Head to head: should portal inflammation be part of grading necroinflammatory activity in metabolic dysfunction-associated steatotic liver disease?

The grading and staging of liver biopsies from patients with steatotic liver disease, in particular metabolic dysfunction-associated steatotic liver disease (MASLD), is of fundamental importance in the execution of clinical trials of new therapeutic agents in this condition. Several semi-quantitative scoring systems have been designed for this purpose, of which the most used is the NASH Clinical Research Network (NASH CRN) system, in which the grade of disease is assessed on the severity of steatosis, hepatocyte ballooning and lobular inflammation. There has been recent interest in the role of portal inflammation (PI) in MASLD. The arguments for and against the inclusion of a semi-quantitative score for PI in grading MASLD activity are discussed in detail.