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MAFLD’s flexibility allows it to address regional variations in liver disease co-occurrence without
[38]
introducing additional terminologies , all within the same diagnostic framework. This adaptability ensures
global applicability and relevance. In contrast, MASLD’s selective use of MetALD focuses primarily on
alcohol-related overlaps, potentially limiting its utility in regions where other contributors, such as viral
hepatitis, are dominant.

[57]
From a therapeutic perspective, coexisting conditions necessitate integrated treatment strategies . For
instance, addressing IR or hyperlipidemia in a patient with viral hepatitis or ALD can subsequently improve
disease outcomes, whereas failure to identify and manage underlying metabolic dysfunction may
compromise the success of targeted therapies . These patterns of coexistence, however, are not uniform
[58]
worldwide; they are shaped by regional differences in disease prevalence, risk factors, and cultural
influences, which further underscore the importance of adaptable frameworks in addressing global
variations in liver disease.

THERE IS NO PRECEDENT FOR DUAL TERMINOLOGY IN OTHER DISEASES
Typically, in medical fields, coexisting conditions are managed collaboratively without the need for new
terminologies . For example, diabetes, dyslipidemia, and hypertension are managed as metabolic
[59]
comorbidities without introducing additional terms to describe their overlap. Similarly, the coexistence of
two autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus, does not require
a distinct term. MAFLD follows this precedent by integrating dual etiology into a unified framework,
ensuring seamless care coordination.

The introduction of MetALD, as proposed by MASLD, deviates from this established practice. Fragmenting
liver disease terminology could complicate clinical workflows and create ambiguity in care coordination.
Evidence from multidisciplinary models suggests that unified approaches lead to better patient outcomes,
emphasizing the practicality of MAFLD’s model over the segmented structure of MASLD .
[57]

CLINICAL AND RESEARCH IMPLICATIONS
MAFLD simplifies clinical management by addressing dual etiologies under a single framework, enabling
integrated care for patients with metabolic dysfunction coexisting with alcohol or viral hepatitis. This
unified approach supports interdisciplinary collaboration and ensures comprehensive treatment strategies
tailored to the multifactorial nature of liver disease .
[60]

The transition to MAFLD has significant implications for the international classification of diseases (ICD)
coding system, used globally to standardize disease classification in healthcare. A global survey revealed that
77.1% of experts advocate updating ICD-11 to include MAFLD, reflecting a consensus toward its
adoption . This update would improve diagnostic precision and ensure accurate epidemiological tracking
[61]
by encompassing a broader spectrum of patients, particularly those with overlapping conditions. Under the
current MASLD framework, patients with metabolic dysfunction and coexisting ALD labeled by a new term
as “MetALD” may be excluded from proper classification, leading to underrepresentation in public health
databases.

From an epidemiological perspective, adopting MAFLD allows for more accurate estimates of disease
burden and better resource allocation, particularly among countries with limited resources that also bear the
highest burden of the disease. This is a vital point, given the high prevalence of the disease and the fact that
only a small proportion of patients concur with the serious consequences of it. In this regard, multiple
studies demonstrated that MAFLD criteria effectively identify individuals with high-risk metabolic profiles