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We aimed to characterize LSM-risk transitions and develop a time-updated, individualized model for predicting state transitions, liver-related events and death (LREs\/death).Methods: In a real-world MASLD cohort, we applied a multi-state, time-homogeneous Markov model to quantify annual transition probabilities and mean state occupancy times across LSM-defined low-, intermediate-, and high-risk strata. A Markov model incorporating age, sex, type 2 diabetes (T2D), hypertension was used to generate individualized, time-updated risk trajectories and probabilities of LREs\/death.Results: Among 11,514 MASLD individuals with \u22652 vibration-controlled transient elastography assessments, the low-risk category demonstrated notable stability, with 92% remaining unchanged at 1 year and a mean occupancy time of 8.43 years (95% confidence interval [CI] 7.94\u20138.95). Contrarily, the intermediate-risk category was highly dynamic, with only 39% remaining unchanged after 1 year and a mean occupancy time of 0.92 years (95% CI 0.88\u20130.96). T2D, hypertension, and obesity substantially shorten low-risk occupancy time, whereas antidiabetic medication was associated with more favorable transitions. Finally, we developed a dynamic, multi-state Markov model integrating longitudinal LSM-defined risk states with relevant covariates to generate individualized predictions of state transitions and risks of LREs\/death.Conclusions: LSM-based strata in MASLD represent distinct and meaningful dynamic trajectories. In particular, the marked instability of the intermediate-risk state supports more frequent reassessment. By quantifying transition pathways and time-updated risks of LREs\/death, this model may inform the personalized surveillance intervals and risk-adapted management.<\/jats:p>","DOI":"10.3350\/cmh.2026.0279","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T05:19:31Z","timestamp":1779254371000},"page":"1333-1348","update-policy":"https:\/\/doi.org\/10.3350\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The natural history and individualized prediction of liver stiffness-based fibrosis risk in metabolic dysfunction-associated steatotic liver disease"],"prefix":"10.3350","volume":"32","author":[{"given":"Yu","family":"Shi","sequence":"first","affiliation":[{"name":"The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruoqi","family":"Zhou","sequence":"additional","affiliation":[{"name":"The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seung Up","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Terry Cheuk-Fung","family":"Yip","sequence":"additional","affiliation":[{"name":"Medical Data Analytics Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China"},{"name":"State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salvatore","family":"Petta","sequence":"additional","affiliation":[{"name":"Section of Gastroenterology and Hepatology, PROMISE Department, University of Palermo, Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elisabetta","family":"Bugianesi","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Division of Gastroenterology and Hepatology, A.O. Citt\u00e0 della Salute e della Scienza di Torino, University of Turin, Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masato","family":"Yoneda","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuel","family":"Romero-Gomez","sequence":"additional","affiliation":[{"name":"Digestive Diseases Unit, Virgen Del Roc\u00edo University Hospital, Seville. Institute of Biomedicine of Seville (HUVR\/CSIC\/US). Ciberehd, ISCIII, Madrid. 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Boon-Bee","family":"Goh","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wah-Kheong","family":"Chan","sequence":"additional","affiliation":[{"name":"Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos\u00e9-Luis","family":"Calleja","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jerome","family":"Boursier","sequence":"additional","affiliation":[{"name":"Hepato-Gastroenterology and Digestive Oncology Department, Angers University Hospital, Angers, 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