Pediatric vs. adult NAFLD to MAFLD transition: a welcome but tangled path

Abstract

The term non-alcoholic fatty liver disease (NAFLD) appears unfitting both in adults and in children. As obesity and metabolic syndrome play a relevant pathogenic role, an international group of adults’ liver disease experts has proposed to rename this condition metabolic (dysfunction)-associated fatty liver disease (MAFLD). While this new more appropriate and useful definition has mostly been met with good reactions in adults, it may present a tangled path in pediatrics. Here we further stress the recommendations of the North American and the European Societies for Pediatric Gastroenterology, Hepatology and Nutrition that a hyperechogenic liver in a child affected by obesity or overweight with chronically elevated liver enzymes should not be assumed to have NAFLD only. Especially in those patients who are not in the classic age range or who have particularly severe laboratory anomalies, other genetic, metabolic (inborn errors of metabolism, IEM), endocrine, intestinal and hepatic pediatric-onset conditions, should in fact be excluded, particularly when response to a weight loss trial is not available. The term pediatric fatty liver disease (PeFLD) with three subtypes (1. contextual diagnosis of an IEM; 2. Metabolic (dysfunction)-associated fatty liver; 3. unknown cause of fatty liver) has recently been proposed aiming to separate true MAFLD from IEM and/or the other above mentioned conditions, which may be rare when considered individually but represent a large group when considered collectively. Although the cost-effectiveness ratio of this attitude is still indeterminate, it is likely that the advantage of the early identification of a specifically treatable pediatric-onset liver disease associated to/mimicking MAFLD would be rewarding.

Evaluation of the feasibility of screening for paediatric non‐alcoholic fatty liver disease

“…Furthermore, the present discussion on the NAFLD nomenclature and diagnostic criteria could possibly affect screening strategies in the future. 37,38 In conclusion, screening for NAFLD by following the NASPGHAN guideline was performed in the vast majority of the children at an outpatient obesity clinic. However, adherence to the guideline after an abnormal initial screening result needs to…”

Mycophenolate Mofetil Use Is Associated With Reduced Incidence of Food Allergy in Liver Transplanted Children

“…This is not surprising given the relative “silence” of NAFLD in its early stages (24). Increased weight is often accompanied by other components of metabolic syndrome (ie, type 2 diabetes) (2), weight stigmatization (25) as well as decreased quality of life (26), which may have more immediate relevance in adolescents’ lives. Thus, harnessing adolescent desire for weight loss (not NAFLD resolution) may be a more salient driver for change.…”

“…N onalcoholic fatty liver disease (NAFLD), an obesity-related comorbidity, is emerging as the leading cause of chronic liver disease in youth (1). This hepatic manifestation of metabolic syndrome often presents alongside other weight-related comorbidities (ie, insulin resistance, hypertension, obstructive sleep apnea) (2,3). Reduction of body mass index (BMI) z score is associated with higher odds of nonalcoholic steatohepatitis resolution in children (4), making dietary and physical activity modifications in the primary clinical intervention (5); however, achieving sustained weight loss and lifestyle change can be challenging.…”

Possible prediction of obesity‐related liver disease in children and adolescents using indices of body composition

“…NAFLD covers a spectrum of liver‐related diseases in the absence of high alcohol consumption, ranging from the accumulation of fat in the liver to end‐stage fibrosis 5,6 . Recently, a new diagnostic criteria framework has been proposed defining fatty liver disease due to metabolic dysfunction, hence a change in name to metabolic dysfunction–associated fatty liver disease (MAFLD) 7,8 . This redefinition encompasses different metabolic phenotypes with either excess adiposity defined by body mass index (BMI) or increased waist circumference, prediabetes or type 2 diabetes, or evidence of metabolic dysregulation.…”

“…5,6 Recently, a new diagnostic criteria framework has been proposed defining fatty liver disease due to metabolic dysfunction, hence a change in name to metabolic dysfunctionassociated fatty liver disease (MAFLD). 7,8 This redefinition encompasses different metabolic phenotypes with either excess adiposity defined by body mass index (BMI) or increased waist circumference, prediabetes or type 2 diabetes, or evidence of metabolic dysregulation. This is in line with studies associating visceral and centrally distributed fat with cardiometabolic health and NAFLD in children and adolescents, 9,10 emphasizing the importance of body fat distribution.…”