Interaction between alcohol consumption and metabolic syndrome in predicting severe liver disease in the general population

Prevalence and Clinical Correlation of Cardiometabolic Risk Factors in Alcohol-Related Liver Disease and Metabolic Dysfunction and Alcohol Associated Liver Disease (MetALD)

Background

Recent introduction of new steatotic liver disease categorizations has necessitated updated epidemiologic studies. Specifically, recognition of (1) "MetALD" defined as where metabolic dysfunction-associated steatotic liver disease (MASLD) overlaps with alcohol use and (2) alcohol-related liver disease (ALD) without cardiometabolic risk factors (CMRFs) creates new clinical phenotypes with undefined prevalence.

Methods

We conducted a cross-sectional multicenter analysis of liver disease associated with alcohol use (ALD and MetALD). We included adults with an International Classification of Diseases (ICD) diagnosis of ALD or both metabolic dysfunction associated liver disease and alcohol use disorder assigned from 1/1/2000-1/1/2024.

Results

Among 4057 patients, only 118 (2.9%) did not have any CMRF ("pure ALD"). Compared to patients with CMRF, patients with pure ALD were more commonly female (56% [0 CRMF] vs. 48%, 45%, 38%, and 42% [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01) and younger (54 vs. 53, 60, 68, and 67 years [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01). Those with pure ALD had higher rates of cirrhosis (49% vs. 39%, 31%, 30%, 34% [1, 2, 3, and 4 CMRFs, respectively]; P < 0.01), hepatocellular carcinoma (10% vs. 6.9%, 5.7%, 4.3%, and 5.1% [1, 2, 3, and 4 CMRFs, respectively]), and death (21% vs. 15%, 17%, 18%, and 21% [1, 2, 3, and 4 CMRFs, respectively]; P = 0.04). Patients whose only CMRF was body mass index (BMI) 25-30 kg/m2 did not differ significantly from patients with pure ALD. Factors associated with cirrhosis in univariable analysis included male sex (odds ratio [OR]: 1.47, confidence interval [CI]: 1.29-1.67), age (OR: 1.08 per 10 years, CI: 1.03-1.13), and diabetes (OR: 1.21, CI: 1.05-1.40) but not BMI 25-30 kg/m2 (OR: 0.86, CI: 0.64-1.14). No differences in single-nucleotide polymorphisms (PNPLA3, GCKR, TM6SF2, MBOAT7, or HSD17B12) were identified between groups.

Conclusions

ALD without diagnosed metabolic disease is uncommon and associated with higher rates of cirrhosis, HCC, and all-cause mortality than ALD with concurrent CMRF. Having a BMI measuring 25-30 kg/m2 did not impact these clinical outcomes, raising the question of optimal BMI cut-off for MetALD. Further investigating these novel disease categories is essential for better understanding their biology and clinical impact.

Μetabolic dysfunction-associated steatotic liver disease: a condition of heterogeneous metabolic risk factors, mechanisms and comorbidities requiring holistic treatment

Μetabolic dysfunction-associated steatotic liver disease (MASLD) comprises a heterogeneous condition in the presence of steatotic liver. There can be a hierarchy of metabolic risk factors contributing to the severity of metabolic dysfunction and, thereby, the associated risk of both liver and extrahepatic outcomes, but the precise ranking and combination of metabolic syndrome (MetS) traits that convey the highest risk of major adverse liver outcomes and extrahepatic disease complications remains uncertain. Insulin resistance, low-grade inflammation, atherogenic dyslipidaemia and hypertension are key to the mechanisms of liver and extrahepatic complications. The liver is pivotal in MetS progression as it regulates lipoprotein metabolism and secretes substances that affect insulin sensitivity and inflammation. MASLD affects the kidneys, heart and the vascular system, contributing to hypertension and oxidative stress. To address the global health burden of MASLD, intensified by obesity and type 2 diabetes mellitus epidemics, a holistic, multidisciplinary approach is essential. This approach should focus on both liver disease management and cardiometabolic risk factors. This Review examines the link between metabolic dysfunction and liver dysfunction and extrahepatic disease outcomes, the diverse mechanisms in MASLD due to metabolic dysfunction, and a comprehensive, personalized management model for patients with MASLD.

Latest Insights in Alcohol-Related Liver Disease and Alcoholic Hepatitis

Alcohol-related liver disease (ALD) is still to this date one of the leading causes of chronic liver disease globally. ALD comprises a wide disease spectrum, from the benign liver steatosis, to the life-threatening inflammatory acute phenotype of alcoholic hepatitis (AH) and ultimately, advanced liver fibrosis and cirrhosis. AH represents an acute inflammatory liver condition caused by prolonged high quantities of alcohol intake. Disease outcome varies from mild to severe, with systemic implication and high mortality. Although the pathogenesis has been extensively studied over the years, little progress has been made regarding therapeutic options. In over 50 years, steroid treatment is still the cornerstone therapeutic option, albeit having multiple limitations and a low success rate. On the other hand, important progress has been made regarding disease management and severity stratification with the implementation of different prognostic score. Although highly prevalent, AH still has many unmet needs, with a growing necessity for novel non-invasive diagnosis, prognosis biomarkers and impactful treatment options.

Immune cell phenotypes as causal factors in liver disease progression revealed by Mendelian randomization

Immune cells are central mediators of the immune response and play critical roles in the pathogenesis and progression of liver diseases. Understanding the specific contributions of immune cells to liver disease progression is essential for developing targeted therapeutic strategies. In this study, we employed a two-sample Mendelian randomization (MR) approach to explore potential causal relationships between peripheral immune cell phenotypes and liver diseases, using genetic instrumental variables from large-scale genome-wide association studies (GWAS). Applying the inverse variance weighted (IVW) methods, we identified that monocyte count(odds ratio (OR) 0.81; 95% confidence interval (CI) 0.74-0.90; P  =  5.95 × 10- 5, PFDR = 3.57 × 10- 4), CD3- lymphocyte/lymphocyte (OR 0.59, 95% CI 0.45-0.79; P  =  3.29 × 10- 4, PFDR = 5.92 × 10- 3) and SSC-A (Side Scatter Area) on Natural Killer (NK) cells (OR 0.89, 95% CI 0.82-0.95; P  =  1.37 × 10- 3, PFDR = 0.0396) acted as protective factors against alcoholic liver disease. Similarly, the trait HLA DR++ monocyte/monocyte was associated with a lower risk of autoimmune hepatitis (OR 0.56, 95% CI 0.41-0.79; P  =  7.42 × 10- 4, PFDR = 0.0475). Conversely, an elevated blood monocytic Myeloid-Derived Suppressor Cells (MDSCs) count was associated with a higher risk of chronic hepatitis (OR 1.23, 95% CI 1.11-1.37; P  =  1.13 × 10- 4, PFDR = 1.58 × 10- 3). Similarly, higher levels of HLA DR on CD14- CD16+ monocyte (OR 0.84, 95% CI 0.78-0.91; P  =  2.07 × 10- 5, PFDR = 1.32 × 10- 3) conferred lower risk for cirrhosis of liver. In hepatic failure, CD39+ resting CD4 regulatory T cell count (OR 0.85, 95% CI 0.79-0.92; P  =  1.70 × 10- 5, PFDR = 5.25 × 10- 3) played a protective role and CD28+ CD45RA- CD8dim T cell/CD8dim T cell (OR 1.14, 95% CI 1.06-1.22; P  =  2.63 × 10- 4, PFDR = 0.0406) exhibited a risk function. Our findings highlight key immune pathways in liver disease progression and underscore potential immunomodulatory targets for future therapeutic interventions. Further research is warranted to clarify the mechanistic underpinnings of these associations.

The steatotic liver disease burden paradox: unravelling the key role of alcohol

The classification of steatotic liver disease (SLD) has evolved, incorporating all conditions characterized by hepatic lipid accumulation. SLD represents a continuum of disorders that are shaped by the dynamic factors of alcohol intake and cardiometabolic risk factors. This updated classification has profound implications for both the management and research of SLD, especially with the new distinct category of patients with both metabolic and alcohol-related liver disease. In this Perspective, we highlight the pivotal role of alcohol within the SLD framework. We introduce the 'SLD burden paradox': a concept illustrating the disparity in which metabolic dysfunction-associated steatotic liver disease is more prevalent, yet individuals with SLD and excessive alcohol intake (such as in metabolic and alcohol-related liver disease and in alcohol-related liver disease) account for greater global liver-related morbidity and mortality. We explore strategies to mitigate the effect of SLD on morbidity and mortality, emphasizing the importance of early detection and reducing stigma associated with alcohol intake. Our discussion extends to methods for assessing and monitoring alcohol intake together with the critical role of managing cardiometabolic risk factors in patients across the SLD spectrum. Conclusively, we advocate for a coordinated care framework that adopts a person-centric approach when managing SLD, aiming to improve outcomes and patient care.

Influence of Obesity Class on Clinical Outcomes in Alcoholic Hepatitis: A National Cohort Study of Mortality, Complications, and Resource Use

Background & Aims

Alcoholic hepatitis (AH) is a severe manifestation of alcoholic liver disease with high morbidity and mortality. This study used the 2016-2020 National Readmission Database to investigate how obesity influences AH outcomes.

Methods

Adult hospitalizations were categorized as those without obesity, Class 1 obesity (BMI 30-34.9), Class 2 obesity (BMI 35-39.9), or Class 3 obesity (BMI ≥ 40). We compared mortality, complications, and resource utilization across these groups using regression models.

Results

Among 82 367 AH admissions, 4.09% had Class 1 obesity, 2.73% had Class 2 obesity, and 4.02% had Class 3 obesity. After adjusting for confounders, Class 3 obesity was associated with higher odds of mortality (Odds ratio OR = 1.74; 95% CI: 1.40-2.17; p < 0.01), septic shock (OR = 2.27; 95% CI: 1.60-3.22; p < 0.01), hepatic encephalopathy (OR = 2.53; 95% CI: 1.15-5.56; p = 0.02), and intensive care unit (ICU) admission (OR = 1.93; 95% CI: 1.57-2.36; p < 0.01). All obesity classes had increased associations with hepatorenal syndrome. No significant differences emerged for spontaneous bacterial peritonitis or variceal bleeding. Resource utilization rose with increasing obesity severity, with Class 3 obesity having a 1.84-day longer adjusted length of stay (p < 0.01) and an additional $20 174 in total hospitalization charges (p < 0.01) compared with hospitalizations without obesity.

Conclusions

Class 3 obesity conferred the greatest burden of mortality, complications, and healthcare costs among hospitalizations with AH. Further research is warranted to clarify the intricate interplay between obesity and AH.

Genetic Risk Factors for Steatotic Liver Disease After Liver Transplantation

BACKGROUND

The role of genetic risk factors for steatotic liver disease (SLD) is intriguing in liver transplantation (LT), as both donor and recipient genetic factors may play a role. There are only a few small-scale studies published so far.

METHODS

We analysed the incidence and risk factors for post-LT SLD and the impact of 56 SLD-associated genetic variants in 595 donor-recipient pairs with liver biopsy available ≥ 6 months after LT. We evaluated whether the polygenic risk score (PRS-5) improves the ability to predict post-LT SLD in addition to non-genetic risk factors.

RESULTS

SLD after LT was diagnosed in 34.5% of patients during a median 7.6-year follow-up. In multivariate analysis including non-genetic risk factors, donor PNPLA3 rs738409-G (HR for SLD: C/G 1.34, p = 0.051, G/G 2.25, p = 0.004), donor HSD17B13 rs72613567-TA (HR for SLD: TA/T 0.68, p = 0.02 TA/TA HR 0.50, p = 0.10) and recipient UCP2 rs695366-G (HR for SLD: A/G 0.63, p = 0.002, G/G HR 0.50, p = 0.04) appeared as the most important genetic risk factors for post-LT SLD. The addition of PRS-5 to a multivariate regression model (including non-genetic risk factors) improved the predictive ability for SLD only modestly (AUC 0.78 to 0.80).

CONCLUSIONS

Various genetic variants contribute to post-LT SLD with separate variants among recipients and donors, with donor PNPLA3 rs738409-G as the most significant risk allele. Still, donor and recipient genotyping provide only modest additional value for individual risk stratification over phenotype data, highlighting the role of modifiable risk factors.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.

Role of Alcohol in Steatotic Liver Disease: Impact on Patients with Cardiometabolic Risk Factors

The new definition of steatotic liver disease (SLD), as a broader concept, was a step forward in the increasing recognition of the substantial overlap between alcohol and cardiometabolic risk factors (CMRFs), in a continuum way. The spectrum of pathophysiological aspects, ranging from liver steatosis to fibrosis, has similarities in MASLD and ALD. Also, there is now considerable evidence that the association of metabolic dysfunction with increased alcohol consumption impacts on the risk of severe liver disease and prognosis. The new MetALD class, as recently proposed, shows clear differences in prognosis when comparing with MASLD and ALD groups. However, there is room for improvement, such as considering the role of previous alcohol intake, fluctuations of consumption over time, including binge drinking, refinement of alcohol assessment, and better understanding of the role of biomarkers. In summary, SLD is no doubt a significant improvement, but the new classification needs to be dynamic and adapting to patients needing frequent reassessment. Furthermore, it brings opportunities for research on the interaction between alcohol consumption and CMRFs.

Is there a safe limit for consumption of alcohol?

In order to understand and curb the harms related to alcohol, it will be necessary to think beyond patterns of use that meet criteria for a diagnosis of alcohol use disorder or addiction. Current research suggests that regular daily alcohol use does not confer a health benefit, and, for many persons, even relatively low consumption is associated with a health risk. Determining a safe limit for alcohol consumption is challenging both for the individual person and for society. We conclude that excessive drinking is always risky. We provide a list of circumstances, such as chronic illness, driving a vehicle, or pregnancy where persons should be advised to abstain from alcohol. We recognise the need to encourage less consumption of alcohol, particularly in young adults and older adults with co-morbid conditions (especially if taking multiple medications). Finally, we offer the modest proposal that, for persons without the contributing negative influences described above, consumption which adheres to one drink per session, with interspersed abstinent days, does not constitute a meaningful risk to health.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

A Narrative Review on Plant Extracts for Metabolic Syndrome: Efficacy, Safety, and Technological Advances

Metabolic syndrome, a global health concern, is characterized by visceral obesity, hyperglycemia, dyslipidemia, hypertension, and chronic low-grade inflammation. Current therapeutic options are limited by their varying efficacy and significantly adverse side effects, fueling interest in natural products, particularly plant extracts, as potential preventive interventions for high-risk individuals. This review examines the role of plant extracts in mitigating metabolic syndrome risk factors, addressing safety concerns and exploring associated technological advancements. The literature indicates that plant extracts hold promise for addressing the pathophysiology of metabolic dysfunction. However, challenges such as safety concerns, a lack of standardized regulation, and potential drug-plant interactions currently limit their clinical application. Rigorous, long-term clinical trials are necessary to confirm the efficacy and safety of plant extracts before they can be established as a preventive strategy for managing metabolic syndrome.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prevalence of metabolic syndrome and its association with selected factors among people with psychiatric conditions in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Metabolic syndrome is a cluster of metabolic risk factors, including glucose intolerance, dyslipidemia, central obesity, high triglyceride levels, and low levels of high-density lipoprotein. It is the commonest type of co-morbidity among people with psychiatric conditions particularly in low and middle-income countries due to poor health care systems and financial burden. Metabolic syndrome among people with psychiatric conditions may be due to prolonged use of psychiatric medications, diminished quality of life, and personal and behavioral-related factors. Except for single studies with fluctuating reports, there is no nationwide study conducted on the prevalence of metabolic syndrome among people with psychiatric conditions in Ethiopia. Thus, this review aims to estimate the pooled prevalence of metabolic syndrome and its association with selected factors among people with psychiatric conditions in Ethiopia.

METHODS

We conducted a thorough search of PubMed, Scopus, Wiley online library, African journals online, and Google Scholar. For analysis, STATA version 14 software was used. A funnel plot and Egger's regression test statistic were used to find the potential reporting bias. A fixed effect model was used to contrast summary effects, odds ratios, and 95% confidence intervals all over research findings. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of each included study.

RESULTS

Eight articles were included in the final review after retrieving 9,714 articles through electronic database searching. By using the national cholesterol education adult treatment panel criteria, the pooled prevalence of metabolic syndrome among people with psychiatric conditions in Ethiopia was found to be 37.33% (95%CI: 24.52-50.14). Being female AOR = 2.66; 95% CI: 0.89, 7.92), urban residency (AOR = 2.84; 95% CI: 0.56, 14.45), physical inactivity (AOR = 3.80; 95% CI: 1.61, 8.98), alcohol consumption (AOR = 4.53; 95% CI: 1.62, 12.71) and body mass index higher than the normal range (AOR = 4.66; 95% CI: 1.22, 17.85) were the factors significantly associated with metabolic syndrome among people with psychiatric conditions. According to the review, schizophrenic-form disorder, delusional disorder, major depressive disorder, schizophrenia, bipolar disorder, and schizoaffective disorder were the frequently reported psychiatric conditions.

CONCLUSION

This systematic review and meta-analysis revealed that the magnitude of metabolic syndrome among people with psychiatric conditions in Ethiopia was high and female gender, physical inactivity, alcohol consumption, and body mass index higher than the normal range were the factors that determined the occurrence of metabolic syndrome. Thus, policymakers, clinicians, and other concerned stakeholders must reinforce effective strategies in the control, timely screening, prevention, and management of metabolic syndrome among people with psychiatric conditions.

PROTOCOL REGISTRATION

PROSPERO CRD42023405293.

Changes in drinking levels and metabolic dysfunction-associated steatotic liver disease: a longitudinal study from the China multi-ethnic cohort study

BACKGROUND

Little is known about the associations of changes in drinking levels with the newly defined metabolic dysfunction-associated steatotic liver disease (MASLD). We therefore sought to estimate the associations between changes in drinking levels and MASLD in less developed regions of China.

METHODS

This longitudinal study included 8727 participants from the China Multi-Ethnic Cohort (CMEC) in less developed regions, all participating in baseline and a follow-up survey. MASLD was defined as hepatic steatosis, along with the presence of at least one of five cardiometabolic risks, in addition to limiting excessive alcohol consumption. We applied the parametric g-formula to evaluate the association between changes in drinking levels and MASLD. We further estimated the association between changes in drinking levels and fibrosis scores (AST-to-platelet ratio and fibrosis-4 index) in patients with MASLD.

RESULTS

Compared with sustained non-drinking, sustained modest drinking was associated with a higher risk of MASLD (Mean Ratio (MR): 1.127 [95% CI: 1.040-1.242]). Compared to sustained non-drinking, the MR for those transitioning from non-drinking to modest drinking was 1.065 [95% CI: 0.983-1.169], while the MR for those changing from modest drinking to non-drinking was 1.059 [95% CI: 0.965, 1.173]. Non-invasive fibrosis scores tended to increase with modest drinking compared to sustained non-drinking.

CONCLUSION

In the less developed regions of China, sustained moderate drinking was associated with the risk of MASLD compared with sustained non-drinking. Increased drinking showed a trend towards a higher risk of MASLD. This study can inform drinking policies related to MASLD and liver fibrosis in less developed regions.

Environmental exposures and the risk of hepatocellular carcinoma

The global epidemiology of HCC is shifting due to changes in both established and emerging risk factors. This transformation is marked by an emerging prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) and type 2 diabetes, alongside traditional risks such as viral hepatitis (HBV and HCV), and exposure to chemical agents like aflatoxin, alcohol, tobacco, and air pollution. This review examines how environmental exposures and evolving liver pathology, exacerbated by lifestyle and metabolic conditions, are contributing to the rising worldwide incidence of HCC. Effective prevention strategies must not only address traditional risk factors through vaccination and therapeutic measures but also confront metabolic and socioeconomic disparities through comprehensive public health efforts. As the burden of liver cancer continues to grow, particularly in resource-limited settings, an expansive and inclusive approach is vital for mitigating its impact across diverse populations.

MetALD: Clinical aspects, pathophysiology and treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD) are the most prevalent causes of chronic liver disease worldwide. Both conditions have many pathophysiological mechanisms in common, such as altered lipid and bile acid metabolism, and share some similar clinical features. Furthermore, metabolic risk factors and alcohol often co-exist in the same individuals and have recently been shown to act synergistically to markedly increase the risk of liver disease. Given the high prevalence and impact of this interaction, steatotic liver disease due to the combination of metabolic dysfunction and moderate-to-high alcohol intake has been termed MetALD in the new steatotic liver disease nomenclature, attracting the interest of the scientific community. Subsequent studies have investigated the prevalence of MetALD, which ranges from 1.7% to 17% in cohorts of patients with steatotic liver disease, depending on the population setting and study design. A few cohort studies have also assessed the prognosis of this patient population, with preliminary data suggesting that MetALD is associated with an intermediate risk of liver fibrosis, decompensation and mortality among steatotic liver disease subtypes. In this review article, we examine the clinical evidence and the experimental models of MetALD and discuss the clinical implications of the term for early detection and management. We provide insight into the pathophysiological mechanisms of the synergistic effect of alcohol and metabolic risk factors, possible screening strategies, the use of biomarkers and emerging models of care, as well as potential therapeutic interventions with a special focus on medications for MASLD, highlighting the most promising drugs for patients with MetALD.

Alcohol-associated liver disease: Natural history, management and novel targeted therapies

Alcohol consumption is a leading cause of preventable morbidity and mortality worldwide and the primary cause of advanced liver disease. Alcohol use disorder is a chronic, frequently relapsing condition characterized by persistent alcohol consumption despite its negative consequences. Alcohol-associated liver disease (ALD) encompasses a series of stages, from fatty liver (steatosis) to inflammation (steatohepatitis), fibrosis, and, ultimately, liver cirrhosis and its complications. The development of ALD is complex, involving both genetic and environmental factors, yet the exact mechanisms at play remain unclear. Alcohol-associated hepatitis (AH), a severe form of ALD, presents with sudden jaundice and liver failure. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD to stop the progression of the disease, making alcohol abstinence the most effective way to improve prognosis across all stages of ALD. For patients with advanced ALD who do not respond to medical therapy, liver transplantation is the only option that can improve prognosis. Recently, AH has become an early indication for liver transplantation in non-responders to medical treatment, showing promising results in carefully selected patients. This review provides an update on the epidemiology, natural history, pathogenesis, and current treatments for ALD. A deeper insight into novel targeted therapies investigated for AH focusing on new pathophysiologically-based agents is also discussed, including anti-inflammatory and antioxidative stress drugs, gut-liver axis modulators, and hepatocyte regenerative molecules.

Moving diagnosis of liver fibrosis into the community

Chronic liver disease (CLD) is a leading cause of death worldwide, with alcohol consumption and metabolic risk factors accounting for the majority of cases of CLD in many developed countries. Currently, specific strategies for the early diagnosis of CLD are lacking and consequently most cases are diagnosed at an advanced stage, which is associated with negative consequences for disease management and prognosis. Screening for CLD is based on either detection of chronic viral hepatitis B and C, or detection of liver fibrosis in patients with steatotic liver disease related to alcohol or metabolic dysfunction. Non-invasive tools, including serological and imaging-based tests, can be used to detect liver fibrosis. Clinical practice guidelines recommend screening for liver fibrosis using algorithms that combine different non-invasive tests, with widely available but low accuracy tests, such as FIB-4, recommended as a first screening step in the primary care setting, and other tests with lower availability but higher accuracy, such as transient elastography or the enhanced liver fibrosis test, recommended as a second step. There are different pathways for early detection of patients with CLD from primary to specialised care, with primary care providers being key for early detection, management and referral of patients. In addition, interventions targeting metabolic risk factors and alcohol consumption should be carried out in collaboration between specialists and primary care. In this review, we describe liver fibrosis from the community perspective, highlighting gaps in knowledge on how to define the optimal combination of tests, target population, the ideal pathway of care for CLD, and how to increase implementation of programmes for early diagnosis of liver diseases in clinical practice.

Transitioning from NAFLD to MAFLD and MASLD: the toxic relationship with alcohol consumption

Alcohol is a well-known toxic etiologic factor for liver injury. Metabolic substrates of alcohol (especially acetaldehyde) have a major responsibility and genetic susceptibility, alterations in microbiota and immune system are important co-factors for this injury. Major injury in liver is hepatocellular lipid accumulation. Therefore the relationship between non-alcoholic and alcoholic fatty liver diseases should have been defined clearly. Recently two major liver committees adopted new terminologies such as metabolic-associated fatty liver disease (MAFLD), metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related liver disease (MetALD), and alcoholic liver disease (ALD) instead of non-alcoholic fatty liver disease (NAFLD). These terminologies were based on the effects of metabolic syndrome on liver. Alcohol consumption was defined differently according to these nomenclatures. MAFLD defined alcohol intake (regardless of amount) as “dual etiology fatty liver disease” and the Delphi consensus defined MASLD, MetALD, or ALD according to daily consumption of alcohol amount.

Associations between neighborhood built-environment characteristics and hepatic steatosis: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

To characterize the spatio-temporal association between features of the built environment and subclinical liver disease.

DESIGN

We used data from a large community-based population, the Multi-Ethnic Study of Atherosclerosis (2000-2002, N = 5542) with linked historical residential data that characterized past exposure to alcohol outlets (bars and liquor stores), healthy foods stores, and physical activity facilities (1990-2001). We examined whether and how past residential relate to hepatic steatosis (proxied by liver attenuation measured using computed tomography, with lower attenuation indicating higher hepatic steatosis). Hepatic steatosis is the most common.

RESULTS

We found significant associations between past residential exposure to neighborhood alcohol outlets, healthy food and physical activity resources, and hepatic steatosis. The spatial scale where the association between these features of the built environment and hepatic steatosis operate lies within 3 km (∼2 miles). The average association on liver attenuation per additional bar, liquor, healthy food store, and physical activity facility within a 2-mile buffer, were: -0.06 (95% CI -0.09, -0.03), -0.02 (95% CI -0.04, -0.009), 0.05 (95% CI 0.02, 0.07), 0.02 (95% CI 0.01, 0.04), respectively, in the preceding year of the measurement of hepatic steatosis. Furthermore, the association and spatial scale remains consistent ten years prior to the measurement of hepatic steatosis.

CONCLUSION

Our results suggest that modifying neighborhood environments (decreasing alcohol outlets and improving access to healthy food and physical activity) may represent an effective population-wide approach to reduce liver-related morbidity.

Impact of historical disease conditions on mortality and life expectancy in patients with advanced schistosomiasis in Hunan Province, China

BACKGROUND

Although the prognosis of advanced schistosomiasis patients has significantly improved, the impact of historical disease conditions on life expectancy remains unclear.

METHODS

Utilizing data from an advanced schistosomiasis cohort (n=10 362) from 2008 to 2019 in Hunan, China, we examined five historical disease conditions: times of praziquantel treatment, the history of ascites, splenectomy, upper gastrointestinal bleeding (UGIB) and hepatic coma. Using latent class analysis, participants were categorized into three groups: Group 1 (characterized by no risk conditions), Group 2 (had ≤3 times of praziquantel treatment without UGIB history) and Group 3 (had UGIB history). Life expectancies were calculated using the life table method.

RESULTS

At the age of 45 y, patients with ≤3 times of praziquantel treatment, a history of ascites, UGIB, hepatic coma and those without splenectomy exhibited lower life expectancies. Groups 1, 2 and 3 had estimated life expectancies of 32.32, 26.76 and 25.38 y, respectively. Compared with Group 1, women in Group 3 experienced greater life expectancy loss than those in Group 2, with the difference narrowing with age.

CONCLUSIONS

Based on the consideration of overall physical conditions, tailored treatment and healthcare, along with public health interventions targeting diverse populations, could mitigate the prevalence of poor disease conditions and premature deaths.

Alcohol-associated liver cancer

Heavy alcohol intake induces a wide spectrum of liver diseases ranging from steatosis, steatohepatitis, cirrhosis, and HCC. Although alcohol consumption is a well-known risk factor for the development, morbidity, and mortality of HCC globally, alcohol-associated hepatocellular carcinoma (A-HCC) is poorly characterized compared to viral hepatitis-associated HCC. Most A-HCCs develop after alcohol-associated cirrhosis (AC), but the direct carcinogenesis from ethanol and its metabolites to A-HCC remains obscure. The differences between A-HCC and HCCs caused by other etiologies have not been well investigated in terms of clinical prognosis, genetic or epigenetic landscape, molecular mechanisms, and heterogeneity. Moreover, there is a huge gap between basic research and clinical practice due to the lack of preclinical models of A-HCC. In the current review, we discuss the pathogenesis, heterogeneity, preclinical approaches, epigenetic, and genetic profiles of A-HCC, and discuss the current insights into and the prospects for future research on A-HCC. The potential effect of alcohol on cholangiocarcinoma and liver metastasis is also discussed.

Alcohol-associated liver disease-Global epidemiology

Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.

Low-to-moderate alcohol consumption is associated with increased fibrosis in individuals with metabolic dysfunction-associated steatotic liver disease

BACKGROUND & AIMS

Both metabolic dysfunction and alcohol consumption cause steatotic liver disease (SLD). The distinction between metabolic dysfunction-associated SLD (MASLD) and MetALD categories is based on arbitrary thresholds of alcohol intake. Thus, we assessed the impact of different levels of alcohol consumption on SLD severity and their interaction with metabolic comorbidities.

METHODS

We performed a population-based study with transient elastography (FibroScan®) data from participants in Spain (derivation cohort) and the US (validation cohort). A controlled attenuation parameter ≥275 dB/m was used to define SLD. At least one cardiometabolic risk factor was required to define MASLD. Among patients with MASLD, low alcohol consumption was defined as an average of 5-9 drinks/week, moderate consumption as 10-13 drinks/week for females and 10-20 drinks/week for males, and increased alcohol intake (MetALD) as 14-35 drinks/week for females and 21-42 drinks/week for males. Significant fibrosis was defined as a liver stiffness measurement ≥8 kPa and at-risk metabolic dysfunction-associated steatohepatitis (MASH) as a FAST score ≥0.35.

RESULTS

The derivation cohort included 2,227 individuals with MASLD (9% reported low, 14% moderate alcohol consumption) and 76 cases with MetALD. Overall prevalences of significant fibrosis and at-risk MASH were 7.6% and 14.8%, respectively. In the multivariable analysis, alcohol consumption was independently associated with significant fibrosis and at-risk MASH. A dose-dependent increase in the prevalence of significant fibrosis and at-risk MASH was observed between the number of drinks/week and the number of cardiometabolic factors. The validation cohort included 1,732 participants with MASLD, of whom 17% had significant fibrosis and 13% at-risk MASH. This cohort validated the association between moderate intake and MASLD at risk of progression (odds ratio 1.69, 95% CI 1.06-2.71).

CONCLUSIONS

Moderate alcohol intake is commonly seen in MASLD and increases the risk of advanced disease to a level similar to that observed in MetALD.

IMPACT AND IMPLICATIONS

Metabolic risk factors such as overweight, diabetes or dyslipidemia, and alcohol consumption can cause liver disease. These factors frequently coexist, but their joint effects on liver fibrosis remain uncertain. In this study, we have analyzed individuals from the general population with MASLD (metabolic dysfunction-associated steatotic liver disease) enrolled in Spain and the US. We show that moderate alcohol consumption has a supra-additive effect with metabolic risk factors, exponentially increasing the risk of liver fibrosis. These results suggest that there are no safe limits of daily alcohol intake in patients with unhealthy metabolic status and MASLD.

Beyond the Liver: A Comprehensive Review of Strategies to Prevent Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, primarily developing in the context of chronic liver disease. Traditional prevention has focused on liver-specific interventions like antiviral therapies and surveillance. However, extrahepatic factors also significantly contribute to HCC risk. This review explores comprehensive strategies for HCC prevention, including both hepatic and extrahepatic factors.

METHODS

An extensive literature search of peer-reviewed articles up to October 2024 was conducted, focusing on studies addressing HCC prevention strategies. Studies that focused on both hepatic and extrahepatic factors were included. Data were extracted and synthesized to provide an overview of current prevention strategies and their effectiveness in reducing HCC incidence.

RESULTS

Hepatitis B vaccination and antiviral treatments for hepatitis B and C significantly reduce HCC incidence. Lifestyle modifications-such as reducing alcohol consumption, maintaining a healthy weight through diet and exercise, and smoking cessation-are crucial in lowering HCC risk. Environmental measures to limit exposure to aflatoxins and other hazards also contribute to prevention. Regular surveillance of high-risk groups enables early detection and improves survival rates. Emerging strategies like immunotherapy and gene therapy show potential for further reducing HCC risk.

CONCLUSIONS

A comprehensive approach combining medical interventions, lifestyle changes, and environmental controls is essential for effectively decreasing HCC incidence globally. Implementing these combined measures could significantly reduce the global burden of HCC.

Alcohol and Metabolic Syndrome Interaction

Alcohol-related liver disease and metabolic-dysfunction-associated steatotic liver disease are the most common causes of chronic liver disease. Globally, alcohol intake, and metabolic syndrome driven by excessive caloric intake and sedentary lifestyle have steadily increased over the past decades. Given the high prevalence rates of both excessive alcohol consumption and components of metabolic syndrome, both can frequently coexist in the same individuals and impact their lives. In this article, we review the impact of alcohol and metabolic syndrome on liver-related outcomes.

Disparities in steatosis prevalence in the United States by Race or Ethnicity according to the 2023 criteria

INTRODUCTION

The 2023 nomenclature defined criteria for steatotic liver disease (SLD), including metabolic dysfunction-associated SLD (MASLD), alcohol-associated liver disease (ALD), and the overlapping MASLD/ALD (MetALD). We aimed to assess racial and ethnic disparities in the SLD prevalence among United States (US) adults based on this new nomenclature.

METHODS

We undertook a cross-sectional study employing the 2017-2018 National Health and Nutrition Examination Survey (NHANES) database. We identified SLD according to a controlled attenuation parameter ≥288 dB/m, liver stiffness ≥7.2 kPa, or elevated aminotransferase levels. Alcohol use thresholds were established according to the updated SLD definition. We estimated prevalences using the complex design of the NHANES survey. Multivariable logistic regressions with complex design weights were employed.

RESULTS

A total of 5532 individuals are included. The mean age is 45.4 years, and 50.9% are women. The adjusted estimated prevalence of MASLD is 42.4% (95% CI: 41.1-43.8%), MetALD 1.7% (95% CI: 1.3-2.0%), and ALD 0.6% (95% CI: 0.3-0.8%). Hispanics exhibit a higher prevalence of SLD, but there are no significant differences in advanced fibrosis prevalence due to SLD among racial/ethnic groups. In MASLD, men, individuals aged 40-64 and ≥65 years, Hispanics, those with health insurance, higher BMI, diabetes, hypertension, hypertriglyceridemia, and low high-density lipoprotein (HDL) cholesterol or use of lipid-lowering agents are independently associated with a higher risk, while Blacks have the lowest risk. In MetALD, men and higher BMI are independently associated with a higher risk of MetALD in adjusted multivariable analysis. In ALD, the adjusted multivariable analysis shows that only health insurance is independently associated with a lower ALD risk.

CONCLUSIONS

MASLD prevalence is high in the US, especially in men, older individuals, and Hispanics. MetALD and ALD prevalence was substantial but could be underestimated.

Global, regional, and national total burden related to hepatitis B in children and adolescents from 1990 to 2021

BACKGROUND

Hepatitis B remains a significant global health concern with widespread communicability. Nevertheless, data on its burden and trends in children and adolescents were limited. We aim to evaluate the global, regional, and national trends of total burden related to hepatitis B in children and adolescents aged 0-19 years from 1990 to 2021.

METHODS

The age-standardized incidence, prevalence, mortality, and disability-adjusted life years (DALYs) were calculated by the Global Burden of Disease (GBD) study from 1990 to 2021. These indicators were stratified by sex, age, socio-demographic index (SDI), and disease stage. We calculated the correlation between them and SDI. The temporal trends were examined using the annual average percentage change (AAPC) and joinpoint regression.

RESULTS

The global age-standardized incidence of hepatitis B in children and adolescents decreased from 1385.20 per 100,000 population in 1990 to 418.68 per 100,000 population in 2021, with an AAPC of -3.76%. Similarly, age-standardized DALYs decreased from 70.78 per 100,000 population to 36.31 per 100,000 population, with an AAPC of -2.13%. The age-standardized prevalence (AAPC - 3.53%) and mortality (AAPC - 2.09%) of hepatitis B also decreased significantly. From 1990 to 2021, the age-standardized incidence and prevalence among males exhibited a higher trend compared to females, although both declined over time. These two indicators also decreased across all age subgroups, with consistently higher rates observed in the 15-19 age group compared to other age groups. The burden of hepatitis B demonstrated a notable reduction in countries with high-middle SDI, while it was highest in countries with low SDI. In 2021, Central sub-Saharan Africa and West sub-Saharan Africa reported the highest age-standardized incidence. For age-standardized DALYs, South Asia was the only region to experience an increase (AAPC 1.09%), while East Asia showed the largest decline (AAPC - 7.58%). Alcohol and drug use remained important risk factors for DALYs among people aged 15-19 years. Furthermore, the impact of drug use on disease burden was increasing, particularly in high-SDI countries.

CONCLUSIONS

The global burden and trends of hepatitis B decreased significantly in children and adolescents, exhibiting regional and national variations. Management of alcohol and drug use remains a major challenge for people aged 15-19 years.

Characteristics and long-term mortality of individuals with MASLD, MetALD, and ALD, and the utility of SAFE score

BACKGROUND & AIMS

The new nomenclature of steatotic liver disease (SLD) was recently launched with sub-classifications of metabolic dysfunction-associated SLD (MASLD), MASLD with increased alcohol intake (MetALD), and alcohol-related liver disease (ALD). Herein, we aimed to evaluate the characteristics and long-term outcomes associated with these subgroups and the utility of non-invasive biomarkers.

METHODS

Using NHANES III (the third National Health and Nutrition Examination Survey) and linked mortality data, all adult participants with available ultrasonographic liver steatosis status were included. Those with viral hepatitis, incomplete data on alcohol consumption, cardiometabolic risk, and missing data that hindered Steatosis-associated Fibrosis Estimator (SAFE) score calculation were excluded. The characteristics of those without SLD (no steatosis on ultrasound), MASLD, MetALD, and ALD were compared. Overall survival (OS) was determined and SAFE score strata were applied to SLD subgroups.

RESULTS

A total of 9,939 participants were eligible; 64% had no SLD, while 30%, 2.3%, and 1% had MASLD, MetALD, and ALD, respectively. A higher proportion of men, as well as active smokers, was observed in the MetALD and ALD groups compared to the MASLD group. Diabetes was more prevalent in the MASLD group than in the MetALD and ALD groups. The ALD subgroup had significantly lower OS than the MASLD group (p = 0.004), but the MetALD did not (p = 0.165). SAFE score strata meaningfully differentiated OS of all SLD subgroups.

CONCLUSIONS

MASLD accounted for the largest proportion of SLD. MetALD shared the characteristics of both MASLD and ALD. The ALD subgroup had a significantly lower OS than the MASLD subgroup but there was no difference between MetALD and MASLD. The SAFE score can be used to stratify long-term outcomes in all SLD subgroups.

IMPACT AND IMPLICATIONS

"Steatotic liver disease (SLD)" is a recently introduced term covering three subgroups: MASLD (metabolic dysfunction-associated SLD), MetALD (MASLD with increased alcohol intake), and ALD (alcohol-related liver disease). We explored the characteristics and outcomes of these subgroups among the US population. We found that MASLD was far more common than MetALD and ALD, but all subgroups shared cardiometabolic risk factors. The ALD subgroup has the worst survival, pointing to the synergistic effect of alcohol and metabolic dysfunction. In addition, the SAFE (Steatosis-associated Fibrosis Estimator) score might be a useful non-invasive test to stratify long-term risk in all three SLD subgroups.

Natural history and progression of metabolic dysfunction-associated steatotic liver disease

The natural history of metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is complex and long. A minority of patients develop inflammation and risk progressive fibrosis that can result in cirrhosis. Progression to cirrhosis occurs in 3-5% of patients and often takes more than 20 years. This narrative review presents an update on the natural history of MASLD, discussing studies and risk estimates for progression to severe outcomes, such as decompensated cirrhosis or hepatocellular carcinoma. We highlight the dynamic progression of liver damage, how to identify patients whose disease progresses over time, and how risk factors might be mitigated to reduce the risk for disease progression.

ALT levels, alcohol use, and metabolic risk factors have prognostic relevance for liver-related outcomes in the general population

Background & Aims

A new nomenclature and subclassification for steatotic liver disease (SLD) was recently introduced. We validated the prognostic value of SLD subclasses in a Finnish population-based cohort and explored the impact of metabolic risk factors and alcohol consumption on liver-related outcomes and death.

Methods

The study included 23,910 individuals (47% men, mean age 50.5 ± 14.0 years, BMI 27.0 ± 4.7 kg/m2) from the FINRISK and Health 2000 health examination surveys with healthcare registry linkage for severe liver-related outcomes and deaths. SLD was identified by alanine aminotransferase (ALT) levels >20 U/L in women and >30 U/L in men (primary analysis) or fatty liver index (FLI) ≥60 (sensitivity analysis).

Results

The prevalence of ALT-defined SLD was 43% (n = 10,380), with subclass rates of 34.5% for metabolic dysfunction-associated steatotic liver disease (MASLD), 4.2% for coexistent MASLD and alcohol-related liver disease (ALD) (i.e., MetALD), and 1.8% for ALD. During a median 13.3-year follow-up, we observed 129 liver-related events. MetALD and ALD increased the age- and sex-adjusted liver-related outcome risk by fourfold (HR 3.83, 95% CI 2.51-5.84, p <0.001) and eightfold (HR 7.90, 95% CI 5.16-12.30, p <0.001), respectively, compared with patients with MASLD. ALD was also associated with the highest risk for non-liver mortality. Metabolic risk factors were present in 93% and 96% of individuals with ALT-defined SLD and ALD, respectively. Alcohol use amplified the risk of liver-related outcomes in individuals with MASLD. Sensitivity analyses by the FLI were similar.

Conclusion

SLD is a significant public health concern. Nearly all ALD cases exhibit metabolic risk factors. Among ALT-defined SLD subclasses, ALD presents the highest risk for both liver-related and non-liver-related outcomes. Alcohol use increases the risk of liver-related outcomes in individuals with MASLD.

Impact and implications

This study provides important information for physicians, researchers, and patients, demonstrating that the new classification of steatotic liver disease (SLD) has prognostic relevance at the population level. Evaluating the SLD subclass for a patient helps in understanding the magnitude of the risk for liver- and non-liver-related outcomes. In particular, the risks are highest in those with alcohol-related liver disease (ALD), but also increased in individuals with coexisting metabolic dysfunction-associated steatotic liver disease (MASLD) and ALD (MetALD) when compared with those with MASLD. However, alcohol use increased the risk of liver-related outcomes also in individuals with MASLD, highlighting the importance of evaluating alcohol use in every patient with SLD. Nearly all individuals with ALD have metabolic risk factors, and it is important to treat these factors to improve the survival of these patients.

Food inequity and insecurity and MASLD: burden, challenges, and interventions

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an 'upstream' risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Point-based risk score for the risk stratification and prediction of hepatocellular carcinoma: a population-based random survival forest modeling study

Background

The precise associations between common clinical biomarkers and hepatocellular carcinoma (HCC) risk remain unclear but hold valuable insights for HCC risk stratification and prediction.

Methods

We examined the linear and nonlinear associations between the baseline levels of 32 circulating biomarkers and HCC risk in the England cohort of UK Biobank (UKBB) (n = 397,702). The participants were enrolled between 2006 and 2010 and followed up to 31st October 2022. The primary outcome is incident HCC cases. We then employed random survival forests (RSF) to select the top ten most informative biomarkers, considering their association with HCC, and developed a point-based risk score to predict HCC. The performance of the risk score was evaluated in three validation sets including UKBB Scotland and Wales cohort (n = 52,721), UKBB non-White-British cohort (n = 29,315), and the Taizhou Longitudinal Study in China (n = 17,269).

Findings

Twenty-five biomarkers were significantly associated with HCC risk, either linearly or nonlinearly. Based on the RSF model selected biomarkers, our point-based risk score showed a concordance index of 0.866 in the England cohort and varied between 0.814 and 0.849 in the three validation sets. HCC incidence rates ranged from 0.95 to 30.82 per 100,000 from the lowest to the highest quintiles of the risk score in the England cohort. Individuals in the highest risk quintile had a 32-73 times greater risk of HCC compared to those in the lowest quintile. Moreover, over 70% of HCC cases were detected in individuals within the top risk score quintile across all cohorts.

Interpretation

Our simple risk score enables the identification of high-risk individuals of HCC in the general population. However, including some biomarkers, such as insulin-like growth factor 1, not routinely measured in clinical practice may increase the model's complexity, highlighting the need for more accessible biomarkers that can maintain or improve the predictive accuracy of the risk score.

Funding

This work was supported by the National Natural Science Foundation of China (grant numbers: 82204125) and the Science and Technology Support Program of Taizhou (TS202224).

EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.

Mild-moderate alcohol consumption and diabetes are associated with liver fibrosis in patients with biopsy-proven MASLD

Background

It is unclear whether patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are allowed variable low levels of alcohol. This study aimed to evaluate the effect of mild-moderate alcohol consumption on the biochemical and histological characteristics of patients with MASLD.

Methods

Alcohol consumption was assessed in 713 patients with steatotic liver disease (SLD) who underwent liver biopsy. Non-drinking, mild-moderate drinking, and excessive drinking were defined as 0 g/day, 1-<20 g/day, and >20 g/day for women and 0 g/day, 1-<30 g/day, and >30 g/day for men, respectively. Liver biopsies were scored according to the NASH CRN system.

Results

A total of 713 participants (median age 39.0 years and 77.1% male) with biopsy-proven SLD were enrolled, including 239 nondrinkers, 269 mild-moderate drinkers and 205 excessive drinkers. Excessive drinking was associated with increased risks for lobular inflammation and liver fibrosis compared to nondrinkers and mild-moderate drinkers. Compared with non-drinkers, mild-moderate drinkers had significantly lower odds for steatosis (OR = 0.60, 95% CI = 0.38-0.93, p = 0.025), hepatocellular ballooning (OR = 0.52, 95% CI = 0.29-0.91, p = 0.020) and fibrosis (OR = 0.50, 95% CI = 0.31-0.81, p = 0.005). However, in non-excessive drinkers with type 2 diabetes mellitus (T2DM), there was no association between mild-moderate alcohol consumption and liver fibrosis (OR = 0.562, 95% CI = 0.207-1.530, p = 0.257).

Conclusions

Mild-moderate alcohol consumption might be protective against liver fibrosis in MASLD patients, which is modified by the presence of T2DM. However, further longitudinal studies are needed to determine the effect of ongoing alcohol consumption on disease severity.

Using liver stiffness to predict and monitor the risk of decompensation and mortality in patients with alcohol-related liver disease

BACKGROUND & AIMS

Liver stiffness measurement (LSM) is recommended for disease prognostication and monitoring. We evaluated if LSM, using transient elastography, and LSM changes predict decompensation and mortality in patients with alcohol-related liver disease (ALD).

METHODS

We performed an observational cohort study of compensated patients at risk of ALD from Denmark and Austria. We evaluated the risk of decompensation and all-cause mortality, stratified for compensated advanced chronic liver disease (cACLD: baseline LSM ≥10 kPa) and LSM changes after a median of 2 years. In patients with cACLD, we defined LSM changes as (A) LSM increase ≥20% ("cACLD increasers") and (B) follow-up LSM <10 kPa or <20 kPa with LSM decrease ≥20% ("cACLD decreasers"). In patients without cACLD, we defined follow-up LSM ≥10 kPa as an LSM increase ("No cACLD increasers"). The remaining patients were considered LSM stable.

RESULTS

We followed 536 patients for 3,008 patient-years-median age 57 years (IQR 49-63), baseline LSM 8.1 kPa (IQR 4.9-21.7)-371 patients (69%) had follow-up LSM after a median of 25 months (IQR 17-38), 41 subsequently decompensated and 55 died. Of 125 with cACLD at baseline, 14% were "cACLD increasers" and 43% "cACLD decreasers", while 13% of patients without cACLD were "No cACLD increasers" (n = 33/246). Baseline LSM, follow-up LSM and LSM changes accurately predicted decompensation (C-index: baseline LSM 0.85; follow-up LSM 0.89; LSM changes 0.85) and mortality (C-index: baseline LSM 0.74; follow-up LSM 0.74; LSM changes 0.70). When compared to "cACLD decreasers", "cACLD increasers" had significantly lower decompensation-free survival and higher risks of decompensation (subdistribution hazard ratio 4.39, p = 0.004) and mortality (hazard ratio 3.22, p = 0.01).

CONCLUSION

LSM by transient elastography predicts decompensation and all-cause mortality in patients with compensated ALD both at diagnosis and when used for monitoring.

IMPACT AND IMPLICATIONS

Patients at risk of alcohol-related liver disease (ALD) are at significant risk of progressive disease and adverse outcomes. Monitoring is essential for optimal disease surveillance and patient guidance, but non-invasive monitoring tools are lacking. In this study we demonstrate that liver stiffness measurement (LSM), using transient elastography, and LSM changes after a median of 2 years, can predict decompensation and all-cause mortality in patients at risk of ALD with and without compensated advanced chronic liver disease. These findings are in line with results from non-alcoholic fatty liver disease, hepatitis C and primary sclerosing cholangitis, and support the clinical utility of LSM, using transient elastography, for disease prognostication and monitoring in chronic liver diseases including ALD, as recommended by the Baveno VII.

Coexistence of metabolic-associated fatty liver disease and autoimmune or toxic liver disease

Fatty liver disease (FLD) affects approximately 25% of global adult population. Metabolic-associated fatty liver disease (MAFLD) is a term used to emphasize components of metabolic syndrome in FLD. MAFLD does not exclude coexistence of other liver disease, but impact of coexisting MAFLD is unclear. We investigated prevalence and characteristics of MAFLD in patients with biopsy-proven autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), or toxic liver disease. Liver histopathology and clinical data from Helsinki University Hospital district (1.7 million inhabitants) between 2009 and 2019 were collected from patients with AIH, PBC, PSC, or toxic liver disease at the time of diagnosis. MAFLD was diagnosed as macrovesicular steatosis ≥5% together with obesity, type-2 diabetes, or signs of metabolic dysregulation. Of 648 patients included, steatosis was observed in 15.6% (n = 101), of which 94.1% (n = 95) was due to MAFLD. Prevalence of coexisting MAFLD in the four liver diseases varied between 12.4 and 18.2% (P = 0.483). Fibrosis was more severe in MAFLD among patients with toxic liver disease (P = 0.01). Histopathological characteristics otherwise showed similar distribution among MAFLD and non-FLD controls. Alcohol consumption was higher in MAFLD group among patients with AIH or PBC (P < 0.05 for both). In AIH, smoking was more common in patients with coexisting MAFLD (P = 0.034). Prevalence of coexisting MAFLD in other primary liver diseases is lower than reported in general population. Histopathology of MAFLD patients did not clearly differ from non-FLD ones. Alcohol and smoking were associated with MAFLD in AIH.

EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.

Impact of metabolic phenotype and alcohol consumption on mortality risk in metabolic dysfunction-associated fatty liver disease: a population-based cohort study

Patients with metabolic dysfunction-associated fatty liver disease (MAFLD) often present with concomitant metabolic dysregulation and alcohol consumption, potentially leading to distinct clinical outcomes. We analyzed data from 8043 participants with MAFLD in the Thai National Health Examination Survey with linked mortality records. According to the MAFLD criteria, 1432 individuals (17.2%) were categorized as having the diabetes phenotype, 5894 (71.0%) as the overweight/obesity phenotype, and 978 (11.8%) as the lean metabolic phenotype. Over 71,145 person-years, 916 participants died. Using Cox proportional hazard models adjusting for physiological, lifestyle, and comorbid factors, both diabetes (adjusted hazards ratio [aHR] 1.59, 95% CI 1.18-2.13) and lean metabolic phenotypes (aHR 1.28, 95% CI 1.01-1.64) exhibited significantly higher mortality risk compared to the overweight/obesity phenotype. A J-shaped relationship was observed between daily alcohol consumption and the risk of all-cause mortality. Daily alcohol intake exceeding 50 g for women and 60 g for men increased the all-cause mortality risk among MAFLD individuals with the lean metabolic phenotype (aHR 3.39, 95% CI 1.02-11.29). Our study found that metabolic phenotype and alcohol consumption have interactive effects on the risk of all-cause mortality in patients with MAFLD, indicating that evaluating both factors is crucial for determining prognostic outcomes and management strategies.

Pharmacological inhibition of the Src homology phosphatase 2 confers partial protection in a mouse model of alcohol-associated liver disease

Alcohol-associated liver disease (ALD) is a leading factor of liver-related death worldwide. ALD has various manifestations that include steatosis, hepatitis, and cirrhosis and is currently without approved pharmacotherapies. The Src homology phosphatase 2 (Shp2) is a drug target in some cancers due to its positive regulation of Ras-mitogen-activated protein kinase signaling and cell proliferation. Shp2 pharmacological inhibition yields beneficial outcomes in animal disease models, but its impact on ALD remains unexplored. This study aims to investigate the effects of Shp2 inhibition and its validity using a preclinical mouse model of ALD. We report that the administration of SHP099, a potent and selective allosteric inhibitor of Shp2, partially ameliorated ethanol-induced hepatic injury, inflammation, and steatosis in mice. Additionally, Shp2 inhibition was associated with reduced ethanol-evoked activation of extracellular signal-regulated kinase (ERK), oxidative, and endoplasmic reticulum (ER) stress in the liver. Besides the liver, excessive alcohol consumption induces multi-organ injury and dysfunction, including the intestine. Notably, Shp2 inhibition diminished ethanol-induced intestinal inflammation and permeability, abrogated the reduction in tight junction protein expression, and the activation of ERK and stress signaling in the ileum. Collectively, Shp2 pharmacological inhibition mitigates the deleterious effects of ethanol in the liver and intestine in a mouse model of ALD. Given the multifactorial aspects underlying ALD pathogenesis, additional studies are needed to decipher the utility of Shp2 inhibition alone or as a component in a multitherapeutic regimen to combat this deadly malady.

Response to semaglutide of non-drinker subjects with type 2 diabetes

BACKGROUND

Metabolic dysfunction-associated Steatotic Liver Disease (MASLD) displays a worse prognosis in subjects with type 2 diabetes (T2D); effective treatments are, so far, scanty. Semaglutide showed efficacy in improving steatohepatitis. We longitudinally observed a MASLD cohort of T2D subjects starting semaglutide, to detect an improvement of non-invasive surrogates of steatosis and fibro-inflammatory liver involvement, evaluating the role of mild alcohol consumption.

PATIENTS AND METHODS

In 62 overweight/obese T2D subjects with MASLD (36 non-drinker and 26 mild alcohol consumers), anthropometric, bio-humoral and transient elastography (TE) data were collected before (T0) and after an average time of 6.4 month (T1) from injective semaglutide prescription. Circulating levels of hormones (GIP, GLP-1, glucagon, insulin) and inflammatory markers (TNFα, MCP-1, IL-18, IL-10) were measured. Steatotic and necro-inflammatory liver involvement was evaluated with FibroScan controlled attenuation parameter (CAP) and liver stiffness (LS), respectively.

RESULTS

Significant (p < 0.006) T0-T1 reductions of BMI, waist circumference, fasting glucose, and HbA1c were observed. AST (-10 ± 3 IU/L), ALT (-18 ± 5 IU/L), GGT (-33 ± 15 IU/L), CAP (-25 ± 8 dB/m) and LS (-0.8 ± 0.4 kPa) were reduced, too. GLP-1 increased (+ 95.9 pM, p < 0.0001) and IL-18 was reduced (-46.6 pg/ml, p = 0.0002). After adjustment for confounders, CAP improving was only related to GLP-1 increase (ß=-0.437, p = 0.0122). Mild alcohol intake did not influence these relations.

CONCLUSION

Use of semaglutide in subjects with T2D and MASLD is associated with a significant decline of liver steatosis and necroinflammation proxies; mild alcohol assumption did not exert any influence. An independent effect of GLP-1 raise was observed on reduction of steatosis, irrespective of alcohol consumption.

Extent to which weight loss contributes to improving metabolic dysfunction-associated and metabolic and alcohol related/associated steatotic liver disease: a study on Japanese participants undergoing health checkups

Introduction

The incidence of steatotic liver disease has increased in recent years. Thus, steatotic liver disease is a major public health issue in Japan. This study investigated the association between weight reduction and the remission of metabolic dysfunction-associated steatotic liver disease (MASLD)/Metabolic and alcohol related/associated liver disease (MetALD) in Japanese individuals undergoing health checkups.

Methods

This retrospective observational study included 8,707 Japanese patients with MASLD/MetALD who underwent health checkups from May 2015 to March 2023. The participants were monitored for its remission at their subsequent visit. MASLD was diagnosed on abdominal ultrasonography and based on the presence of at least one of five metabolic abnormalities. The impact of body mass index (BMI) reduction on MASLD/MetALD remission was assessed via logistic regression analysis and using receiver operating characteristic curves.

Results

Logistic regression analysis revealed that weight loss was significantly associated with MASLD/MetALD remission. Other factors including exercise habits and reduced alcohol consumption were significant predictors of MASLD/MetALD remission in the overall cohort and in male patients. The optimal BMI reduction cutoff values for MASLD/MetALD remission were 0.9 kg/m2 and 4.0% decrease in the overall cohort, 0.85 kg/m2 and 3.9% decrease in males, and 1.2 kg/m2 and 4.5% decrease in females. In participants with a BMI of 23 kg/m2, the cutoff values were 0.75 kg/m2 and 2.7% BMI reduction.

Discussion

Weight reduction plays an important role in both MASLD and MetALD remission among Japanese individuals. That is, targeting specific BMI reduction is effective. This underscores the importance of targeted weight management strategies in preventing and managing MASLD/MetALD in the Japanese population.

Screening for Fibrosis Promotes Lifestyle Changes: A Prospective Cohort Study in 4796 Individuals

BACKGROUND AND AIMS

Early detection of liver fibrosis is believed to promote lifestyle changes. We evaluated self-reported changes in alcohol intake, diet, exercise, and weight after participating in a screening study for liver fibrosis.

METHODS

We conducted a prospective screening study of individuals at risk of alcohol-related liver disease (ALD) or metabolic dysfunction-associated steatotic liver disease (MASLD). We provided lifestyle advice to all participants and evaluated lifestyle changes by questionnaires after 1 week and 6 months, with re-examination of a subgroup after 2 years.

RESULTS

A total of 1850 at risk of ALD and 2946 at risk of MASLD were included, of whom 383 (8%) were screening positive (transient elastography ≥8 kPa). A total of 84% replied to the 6-month questionnaire. In ALD participants, excessive drinking decreased from 46% to 32% after 6 months. Only 15% reported increased drinking, without differences between screening positive and negative individuals (P = .698). In high-risk drinkers, a positive screening test predicted abstinence or decreased alcohol use after 6 months (odds ratio, 2.45; 95% confidence interval, 1.32-4.57; P = .005). After 2 years, excessive drinking decreased from 52% to 41% in a subgroup of 752 individuals and a positive screening test predicted abstinence or decreased alcohol use after 2 years (odds ratio, 1.84; 95% confidence interval, 1.09-3.11, P = .023). MASLD participants showed similar improvements: 35% improved their diet, 22% exercised more, and 13% reported a weight loss ≥5% after 6 months.

CONCLUSIONS

Screening for liver fibrosis is associated with sustained improvements in alcohol consumption, diet, weight, and exercise in at-risk ALD and MASLD. The changes are most pronounced in screening positive participants but not limited to this group.

Misclassified Alcohol-related Liver Disease is Common in Presumed Metabolic Dysfunction-associated Steatotic Liver Disease and Highly Increases Risk for Future Cirrhosis

BACKGROUND & AIMS

Alcohol overconsumption is a risk factor for disease progression in patients with presumed metabolic dysfunction-associated steatotic liver disease (MASLD). How commonly this occurs and how it affects progression to major adverse liver outcomes (MALOs) is not well known.

METHODS

We did a register-based cohort study, including all patients with a diagnosis of MASLD in Sweden between 1987 and 2020. Patients were stratified on co-occurrence of diagnoses of alcohol-related liver disease (ALD) or alcohol use disorder (AUD) prior to MASLD diagnosis. Incident MALOs were derived from national registers. Cox regression was used to calculate hazard ratios (HRs) for incident MALO.

RESULTS

A total of 15,107 patients with MASLD were identified. The median age was 55 years, and 52% were female. Of the patients, 1843 (12%) had a prior diagnosis of ALD or AUD. During follow-up, a further 787 patients (5.2%) received a diagnosis of ALD or AUD. Patients with previous ALD or AUD diagnoses at or before baseline had considerably higher rates of MALOs compared with patients without (19.5% vs 7.8%; adjusted HR, 3.12; 95% confidence interval, 2.74-3.55). Acquiring an ALD or AUD diagnosis after MASLD diagnosis was associated with higher rates of MALOs (adjusted HR, 5.81; 95% confidence interval, 4.90-6.88).

CONCLUSIONS

ALD or AUD is commonly diagnosed prior to or after MASLD diagnosis. Such patients have considerably higher rates of progression to MALOs. Correctly separating between MASLD and ALD is vital to assess prognosis.

Navigating the Nomenclature of Liver Steatosis: Transitioning from NAFLD to MAFLD and MASLD - Understanding Affinities and Differences

The escalating prevalence of non-alcoholic fatty liver disease (NAFLD) represents a significant challenge to public health, with an increasing impact observed across various demographics. This review delivers a comprehensive evaluation of the evolving terminology in steatotic liver disease (SLD), documenting the transition from NAFLD to metabolic dysfunction-associated fatty liver disease (MAFLD), and progressing to the latest terms, metabolic dysfunction-associated fatty liver disease (MASLD) and MASLD with increased alcohol intake (MetALD). We conducted a comprehensive review of literature discussing the benefits and drawbacks of these nomenclatural changes. Clinical evidence supporting MASLD and MetALD, including the implications of alcohol consumption thresholds on disease classification and outcomes, was analyzed. The “MAFLD” and “MASLD” labels align with the pathophysiology of metabolic diseases, afford a positive disease connotation, and facilitate the identification of more severe diseases, such as significant fibrosis or advanced liver disease. However, the MAFLD criteria may underdiagnose lean, non-overweight, or non-obese individuals with MAFLD. The review underscores the understanding of liver diseases linked to metabolic dysfunction and alcohol use. The shift in terminology marks progress towards a clinical diagnosis that reflects underlying pathophysiology. However, additional studies are necessary to assess the longterm effects of these changes and their efficacy in enhancing patient care and health outcomes.

Alcohol associated liver disease and bariatric surgery: Current perspectives and future directions

Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity. However, bariatric surgery has also been linked to increased alcohol use with up to 30% of these patients developing alcohol use disorder (AUD). The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic, metabolic, and neurohumoral changes associated with post-surgical anatomy. These patients are at increased risk of alcohol associated liver disease and, in some cases, require liver transplantation. In this article, we provide a scoping review of epidemiology, pathophysiology, and clinical outcomes of alcohol-related health conditions after bariatric surgery.

Interactions between the metabolic syndrome and alcohol consumption increases the risk of liver disease

Alcohol-related liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD, recently renamed metabolic dysfunction-associated steatotic liver disease [MASLD]) share many features, including certain pathophysiological mechanisms, susceptibility genes, and histological lesions. However, the natural history of the two diseases, studied separately, is significantly different, with ALD being associated with a higher risk of cirrhosis and liver-related mortality. Moreover, evidence suggests an interactive effect between ALD and metabolic risk factors that are associated with NAFLD on the risk of progressive fibrosis and development of cirrhosis. Patients with both a high consumption of alcohol and metabolic risk factors, such as obesity or diabetes, should therefore be considered a particularly high-risk group for cirrhosis. Additional studies regarding the efficacy of screening for advanced liver fibrosis or cirrhosis in these risk groups are needed. The most effective and established method for reducing the risk of progression in ALD is alcohol abstinence, whereas weight loss is effective in NAFLD. In this narrative review, we introduce the reader to the literature of the field and present key studies showing this interactive effect.

Prevalence of steatotic liver disease, MASLD, MetALD and significant fibrosis in people with HIV in the United States

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) has recently been proposed as a replacement term for NAFLD.

AIMS

To assess the effects of this new nomenclature on the prevalence and distribution of different SLD categories in people with HIV (PWH) and identified factors associated with MASLD and clinically significant fibrosis (CSF).

METHODS

PWH were prospectively enrolled from 9 US centres and underwent clinical evaluation and vibration-controlled transient elastography for controlled attenuation parameter (CAP) and liver stiffness measurement (LSM). SLD was defined as CAP ≥ 263 dB/m, CSF as LSM of ≥8 kPa, and advanced fibrosis (AF) as LSM ≥ 12 kPa. The prevalence of SLD, MASLD, metabolic dysfunction and alcohol-associated liver disease (MetALD), ALD, cryptogenic (cSLD), CSF and AF were determined. Uni- and multivariate logistic regression models were used to assess factors associated with MASLD and CSF risk.

RESULTS

Of 1065 participants, 74% were male, mean (SD) age 51.6 ± 11.9 years, 46% non-Hispanic Black and 74% with undetectable HIV RNA. The prevalence of SLD was 52%, MASLD 39%, MetALD 10%, ALD 3%, CSF 15% and AF 4%. Only 0.6% had cSLD. Black race was protective whereas obesity, ALT and AST levels were associated with increased risk of MASLD and CSF in MASLD. HIV or antiretroviral therapy did not affect MASLD risk.

CONCLUSIONS

MASLD and MetALD are the dominant causes of SLD in PWH, affecting almost half. Application of the new nomenclature resulted in minimal change in the proportion of patients with MASLD who would have been diagnosed previously with NAFLD.