Metabolic dysfunction associated with steatotic liver disease (MASLD) has evolved into a leading cause of chronic liver disease.^{1, 2} Our current understanding of MASLD, is largely dictated by literature based on Western cohorts.³ Data regarding MASLD in people with HIV is sparse, with a notable gap from Sub-Saharan Africa.⁴

In the current manuscript, authors from Karolinska University (Sweden), Rakai Health Sciences Program (Uganda) and Johns Hopkins University (USA) aimed to non-invasively determine the prevalence and risk factors of MASLD among black people between 35 and 49 years old, with and without HIV, enrolled in a recent cross-sectional survey conducted between May 2016 and May 2018 at the existing Rakai Community Cohort Study (RCCS) in Uganda.⁵

After excluding pregnant females and recent alcohol drinkers, MASLD prevalence was 12%, and less than 1% had advanced fibrosis (AF). MASLD prevalence was numerically, but not statistically, higher in HIV versus non-HIV people. Female gender, non-agriculture-focused jobs, elevated blood pressure and low HDL were independently associated with MASLD. In this study, females had a higher elevated hip-to-waist ratio, which makes one wonder if adjusting for the hip-to-waist ratio in the multivariable model would have offered more discernment. While the exact reason for the association of non-agricultural focused occupations, and MASLD is unclear, the impact of lifestyle changes associated with industrialisation is suspect.⁶

The prevalence of MASLD and AF are notably low in this sub-Saharan cohort, divergent from the widely reported high prevalence from Western countries and even from the combined regions of Northern Africa and the Middle East (MENA).^{7, 8} These lower-than-expected prevalences of MASLD and AF are likely a reflection of the lower prevalence of metabolic syndrome in Uganda compared to the rest of the world.⁹ Thus, the low prevalence of MASLD may be partly a reflection of the lag time in the lifestyle changes associated with industrialisation.

In addition to lifestyle factors, it is important to consider the possible role of genetic risk factors in the current finding of low MASLD prevalence. Patatin-like phospholipase domain protein 3 (PNPLA3) polymorphisms (rs738409 C>G) is associated with hepatic steatosis and fibrosis,¹⁰ and is uncommon in African individuals. Additionally, PNPLA3-S453I, seen in African-American individuals, is protective against hepatic steatosis.¹¹

A few factors limit the generalisability of the study results. The narrow age range of inclusion might have resulted in an underestimation of MASLD, which is commonly associated with age. The study design captured alcohol consumption history within a week of enrollment, thus missing all other patterns of alcohol abuse. Despite the limitations, the study sheds light on the burden of MASLD from an understudied population. Future collaborative studies with prospective study designs are needed to address the limitations of the current study, confirm its findings, and verify the results from other countries in the African continent, particularly the sub-Saharan region.

与脂肪肝病（MASLD）相关的代谢功能障碍已发展成为慢性肝病的主要原因。^{1, 2}我们目前对 MASLD 的理解很大程度上取决于基于西方群体的文献。³有关 HIV 感染者 MASLD 的数据很少，与撒哈拉以南非洲地区存在显着差距。⁴

在当前的手稿中，来自卡罗林斯卡大学（瑞典）、拉凯健康科学项目（乌干达）和约翰·霍普金斯大学（美国）的作者旨在非侵入性地确定 35 至 49 岁黑人中 MASLD 的患病率和危险因素，感染和未感染艾滋病毒的患者参加了最近在乌干达现有的 Rakai 社区队列研究 (RCCS) 中于 2016 年 5 月至 2018 年 5 月期间进行的一项横断面调查。⁵

排除怀孕女性和近期饮酒者后，MASLD 患病率为 12%，其中不到 1% 患有晚期纤维化 (AF)。从数字上看，HIV 人群中 MASLD 的患病率高于非 HIV 人群，但统计数据显示，MASLD 的患病率较高。女性、非农业工作、高血压和低 HDL 与 MASLD 独立相关。在这项研究中，女性的臀腰比更高，这让人怀疑在多变量模型中调整臀腰比是否会提供更多的辨别力。虽然非农业职业与 MASLD 相关的确切原因尚不清楚，但与工业化相关的生活方式改变的影响值得怀疑。⁶

在撒哈拉以南地区的人群中，MASLD 和 AF 的患病率明显较低，这与广泛报道的西方国家甚至北非和中东联合地区 (MENA) 的高患病率不同。^{7, 8} MASLD 和 AF 的患病率低于预期可能反映了乌干达代谢综合征的患病率低于世界其他地区。⁹因此，MASLD 的低患病率可能部分反映了与工业化相关的生活方式改变的滞后时间。

除了生活方式因素外，重要的是要考虑遗传危险因素在目前 MASLD 患病率低的发现中可能发挥的作用。 Patatin 样磷脂酶结构域蛋白 3 (PNPLA3) 多态性 (rs738409 C>G) 与肝脂肪变性和纤维化相关¹⁰ ，并且在非洲个体中并不常见。此外，在非洲裔美国人中发现的PNPLA3 -S453I 可以预防肝脂肪变性。 ¹¹

一些因素限制了研究结果的普遍性。纳入的年龄范围较窄可能导致 MASLD 被低估，而 MASLD 通常与年龄相关。该研究设计记录了入组后一周内的饮酒历史，从而忽略了所有其他酗酒模式。尽管存在局限性，但该研究揭示了未充分研究人群的 MASLD 负担。未来需要进行前瞻性研究设计的合作研究，以解决当前研究的局限性，证实其研究结果，并验证非洲大陆其他国家，特别是撒哈拉以南地区的结果。