Comparing NAFLD, MAFLD, and MASLD criteria for identifying significant liver fibrosis: A cross-sectional study

Abstract

Objective

Different diagnostic frameworks for fatty liver disease include the exclusion-based non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) and the inclusion-based metabolic dysfunction-associated fatty liver disease (MAFLD) criteria. Their implications remain debated, especially in high viral hepatitis and alcohol use settings. This study evaluated diagnostic concordance and compared fibrosis detection across frameworks in a Vietnamese cohort.

Patients and methods

In this cross-sectional study of 360 adults, liver fibrosis and steatosis were assessed using transient elastography. Significant fibrosis was defined as LSM ≥7.0 kPa (F2), with F3 (≥8.7) and F4 (≥11.5). Steatosis was classified by CAP (S1–S3). Patients were classified categorized as NAFLD, MASLD, and MAFLD. Univariable and multivariable logistic regression were performed to identify factors associated with significant fibrosis.

Results

Among participants, 76.67% (n = 276) met all three definitions, while 15.83% (n = 57) fulfilled only MAFLD criteria. The MAFLD group demonstrated higher liver stiffness than non-MAFLD group (median 5.0 vs. 4.1 kPa; p = 0.004). In multivariable analysis, NAFLD and MASLD were inversely associated with significant fibrosis (OR = 0.418, p = 0.045; OR = 0.418, p = 0.046, respectively). MAFLD showed a positive but non-significant association (OR = 1.347, p = 0.791), reflecting inclusion of dual-etiology patients (e.g., metabolic dysfunction with viral hepatitis or alcohol use) who are excluded under NAFLD/MASLD criteria.

Conclusion

The observed inverse association between NAFLD/MASLD and significant fibrosis likely reflects the exclusion of patients with coexisting metabolic dysfunction and viral or alcohol-related liver disease. MAFLD, by contrast, retains these dual-etiology cases and captures a more heterogeneous risk profile.

Resumen

Objetivo

Los marcos diagnósticos de la enfermedad del hígado graso incluyen NAFLD (basado en exclusión), MASLD y MAFLD (basados en inclusión). Sus implicaciones siguen en debate, especialmente en contextos con alta prevalencia de hepatitis viral y consumo de alcohol. Este estudio evaluó la concordancia diagnóstica y comparó la detección de fibrosis en una cohorte vietnamita.

Pacientes y métodos

Se realizó un estudio transversal en 360 adultos. La fibrosis hepática y la esteatosis se evaluaron mediante elastografía transitoria. La fibrosis significativa se definió como LSM ≥7,0 kPa (F2), con puntos de corte para F3 (≥8,7) y F4 (≥11,5). La esteatosis se clasificó mediante CAP (S1–S3). Los pacientes fueron categorizados según NAFLD, MASLD y MAFLD. Se aplicaron modelos de regresión logística para identificar factores asociados con fibrosis significativa.

Resultados

El 76,67% (n = 276) cumplió las tres definiciones, mientras que el 15,83% (n = 57) solo cumplió criterios de MAFLD. El grupo MAFLD presentó mayor rigidez hepática que el grupo no MAFLD (5,0 vs. 4,1 kPa; p = 0,004). En el análisis multivariable, NAFLD y MASLD se asociaron inversamente con fibrosis significativa (OR = 0,418; p ≈ 0,045). MAFLD mostró asociación positiva no significativa (OR = 1,347; p = 0,791).

Conclusión

La asociación inversa de NAFLD/MASLD con fibrosis probablemente refleja la exclusión de pacientes con etiología dual. MAFLD incluye estos casos y capta un perfil de riesgo más heterogéneo en esta población.