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Page 4 of 9 Targher et al. Hepatoma Res 2020;6:64 I http://dx.doi.org/10.20517/2394-5079.2020.71

Figure 2. Flowchart for the proposed “positive” diagnostic criteria for metabolic dysfunction-associated fatty liver disease (MAFLD)
in adult individuals. These diagnostic criteria are not applicable to the paediatric population. This figure is reproduced with permission
from Eslam et al. [5]

The panel of international experts has also proposed that MAFLD should be the single “overarching” term
[4,5]
to describe this fatty liver disease . Similar to that accepted for other chronic liver diseases, they proposed
that the histological severity of liver disease should be defined by its grade of activity and its stage of
[5]
fibrosis . This recognizes that the grade of MAFLD activity is a disease continuum and the all-embracing
term of MAFLD should replace the current stratification of liver disease into NASH and non-NASH,
which may also have some important limitations (e.g., there is significant inter-observer and intra-observer
[5]
variability for the histologic confirmation of NASH, particularly for ballooned hepatocytes) . From a
clinical and pathological perspective, this suggestion should also result in improved case identification,
while sub-classification of MAFLD (based on the use of liver histology) may also capture histological
changes in disease status with relevant impacts on the disease course . As suggested by the panel of
[5]
international experts, it is reasonable to assume that MAFLD could be sub-classified in the foreseeable
future, based on new epidemiological and experimental data that might suggest the predominant
pathophysiological pathway that drives the development of specific features of liver histology (steatosis,
necro-inflammation or fibrosis), but which might lead to different hepatic and extra-hepatic clinical
[5]
complications (e.g., cardiovascular disease, extra-hepatic cancers or chronic kidney disease) .
The expert panel has also proposed a set of diagnostic criteria to define MAFLD-related cirrhosis (in
order to avoid the use of the term “cryptogenic cirrhosis” in this patient group) and proposed a conceptual
[5]
framework to consider other causes of fatty liver disease . The diagnostic criteria for MAFLD-related
cirrhosis include patients with established cirrhosis in the absence of the typical histological signs