Metabolic dysfunction–associated fatty liver disease improves detection of high liver stiffness: The Rotterdam Study

BACKGROUND AND AIMS: Recently metabolic dysfunction–associated fatty liver disease (MAFLD) has been introduced and was defined as hepatic steatosis with either overweight, diabetes, and/or a combination of other metabolic risk factors. We investigated the application of the MAFLD criteria as compared with NAFLD. APPROACH AND RESULTS: We performed a cross‐sectional analysis within the Rotterdam Study, a large prospective population‐based cohort. Participants who attended the liver ultrasound and transient elastography program between 2009 and 2014 were eligible for inclusion. Subsequently, individuals with viral hepatitis, alcohol intake >60 g/day, missing alcohol data, and/or missing body mass index were excluded. According to their NAFLD and MAFLD status based on metadata and ultrasound, participants were allocated in overlap fatty liver disease (FLD), NAFLD‐only, MAFLD‐only, or no FLD. Fibrosis was defined as liver stiffness ≥8.0 kPa. In our analysis, 5445 participants were included: 1866 (34.3%) had MAFLD and 1604 (29.5%) [Correction added on December 27, 2021 after first online publication: The preceding fragment was changed from “1623 (29.8%)”] had NAFLD. This resulted in 1547 (28.4%) [Correction added on December 27, 2021 after first online publication: The preceding fragment was changed from “1566 (28.8%)”] individuals with overlap FLD, 319 (5.9%) [Correction added on December 27, 2021 after first online publication: The preceding fragment was changed from “300 (5.5%)”] with MAFLD‐only, 57 (1.0%) with NAFLD‐only, and 3522 (64.7%) with no FLD. The MAFLD‐only group was strongly associated with fibrosis (adjusted OR 5.30 [Correction added on December 27, 2021 after first online publication: The preceding fragment was changed from "OR 5.27"], p < 0.001) and log‐transformed liver stiffness (adjusted beta 0.116, p < 0.001), as opposed to the NAFLD‐only group, in which no cases of fibrosis were identified and no association with liver stiffness (adjusted beta 0.006, p = 0.90) was found. CONCLUSIONS: FLD is highly prevalent in the general population. However, not the NAFLD‐only, but the MAFLD‐only group was associated with fibrosis and higher liver stiffness—independent of demographic and lifestyle factors. We believe that using the MAFLD criteria will help improve the identification and treatment of patients with FLD at risk for fibrosis.