INTRODUCTION:Metabolic dysfunction-associated fatty liver disease (MAFLD) affects 25-30% of the global population, with the Middle East and North Africa (MENA) region showing some of the highest prevalence rates, reaching up to 40%. MAFLD is a common cause of cirrhosis and hepatocellular carcinoma and is a leading indication for liver transplantation in this region. Hitherto, there have been no specific pharmacotherapies for MAFLD. However, the recent conditional approval of resmetirom and semaglutide by the FDA for the treatment of non-cirrhotic moderate-to-advanced (fibrosis stages 2 or 3) metabolic-associated steatohepatitis (MASH) offers a much-needed therapeutic option for this largely underserved condition. AREAS COVERED:An expert panel from the MENA region conducted a comprehensive literature search via PubMed and Google Scholar, focusing on clinical trials and international guidelines for resmetirom and semaglutide. This review identifies the target treatment population, proposes criteria for cessation of therapy, outlines monitoring protocols, and addresses regional knowledge gaps. EXPERT OPINION:The approval of the first two drugs for MASH is a milestone. Access to and affordability of these therapies will be the crucial determinants of their actual adoption. Future efforts should consider individualized treatment pathways stratified by cost, regulatory status, and healthcare infrastructure, while generating further regional evidence.

Transarterial radioembolization (TARE) and transarterial chemoembolization (TACE) are recognized locoregional therapies (LRTs) for patients with unresectable hepatocellular carcinoma (uHCC). We assessed the predictors of hepatic decompensation (HD) and its impact on overall survival (OS) in patients with uHCC undergoing TACE and TARE.We analyzed patients treated with TARE (n=135) or TACE (n=177) at four tertiary centers. HD was defined as ascites, variceal bleeding or portosystemic encephalopathy at baseline or its occurrence ≤6 months post LRT. Median OS and objective response (per mRECIST) were assessed.The cohort was predominantly male (73.9%), with a mean age of 67.1 ± 10.5 years; most had intermediate-stage (BCLC B, 54.5%), followed by early-stage (BCLC 0/A, 34.0%) and locally advanced-stage disease (BCLC C, 11.5%). HD was present at baseline in 36 patients (11.5%) and occurred after LRT in 48 patients (15.4%). The post-LRT HD group showed lower complete response rates (10.9%) than those without HD (31.4%; P = 0.002). The mOS was longer in patients without HD (41.0 months) than in those with HD at presentation (15.0 months [HR 2.35; 95% CI: 1.37-4.01) or after LRT (14.0 months [HR, 2.66; 95% CI: 1.68-4.26]). Multivariable analyses revealed hepatitis C etiology (OR 0.28, 95% CI: 0.11-0.66, P = 0.006), ALBI score (OR 2.12, 95% CI: 1.38-3.32, P = 0.001) and intervention with TARE (OR 2.20, 95% CI:1. 11-4.44, P = 0.026) as independent predictors of HD post-LRT.Post-LRT HD is common and strongly associated with reduced survival in patients with uHCC. Baseline hepatic reserve and intervention with TARE are crucial factors in predicting post-LRT HD. These findings underscore that treatment-related hepatic injury can outweigh its benefits when hepatic reserve is marginal.

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive subtype, metabolic dysfunction-associated steatohepatitis (MASH), are growing global health concerns. In the Middle East, rising rates of obesity and diabetes contribute to an increasing burden of MASLD and MASH. However, countries across the region vary in care models, health care infrastructure, and workforce capacity. Gaps remain in health policy, research infrastructure, and participation in global studies. This review outlines the current landscape of MASH in the Middle East and discusses strategies to strengthen diagnosis, management, and regionally relevant evidence generation.

Background: Metabolic dysfunction-associated fatty liver disease (MAFLD) is a prevalent and increasing global health threat, yet its epidemiology among adolescents and young adults, aged 15-39, in the Arab region remains understudied, hindering targeted public health responses. This study aims to analyze the trends in incidence, prevalence, and disability-adjusted life years (DALYs) of MAFLD, and project its future burden up to 2050, within this specific demographic across the Arab region. Methods: This study utilizes Global Burden of Disease (GBD) 2021 data to analyze the incidence, prevalence, and DALYs associated with MAFLD in individuals aged 15 to 39 in the Arab region from 1990 to 2021 accompanied by projected trend for 2050. Results: In 2021, 49 million Arab adolescents and young adults were affected by MAFLD, representing 11.6% of global cases, with Egypt bearing the largest burden (13.3 million cases). Qatar had the highest agestandardized prevalence rate (ASPR) at 37,750.8, while Saudi Arabia exhibited the fastest prevalence growth (estimated annual percentage change: 1.62%) and the highest DALYs rate (12.9). Gender disparities were notable, with a higher age-standardized incidence rate among males, particularly in Egypt's 15-19 years age group. By 2050, Kuwait, Qatar, and Saudi Arabia are projected to have the highest ASPR, exceeding global averages. Conclusions: This study highlights the urgent need for comprehensive public health initiatives focusing on modifiable risk factors to address the rising MAFLD burden among adolescents and young adults in the Arab region.

Background Cirrhosis is a major contributor to disease burden in the Middle East and North Africa (MENA) region, with variations in outcomes across socioeconomic contexts and etiologies. The primary aim of this study was to assess the temporal trends in cirrhosis-related mortality and disability across the MENA region, with a focus on variations by aetiology and Socio-demographic Index (SDI). By identifying patterns and disparities in disease burden, the study seeks to support evidence-based policymaking and optimise regional liver health planning efforts.Methods We analysed age-standardised data from the Global Burden of Disease Study to evaluate cirrhosis burden in the MENA region by SDI level in 2021 and by etiologic subtype in 1990 and 2021. Burden metrics included disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), and the YLL-to-YLD ratio, applied as a novel epidemiologic indicator to illustrate evolving patterns in disease mortality versus chronicity. Aetiology-specific trends were quantified using Estimated Annual Percentage Change (EAPC) and stratified by SDI to assess variability across countries and over time.Results In 2021, cirrhosis burden varied markedly by SDI in the MENA region. Low-SDI countries experienced the highest YLL-to-YLD ratio (122.2), reflecting a predominantly fatal disease course, whereas high-middle and high-SDI countries demonstrated lower ratios (51.3 and 56.1, respectively), indicating improved survival but with more patients living longer with disability. From 1990 to 2021, the total age-standardised DALY rate for cirrhosis decreased from 18498.2 in 1990-9749.3 in 2021, with the YLL-to-YLD ratio dropping from 123.6 to 71, signalling a transition toward less fatal and more manageable disease. Aetiology-specific trends showed consistent decreases in YLL-to-YLD ratios across all causes: chronic hepatitis C (186.6-108.5), chronic hepatitis B (180.4-105.1), alcohol-related cirrhosis (188.4-116.1), and non-alcoholic fatty liver disease (166.6-94.4). Cirrhosis from other causes remained the most disability-predominant subtype (YLL-to-YLD ratio 25.6 in 2021).Conclusions Cirrhosis in the MENA region is undergoing a transition from fatal disease to a chronically disabling condition. These changes reflect advances in detection, treatment, and survival, but also underscore the need for policy adaptation to improve awareness, prevention, early diagnosis, expand long-term care infrastructure, and reduce disparities across SDI levels.

Background: Coronavirus disease 2019 (COVID-19) vaccines have significantly reduced global morbidity and mortality. While generally safe, rare immune-mediated liver injuries, including autoimmune hepatitis (AIH) and drug-induced liver injury have been reported post-vaccination. Case series: We present three cases that developed liver injury following Pfizer-BioNTech (BNT162b2) COVID-19 vaccination. Case 1 describes a 64-year-old female with new-onset AIH confirmed by serology, histology, and clinical response to corticosteroids. Case 2 is a 36-year-old female who developed transient liver injury that resolved without immunosuppressive therapy. Case 3 involves a 35-year-old male with a history of AIH in remission who experienced a flare, requiring intensification of immunosuppressive treatment. Discussion: The mechanisms underlying liver injuries following COVID-19 vaccination remain incompletely understood, and a causal relationship has not been definitively established. One possible mechanism is molecular mimicry, in which the immune system targets liver cells after recognizing similarities with viral spike proteins. Vaccine adjuvants may also contribute to immune dysregulation in individuals with certain genetic factors like HLA-DR3 and HLA-DR4, which have been linked to AIH. Multiple reviews of vaccine-associated liver injury suggest that the majority of patients improve with immunosuppressive therapy, although there have been rare reports of severe presentations, including progression to liver failure. Conclusion: Although rare, COVID-19 vaccines may be associated with various forms of liver injury. This case series highlights the heterogeneous clinical spectrum and disease course of COVID-19 vaccine-associated liver injuries, ranging from transient liver enzyme abnormalities to more persistent disease ,such as autoimmune hepatitis, requiring treatment. While causality can not be established, these findings emphasize the importance of clinical vigilance and individualized assessment in at-risk populations.

In 2024, a comprehensive framework for the screening, diagnosis, and management of metabolic dysfunction–associated steatotic liver disease (MASLD) was incorporated in the EASL-EASD-EASO clinical practice guidelines. However, physicians often face barriers applying these recommendations in routine clinical care, especially in the Southeastern Europe, Middle East, and Africa (SEEMEA) region. As a multidisciplinary group of physicians involved in MASLD and metabolic dysfunction-associated steatohepatitis (MASH) management, our objective is to provide a practice-oriented roadmap including practical and educational considerations beyond the hepatology field that could improve patient care and support implementation of clinical guidance within the SEEMEA region. This work is informed by a narrative review and expert input obtained through structured discussions, to examine the status quo and identify key gaps in the MASLD/MASH management, unravelling the patient journey from screening and diagnosis to treatment and follow-up. Furthermore, we advise on priorities on screening triggers and, considering the limited availability of vibration-controlled transient elastography (VCTE), discuss alternative approaches to achieve accurate and timely diagnosis. Finally, following the approval of resmetirom and semaglutide 2.4 mg for MASH treatment, we review the evolving pharmacotherapy landscape and propose a “blueprint” for a specialised MASLD clinic, suggesting mandatory and optional facilities for optimised care.

Objectives:The burden of cancers related to metabolic dysfunction in the Arab countries is not well defined. This study aimed to summarize the latest estimates for 10 cancers associated with metabolic dysfunction in the region and provide future projections to inform cancer control policies. Methods:We extracted estimates of new cancer cases and deaths for colon, liver, gallbladder, pancreas, breast, corpus uteri, ovarian, kidney, thyroid, and multiple myeloma cancers from the GLOBOCAN database for the year 2022. We present age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs) for 2022 alongside projections for 2050. Results:In 2022, the 22 member countries of the Arab League reported a total of 502 959 new cancer cases. Of these, 218 746 (43.9%) cases were attributed to metabolic dysfunction. Breast cancer was the most commonly diagnosed, accounting for 43.7% of metabolic dysfunction-related cases, followed by liver cancer (16.8%) and colon cancer (10.4%). Projections indicate significant increases in incidence by 2050 for all studied cancers in the Arab region, with the largest relative increases expected in Gulf Cooperation Council countries, especially Kuwait, the UAE, and Qatar. Conclusions:Cancers related to metabolic dysfunction account for nearly half of the cancer burden in Arab countries, with marked regional differences. The projected rise in incidence and mortality by 2050 highlights the need for comprehensive, multisectoral cancer control policies implemented at the regional level and tailored to the cancer profiles of individual countries.

BACKGROUND & AIMS:Metabolic dysfunction-associated steatotic liver disease is the most common chronic liver disease worldwide. We aimed to estimate the prevalence, severity, and metabolic determinants of metabolic dysfunction-associated steatotic liver disease and liver fibrosis among Saudi adults using vibration-controlled transient elastography. METHODS:We conducted a cross-sectional analysis from the prospective, population-based Genomics and Environmental Noninvasive Evaluation for Saudi Intrahepatic Steatosis (GENESIS) cohort across 7 primary care centers in Saudi Arabia between March 2024 and June 2025. Eligible adults underwent clinical assessment, laboratory testing, and vibration-controlled transient elastography. We defined metabolic dysfunction-associated steatotic liver disease as controlled attenuation parameter ≥268 dB/m with ≥1 cardiometabolic risk factor, and significant fibrosis as liver stiffness measurement ≥8 kPa. RESULTS:Among 2979 participants included in the analytic cohort (mean age, 41.9 years; 49.7% men), 1111 met metabolic dysfunction-associated steatotic liver disease criteria, yielding a crude prevalence of 37.3% (95% confidence interval, 35.6%-39.0%) and an age- and sex-adjusted prevalence of 34.2% (95% confidence interval, 32.5%-35.9%). Forty-eight (4.3%) participants with metabolic dysfunction-associated steatotic liver disease had significant fibrosis. Diabetes (odds ratio, 1.80; 95% confidence interval, 1.43-2.27), waist circumference (odds ratio, 1.35; 95% confidence interval, 1.30-1.40), and high obstructive sleep apnea risk (odds ratio, 1.47; 95% confidence interval, 1.21-1.80) were independently associated with metabolic dysfunction-associated steatotic liver disease. Diabetes (odds ratio, 4.41; 95% confidence interval, 2.12-9.14), male sex (odds ratio, 2.83; 95% confidence interval, 1.31-6.13), and waist circumference (odds ratio, 1.24; 95% confidence interval, 1.11-1.39) were independently associated with significant fibrosis among individuals with metabolic dysfunction-associated steatotic liver disease. CONCLUSIONS:Metabolic dysfunction-associated steatotic liver disease affects more than one-third of Saudi adults and is associated with central obesity and metabolic dysfunction, whereas significant fibrosis remains relatively low. These findings provide the first prospective, population-level metabolic dysfunction-associated steatotic liver disease estimates at a country level in Saudi Arabia and support scalable vibration-controlled transient elastography-based risk stratification.