# Immune Determinants of MASLD Progression: From Immunometabolic Reprogramming to Fibrotic Transformation

## TL;DR

This paper reviews how immune and fibrotic interactions drive the progression of metabolic liver disease and highlights new strategies for precision treatment.

## Contribution

The paper introduces integrated frameworks combining clinical, imaging, and biomarker data to better understand and treat immune-fibrotic networks in MASLD.

## Key findings

- Immune–fibrotic networks are central to the progression from MASLD to MASH and fibrosis.
- Integrated biomarker and imaging approaches can identify immune–fibrotic signatures for better disease stratification.
- Targeting immunometabolic circuits and multi-system dysfunction offers new therapeutic strategies.

## Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) can progress from simple steatosis to inflammatory injury and fibrosis. Beyond lipid accumulation, immune activation and fibrotic remodeling have emerged as key determinants of disease progression. This review synthesizes recent evidence showing how metabolic stress reshapes immune responses and stromal cell interactions, forming immune–fibrotic networks that drive disease evolution. Emphasis is placed on integrated clinical, imaging, and biomarker-based frameworks to capture immune–fibrotic signatures relevant to disease stratification and therapeutic response.

Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a progressive spectrum of metabolic liver injury in which immune activation, metabolic stress, and stromal remodeling evolve in a tightly interdependent manner. Although early disease stages are dominated by metabolic overload, accumulating evidence indicates that immunometabolic rewiring and fibro-inflammatory amplification critically shape the transition toward metabolic dysfunction-associated steatohepatitis (MASH) and advanced fibrosis. This review synthesizes emerging insights into how hepatocyte stress responses, innate and adaptive immune circuits, and extracellular matrix-producing stromal populations interact to form a dynamic, feed-forward network driving disease progression. Particular emphasis is placed on the deterministic role of immune–fibrotic coupling in shaping clinical phenotypes, disease trajectory, and therapeutic responsiveness. Rather than focusing on individual molecular layers, we highlight how integrated clinical, imaging, and biomarker-informed frameworks can capture immune–fibrotic signatures relevant to risk stratification and precision intervention. Building on this systems-level perspective, we outline next-generation therapeutic strategies targeting immunometabolic circuits, cross-organ communication, and multi-system dysfunction. Finally, we discuss how future precision medicine—supported by integrative biomarker profiling and dynamic physiological assessment—may reshape MASLD management and improve long-term hepatic and cardiometabolic outcomes.