MAFLD 2022: An ELPA/ALPA/EASO-ECPO joint statement on disease stigma

Progress is impossible without change: understanding the evolving nomenclature of steatotic liver disease and its effect on hepatology practice

The American, European, and Latin American liver societies have proposed a change in the nomenclature we use to describe alcohol-related liver disease and non-alcoholic fatty liver disease. Additionally, a term encompassing both is now advocated: steatotic liver disease, which includes metabolic dysfunction associated steatotic liver disease (MASLD) and MASLD with greater alcohol consumption (MetALD). These classifications offer increased relevance for clinicians, researchers, and patients alike. In this Viewpoint, we discuss the basis for this nomenclature shift and how it was developed. We also explore the challenges that will be faced in the adoption of such change. The proposed change seeks to banish stigma associated with phrasing such as alcoholic and fatty. However stigma, particularly related to the term fatty, is culturally nuanced, and reflects different entities depending on location. If such a change is internationally accepted, there will be wide-reaching effects on practitioners in primary care and metabolic medicine, and on patients. We discuss those effects and the opportunities the nomenclature change could offer, particularly for patients with alcohol and metabolic risk factors who represent a group previously ignored by clinical trials.

Waiting for the changes after the adoption of steatotic liver disease

Steatotic liver disease was suggested as an overarching term encompassing various etiologies of hepatic steatosis. Experts from multinational liver societies went through the Delphi process, including four rounds of surveys, and consented to adopt a new nomenclature and definition instead of the conventional nonalcoholic fatty liver disease (NAFLD). This was to improve the understanding of the patients and primary care physicians, with an explanation of the pathophysiology in the name of the disease. Also, it could minimize the stigmatization of patients by using the histological neutral term "steatosis" instead of "fatty". Herein, we will discuss the changes and continuity between the two nomenclatures, metabolic dysfunction-associated steatotic liver disease (MASLD) and NAFLD, as well as the challenges to MASLD which need to be addressed in future.

Body Composition Analysis in Patients with Metabolic Dysfunction-Associated Fatty Liver Disease

We sought to examine body composition using bioimpedance analysis in patients with metabolic dysfunction-associated fatty liver disease (MAFLD, 2014 males and 949 females). Factors linked to the fat-free mass index (FF index) were examined using univariate and multivariate analysis. An FF index < 18 kg/m2 in males and an FF index < 15 kg/m2 in females were defined as having decreased skeletal muscle mass. The median age and body mass index (BMI) were 55 years and 25.4 kg/m2 in males, and 57 years and 25.4 kg/m2 in females, respectively. The FF index strongly correlated with muscle mass index both in males (r = 0.999) and females (r = 0.999). The prevalence of patients with an FF index < 18 kg/m2 in males and an FF index < 15 kg/m2 in females was well stratified according to age, BMI, severity of FL, and FIB4 index. In the males, in the multivariate analysis, BMI (p < 0.0001), fat mass index (p < 0.0001), and waist circumference (p = 0.0050) were found to be significant factors linked to FF index. In the females, in the multivariate analysis, BMI (p < 0.0001) and fat mass index (p < 0.0001) were found to be significant. In conclusion, fat accumulation as reflected by BMI, which is an easily available marker, could be a useful indicator for the skeletal muscle mass in MAFLD.

Post-liver transplantation patient experience

Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.

NAFLD, MAFLD, and beyond: one or several acronyms for better comprehension and patient care

The term non-alcoholic fatty liver disease (NAFLD) has rapidly become the most common type of chronic liver disease. NAFLD points to excessive hepatic fat storage and no evidence of secondary hepatic fat accumulation in patients with "no or little alcohol consumption". Both the etiology and pathogenesis of NAFLD are largely unknown, and a definitive therapy is lacking. Since NAFLD is very often and closely associated with metabolic dysfunctions, a consensus process is ongoing to shift the acronym NAFLD to MAFLD, i.e., metabolic-associated fatty liver disease. The change in terminology is likely to improve the classification of affected individuals, the disease awareness, the comprehension of the terminology and pathophysiological aspects involved, and the choice of more personalized therapeutic approaches while avoiding the intrinsic stigmatization due to the term "non-alcoholic". Even more recently, other sub-classifications have been proposed to concentrate the heterogeneous causes of fatty liver disease under one umbrella. While awaiting additional validation studies in this field, we discuss the main reasons underlying this important shift of paradigm.