Metabolic Dysfunction-Associated Steatotic Liver Disease: Clinical Heterogeneity, Risk Stratification, and Personalized Care.

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as the most prevalent chronic liver disease worldwide, reflecting the global epidemic of obesity, type 2 diabetes, and metabolic syndrome. However, MASLD is not a homogeneous condition; rather, it encompasses a broad clinical and biological spectrum ranging from simple steatosis to progressive steatohepatitis, advanced fibrosis, cirrhosis, and hepatocellular carcinoma. This heterogeneity is driven by complex interactions between metabolic dysfunction, genetic susceptibility, environmental exposures, and extrahepatic comorbidities. Recent advances have shifted the paradigm from a "one-size-fits-all" approach toward risk stratification and personalized care. Non-invasive tests (NITs), including FIB-4, transient and shear wave elastography, and novel biomarkers, have enabled scalable fibrosis assessment and prognostic stratification in real-world settings. At the same time, emerging therapies targeting metabolic pathways, inflammation, and fibrosis are paving the way for individualized treatment strategies. This review provides an updated and clinically oriented synthesis of MASLD by integrating clinical heterogeneity, phenotype-based disease trajectories, multidimensional risk stratification, and personalized management into a practical framework for precision hepatology. In addition, we summarize recent therapeutic advances, discuss current controversies and implementation challenges, and highlight future directions toward individualized care.