Comparing NAFLD, MAFLD, and MASLD criteria for identifying significant liver fibrosis: A cross-sectional study

Different diagnostic frameworks for fatty liver disease include the exclusion-based non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) and the inclusion-based metabolic dysfunction-associated fatty liver disease (MAFLD) criteria. Their implications remain debated, especially in high viral hepatitis and alcohol use settings. This study evaluated diagnostic concordance and compared fibrosis detection across frameworks in a Vietnamese cohort.

In this cross-sectional study of 360 adults, liver fibrosis and steatosis were assessed using transient elastography. Significant fibrosis was defined as LSM ≥7.0kPa (F2), with F3 (≥8.7) and F4 (≥11.5). Steatosis was classified by CAP (S1-S3). Patients were classified categorized as NAFLD, MASLD, and MAFLD. Univariable and multivariable logistic regression were performed to identify factors associated with significant fibrosis.

Among participants, 76.67% (n=276) met all three definitions, while 15.83% (n=57) fulfilled only MAFLD criteria. The MAFLD group demonstrated higher liver stiffness than non-MAFLD group (median 5.0 vs. 4.1kPa; p=0.004). In multivariable analysis, NAFLD and MASLD were inversely associated with significant fibrosis (OR=0.418, p=0.045; OR=0.418, p=0.046, respectively). MAFLD showed a positive but non-significant association (OR=1.347, p=0.791), reflecting inclusion of dual-etiology patients (e.g., metabolic dysfunction with viral hepatitis or alcohol use) who are excluded under NAFLD/MASLD criteria.

The observed inverse association between NAFLD/MASLD and significant fibrosis likely reflects the exclusion of patients with coexisting metabolic dysfunction and viral or alcohol-related liver disease. MAFLD, by contrast, retains these dual-etiology cases and captures a more heterogeneous risk profile.