A new risk stratification strategy for fatty liver disease by incorporating MAFLD and fibrosis score in a large US population

Background Metabolic dysfunction-associated fatty liver disease (MAFLD) is a newly proposed definition of fatty liver disease (FLD) independent of excessive alcohol consumption (EAC) and hepatitis viral infection. Evidence on the mortality risk in different types of FLD [nonalcoholic FLD (NAFLD), alcoholic FLD (AFLD), and MAFLD] is sparse, hindering the identification of high-risk populations for preferential clinical surveillance. Methods A total of 11,000 participants in the Third National Health and Nutrition Examination Survey were enrolled. Participants were categorized into three groups [FLD( − ), MAFLD( − ), and MAFLD( +)] according to FLD and MAFLD criteria, and further categorized into six groups by EAC. Multivariate Cox proportional hazard model was used to estimate the risk of all-cause, cardiovascular-related, and cancer-related mortality. Results During a median follow-up of 23.2 years, a total of 3240 deaths were identified. Compared with FLD( − )/EAC( − ) participants, MAFLD( +) individuals had higher all-cause mortality risk [hazard ratio (HR) = 1.28, 95% confidence interval (CI) = 1.18–1.39] regardless of EAC status [MAFLD( +)/NAFLD: HR = 1.22, 95%CI = 1.11–1.34; MAFLD( +)/AFLD: HR = 1.83, 95%CI = 1.46–2.28], while not for MAFLD( − ) individuals. Furthermore, diabetes-driven-MAFLD had higher mortality risk (HR = 2.00, 95%CI = 1.77–2.27) followed by metabolic dysregulation-driven-MAFLD (HR = 1.30, 95%CI = 1.06–1.60) and overweight/obesity-driven-MAFLD (HR = 1.11, 95%CI = 1.00–1.22). Additionally, MAFLD( − ) participants with elevated fibrosis score were also associated with statistically significantly higher mortality risk (HR = 3.23, 95%CI = 1.63–6.40). Conclusions Utilizing a representative sample of the US population, we proved the validity of MAFLD subtype and fibrosis score, rather than the traditional definition (NAFLD and AFLD), in the risk stratification of FLD patients. These findings may be applied to guide the determination of surveillance options for FLD patients.