Letter to the editor: Reflection on the no‐association between the presence of fatty liver disease and mortality in the elderly

To the editor, We followed with interest the report by Laurens et al. on increased mortality that was not associated with fatty liver disease (FLD) in the elderly.1 Their impressive results suggested that screening for hepatic steatosis in the elderly was unlikely to improve outcome, which was different from the recommendations of several current guidelines. However, the findings should be interpreted with caution given the following aspects. First, in this study, 8.0 kPa was used as the threshold for categorizing liver stiffness (LS). Previous studies have shown that patients with cirrhosis typically have an LS of >12–15 kPa.2 Choosing different thresholds may lead to entirely different conclusions. How to determine a reasonable cut‐off value needs further explanation. In addition, the prevalence of advanced fibrosis in patients with NAFLD >60 years old is higher than in younger patients, which is related to slow development of the natural history of NAFLD.3 However, all‐cause and liver‐related mortality of patients with stage 4 fibrosis are higher than those without fibrosis.4 Monitoring and intervention of liver fibrosis (LF) in elderly patients with FLD may improve the survival of this population. To our knowledge, NAFLD has a solid genetic background. Some studies have shown that Asians have a higher mortality rate than Europeans with the same level of obesity.5 The study suggests that populations of different races may have different degrees of susceptibility to NAFLD, leading to heterogeneity in clinical outcomes. Considering that the characteristics of NAFLD may differ substantially between ethnic groups, we believe that it is necessary to validate the findings of this study in a prospective cohort that includes different ethnicities. Third, this cohort study is susceptible to detection and selection bias because patients with FLD may be subject to more medical monitoring and lifestyle supervision (e.g., exercise and coffee consumption) after the initial diagnosis. The improvement of baseline characteristics and adjustment during model fitting will improve the evidence level of research results. In conclusion, this study provides a new reference for developing FLD and LF screening programs in the elderly.