When you have a serious health condition, such as metabolic dysfunction-associated steatohepatitis (MASH), it helps to learn all you can about it — what it means, what you can expect to happen, and what you can do to improve your health. MASH happens when another more common condition, called metabolic dysfunction-associated steatotic liver disease (MASLD), gets worse. Doctors used to call it nonalcoholic fatty liver disease (NAFLD). Over time, the damage can cause liver scarring, or fibrosis, which interferes with your liver’s ability to function.
Why Understanding MASH Progression Matters
When you have a diagnosis of stage II or III MASH, there’s a lot you can still do to slow its advance and even reverse some of the damage. It’s important to work with your doctor to understand your current condition, including other health conditions or lifestyle factors that may increase your liver-related health risks and speed up disease progression. It’s a good time to do all you can to take control of your health.
“Once you have the inflammation [in your liver], then [you’re] moving along progressive stages of fibrosis,” says Meena Bansal, MD, a gastroenterologist at Mount Sinai’s Institute for Liver Medicine in New York. “Once you hit stage II, that’s where the [serious] liver-related outcomes start to emerge as a potential reality in the future.”
MASH Progression and Timeline
MASH progresses, or worsens, as the scarring in your liver builds up. This can happen unless you take steps to slow or reverse the inflammation and the damage it’s causing. If you don’t work closely with your doctor, the disease can worsen without you noticing until it’s too late. Eventually, MASH can lead to permanent damage, cirrhosis, and liver failure. You shouldn’t expect MASH to progress at a constant or easily predictable rate.
“[MASH progression] is not totally linear, meaning once you hit stage II and III, it might progress a little bit faster,” Bansal says. “But, on average, it’s around one stage every seven years.”
According to Jamile Wakim-Fleming, MD, a hepatologist at Cleveland Clinic, the timeline for progression varies, depending on your general state of health and whether you drink alcohol or take in any toxic substances, such as through smoking or illegal drugs.
Stages of MASH
Your doctor will use the results of imaging or blood tests to check how stiff your liver is now. Liver stiffness isn’t the same as fibrosis, but it’s a good way for your doctor to tell how much scarring your liver may have.
Your MASH stage gives you an idea about how much fibrosis there is and how advanced your disease has become. It’s based on the amount of scarring around major vessels in your liver. It also depends on how many fibrous bands of tissue called septa are in your liver.
In some cases, your liver disease may fall right on the edge between two different stages. With treatment and other steps to improve your liver health, it’s possible your liver scarring could get better instead of worse over time.
Because MASH often doesn’t come with obvious symptoms, you won’t be able to track the progression based solely on the way you feel. But it’s important to let your doctor know if you’re having any new symptoms that may be related to MASH progression. Learn more about the stages of MASH, from 0 to IV:
Stage 0 MASH or MASLD
What does this stage mean?
You have no scarring, fibrosis, or inflammation in your liver.
Average time to progression
MASH is a progressive condition, but the rate can vary depending on many factors. You may begin to develop fibrosis slowly over time unless you’re able to reduce fat and inflammation in your liver.
Symptoms or complications
You’ll have more fat than normal in your liver, but you’re unlikely to notice any symptoms at this stage.
Stage I MASH
What does this stage mean?
You’ll have scarring, or fibrosis, around vessels known as the portal tract in your liver. But you won’t have any fibrous bands of tissue called septa. The amount of fibrosis is mild to moderate at this stage. MASH is a progressive condition, but you can take steps to stop or even reverse the scarring.
Average time to progression
On average, it takes about seven years to reach stage I MASH. But you may progress faster or slower than average.
Symptoms or complications
Liver disease is often a silent condition. You’re unlikely to notice any symptoms or liver complications at this stage, even as your MASH gets worse.
Stage II MASH
What does this stage mean?
You’ll have significant amounts of fibrosis in your liver. Your doctor can measure it based on increasing stiffness. You’ll have more scarring around vessels in your liver and may begin to develop fibrous bands called septa. Any septa at this stage will be limited in number. Your liver can heal itself (regenerate), so it’s possible to reverse some fibrosis if you can stop the inflammation in your liver and avoid habits, such as drinking alcohol, that are hard on your liver.
Average time to progression
On average, it takes about 14 years to reach stage II MASH. But it’s different for everyone.
Symptoms or complications to watch for
You may or may not notice any symptoms despite the scarring in your liver. That’s why it’s so important to work closely with your doctor to track how your disease advances.
“It’s often a very silent and indolent kind of thing,” Bansal says. “Patients may report some fatigue, they may report some itchiness — or overall — just not feeling well. So, it's hard to pin it [down]…Sometimes people will have a little bit of a dull ache in their right upper abdomen, but it's pretty rare. Mostly in the early stages, it is asymptomatic, and then people progress. Once you have symptoms, it's unfortunately often at a much later stage.”
Stage III MASH
What does this stage mean?
Your fibrosis at this stage is severe and advanced. You will also have numerous septa. But you don’t yet have cirrhosis. It’s still possible for your liver to repair itself at this stage.
Average time to progression
On average, it takes about 21 years to reach stage III MASH. But don’t forget that the rate of progression varies.
Symptoms or complications to watch for
You may or may not notice pain in your belly, near the upper right side, around your liver.
If you do have other symptoms, they may include:
- Fatigue
- Weight loss you can’t explain
- Weak muscles and muscle loss
- Swelling in your belly or legs
- Yellowing eyes or skin (jaundice)
Stage IV MASH or cirrhosis
What does this stage mean?
Your liver fibrosis or scarring is now very advanced. Once you’ve entered cirrhosis, the fibrosis in your liver is likely to be permanent. Your liver may no longer be able to regenerate itself to repair the damaged tissue.
Average time to progression
“It takes 30 years to develop cirrhosis in the average individual,” Bansal says. But for some people, the condition worsens much faster than for others.
Symptoms or complications to watch for
You may not notice symptoms of stage IV MASH or cirrhosis until your liver begins to fail or stops working properly. About 5% of people will go on to develop liver cancer, or hepatocellular carcinoma, Wakim-Fleming says.
Early symptoms of cirrhosis may include:
- Nausea
- Lack of interest in eating
- Weakness
- Feeling tired
- Pain in your upper belly
- Blood vessels you can see through your skin
- Red palms
Later symptoms of cirrhosis include:
- Yellow skin (jaundice)
- Dark pee and light poop
- Itchiness without a rash
- Small bumps on your eyelids or skin
- Weight and muscle loss
- Irregular periods
- Belly swelling from fluid (ascites)
- Bleeding and bruising easily
Liver failure
What does this stage mean?
Your liver can no longer work as it should. As your liver stops working, your overall health will also worsen. You may need a liver transplant.
Average time to progression
Liver failure can happen fast or slow. But it’s likely your liver has been slowly failing for many years or even decades before this point.
Symptoms or complications to watch for
Some symptoms of liver failure can look similar to cirrhosis. But you may also have:
- Vomiting
- Altered mental state or confusion (hepatic encephalopathy)
- Abnormal movements, such as twitching, tremors, or loss of muscle control
- Trouble digesting food, especially fats
- Peeing less
- Shortness of breath
Things That Affect Progression
MASH progression usually happens over many years or decades, but for some people, it may worsen faster.
If you’re living with multiple conditions at the same time, such as diabetes, obesity, and high blood pressure, your MASH and the underlying fibrosis may worsen at an even faster rate. The more of these risk factors you have, the more likely it is that your fibrosis will worsen faster.
How Will Your Doctor Track MASH Progression?
Your doctor can help you track the fibrosis in your liver, so you know how fast you’re moving from one stage to the next. Because the rate of progression can vary a lot from one person to the next, they’ll need to consider what’s happening for you.
You won’t normally need a biopsy to see how much fibrosis is in your liver. Your doctor may suggest a biopsy if they want to rule out other conditions, such as autoimmune hepatitis, Bansal says. If the goal is to stage the MASH based on the amount of fibrosis, they’ll more likely order noninvasive tests, such as a FibroScan or Fibrosis-4 (FIB-4).
The FibroScan test uses an ultrasound technique called liver elastography to measure the stiffness of your liver. FIB-4 uses your age, platelet counts, and levels of two liver enzymes to estimate scarring in your liver.
A FIB-4 score less than 1.3 means you aren’t likely to have advanced fibrosis, while scores over 2.67 mean advanced fibrosis is likely. Scores between 1.3 and 2.67 are harder to understand. While the FIB-4 test isn’t perfect, it can help you and your doctor figure out your stage and progression and decide whether you need more tests to measure changes in your liver.
MASH Treatment and Interventions by Stage
Your treatment and how often you’ll see your doctor will depend on your MASH stage and how fast it’s advancing. At very early stages, such as stage 0 or I, your primary care doctor or endocrinologist may be able to watch over you. As your fibrosis and MASH get worse, you’ll need to see a doctor who specializes in tracking and treating MASH and other liver diseases, such as a gastroenterologist or hepatologist.
Stage 0 or Stage I
At this stage, you may see your doctor annually for a FibroScan to see how your liver disease is worsening. Your doctor will recommend lifestyle changes to help you improve your overall health and cut the levels of fat building up in your liver. If you have diabetes, obesity, high blood pressure, or other health conditions, it’s important to manage those as best you can.
Stage II
The picture will shift once you reach MASH stage II.
“If someone has F2 fibrosis, then I might see them a little bit more frequently, and they’re also eligible for FDA-approved therapies,” Bansal says.
Once you decide to start treatment, your doctor will want to watch you more closely to see how it’s working. Bansal suggests you may go in for monitoring every six months.
Stage III
Once your fibrosis reaches stage III, it’s even more important to explore treatment options if you haven’t already. You may see your doctor as often as every three months to check your progression and treatment response, Bansal says.
Stage IV or cirrhosis
At this stage, the damage to your liver may be permanent, and there are no approved treatments available. You may be in this stage for many years before your liver starts to fail.
Your doctor will need to see you at least every six months for an ultrasound to screen you for liver cancer. As your cirrhosis gets worse, you may need to see your doctor more often for help with complications, such as ascites, bleeding, or confusion.
What Can You Do to Slow Down MASH Progression?
While your liver disease has already moved into progressive stages, it isn’t too late for you or your loved one with stage II or III MASH to slow it down and avoid cirrhosis. It’s possible to reverse some of the fibrosis. Any positive changes you can make now will help protect your liver and your overall health in the years to come.
“Treatment of the underlying disorders that led to MASH will stop MASH from progressing and may reverse the disease to lower stages even if cirrhosis is present,” Wakim-Fleming says. “When the cirrhosis is very advanced or decompensated, it is unlikely to reverse.”
There are many steps you can take to make a difference in your liver health and MASH progression, Bansal says. Here’s her advice:
- Ask if you’re eligible for a medication that’s approved for treating stage II or III MASH, including resmetirom (Rezdiffra) or semaglutide (Wegovy).
- Avoid alcohol.
- Exercise for at least 150 minutes ( two and a half hours) per week at moderate intensity.
- Use rubber bands or weights to strengthen your muscles at least twice a week to keep from losing muscle.
- Ask your doctor about drinking two to three cups per day of black coffee, which may have protective effects for your liver. Avoid the extra calories and fat by skipping the cream and sugar.
- Avoid sweetened drinks containing high-fructose corn syrup, which is converted into fat in your liver.
- Eat a Mediterranean-style diet.
“Half of your plate should be vegetables, a quarter should be lean chicken and fish, and then you want healthy oils, like avocado [or] olive oil,” Bansal says. The remaining quarter of your plate should be grains. Aim for half of these to be whole grains. “You want to avoid processed food and ultra-processed food. Farm to table is the mantra, as fresh as it comes.”
