NAFLD Gets a New Name. Will This One Stick?

Noting that the term "nonalcoholic fatty liver disease" (NAFLD) is stigmatizing, an international group of medical organizations proposed a name change to "metabolic dysfunction-associated steatotic liver disease" (MASLD).

This new name, formulated by 236 experts from 54 countries, was recently announced in a consensus statement in the journal Hepatology, after 74% of panelists agreed that the current name was "sufficiently flawed."

"The consensus was the result of a transparent and fair process that engaged the global community and the patient community," said panelist Meena B. Bansal, MD, of the Icahn School of Medicine at Mount Sinai in New York City and a spokesperson for the American Association for the Study of Liver Diseases (AASLD). "It wasn't just a small group of experts."

Bansal pointed out that a "big advance is that by using the umbrella term 'steatotic,' we are setting ourselves up for growth and discovery. This is a heterogeneous disease, and we can discover new etiologies under that umbrella."

"We don't want to pigeonhole ourselves and have to do this over again," she added. "We want a durable infrastructure that allows for growth and can accommodate scientific discovery."

This change is expected to yield greater awareness, better patient identification, more funding, and ultimately reductions in mortality, the group said.

It was long thought that NAFLD overemphasized the nonalcoholic component, while under-emphasizing the metabolic origin of this widespread disease affecting more than 30% of the world's population. Not only did the "nonalcoholic" characterization fail to accurately capture the metabolic etiology, but the descriptor "fatty" was seen as pejorative.

The old nomenclature also did not adequately recognize individuals with risk factors such as type 2 diabetes who consume more alcohol than the relatively strict thresholds used to define the "nonalcoholic" designation, which led to their exclusion from trials and consideration for treatments.

"There is a recognition now that there are overlapping biological processes which may contribute to both NAFLD and alcohol-related liver disease (ALD)," the panelists wrote. "All of these factors have led to growing dissatisfaction with the current nomenclature."

That dissatisfaction resulted first in an earlier nomenclature change from NAFLD to MAFLD, or "metabolic-associated fatty liver disease." This term included patients with a fatty liver regardless of the amount and pattern of their alcohol intake. While acceptable to some experts, MAFLD was still considered suboptimal owing to its mixing of etiologies and retention of "fatty." Of particular concern was the potential negative impact of changes in diagnostic criteria in terms of biomarker and therapy development.

"Another issue was raised by pediatricians. For them, 'metabolic' refers to congenital disorders in children," Bansal said. Many pediatric panelists felt that the term "nonalcoholic" was especially stigmatizing for children, adolescents, and their parents.

The group decided it was time to go back to the drawing board, with the recent consensus adding the term "dysfunction" and settling on MASLD.

The new nomenclature was developed from 2021 to 2022 under the auspices of the AASLD, the European Association for the Study of the Liver, and the Asociación Latinoamericana para el Estudio del Hígado, with input from other liver and other medical societies. The global consultation process used the structured, multistage survey-based Delphi technique.

Though confident in the general acceptability of the new term, Bansal cautioned that "change is never easy. Some people are not thrilled at changing the name but they come around when you discuss the added clarity."

She also noted that some patient groups that use "fatty liver" in their name may not have the funding needed to alter it on their literature. "But we as leaders in the field want to partner with them and help them to do that. But it won't happen overnight," she said.

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