From Pathophysiology to Practice: Navigating Liver Values in Clinical Medicine

What motivated you to work on this updated Falk Foundation brochure, and which gap in clinical practice did you want to address?

Prof. Ali Canbay: In daily clinical practice, elevated liver values are extremely common—yet many physicians are unsure how to interpret them. Over many years, I have studied different mechanisms of cell death while simultaneously treating patients, performing biopsies, and analyzing serum samples. Because I understand how viral, metabolic, ischemic, drug‑induced, and alcohol-related cell death occurs, I can clearly recognize diagnostic patterns in liver values.

Colleagues from across Germany would often call me, read out laboratory values, and I could immediately tell them the likely diagnosis. As these assessments consistently proved accurate, I realized I needed to create a kind of guiding tool for my colleagues—a clear reference that helps them understand why liver values rise in specific constellations.

Why is early diagnosis of liver disease more important than ever?

Prof. Ali Canbay: If you want to grow old in good health, and one day play with your grandchildren, you must take care of your liver. The liver is central to lipid and protein metabolism and plays a decisive role in the development of arteriosclerosis and even dementia. Prevention does not begin with coronary heart disease; it begins much earlier, with fatty liver disease. I often use a metaphor from Chinese mythology: the liver is the mother and the heart is the child. The heart cries out immediately when something is wrong, but the liver keeps working silently until it can no longer compensate. 

The terminology for steatotic liver disease has changed significantly. Why is this shift clinically relevant?

Prof. Ali Canbay: For years I argued that we needed more precise terminology. Many patients present with a combination of metabolic risk factors and alcohol consumption, and this overlap accelerates disease progression far more than either factor alone. The former terms—NAFLD and NASH—were no longer sufficient to reflect this complexity.

The updated nomenclature mirrors clinical reality: MASLD describes metabolic dysfunction–associated steatotic liver disease, MASH refers to cases where steatohepatitis is present, and MetALD applies when both metabolic factors and alcohol contribute significantly. This refined terminology improves diagnostic clarity, aligns more closely with underlying disease mechanisms, and helps reduce stigma for patients whose condition is not primarily driven by alcohol use.

Your brochure includes diagnostic pathways and visual algorithms. Which elements are especially helpful for clinicians?

Prof. Ali Canbay: The strength of the brochure lies in its clarity. The diagnostic algorithms allow clinicians, particularly non-specialists, to quickly recognize whether a patient shows a cholestatic pattern, a viral infection, metabolic disease, alcohol-related injury, or a rare condition such as autoimmune or genetic liver disease. The illustrations are intentionally simple yet highly informative. They help avoid common biases: for example, assuming alcohol misuse when the laboratory profile clearly points to a metabolic cause.

If clinicians remember just one core message from your brochure, what should it be?

Prof. Ali Canbay: Liver values never lie.
Patients often say, “I don’t drink,” or “This can’t be serious,” but the laboratory values tell the truth—in both directions. They reveal what is really happening inside the liver. 
A second message is equally important:
We must honor the liver like a mother.
The liver works tirelessly, forgives a great deal, and can regenerate impressively. But once it fails, it cannot be replaced by a machine, unlike the heart, lungs, or kidneys. That is why early detection and accurate interpretation of elevated liver values are essential.

The Falk Foundation thanks Prof. Ali Canbay for the interview.