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Vol.17 No.2
March, 2023
Frequency : Bimonthly
pISSN 1976-2283
eISSN 2005-1212 
Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.
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Eileen L. Yoon 
, Dae Won Jun
Correspondence to: Dae Won Jun
ORCID https://orcid.org/0000-0002-2875-6139
E-mail noshin@hanyang.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gut Liver 2022;16(3):319-320. https://doi.org/10.5009/gnl220183
Published online May 15, 2022, Published date May 15, 2022
Copyright © Gut and Liver.
In this issue of
MAFLD is known to be better at stratifying those at a higher risk for advanced liver fibrosis and overall mortality than the previous NAFLD definition.2-4 Due to the exclusive nature of the NAFLD definition, we could not call comorbid hepatic steatosis as NAFLD when it co-exists with viral hepatitis, for example. However, MAFLD includes those patients with other chronic liver diseases permitting dual etiologies in a same patient. In this regard, the diagnoses of “MAFLD and alcoholic liver disease” or “MAFLD and chronic hepatitis B” can be made. Recently, it is known that the burden of metabolic risk factors are associated with the increasing risks of hepatocellular carcinoma and all-cause mortality in patients with chronic hepatitis B.5 Therefore, MAFLD definition supports the holistic approach for a patient with varying number of co-existing liver diseases frequently met in real-life practice.6
However, there are following major concerns with the newly emerging definition of MAFLD. First, higher risk of overall mortality in MAFLD is mainly due to increasing mortality of other cancers as seen in this study.1 Furthermore, it is unclear whether the liver-related mortality increases in those with MAFLD.3 Second, the increasing overall mortality in MAFLD is mainly seen in MAFLD subgroups II (lean with metabolic dysfunction) and III (diabetes), but not clear in subgroup I (simple obese). Nevertheless, the majority of MAFLD in real-life practice is compatible to subgroup I. In previous study, nearly 90% of MAFLD subjects were categorized into subgroup I.7 Third, high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, hemoglobin A1c, and insulin levels need to be measured for the accurate diagnosis of MAFLD according to the definition, but most physicians do not test these markers as their routine labs in patients with fatty liver. Fourth, many previous reports suggested that prevalence of MAFLD is higher than that of NAFLD in the same population.7,8 If we apply the newly proposed definition of MAFLD in the outpatient clinic, the prevalence of fatty liver of medical interest would be significantly increased. Unfortunately, the data on the cost effectiveness on the application of MAFLD definition is lacking. Further studies would be needed whether the application of new MAFLD definition would reduce the social costs by active screening of those at a higher risk from the general population and thereby facilitating active referral and treatment. Fifth, there are so many factors which can affect the pathogenesis of fatty liver, not only the metabolic abnormalities but also the metabolism of bile acid, dysbiosis, sarcopenia, and diet. Therefore, the MAFLD definition would paradoxically misdirect therapeutic approaches only to the metabolic abnormalities.
To summarize, the newly proposed MAFLD concept has a positive aspect reminding several components of its pathogenesis (e.g., metabolic dysfunction, presence of diabetes, etc.) which underlies the fatty liver disease.9 MAFLD additionally raised important questions about the ambiguous nomenclature system of the conventional NAFLD definition. However, we believe that the new nomenclature requires agreement among the pan-national stakeholders and needs more clinical data for its wide acceptance in clinical practice. It would be prudent to wait for the outcome of the multi-stakeholders’ consensus position statement for the new NAFLD nomenclature.
No potential conflict of interest relevant to this article was reported.
Gut and Liver 2022; 16(3): 319-320
Published online May 15, 2022 https://doi.org/10.5009/gnl220183
Copyright © Gut and Liver.
Eileen L. Yoon , Dae Won Jun
Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
Correspondence to:Dae Won Jun
ORCID https://orcid.org/0000-0002-2875-6139
E-mail noshin@hanyang.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
In this issue of
MAFLD is known to be better at stratifying those at a higher risk for advanced liver fibrosis and overall mortality than the previous NAFLD definition.2-4 Due to the exclusive nature of the NAFLD definition, we could not call comorbid hepatic steatosis as NAFLD when it co-exists with viral hepatitis, for example. However, MAFLD includes those patients with other chronic liver diseases permitting dual etiologies in a same patient. In this regard, the diagnoses of “MAFLD and alcoholic liver disease” or “MAFLD and chronic hepatitis B” can be made. Recently, it is known that the burden of metabolic risk factors are associated with the increasing risks of hepatocellular carcinoma and all-cause mortality in patients with chronic hepatitis B.5 Therefore, MAFLD definition supports the holistic approach for a patient with varying number of co-existing liver diseases frequently met in real-life practice.6
However, there are following major concerns with the newly emerging definition of MAFLD. First, higher risk of overall mortality in MAFLD is mainly due to increasing mortality of other cancers as seen in this study.1 Furthermore, it is unclear whether the liver-related mortality increases in those with MAFLD.3 Second, the increasing overall mortality in MAFLD is mainly seen in MAFLD subgroups II (lean with metabolic dysfunction) and III (diabetes), but not clear in subgroup I (simple obese). Nevertheless, the majority of MAFLD in real-life practice is compatible to subgroup I. In previous study, nearly 90% of MAFLD subjects were categorized into subgroup I.7 Third, high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, hemoglobin A1c, and insulin levels need to be measured for the accurate diagnosis of MAFLD according to the definition, but most physicians do not test these markers as their routine labs in patients with fatty liver. Fourth, many previous reports suggested that prevalence of MAFLD is higher than that of NAFLD in the same population.7,8 If we apply the newly proposed definition of MAFLD in the outpatient clinic, the prevalence of fatty liver of medical interest would be significantly increased. Unfortunately, the data on the cost effectiveness on the application of MAFLD definition is lacking. Further studies would be needed whether the application of new MAFLD definition would reduce the social costs by active screening of those at a higher risk from the general population and thereby facilitating active referral and treatment. Fifth, there are so many factors which can affect the pathogenesis of fatty liver, not only the metabolic abnormalities but also the metabolism of bile acid, dysbiosis, sarcopenia, and diet. Therefore, the MAFLD definition would paradoxically misdirect therapeutic approaches only to the metabolic abnormalities.
To summarize, the newly proposed MAFLD concept has a positive aspect reminding several components of its pathogenesis (e.g., metabolic dysfunction, presence of diabetes, etc.) which underlies the fatty liver disease.9 MAFLD additionally raised important questions about the ambiguous nomenclature system of the conventional NAFLD definition. However, we believe that the new nomenclature requires agreement among the pan-national stakeholders and needs more clinical data for its wide acceptance in clinical practice. It would be prudent to wait for the outcome of the multi-stakeholders’ consensus position statement for the new NAFLD nomenclature.
No potential conflict of interest relevant to this article was reported.
pISSN 1976-2283
eISSN 2005-1212
Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.
