Understanding Liver Disease’s New Names—NASH is now MASH

August 2023

By A.J. Hostetler
The liver, one of our body's overlooked heroes, plays a crucial role in our overall health. Despite its central role to our well-being, liver disease is growing health concern, affecting millions of people worldwide.

This summer, the director of VCU’s Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Arun Sanyal, M.D., introduced at an international conference in Vienna a game-changing approach to tackling fatty liver disease. The new naming and classification system for liver disease, the Delphi Consensus Nomenclature, was a call to recognize the importance of precision and patient-centered care in managing non-alcoholic fatty liver disease.

The liver is a powerhouse organ: it handles essential functions such as detoxification, metabolism and nutrient storage. It breaks down toxins, aids digestion and produces bile to help absorb fats and fat-soluble vitamins. Although resilient, the liver is susceptible to various diseases, including fatty liver disease.

What Patients Need to Know

If you suspect you may have steatotic liver disease or have been diagnosed with it, talking openly with your primary care physician is essential. Here are some tips for discussing the condition with your doctor:

• Be honest when talking to your physician about your alcohol consumption, dietary habits and exercise routine. This information will help them understand the potential causes and risk factors for your liver disease.
• Don't hesitate to ask your doctor about the diagnosis, the new nomenclature, and what it means for you. Understanding your condition empowers you to take an active role in managing it.
• Depending on the severity of your disease, your doctor may recommend lifestyle changes, such as weight loss and exercise, or specific medications. Make sure to discuss the available treatment options and their potential benefits and risks.
• Regular follow-up appointments are essential to monitor your liver health and track any changes in your condition. Stay committed to your treatment plan and report any new symptoms or concerns to your physician.

What Health Care Providers Need to Know

Identifying patients at risk of MAFLD or AALD is crucial for early intervention and tailored treatment plans. Use the following steps to help identify patients who may be at risk:

• Ask patients about metabolic disorders such as obesity, type 2 diabetes, dyslipidemia, and hypertension during patient evaluations.
• Assess alcohol consumption patterns to identify patients at risk of AALD.
• Evaluate BMI to recognize patients at risk of MAFLD due to obesity.
• When appropriate, conduct liver function tests to assess liver health and detect elevated liver enzymes, indicating the presence of fatty liver disease.
• Consider performing imaging studies to visualize liver fat and assess liver stiffness, aiding in diagnosis and staging.

Fatty liver disease, now called steatotic liver disease, occurs when excessive fat accumulates in liver cells. This condition can progress to a more severe form, which involves liver inflammation and potential scarring, which can worsen into cirrhosis and perhaps lead to a liver transplant. As many as 15 million people in the United States are affected by advanced steatotic liver disease and there are no approved treatments.

Over the years, this disease has been defined and classified by various terms, leading to confusion among health care providers, researchers and patients. This hindered effective communication and even research efforts to address this complex liver disease comprehensively.

In 2020, multinational liver associations and patient advocacy groups convened a group to review naming and definition options for the stages of fatty liver disease. The names adopted this summer emphasize the metabolic underpinnings of the liver condition, aligning it more closely with its root causes, such as obesity or diabetes.

What to know about the new nomenclature:

• Steatotic liver disease (SLD) was chosen as an overarching term to encompass the various causes of steatosis.
• The term steatohepatitis was felt to be an important pathophysiological concept that should be retained.
• Nonalcoholic fatty liver disease (NAFLD) will now be metabolic dysfunction-associated steatotic liver disease (MASLD), which includes patients who have hepatic steatosis and have at least one of five cardiometabolic risk factors.
• A new category, called MetALD (pronounced: Met A-L-D) now describes those with MASLD who consume amounts of alcohol per week than 140 g/week for women and 210 g/week for men.
• Metabolic dysfunction-associated steatohepatitis (MASH) replaces NASH.

With clearer communication, tailored treatment plans, and patient empowerment, health care providers, patients and the public can work together towards fostering a health future for all.

In addition to following the latest guidelines, Practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease, physicians working with patients to manage steatotic liver disease can implement the following treatment strategies:

• Encourage patients with MAFLD to adopt a healthy lifestyle, including regular exercise, a balanced diet and weight management.
• Advise alcohol abstinence or moderation, depending on the severity of liver damage, for patients with AALD.
• Consider prescribing medications for MAFLD patients who haven't achieved sufficient improvement through lifestyle changes alone.
• Regularly monitor liver function and other factors to track treatment progress and ensure patient adherence.
• Work with other healthcare professionals, such as dietitians, hepatologists and addiction specialists, to provide comprehensive support for patients.