When one of Dr. Greg Gonzaba’s closest friends from medical school called him out of the blue, Gonzaba expected a conversation about his practice and life in Austin. But fat had been building up in his friend’s liver undetected, until it was too late.
“He told me he was on hospice,” Gonzaba said.
He died a few months later, at 53.
Gonzaba, an internal medicine physician with Gonzaba Medical Group in San Antonio, has since seen several patients die from fatty liver disease over his 27 years in practice.
“Sometimes the families, they’re perplexed,” he said. “They’re like, ‘What do you mean? You never told us we had this, and where did this come from?’ It can sneak up on you if it’s not caught early.”
Metabolic dysfunction-associated steatohepatitis (MASH) occurs when excess fat cells build up in the liver, driving chronic inflammation. It was formerly known as non-alcoholic steatohepatitis (NASH). The condition is a subgroup of fatty liver diseases, which also includes alcohol-associated liver disease.
Gonzaba is now leading efforts to recruit patients in San Antonio for a national study led by the Foundation for the National Institutes of Health (FNIH) looking to find better ways to detect fat buildup in the liver sooner, and more often.
San Antonio was one of four sites chosen, Gonzaba said, in part due to the high prevalence of comorbidities and risk factors that often accompany fatty liver diseases, including obesity, diabetes and high-fat diets. It was also chosen for its significant Hispanic population, a group that is more susceptible to the disease on average.
MASH rates increasing
MASH is on a dramatic rise in the U.S.
In 2000, 0.1% of liver transplants were driven by MASH nationally. In 2022, that number jumped to 16%, the leading cause after alcohol-driven liver disease only, according to a 2024 study published in the Southern Medical Journal.
Other research suggests that MASH prevalence and mortality is increasing and will continue to rise through 2030 in the U.S. — driven by increasing rates of obesity and diabetes, as well as an aging population. There is also a genetic component to the disease.
A 2016 study also found that Hispanic people living in Cameron County in South Texas experienced liver cirrhosis nearly four times the national average, driven by high rates of obesity and diabetes. The study also notes that Hispanics in South Texas have the highest incidence of liver cancer in the country.
“I do see a lot of Hispanic patients, and I see a lot of people that are overweight, a lot of people with diabetes,” said Gonzaba, who practices out of Gonzaba Medical Group’s Northwest Clinic in San Antonio. “Believe it or not, almost anyone that we do a liver scan on, looking at their gallbladder for gallstones or look at their kidneys, we see fatty liver buildup.”
The good news is that fatty liver disease is treatable and reversible. The intervention for MASH is largely lifestyle-focused, but two recently approved drugs are also available, including the GLP-1 agonist semaglutide, approved to treat MASH in 2025.
To best combat the disease, “If you’re overweight, lose weight. If you’re a diabetic, control your diabetes, and if you eat a lot of food that is high in fat, change your diet and get regular exercise,” Gonzaba said. “In some people, that’s more than enough to even reverse this.”
The bad news is that a significant portion of patients won’t know they have MASH until it’s too late, largely because of inadequate diagnostics.
Skipping the needle
MASH currently requires a lengthy diagnosis. This involves imperfect blood tests that can miss certain patients, imaging and ultimately a liver biopsy, a bedside procedure that requires inserting a hollow needle through the skin into the liver to get a sample of liver tissue.
“That’s a little more invasive,” Gonzaba said. “It can be painful and expensive.”
The FNIH’s Biomarkers Consortium is seeking to validate new biomarkers to detect MASH without the need for a liver biopsy, ultimately helping catch this earlier and in more patients before significant liver damage occurs.
The organization is leading successive studies seeking to find reliable non-invasive ways to diagnose and treat liver disease. This includes the NIMBLE project, which the Gonzaba Medical Group is helping recruit patients for.
The FNIH laid out its motivations for finding better diagnostics for MASH in a 2026 correspondence in Nature Communications.
“The status quo has many limitations,” the authors wrote. “It requires liver biopsy, which is invasive and associated with the potential for severe morbidity and even death, and is further negatively impacted by sampling and observer variability. These have contributed to high screen failure rates for clinical trials.
“Together these constitute a major barrier to drug development for this public health threat.”
Gonzaba Medical Group is helping recruit patients across its San Antonio clinics for the larger study that will be conducted. So far, the medical group has about 10 participants.
Because the criteria are so strict, finding participants is a lengthy process. Study participants are compensated for their time. Gonzaba and his team are aiming to recruit roughly 200 patients.
“Catching it earlier can be life-saving for a lot of people,” Gonzaba said.
