Clinical Scorecard: Reassessing Nomenclature: Transitioning from NAFLD to MASLD (Metabolic Dysfunction–Associated Steatotic Liver Disease)

At a Glance

Key Highlights

• MASLD replaces NAFLD to emphasize metabolic origin and reduce stigma by removing 'nonalcoholic' and 'fatty' terms.
• Diagnosis requires liver steatosis plus one or more metabolic risk factors; excludes excessive alcohol intake above defined limits.
• New category MetALD recognizes combined metabolic dysfunction and alcohol-related liver disease, associated with increased mortality.

Guideline-Based Recommendations

Diagnosis

• Diagnose MASLD by presence of hepatic steatosis and at least one cardiometabolic risk factor.
• Exclude individuals with alcohol consumption ≥30 g/day for men and ≥20 g/day for women from MASLD diagnosis.
• Liver biopsy required to diagnose steatohepatitis (MASH) showing steatosis, ballooning, and inflammation.

Management

• Focus on addressing metabolic risk factors including obesity, dysglycemia, and dyslipidemia.
• Consider insulin resistance as a therapeutic target to reduce hepatic lipid accumulation.
• Recognize MetALD patients for tailored management due to combined metabolic and alcohol-related risks.

Monitoring & Follow-up

• Case-finding for advanced fibrosis recommended in high-risk groups such as patients with diabetes and persistently elevated liver enzymes.
• Routine mass population screening for MASLD not currently recommended due to lack of cost-effectiveness.

Risks

• Presence of metabolic syndrome traits increases risk of severe fibrosis, liver-related morbidity, and mortality.
• Excess alcohol intake in MetALD increases all-cause mortality.
• Advanced fibrosis correlates with worse liver-related outcomes.

Patient & Prescribing Data

Patients with hepatic steatosis and metabolic dysfunction, including those with diabetes and obesity

Insulin therapy may reduce liver fat; managing insulin resistance and metabolic risk factors is key to treatment

Clinical Best Practices

• Use the MASLD nomenclature to improve patient communication and reduce stigma.
• Screen high-risk patients (e.g., diabetes, metabolic syndrome) for advanced fibrosis rather than general population screening.
• Incorporate assessment of alcohol intake to differentiate MASLD from MetALD for appropriate management.
• Employ multidisciplinary approaches targeting metabolic dysfunction to prevent progression to MASH and fibrosis.

References

• Eslam et al., 2020 - Proposal of MAFLD nomenclature
• Multisociety consensus on MASLD nomenclature, 2023
• NAFLD Pathophysiology and Metabolic Syndrome Association