Response to the letter to the editor Fibrosis or steatosis: which is the best screening target? Comment on the Brazilian evidence-based guideline for screening, diagnosis, treatment, and follow-up of metabolic dysfunction-associated steatotic liver disease (MASLD) in adult individuals with overweight or obesity

DEAR EDITOR AND COLLEAGUES,

The letter by Mateus Severo raises important questions regarding the screening and diagnosis of metabolic dysfunction-associated steatotic liver disease (MASLD) in adult individuals with overweight or obesity. The points presented in the letter have been discussed in detail by the authors during the Brazilian Evidence-Based guideline elaboration (¹) and deserves further clarification.

Liver steatosis is the most common manifestation and the hallmark feature of MASLD. It is now considered to be an independent risk factor for cardiovascular diseases (²) and it is also strongly correlated to metabolic disturbances (³). Therefore, it may indicate that overweight and obese individuals with liver steatosis deserves a specific and individualized approach. Although the authors strongly agree that the identification of liver fibrosis is one of the major goals in the evaluation of patients with MASLD, they also reinforce that screening for liver steatosis should not be neglected.

Abdominal Ultrasound does have limitations, particularly in individuals with Body Mass Index (BMI) > 35 kg/m². However, as stated in the letter, "the projected prevalence of overweight and obesity in Brazil for 2030 is 68.1% and 29.6%, respectively (⁴)". The vast majority of individuals with overweight will have a BMI between 25 and 30 kg/m². In this population, in which the estimated prevalence of liver steatoses may be as low as 40% (⁵), an exam with a sensitivity of 85% may be more than adequate to identify patients. The meta-analysis by Ruben Hernaez and cols. (⁵) cited by Mateus Severo concludes "that liver ultrasonography is an accurate, reliable tool to detect moderate to severe fatty liver, with sensitivity and specificity of 84.8% and 93.6%…". Moreover, it also states that "together with the relatively low cost and lack of radiation exposure, support the use of ultrasound as the imaging technique of choice for screening for fatty liver in clinical settings and population studies".

Finally, the panel strongly believes that there is an important gap on the knowledge of liver steatoses by non-specialists. A significant number of physicians needs clarification about what should be and what should not be done in overweight individuals with steatosis. Therefore, the guideline provides evidence-based recommendations for the most common manifestation of MASLD.

REFERENCES

• ¹ Moreira RO, Valerio CM, Villela-Nogueira CA, Cercato C, Gerchman F, Lottenberg AMP, et al. Brazilian evidence-based guideline for screening, diagnosis, treatment, and follow-up of metabolic dysfunction-associated steatotic liver disease (MASLD) in adult individuals with overweight or obesity: A joint position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Hepatology (SBH), and Brazilian Association for the Study of Obesity and Metabolic Syndrome (Abeso). Arch Endocrinol Metab. 2023;67(6):e230123. https://doi.org/10.20945/2359-4292-2023-0123
  » https://doi.org/10.20945/2359-4292-2023-0123
• ² Alon L, Coica B, Raparelli V, Cangemi R, Basili S, Proietti M, et al. Risk of cardiovascular events in patients with non-alcoholic fatty liver disease: a systematic review and meta-analysis. Eur J Prev Cardiol 2022;29(6):938-46. doi: 10.1093/eurjpc/zwab212.
  » https://doi.org/10.1093/eurjpc/zwab212
• ³ Fabbrini E, Magkos F. Hepatic Steatosis as a Marker of Metabolic Dysfunction. Nutrients 2015;7(6):4995-5019. doi: 10.3390/nu7064995.
  » https://doi.org/10.3390/nu7064995
• ⁴ Quek J, Chan KE, Wong ZY, Tan C, Tan B, Lim WH, et al. Global prevalence of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in the overweight and obese population: a systematic review and metaanalysis. Lancet Gastroenterol Hepatol. 2023;8(1):20-30. doi: 10.1016/S2468-1253(22)00317-X.
  » https://doi.org/10.1016/S2468-1253(22)00317-X
• ⁵ Hernaez R, Lazo M, Bonekamp S, Kamel I, Brancati FL, Guallar E, et al. Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology. 2011;54(3):1082-90. doi: 10.1002/hep.24452.
  » https://doi.org/10.1002/hep.24452

Publication Dates

• Publication in this collection
  24 June 2024
• Date of issue
  2024

History

• Received
  04 Mar 2024
• Accepted
  04 Apr 2024