New MASLD Nomenclature

No more NAFLD! Steatotic Liver Disease is the overarching term; NAFLD is now MASLD. 

Dig Deeper!

There is so much to know about the new NAFLD Nomenclature. Read all about it in HEPATOLOGY's joint-publication.

Read Now

MASLD Decision Tree

Does the patient have elevated liver enzymes?
  • ALT> 33 males
  • ALT> 25 females
Have you ruled out Hepatitis B, C or other causes of chronic liver disease?
Does the patient have hepatic steatosis?
As identified by ...
  • Imaging
  • Biopsy

Check Hepatitis C Ab with Reflex to PCR Hepatitis BsAg, sAb, cAb Ceruloplasmin lmmunoglobulins ANA, ASMA, AMA Iron Studies Celiac Antibodies Alpha-1-AT levels
OR
Rule out other underlying etiologies of liver diseases

The patient has steatotic liver disease.

Does the adult patient meet any one of the cardiometabolic criteria?
  • BMI ≥ 25 kg/m2 [23 Asia] OR WC> 94 cm (M) 80 cm (F) OR ethnicity adjusted
  • Fasting serum glucose ≥ 5.6 mmol/L [100 mg/dL] OR 2-hour post-load glucose levels ≥ 7.8 mmol/L [≥140 mg/dL] OR HbA1c ≥ 5.7% [39 mmol/L] OR type 2 diabetes OR treatment for type 2 diabetes
  • Blood pressure ≥ 130/85 mmHg OR specific antihypertensive drug treatment
  • Plasma triglycerides ≥ 1.70 mmol/L [150 mg/dL] OR lipid lowering treatment
  • Plasma HDL-cholesterol ≤ 1.0 mmol/L [40 mg/dL] (M) and ≤ 1.3 mmol/L [50 mg/dL] (F) OR lipid lowering treatment
Does the patient have features suggestive of cirrhosis?
Does the adult patient meet any one of the cardiometabolic criteria?
  • BMI ≥ 25 kg/m2 [23 Asia] OR WC> 94 cm (M) 80 cm (F) OR ethnicity adjusted
  • Fasting serum glucose ≥ 5.6 mmol/L [100 mg/dL] OR 2-hour post-load glucose levels ≥ 7.8 mmol/L [≥140 mg/dL] OR HbA1c ≥ 5.7% [39 mmol/L] OR type 2 diabetes OR treatment for type 2 diabetes
  • Blood pressure ≥ 130/85 mmHg OR specific antihypertensive drug treatment
  • Plasma triglycerides ≥ 1.70 mmol/L [150 mg/dL] OR lipid lowering treatment
  • Plasma HDL-cholesterol ≤ 1.0 mmol/L [40 mg/dL] (M) and ≤ 1.3 mmol/L [50 mg/dL] (F) OR lipid lowering treatment

No, it is likely not Metabolic Dysfunction Associated Steatotic Liver Disease.

Your patient may have Metabolic Dysfunction Associated Steatotic Liver Disease cirrhosis.
*We also encourage you check for other discernable causes.

You should investigate for other underlying liver etiologies

Are there any other causes of steatosis, such as ALD, Drug-Induced Liver Injury (DILI), Monogenic diseases or Miscellaneous (see SLD Classifications)?

Your patient may have cyrptogenic SLD or possible MASLD.

Does your patient regularly drink >50 g/day for females or >60 g/day for males?
Does your patient regularly drink alcohol (140-350 g/week (20-50 g/day) for females or 210-420 g/week (30-60 g/day) for males)?

Your patient has primarily ALD.

Your patient has MASLD.
*Multiple etiologies may coexist in a patient, thus exclude other causes of liver disease as appropriate.

Your patient has Met-ALD.
*Multiple etiologies may coexist in a patient, thus exclude other causes of liver disease as appropriate.

MASLD Resources

Power Point Presentation

Implementing the MASLD nomenclature is going to take time. Here's a helpful PowerPoint presentation that walks you through the consensus effort through the application.

Download the PPT

Decision Tree Infographic

Is it MASLD or is it something else? This handy infographic will help you navigate your diagnosis.

See The Infographic

SLD Implementation Webinar

Experts presented on the latest in the MASLD nomenclature implementation. See what was covered!

Watch the Webinar

Special thanks to our friends and ALEH and CASL for their help with the MASLD translations!

About Steatotic Liver Disease (SLD)

AASLD and its members are proud to have been one of the leading multinational liver societies that developed and finalized the new nomenclature for liver disease, which was announced in June 2023.

What to know about the new nomenclature:

  • Steatotic liver disease (SLD) was chosen as an overarching term to encompass the various aetiologies of steatosis. 
  • The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. 
  • Nonalcoholic fatty liver disease (NAFLD) will now be metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD encompasses patients who have hepatic steatosis and have at least one of five cardiometabolic risk factors. 
  • A new category, outside pure MASLD, termed MetALD (pronunciation: Met A-L-D) was selected to describe those with MASLD who consume greater amounts of alcohol per week (140 g/week and 210 g/week for females and males respectively).
  • Metabolic dysfunction-associated steatohepatitis (MASH) is the replacement term for NASH.
  • Those with no metabolic parameters and no known cause have cryptogenic SLD. 

Steatotic Liver Disease Classifications

SLD Sub-classification figure with legend, citation, and copyright

Norah Terrault, MD, MPH, FAASLD, Discusses the New Nomenclature

Remote video URL

Introducing MASLD and MetALD

MASLD, formerly known as NAFLD, is the most common chronic liver disease around the world, affecting more than 30% of global population. This was why it was vital that the global liver community coalesce around an affirmative, non-stigmatizing name and diagnosis. Ultimately, the global members of the Nomenclature Development Initiative were focused on ensuring the global community had better nomenclature that could be used around the world so that the research and funding could be better directed to save more people’s lives.

After six stages, including four online surveys and two in-person meetings, the average response rate was more than 75% for the four rounds of data collection with 89% final response rate and 85% of whom ultimately approved the recommendation. We are also proud of the numerous societies and organizations that endorsed the recommendations. As the transparent and collaborative Delphi process identified and agreed upon, we will no longer use the previously exclusionary, negative and confounder terms that used potentially stigmatizing language of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH).

The Delphi panel understands that not everyone agrees that this is an issue. The tolerable threshold for the amount of people that feel stigmatized is not for anyone to determine. Simply, if it can be avoided, it should be. With the new nomenclature, we now have an affirmative name and diagnosis without using stigmatizing language.

But to be clear: SLD does not alter natural history, clinical trials or biomarkers nor will it impede development. The staging and severity that we use today will stay the same too. The Delphi panel has defined and outlined a group that has not been studied (MetALD), who will benefit from being included in clinical trials and integrated into care pathways.

There is more work to be done to increase disease awareness, reduce stigma and accelerate drug and biomarker development to benefit patients with MASLD and MetALD.

Norah Terrault, MD, MPH, FAASLD and Mary Rinella, MD, FAASLD Explain New Nomenclature

Remote video URL

Mazen Noureddin, MD, MHSC, on the New NAFLD Nomenclature

Remote video URL

Society Endorsements

The new NAFLD Nomenclature has been supported and endorsed by the following societies and organizations:

endorsement logos

AEEH (Spanish Association for the Study of the Liver) Asociación Española para el Estudio del Hígado

AFEF (Association Française pour l'Etude du Foie)

American College of Gastroenterology

American Gastroenterological Association

American Liver Foundation

APEF (Portuguese Association for the Study of Liver)

APPSPGHAN

ASGE

Asociación Chilena de Hepatología ACHHEP

Asociación Colombiana de Hepatología

Asociación de Especialistas en Gastroenterología y Endoscopia Digestiva de Costa Rica

Asociación Guatemalteca de Gastroenterología, Hepatología y Endoscopía Gastrointestinal

Asociación Mexicana de Hepatología AMH

Asociación Peruana para el Estudio del Hígado ( APEH )

Asociación Puertorriqueña de Gastroenterología

Associazione Italiana per lo Studio del Fegato - AISF

Azerbaijan Gastroenterologists and Hepatologists Association

Banner Liver Support Group

Belgian Week of Gastroenterology

British Association for the Study of the Liver (BASL)

British Liver Trust

British Society of Gastroenterology

Canadian Association for the Study of the Liver

Croatian Society of Gastroenterology

Danish Society for Gastroenterology and Hepatology (DSGH)

DGVS - German Society for Gastroenterology, Digestive and Metabolic Diseases

ESPGHAN

European Liver Patient Association

Facebook Cirrhosis Support Group: helping each other!

Fatty liver Foundation

FISPGHAN

Global Liver Institute

HELLENIC ASSOCIATION FOR THE STUDY OF THE LIVER (HASL)

Indian National Association for Study of the Liver (INASL)

Japan Society of Hepatology

Japan Study Group of NAFLD (JSG-NAFLD)

Korean NAFLD Study Group

Leverforeningen Danmark

NASPGHAN

Norwegian Gastroenterology Society

Norwegian Gastroenterology Society

Österreichische Gesellschaft für Gastroenterologie und Hepatologie ÖGGH

Polsih Association for teh Study of Liver (PASL)

Public Organisation «Ukrainian Association for the Study of Liver Diseases»

Romanian Society of Gastroenterology and Hepatology

Sociedad Argentina de Hepatología SAHe

Sociedad Cubana de Gastroenterología

sociedad de gastroenterología del uruguay

sociedad dominicana de gastroenterologia

SOCIEDAD ESPAÑOLA DE PATOLOGÍA DIGESTIVA (SEPD) (SPANISH SOCIETY OF DIGESTIVE DISEASES)

Sociedad Paraguaya de Diabetologia

sociedad Venezolana de Gastroenterologia

Sociedade Brasileira de Hepatologia

Society of Gastroenterology and Hepatology of the Republic of Moldova

SOCIETY ON LIVER DISEASE IN AFRICA (SOLDA)

South Asian Association for Study of the Liver [SAASL]

Swedish Society of Gastroenterology

Swiss Association for the Study of the Liver (SASL)

The American Society for Preventive Cardiology

The Association of Black Gastroenterologists and Hepatologists (ABGH)

The Liver Forum

Turkish Association for the Study of the Liver

United European Gastroenterology

Zambia Association of Gastroenetrology and Nutrition

Mazen Noureddin, MD, MHSC and Juan Pablo Arab, MD Discuss Highlights of New NAFLD Nomenclature

Remote video URL

Meena Bansal, MD, FAASLD on Alignment and Future Opportunities

Remote video URL

Juan Pablo Arab, MD, Explains New NAFLD Nomenclature

Remote video URL

Global Nomenclature Initiative: New Nomenclature Announced

AASLD is pleased to share that the new nomenclature was announced in June 2023. 

Steatotic liver disease (SLD) was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. Nonalcoholic fatty liver disease (NAFLD) will now be metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD (pronunciation: Ma-zuld) encompasses patients who have hepatic steatosis and have at least one of five cardiometabolic risk factors. A new category, outside of pure MASLD, termed MetALD (pronunciation: Met A-L-D) was selected to describe those with MASLD who consume greater amounts of alcohol per week (140 g/week and 210 g/week for females and males respectively).Those with no metabolic parameters and no known cause have cryptogenic SLD. Metabolic dysfunction-associated steatohepatitis (MASH) is the replacement term for NASH.

Additional details about the new nomenclatures are available in the multinational liver societies’ joint publication.

Background:

The NAFLD Nomenclature Development Initiative is a global multi-stakeholder process that has been focused on examining the options and ramifications around nomenclature for nonalcoholic fatty liver disease (NAFLD).

Since 2020, the transparent and collaborative Initiative has involved multiple global hepatology and gastroenterology societies, patients and patient advocacy organizations, regulators and industry representatives to determine if new nomenclature would be needed - and if so, what - because the vast majority of diseases currently designated as NAFLD are related to so-called “metabolic” factors including overweight, visceral obesity, insulin resistance and dyslipidaemia. In addition, patients and providers noted that “fatty” in the title can be considered stigmatizing.

The Initiative’s participants have recognized that if we have better nomenclature that is used around the world, we can better direct our research and funding to saving people’s lives. 

The Initiative embarked on a collaborative, transparent, modified Delphi process that had 200+ participants in the Delphi panel, with a final response rate of >75% for four rounds of data collection.

We are pleased that we have a way to move forward that is supported by the supermajority. The final paper is expected to be released in the summer of 2023.

In the meantime, we invite you to learn more about this collaborative and global Initiative by endorsing the process and/or signing up for more information below.

Latest News

 

The Process

The Initiative embarked on a collaborative, transparent, modified Delphi process that had 200+ participants in the Delphi panel, with a final response rate of >75% for four rounds of data collection.

The process included six stages, including four online surveys (7 Apr-9 May 2022, 15-27 June 2022, with additional panelists surveyed 8 Sept-16 Oct 2022, 17-27 Oct 2022, and 2 Dec  2022-22 Jan 2023) and two in-person meetings (Nomenclature Consensus Meeting, Chicago, IL, USA, July  2022 and AASLD annual meeting, Washington, DC, USA, Nov 2022). In total, 225 stakeholder panelists participated in one or more stages of the process. The stakeholders were nominated by their respective organizations and were diverse regarding their demographics, professional expertise, and geographic representation.

The statements covered six topical areas: (1) patient-centered perspective, (2) pros and cons of the  current nomenclature, (3) defining fatty liver disease in the setting of metabolic dysfunction, (4) disease heterogeneity, (5) histopathology, and (6) and how to manage the role of alcohol in dual pathology. The stakeholder panelists rated the statements during each survey round using 4-point Likert-type response categories (e.g., agree/somewhat agree/somewhat disagree/disagree) or 3-point responses (e.g., increase, no change, decrease). Consensus with individual statements was defined a priori based on the minimum super majority (i.e. >67%) cut-off. During each stage, panelists provided comments and suggested edits, which were reviewed and used to modify statements in subsequent survey rounds. This process, supplemented by in-person meetings, resulted in the final, fourth survey round, which focused panelist voting on determining the nomenclature following a decision-tree approach.

For the final decision on both acronym and definition, an external committee, comprised of content experts from hepatology, endocrinology, pediatrics and patient advocacy representatives, was created and led by two members of the Steering Committee (VR, AJS). The committee was established based on geographic diversity and diversity in terms of expertise with members chosen based on prior substantial  high-impact publication record in the field. It was composed of 21 members (including 15 who were not  part of the Steering Committee) and included 4 endocrinologists and 5 pediatric hepatologists). The external committee discussed and recommended the final name and acronym from the top three  choices that emerged from the final Delphi round. Additionally, following the mandate from the Delphi  process up to this point, the external committee refined the definition, including metabolic parameters  for both adult and pediatric disease. The proposal from this external committee was then discussed and  approved by the broader NAFLD Nomenclature steering committee, then presented to society leadership (AASLD, EASL and ALEH) for additional commentary and approval. 

We are pleased that we have a way to move forward that is supported by the supermajority. The final paper is expected to be released in the summer of 2023.

The Challenge

Since the original description in 1849 of visceral and subcutaneous adiposity in overfed children by von Rokitansky (reviewed in PMID: 34036255), the field has struggled to come up with an adequate nomenclature.

The term non-alcoholic fatty liver disease (NAFLD) was chosen simply because we did not have enough data to better understand the pathophysiology and because we lacked a better term. In the absence of alternatives, NAFLD was adopted because it described the presence of fat inside the liver while excluding another common cause, namely excess alcohol.

Thanks to the global liver community’s research, we now know that the vast majority of diseases currently designated as NAFLD are related to so-called “metabolic” factors including overweight, visceral obesity, insulin resistance and dyslipidaemia.

The three multinational societies (American Association for the Study of Liver Diseases (AASLD), La Asociación Latinoamericana para el Estudio del Hígado (ALEH) and European Association for the Study of the Liver (EASL)) identified some of the key shortcomings of the term in an editorial that was published in the societies’ respective journals.

As the editorial notes, metabolic dysfunction associated fatty liver disease (MAFLD), which required the presence of steatosis in co-existence with stipulated metabolic criteria, was put forward in 2019. This had the advantage of being both an affirmative name and diagnosis.

However, the use of fatty in the title retained stigmatizing terminology according to both patients and providers. Yet MAFLD had the potential to be a much better term than NAFLD if we removed the stigmatizing “fatty” term. Ultimately, the Initiative was looking to find an affirmative non-stigmatizing name and diagnosis.

We are pleased that we have a way to move forward that is supported by the supermajority. The final paper is expected to be released in the summer of 2023.

 

Join the conversation online by following @AASLDtweets and #NAFLDNomenclature 

At its inception, the participating liver societies were the American Association for the Study of Liver Diseases (AASLD), La Asociación Latinoamericana para el Estudio del Hígado (ALEH), Asian Pacific Association for the Study of the Liver (APASL) and European Association for the Study of the Liver (EASL), with the patient bodies being the Global Liver Institute, European Liver Patients’ Association (ELPA), Liver Patients International (LPI), Fatty Liver Foundation (FLF) and the American Liver Foundation (ALF).

Each society and patient group was asked to nominate experts from their membership who would add input and vote in this process. Additionally, endocrinologists and pediatricians were involved at every stage of the process.

Subsequently, the NAFLD Nomenclature Development Initiative has retained active involvement from American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), the Latin American Association for the Study of the Liver (ALEH) along with various national hepatology societies and patient advocacy organizations, which convened a steering committee to objectively examine the need for revisiting the NAFLD nomenclature and for a name and/or definition change.

Steering Committee Members

  • Manal Abdelmalek, MD, MPH, FAASLD United States
  • Quentin M. Anstee, MBBS, PhD, FRCP United Kingdom
  • Marco Arrese, MD, FAASLD Chile
  • Ulrich Beuers, MD Netherlands
  • Elisabetta Bugianesi, MD, PhD Italy
  • Graciela Castro Narró, MD México
  • Helena Cortez-Pinto, MD, PhD, FAASLD Portugal
  • Donna Cryer, JD United States
  • Kenneth Cusi, MD, FACP, FACE United States
  • Mohamed El-Kassas, PhD Egypt 
  • Wayne Eskridge United States
  • Jiangao Fan, MD, PhD China
  • Sven M. Francque, MD, PhD Belgium
  • Cynthia D. Guy, MD United States
  • Stephen A. Harrison, MD, FAASLD United States
  • Fasiha Kanwal, MD, MSHS, AGAF, FAASLD United States
  • Bart Koot, MD, PhD Netherlands
  • Marko Korenjak Belgium
  • Jeffrey V Lazarus, PhD Spain
  • Rohit Loomba, MD, FAASLD United States
  • Robert Mitchell-Thain United Kingdom
  • Philip N. Newsome, MD, PhD United Kingdom
  • Shivaram Prasad Singh, MBBS, MD, DM India
  • Vlad Ratziu, MD France
  • Mary E. McCarthy Rinella, MD, FAASLD United States
  • Michael Roden, MD Germany
  • Arun J. Sanyal, MD, FAASLD United States
  • Shiv Kumar Sarin, MD, FAASLD India
  • Silvia C. Sookoian, MD, PhD, FAASLD Argentina
  • Wendy Spearman MBChB, FCP, FRCP, MMed, PhD South Africa
  • Dina Tiniakos, MD, PhD, FRCPath Greece
  • Luca Valenti, MD Italy
  • Miriam B. Vos, MD, MSPH, FAASLD United States
  • Vincent Wong, MD China
  • Yusuf Yilmaz, MD Turkey
  • Zobair Younossi, MD, MPH, FAASLD United States

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NAFLD Nomenclature Consensus Form

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