MAFLD Pathway for Australian GPs: RACGP Context & GESA 2023 Alignment
A practical summary of who to screen, how to use FIB-4, and when liver elastography closes the indeterminate gap — aligned with GESA's MAFLD clinical care pathway used in Australian practice.
The September 2025 Australian Consensus Statement — What It Says
The Medical Journal of Australia published an evidence-based consensus statement on MAFLD in primary care in September 2025 (doi: 10.5694/mja2.70008), co-authored by 16 leading Australian clinicians including:
- Professor Jacob George — Storr Liver Centre, Westmead Hospital
- Professor Leon Adams — University of Western Australia
- Professor Stuart Roberts — Alfred Hospital Melbourne
- Professor Elizabeth Powell — Princess Alexandra Hospital Brisbane
- Professor Gerald Watts — University of Western Australia
The primary recommendations:
- Adults with type 2 diabetes, obesity, or two or more metabolic risk factors should be tested for MAFLD
- Hepatic steatosis should be evaluated using ultrasound
- Liver fibrosis risk requires assessment using the FIB-4 Index
- Patients with indeterminate FIB-4 (1.3–2.67) should undergo liver elastography as second-line assessment
- Patients with high FIB-4 (above 2.67) or elevated elastography should be referred for specialist evaluation
The GLP-1 implication: Every patient prescribed a GLP-1 medication in Australia meets the criteria for MAFLD assessment under this guideline — type 2 diabetes and obesity are both primary indications for GLP-1 prescription and both high-risk conditions for MASLD.
Full patient guide for GLP-1 patients → · Find a liver elastography clinic →
Australian GPs manage the largest volume of metabolic liver disease in the country. RACGP chronic disease frameworks emphasise cardiovascular and diabetes risk — MAFLD sits at the intersection. GESA published an updated MAFLD clinical care pathway in 2023 that gives primary care a clear sequence: identify at-risk patients → calculate FIB-4 → use elastography when FIB-4 is indeterminate or when staging is needed for management decisions.
Step 1 — Who to assess
Prioritise patients with:
- Type 2 diabetes (MAFLD prevalence 50–75% in many cohorts)
- BMI ≥30 or metabolic syndrome
- Persistent ALT elevation on repeat testing
- Known MAFLD on imaging with unclear fibrosis stage
Step 2 — FIB-4 first
FIB-4 uses age, AST, ALT, and platelet count. It is near-zero marginal cost and performs well as a rule-out test. Use the FIB-4 calculator in clinic. Remember age skews FIB-4 upward — consider adjusted thresholds in patients over 65.
| FIB-4 | Interpretation | Typical action |
|---|---|---|
| < 1.3 | Low risk | Lifestyle + repeat FIB-4 in 1–2 years |
| 1.3 – 2.67 | Indeterminate | Elastography recommended |
| > 2.67 | High risk | Refer or elastography + specialist review |
Step 3 — Elastography when FIB-4 is indeterminate
GESA recommends liver stiffness measurement (LSM) for patients in the grey zone. Community-based guided elastography allows same-visit staging without a hospital FibroScan queue. For MAFLD, LSM <8 kPa generally supports ongoing primary care; ≥12 kPa warrants hepatology referral.
MSAC 1797 — what GPs should know
MSAC did not fund standalone FibroScan on the MBS for MASLD screening (Application 1797, early 2025). That affects how private FibroScan clinics bill — not whether elastography is clinically useful. Some integrated ultrasound pathways attract partial MBS contribution when criteria are met. See MBS rebate update and MSAC 1797 analysis.
For a longer screening guide, see MAFLD screening Australia (clinical guide).
GP FAQ
What FIB-4 score is low risk in MAFLD?
For patients under 65, FIB-4 below 1.3 is generally low risk for advanced fibrosis. Above 2.67 is high risk and warrants referral or further investigation. Between 1.3 and 2.67 is indeterminate — elastography is the recommended second-line test per GESA MAFLD guidance.
Does RACGP recommend elastography for fatty liver?
RACGP and GESA-aligned pathways support non-invasive staging in primary care when blood-based scores are indeterminate or when metabolic risk is high. Elastography is not a population screening test for all Australians — it is used in risk-selected patients after FIB-4 or when clinical suspicion is elevated.
What kPa threshold matters after an indeterminate FIB-4?
For MAFLD/MASLD, liver stiffness below ~8 kPa generally supports primary care management; 8–12 kPa is intermediate; above 12 kPa warrants hepatology input. Disease-specific thresholds differ for HBV and HCV.