Dear Editor,
Patients with steatotic liver disease (SLD) associated with cardiometabolic dysregulation exhibit a higher incidence of extrahepatic diseases, including atherosclerotic cardiovascular disease (ASCVD) [
1]. In June 2023, the consensus group composed of multiple societies opted to replace the term nonalcoholic fatty liver disease (NAFLD) with metabolic dysfunction-associated steatotic liver disease (MASLD), aiming to minimize the potential for stigma and more accurately reflect its underlying pathophysiology [
2]. MASLD requires a new inclusion criterion of “the presence of at least one or more cardiometabolic risk factors,” which reflects the importance of cardiometabolic dysregulation in patients with SLD [
2,
3]. While the use of alternative terminology can lead to occasional misunderstandings and hinder progress, it is crucial to extend investigations on NAFLD to MASLD. This will ensure that valuable research resources are effectively utilized and contribute to the advancement of knowledge in this field.
We aimed to compare the prevalence and progression of ASCVD risk in patients with NAFLD and those with MASLD in Asia. This investigation included 7,286 consecutive health check examinees who were subjected to ultrasonography and monitored at the Saga Health and Clinical Examination Center (Saga, Japan) from January 2010 to March 2020. All the individuals were Asian. We eliminated 895 participants from our sample because of insufficient data on alcohol consumption habits (n=541), alcohol consumption ≥60 g/day (n=161), hepatitis B virus infection (n=81), and hepatitis C virus infection (n=112). The study population comprised 2,306 individuals diagnosed with SLD [
4].
NAFLD was diagnosed in 63.4% (1,462/2,306) of the patients, including 98 who did not fulfill the cardiometabolic criteria for MASLD (
Fig. 1A). These cases were classified as cryptogenic SLD, and a significant proportion (93.3%) of patients with NAFLD were also diagnosed with MASLD. Our findings align well with those of previous studies that reported that almost all NAFLD patients fulfilled the MASLD criteria [
5-
7].
There were no significant differences in age, sex, baseline Suita score, or Framingham risk score between the NAFLD and MASLD groups (Suita score, low/middle/high, 795/531/79 vs. 715/521/79,
P=0.507; Framingham Risk Score, low/high, 1,025/239 vs. 948/235,
P=0.543). We defined the event as worsening of the Suita score (from low-risk [≤40] to middlerisk [41–55] or high-risk [≥56]) [
8] or Framingham risk score (from low-risk [<15] to high-risk [≥15]) [
9]. To compare the incidence of worsening ASCVD risk scores between the groups, we constructed Kaplan–Meier curves (
Fig. 1B,
C). The rate of five-year/ten-year cumulative incidence of worsening scores was not significantly different between patients with NAFLD and those with MASLD (
Fig. 1B,
C). These results indicate that the prevalence and progression of ASCVD risk are similar in patients with MASLD and NAFLD. These results were similar to previous studies that have compared the differences between MASLD and NAFLD, accentuating the augmented risk of cardiovascular diseases, including ASCVD [
1,
10]. Although previous studies have reported from the U.S. and the EU, our report highlights similar importance in Asia.
In conclusion, data on ASCVD obtained using the term NAFLD can be extrapolated to MASLD.
ACKNOWLEDGMENTS
This research was supported by the Japan Agency for Medical Research and Development (AMED) under grant number JP23fk0210090.
FOOTNOTES
-
Authors’ contribution
Hiroyuki Suzuki and Tsubasa Tsutsumi: study concept, design, and drafting; Keisuke Amano: data extraction, interpretation of data, and critical revision of the manuscript; Machiko Kawaguchi: interpretation of data, statistical analysis, and interpretation of data and critical revision of the manuscript; Takumi Kawaguchi: study concept, interpretation of data and critical revision of the manuscript.
-
Conflicts of Interest
Takumi Kawaguchi received lecture fees from Janssen Pharmaceutical K.K., Taisho Pharmaceutical Co., Ltd., Kowa Company, Ltd., Otsuka Pharmaceutical Co., Ltd., Eisai Co., Ltd., ASKA Pharmaceutical Co., Ltd., AbbVie GK., and EA Pharma Co., Ltd. The other authors have no conflicts of interest to declare.
Figure 1.Differences in the incidence of worsening atherosclerotic cardiovascular disease risk scores between the NAFLD and MASLD groups. (A) Prevalence of NAFLD and MASLD in the study cohort. (B, C) Differences in the incidence of worsening Suita score (B) and Framingham risk score (C) between the NAFLD and MASLD groups. MASLD, metabolic dysfunction-associated steatotic liver disease; NAFLD, non-alcoholic fatty liver disease; ASCVD, atherosclerotic cardiovascular disease.
Abbreviations
atherosclerotic cardiovascular disease
nonalcoholic fatty liver disease
metabolic dysfunction-associated steatotic liver disease
REFERENCES
- 1. Younossi ZM, Paik JM, Stepanova M, Ong J, Alqahtani S, Henry L. Clinical profiles and mortality rates are similar for metabolic dysfunction-associated steatotic liver disease and non-alcoholic fatty liver disease. J Hepatol 2024;80:694-701.
- 2. Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023;79:1542-1556.
- 3. Kim GA, Moon JH, Kim W. Critical appraisal of metabolic dysfunction-associated steatotic liver disease: Implication of Janus-faced modernity. Clin Mol Hepatol 2023;29:831-843.
- 4. Tsutsumi T, Eslam M, Kawaguchi T, Yamamura S, Kawaguchi A, Nakano D, et al. MAFLD better predicts the progression of atherosclerotic cardiovascular risk than NAFLD: Generalized estimating equation approach. Hepatol Res 2021;51:1115-1128.
- 5. Suzuki H, Shimose S, Iwamoto H, Niizeki T, Kawaguchi T. Changing from NAFLD to MASLD: Similar prognosis of patients with HCC under atezolizumab/bevacizumab treatment between NAFLD and MASLD. Clin Mol Hepatol 2024;30:263-265.
- 6. Suzuki H, Tanaka T, Yamaguchi S, Miwa K, Kawaguchi T. Changing from NAFLD to MASLD: Similar prognosis of unresectable extrahepatic gastrointestinal cancer under chemotherapy between NAFLD and MASLD. J Hepatol 2024;80:e150-e151.
- 7. Hagström H, Vessby J, Ekstedt M, Shang Y. 99% of patients with NAFLD meet MASLD criteria and natural history is therefore identical. J Hepatol 2024;80:e76-e77.
- 8. Nishimura K, Okamura T, Watanabe M, Nakai M, Takegami M, Higashiyama A, et al. Predicting coronary heart disease using risk factor categories for a Japanese urban population, and comparison with the framingham risk score: the suita study. J Atheroscler Thromb 2014;21:784-798.
- 9. D’Agostino RB Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008;117:743-753.
- 10. Lee HH, Lee HA, Kim EJ, Kim HY, Kim HC, Ahn SH, et al. Metabolic dysfunction-associated steatotic liver disease and risk of cardiovascular disease. Gut 2024;73:533-540.
Citations
Citations to this article as recorded by
- Serum Desmosterol Level Reflects Hepatic Inflammation Grade in Patients with Biopsy-Confirmed Metabolic Dysfunction-Associated Steatotic Liver Disease
Takashi Omatsu, Masahiro Koseki, Kaori Ito, Ayami Saga, Hiroshi Sawabe, Katsunao Tanaka, Hiroyasu Inui, Takeshi Okada, Makoto Nishida, Hirokazu Takahashi, Shinichi Aishima, Yoshihiro Kamada, Hiroshi Yoshida, Yasushi Sakata
Journal of Atherosclerosis and Thrombosis.2026; 33(1): 29. CrossRef - Assessing Nutritional Factors for Metabolic Dysfunction-Associated Steatotic Liver Disease via Diverse Statistical Tools
Yea-Chan Lee, Hye Sun Lee, Soyoung Jeon, Yae-Ji Lee, Yu-Jin Kwon, Ji-Won Lee
Diabetes & Metabolism Journal.2026; 50(1): 178. CrossRef - Reduced skeletal muscle mass and elevated phase angle are linked to metabolic dysfunction-associated steatotic liver disease in Japanese males
Satoko Tajirika, Takao Miwa, Masahito Shimizu, Mayumi Yamamoto
Nutrition.2026; 146: 113118. CrossRef - Burden and Health System Challenges in MASLD Across East and Southeast Asia: A Narrative Review
Jonathan Jaime G. Guerrero, Paolo C. Encarnacion, Wan‐Yu Wang, Shu‐Fen Liao, Ching‐Wen Chang
Health Science Reports.2026;[Epub] CrossRef - Metabolic dysfunction-associated steatotic liver disease and risk of four intrahepatic and extrahepatic diseases
Yiyuan Xiao, Sihua Xu, Wenyan Hu, Jiapeng Huang, Deke Jiang, Rong Na, Zhaoqing Yin, Jingjing Zhang, Haitao Chen
Annals of Hepatology.2025; 30(1): 101750. CrossRef - Role of noninvasive tests in the prognostication of metabolic dysfunction-associated steatotic liver disease
Yue Wang, Sherlot Juan Song, Yichong Jiang, Jimmy Che-To Lai, Grace Lai-Hung Wong, Vincent Wai-Sun Wong, Terry Cheuk-Fung Yip
Clinical and Molecular Hepatology.2025; 31(Suppl): S51. CrossRef - Pathogenic Mechanisms of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-Associated Hepatocellular Carcinoma
Toru Nakamura, Atsutaka Masuda, Dan Nakano, Keisuke Amano, Tomoya Sano, Masahito Nakano, Takumi Kawaguchi
Cells.2025; 14(6): 428. CrossRef - C-C motif chemokines ligand 7 contributes to metabolic dysfunction-associated steatotic liver disease by enabling redox-sensitive induction of hypermethylated in cancer 1
Xinyue Sun, Jinge Wu, Huiqian Lv, Ben Wang, Xuelian Chen, Wenjing Ren, Xiulian Miao, Yan Guo, Xiaocen Kong, Huihui Xu, Zeqing Bao, Yong Xu, Zilong Li
Metabolism.2025; 168: 156242. CrossRef - Pemafibrate Reduced Liver Stiffness in Patients with Metabolic Dysfunction-associated Steatotic Liver Disease Complicated with Hyperlipidemia and Liver Fibrosis with a Fibrosis-4 Index Above 1.3
Tatsuki Ichikawa, Mio Yamashima, Shinobu Yamamichi, Makiko Koike, Yusuke Nakano, Hiroyuki Yajima, Osamu Miyazaki, Tomonari Ikeda, Takuma Okamura, Naohiro Komatsu, Sayuri Sugio, Miruki Yoshino, Hisamitsu Miyaaki
Internal Medicine.2025; 64(9): 1296. CrossRef - All-cause and disease-specific mortality in young adults with MASLD: A nationwide cohort study
Jeayeon Park, Goh Eun Chung, Su Jong Yu, Yoon Jun Kim, Jung-Hwan Yoon, Kyungdo Han, Eun Ju Cho
JHEP Reports.2025; 7(9): 101477. CrossRef - Evolving Public Attention to Steatotic Liver Disease: A 20‐Year Analysis (2004–2024)
Pojsakorn Danpanichkul, Charat Thongprayoon, Kanokphong Suparan, Donghee Kim, Ornpailin Wanichthanaolan, Phuuwadith Wattanachayakul, Yanfang Pang, Mark D. Muthiah, Anand V. Kulkarni, Ju Dong Yang, Apichat Kaewdech, Wisit Cheungpasitporn, Karn Wijarnpreech
Journal of Gastroenterology and Hepatology.2025; 40(8): 2053. CrossRef - Impact of Continuous Nutritional Counseling on Liver Function and Body Composition in Patients with MASLD/MASH
Shiho Asai, Naoto Kawabe, Akemi Ito, Teiji Kuzuya, Eizaburo Ohno, Takuji Nakano, Kazunori Nakaoka, Hiroyuki Tanaka, Yuka Ochi, Sayuri Miyaji, Sayaka Morisaki, Yoshiki Hirooka
Kanzo.2025; 66(6): 222. CrossRef - Temporal Trends in Cardiovascular Mortality in Underlying Viral Hepatitis: A Retrospective Analysis of Gender, Racial/Ethnic, and Regional Disparities
Wania Sultan, Haider Ashfaq, Hamza Ashraf, Ahmad Khan, Ayman Omair Hashmi, Muhammad Omar Larik, Maheen Zahid, Yasir Majeed, Pratik Bhattarai, Ashujot K. Dang, Ahmed Ali Aziz, Hafiz Muhammad Sharjeel Arshad
JGH Open.2025;[Epub] CrossRef -
Phocaeicola dorei
ameliorates progression of steatotic liver disease by regulating bile acid, lipid, inflammation and proliferation
Jieun Choi, Ye Rin Choi, Min Kyo Jeong, Hyun Ho Song, Jeong Seok Yu, Seol Hui Song, Jeong Ha Park, Min Ju Kim, Hyunjoon Park, Young Lim Ham, Sang Hak Han, Dong Joon Kim, Do Yup Lee, Ki Tae Suk
Gut Microbes.2025;[Epub] CrossRef - Usefulness of health checkup‐based indices in identifying metabolic dysfunction‐associated steatotic liver disease
Takao Miwa, Satoko Tajirika, Nanako Imamura, Miho Adachi, Ryo Horita, Tatsunori Hanai, Cheng Han Ng, Mohammad Shadab Siddiqui, Taku Fukao, Masahito Shimizu, Mayumi Yamamoto
JGH Open.2024;[Epub] CrossRef - Association between nonalcholic fatty liver disease and pancreatic cancer: Epidemiology, mechanisms, and antidiabetic medication
Takahiko Sakaue, Hiroya Terabe, Hidetoshi Takedatsu, Takumi Kawaguchi
Hepatology Research.2024; 54(8): 729. CrossRef - Equivalent prevalence and progression of chronic kidney disease in non-alcoholic fatty liver disease and metabolic dysfunction-associated steatotic liver disease
Hiroyuki Suzuki, Tsubasa Tsutsumi, Machiko Kawaguchi, Keisuke Amano, Takumi Kawaguchi
Clinical and Molecular Hepatology.2024; 30(4): 962. CrossRef
