• cirrhosis
• hepatocellular carcinoma
• nonalcoholic steatohepatitis

The exclusion of alcohol to diagnose non-alcoholic fatty liver disease (NAFLD) has long been a semantical and technical nuisance. The accurate assessment of long-term alcohol use is complex and prone to error. Further, the relatively low cut-offs for alcohol as the predominant aetiological factor seem overly strict, precluding a NAFLD diagnosis in patients with relevant metabolic factors and moderate alcohol consumption. A group of experts proposed the term metabolic associated fatty liver disease (MAFLD) to ‘reflect the metabolic (dys)function-associated fatty liver disease’ and provide a more overarching, inclusive term,1 in contrast to the ‘exclusion’-based term NAFLD. Patients with MAFLD with other contributing factors should be defined as having dual (or more) aetiology fatty liver disease.2

Vitale et al used this newly coined term MAFLD to reanalyse patients with hepatocellular carcinoma (HCC) retrospectively, using the well-established Italian Liver Cancer (ITA.LI.CA) group.3 The authors analysed 6882 consecutive patients with HCC enrolled from 2002 to 2019 in 23 Italian Liver Cancer centres, with at least 2-year follow-up. They grouped the patients using the novel MAFLD concept in three categories: single aetiology MAFLD (S-MAFLD); mixed aetiology MAFLD (metabolic and others, M-MAFLD) and non-MAFLD. The majority of patients with HCC had MAFLD (68.4%). The proportion of S-MAFLD significantly increased over the study period from 3.6% (2002–2003) to 28.9% (2018–2019). In contrast, M-MAFLD remained constant (46.8% in the first biennium to 48.4% in the last period); and non-MAFLD, decreased from 49.6% to 22.7%. The findings regarding the outcomes, in particular survival, are interesting but not conclusive. When the authors grouped patients according to the MAFLD definition, they found a lower median overall survival in non-MAFLD (23.8 months) than S-MAFLD (28.1 months) and M-MAFLD (27.1 months). While HCC-related and liver …