We read with interest the study by Pan and colleagues showing that criteria for metabolic dysfunction associated fatty liver disease (MAFLD) are superior to metabolic dysfunction associated steatotic liver disease (MASLD) in identifying individuals at risk of chronic kidney disease [1]. This study is consistent with what we and others have recently demonstrated that MAFLD outperforms MASLD in identifying metabolic dysfunction, fibrosis, cardiovascular disease and mortality [2-5]
The concept of MASLD is derived from MAFLD. It is not a secret that the proponents of MASLD have been vocal in their resistance accepting the MAFLD definition and opposing the mainstream in the field, opting to accept anything rather than MAFLD including even retaining the clinical status quo despite its limitations. This leads to an intriguing question: is the NAFLD-MASLD-MAFLD continuum merely the pendulum clock swinging back and forth? NAFLD and MAFLD are like 12 and 6 on a clock, representing 180-degree different concepts. MASLD, on the other hand, represents a movement of the clock and falls somewhere between 3 and 4 on the clock, closer to MAFLD. In support of this hypothesis, the discussion has shifted currently from do we need the change or not to what this change should be. Thus, perhaps MASLD represents another phase of transient resistance to MAFLD, while the pendulum continues to move. This could at least partially explain the accumulating recent data suggest that the MAFLD definition performs better than the MASLD definition [2,4,5]. This outcome is curious, as new definitions should provide substantial conceptual advances over previous ones; alternatively what is the point of the change. As the key purpose of the MASLD proposal was likely just to resist the widespread of the endorsement of MAFLD rather than devoting the effort and getting benefit of the opportunity of coming second to provide an actual conceptual advance capitalising on the MAFLD definition.
Interestingly, it took more than a decade for Helicobacter pylori to be universally accepted, which became known as the "gastric ulcer war" [6]. Only time will tell if the same will happen for the NAFLD-MASLD-MAFLD continuum, and if so, how long will it take.
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