Correspondence: “A multisociety Delphi consensus statement on new fatty liver disease nomenclature”

Dear Editor,

Steatotic liver disease (SLD) has been proposed by Rinella et al. as the new overarching term to encompass various aetiologies of steatosis, including metabolic dysfunction-associated steatotic liver disease (MASLD), MASLD and increased alcohol intake (MetALD), alcohol-associated liver disease (ALD), specific aetiology SLD, and cryptogenic SLD [1]. However, unlike metabolic dysfunction-associated fatty liver disease (MAFLD) suggested by Eslam et al. in 2020, blood biomarkers and scores were not explicitly outlined as one of the methods for identifying hepatic steatosis [2]. These biomarkers or scores, such as the fatty liver index, are deemed appropriate for extensive epidemiological studies to detect hepatic steatosis in adults [2]. Indeed, the European clinical practice guidelines stated that validated biomarkers and scores are acceptable substitutes to diagnose fatty liver when imaging methods are unavailable or impractical, such as in big epidemiological surveys [3].

With increasing clinical and public health burdens from SLD, a population-based study is currently being conducted to determine its prevalence in Malaysia [4]. Biomarkers and scores are very useful here because imaging is neither financially nor logistically feasible in the nationwide survey [4]. Thus, biomarkers and scores can be important for low- and middle-income countries like Malaysia, where the availability and cost of imaging affect feasibility [3]. Besides that, their use in primary care can increase awareness and early diagnosis of SLD, which is essential for secondary disease prevention. Furthermore, the fibrosis-4 (FIB-4) score can be used to screen for more severe SLD.[5] Those with less severe SLD can be managed in the primary care setting. In contrast, referrals for further evaluations are necessary for individuals with high or intermediate scores [5].

With a better understanding of the pathophysiology and epidemiology of SLD, it is clear that multi-disciplinary collaborative efforts are vital to managing the complex disease [1,2,5]. Public health-wise, determining the national prevalence of SLD is essential to gauge the issue's magnitude [4] accurately. The information can raise SLD priority in health agenda setting at the national level, catalyze evidence-based policymaking to prevent and manage SLD, and incorporate SLD into the broader noncommunicable disease prevention and control initiatives due to shared common risk factors [4,5]. Public health practitioners play a crucial role in raising awareness and knowledge of various stakeholders on SLD, with healthcare professionals in primary care and the general population being the key target groups [5]. In this sense, accepting and including readily available biomarkers and scores for identifying hepatic steatosis is essential and should be considered in future updates of the nomenclature or guidelines on the disease.

Funding

This work was supported by the Ministry of Health Malaysia, grant number 91000050.

Ethical statement

The Medical Research and Ethics Committee of the Ministry of Health Malaysia has granted ethical approval to conduct the study (NMRR ID-22-02845-GUT).