Professor Jacob George
It might not have hit prime time yet but there’s been a huge amount of discussion globally regarding a single letter name change for a condition which affects about 30% of the world’s population.
Hepatologist Professor Jacob George told GESA AGW 2020 that, despite its prevalence, NAFLD had failed to attract an adequate public health response or appropriate levels of funding.
He said none of 29 European countries had written strategies or action plans dedicated to NAFLD and it was not considered in screening guidelines of diabetes or other related diseases.
The situation appeared to be similar in the Asia Pacific region.
One of the problems with the NAFLD terminology was that it captured a highly heterogeneous patient group, without a clear link to the condition’s pathophysiology.
It did not define an individual’s phenotype precisely, which led to sub-optimal or no response to therapy. And trial entry was typically based on histopathology instead of pathophysiology – again leading to poor responses and trial failures.
“We also need to move away from the term ‘non-alcoholic’ as it trivialises and discriminates. And when we think of a new term we also need to distance the disease from obesity,” he said.
Professor George, from the Storr Liver Centre at Westmead, said use of the term NAFLD was also complicated given that about two-thirds of Australians and other populations consumed significant amounts of alcohol.
After a 2-stage Delphi process, a majority of experts from across the world eventually decided that NAFLD would be better described as metabolic dysfunction associated fatty liver disease (MAFLD).
“Diagnosis of MAFLD should be based on the presence of metabolic dysfunction not the absence of other conditions.”
He said despite the nomenclature change, MAFLD was still a heterogeneous entity and there was a need to more precisely define subtypes of the disease.
One of those would be the patients with MAFLD and a contribution from alcohol – “a large and important group that require further characterisation”.
Under the new approach, steatosis in the context of overweight / obesity or type 2 diabetes would constitute a diagnosis of MAFLD.
In patients with steatosis who were lean or of normal weight, a MAFLD diagnosis required at least two other metabolic risk abnormalities such as high waist circumference, hypertension, dyslipidaemia, prediabetes, or a high CRP.
#mafld has been diagnosed based on the exclusion of other chronic liver diseases. Mohammed Eslam, @phil_newsome7, @VladRatziu and other international experts propose a new definition for the #diagnosis of MAFLD https://t.co/FR6rca9L21 #liverdisease #livertwitter pic.twitter.com/9YlPBZbw8m
— Journal of Hepatology (@JHepatology) June 19, 2020
Professor George said the definition was more practical in identifying those patients with fatty liver disease at high risk of disease progression and there was real world evidence to shows the MAFLD was superior than NAFLD in different clinical settings.
He said the new name has been widely endorsed by hepatologists, multiple liver associations including APASL, and patient associations.
What does #livertwitter think of the proposed name change of #NAFLD to #MAFLD? Vote now on your take on #fattyliver
— Nature Reviews Gastroenterology & Hepatology (@NatRevGastroHep) May 27, 2020
“We have achieved a positive definition that can be used in daily practice, in all settings, and can frequently coexist with other liver diseases.”
Professor George recognised the work towards a name change had been driven by his friend and colleague at Westmead Associate Professor Mohammed Eslam.