MAFLD: Now is the time to capitalize on the momentum
2021; Elsevier BV; Volume: 74; Issue: 5 Linguagem: Inglês
10.1016/j.jhep.2021.02.002
ISSN1600-0641
Autores Tópico(s)Diet, Metabolism, and Disease
ResumoWe thank Abdel Alem et al.,[1]Alem S.A. Gaber Y. AbdAlla M. Said E. Fouad Y. Capturing patient experience: a qualitative study of change from NAFLD to MAFLD real-time feedback.J Hepatol. 2021; 74: 1261-1262Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Kasper et al.[2]Kasper P. Martin A. Lang S. Demir M. Steffen H.-M. Hypertension in NAFLD: an uncontrolled burden.J Hepatol. 2021; 74: 1258-1260Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Fouad et al.[3]Fouad Y.G.A. semida N. Abdel Ghany W. Attia D. Change from NAFLD to MAFLD increases the awareness of fatty liver disease of primary care physicians and specialists.J Hepatol. 2021; 74: 1254-1256Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and Spearman et al.[4]Spearman C.W. Desalegn H. Ocama P. Awuku Y.A. Ojo O. Elsahhar M. et al.The sub-Saharan Africa position statement on the redefinition of fatty liver disease: from NAFLD to MAFLD.J Hepatol. 2021; 74: 1256-1258Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar for their interest in our work.[5]Eslam M. Sanyal A.J. George J. International Consensus P. MAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease.Gastroenterology. 2020; 158 (1999-2014 e1991)Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar,[6]Eslam M. Newsome P.N. Sarin S.K. Anstee Q.M. Targher G. Romero-Gomez M. et al.A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement.J Hepatol. 2020; 73: 202-209Abstract Full Text Full Text PDF PubMed Scopus (514) Google Scholar Abdel Alem et al.[1]Alem S.A. Gaber Y. AbdAlla M. Said E. Fouad Y. Capturing patient experience: a qualitative study of change from NAFLD to MAFLD real-time feedback.J Hepatol. 2021; 74: 1261-1262Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar report an important qualitative study that shows a high level of dissatisfaction among patients with the old acronym "NAFLD" and their strong preference for a name change to "MAFLD". This study in concert with a recent statement by >30 patient advocacy associations led by the European Liver Patients' Association (ELPA) and associations across different disciplines from diabetes to renal medicine and obesity medicine, highlights the increasing traction that MAFLD has received.[7]Shiha G. Korenjak M. Eskridge W. Casanovas T. Velez-Moller P. Hogstrom S. et al.Redefining fatty liver disease: an international patient perspective.Lancet Gastroenterol Hepatol. 2021; 6: 73-79Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Kasper et al.[2]Kasper P. Martin A. Lang S. Demir M. Steffen H.-M. Hypertension in NAFLD: an uncontrolled burden.J Hepatol. 2021; 74: 1258-1260Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar applaud and strongly support the incorporation of hypertension as one of the diagnostic criteria for MAFLD but suggest that 24-hour-ambulatory blood pressure monitoring (24-h-ABPM) should be the preferred method of measurement. Although this suggestion is sound, as acknowledged by the authors, potential barriers to the integration of ABPM-based hypertension screening programs include increased costs and the lack of proprietary software in many healthcare systems, particularly in resource-constrained settings. They also acknowledge the difficulties of patient education, device application and data interpretation. The simplicity of the MAFLD criteria and its applicability across most healthcare settings is one of its major attributes. One of the arguments that has been raised about the proposed new name in favour of retaining the old acronym is the expected confusion from primary care providers and other specialists. As elegantly espoused by Fouad and colleagues, evidence rather than opinion should be used to test this argument.[8]Fouad Y. Elwakil R. Elsahhar M. Said E. Bazeed S. Ali Gomaa A. et al.The NAFLD-MAFLD debate: eminence vs evidence.Liver Int. 2021; 41: 255-260Crossref PubMed Scopus (22) Google Scholar In their recent work, Fouad et al.[3]Fouad Y.G.A. semida N. Abdel Ghany W. Attia D. Change from NAFLD to MAFLD increases the awareness of fatty liver disease of primary care physicians and specialists.J Hepatol. 2021; 74: 1254-1256Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar provide clear evidence that in contrast to what was expected, the change to MAFLD led to increased awareness and familiarity of the disease among primary care providers and specialists. This study provides strong support that evidence rather than opinion is the way forward and may often reveal the unexpected. In the work by Spearman et al. under the umbrella of the African Middle East Association of Gastroenterology (AMAGE), key opinion leaders in sub-Saharan Africa utilised the Delphi method to reach consensus and endorse the proposal for the redefinition of fatty liver disease associated with metabolic dysfunction. Notably, they provide an elegant, contextualised perspective on the positive attributes of the MAFLD proposal. In low and middle-income countries, policymakers are struggling with severe resource limitations. The MAFLD criteria allow these countries to move forward in locally appropriate ways. This endorsement adds to similar ones from other key liver organisations namely the Asian Pacific Association for the Study of the Liver (APASL), the Latin American Association for the Study of the Liver (ALEH), and the Middle East and North Africa. In addition, the new name and definition has received the support and endorsement from multiple stakeholders, including patients, patient advocacy associations, nurses and allied health leaders, indicating that a broad consensus is emerging.9Shiha G. Alswat K. Al Khatry M. Sharara A.I. Ormeci N. Waked I. et al.Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.Lancet Gastroenterol Hepatol. 2021; 6: 57-64Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 10Mendez-Sanchez N. Arrese M. Gadano A. Oliveira C.P. Fassio E. Arab J.P. et al.The Latin American Association for the Study of the Liver (ALEH) position statement on the redefinition of fatty liver disease.Lancet Gastroenterol Hepatol. 2021; 6: 65-72Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 11Eslam M. Sarin S.K. Wong V.W. Fan J.G. Kawaguchi T. Ahn S.H. et al.The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease.Hepatol Int. 2020; 14: 889-919Crossref PubMed Scopus (83) Google Scholar Beyond this, the trajectory of evidence supporting the utility of the definition in practice continues to be forthcoming.[12]Eslam M. Ratziu V. George J. Yet more evidence that MAFLD is more than name change.J Hepatol. 2021; Abstract Full Text Full Text PDF Google Scholar The MAFLD criteria identifies patients with more advanced hepatic fibrosis,[13]Yamamura S. Eslam M. Kawaguchi T. Tsutsumi T. Nakano D. Yoshinaga S. et al.MAFLD identifies patients with significant hepatic fibrosis better than NAFLD.Liver Int. 2020; Crossref PubMed Google Scholar incident cardiovascular disease,[14]Lee H. Lee Y.H. Kim S.U. Chang Kim H. Metabolic dysfunction-associated fatty liver disease and incident cardiovascular disease risk: a nationwide cohort study.Clin Gastroenterol Hepatol. 2020; Abstract Full Text Full Text PDF Google Scholar chronic kidney disease,[12]Eslam M. Ratziu V. George J. Yet more evidence that MAFLD is more than name change.J Hepatol. 2021; Abstract Full Text Full Text PDF Google Scholar,[15]Sun D.Q. Jin Y. Wang T.Y. Zheng K.I. Rios R.S. Zhang H.Y. et al.MAFLD and risk of CKD.Metabolism. 2021; 115: 154433Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar and those who would benefit from an assessment of genetic risks for fatty liver[16]Xia M. Zeng H. Wang S. Tang H. Gao X. Insights into contribution of genetic variants towards the susceptibility of MAFLD revealed by the NMR_based lipoprotein profiling.J Hepatol. 2020; Abstract Full Text Full Text PDF Google Scholar,[17]Liu Z. Suo C. Shi O. Lin C. Zhao R. Yuan H. et al.The health impact of MAFLD, a novel disease cluster of NAFLD, is amplified by the integrated effect of fatty liver disease-related genetic variants.Clin Gastroenterol Hepatol. 2020; Abstract Full Text Full Text PDF Google Scholar better than the old criteria. The utility of the MAFLD definition has also been shown in patients with other diseases such as hepatitis B,[18]Mak L.-Y. Yuen M.-F. Seto W.-K. Letter regarding "A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement".J Hepatol. 2020; 73: 1573-1574Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar hepatitis C,[19]Fouad Y. Saad Z. Raheem E.A. Moness H. Osman N. Abdelhameed W. et al.Clinical Validity of the diagnostic criteria for metabolic-associated fatty liver disease: a real-world experience.medRxiv. 2020; Google Scholar,[20]Al Omary A. Byth K. Weltman M. George J. Eslam M. Metabolic-associated fatty liver disease increases fibrosis severity in patients with chronic hepatitis C.J Gastroen Hepatol. 2020; (WILEY 111 RIVER ST, HOBOKEN 07030-5774, NJ USA; 2020): 44-45PubMed Google Scholar HIV,[21]Jongraksak T. Sobhonslidsuk A. Jatchavala J. Warodomwichit D. Kaewduang P. Sungkanuparph S. Prevalence and predicting factors of metabolic-associated fatty liver disease diagnosed by transient elastography with controlled attenuation parameters in HIV-positive people.Int J STD AIDS. 2020; (0956462420960997)PubMed Google Scholar celiac disease,[22]Rispo A, Imperatore N, Guarino M, Tortora R, Alisi A, Cossiga V, et al. Metabolic-associated fatty liver disease (MAFLD) in celiac disease. Liver Int.Google Scholar myotonic dystrophy type 1 (DM1)[23]Miele L. Perna A. Dajko M. Zocco M.A. De Magistris A. Nicoletti T.F. et al.Clinical characteristics of metabolic associated fatty liver disease (MAFLD) in subjects with myotonic dystrophy type 1 (DM1).Dig Liver Dis. 2021; Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and Gaucher disease.[24]Nascimbeni F. Lugari S. Cassinerio E. Motta I. Cavicchioli A. Dalla Salda A. et al.Liver steatosis is highly prevalent and is associated with metabolic risk factors and liver fibrosis in adult patients with type 1 Gaucher disease.Liver Int. 2020; Crossref Scopus (7) Google Scholar This all begs the question, why do we not put the debate aside, capitalize on maintaining momentum and progress the field with the only thing that can – more evidence. The MAFLD proposal can be the stepping-stone for new vigour among clinicians for patient management on the one hand and on the other, to enhance community and other stakeholder engagement for the benefit of patients. Among the many positive attributes of the change from NAFLD to MAFLD, we should not lose sight of the fact that it has generated a momentum of its own that should now be encouraged rather than emasculated. Gathering more evidence is the only way forward for the holistic management of patients with fatty liver disease related to metabolic dysfunction and for the rapid development of new treatments and multidisciplinary models of care. M.E. and J.G. are supported by the Robert W. Storr Bequest to the Sydney Medical Foundation, University of Sydney, National Health and Medical Research Council of Australia (NHMRC) Program Grants ( APP1053206 , APP1149976 ) and Project grants ( APP1107178 , APP2001692 and APP1108422 ). The authors contributed equally to the work. The authors declare no competing interests or any conflict of interest. Please refer to the accompanying ICMJE disclosure forms for further details. The following is the supplementary data to this article: Download .pdf (.15 MB) Help with pdf files Multimedia component 1 Change from NAFLD to MAFLD increases the awareness of fatty liver disease in primary care physicians and specialistsJournal of HepatologyVol. 74Issue 5PreviewThe recent landmark articles by Eslam et al1,2 have attracted substantial attention from various stakeholders.3–9 although concerns have been raised that such a change may lead to confusion, particularly among non-hepatologists.10 Full-Text PDF Hypertension in NAFLD: An uncontrolled burdenJournal of HepatologyVol. 74Issue 5PreviewWith great interest we have read the recent consensus statement of Eslam et al. suggesting the redefinition of non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction)-associated fatty liver disease (MAFLD).1 One of the proposed metabolic abnormalities within the diagnostic criteria is an office blood pressure (OBP) ≥130/85 mmHg, or antihypertensive drug treatment.1 Full-Text PDF Capturing patient experience: A qualitative study of change from NAFLD to MAFLD real-time feedbackJournal of HepatologyVol. 74Issue 5PreviewWe read with great interest the recent influential article by Eslam et al. suggesting the shift in nomenclature from non-alcoholic fatty liver diseases to metabolic dysfunction-associated fatty liver disease (MAFLD) and introducing, for the first time, positive diagnostic criteria;1,2 a proposal that seems to be gaining momentum.3–7 Full-Text PDF A new definition for metabolic dysfunction-associated fatty liver disease: An international expert consensus statementJournal of HepatologyVol. 73Issue 1PreviewThe exclusion of other chronic liver diseases including "excess" alcohol intake has until now been necessary to establish a diagnosis of metabolic dysfunction-associated fatty liver disease (MAFLD). However, given our current understanding of the pathogenesis of MAFLD and its rising prevalence, "positive criteria" to diagnose the disease are required. In this work, a panel of international experts from 22 countries propose a new definition for the diagnosis of MAFLD that is both comprehensive and simple, and is independent of other liver diseases. Full-Text PDF The sub-Saharan Africa position statement on the redefinition of fatty liver disease: From NAFLD to MAFLDJournal of HepatologyVol. 74Issue 5PreviewWe read with great interest the landmark consensus on the redefinition of fatty liver disease by Eslam et al. This includes a shift in nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated fatty liver disease (MAFLD) as a more apt term, as well as the adoption of a set of simple and pertinent "positive" criteria to diagnose the disease, independent of alcohol intake or other liver diseases.1,2 These twin proposals provide a major advance in the conceptualisation of fatty liver diseases, but given the variation between different health systems, reaching a broad and global consensus is imperative. Full-Text PDF
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