# Liver disease classifier

Use Case: This tool helps you classify if your patient has MASLD, MetALD or Alcoholic liver disease based on the clinical parameters and Alcohol intake

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Notes

Q. What is steatotic (fatty) liver disease and how has it evolved?

A. Steatotic liver disease refers to hepatic steatosis identified on radiologic imaging or by liver biopsy. The terminology has evolved:

• Initially described in 1980 as NAFLD by Ludwig et al
• In 2020, term MAFLD was proposed
• In 2023, global consensus led to new terminology:
  • NAFLD → MASLD
  • NASH → MASH
  • Term “fatty” replaced with “steatotic” to avoid stigma
  • New category MetALD introduced

Q. What is the global prevalence and risk factors?

A. Global prevalence and risk factors include:

• 33% global prevalence (25% in Western Europe to 44% in Latin America)
• Key risk factors:
  • 43% overweight
  • 16% obesity
  • 6% type 2 diabetes
  • 50% regular alcohol consumption
  • 25% carry PNPLA3 genetic risk alleles
  • Presence of cardiometabolic risk factors
  • Dyslipidemia
  • Metabolic syndrome

Q. How is steatotic liver disease classified?

A. Classification includes:

MASLD (Metabolic dysfunction-associated steatotic liver disease)

• Fatty liver (>5% hepatic steatosis)
• At least one cardiometabolic risk factor like dyslipidemia or obesity
• No other causes of steatotic liver disease
• Minimal alcohol consumption (<20g/day females, <30g/day males)
• Previously known as NAFLD

MASH (Metabolic dysfunction-associated steatohepatitis)

• Shows histologic inflammation
• Hepatocellular injury with ballooning
• With/without fibrosis
• Previously known as NASH

MASH cirrhosis

• Cirrhosis with current/previous MASH evidence
• Or history of MASLD

MetALD (Metabolic dysfunction- and alcohol-associated liver disease)

• Liver steatosis
• At least one metabolic risk factor
• Moderate alcohol use:
  • Females: 20-50g/day (140-350g/week)
  • Males: 30-60g/day (210-420g/week)

Key points:

1. Hepatic steatosis + CardioMetabolic risk factors (CMRF) = MASLD
2. MASLD + Moderate alcohol intake = MetALD
3. MASLD + Heavy alcohol intake = ALD
4. Hepatic Steatosis + Moderate to Heavy alcohol use - (minus) CMRF = ALD
5. Hepatic Steatosis - (minus) CMRF - (minus) Moderate to Heavy alcohol use = Other causes of Hepatic steatosis

Q. What are the criteria for alcohol consumption classification?

A. Alcohol consumption is classified as:

Minimal (for MASLD)

• Females: <20g daily
• Males: <30g daily

Moderate (for MetALD)

• Females: 20-50g daily (140-350g/week)
• Males: 30-60g daily (210-420g/week)

Heavy

• Females: >50g daily
• Males: >60g daily

A standard alcoholic beverage contains approximately 14g of pure alcohol.

Q. What is the natural history of steatotic liver disease?

A. Disease progression follows:

1. Natural course:

• Normal liver → Steatosis → Steatohepatitis → Progressive fibrosis → Cirrhosis

1. Complications:

• Hepatocellular carcinoma (highest risk in cirrhosis)
• Disease regression possible with metabolic improvement
• Faster progression with multiple risk factors

1. Special considerations:

• Steatosis may resolve with alcohol abstinence
• Features of steatosis/steatohepatitis may disappear in advanced cirrhosis
• Diagnosis possible without steatosis in advanced disease