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Letter to the Editor

What is new in the 2024 Chinese guidelines for fatty liver disease?

Rui-Xu Yang1, Vincent Wai-Sun Wong2,3, Jian-Gao Fan1,4orcid
Clinical and Molecular Hepatology 2025;31(3):e239-e246.
Published online: January 21, 2025

1Center for Fatty Liver, Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China

2Medical Data Analytics Center, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China

3State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China

4Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Shanghai, China

Corresponding author : Jian-Gao Fan Center for Fatty Liver, Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, 1665 Kongjiang Road, Yangpu District, Shanghai 200092, China Tel: +86-21-25077340, E-mail: fanjiangao@xinhuamed.com.cn

Editor: Won Kim, Seoul National University College of Medicine, Korea

• Received: December 27, 2024   • Revised: January 13, 2025   • Accepted: January 18, 2025

Copyright © 2025 by The Korean Association for the Study of the Liver

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Dear Editor,
Together with the global epidemic of obesity and type 2 diabetes mellitus (T2DM), metabolic dysfunction-associated fatty liver disease (MAFLD) has become the most common chronic liver disease, affecting over 30% of the global population [1,2]. In terms of geographical regions worldwide, there are the highest incidence and the largest increase in the prevalence of MAFLD over the past two decades in China [3]. In response, the Chinese Society of Hepatology, Chinese Medical Association has recently updated the guideline for the prevention and treatment of MAFLD (version 2024) [4]. The purpose of this commentary is to highlight the new recommendations (Table 1) as well as the similarities and differences between the new Chinese guideline and other regional guidelines (Table 2)
There has been a debate on the nomenclature, definition, and classification of fatty liver disease in the past few years. In 2023, a multi-society consensus recommended the use of steatotic liver disease as the overarching term, while metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) would replace the old term nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) [5]. The Chinese guideline highlights that the Chinese translation of MAFLD and MASLD is identical and considers the two terms interchangeable. The diagnostic criteria of MAFLD/MASH, and the classifications of secondary, mixed etiology and cryptogenic fatty liver disease are largely similar between the Chinese guideline and international consensus. Subtle differences in the diagnostic criteria and overlap with other liver disease by various guidelines and consensuses are listed in Table 2. In patients with alcohol-related liver disease or secondary fatty liver, we suggest that the diagnosis of MAFLD should be based on the presence of T2DM, obesity or metabolic syndrome instead of one single cardiometabolic risk factor. This is because excessive alcohol consumption and some secondary causes (e.g., systemic corticosteroids) are known to cause high blood pressure, glucose, and lipids. Our view is similar to that of the Expert Panel on Alcoholrelated Liver Disease, which cautioned against the reliance of a single cardiometabolic risk factor to diagnose MASLD in this context [6].
One important new development in the MASLD nomenclature was the introduction of an entity titled MASLD with increased alcohol intake (MetALD) for men and women who consume 30–60 g and 20–50 g of alcohol per day, respectively [5]. Regardless of the severity of metabolic dysfunction, patients with alcohol consumption exceeding the above thresholds are classified as alcohol-related liver disease (ALD). In principle, the Chinese guideline considers it important that clinicians recognize that over-nutrition related metabolic dysfunction and harmful alcohol use can contribute to liver injury at the same time. One potential limitation of the MetALD-ALD distinction is that the contribution of cardiometabolic risk factors to the progression of ALD is downplayed. Therefore, instead of adopting the term MetALD, the Chinese guideline allows MAFLD to coexist with ALD for the following reasons: (1) Moderate alcohol consumption is known to increase serum triglycerides and blood pressure, independently of insulin resistance [7]. (2) In patients with heavy drinking and obesity/sarcopenic obesity or T2DM or metabolic syndrome, the term ALD ignores the contribution of metabolic factors to liver injury. (3) The quantification of alcohol consumption in routine clinical practice is inaccurate [8]. (4) Alcohol consumption can be dynamic, and a classification based on current alcohol consumption may result in changing disease labels over time, which could be confusing for both clinicians and patients [9]. The implementation of the classification of MetALD would require a consensus on the period of alcohol assessment and how to handle historical heavy drinking.
On top of metabolic dysfunction-associated simple fatty liver, MASH and metabolic dysfunction-associated cirrhosis, the Chinese guideline introduced the concept of metabolic dysfunction-associated liver fibrosis, defined by histological and noninvasive test evidence of significant or advanced fibrosis, regardless of the presence of elevated liver enzymes or MASH [4]. Similar to the American and multi-society European guidelines [10,11], the Chinese guideline recommends the use of Fibrosis-4 index (FIB-4) and liver stiffness measurement by transient elastography to assess clinical staging of MAFLD based on their availability and proven diagnostic and prognostic performance [12]. The FIB-4 cutoff of 1.3 is the threshold to trigger transient elastography or other fibrosis assessment, and it is recognized that a cutoff of 2.0 would yield fewer false-positive results in patients older than 65 years [13,14]. The Chinese guideline also recognizes the role of the FibroScan-aspartate aminotransferase score to detect “at-risk” MASH [15].
Both the Chinese and Western guidelines emphasize the multisystem nature of MAFLD, and the central role of weight reduction and glycemic control in the management of MAFLD. The Chinese guideline also covered the role of lipid lowering drugs, antihypertensives, antiplatelet drugs, and treatment of clinically significant portal hypertension in patients with the corresponding indications. Resmetirom, a thyroid hormone receptor-β agonist, achieved both MASH resolution and fibrosis improvement in the phase 3 MAESTRO-NASH study [16], and became the first approved drug by the US Food and Drug Administration for the treatment of MASH with F2-F3 fibrosis. Because resmetirom is yet to become available in China, the Chinese guideline recommends patients with “at-risk” MASH to consider hepatoprotectants such as silymarin or participate in clinical trials. The Chinese guideline highlights the importance of a multidisciplinary approach in the management of MAFLD, suggests the preferential use of cardiometabolic drugs benefit multiple organs including cardiovascular-kidney-liver diseases [17], and discusses the indications and precautions of metabolic surgery and liver transplantation.
In terms of treatment monitoring, the Chinese guideline emphasizes that the target should be an improvement in general health, with improvements in not only major adverse liver outcomes but also cardiovascular-kidney-metabolic diseases, and reduced risk for extrahepatic cancers. This should be accompanied by improvements in patient reported outcomes and health-related quality of life. The assessment should encompass lifestyle evaluation, anthropometric measurements, biochemical assays for liver-kidney-metabolic parameters, and noninvasive tests of hepatic steatosis and fibrosis. If a patient has over 5% weight reduction but no improvement in insulin sensitivity and other cardiometabolic parameters during follow-up, clinicians should consider the possibilities of sarcopenia, worsened glycemic control, thyrotoxicosis, and other catabolic conditions. In particular, sarcopenia is a well-recognized feature in patients with cirrhosis and is associated with increased mortality [18]. In patients with MASH, low body weight is associated with lower survival after liver transplantation [19]. In contrast, if a patient has weight reduction and improved cardiometabolic profile but there is no improvement in liver enzymes, concomitant liver insults such as underreported alcohol consumption, autoimmune liver diseases and hereditary liver diseases should be considered. Additionally, liver enzymes and hepatic steatosis can decrease in patients progressing to cirrhosis. Therefore, it is imperative to follow patients with noninvasive tests of liver fibrosis.
While international guidelines recommend surveillance for hepatocellular carcinoma (HCC) only in patients with cirrhosis or chronic hepatitis B infection together with highrisk features [20,21], the Chinese guidelines recommend HCC surveillance in patients with MAFLD and advanced fibrosis. As highlighted in the Baveno consensus, it is sometimes difficult to distinguish between advanced fibrosis and cirrhosis by noninvasive tests or even histology [22]. That is why the term compensated advanced chronic liver disease was introduced to highlight that it was a continuum. In the prospective NASH Clinical Research Network cohort, patients with advanced fibrosis did not have lower incidence of HCC than those with cirrhosis [23]. Additionally, abdominal ultrasonography and follow-up imaging such as computed tomography or magnetic resonance imaging can be performed at low costs in China, thus making a case for more liberal surveillance.
Finally, the Chinese guideline adopts local definitions of overweight, obesity, and central obesity based on ethnicspecific cutoffs for body mass index and waist circumference, and recommends the modified criteria of metabolic syndrome components (Table 2). Given that a significant proportion of MASH-related HCC can arise before the development of cirrhosis [24], liver cancer surveillance may be considered in patients with advanced fibrosis, especially as abdominal ultrasonography is relatively inexpensive and wide available in China.

Authors’ contributions

Rui-Xu Yang and Vincent Wai-Sun Wong drafted the manuscript. Jian-Gao Fan reviewed and finalized the manuscript.

Acknowledgements

This work was supported by Noncommunicable Chronic Disease-National Science and Technology Major Project of China (No: 2023ZD0508700).

Conflicts of Interest

The authors have no conflicts to disclose.

Table 1.
Recommendations of the Chinese guidelines for MAFLD (2024 version)
Table 1.
Epidemiology, natural history, and screen
 1 MAFLD is the most common chronic progressive liver disease in China and should be a priority in screening and prevention efforts (B, 1).
 2 High-risk populations, such as individuals with obesity (BMI ≥28 kg/m2), T2DM, MetS (≥3 cardiometabolic risk factors), or elevated serum aminotransferases without symptoms, should be screened for MAFLD and liver fibrosis (B, 1).
 3 Patients with MAFLD should be screened and monitored for liver fibrosis (B, 1).
 4 MAFLD patients with advanced fibrosis should be screened for HCC, and if cirrhosis is diagnosed, screening for esophageal varices and hepatic decompensation events should also be performed (B, 1).
 5 Patients with MAFLD should be screened and monitored for MetS components and T2DM using fasting plasma glucose, hemoglobin A1c, and oral glucose tolerance tests, if necessary (B, 1).
 6 Patients with MAFLD should be screened for CKD using estimated glomerular filtration rate and/or urine albumin, and the 10-year and lifetime CVD risk assessment model should be used to evaluate CVD risk in Chinese adults (B, 1).
 7 MAFLD patients should adhere to age- and gender-stratified screening for common malignancies (C, 1).
Diagnosis and evaluation of the disease severity
 8 The diagnosis of MAFLD should meet the following three criteria: (1) Imaging techniques and/or liver biopsy confirming hepatic steatosis; (2) Presence of one or more components of MetS; (3) Exclusion of other potential etiologies of hepatic steatosis (B, 1).
 9 In patients with ALD and/or fatty liver caused by other specific etiologies, the presence of obesity and/or T2DM, MetS should be considered as a potential coexistence of MAFLD (C, 1).
 10 MAFLD can often coexist with other liver diseases, such as chronic hepatitis B infection (B, 1).
 11 Ultrasonography is the preferred imaging technique for diagnosing hepatic steatosis and for screening and monitoring HCC (B, 1).
 12 Transient elastography cut-off values of CAP/UAP (248/244 dB/m, 268/269 dB/m, and 280/296 dB/m for diagnosis of steatosis degree as ≥S1, ≥S2, and S3, respectively) and LSM (8 kPa to rule out and 12 kPa to rule in advanced fibrosis) can be used for non-invasive assessments of hepatic steatosis and advanced fibrosis (B, 1).
 13 MRI-PDFF can accurately assess hepatic fat content and its changes in some clinical trials of MAFLD (B, 1).
 14 The FIB-4 score can serve as an initial tool to evaluate the risk of advanced fibrosis in MAFLD patients and high-risk populations. Individuals with FIB-4 ≥1.3 should undergo LSM by transient elastography for further risk stratification of fibrosis (B, 1).
 15 MAFLD patients with FIB-4 ≥1.3 and LSM ≥8 kPa should undergo further diagnosis and assessment by hepatologists (B, 1).
 16 MAFLD patients with inconsistent NIT results for fibrosis assessment and/or persistent elevation of serum aminotransferases should undergo further diagnosis and assessment by hepatologists (C, 1).
 17 Indications for liver biopsy in suspected MAFLD patients include: the need for accurate assessment of MASH and fibrosis in clinical trials; differential diagnosis or identification of primary etiology when two or more liver injury factors coexist; uncertain or inconsistent results from NITs for advanced fibrosis; bariatric surgery; and atypical presentations, such as moderate to severe elevation of transaminases or persistent abnormal transaminases after weight loss (B, 1).
 18 Liver biopsy specimens require hematoxylin-eosin staining, as well as Sirius red or Masson’s trichrome staining. Pathological results should be described using standardized scoring systems, such as the SAF and NAFLD Activity Score (C, 1).
 19 The diagnosis of MASH should be based on the following two criteria: (1) Meeting clinical diagnostic criteria for MAFLD; (2) Presence of ≥5% macrovesicular steatosis with hepatocyte ballooning and lobular inflammation and/or portal inflammation (C, 1).
 20 The diagnosis of metabolic dysfunction-associated liver fibrosis may be based on the following three criteria: (1) Liver biopsy-proven significant fibrosis (F2 and F3) and/or NITs diagnosing advanced fibrosis (F3 and F4); (2) Presence of one or more components of MetS; (3) Exclusion of other potential etiologies of liver fibrosis (C, 1).
 21 The diagnosis of metabolic dysfunction-associated cirrhosis/MAFLD-related cirrhosis may be based on the following three criteria: (1) Liver biopsy and/or NITs proven cirrhosis; (2) Past or present history of MAFLD; (3) Exclusion of other potential etiologies of liver cirrhosis (C, 1).
 22 For MAFLD patients with cirrhosis, endoscopic screening for esophageal varices can be determined based on platelet count and LSM obtained through transient elastography (C, 1).
Treatment metabolic dysfunction and liver disease, and prevent major adverse outcomes
 23 Patients with MAFLD require health education to promote lifestyle modifications. Structured dietary and exercise programs are the cornerstones of MAFLD treatment (B, 1).
 24 For MAFLD patients who are overweight or obese, a weight reduction of at least 5% to 10% is crucial for treating metabolic disorders and liver disease. For patients with a normal BMI, a weight loss of 3% to 5% is sufficient (B, 1).
 25 Patients with MAFLD should adhere to energy-deficit dietary therapy, limiting the intake of ultra-processed foods, high-saturated-fat foods, and high-sugar/fructose foods or beverages, while increasing consumption of high-fiber foods such as vegetables, whole grains, and foods rich in unsaturated fatty acids (C, 1).
 26 Patients with MAFLD should engage in physical activity, aiming for moderate-intensity aerobic exercise for at least 150 mins per week and/or high-intensity interval training for three to five days per week over a period of more than three months (B, 1).
 27 Patients with MAFLD should avoid unhealthy behaviors such as irregular eating, soft drink consumption, smoking, alcohol intake, and a sedentary lifestyle (C, 1).
 28 Coexisting conditions in MAFLD patients, such as obesity, T2DM, dyslipidemia, hypertension, and CVD, should be managed in a standardized manner by appropriate specialists or general practitioners (C, 1).
 29 MAFLD patients with a BMI ≥28 kg/m2 may consider using weight loss medications, with a priority on incretin-based therapies for those with coexisting T2DM (B, 1).
 30 For T2DM management in MAFLD patients, priority should be given to drugs with potential hepatic benefits, such as incretin-based therapies, SGLT-2 inhibitors, pioglitazone, and metformin (B, 1).
 31 In patients with compensated MAFLD, statins are the preferred treatment for atherosclerotic dyslipidemia. However, statins should be discontinued in patients with decompensated cirrhosis or ACLF (C, 1).
 32 For managing hypertension in MAFLD patients, the preferred medications are ACEIs or ARBs. In cases of clinically significant portal hypertension, non-selective beta-blockers can be used alone or in combination with ACEIs or ARBs (C, 1).
 33 MAFLD patients with biopsyproven MASH and fibrosis, or NITs indicating suspected liver inflammation and/or fibrosis, can be treated with long-term liver injury therapeutic agents or be encouraged to participate in clinical trials (C, 1).
 34 Non-cirrhotic MAFLD patients who meet the criteria for bariatric surgery may consider undergoing the surgery for the treatment of MASH and fibrosis (C, 2).
 35 Patients with MAFLD-related decompensated cirrhosis, ACLF, or HCC should consider liver transplantation (B, 1).
 36 MAFLD patients with advanced fibrosis and cirrhosis should strengthen management of body weight and plasma glucose levels. Medications such as statins, metformin, aspirin, and strategies for smoking cessation and alcohol abstinence may help reduce the risk of HCC (C, 1).
Follow-up and treatment monitoring
 37 Follow-up indicators for MAFLD patients include assessing lifestyle changes, body weight, regular monitoring of blood pressure, blood biochemical indexes, hepatic steatosis degree, fibrosis stage, and extrahepatic comorbidities (C, 1).
 38 If serum biochemical indicators, such as aminotransferases, do not improve after weight loss in patients with MAFLD, further investigation and management of the etiology are necessary (C, 1).
 39 Histological resolution of steatohepatitis in MAFLD patients may be predicted by changes in non-invasive markers (e.g., serum ALT reduction by ≥17 U/L, MRI-PDFF relative reduction by ≥30%) in the context of RCTs and depending on the mode of intervention (C, 2).
 40 An increase in FIB-4 and LSM by transient elastography during follow-up in MAFLD patients usually indicates liver disease progression and an increased risk for liver-related events (B, 1).
 41 Treatment for other liver diseases coexisting with MAFLD should adhere to recommendations from relevant disease prevention and treatment guidelines (C, 1).
 42 Patients with MAFLD, regardless of whether they have concomitant ALD, must reduce alcohol consumption and strive for abstinence whenever possible (C, 1).

MAFLD, metabolic dysfunction-associated fatty liver disease; BMI, body mass index; T2DM, type 2 diabetes mellitus; MetS, metabolic syndrome; HCC, hepatocellular carcinoma; CKD, chronic kidney disease; CVD, cardiovascular disease; ALD, alcohol-related liver disease; CAP, controlled attenuation parameter; UAP, ultrasonic attenuation parameter; LSM, liver stiffness measurement; MRI-PDFF, magnetic resonance imaging proton density fat fraction; FIB-4, fibrosis 4 index; NIT, non-invasive test; MASH, metabolic dysfunctionassociated steatohepatitis; SGLT-2, sodium-glucose cotransporter 2; ACLF, acute-on-chronic liver failure; ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers.

Table 2.
The comparison between ‘NAFLD’, ‘2020 MAFLD’, ‘2023 MASLD’, and ‘2024 Chinese MAFLD’
Table 2.
NAFLD 2020 MAFLD 2023 MASLD 2024 Chinese MAFLD
Diagnostic logic Exclusionary criteria Positive diagnostic criteria Exclusionary plus positive criteria Coexistence of exclusive and positive diagnostic logic.
Diagnosis: Hepatic steatosis + exclude causes for secondary steatosis Diagnosis: Hepatic steatosis + metabolic dysfunction Diagnosis: Hepatic steatosis + metabolic dysfunction + exclude causes for secondary steatosis, that is NAFLD + metabolic dysfunction Diagnosis: Hepatic steatosis + metabolic dysfunction + exclude causes for secondary steatosis
Not allowing co-diagnosis with other etiologies of hepatic steatosis. Allowing co-diagnosis with other etiologies of hepatic steatosis. Allowing co-diagnosis with moderate drinking (MetALD) but not mention co-diagnosis with other etiologies of steatosis. Allowing co-diagnosis with other etiologies of hepatic steatosis if significant metabolic dysfunction exist (obesity/T2DM/≥3 MetS components).
Definition of hepatic steatosis Either by liver imaging or by histology Either by imaging, blood biomarkers/scores or by liver histology Either by liver imaging or histology Either by liver imaging or histology
Alcohol consumption Requires exclusion of excessive alcohol consumption or harmful alcohol use No need to exclude excessive alcohol intake The diagnosis of MASLD requires the exclusion of excessive alcohol consumption (20 g/day in women and >30 g/day in men). The diagnosis of MAFLD requires the exclusion of excessive alcohol consumption (≥210 g per week in men, ≥140 g per week in women).
Concomitant ALD and MAFLD in case of harmful drinking If alcohol consumption is 20–50 g/day in women and 30–60 g/day in men + 1 cardiometabolic criteria, the diagnosis is MetALD; if alcohol intake >50 g/day in women and >60 g/day in men regardless of cardiometabolic criteria, the diagnosis is ALD. If alcohol intake is ≥210 g /week in men and ≥140 g/week in women + obesity/T2DM/ MetS, the diagnosis is MAFLD + ALD
Secondary cause of steatosis Need exclusion of secondary causes No need to exclude secondary causes of steatosis and directly diagnosis MAFLD + other liver disease. Need exclusion of secondary causes of steatosis. Need exclusion of secondary steatosis and diagnosis MAFLD + other liver disease when secondary cause of steatosis coexist with obesity and/or T2DM, MetS.
Definition of metabolic dysfunction None Overweight/obesity, and/or T2DM, ≥2 metabolic abnormalities At least one of cardiometabolic criteria: At least one of the MetS components
Definition of metabolic abnormalities: Definition of cardiometabolic criteria: Definition of MetS components:
1. Waist circumference ≥102/88 cm in Caucasian men and women (or ≥90/80 cm in Asian men and women). 1. BMI ≥25 kg/m2 (≥23 kg/m2 in people of Asian); Waist circumference ≥94 cm in men and ≥80 cm in women (Europeans); ≥90 cm in men and ≥80 cm in women (South Asians and Chinese); ≥85 cm in men and ≥90 cm in women (Japanese). 1. BMI ≥24.0 kg/m2, or waist circumference ≥90 cm (male)/85 cm (female), or excessive body fat content and percentage.
2. Blood pressure ≥130/85 mmHg or specific drug treatment.
3. Plasma triglycerides ≥1.70 mmol/l or specific drug treatment. 2. Prediabetes: HbA1c 5.7–6.4% or fasting plasma glucose 5.6–6.9 mmol/L or 2-h plasma glucose during OGTT 7.8–11 mmol/L or T2DM: HbA1c ≥6.5% or fasting plasma glucose ≥7.0 mmol/L or 2-h plasma glucose during OGTT ≥11.1 mmol/L or treatment for T2DM. 2. Blood pressure ≥130/85 mmHg, or undergoing antihypertensive medication therapy.
4. Plasma HDL-cholesterol <1.0 mmol/L for men and <1.3 mmol/L for women or specific drug treatment. 3. Fasting plasma glucose ≥6.1 mmol/L, or 2-hour postprandial plasma glucose ≥7.8 mmol/L, or HbA1c ≥5.7%, or history of T2DM, or HOMA-IR ≥2.5.
5. Prediabetes (fasting glucose levels 5.6 to 6.9 mmol/L, or 2-hour post-load glucose levels 7.8 to 11.0 mmol or HbA1c 5.7% to 6.4%. 3. Plasma triglycerides ≥1.7 mmol/L or lipidlowering treatment. 4. Plasma triglycerides ≥1.70 mmol/L, or undergoing lipid-lowering medication therapy.
6. HOMA-IR ≥2.5. 4. HDL-cholesterol ≤1.0 mmol/L in men and ≤1.3 mmol/L in women or lipid-lowering treatment. 5. Plasma HDL-cholesterol ≤1.0 mmol/L (male)/1.3 mmol/L (female), or undergoing lipid-lowering medication therapy.
7. Plasma high-sensitivity C-reactive protein level >2 mg/L. 5. Blood pressure ≥130/85 mmHg or treatment for hypertension.

MAFLD, metabolic dysfunction-associated fatty liver disease; MASLD, metabolic dysfunction-associated steatotic liver disease, ALD, alcohol-related liver disease; MetALD, metabolic dysfunction-associated and alcohol-related liver disease; BMI, body mass index; T2DM, type 2 diabetes mellitus; MetS, metabolic syndrome; HOMA-IR, homeostasis model assessment insulin resistance score; HD, high density lipoprotein; OGTT, oral glucose tolerance test; HbA1c, hemoglobin A1c.

ALD

alcohol-related liver disease

FIB-4

Fibrosis-4 index

HCC

hepatocellular carcinoma

MAFLD

metabolic dysfunction-associated fatty liver disease

MASH

metabolic dysfunction-associated steatohepatitis

MASLD

metabolic dysfunction-associated steatotic liver disease

NAFLD

nonalcoholic fatty liver disease

NASH

nonalcoholic steatohepatitis

T2DM

type 2 diabetes mellitus
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What is new in the 2024 Chinese guidelines for fatty liver disease?
Clin Mol Hepatol. 2025;31(3):e239-e246.   Published online January 21, 2025
DOI: https://doi.org/10.3350/cmh.2024.1165
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What is new in the 2024 Chinese guidelines for fatty liver disease?
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DOI: https://doi.org/10.3350/cmh.2024.1165
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What is new in the 2024 Chinese guidelines for fatty liver disease?
What is new in the 2024 Chinese guidelines for fatty liver disease?
Epidemiology, natural history, and screen
 1 MAFLD is the most common chronic progressive liver disease in China and should be a priority in screening and prevention efforts (B, 1).
 2 High-risk populations, such as individuals with obesity (BMI ≥28 kg/m2), T2DM, MetS (≥3 cardiometabolic risk factors), or elevated serum aminotransferases without symptoms, should be screened for MAFLD and liver fibrosis (B, 1).
 3 Patients with MAFLD should be screened and monitored for liver fibrosis (B, 1).
 4 MAFLD patients with advanced fibrosis should be screened for HCC, and if cirrhosis is diagnosed, screening for esophageal varices and hepatic decompensation events should also be performed (B, 1).
 5 Patients with MAFLD should be screened and monitored for MetS components and T2DM using fasting plasma glucose, hemoglobin A1c, and oral glucose tolerance tests, if necessary (B, 1).
 6 Patients with MAFLD should be screened for CKD using estimated glomerular filtration rate and/or urine albumin, and the 10-year and lifetime CVD risk assessment model should be used to evaluate CVD risk in Chinese adults (B, 1).
 7 MAFLD patients should adhere to age- and gender-stratified screening for common malignancies (C, 1).
Diagnosis and evaluation of the disease severity
 8 The diagnosis of MAFLD should meet the following three criteria: (1) Imaging techniques and/or liver biopsy confirming hepatic steatosis; (2) Presence of one or more components of MetS; (3) Exclusion of other potential etiologies of hepatic steatosis (B, 1).
 9 In patients with ALD and/or fatty liver caused by other specific etiologies, the presence of obesity and/or T2DM, MetS should be considered as a potential coexistence of MAFLD (C, 1).
 10 MAFLD can often coexist with other liver diseases, such as chronic hepatitis B infection (B, 1).
 11 Ultrasonography is the preferred imaging technique for diagnosing hepatic steatosis and for screening and monitoring HCC (B, 1).
 12 Transient elastography cut-off values of CAP/UAP (248/244 dB/m, 268/269 dB/m, and 280/296 dB/m for diagnosis of steatosis degree as ≥S1, ≥S2, and S3, respectively) and LSM (8 kPa to rule out and 12 kPa to rule in advanced fibrosis) can be used for non-invasive assessments of hepatic steatosis and advanced fibrosis (B, 1).
 13 MRI-PDFF can accurately assess hepatic fat content and its changes in some clinical trials of MAFLD (B, 1).
 14 The FIB-4 score can serve as an initial tool to evaluate the risk of advanced fibrosis in MAFLD patients and high-risk populations. Individuals with FIB-4 ≥1.3 should undergo LSM by transient elastography for further risk stratification of fibrosis (B, 1).
 15 MAFLD patients with FIB-4 ≥1.3 and LSM ≥8 kPa should undergo further diagnosis and assessment by hepatologists (B, 1).
 16 MAFLD patients with inconsistent NIT results for fibrosis assessment and/or persistent elevation of serum aminotransferases should undergo further diagnosis and assessment by hepatologists (C, 1).
 17 Indications for liver biopsy in suspected MAFLD patients include: the need for accurate assessment of MASH and fibrosis in clinical trials; differential diagnosis or identification of primary etiology when two or more liver injury factors coexist; uncertain or inconsistent results from NITs for advanced fibrosis; bariatric surgery; and atypical presentations, such as moderate to severe elevation of transaminases or persistent abnormal transaminases after weight loss (B, 1).
 18 Liver biopsy specimens require hematoxylin-eosin staining, as well as Sirius red or Masson’s trichrome staining. Pathological results should be described using standardized scoring systems, such as the SAF and NAFLD Activity Score (C, 1).
 19 The diagnosis of MASH should be based on the following two criteria: (1) Meeting clinical diagnostic criteria for MAFLD; (2) Presence of ≥5% macrovesicular steatosis with hepatocyte ballooning and lobular inflammation and/or portal inflammation (C, 1).
 20 The diagnosis of metabolic dysfunction-associated liver fibrosis may be based on the following three criteria: (1) Liver biopsy-proven significant fibrosis (F2 and F3) and/or NITs diagnosing advanced fibrosis (F3 and F4); (2) Presence of one or more components of MetS; (3) Exclusion of other potential etiologies of liver fibrosis (C, 1).
 21 The diagnosis of metabolic dysfunction-associated cirrhosis/MAFLD-related cirrhosis may be based on the following three criteria: (1) Liver biopsy and/or NITs proven cirrhosis; (2) Past or present history of MAFLD; (3) Exclusion of other potential etiologies of liver cirrhosis (C, 1).
 22 For MAFLD patients with cirrhosis, endoscopic screening for esophageal varices can be determined based on platelet count and LSM obtained through transient elastography (C, 1).
Treatment metabolic dysfunction and liver disease, and prevent major adverse outcomes
 23 Patients with MAFLD require health education to promote lifestyle modifications. Structured dietary and exercise programs are the cornerstones of MAFLD treatment (B, 1).
 24 For MAFLD patients who are overweight or obese, a weight reduction of at least 5% to 10% is crucial for treating metabolic disorders and liver disease. For patients with a normal BMI, a weight loss of 3% to 5% is sufficient (B, 1).
 25 Patients with MAFLD should adhere to energy-deficit dietary therapy, limiting the intake of ultra-processed foods, high-saturated-fat foods, and high-sugar/fructose foods or beverages, while increasing consumption of high-fiber foods such as vegetables, whole grains, and foods rich in unsaturated fatty acids (C, 1).
 26 Patients with MAFLD should engage in physical activity, aiming for moderate-intensity aerobic exercise for at least 150 mins per week and/or high-intensity interval training for three to five days per week over a period of more than three months (B, 1).
 27 Patients with MAFLD should avoid unhealthy behaviors such as irregular eating, soft drink consumption, smoking, alcohol intake, and a sedentary lifestyle (C, 1).
 28 Coexisting conditions in MAFLD patients, such as obesity, T2DM, dyslipidemia, hypertension, and CVD, should be managed in a standardized manner by appropriate specialists or general practitioners (C, 1).
 29 MAFLD patients with a BMI ≥28 kg/m2 may consider using weight loss medications, with a priority on incretin-based therapies for those with coexisting T2DM (B, 1).
 30 For T2DM management in MAFLD patients, priority should be given to drugs with potential hepatic benefits, such as incretin-based therapies, SGLT-2 inhibitors, pioglitazone, and metformin (B, 1).
 31 In patients with compensated MAFLD, statins are the preferred treatment for atherosclerotic dyslipidemia. However, statins should be discontinued in patients with decompensated cirrhosis or ACLF (C, 1).
 32 For managing hypertension in MAFLD patients, the preferred medications are ACEIs or ARBs. In cases of clinically significant portal hypertension, non-selective beta-blockers can be used alone or in combination with ACEIs or ARBs (C, 1).
 33 MAFLD patients with biopsyproven MASH and fibrosis, or NITs indicating suspected liver inflammation and/or fibrosis, can be treated with long-term liver injury therapeutic agents or be encouraged to participate in clinical trials (C, 1).
 34 Non-cirrhotic MAFLD patients who meet the criteria for bariatric surgery may consider undergoing the surgery for the treatment of MASH and fibrosis (C, 2).
 35 Patients with MAFLD-related decompensated cirrhosis, ACLF, or HCC should consider liver transplantation (B, 1).
 36 MAFLD patients with advanced fibrosis and cirrhosis should strengthen management of body weight and plasma glucose levels. Medications such as statins, metformin, aspirin, and strategies for smoking cessation and alcohol abstinence may help reduce the risk of HCC (C, 1).
Follow-up and treatment monitoring
 37 Follow-up indicators for MAFLD patients include assessing lifestyle changes, body weight, regular monitoring of blood pressure, blood biochemical indexes, hepatic steatosis degree, fibrosis stage, and extrahepatic comorbidities (C, 1).
 38 If serum biochemical indicators, such as aminotransferases, do not improve after weight loss in patients with MAFLD, further investigation and management of the etiology are necessary (C, 1).
 39 Histological resolution of steatohepatitis in MAFLD patients may be predicted by changes in non-invasive markers (e.g., serum ALT reduction by ≥17 U/L, MRI-PDFF relative reduction by ≥30%) in the context of RCTs and depending on the mode of intervention (C, 2).
 40 An increase in FIB-4 and LSM by transient elastography during follow-up in MAFLD patients usually indicates liver disease progression and an increased risk for liver-related events (B, 1).
 41 Treatment for other liver diseases coexisting with MAFLD should adhere to recommendations from relevant disease prevention and treatment guidelines (C, 1).
 42 Patients with MAFLD, regardless of whether they have concomitant ALD, must reduce alcohol consumption and strive for abstinence whenever possible (C, 1).
NAFLD 2020 MAFLD 2023 MASLD 2024 Chinese MAFLD
Diagnostic logic Exclusionary criteria Positive diagnostic criteria Exclusionary plus positive criteria Coexistence of exclusive and positive diagnostic logic.
Diagnosis: Hepatic steatosis + exclude causes for secondary steatosis Diagnosis: Hepatic steatosis + metabolic dysfunction Diagnosis: Hepatic steatosis + metabolic dysfunction + exclude causes for secondary steatosis, that is NAFLD + metabolic dysfunction Diagnosis: Hepatic steatosis + metabolic dysfunction + exclude causes for secondary steatosis
Not allowing co-diagnosis with other etiologies of hepatic steatosis. Allowing co-diagnosis with other etiologies of hepatic steatosis. Allowing co-diagnosis with moderate drinking (MetALD) but not mention co-diagnosis with other etiologies of steatosis. Allowing co-diagnosis with other etiologies of hepatic steatosis if significant metabolic dysfunction exist (obesity/T2DM/≥3 MetS components).
Definition of hepatic steatosis Either by liver imaging or by histology Either by imaging, blood biomarkers/scores or by liver histology Either by liver imaging or histology Either by liver imaging or histology
Alcohol consumption Requires exclusion of excessive alcohol consumption or harmful alcohol use No need to exclude excessive alcohol intake The diagnosis of MASLD requires the exclusion of excessive alcohol consumption (20 g/day in women and >30 g/day in men). The diagnosis of MAFLD requires the exclusion of excessive alcohol consumption (≥210 g per week in men, ≥140 g per week in women).
Concomitant ALD and MAFLD in case of harmful drinking If alcohol consumption is 20–50 g/day in women and 30–60 g/day in men + 1 cardiometabolic criteria, the diagnosis is MetALD; if alcohol intake >50 g/day in women and >60 g/day in men regardless of cardiometabolic criteria, the diagnosis is ALD. If alcohol intake is ≥210 g /week in men and ≥140 g/week in women + obesity/T2DM/ MetS, the diagnosis is MAFLD + ALD
Secondary cause of steatosis Need exclusion of secondary causes No need to exclude secondary causes of steatosis and directly diagnosis MAFLD + other liver disease. Need exclusion of secondary causes of steatosis. Need exclusion of secondary steatosis and diagnosis MAFLD + other liver disease when secondary cause of steatosis coexist with obesity and/or T2DM, MetS.
Definition of metabolic dysfunction None Overweight/obesity, and/or T2DM, ≥2 metabolic abnormalities At least one of cardiometabolic criteria: At least one of the MetS components
Definition of metabolic abnormalities: Definition of cardiometabolic criteria: Definition of MetS components:
1. Waist circumference ≥102/88 cm in Caucasian men and women (or ≥90/80 cm in Asian men and women). 1. BMI ≥25 kg/m2 (≥23 kg/m2 in people of Asian); Waist circumference ≥94 cm in men and ≥80 cm in women (Europeans); ≥90 cm in men and ≥80 cm in women (South Asians and Chinese); ≥85 cm in men and ≥90 cm in women (Japanese). 1. BMI ≥24.0 kg/m2, or waist circumference ≥90 cm (male)/85 cm (female), or excessive body fat content and percentage.
2. Blood pressure ≥130/85 mmHg or specific drug treatment.
3. Plasma triglycerides ≥1.70 mmol/l or specific drug treatment. 2. Prediabetes: HbA1c 5.7–6.4% or fasting plasma glucose 5.6–6.9 mmol/L or 2-h plasma glucose during OGTT 7.8–11 mmol/L or T2DM: HbA1c ≥6.5% or fasting plasma glucose ≥7.0 mmol/L or 2-h plasma glucose during OGTT ≥11.1 mmol/L or treatment for T2DM. 2. Blood pressure ≥130/85 mmHg, or undergoing antihypertensive medication therapy.
4. Plasma HDL-cholesterol <1.0 mmol/L for men and <1.3 mmol/L for women or specific drug treatment. 3. Fasting plasma glucose ≥6.1 mmol/L, or 2-hour postprandial plasma glucose ≥7.8 mmol/L, or HbA1c ≥5.7%, or history of T2DM, or HOMA-IR ≥2.5.
5. Prediabetes (fasting glucose levels 5.6 to 6.9 mmol/L, or 2-hour post-load glucose levels 7.8 to 11.0 mmol or HbA1c 5.7% to 6.4%. 3. Plasma triglycerides ≥1.7 mmol/L or lipidlowering treatment. 4. Plasma triglycerides ≥1.70 mmol/L, or undergoing lipid-lowering medication therapy.
6. HOMA-IR ≥2.5. 4. HDL-cholesterol ≤1.0 mmol/L in men and ≤1.3 mmol/L in women or lipid-lowering treatment. 5. Plasma HDL-cholesterol ≤1.0 mmol/L (male)/1.3 mmol/L (female), or undergoing lipid-lowering medication therapy.
7. Plasma high-sensitivity C-reactive protein level >2 mg/L. 5. Blood pressure ≥130/85 mmHg or treatment for hypertension.
Table 1. Recommendations of the Chinese guidelines for MAFLD (2024 version)

MAFLD, metabolic dysfunction-associated fatty liver disease; BMI, body mass index; T2DM, type 2 diabetes mellitus; MetS, metabolic syndrome; HCC, hepatocellular carcinoma; CKD, chronic kidney disease; CVD, cardiovascular disease; ALD, alcohol-related liver disease; CAP, controlled attenuation parameter; UAP, ultrasonic attenuation parameter; LSM, liver stiffness measurement; MRI-PDFF, magnetic resonance imaging proton density fat fraction; FIB-4, fibrosis 4 index; NIT, non-invasive test; MASH, metabolic dysfunctionassociated steatohepatitis; SGLT-2, sodium-glucose cotransporter 2; ACLF, acute-on-chronic liver failure; ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers.

Table 2. The comparison between ‘NAFLD’, ‘2020 MAFLD’, ‘2023 MASLD’, and ‘2024 Chinese MAFLD’

MAFLD, metabolic dysfunction-associated fatty liver disease; MASLD, metabolic dysfunction-associated steatotic liver disease, ALD, alcohol-related liver disease; MetALD, metabolic dysfunction-associated and alcohol-related liver disease; BMI, body mass index; T2DM, type 2 diabetes mellitus; MetS, metabolic syndrome; HOMA-IR, homeostasis model assessment insulin resistance score; HD, high density lipoprotein; OGTT, oral glucose tolerance test; HbA1c, hemoglobin A1c.

Table 1.

Table 2.

CMH : Clinical and Molecular Hepatology
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