Metabolically dysregulated steatotic liver disease (MASLD) affects approximately one-third of the global adult population. This narrative review presents the clinical profile of the contemporary patient with MASLD, focusing on the systemic nature of the disease and risk stratification. MASLD is a systemic metabolic disorder in which hepatic steatosis serves as a marker of insulin resistance, systemic inflammation, and atherogenic dyslipidemia. The leading cause of death in MASLD patients is cardiovascular events, with a two-fold increase in cardiovascular mortality that persists across all fibrosis stages. Disease trajectory is determined by fibrosis stage, comorbid profile (type 2 diabetes, hypertension, dyslipidemia), and phenotype. Three main phenotypes have been identified: classical metabolic (60-70%, dominant cardiovascular risk), lean (15-20%, higher PNPLA3 I148M carriage, faster fibrosis progression, underdiagnosis), and mixed Met-ALD (10–15%, synergistic liver damage from alcohol and metabolic disturbances). Non-invasive fibrosis assessment using FIB-4 followed by elastography is the first step after diagnosis. Patients with fibrosis F3–F4 require aggressive monitoring, including hepatocellular carcinoma screening every 6 months, while patients with F0–F2 require mandatory cardiovascular risk control in primary care. Management priorities differ by phenotype: cardiometabolic control for classical metabolic, fibrosis screening and genetic counseling for lean, and complete alcohol cessation for Met-ALD. Lifestyle modification (weight loss of 5–10%, Mediterranean diet, 150 minutes of physical activity per week) has stronger evidence than any experimental drug. The proposed risk stratification algorithm can be implemented both in primary care and in specialized hepatology centers.
