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Ciardullo et al. Metab Target Organ Damage 2024;4:30 Metabolism and
DOI: 10.20517/mtod.2024.39
Target Organ Damage

Review Open Access

From NAFLD to MAFLD and MASLD: a tale of
alcohol, stigma and metabolic dysfunction

Stefano Ciardullo 1,2 , Gianluca Perseghin 1,2
1
Department of Medicine and Rehabilitation, Policlinico di Monza, Monza 20900, Italy.
2
School of Medicine and Surgery, University of Milano Bicocca, Milan 20900, Italy.
Correspondence to: Dr. Stefano Ciardullo, Department of Medicine and Rehabilitation, Policlinico di Monza, Via Modigliani 10,
Monza 20900, Italy. E-mail: stefano.ciardullo@unimib.it
How to cite this article: Ciardullo S, Perseghin G. From NAFLD to MAFLD and MASLD: a tale of alcohol, stigma and metabolic
dysfunction. Metab Target Organ Damage 2024;4:30. https://dx.doi.org/10.20517/mtod.2024.39
Received: 7 May 2024 First Decision: 1 Jul 2024 Revised: 9 Aug 2024 Accepted: 21 Aug 2024 Published: 28 Aug 2024

Academic Editor: Amedeo Lonardo Copy Editor: Yu-Fei Wang Production Editor: Yu-Fei Wang

Abstract
Liver steatosis is a frequent finding in clinical practice and it is estimated to affect 30% of the general adult
population worldwide. It became one of the leading causes of end-stage liver disease and hepatocellular carcinoma.
From its first description, a diagnosis of nonalcoholic fatty liver disease (NAFLD) required the exclusion of
excessive alcohol consumption and concomitant chronic liver diseases of different origins, making it a diagnosis of
exclusion. In recent years, the need to stress the strict association between liver steatosis and metabolic
dysfunction (i.e., insulin resistance, overweight/obesity, type 2 diabetes, and metabolic syndrome), as well as the
desire to define a condition in a positive rather than negative way, led to new definitions and new diagnostic
criteria. Metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed by Eslam et al. in 2020. More
recently, a Delphi consensus endorsed by several international hepatologic societies proposed a new terminology
[metabolic dysfunction-associated steatotic liver disease (MASLD)] and a new set of diagnostic criteria. The
MAFLD and MASLD definitions have a good degree of concordance. They mainly differ in the number of metabolic
derangements needed to define “metabolic dysfunction” in normal-weight individuals and in alcohol consumption.
Indeed, while MAFLD does not exclude patients with significant alcohol consumption, the recent Delphi consensus
included the metabolic dysfunction and alcohol-related liver disease (MetALD) disease entity, a condition in which
steatosis, metabolic dysfunction, and moderate alcohol intake coexist. In the present narrative review, we underline
the strengths and possible limitations of each definition and summarize available evidence from epidemiologic
studies evaluating the clinical usefulness of each set of diagnostic criteria.

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0
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