Letter to the Editor: NAFLD vs. MASLD—There ain’t no such thing as a free lunch
Authors: Marcin Krawczyk, Frank Lammert
Journal: Hepatology (2024)

To the editor, In 2023, major international societies dedicated to the study of liver diseases introduced a new nomenclature for NAFLD, proposing that metabolic dysfunction–associated steatotic liver disease (MASLD) should replace the old acronym.1 This evolution in terminology was received with enthusiasm, reflecting the readiness to adapt the NAFLD terminology. However, the change has also prompted some reserved commentaries. The new nomenclature does more than rebrand one of the most prevalent liver conditions—it also introduces new considerations for physicians. In brief, the acronym MASLD is designed for patients with fatty liver, now called steatotic liver disease (SLD), who also exhibit at least 1 of the 5 predefined cardiometabolic conditions. Here, we would like to comment on this new terminology. On one hand, it is patient-centered, avoiding stigmatization, and it highlights the importance of cardiometabolic factors. On the other hand, diagnosing MASLD increases the workload for practitioners and necessitates extra health care costs. According to the latest studies,2 over 30% of adults worldwide might suffer from fatty liver. From now on, these patients are entitled to determine whether they present with simple SLD or the more progressive form of MASLD. Each of these patients will require extra minutes in the outpatient clinic to assess and document the risk factors for MASLD diagnosis. In Germany, the average salary costs alone for the regular work of physicians are close to 1€ per minute. Hence, staff and laboratory costs due to this new policy, arising from the new terminology, should be expected to be substantial. Of note the authors of the new nomenclature suggest: "… if there is uncertainty and the clinician strongly suspects metabolic dysfunction despite the absence of CMRF, then the term possible MASLD can be considered pending additional testing (e.g., Homeostatic Model Assessment for Insulin Resistance (HOMAIR) and oral glucose tolerance tests) although this should be left to the discretion of the clinical team. Such cases and also cryptogenic cases that subsequently manifest CMRF can be rebadged as MASLD."1 We believe that the majority of former patients with NAFLD will find this approach unsatisfactory and might even necessitate a follow-up visit once the requisite assessment of cardiometabolic risk factors is completed. Therefore, we reckon that discussion should continue on the MASLD concept, which, while definitely well-intentioned, could lead to time and economic challenges in clinical practice. The last years have witnessed the rebranding of PBC—previously known as primary biliary cirrhosis, now termed primary biliary cholangitis.3 However, this change did not modify the diagnostic criteria and aimed solely to alleviate stigma for patients who, despite a PBC diagnosis, do not necessarily progress to cirrhosis. Thus, it presents a simpler case than the transition from NAFLD to MASLD. The latter not only redefines the disease but also potentially increases the utility and costs of decision-making, a factor that might better undergo careful consideration and scientific assessment a priori.