SUN-710 - Complete Radiologic Reversal of Advanced MASH with GLP-1 Therapy: A Case of Early Cirrhosis Regression

Background:

Metabolic dysfunction–associated steatohepatitis (MASH) is a leading cause of progressive fibrosis with limited options for reversal. GLP-1 agonist therapies improve weight and metabolic health and may influence hepatic inflammation and fibrosis. Documented cases of complete radiologic reversal, however, remain rare.

Case:

A 41-year-old male with obesity, biopsy-proven MASH, and hyperlipidemia had four biopsies over several years, with the most recent (3/2022) showing stage 3/4 fibrosis. An MRI in 2018 demonstrated features concerning for early cirrhosis, including irregular hepatic contour and parenchymal heterogeneity. He denied any alcohol use, hepatotoxic exposures, viral hepatitis risk factors, and extensive workup for secondary liver disease had been unremarkable. His baseline weight was 224 lbs and he struggled with diet and exercise. He also had persistent LDL elevation. He was intolerant to various statin therapies and had experienced marked elevations in his liver transaminases and hepatotoxicity.

Liraglutide was initiated 3/2022 and over the following months, his weight decreased to 195 lbs with slow improvement in his liver transaminases. Serial FibroScans also demonstrated improving liver stiffness. In 5/2024, his therapy transitioned to semaglutide and his weight further decreased to a nadir of 176 lbs. This medication was well tolerated, and he was able to resume regular exercise with sustained appetite suppression. Liver transaminases continued to improve.

A repeat MRI in early 2025 showed complete resolution of steatosis, no evidence of fibrosis, and normalization of liver morphology. The irregularities and concerning features on the prior 2018 MRI and biopsy findings were absent. Interestingly, the imaging did note that the visceral fat remained pronounced compared to his peripheral fat, however the hepatic fat and fibrosis had resolved.

Discussion:

This case highlights a real-world example of the use of GLP-1 agonists and their dramatic potential as disease-modifying agents within MASH management. While weight loss likely played a major role, the degree of radiologic reversal is impressive – from biopsy-confirmed stage 3/4 fibrosis and MRI-suspected early cirrhosis to normal imaging. This case serves as an important reminder that GLP-1 therapies may reduce hepatic fat, inflammation, and metabolic stress, allowing regression of fibrosis in select patients.

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