> screen them for MASH with via fibroscan
• For everyone else with any component of metabolic syndrome (e.g. overweight, a1c>6%, hypertension, HDL<40 (F) and <50 (M), triglycerides>150)>> use FIB-4 to screen first
• if the FIB4>1.3>> Fibroscan,
• unless they are >65yo, then use FIB-4>2.0
• Fibroscan uses a weighted hammer/pulse to measure liver stiffness-- this is available through Sutter Airway)

• Fibroscan <8 is normal (=reassuring, low risk), >14 demonstrates cirrhosis
• for those with a normal fibroscan, focus on lifestyle modification for metabolic disorders
• for those with an abnormal fibroscan, refer to hepatology
• Fibrosis predicts liver-related mortality (see graph below from J. Hepatology 2017)
• stage 0/1 fibrosis: no increased mortality
• stages 2, 3, 4>> increased liver mortality 
• 

As per the 2024 AASLD Guidelines for clinical suspicion of steatotic liver disease

What are the treatment options for MASLD and MASH?

• Pharmacologic:
• Vitamin E: 96 week RCT: reduced fibrosis 41% vs. 31% (placebo)
• Pioglitazone: meta-analysis, reduced fibrosis vs. placebo OR 1.77
  
• There are two FDA approved medications:
• Resmetirom (2024): TRH-beta agonist, 52 week RCT vs. placebo, reduced fibrosis 24% vs. 14%
• Semaglutide (2025): GLP1 agonist, 72 week RCT vs. placebo, reduced fibrosis 37% vs. 22% 
• Non-Pharmacologic: diet/exercise/weight loss
• weight loss improves liver histology! Even 5%!!!
• 
  

Now, a little bit on ALD

• Defining Alcohol use disorder (AUD)
• 
• Biomarkers for ETOH
• Urine tests (EtG, EtS) have a very short detection window (<48 hours)
• PEth is current "truth serum", gives us information about the last 30 days, though there are some false positives in the lower ranges (20-40). Very high results (>400-1000 are very reliable)
• Diagnosing Alcoholic Hepatitis can be tricky!
• elevated MCV (100), elevated WBC, jaundice

• Treatment of alcohol-associated hepatitis with prednisolone (rather than prednisone due to first pass metabolism, when not available, prednisone is acceptable) FOR: 
• Patients WITH Maddrey Discriminant Function >32>> 
• AND WITHOUT
• evidence of biliary obstruction on ultrasound
• uncontrolled infection (especially bacteremia)
• AKI with SCr>2.5
• UGI bleeding
• Severe shock/hemodynamically unstable
• Expect 3 month recovery (bili will remain high)
• You can wait a couple of days before starting prednisolone (e.g. if any of the above active), pts can still benefit with delayed start
• Use the Lille score to predict (7 days) who will respond

• N-Acetylcysteine= mixed bag, there does appear to be a mortality benefit at 30 days but not at 3 months/6 months (NEJM 2011, see image)
• 
  
  
  
• What about liver transplant (LT) in ALD?
• 2011 RCT from France (NEJM 2011) was practice changing, randomized patients with AH without sobriety and first decompensating event  to LT vs. no LT (only <10% deemed candidates)>> found that 1 and 3 year survival was the same for patients with ALD as any other liver disease
• This led to a change in practice in which transplant can/may be considered for alcoholic hepatitis in select patients, not specified as a specific duration of sobriety>> at CPMC, this is called the "limited sobriety pathway to LT"
• Careful patient selection for LT (with ALD) is key. 
• Family support
• Absence of untreated psychiatric disorder
• Agreement by patient with support to LIFELONG abstinence (this can be harder to get to that you might imagine)
• This assessment is done by LT SW at CPMC (often via video visit prior to Transfer)
• We know that patients with AUD will relapse

Ethical Deviations and Inequities in the Delivery of Health Care (Matthews, 2/11/26)

A recording of this presentation is available HERE.

***

Special thanks to Dr. Adora Matthews, Sutter's CME of Inclusion and Belonging. She gave an important presentation on Inequity in the Delivery of Health Care-- as a celebration/reminder of Black History Month and a reminder of our commitment to delivering equitable and excellent care to every patient we serve. 

Dr. Matthews reminded us of four important historical occurrences that still contribute to fractured trust in the medical system for black Americans:

1) Dr J. Marion Sims, often referred to as "the father of modern gynecology", a white man, who operated on black slaves without anesthesia, perfected his hysterectomies and vesico-vaginal fistula repair on black slaves without consent, and contributed to a long-held notion in medicine that "black people don't feel pain the same as white people". After  all surgical assistants resigned due to discomfort with his work, he ultimately forced three black slave women (named Anarcha, Betsy, and Lucy) to assist him in these experimental surgeries.

A statue to honor these three women, the "Mothers of Gynecology" stands today in Montgomery, Alabama. 

2) The Tuskegee Syphilis experiment, which took place from 1932-1972, in which 400 black male sharecroppers were knowingly observed to study the natural history of syphilis, even after cure/treatment for syphilis was widely available (in the form of penicillin!). Spouses were infected, babies were born with congenital syphilis, extreme pathology was documented. This is widely considered the greatest failure of medical ethics in our country. This experiment didn't end until it was leaked to the press in 1972. A formal apology rendered by President Bill Clinton in 1997, calling the experiment "shameful and racist". 

3) Henrietta Lacks was a black woman who was treated in 1951 for cervical cancer at John's Hopkins University. After she died that same year, her cell line (HeLa) was used (without consent) for countless projects, including vaccine development, medical research, most recently for the COVID vaccine development. 110,000 publications are attributed to her cell lines, which are still in use today. The Lacks family was unaware of this use of her cells until 1973, when they were approached by a scientist who wanted to study them. 

These historical truths (and many others) contribute now to systemic inequity and mistrust. We must be aware of these histories, warned Dr. Adora Matthews, when we are caring for black American patients. We must be aware of them when we see current inequities. And while being aware isn't enough, it's a start.

Four current inequities for Black patients:

1) Healthcare access: black and brown patients have higher rates of being uninsured, are less likely to have preventive care, and less likely to have a regular PCP.

2) Chronic disease management: black American women have some of the highest rates (40%) of metabolic syndrome, which doubles CV risk, increases all cause mortality, and is associated with DM, CKD and stroke.

3) Maternal and fetal health outcomes: black women have highest rates of maternal mortality and fetal mortality, even when controlling for SES (see graphs below)

4) Pain management: Biased beliefs about black patients and pain tolerance dating back centuries with no evidence-- still exist today. There is literature from emergency rooms, hospitals and clinics that black patients are less likely to receive pain medication for the same painful condition.

Dr. Matthews reminded us that knowing the history (and the current inequities) is where we begin-- from here we begin to look at systems and address systemic racism in the daily work we do. We turn our grief, sadness, anger and despair into hope for our patients. We confront our own biases by attending lectures like these and participating in unconscious/implicit bias assessment ( Harvard's can be found HERE). 

"Hotter than Ever" Menopause and Non-Hormonal Therapies (Kareer, 2/4/2026)

A recording of this presentation is available HERE.