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Rinella ME, Lazarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023;78(6):1966-1986. PMID 37363821

One-paragraph summary

Three large pan-national liver associations ran a modified Delphi process to decide whether "non-alcoholic fatty liver disease" should be replaced, and if so with what. 236 panellists from 56 countries participated across four online surveys (response rates 87%, 83%, 83%, 78%) and two hybrid meetings, with consensus set a priori at a 67% supermajority; an independent committee external to the process made the final decision on the acronym and its diagnostic criteria. 74% judged the existing nomenclature sufficiently flawed to consider a change; 61% found "nonalcoholic" stigmatising and 66% found "fatty" stigmatising. The outputs were: steatotic liver disease (SLD) as the umbrella term; retention of steatohepatitis as a pathophysiological concept; MASLD replacing NAFLD, now requiring at least one of five cardiometabolic criteria rather than the mere absence of alcohol and other causes; MetALD as a new named category for metabolic steatosis with intermediate alcohol intake (140–350 g/week in women, 210–420 g/week in men); and cryptogenic SLD for steatosis with no metabolic parameter and no known cause.

Key findings

  • 236 panellists, 56 countries, four survey rounds; consensus threshold 67%.
  • 74% considered the old nomenclature flawed enough to warrant change.
  • Stigma perceptions among panellists: "nonalcoholic" 61%, "fatty" 66%.
  • MASLD requires steatosis plus ≥1 of 5 cardiometabolic criteria — the first positively defined version of this diagnosis.
  • MetALD created as a countable category that did not previously exist in any classification.
  • Steatohepatitis retained deliberately, so NASH → MASH rather than being abolished.

Limitations

  • The stigma figures are panellist perceptions, not patient experience. A later 1,976-patient global survey found only 8% of patients reporting stigma from the liver diagnosis against 26% from overweight/obesity, and no substantial patient preference between NAFLD, FLD, NASH and MAFLD (Younossi 2024, PMID 37984709).
  • Panel composition was expert- and advocate-weighted; patient representation is described but not quantified in a way that allows the patient voice to be separated from the expert voice.
  • The document is a naming and definitional decision, not evidence about the disease. It generated no new data on prevalence, mechanism or outcome.
  • It does not reconcile with the competing 2020 MAFLD definition (Eslam 2020, PMID 32044314), which remains in parallel use in APASL and Chinese guidance.

Why it matters

It split the literature. Every search in this condition must union old and new vocabulary or return a field that appears to begin in 2023 — on 2026-09-02, metabolic dysfunction-associated steatotic liver disease OR MASLD returned 50,200 PubMed records against 78,992 for the union query. It also changed the diagnosed population at the margin: overlap with NAFLD is ≥94% (Cohen's κ 0.968 in NHANES III), yet in the same sample NAFLD was not associated with all-cause mortality while MASLD was (Song 2024, PMID 38293788; Younossi 2024, PMID 38286339). And it created MetALD, which turned out to carry adverse liver outcomes at HR 1.56 versus MASLD (Ochoa-Allemant 2025, PMID 40522656) — a category that is genuinely new rather than a rename.

Cited by wiki pages

  • nomenclature-and-definitions.md
  • overview.md
  • patient-experience-and-advocacy.md
  • red-flags-and-safety-concerns.md