A multisociety Delphi consensus statement on new fatty liver disease nomenclature

NAFLD Nomenclature consensus group

doi:10.1016/j.jhep.2023.06.003

A multisociety Delphi consensus statement on new fatty liver disease nomenclature

NAFLD Nomenclature consensus group

Medical and Dental Sciences

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Abstract

The 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. A total of 236 panellists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and non-stigmatising, and can improve awareness and patient identification.

Original language	English
Pages (from-to)	1542-1556
Number of pages	15
Journal	Journal of Hepatology
Volume	79
Issue number	6
Early online date	24 Jun 2023
DOIs	https://doi.org/10.1016/j.jhep.2023.06.003
Publication status	Published - Dec 2023

Bibliographical note

Acknowledgments:
The authors thank the governing boards of the 3 lead societies, AASLD, ALEH, and EASL, and specifically society leadership, Norah Terrault (AASLD President 2023), Laurie DeLeve (AASLD President 2022), W. Ray Kim (AASLD President-elect), Graciela E. Castro Narro (ALEH President), Thomas Berg (EASL Secretary General 2021–2023), and Aleksander Krag (EASL Secretary General 2023–2025). The authors thank Matthew D’Uva from AASLD for his tireless work and support of this project and recognise the contributions of all of the members of the NAFLD nomenclature consensus group who provided feedback, analysis, and recommendations over multiple Delphi rounds (Table 2). The authors acknowledge the assistance of the EU-IMI2–funded LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis) consortium for the analysis of data derived from the European NAFLD Registry. Finally, the authors and the methodology team thank Delfina Boudou and Trenton White (ISGlobal, Spain).

Copyright:
© 2023 Mary E. Rinella, Jeffrey V. Lazarus, Vlad Ratziu, Sven M. Francque, Arun J. Sanyal, Fasiha Kanwal, Diana Romero, Manal F. Abdelmalek, Quentin M. Anstee, Juan Pablo Arab, Marco Arrese, Ramon Bataller, Ulrich Beuers, Jerome Boursier, Elisabetta Bugianesi, Christopher Byrne, Graciela E. Castro Narro, Abhijit Chowdhury, Helena Cortez-Pinto, Donna Cryer, Kenneth Cusi, Mohamed El-Kassas, Samuel Klein, Wayne Eskridge, Jiangao Fan, Samer Gawrieh, Cynthia D. Guy, Stephen A. Harrison, Seung Up Kim, Bart Koot, Marko Korenjak, Kris Kowdley, Florence Lacaille, Rohit Loomba, Robert Mitchell-Thain, Timothy R. Morgan, Elisabeth Powell, Michael Roden, Manuel Romero-Gómez, Marcelo Silva, Shivaram Prasad Singh, Silvia C. Sookoian, C. Wendy Spearman, Dina Tiniakos, Luca Valenti, Miriam B. Vos, Vincent Wai-Sun Wong, Stavra Xanthakos, Yusuf Yilmaz, Zobair Younossi, Ansley Hobbs, Marcela Villota-Rivas, Philip N. Newsome, NAFLD Nomenclature consensus group. Published by Elsevier B.V. All rights reserved.

Keywords

Female
Male
Humans
Non-alcoholic Fatty Liver Disease/diagnosis
Delphi Technique
Ethanol
Consensus
Hepatomegaly

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@article{8aa543b26e634a728b0f71c5a3dad256,

title = "A multisociety Delphi consensus statement on new fatty liver disease nomenclature",

abstract = "The 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. A total of 236 panellists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms {"}nonalcoholic{"} and {"}fatty{"} were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and non-stigmatising, and can improve awareness and patient identification.",

keywords = "Female, Male, Humans, Non-alcoholic Fatty Liver Disease/diagnosis, Delphi Technique, Ethanol, Consensus, Hepatomegaly",

author = "{NAFLD Nomenclature consensus group} and Rinella, {Mary E.} and Lazarus, {Jeffrey V.} and Vlad Ratziu and Francque, {Sven M.} and Sanyal, {Arun J.} and Fasiha Kanwal and Diana Romero and Abdelmalek, {Manal F.} and Anstee, {Quentin M.} and Arab, {Juan Pablo} and Marco Arrese and Ramon Bataller and Ulrich Beuers and Jerome Boursier and Elisabetta Bugianesi and Byrne, {Christopher D.} and {Castro Narro}, {Graciela E.} and Abhijit Chowdhury and Helena Cortez-Pinto and Cryer, {Donna R.} and Kenneth Cusi and Mohamed El-Kassas and Samuel Klein and Wayne Eskridge and Jiangao Fan and Samer Gawrieh and Guy, {Cynthia D.} and Harrison, {Stephen A.} and Kim, {Seung Up} and Koot, {Bart G.} and Marko Korenjak and Kowdley, {Kris V.} and Florence Lacaille and Rohit Loomba and Robert Mitchell-Thain and Morgan, {Timothy R.} and Powell, {Elisabeth E.} and Michael Roden and Manuel Romero-G{\'o}mez and Marcelo Silva and Singh, {Shivaram Prasad} and Sookoian, {Silvia C.} and Spearman, {C. Wendy} and Dina Tiniakos and Luca Valenti and Vos, {Miriam B.} and Wong, {Vincent Wai-Sun} and Stavra Xanthakos and Yusuf Yilmaz and Newsome, {Philip N.}",

note = "Acknowledgments: The authors thank the governing boards of the 3 lead societies, AASLD, ALEH, and EASL, and specifically society leadership, Norah Terrault (AASLD President 2023), Laurie DeLeve (AASLD President 2022), W. Ray Kim (AASLD President-elect), Graciela E. Castro Narro (ALEH President), Thomas Berg (EASL Secretary General 2021–2023), and Aleksander Krag (EASL Secretary General 2023–2025). The authors thank Matthew D{\textquoteright}Uva from AASLD for his tireless work and support of this project and recognise the contributions of all of the members of the NAFLD nomenclature consensus group who provided feedback, analysis, and recommendations over multiple Delphi rounds (Table 2). The authors acknowledge the assistance of the EU-IMI2–funded LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis) consortium for the analysis of data derived from the European NAFLD Registry. Finally, the authors and the methodology team thank Delfina Boudou and Trenton White (ISGlobal, Spain). Copyright: {\textcopyright} 2023 Mary E. Rinella, Jeffrey V. Lazarus, Vlad Ratziu, Sven M. Francque, Arun J. Sanyal, Fasiha Kanwal, Diana Romero, Manal F. Abdelmalek, Quentin M. Anstee, Juan Pablo Arab, Marco Arrese, Ramon Bataller, Ulrich Beuers, Jerome Boursier, Elisabetta Bugianesi, Christopher Byrne, Graciela E. Castro Narro, Abhijit Chowdhury, Helena Cortez-Pinto, Donna Cryer, Kenneth Cusi, Mohamed El-Kassas, Samuel Klein, Wayne Eskridge, Jiangao Fan, Samer Gawrieh, Cynthia D. Guy, Stephen A. Harrison, Seung Up Kim, Bart Koot, Marko Korenjak, Kris Kowdley, Florence Lacaille, Rohit Loomba, Robert Mitchell-Thain, Timothy R. Morgan, Elisabeth Powell, Michael Roden, Manuel Romero-G{\'o}mez, Marcelo Silva, Shivaram Prasad Singh, Silvia C. Sookoian, C. Wendy Spearman, Dina Tiniakos, Luca Valenti, Miriam B. Vos, Vincent Wai-Sun Wong, Stavra Xanthakos, Yusuf Yilmaz, Zobair Younossi, Ansley Hobbs, Marcela Villota-Rivas, Philip N. Newsome, NAFLD Nomenclature consensus group. Published by Elsevier B.V. All rights reserved.",

year = "2023",

month = dec,

doi = "10.1016/j.jhep.2023.06.003",

language = "English",

volume = "79",

pages = "1542--1556",

journal = "Journal of Hepatology",

issn = "0168-8278",

publisher = "Elsevier",

number = "6",

}

TY - JOUR

T1 - A multisociety Delphi consensus statement on new fatty liver disease nomenclature

AU - NAFLD Nomenclature consensus group

AU - Rinella, Mary E.

AU - Lazarus, Jeffrey V.

AU - Ratziu, Vlad

AU - Francque, Sven M.

AU - Sanyal, Arun J.

AU - Kanwal, Fasiha

AU - Romero, Diana

AU - Abdelmalek, Manal F.

AU - Anstee, Quentin M.

AU - Arab, Juan Pablo

AU - Arrese, Marco

AU - Bataller, Ramon

AU - Beuers, Ulrich

AU - Boursier, Jerome

AU - Bugianesi, Elisabetta

AU - Byrne, Christopher D.

AU - Castro Narro, Graciela E.

AU - Chowdhury, Abhijit

AU - Cortez-Pinto, Helena

AU - Cryer, Donna R.

AU - Cusi, Kenneth

AU - El-Kassas, Mohamed

AU - Klein, Samuel

AU - Eskridge, Wayne

AU - Fan, Jiangao

AU - Gawrieh, Samer

AU - Guy, Cynthia D.

AU - Harrison, Stephen A.

AU - Kim, Seung Up

AU - Koot, Bart G.

AU - Korenjak, Marko

AU - Kowdley, Kris V.

AU - Lacaille, Florence

AU - Loomba, Rohit

AU - Mitchell-Thain, Robert

AU - Morgan, Timothy R.

AU - Powell, Elisabeth E.

AU - Roden, Michael

AU - Romero-Gómez, Manuel

AU - Silva, Marcelo

AU - Singh, Shivaram Prasad

AU - Sookoian, Silvia C.

AU - Spearman, C. Wendy

AU - Tiniakos, Dina

AU - Valenti, Luca

AU - Vos, Miriam B.

AU - Wong, Vincent Wai-Sun

AU - Xanthakos, Stavra

AU - Yilmaz, Yusuf

AU - Newsome, Philip N.

N1 - Acknowledgments: The authors thank the governing boards of the 3 lead societies, AASLD, ALEH, and EASL, and specifically society leadership, Norah Terrault (AASLD President 2023), Laurie DeLeve (AASLD President 2022), W. Ray Kim (AASLD President-elect), Graciela E. Castro Narro (ALEH President), Thomas Berg (EASL Secretary General 2021–2023), and Aleksander Krag (EASL Secretary General 2023–2025). The authors thank Matthew D’Uva from AASLD for his tireless work and support of this project and recognise the contributions of all of the members of the NAFLD nomenclature consensus group who provided feedback, analysis, and recommendations over multiple Delphi rounds (Table 2). The authors acknowledge the assistance of the EU-IMI2–funded LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis) consortium for the analysis of data derived from the European NAFLD Registry. Finally, the authors and the methodology team thank Delfina Boudou and Trenton White (ISGlobal, Spain). Copyright: © 2023 Mary E. Rinella, Jeffrey V. Lazarus, Vlad Ratziu, Sven M. Francque, Arun J. Sanyal, Fasiha Kanwal, Diana Romero, Manal F. Abdelmalek, Quentin M. Anstee, Juan Pablo Arab, Marco Arrese, Ramon Bataller, Ulrich Beuers, Jerome Boursier, Elisabetta Bugianesi, Christopher Byrne, Graciela E. Castro Narro, Abhijit Chowdhury, Helena Cortez-Pinto, Donna Cryer, Kenneth Cusi, Mohamed El-Kassas, Samuel Klein, Wayne Eskridge, Jiangao Fan, Samer Gawrieh, Cynthia D. Guy, Stephen A. Harrison, Seung Up Kim, Bart Koot, Marko Korenjak, Kris Kowdley, Florence Lacaille, Rohit Loomba, Robert Mitchell-Thain, Timothy R. Morgan, Elisabeth Powell, Michael Roden, Manuel Romero-Gómez, Marcelo Silva, Shivaram Prasad Singh, Silvia C. Sookoian, C. Wendy Spearman, Dina Tiniakos, Luca Valenti, Miriam B. Vos, Vincent Wai-Sun Wong, Stavra Xanthakos, Yusuf Yilmaz, Zobair Younossi, Ansley Hobbs, Marcela Villota-Rivas, Philip N. Newsome, NAFLD Nomenclature consensus group. Published by Elsevier B.V. All rights reserved.

PY - 2023/12

Y1 - 2023/12

N2 - The 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. A total of 236 panellists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and non-stigmatising, and can improve awareness and patient identification.

AB - The 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. A total of 236 panellists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and non-stigmatising, and can improve awareness and patient identification.

KW - Female

KW - Male

KW - Humans

KW - Non-alcoholic Fatty Liver Disease/diagnosis

KW - Delphi Technique

KW - Ethanol

KW - Consensus

KW - Hepatomegaly

U2 - 10.1016/j.jhep.2023.06.003

DO - 10.1016/j.jhep.2023.06.003

M3 - Review article

C2 - 37364790

SN - 0168-8278

VL - 79

SP - 1542

EP - 1556

JO - Journal of Hepatology

JF - Journal of Hepatology

IS - 6

ER -

A multisociety Delphi consensus statement on new fatty liver disease nomenclature

Abstract

Bibliographical note

Keywords

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