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Targher et al. Hepatoma Res 2020;6:64 I http://dx.doi.org/10.20517/2394-5079.2020.71 Page 7 of 9

good reason to change the nomenclature and the diagnostic criteria for defining this fatty liver disease is
that current diagnostic criteria focused on diagnosing NASH by histology only is hindering both the testing
of novel treatments for NAFLD and the discovery of new biomarkers. As the change in nomenclature
and diagnostic criteria for this fatty liver disease have not been accepted by the major scientific societies,
it has been recommended that an international consensus conference should be jointly organized by
the major relevant scientific societies along with the patient advocacy organizations, biopharmaceutical
industry, regulatory agencies and policy makers to thoughtfully consider any implications of a change in
[35]
terminology of NAFLD as we know it . Following the same process that occurred for changing the term
“primary biliary cirrhosis” to “primary biliary cholangitis”, all the main scientific societies should approve
the different steps, reach a consensus and publish a position paper on MAFLD.

CONCLUSION
Based on pathophysiological insights gained from the past decades, two new articles from a panel of
international experts from 22 countries have proposed a new name and definition for NAFLD in adults - i.e.,
[4,5]
MAFLD . We believe that a change in the nomenclature and definition for this burdensome liver disease
affecting nearly one billion people globally is overdue, as knowledge gained from the last two decades has
clearly established that MAFLD is a (predominantly) metabolic liver disease. Furthermore, the term “non-
alcoholic” over-emphasizes the absence of significant alcohol consumption and does not acknowledge the
importance of overweight/obesity, type 2 diabetes mellitus, insulin resistance and other metabolic risk
abnormalities that fuel the risk of liver disease progression and the development of serious adverse extra-
hepatic outcomes (e.g., cardiovascular disease, extra-hepatic malignancies or chronic kidney disease) [36-41] .
To date, it is known that there is a substantial under-appreciation of NAFLD by both primary care
clinicians and patients [42,43] . We believe that the proposed change of the name from NAFLD to MAFLD
holds promise to aid in increasing awareness of this liver disease and decreasing its possible social stigma
due to its link to alcohol intake. It is reasonable to propose that this new definition might also promote
the establishment of MAFLD clinics run jointly by hepatologists and diabetologists to further improve
patient care. To date, however, a number of challenges and uncertainties remain before making this step-
change. As discussed above, a change to the nomenclature and diagnostic criteria for NAFLD is a potential
first relevant step to acknowledging that NAFLD is an important metabolic liver disease whose aetiology
and pathogenesis extend beyond the liver. Indeed, it is known that NAFLD is a novel risk factor for the
development of cardiovascular disease, chronic kidney disease, type 2 diabetes and some extra-hepatic
malignancies (e.g., colorectal cancers) [36-41] . In the meantime, an international consensus conference should
be jointly organized by the major relevant scientific societies to discuss the implications of a change in
terminology from NAFLD to MAFLD and to achieve a consensus regarding any change in nomenclature
and definition for this common metabolic liver disease.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and contributed equally to write this
commentary article: Targher G, Byrne CD

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest. Targher G was a coauthor of one of the two
recent articles proposing the change of terminology from NAFLD to MAFLD.
[5]