Abstract
Purpose of Review
The objective of this manuscript is to examine the current literature on the epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD), its correlation with cardiovascular disease (CVD) outcomes, as well as to evaluate the update in nomenclature from non-alcoholic liver disease (NAFLD).
Recent Findings
The update of diagnostic criteria from NAFLD to MASLD reduces the stigma associated with alcohol consumption and poor health choices. It also shines a light on the crucial role of cardiometabolic risk factors in disease pathophysiology. The incidence and prevalence of MASLD are projected to increase significantly in the future as the population burden of cardiometabolic risk factors rises. MASLD is also a potent risk factor for developing CVD that should be tackled by using a multi-disciplinary team with a holistic approach.
Summary
As the new nomenclature for metabolic liver disease is adopted on a global scale, more research is needed to investigate the applicability of findings from previous trials focusing on NAFLD. It is anticipated that the epidemic of MASLD will continue to increase globally, hence the urgent need for therapeutic approaches to reverse this trend.
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Data Availability
No datasets were generated or analysed during the current study.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Cheemerla S, Balakrishnan M. Global epidemiology of chronic liver disease. Clin Liver Dis (Hoboken). 2021;17(5):365–70. https://doi.org/10.1002/cld.1061.
•• Rinella ME, Lazarus JV, Ratziu V, et al. A multi-society Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023. https://doi.org/10.1097/hep.0000000000000520. This study proposed the change in nomenclature from NAFLD to MASLD, following a modified Delphi consensus from an international committee of experts.
Riazi K, Azhari H, Charette JH, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2022;7(9):851–61. https://doi.org/10.1016/s2468-1253(22)00165-0.
Younossi ZM, Golabi P, de Avila L, et al. The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: a systematic review and meta-analysis. J Hepatol. 2019;71(4):793–801. https://doi.org/10.1016/j.jhep.2019.06.021.
Puri P, Fuchs M. Population management of nonalcoholic fatty liver disease. Fed Pract. 2019;36(2):72–82.
Ludwig J, Viggiano TR, McGill DB, Oh BJ. Nonalcoholic steatohepatitis: Mayo Clinic experiences with a hitherto unnamed disease. Mayo Clin Proc. 1980;55(7):434–8.
Eslam M, Sanyal AJ, George J. MAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease. Gastroenterology. 2020;158(7):1999-2014.e1. https://doi.org/10.1053/j.gastro.2019.11.312.
Eslam M, Newsome PN, Sarin SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol. 2020;73(1):202–9. https://doi.org/10.1016/j.jhep.2020.03.039.
García-Compeán D, Jiménez-Rodríguez AR. NAFLD VS MAFLD. The evidence-based debate has come. Time to change? https://doi.org/10.1016/j.aohep.2022.100765. Annals Hepatol. 2022. https://doi.org/10.1016/j.aohep.2022.100765
Gofton C, Upendran Y, Zheng MH, George J. MAFLD: how is it different from NAFLD? Clin Mol Hepatol. 2023;29(Suppl):S17-s31. https://doi.org/10.3350/cmh.2022.0367.
De A, Ahmad N, Mehta M, Singh P, Duseja A. NAFLD vs MAFLD – it is not the name but the disease that decides the outcome in fatty liver. J Hepatol. 2022;76(2):475–7. https://doi.org/10.1016/j.jhep.2021.09.002.
WHO. Cardiovascular diseases (CVDs). Updated 11 June 2021. Accessed 9 Oct 2023, 2023. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
Kasper P, Martin A, Lang S, Kütting F, Goeser T, Demir M, et al. NAFLD and cardiovascular diseases: a clinical review. Clin Res Cardiol. 2021;110(7):921–37. https://doi.org/10.1007/s00392-020-01709-7.
Federation WH. Deaths from cardiovascular disease surged 60% globally over the last 30 years: report. Updated 20 May 2023. Accessed 9 Oct 2023, https://world-heart-federation.org/news/deaths-from-cardiovascular-disease-surged-60-globally-over-the-last-30-years-report/#:~:text=Search%20for%3A%20Search-,Deaths%20from%20cardiovascular%20disease%20surged%2060%25%20globally,the%20last%2030%20years%3A%20Report&text=GENEVA%2C%2020%20May%202023%20%E2%80%93%20Deaths,World%20Heart%20Federation%20(WHF)
Li H, Guo M, An Z, Meng J, Jiang J, Song J, et al. Prevalence and risk factors of metabolic associated fatty liver disease in Xinxiang, China. Int J Environ Res Public Health. 2020;17(6). https://doi.org/10.3390/ijerph17061818. https://mdpi-res.com/d_attachment/ijerph/ijerph-17-01818/article_deploy/ijerph-17-01818.pdf?version=1583935402
Zhang D, Zhang L, Chen S, Chen R, Zhang X, Bai F. Prevalence and risk factors of metabolic-associated fatty liver disease among hospital staff. Diabetes, Metabolic Syndrome and Obesity. 2023;16:1221–34. https://doi.org/10.2147/dmso.s407657.
Chen Y-L, Li H, Li S, et al. Prevalence of and risk factors for metabolic associated fatty liver disease in an urban population in China: a cross-sectional comparative study. BMC Gastroenterol. 2021;21(1). https://doi.org/10.1186/s12876-021-01782-w
Guan L, Zhang X, Tian H, et al. Prevalence and risk factors of metabolic-associated fatty liver disease during 2014–2018 from three cities of Liaoning Province: an epidemiological survey. BMJ Open. 2022;12(2): e047588. https://doi.org/10.1136/bmjopen-2020-047588.
Yuan Q, Wang H, Gao P, Chen W, Lv M, Bai S, et al. Prevalence and risk factors of metabolic-associated fatty liver disease among 73,566 individuals in Beijing, China. Int J Environ Res Public Health. Feb 13 2022;19(4). https://doi.org/10.3390/ijerph19042096
Rezaianzadeh A, Moftakhar L, Seif M, Johari MG, Hosseini SV, Dehghani SS. Incidence and risk factors of cardiovascular disease among population aged 40–70 years: a population-based cohort study in the South of Iran. Trop Med Health. 2023/06/12 2023;51(1):35. https://doi.org/10.1186/s41182-023-00527-7
Arsyad DS, Westerink J, Cramer MJ, et al. Modifiable risk factors in adults with and without prior cardiovascular disease: findings from the Indonesian National Basic Health Research. BMC Public Health. 2022;22(1):660. https://doi.org/10.1186/s12889-022-13104-0
Tran DT, Lekhak N, Gutierrez K, Moonie S. Risk factors associated with cardiovascular disease among adult Nevadans. PLoS ONE. 2021;16(2): e0247105. https://doi.org/10.1371/journal.pone.0247105.
Maharani A, Sujarwoto, Praveen D, Oceandy D, Tampubolon G, Patel A. Cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in Indonesia: the SMARThealth extend study. PLOS ONE. 2019;14(4):e0215219. https://doi.org/10.1371/journal.pone.0215219
Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the study of liver diseases. Hepatology. 2018;67(1):328–57. https://doi.org/10.1002/hep.29367.
Liu Q, Zhao G, Li Q, Wu W, Zhang Y, Bian H. A comparison of NAFLD and MAFLD diagnostic criteria in contemporary urban healthy adults in China: a cross-sectional study. BMC Gastroenterol. 2022/11/19 2022;22(1):471. https://doi.org/10.1186/s12876-022-02576-4
Eslam M, Newsome PN, Sarin SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol. 2020;73(1):202–209. https://doi.org/10.1016/j.jhep.2020.03.039
Lin S, Huang J, Wang M, et al. Comparison of MAFLD and NAFLD diagnostic criteria in real world. Liver Int. 2020;40(9):2082–9. https://doi.org/10.1111/liv.14548.
Younossi ZM, Rinella ME, Sanyal AJ, et al. From NAFLD to MAFLD: implications of a premature change in terminology. Hepatology. 2021;73(3):1194–8. https://doi.org/10.1002/hep.31420.
Huang J, Kumar R, Wang M, Zhu Y, Lin S. MAFLD criteria overlooks a number of patients with severe steatosis: is it clinically relevant? J Hepatol. 2020;73(5):1265–7. https://doi.org/10.1016/j.jhep.2020.06.016.
Younossi ZM, Stepanova M, Negro F, Hallaji S, Younossi Y, Lam B, et al. Nonalcoholic fatty liver disease in lean individuals in the United States. Medicine (Baltimore). 2012;91(6):319–27. https://doi.org/10.1097/MD.0b013e3182779d49.
Pal P, Palui R, Ray S. Heterogeneity of non-alcoholic fatty liver disease: implications for clinical practice and research activity. World J Hepatol. 2021;13(11):1584–610. https://doi.org/10.4254/wjh.v13.i11.1584.
• Lim GEH, Tang A, Ng CH, et al. An observational data meta-analysis on the differences in prevalence and risk factors between MAFLD vs NAFLD. Clin Gastroenterol Hepatol. 2023/03/01/ 2023;21(3):619–629.e7. https://doi.org/10.1016/j.cgh.2021.11.038. This meta-analysis shows how patients had a significantly higher odds of being diagnosed with MAFLD compared to NAFLD, showcasing the greater prevalence of MAFLD over NAFLD.
Song R, Li Z, Zhang Y, Tan J, Chen Z. Comparison of NAFLD, MAFLD, MASLD and pure-MASLD characteristics and mortality outcomes in United States adults. medRxiv. 2023:2023.09.26.23296130. https://doi.org/10.1101/2023.09.26.23296130
Chan KE, Ng CH, Fu CE, et al. The spectrum and impact of metabolic dysfunction in MAFLD: a longitudinal cohort analysis of 32,683 overweight and obese individuals. Clin Gastroenterol Hepatol. 2023;21(10):2560-2569.e15. https://doi.org/10.1016/j.cgh.2022.09.028.
Chun HS, Lee JS, Lee HW, et al. Metabolic dysfunction associated fatty liver disease identifies subjects with cardiovascular risk better than nonalcoholic fatty liver disease. Hepatol. 2022;76 (Supplement 1):S789. Annual meeting of the American Association for the Study of Liver Diseases, AASLD 2022. Virtual. https://doi.org/10.1002/hep.32697
Lee H, Lee Y-H, Kim SU, Kim HC. Metabolic dysfunction-associated fatty liver disease and incident cardiovascular disease risk: a nationwide cohort study. Clin Gastroenterol Hepatol. 2021;19(10):2138–2147.e10. Comment in: Clin Gastroenterol Hepatol. 2021 Oct;19(10):2025–2028 PMID: 33610759 [https://www.ncbi.nlm.nih.gov/pubmed/33610759]. https://doi.org/10.1016/j.cgh.2020.12.022
Lei F, Qin J-J, Song X, et al. The prevalence of MAFLD and its association with atrial fibrillation in a nationwide health check-up population in China. Front Endocrinol. 2022;13:1007171. https://doi.org/10.3389/fendo.2022.1007171.
Liu Z, Suo C, Shi O, 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. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2022;20(4):e855–75. https://doi.org/10.1016/j.cgh.2020.12.033.
Park H, Yoon EL, Kim M, Cho S, Nah E-H, Jun DW. Nomenclature dilemma of metabolic associated fatty liver disease (MAFLD): considerable proportions of MAFLD are metabolic healthy. Clin Gastroenterol Hepatol. 2023;21(4):1041–1049.e3. Comment in: Clin Gastroenterol Hepatol. 2023;21(3):857–858 PMID: 35643417. [https://www.ncbi.nlm.nih.gov/pubmed/35643417] Comment in: Clin Gastroenterol Hepatol. 2023 Apr;21(4):1114–1115 PMID: 35700885. https://www.ncbi.nlm.nih.gov/pubmed/35700885. https://doi.org/10.1016/j.cgh.2022.04.012
Thrift AP, Nguyen TH, Pham C, et al. The prevalence and determinants of NAFLD and MAFLD and their severity in the VA primary care setting. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2023;21(5):1252-1260.e5. https://doi.org/10.1016/j.cgh.2022.05.046.
Zeng J, Qin L, Jin Q, et al. Prevalence and characteristics of MAFLD in Chinese adults aged 40 years or older: a community-based study. Hepatobiliary & pancreatic diseases international : HBPD INT. 2022;21(2):154–161. Comment in: Hepatobiliary Pancreat Dis Int. 2022 Apr;21(2):103–105 PMID: 35125337. https://www.ncbi.nlm.nih.gov/pubmed/35125337. https://doi.org/10.1016/j.hbpd.2022.01.006
Golabi P, Paik JM, AlQahtani S, Younossi Y, Tuncer G, Younossi ZM. Burden of non-alcoholic fatty liver disease in Asia, the Middle East and North Africa: data from global burden of disease 2009–2019. J Hepatol. 2021;75(4):795–809. https://doi.org/10.1016/j.jhep.2021.05.022
Wang J, He W, Tsai P-J, Chen P-H, Ye M, Guo J, et al. Mutual interaction between endoplasmic reticulum and mitochondria in nonalcoholic fatty liver disease. Lipids Health Dis. 2020;19(1):72. https://doi.org/10.1186/s12944-020-01210-0.
Oda K, Uto H, Mawatari S, Ido A. Clinical features of hepatocellular carcinoma associated with nonalcoholic fatty liver disease: a review of human studies. Clin J Gastroenterol. 2015;8(1):1–9. https://doi.org/10.1007/s12328-014-0548-5.
Bae SDW, George J, Qiao L. From MAFLD to hepatocellular carcinoma and everything in between. Chin Med J (Engl). 2022;135(5):547–56. https://doi.org/10.1097/cm9.0000000000002089.
Yu J. Obesity, fatty liver and liver cancer. vol 1061. Advances in experimental medicine and biology. Springer Singapore; 2018:157.
Chen X, Chen S, Pang J, Tang Y, Ling W. Are the different MAFLD subtypes based on the inclusion criteria correlated with all-cause mortality? J Hepatol. 2021;75(4):987–989. https://doi.org/10.1016/j.jhep.2021.06.013
Park H, Yoon EL, Kim M, Cho S, Nah E-H, Jun DW. Nomenclature dilemma of metabolic associated fatty liver disease (MAFLD): considerable proportions of MAFLD are metabolic healthy. Clin Gastroenterol Hepatol. 2023;21(4):1041–1049.e3. https://doi.org/10.1016/j.cgh.2022.04.012
Niederseer D, Wernly B, Aigner E, Stickel F, Datz C. NAFLD and cardiovascular diseases: epidemiological, mechanistic and therapeutic considerations. J Clin Med. Jan 26 2021;10(3). https://doi.org/10.3390/jcm10030467
Lim S, Meigs JB. Links between ectopic fat and vascular disease in humans. Arterioscler Thromb Vasc Biol. 2014;34(9):1820–6. https://doi.org/10.1161/ATVBAHA.114.303035.
Stepanova M, Younossi ZM. Independent association between nonalcoholic fatty liver disease and cardiovascular disease in the US population. Clin Gastroenterol Hepatol. 2012;10(6):646–50. https://doi.org/10.1016/j.cgh.2011.12.039.
Wu S, Wu F, Ding Y, Hou J, Bi J, Zhang Z. Association of non-alcoholic fatty liver disease with major adverse cardiovascular events: a systematic review and meta-analysis. Sci Rep. 2016;6:33386. https://doi.org/10.1038/srep33386
Zhou X-D, Targher G, Byrne CD, et al. An international multidisciplinary consensus statement on MAFLD and the risk of CVD. Hepatol Int. 2023;17(4):773–791. https://doi.org/10.1007/s12072-023-10543-8
Clinic M. Metabolic syndrome. Updated 6 May 2021. Accessed 9 Oct 2023. https://www.mayoclinic.org/diseases-conditions/metabolic-syndrome/diagnosis-treatment/drc-20351921
Shaw DI, Hall WL, Williams CM. Metabolic syndrome: what is it and what are the implications? Proceedings of the Nutrition Society. 2005;64(3):349–57. https://doi.org/10.1079/PNS2005442.
Solomon A, Negrea MO, Cipăian CR, et al. Interactions between metabolic syndrome, MASLD, and arterial stiffening: a single-center cross-sectional study. Healthcare. 2023;11(19):2696. https://doi.org/10.3390/healthcare11192696.
Frith J, Day CP, Henderson E, Burt AD, Newton JL. Non-alcoholic fatty liver disease in older people. Gerontology. 2009;55(6):607–13. https://doi.org/10.1159/000235677.
Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–528. https://doi.org/10.1161/cir.0000000000000659.
Amer OE, Sabico S, Khattak MNK, et al. Increasing prevalence of pediatric metabolic syndrome and its components among Arab youth: a time-series study from 2010–2019. Children (Basel). 2021;8(12). https://doi.org/10.3390/children8121129
Anand VV, Zhe ELC, Chin YH, et al. Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: a meta-analysis using multidimensional socioeconomic status indices. Int J Cardiol. 2023;383:140–50. https://doi.org/10.1016/j.ijcard.2023.04.042.
Das M. WHO urges immediate action to tackle non-communicable diseases. Lancet Oncol. 2022;23(11):1361. https://doi.org/10.1016/S1470-2045(22)00606-4.
Eslam M, Sarin SK, Wong VW-S, 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(6):889–919. https://doi.org/10.1007/s12072-020-10094-2
Marx N, Federici M, Schütt K, et al. ESC guidelines for the management of cardiovascular disease in patients with diabetes: developed by the task force on the management of cardiovascular disease in patients with diabetes of the European Society of Cardiology (ESC). Eur Heart J. 2023. https://doi.org/10.1093/eurheartj/ehad192
Duell PB, Welty FK, Miller M, et al. Nonalcoholic fatty liver disease and cardiovascular risk: a scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol. 2022;42(6):e168–85. https://doi.org/10.1161/ATV.0000000000000153.
Machado MV, Cortez-Pinto H. Non-alcoholic fatty liver disease: what the clinician needs to know. World J Gastroenterol. 2014;20(36):12956–80. https://doi.org/10.3748/wjg.v20.i36.12956.
Machado MV. Aerobic exercise in the management of metabolic dysfunction associated fatty liver disease. Diabetes Metab Syndr Obes. 2021;14(null):3627–3645. https://doi.org/10.2147/DMSO.S304357
van der Windt DJ, Sud V, Zhang H, Tsung A, Huang H. The effects of physical exercise on fatty liver disease. Gene Expr. 2018;18(2):89–101. https://doi.org/10.3727/105221617x15124844266408.
Golabi P, Locklear CT, Austin P, Afdhal S, Byrns M, Gerber L, et al. Effectiveness of exercise in hepatic fat mobilization in non-alcoholic fatty liver disease: systematic review. World J Gastroenterol. 2016;22(27):6318–27. https://doi.org/10.3748/wjg.v22.i27.6318.
Tsompanaki E, Thanapirom K, Papatheodoridi M, Parikh P, Chotai de Lima Y, Tsochatzis EA. Systematic review and meta-analysis: the role of diet in the development of nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2023;21(6):1462–1474.e24. https://doi.org/10.1016/j.cgh.2021.11.026
Stewart KE, Haller DL, Sargeant C, Levenson JL, Puri P, Sanyal AJ. Readiness for behaviour change in non-alcoholic fatty liver disease: implications for multidisciplinary care models. Liver Int. 2015;35(3):936–43. https://doi.org/10.1111/liv.12483.
Wing RR, Phelan S. Long-term weight loss maintenance23. Am J Clin Nutr. 2005;82(1):222S-225S. https://doi.org/10.1093/ajcn/82.1.222S
Anand VV, Zhe ELC, Chin YH, et al. Barriers and facilitators to engagement with a weight management intervention in Asian patients with overweight or obesity: a systematic review. Endocr Pract. 2023;29(5):398–407. https://doi.org/10.1016/j.eprac.2022.10.006.
Foster D, Sanchez-Collins S, Cheskin LJ. Multidisciplinary team-based obesity treatment in patients with diabetes: current practices and the state of the science. Diabetes Spectr. 2017;30(4):244–9. https://doi.org/10.2337/ds17-0045.
Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311–22. https://doi.org/10.1056/NEJMoa1603827.
Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834–44. https://doi.org/10.1056/NEJMoa1607141.
ACC. Semaglutide reduces risk of MACE in adults with overweight or obesity. Updated 10 Aug 2023. Accessed 9 Oct 2023, https://www.acc.org/Latest-in-Cardiology/Articles/2023/08/10/14/29/SELECT-Semaglutide-Reduces-Risk-of-MACE-in-Adults-With-Overweight-or-Obesity#:~:text=Subcutaneous%20once%2Dweekly%20semaglutide%202.4,8%20press%20release.
Harrison SA, Bashir MR, Guy CD, et al. Resmetirom (MGL-3196) for the treatment of non-alcoholic steatohepatitis: a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. The Lancet. 2019;394(10213):2012–24. https://doi.org/10.1016/s0140-6736(19)32517-6.
Powell NR, Liang T, Ipe J, et al. Clinically important alterations in pharmacogene expression in histologically severe nonalcoholic fatty liver disease. Nature Commun. 2023;14(1):1474. https://doi.org/10.1038/s41467-023-37209-1
Wen W, Li H, Wang C, et al. Metabolic dysfunction-associated fatty liver disease and cardiovascular disease: a meta-analysis. Front Endocrinol (Lausanne). 2022;13: 934225. https://doi.org/10.3389/fendo.2022.934225.
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Lee, E.C.Z., Anand, V.V., Razavi, A.C. et al. The Global Epidemic of Metabolic Fatty Liver Disease. Curr Cardiol Rep 26, 199–210 (2024). https://doi.org/10.1007/s11886-024-02025-6
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DOI: https://doi.org/10.1007/s11886-024-02025-6