We thank Dr. Manikat and colleagues for their insightful comments.1 We concur with their views that use of the new NAFLD nomenclature may reduce stigma in people living with HIV (PWH) while allowing the use of accurate terminology to characterize different steatotic liver disease (SLD) phenotypes.2 It was reassuring to observe that application of the new criteria for defining each SLD phenotype/category did not result in a significant change in the proportion of PWH who would have been previously diagnosed with NAFLD but are now diagnosed with MASLD. Only 0.6% of the participants with SLD in our cohort had no cardiometabolic risk factors, thus not qualifying as MASLD.3 These participants would have been previously classified as lean NAFLD. Therefore, it would be safe to think that prior research findings pertaining to NAFLD in PWH could be extended in future studies to MASLD in this population.
Patients with SLD who consume moderate amounts of alcohol and also have cardiometabolic risk factors are now classified as having MetALD, constituting 20% of PWH with SLD. This observation underscores the relatively high prevalence of alcohol use and its importance in the pathogenesis SLD in PWH.4 Since these patients were excluded from prior research studies for not meeting the definition for NAFLD or ALD, more studies will be needed to understand if the performance of biomarkers of NAFLD/MASLD would be similar in these patients and whether they would have a more accelerated disease course and develop liver-related outcome faster or at higher rates compared to those with MASLD or ALD.5
References
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