Faculty

Yu-Cheng Lin

Diagnosis and Management

Nonalcoholic fatty liver disease (NAFLD), or the recently redefined metabolic-associated fatty liver disease (MAFLD), is a progressive liver disease that has become a public health problem in children. The pathogenesis of MAFLD is multifactorial; it is strongly associated with obesity and insulin resistance. However, not all obese children develop MAFLD, suggesting that genetic and environmental factors can modify an individual's susceptibility to MAFLD.

In recent years, important advances have been made in the diagnosis, etiology, genetics, and management of NAFLD. However, better care of children with MAFLD requires a greater understanding of the natural history and pathogenesis, with particular attention to the interplay of dietary, genetic, gut microbiome, and environmental factors. These advances can help determine which children will benefit most from intensive multidisciplinary care and specific treatment.

Clinically, serum alanine aminotransferase and liver ultrasonography are first-line tools for screening children with suspected MAFLD. Liver biopsy remains the gold standard for accurate assessment of the severity of MAFLD in children, but it is invasive. To better stratify high-risk patients and monitor patient response to therapy, the development and validation of non-invasive biomarkers and imaging modalities will be invaluable. However, serological tests, such as the Fibrosis-4 index (FIB-4), AST to platelet ratio (APRI), etc., are not as predictive in children as they are in adults. More studies are needed to establish serological scores specific for pediatric MAFLD. Likewise, validated cut-offs for controlled attenuation parameters and liver stiffness are lacking when using vibration-controlled transient elastography (VCTE) in children with MAFLD.

Currently, lifestyle interventions remain the cornerstone of obesity and MAFLD treatment. In clinical practice, however, it is uncommon to rely on lifestyle interventions to achieve meaningful and sustained weight loss in children. To date, no drug has been formally approved, although many pharmacological strategies have been tested in MAFLD clinical studies. In the future, a comprehensive analysis of individualized genetic and environmental factors will facilitate accurate assessment of risk and individualized treatment for children with MAFLD.

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