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A multisociety Delphi consensus statement on new fatty liver disease nomenclature |
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Hepatology. 2023 Dec 1;78(6):1966-1986. doi: 10.1097/HEP.0000000000000520.Epub 2023 Jun 24.
Mary E Rinella 1, Jeffrey V Lazarus 2 3, Vlad Ratziu 4, Sven M Francque 5 6, Arun J Sanyal 7, Fasiha Kanwal 8 9, Diana Romero 2, Manal F Abdelmalek 10, Quentin M Anstee 11 12, Juan Pablo Arab 13 14 15, Marco Arrese 15 16, Ramon Bataller 17, Ulrich Beuers 18, Jerome Boursier 19, Elisabetta Bugianesi 20, Christopher D Byrne 21 22, Graciela E Castro Narro 16 23 24, Abhijit Chowdhury 25 26, Helena Cortez-Pinto 27, Donna R Cryer 28, Kenneth Cusi 29, Mohamed El-Kassas 30, Samuel Klein 31, Wayne Eskridge 32, Jiangao Fan 33, Samer Gawrieh 34, Cynthia D Guy 35, Stephen A Harrison 36, Seung Up Kim 37, Bart G Koot 38, Marko Korenjak 39, Kris V Kowdley 40, Florence Lacaille 41, Rohit Loomba 42, Robert Mitchell-Thain 43, Timothy R Morgan 44 45, Elisabeth E Powell 46 47 48, Michael Roden 49 50 51, Manuel Romero-Gómez 52, Marcelo Silva 53, Shivaram Prasad Singh 54, Silvia C Sookoian 15 55 56, C Wendy Spearman 57, Dina Tiniakos 11 58, Luca Valenti 59 60, Miriam B Vos 61, Vincent Wai-Sun Wong 62, Stavra Xanthakos 63, Yusuf Yilmaz 64, Zobair Younossi 65 66 67, Ansley Hobbs 2, Marcela Villota-Rivas 68, Philip N Newsome 69 70; NAFLD Nomenclature consensus group
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Author information
Collaborators
- NAFLD Nomenclature consensus group:
Veeral Ajmeral, William Alazawi, Maryam Alkhatry, Naim Alkhouri, Alina Allen, Michael Allison, Khalid Alswat, Mario R Alvares-da-Silva, Michele Alves-Bezerra, Matthew J Armstrong, Diego Arufe, Pablo Aschner, Gyorgy Baffy, Meena Bansal, Pierre Bedossa, Renata Belfort, Thomas Berg, Annalisa Berzigotti, Michael Betel, Cristiana Bianco, Clifford Brass, Carol L Brosgart, Elizabeth Matthews Brunt, Maria Buti, Steve Caldwell, Rotonya Carr, Teresa Casanovas, Laurent Castera, Cyrielle Caussy, Eira Cerda, Naga Chalasani, Wah Kheong Chan, Phunchai Charatcharoenwitthaya, Michael Charlton, Amanda Cheung, Daniela Chiodi, Ray Chung, David Cohen, Kathleen Corey, Helma P Cotrim, Javier Crespo, Anuradha Dassanayake, Nicholas Davidson, Robert De Knegt, Victor De Ledinghen, Münevver Demir, Sebastian Diaz, Anna Mae Diehl, Bruce Dimmig, Melisa Dirchwolf, Ajay Duseja, Karel Dvorak, Mattias Ekstedt, Reda El Wakil, María Lucía Ferraz, Scott Friedman, Michael Fuchs, Amalia Gastaldelli, Anja Geerts, Andreas Geier, Marcos Girala, George Goh, Nicolas Goossens, Isabel Graupera, Hannes Hagström, Zachary Henry, Bela Hunyady, Alan Hutchison, Scott Isaacs, François Jornayvaz, Cynthia Kemp, Denise Kile, Won Kim, David Kleiner, Rohit Kohli, Marcelo Kugelmas, Joel Lavine, Mariana Lazo, Nathalie Leite, Adelina Lozano, Panu Luukkonen, Paula Macedo, Dina Mansour, Christos Mantzoros, Giulio Marchesini, Sebastián Marciano, Kim Martinez, Lyudmila Vladimirova Mateva, Jose M Mato, Alexis McCary, Luca Miele, Ivana Mikolasevic, Veronica Miller, Rosalba Moreno, Cynthia Moylan, Atsushi Nakajima, Jean Charles Nault, Suzanne Norris, Mazen Noureddin, C P Oliveira, Arlin Ong, Martín Padilla, Raluca Pais, Arturo Panduro, Manas K Panigrahi, George Papatheodoridis, Serena Pelusi, Marlene Pérez, Juanita Perez Escobar, Gianluca Perseghin, Mario Pessoa, Salvatore Petta, Massimo Pinzani, Monica Platon Lupsor, Atoosa Rabiee, Stefano Romeo, Yaron Rotman, Ian Rowe, Riina Salupere, Sanjaya Satapathy, Jörn M Schattenberg, Wendy Schaufert, Bernd Schnabl, Lynn Seim, Lawrence Serfaty, David Shapiro, Ashwani K Singal, Lubomir Skladany, Norbert Stefan, Jonathan Stine, Shikha Sundaram, Gianluca Svegliati-Baroni, Gyonzgi Szabo, Frank Tacke, Tawesak Tanwandee, Giovanni Targher, Norah Terrault, Brent Tetri, Maja Thiele, Baron Tisthammer, Aldo Torre Delgadillo, Michael Trauner, Emmanuel Tsochatzis, Laurens Van Kleef, Saskia Van Mil, Lisa VanWagner, Jose Antonio Velarde Ruiz Velasco, Mette Vesterhus, Eduardo Vilar-Gomez, Kymberly Watt, Julia Wattacheril, Fonda Wilkins, José Willemse, Amany Zekry, Shira Zelber-Sagi
Affiliations
- 1University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA.
- 2City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA.
- 3Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain.
- 4Sorbonne Université, ICAN Institute for Metabolism and Nutrition, Hospital Pitié-Salpêtrière, Paris, France.
- 5Department of Gastroenterology Hepatology, Antwerp University Hospital, Edegem, Belgium.
- 6InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.
- 7Virginia Commonwealth University, Richmond, Virginia, USA.
- 8Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
- 9VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
- 10Mayo Clinic, Rochester, Minnesota, USA.
- 11Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
- 12Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK.
- 13Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada.
- 14Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada.
- 15Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile.
- 16Latin American Association for the Study of the Liver (ALEH) Santiago, Chile.
- 17Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- 18Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
- 19Hepato-Gastroenterology and Digestive Oncology Department, Angers University Hospital, Angers, France & HIFIH Laboratory UPRES EA3859, SFR 4208, Angers University, Angers, France.
- 20Department of Medical Sciences, University of Torino, Torino, Italy.
- 21Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK.
- 22National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.
- 23Hepatology and Transplant Unit, Hospital Médica Sur, Mexico City, Mexico.
- 24Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubirán" Mexico City, Mexico.
- 25Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India.
- 26John C. Martin Centre for Liver Research and Innovations, Sonarpur, Kolkata, India.
- 27Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
- 28Global Liver Institute, Washington, District of Columbia, USA.
- 29Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, Florida, USA.
- 30Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt.
- 31Washington University School of Medicine, St. Louis, Missouri, USA.
- 32Fatty Liver Foundation, Boise, Idaho, USA.
- 33Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- 34Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
- 35Department of Pathology, Duke Health Systems, Durham, North Carolina, USA.
- 36Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
- 37Yonsei University College of Medicine, Seoul, Korea.
- 38Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- 39European Liver Patients' Association, Brussels, Belgium.
- 40Liver Institute Northwest Elson S. Floyd College of Medicine Washington State University Seattle, Washington, USA.
- 41Hôpital Universitaire Necker-Enfants Maladies, Paris, France.
- 42NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA.
- 43PBC Foundation, Liver Patients International, Edinburgh, Scotland.
- 44Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA.
- 45Department of Medicine, University of California, Irvine, California, USA.
- 46Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia.
- 47QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.
- 48Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
- 49Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
- 50Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
- 51German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany.
- 52Digestive Diseases and Ciberehd, Virgen del Rocio University Hospital, Institute of Biomedicine of Seville (CSIC/HUVR/US), University of Seville, Seville, Spain.
- 53Austral University Hospital, Buenos Aires, Argentina.
- 54Kalinga Gastroenterology Foundation, Cuttack, Odisha, India.
- 55Clinical and Molecular Hepatology, Centro de Altos Estudios en Ciencias Humanas y de la Salud (CAECIHS), Universidad Abierta Interamericana, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.
- 56Universidad Maimónides, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina.
- 57Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- 58Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
- 59Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
- 60Biological Resource Center Unit, Precision Medicine lab, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
- 61Division of Gastroenterology, Department of Paediatrics, Hepatology and Nutrition, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
- 62Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
- 63Department of paediatrics, Division of Gastroenterology Hepatology and Nutrition, Cincinnati Children's, Nonalcoholic Steatohepatitis Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
- 64Department of Gastroenterology, School of Medicine, Recep Tayyip Erdogan University, Rize, Turkey.
- 65Inova Medicine, Inova Health System, Falls Church, Virginia, USA.
- 66Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States.
- 67Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States.
- 68Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain.
- 69National Institute for Health Research, Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK.
- 70Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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 favor 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 panelists 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. 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 nonstigmatising, and can improve awareness and patient identification.
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