Joint position statement from the Middle East and North Africa and sub-Saharan Africa on continuing to endorse the MAFLD definition
Authors: Yasser Fouad, Hasmik Ghazinyan, Mohamed Alboraie, Maryam Al Khatry, Hailemichael Desalegn, Fuad Al-Ali, Mortada H.F. El-Shabrawi, Ponsiano Ocama, Moutaz Derbala, Salma Barakat, Yaw Asante Awuku, Dennis Amajuoyi Ndububa, Meriam Sabbah, Waseem Hamoudi, Masolwa Ng'wanasayi, Reda Elwakil, Reidwan Ally, Said A. Al-Busafi, Almoutaz Hashim, Gamal Esmat, Gamal Shiha
Journal: Journal of Hepatology (2024)

A multisociety Delphi consensus statement on new fatty liver disease nomenclatureJournal of HepatologyVol. 79Issue 6PreviewThe principal limitations of the terms NAFLD and NASH are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favour of a change in nomenclature and/or definition. A modified Delphi process was led by three large pan-national liver associations. The consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. Full-Text PDF Open Access In a tremendous conceptual advance, Eslam et al.1Eslam M. Newsome P.N. Sarin S.K. et al.A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement.J Hepatol. 2020; 73: 202-209Abstract Full Text Full Text PDF PubMed Scopus (2259) Google Scholar, 2Eslam M. Sanyal A.J. George J. et al.MAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease.Gastroenterology. 2020; 158: 1999-2014. e1Abstract Full Text Full Text PDF PubMed Scopus (1854) Google Scholar, 3Eslam M. Alkhouri N. Vajro P. et al.Defining paediatric metabolic (dysfunction)-associated fatty liver disease: an international expert consensus statement.Lancet Gastroenterol Hepatol. 2021; 6: 864-873Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar put forth two landmark articles that changed the narrative of fatty liver disease associated with metabolic dysfunction, including a correction in nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated fatty liver disease (MAFLD) as a more apt term. They also introduced a set of simple and appropriate "positive" criteria for diagnosing the disease, independent of alcohol intake or other liver diseases. These criteria apply to both adults and children as the disease is a continuum across the lifespan. We were among the other societies and stakeholders that endorsed this proposal for a multitude of reasons,4Shiha G. Alswat K. Al Khatry M. et al.Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.Lancet Gastroenterol Hepatol. 2021; 6: 57-64Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 5Spearman C.W. Desalegn H. Ocama P. et al.The sub-Saharan Africa position statement on the redefinition of fatty liver disease: from NAFLD to MAFLD.J Hepatol. 2021; 74: 1256-1258Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 6Méndez-Sánchez N. Bugianesi E. Gish R.G. et al.Global multi-stakeholder endorsement of the MAFLD definition.Lancet Gastroenterol Hepatol. 2022; 7: 388-390Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar including a) value the evidence: a wealth of data have provided unequivocal evidence for the superior utility of the MAFLD diagnostic criteria compared to the traditional NAFLD criteria across various outcomes.7Alharthi J. Gastaldelli A. Cua I.H. Ghazinian H. Eslam M. Metabolic dysfunction-associated fatty liver disease: a year in review.Curr Opin Gastroenterol. 2022; 38: 251-260Crossref PubMed Scopus (38) Google Scholar b) The simplicity and practicality of these criteria. c) Nomenclature that is devoid of any stigma and appropriately reflects the pathophysiology of the disease makes it easier to communicate with various stakeholders including patients, general practitioners, nurses, other non-hepatology specialists and policy makers.8Shiha G. Korenjak M. Eskridge W. et al.Redefining fatty liver disease: an international patient perspective.Lancet Gastroenterol Hepatol. 2021; 6: 73-79Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 9Clayton M. Fabrellas N. Luo J. et al.From NAFLD to MAFLD: nurse and allied health perspective.Liver Int. 2021; 41: 683-691Crossref PubMed Scopus (34) Google Scholar, 10Farahat T.M. Ungan M. Vilaseca J. et al.The paradigm shift from NAFLD to MAFLD: a global primary care viewpoint.Liver Int. 2022; 42: 1259-1267Crossref PubMed Scopus (14) Google Scholar, 11Eslam M. Ahmed A. Després J.-P. et al.Incorporating fatty liver disease in multidisciplinary care and novel clinical trial designs for patients with metabolic diseases.Lancet Gastroenterol Hepatol. 2021; 6: 743-753Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Recently and after a lengthy and complex Delphi process that raised more questions than it resolved, an attempt was made to develop another consensus statement on fatty liver disease. A group of experts under the umbrella of three liver societies proposed using the term metabolic dysfunction-associated steatotic liver disease" (MASLD) and adopted diagnostic criteria from the definition of MAFLD.12Rinella M.E. Lazarus J.V. Ratziu V. et al.A multi-society Delphi consensus statement on new fatty liver disease nomenclature.Ann Hepatol. 2023; 101133PubMed Google Scholar As regional leaders, whose utmost priority is our patients, we spent several months analysing the new data and views on this proposal to determine our regional stance on it. Consequently, under the umbrella of the African Middle East Association of Gastroenterology (AMAGE), we, the undersigned, comprising over 100 signatories representing multiple stakeholders and regional key opinion leaders from over 31 countries, have decided to continue using the name MAFLD as an overarching term and its definition for fatty liver diseases associated with metabolic dysregulation as the official terminology in our region. We made this decision based on: 1) Emerging evidence suggesting that MAFLD more accurately reflects the underlying pathogenesis of the disease and is better at identifying those at high risk of disease outcomes than the proposed MASLD criteria. At a minimum, the MASLD criteria did not lead to any significant improvements that can justify the confusion that could be caused by this change.13Chen L. Tao X. Zeng M. Mi Y. Xu L. Clinical and histological features under different nomenclatures of fatty liver disease: NAFLD, MAFLD, MASLD and MetALD.J Hepatol. 2023; Google Scholar,14Zhao Q. Deng Y. Comparison of mortality outcomes in individuals with MASLD and/or MAFLD.J Hepatol. 2023; Abstract Full Text Full Text PDF Scopus (7) Google Scholar Additionally, numerous studies have demonstrated that the MASLD criteria lack granularity and specificity15Tanaka M. Mori K. Takahashi S. et al.Metabolic dysfunction–associated fatty liver disease predicts new onset of chronic kidney disease better than fatty liver or nonalcoholic fatty liver disease.Nephrol Dial Transplant. 2023; 38: 700-711Crossref PubMed Scopus (20) Google Scholar,16Anirvan P. Khatua C.R. Panigrahi M.K. Singh S.P. Definition of metabolic dysfunction: shifting goalposts.J Clin Exp Hepatol. 2023; Google Scholar. Therefore, the MAFLD definition is the only one that maintains the right balance between sensitivity and specificity. This finding is expected to have significant implications for health policy and cost-effective analysis. 2) The proposed change from MAFLD to MASLD is based on the argument that the term "fatty" can be stigmatising. However, multiple studies and statements have refuted this claim. This point has been accurately illustrated by liver patients' spokespeople, who have also highlighted that "in some cultures being fat is regarded as a sign of good health".17Shiha G. Korenjak M. Casanovas T. et al.MAFLD 2022: an ELPA/ALPA/EASO-ECPO joint statement on disease stigma.J Hepatol. 2022; 77: 1717-1719Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar A recent study also showed that the perception of NAFLD stigma varies significantly among patients, providers, geographic locations, and sub-specialties. Only 8% of patients perceived stigma compared to 38% of doctors.18Younossi Z.M. AlQahtani S.A. Alswat K. et al.Global survey of stigma among physicians and patients with nonalcoholic fatty liver disease.J Hepatol. 2023; Abstract Full Text Full Text PDF Scopus (12) Google Scholar Another study demonstrated that the term "fatty" is not necessarily stigmatising in all cultures.19Méndez-Sánchez N. Pal S.C. Fassio E. Díaz-Ferrer J. Prado-Robles J.A. MAFLD: perceived stigma—a single-center Mexican patient survey.Hepatol Int. 2023; 17: 507-508Crossref PubMed Scopus (6) Google Scholar We point out that "steatotic" and "fatty" have the same translation in the languages spoken in our region. We believe that the findings collectively weaken the argument for changing "fatty" to "steatotic". These findings can be a sufficient basis to avoid any abrupt changes in the nomenclature of fatty liver disease. Studies have shown that the transition to MAFLD has positive implications in increasing disease awareness among patients and healthcare providers. It also increases attention to MAFLD at conferences across countries and health systems.20Fouad Y. Gomaa A. Semida N. Ghany W.A. Attia D. Change from NAFLD to MAFLD increases the awareness of fatty liver disease in primary care physicians and specialists.J Hepatol. 2021; 74: 1254-1256Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,21Fouad Y. Abdel Salam S. AbdAllah M. Attia D. The change from NAFLD to MAFLD expands fatty liver information flow.Hepatol Res. 2022; 52: 488-489Crossref PubMed Scopus (2) Google Scholar In conclusion, after considering the proposal for a new definition of fatty liver disease, the experts from the Middle East and North Africa, as well as Sub-Saharan Africa, have decided not to endorse the proposed definition. They have instead opted to continue using the existing definition of liver disease (MAFLD) as before. The Asian Pacific Association for the Study of the Liver (APASL) has also taken the same decision. Further studies to confirm the validity of the proposed MASLD definition are needed. No funding was obtained or required for this study. All authors have nothing to disclose relevant to this work. Please refer to the accompanying ICMJE disclosure forms for further details. All authors shared conceptualisation and designed the idea. Yasser Fouad wrote the initial draft. All authors revised the manuscript and approved the final version. Middle East and North Africa and sub-Saharan Africa position statement contributing authors list: Sherief M Abd-elsalam Tropical Medicine and Infectious Diseases Department, Faculty of Medicine, Tanta University, Tanta, Egypt. Mohamed AbdAllah Department of Gastroenterology, Hepatology, Medical Research Division, National Research Center, Egypt. Nermeen Abdeen Tropical Medicine Department, Faculty of Medicine, Alexandria University, Alexandria. Shereen Abdelaleem Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt. Yasser Abdelghani Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Wafaa Abdelhamid Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Haitham Abdel Hamid Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Nadia Abdelaaty Tropical Medicine Department, Ain Shams University, Egypt. Mostafa Abdellhalim Ministry of Health and population, Egypt. Ahmed Abdelmohsen Tropical Medicine and Gastroenterology Department, Assiut University, Assiut, Egypt. Doaa Abdeltawab Tropical Medicine and Gastroenterology Department, Assiut University, Assiut, Egypt. Mosaab Abdulkarim Department of Gastroenterology, Hepatology, Tripoli medical university, Libya. Bounena Abidine Department of Gastroenterology, Hepatology, Centre Hospitalier National de Nouakchott, Mauritania. Ahmed Aboalela Ministry of health and population, Egypt. YousryAboamer Hepatology, Gastroenterology and Infectious diseases Department, Mahala Hepatology Teaching Hospital, Egypt. Sayed Ahmed Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Mohammed Amer Department of Internal Medicine, Al-Azhar University, Cairo, Egypt. Kafya Akrouf Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Hameed Al Jameel Department of Medicine, university of Kerbala, Iraq. Munira Al Tarrah Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Abeer Al-Gharabally Hepatology, Gastroenterology and Infectious diseases Department, Al-Amiri Hospital, Kuwait City, Kuwait. Nourhan Alaa Ataa Ministry of Health and population, Egypt. Pezhman Alavinejad Department of Internal Medicine, School of Medicine, Alimentary Tract Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Khuzestan, Iran. Moussa Ali Mahamat Department of Internal Medicine and Gastroenterology, Chad. Alice Guingané Département d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso. Taha A. Alkarboly Alkarboly Kurdistan Center for Gastroenterology and Hepatology, Assulaymaniah, Kurdistan, Iraq. Nawal Alkhalidi Gastroenterology & Hepatology Teaching Hospital, Medical City, Ministry of Health and Environment, Baghdad, Iraq. Abdullah Alyouzbaki College of Medicine, University of Mosul, Iraq. Nazugum A. Ashimova Astana Medical University, Astana, Kazakhstan. Ahmed Badi Hamad medical corporation, Qatar. Ibrahim Halil Bahcecioglu Firat University, Faculty of Medicine, Department of Gastroenterology, Turkey. Shamardan Bazeed Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, South Valley University, Qena, Egypt. Asad Dajani ADSC, Medcare Hospital and Saudi German Hospital, Sharjah, Al Khan, PO Box 6328, United Arab Emirates. Mahmoud Desoky Division of Gastroenterology and Hepatology, Sultan bin Abdulalaziz city, Saudi Arabia. Ibrahima Diallo Department of Internal Medicine and Hepatogastroenterology, Hôpital Principal de Dakar, Dakar, Senegal. Mohammed Elbadri Hamad Medical Corporation, Qatar. Amr M. Elsayed Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Aisha Elsharkawy Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt. Doaa Elwazzan Tropical Medicine Department, Alexandria University, Alexandria, Egypt. Eman Fares Gastroenterology and tropical medicine department, Fayoum University, Egypt. Manar Farhat Gastroenterology and tropical medicine department, Fayoum University, Egypt. Yasmine Gaber Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt. Manik Gemilyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Yahya Ghanem Sanaa University, medical college, Yemen. Ahmed Gomaa Department of Hepatology, Gastroenterology and Endemic Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt. Ibrahima Gueye Président Association Saafara Hépatites, Sénégal. Azaa Hafez Faculty of Nursing, Minia University, Minia, Egypt. Gagik Hakobyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Adel Hasan Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Suez Canal University, Suez, Egypt. Fuad Hasan The Royale Hayat Hospital, Kuwait. Alshymaa Hassnine Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Taha M Hassanin Department of Gastroenterology, Hepatology and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt. Bilal Hotayt Khoury Hamra, Beirut, Lebanon. Alkassoum Salifou Abdou Moumouni University of Niamey, Niamey, Niger. Enas Kamal Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Qalandar Kasnazan Kurdistan Higher Council Fir Medical Specialities, KHCMS, Iraq. Rofida Khalifa Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Ashkhen Keryan Department of Hepatology, Nikomed Medical center, Armenia. Mohammed Khan King Abdulla Medical City, Mecca, Saudi Arabia. Saro Khemichyan Division of Gastrointestinal and liver Diseases, Keck Medical Center of USC, Armenia. Elmira K. Kuantay S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Dlovan Khoushnow DK radiology clinic, Erbil Governorate, Iraq. Alaa M Mostafa Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Reem Mahdy Gastroenterology and tropical medicine department, Assuit University, Minia, Egypt. Amna Mahmoud Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Saltanat S. Madenova S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Gayane Matsakyan Department of Gastroenterology and Hepatology, Yerevan State Medical University, Armenia. Nahed Makhlouf Gastroenterology and tropical medicine department, Assuit University, Assuit, Egypt. Mai Mehrez Department of Hepatology, Armed Forces College of Medicine, Egypt. Souraia Mezhoud Hamad medical corporation HMC, Qatar. Eileen Micah Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana. Safaa Mohamed Abdelhalim Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Menna Mostafa Kuwait medical centre, Kuwait. Shaymaa Nafady Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt. Aren Nersisyan Nikomed Medical center, Armenia. Alexander V. Nersesov Department of Gastroenterology, S.D. Asfendiyarov Kazakh National Medical University, Kazakhstan. Kalys Nogoibaeva Kyrgyz State Medical Academi, Kyrgyzstan. Necati ORMECİ Department of Internal Medicine, Gastroenterology and Hepatology İstanbul Health and Technology University, Istanbul, Türkiye. Marian Muse Osman Somalia National Institute of Health, Somalia. Venera S. Rakhmetova Astana Medical University, Astana, Kazakhstan. Abdulfattah Rajab Medical department Central Tripoli Hospital, Libya. Aigul M. Raissova S.D. Asfendiyarov National Medical University, Kazakh Association for the Study of the Liver, Almaty, Kazakhstan. Ebada M Said Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Benha University, Benha, Egypt. Asmaa Salama Department of Gastroenterology, Hepatology and Infectious Diseases, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt. Eman Salama Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Ruzanna Safaryan Nikomed Medical center, Armenia. Violeta Sargsyan Violeta Medical center, Armenia. Nady Semeda Gastroenterology and tropical medicine department, Minia University, Minia, Egypt. Nara Stepanyan Nikomed Medical center, Armenia. Isaac Thom Shawa University of Malawi College of Medicine, Blantyre, Malawi. Aya Shazly Ministry of health, Saudi Arabia. Said Taharboucht Internal medicine department, CHU de Douera, University of Blida, Algiers, Algeria. Ali Tumi Central Hospital Tripoli Liya, Libya. Mariam Zaghloul Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University,Egypt. Samy Zaky Department of Hepatogastroenterology and Infectious Diseases, Al-Azhar University, Cairo, Egypt. The following are the supplementary data to this article: Download .pdf (.95 MB) Help with pdf files Multimedia component 1