Introduction
Non-Alcoholic Fatty Liver disease (NAFLD) is the most common cause of chronic liver disease, affecting 20%-30% of the world’s population. In recent years, research on various aspects of the disease has progressed. In 2020, an international panel of experts introduced a new term, metabolism-associated fatty liver disease (MAFLD), as a more appropriate term for fatty liver disease associated with metabolic syndrome.
In January 2022, the Malaysian Society of Gastroenterology and Hepatology issued a 27-point consensus statement on MAFLD, covering the definition, prevalence of MAFLD Pathology, assessment and management.
The diagnosis and treatment of MAFLD: 27 consensus statements released!
I. Definitions and Natural History
< p>1. Patients with fatty liver diagnosed based on imaging, non-invasive scoring, or histology who are overweight or obese, have type 2 diabetes mellitus (T2DM), or have at least two metabolic risk abnormalities are diagnosed with MAFLD. (Evidence level: III; Strength of recommendation: A)
2. Cardiovascular disease (CVD) is the main cause of death in patients with MAFLD. MAFLD patients with more severe fibrosis are at increased risk of liver-related complications and death. (Level of Evidence: I; Strength of Recommendation: A)
II. Epidemiology p>
3. MAFLD is common in the local Malaysian population, and the prevalence of MAFLD is on the rise due to the increasing prevalence of obesity and obesity-related diseases. (Level of Evidence: III; Strength of Recommendation: A)
4. The high prevalence and increased prevalence of MAFLD will lead to hepatocytes Increased mortality from cancer (HCC), decompensated cirrhosis and liver-related diseases. (Level of Evidence: III; Strength of Recommendation: B)
III. Evaluation
5. MAFLD patients with elevated serum aminotransferase levels should undergo a comprehensive history of medications, supplements, herbal remedies, and alcohol intake, and be screened for hepatitis B and C Viral infection. (Evidence level: III; strength of recommendation: A)
6. Patients with elevated serum aminotransferase levels should undergo ultrasonography to diagnose fatty liver, and Liver focal lesions were excluded. (Evidence level: III; strength of recommendation: A)
7. MAFLD patients should use the liver fibrosis index (FIB-4) for liver fibrosis If FIB-4 < 1.3, the risk of advanced liver fibrosis is low. MAFLD patients with FIB-4 ≥ 1.3 are at increased risk of developing advanced liver fibrosis and should be further assessed by liver stiffness measurements. (Evidence Level: I; Strength of Recommendation: A)
8. Or when another liver pathology needs to be excluded, when the diagnosis of steatohepatitis is uncertain or when confirmation is required, and when therapeutic testing is required, liver biopsy may be considered. (Level of Evidence: II; Strength of Recommendation: A)
IV. More seriousMAFLD
9. T2DM patients are an important target group for screening for more severe MAFLD. FIB-4 can be used as a screening tool. Patients with intermediate or high FIB-4 scores may have advanced liver fibrosis and should be considered for liver stiffness measurement. (Evidence level: III; strength of recommendation: A)
10. MAFLD patients with liver stiffness ≥10 kPa may have advanced liver fibrosis and should Consider referral to gastroenterology/hepatology. MAFLD patients with liver stiffness ≥15 kPa should be considered for HCC screening. Patients with MAFLD with liver stiffness ≥20-25 kPa are likely to have clinically significant portal hypertension and should be referred to a gastroenterology/hepatology unit and varicose vein screening should be considered. (Level of Evidence: III; Strength of Recommendation: A)
V. Lifestyle intervention isThe cornerstone of MAFLD management
11. Dietary intervention is beneficial to control disease activity and CVD risk. MAFLD patients should Take dietary interventions. (Level of Evidence: I; Strength of Recommendation: B)
12. Exercise can reduce liver fat, and patients with MAFLD should take exercise regardless of weight loss intervention. (Level of Evidence: I; Strength of Recommendation: B)
13. Weight loss through lifestyle intervention was associated with improvement in MAFLD regardless of obesity status. (Level of Evidence: I; Strength of Recommendation: A)
6. Treatment of metabolic risk factors to reduce CVD risk
14. Standard detailed cardiometabolic risk screening is mandatory for all MAFLD patients and positive adjustment for CVD risk factors. (Level of Evidence: I; Strength of Recommendation: A)
15. According to current guideline recommendations, patients with MAFLD who meet the criteria should be started on statins drug. (Level of Evidence: I; Strength of Recommendation: A)
16. Angiotensin-converting enzyme inhibitor (ACE-i) and angiotensin Receptor blockers are the first-line antihypertensive drugs of choice in patients with MAFLD. (Evidence level: I; strength of recommendation: A)
17. MAFLD patients with diabetes should consider the use of sodium-glucose cotransporter-2 inhibition agent (SGLT2-i). (Level of Evidence: II; Strength of Recommendation: B)
18.In patients with diabetes and/or obesity, glucagon-like peptide-1 receptor agonists (GLP1-RA) should be considered. (Level of Evidence: I; Strength of Recommendation: A)
19. Although metformin has not been shown to improve steatohepatitis, it may improve metabolic parameters , can be used for the treatment of diabetes in MAFLD patients. (Level of Evidence: II; Strength of Recommendation: B)
VII. Medications for MAFLD Treatment
20. Pioglitazone 30-45 mg/d can be considered for the treatment of steatohepatitis, but its poor The response is weight gain and may be associated with an increased risk of fractures and bladder cancer. (Level of Evidence: II; Strength of Recommendation: C)
21. Vitamin E 800 IU/d may be considered for the treatment of steatohepatitis, but its May be associated with increased risk of prostate cancer and hemorrhagic stroke. (Level of Evidence: II; Strength of Recommendation: C)
VIII.Reduction of MAFLD Major surgery
22. As a comorbidity, MAFLD should be promptly considered for BMI that fails lifestyle intervention Bariatric surgery was performed in patients ≥35 kg/m2. (Evidence level: II; recommendation strength: B)
IX. Screening for gastroesophageal varices span>
23. MAFLD patients with clinically significant risk factors for portal hypertension should be screened for gastroesophageal varices. (Level of Evidence: II; Strength of Recommendation: A)
X.Screening for HCC
24. Patients with MAFLD-related cirrhosis should be screened for HCC. HCC screening may be considered in patients with MAFLD without cirrhosis but with advanced fibrosis. (Level of Evidence: II; Strength of Recommendation: A)
XI. Liver Transplantation p>
25. Patients with MAFLD-related cirrhosis and end-stage liver disease and/or HCC should be considered for liver transplantation. (Level of Evidence: II; Strength of Recommendation: A)
Twelve. Primary care in Important role in MAFLD management
26. For patients ≥30 years of age attending primary care clinics Patients should be assessed for the presence of metabolic syndrome and risk stratified using the 10-year overall CVD Framingham Risk Score (FRS). Ultrasonography is recommended to screen for MAFLD if obesity or T2DM or ≥2 metabolic syndromes or elevated alanine aminotransferase (ALT) (≥34 U/L) or high FRS are found. (Level of Evidence: I; Strength of Recommendation: A)
Thirteen, public health in Important role in MAFLD
27. Raise awareness and knowledge of MAFLD among various stakeholders, Incorporating MAFLD into existing non-communicable disease (NCD)-related programmes and activities is an important step towards addressing this disease. (Level of Evidence: III; Strength of Recommendation: B)