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

Longitudinal Clinical Outcomes and Mortality from Steatotic Liver Disease: A Meta-Analysis

INTRODUCTION

The updated consensus introduces "steatotic liver disease" as an umbrella term for all patients with hepatic steatosis, with specific subtypes such as metabolic dysfunction-associated steatotic liver disease (MASLD), MetALD (MASLD with moderate alcohol intake), and alcohol-associated liver disease. Understanding the characteristics and long-term outcomes of these subtypes is essential.

METHODS

A systematic review and meta-analysis examined studies published between January 2023 and August 2024 in MEDLINE and EMBASE on liver-related events, cardiovascular outcomes, and mortality across steatotic liver disease subtypes.

RESULTS

A total of 13 studies, involving 17.6 million patients were included. Of these, 6.8 million individuals were diagnosed with steatotic liver disease. Subtype analysis revealed a significant increase in liver-related events and composite cardiovascular outcomes across all steatotic liver disease subtypes compared to non-steatotic liver disease. Patients with MetALD and alcohol-associated liver disease were associated with a higher risk of all-cause mortality when compared to non-steatotic liver disease. Compared to MASLD, patients with MetALD and alcohol-associated liver disease significantly elevated the risk of liver-related events and individuals with alcohol-associated liver disease were associated with increased risk of all-cause mortality. Sensitivity analysis demonstrated that certain mortality outcomes were no longer significant.

CONCLUSION

Individuals across steatotic liver disease face an elevated risk of liver-related events, liver cancer, and cardiovascular outcomes. For liver-related events, the risk is progressively higher across MASLD, MetALD, and alcohol-associated liver disease, respectively. Misclassification may be introduced when using different diagnostic methods, leading to changes in outcomes. These findings validate the impact of the new classification in predicting outcomes.

MAFLD vs. MASLD: a year in review

INTRODUCTION

In 2023, metabolic dysfunction-associated steatotic liver disease (MASLD) was introduced following metabolic dysfunction-associated fatty liver disease (MAFLD). Both aim to address the limitations of nonalcoholic fatty liver disease (NAFLD). This review analyzes the similarities and differences between MAFLD and MASLD, focusing on their impacts on epidemiology, diagnosis, stigma, and related liver diseases.

AREAS COVERED

Current evidence suggests that MAFLD criteria effectively identify individuals at higher risk through a good balance of sensitivity and specificity. Moreover, MAFLD is a more generalizable term that is easily understood globally.

EXPERT OPINION

The transition from NAFLD to MAFLD and MASLD marks a significant advance in understanding fatty liver disease within hepatology. MAFLD identifies a homogeneous cohort of patients with fatty liver due to metabolic dysfunction and provides a valuable framework for holistic, patient-centered management strategies that consider various contributing factors to improve health outcomes.

Phosphatidylethanol levels distinguish steatotic liver disease subgroups and are associated with risk of major liver outcomes

BACKGROUND & AIMS

Phosphatidylethanol (PEth) is an ethanol metabolite used as a specific biomarker for recent alcohol consumption. We aimed to determine the proportion of patients with or at risk for metabolic dysfunction-associated steatotic liver disease (MASLD) who had PEth levels indicative of harmful alcohol consumption, and to assess associations between PEth levels and the risk of major adverse liver outcomes (MALOs).

METHODS

We conducted a cohort study involving persons tested for PEth in Stockholm, Sweden between 2012 and 2020 (N=46,406), including patients with various steatotic liver disease (SLD) subtypes and individuals without SLD. Cumulative incidences of MALOs were calculated for the different groups while accounting for competing risk. Cox regression was used to evaluate the association between baseline PEth levels and the incidence of MALOs.

RESULTS

Among 6,377 patients with presumed MASLD, 1,294 (20%) had baseline PEth levels between 0.05 and 0.30 μmol/L (35-210 ng/ml), indicating excessive alcohol intake (MetALD), while 854 patients (13%) had values >0.30 μmol/L, indicating alcohol-related liver disease (ALD). Patients with MASLD and PEth levels between 0.05-0.30 μmol/L had similar median FIB-4 scores and cirrhosis prevalence as those with MASLD and PEth levels <0.05 μmol/L. However, patients with PEth levels between 0.05-0.30 μmol/L had higher cumulative incidences of MALOs compared to those with PEth levels <0.05 μmol/L. Elevated PEth levels were significantly linked to higher rates of MALOs in patients without cirrhosis, even after adjustments for age, sex, SLD subtype, and FIB-4 score. Patients with ALD had the highest PEth levels and worst prognosis.

CONCLUSIONS

PEth is a valuable alcohol biomarker for distinguishing between SLD subtypes, especially ALD, and predicts adverse outcomes in people with and without SLD.

IMPACT AND IMPLICATIONS

There is controversy regarding the various proposed steatotic liver disease (SLD) subtypes, the most recent definition suggesting that patients with an elevated alcohol consumption and MASLD should be classified as having MetALD. Here, we address this challenge by classifying patients with SLD by utilizing the biomarker phosphatidylethanol (PEth), a direct and reliable biomarker for recent alcohol consumption. Our analysis of this large cohort-comprising 46,406 patients-revealed that using the objective PEth biomarker may be a valuable tool for distinguishing between MASLD and MetALD, and that PEth is strongly associated with the risk of liver outcomes in individuals with and without known SLD. Integrating PEth testing into routine diagnostic evaluations could enhance knowledge on the underlying pathophysiology in SLD, reduce the potential for misclassification, and ultimately improve patient outcomes by enabling clinicians to offer appropriate therapies. Further research is needed to validate these findings in other populations and to explore the potential integration of PEth into broader clinical guidelines for managing SLD.

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.

Risk of hepatic decompensation or HCC is similar in patients with ALD- and MASLD-cirrhosis: A population-based cohort study

BACKGROUND

It is unclear if the risk of hepatic decompensation or hepatocellular carcinoma (HCC) differs between patients with compensated alcohol-related liver disease (ALD)- and metabolic dysfunction-associated steatotic liver disease (MASLD)-cirrhosis. We investigated the risk to develop hepatic decompensation or HCC based on ALD or MASLD as the underlying etiology of cirrhosis.

METHODS

All patients with a new diagnosis in hospital-based outpatient care of ALD- or MASLD-cirrhosis in Sweden between 2002 and 2020 were identified using national registers. Hepatic decompensation was analyzed as a composite outcome with HCC. Cox regression was employed to compare rates of hepatic decompensation or HCC, and subsequent death.

RESULTS

1660 patients with ALD-cirrhosis and 943 patients with MASLD-cirrhosis were identified. The median ages were 64 years (IQR 57-70) and 69 years (IQR 62-75) in patients with ALD- and MASLD-cirrhosis, respectively. Patients with ALD-cirrhosis consisted of 69.4 % males, compared to 47.6 % males in the MASLD-cirrhosis group. 581 (35 %) patients with ALD-cirrhosis and 284 (30 %) patients with MASLD-cirrhosis developed hepatic decompensation or HCC (median follow-up time: 25 months), resulting in an adjusted hazard ratio of 1.12 (ALD- vs. MASLD-cirrhosis, 95 %-confidence interval=0.88-1.41). The adjusted risk of mortality afterwards was lower in patients with ALD-cirrhosis compared to patients with MASLD-cirrhosis (adjusted hazard ratio 0.62, 95 %-confidence interval=0.39-0.97).

CONCLUSIONS

The risk of hepatic decompensation or HCC is comparable in patients with ALD- and MASLD-cirrhosis, but the risk of mortality after a decompensation event or HCC tends to be higher in patients with MASLD-cirrhosis.

Diagnosis and Management of Early Stages of ALD

Early forms of alcohol-associated liver disease (ALD) include different stages in the progression of compensated liver disease ranging from steatosis to steatohepatitis and fibrosis. ALD has been classically diagnosed at advanced stages more frequently than other liver diseases. This fact probably contributed to the scarcity of studies on early forms of ALD. Recent studies have investigated the prevalence of early ALD in the general population and have described the natural history of alcohol-induced steatosis and fibrosis, which have been linked to worse prognosis compared with early stages of other chronic liver diseases. In addition, studies on screening and early diagnosis of ALD in at-risk populations have shown that these strategies allow early detection and intervention. Of note, up to 28% of the United States population has concurrent alcohol use and metabolic syndrome, and estimated prevalence of advanced fibrosis among heavy drinkers with metabolic syndrome has increased from 3% in the 1990s to more than 10% in the 2010s. Therefore, new challenges and treatment opportunities will emerge for patients with ALD. In this review, we provide an overview of the state of the art in early ALD, focusing on natural history, diagnosis, and management, and provide insights into future perspectives.

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.

Cluster analysis of diet and lifestyle factors associated with metabolic dysfunction-associated steatotic liver disease: findings from Korean Genome and Epidemiology Study

PURPOSE

As the global prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to increase, its early detection is crucial. We investigated the combined effects of various factors on MASLD development to enhance the understanding of individuals at high risk of MASLD.

METHODS

A total of 4670 participants from the Korean Genome and Epidemiology Study were included. Cluster analysis and Cox proportional hazards regression were conducted to identify distinct risk factor clusters and evaluate their association with MASLD incidence.

RESULTS

Four clusters were identified based on lifestyle characteristics: Cluster 1 (LA)-low activity, Cluster 2 (HPF)-lowest carbohydrate intake with high protein and fat intake, Cluster 3 (HC)-highest carbohydrate intake with low protein and fat intake, and Cluster 4 (ASC)-highest alcohol consumption and smoking levels. Cluster 4 (ASC) exhibited the highest cumulative incidence of MASLD, followed by Cluster 3 (HC). Compared to Clusters 1, 2, and 3, Cluster 4 (ASC) had significantly higher hazard ratios (HRs) for MASLD incidence (HR: 1.35 [95% confidence interval {CI}: 1.19-1.53]; p < 0.001, HR: 1.31 [95% CI: 1.14-1.50]; p < 0.001, and HR: 1.22 [95% CI: 1.07-1.38]; p = 0.002, respectively).

CONCLUSION

Clusters exhibiting various risk factor phenotypes were identified, and smoking, alcohol consumption, and carbohydrate intake were significantly associated with a higher risk of MASLD. Our findings support the importance of early screening and personalized approaches for individuals at high risk of MASLD.

Psychosocial risks in metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly becoming more prevalent in the general population. MASLD is more common in persons with low socioeconomic status (SES), yet little is known about the psychosocial challenges associated with this disease, and clinical recommendations on how to approach psychosocial challenges are lacking.

AREAS COVERED

A PubMed search using the search terms MASLD, psychosocial risks, stigmatization, psychiatric comorbidities (i.e. depression, bipolar disorder, psychosis, attention deficit hyperactivity disorder, and substance abuse), SES, quality of life (QoL), over the past 20 years (2004-2024) was performed.

EXPERT OPINION

Persons with MASLD often experience psychosocial adversities that may be expressed as lower SES, high prevalence of depression, and reduced QoL. Knowledge gaps remain regarding the association between severe mental disorders (e.g. psychosis and bipolar disorders). Timely detection and treatment of MASLD in persons with psychosocial risks may require attention and cross-field collaboration. Studies on QoL in persons with MASLD differ in methodology which makes formal comparisons difficult. Psychosocial adversity may be a barrier to lifestyle modifications, which remain the cornerstone of MASLD management. Guidelines on how to address psychosocial adversities in a clinical setting are warranted to improve outcomes and decrease further multimorbidity.

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.

Waitlisting and liver transplantation for MetALD in the United States: An analysis of the UNOS national registry

BACKGROUND AND AIMS

The new steatotic liver disease (SLD) nomenclature introduced metabolic and alcohol-associated liver disease (MetALD), describing the intersection of metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease. Waitlisting and liver transplantation for MetALD are not well defined. We aimed to develop and validate an algorithm for identifying SLD phenotypes and assessing trends in waitlisting and transplant outcomes.

APPROACH AND RESULTS

We conducted a retrospective cohort study using the United Network for Organ Sharing registry, supplemented with detailed single-center data. We developed 5 candidate algorithms for SLD classification and calculated their diagnostic performance. Trends in waitlist registrations and transplants were estimated, and competing risk analyses and Cox regression models were conducted to assess waitlist removal and posttransplant outcomes among SLD phenotypes. The best-performing algorithm demonstrated substantial agreement (weighted kappa, 0.62) for SLD phenotypes, with acceptable sensitivity (73%) for MetALD. Between 2002 and 2022, waitlist registrations and transplants for MetALD increased 2.9-fold and 3.3-fold, respectively. Since 2013, there has been a significant increase in the absolute number of waitlist registrations (122 per year; 95% CI, 111-133) and transplants (107 per year; 95% CI, 94-120) for MetALD. Patients with MetALD experienced higher waitlist removal (adjusted subdistribution hazard ratio, 1.10; 95% CI, 1.03-1.17), all-cause mortality (adjusted hazard ratio, 1.13; 95% CI, 1.03-1.23), and graft failure (adjusted hazard ratio, 1.12; 95% CI, 1.03-1.21) than those with alcohol-associated liver disease.

CONCLUSIONS

We developed and validated an algorithm for identifying SLD phenotypes in UNOS. MetALD is the third leading etiology among those waitlisted and underwent transplantation, exhibiting worse pretransplantation and posttransplantation outcomes compared to alcohol-associated liver disease. Identifying and addressing factors determining poor outcomes is crucial in this patient population.

Quantification of alcohol intake in patients with steatotic liver disease and excessive alcohol intake

Background & Aims

Quantifying alcohol intake is crucial for subclassifying participants with steatotic liver disease (SLD) and interpreting clinical trials of alcohol-related liver disease (ALD) and metabolic and alcohol-related liver disease (MetALD). However, the accuracy of self-reported alcohol intake is considered imprecise. We compared the diagnostic and prognostic utility of self-reported alcohol intake with blood-based biomarkers of alcohol intake: phosphatidylethanol (PEth) and carbohydrate-deficient transferrin (CDT).

Methods

We studied 192 participants from two randomized controlled trials on MetALD and ALD, all with current or former excessive alcohol intake (≥24/36 [♀/♂] grams daily for at least 1 year) and biopsy-proven liver disease. We assessed self-reported alcohol intake, PEth, and CDT at four time points. We collected follow-up data on hepatic decompensation and death manually through electronic medical records.

Results

Most participants were male (n = 161, 84%) with a mean age of 59 (SD 9) years and 73 participants reported 1-week abstinence before inclusion; the remaining reported a median alcohol intake of 43 g/day. Median PEth was 0.5 μmol/L (IQR: 0.0-1.3) and %CDT = 1.9 (IQR: 1.6-2.3). Of 32 patients reporting at least 6 months of abstinence; 27 (84%) was confirmed by PEth <0.05 μmol/L. Self-reported alcohol intake correlated well with PEth (r = 0.617) and moderately with CDT (r = 0.316). Self-reported alcohol intake, PEth, and CDT all predicted hepatic decompensation and death. However, PEth showed the highest prediction, surpassing self-reported alcohol intake (Harrel's C, PEth = 0.80 vs. self-reported = 0.68, p = 0.026).

Conclusions

Self-reported abstinence can be considered reliable in clinical trials. However, PEth is superior in predicting hepatic decompensation and death in patients with MetALD and ALD.

Impact and implications

An accurate quantification of alcohol intake is crucial in the clinical phenotyping of patients with steatotic liver disease and when designing clinical trials. This study found self-reported abstinence to be reliable but phosphatidylethanol was a more accurate prognostic biomarker of hepatic decompensation and death in a clinical trial setting. Findings may inform the design of future trials in patients with steatotic liver disease.

Steatotic liver disease

Steatotic liver disease is the overarching term for conditions characterised by abnormal lipid accumulation in the liver (liver or hepatic steatosis). Steatotic liver disease encompasses what was previously termed non-alcoholic fatty liver disease (NAFLD), which is now called metabolic dysfunction-associated steatotic liver disease (MASLD). Additionally, steatotic liver disease includes alcohol-related liver disease (ALD) and MetALD, the new classification for the overlap between MASLD and ALD, and rare causes of liver steatosis. Cirrhosis is globally the 11th leading cause of death, and steatotic liver disease has become the leading cause of cirrhosis in the EU and USA. Steatotic liver disease affects around 30% of the global population and is mainly driven by obesity, type 2 diabetes, and alcohol intake, but only a minor proportion with steatotic liver disease progress to cirrhosis. The presence and progression of liver fibrosis led by hepatic inflammation is the main predictor of liver-related death across the entire spectrum of steatotic liver diseases. A combination of recent advancements of widely available biomarkers for early detection of liver fibrosis together with considerable advancements in therapeutic interventions offer the possibility to reduce morbidity and mortality in patients with steatotic liver disease. This Seminar covers the recent reclassification of steatotic liver disease and how it reflects clinical practice and prognosis. For early detection of liver fibrosis, we propose a collaborative diagnostic framework between primary care and liver specialists. Lastly, we discuss current best practices for managing steatotic liver disease, we explore therapeutic targets across the spectrum of steatotic liver diseases, and we review the pipeline of drugs in development for MASLD.

Socioeconomic factors associated with the presence of and outcomes in metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

The association between socioeconomic factors and disease severity is not well studied in people living with metabolic dysfunction-associated steatotic liver disease (MASLD). We thus examined if socioeconomic factors influence the presence of, or risk for future, major adverse liver outcomes (MALOs) in people living with MASLD.

METHODS

We conducted a register-based cohort study that included all individuals with a MASLD diagnosis between 1987 and 2020 in Sweden. Logistic and Cox regression were used to examine the association between socioeconomic factors (country of birth, educational level, and marital status) and the presence of MALOs before or upon MASLD diagnosis or during follow-up, respectively.

RESULTS

In total, 14 026 people living with MASLD were identified, among whom the median age was 55 years, 50% were male and 775 (5.5%) had MALOs before or upon diagnosis. The adjusted odds ratio (aOR) for pre-existing MALOs was higher in divorced (aOR = 1.29, 95% confidence interval [CI] = 1.06-1.57) compared to married individuals. The aOR for pre-existing MALOs was lower among those with >12 years of education (aOR = .76, 95% CI = .62-.93) compared to individuals with an education level of 10-12 years. During a 5.2-year median follow-up, several socioeconomic factors were associated with increased rates of developing MALOs in a crude model; however, none were independently associated with incident MALOs after adjustment for confounders.

CONCLUSIONS

Socioeconomic factors were associated with somewhat higher odds for prevalent, but not incident, MALOs in people living with MASLD, after adjustments. This suggests primarily that risk factors for fibrosis progression are differently distributed across socioeconomic subgroups.

Metabolic characteristics of patients with MetALD: Caveats of a new definition

BACKGROUND AND AIMS

Recently, a new entity was introduced, MetALD, which includes patients with metabolic dysfunction-associated steatotic liver disease (MASLD), who consume moderate amounts of alcohol. However, little is known regarding the metabolic and clinical characteristics of these patients.

METHODS

Data from the National Health and Nutrition Examination Surveys 2017-2020 was used. Participants without valid transient elastography (TE) measurements, incomplete alcohol consumption report, or with alternative etiologies of liver steatosis were excluded.

RESULTS

A total of 6901 patients were included in the study, of which 106 (1.5%) had MetALD. Overall, MetALD patients showed a metabolic profile that was more similar to patients with alcohol related liver disease (ALD) than MASLD. Specifically, while patients with MetALD showed values in-between MASLD and ALD for body mass index (BMI), aspartate transaminase (AST), alanine transaminase (ALT), gamma glutamyltransferase (GGT) and haemoglobin A1c, they had similar high-density lipoprotein cholesterol (HDL-C), blood pressure, prevalence of diabetes and insulin resistance to ALD patients. Increasing alcohol consumption was associated with lower insulin resistance and A1c and higher triglycerides, HDL-C and blood pressure. Moreover, while AST, ALT and GGT increased with alcohol consumption, this did not translate into worse hepatic steatosis or liver fibrosis by TE.

CONCLUSIONS

MetALD patients share some characteristics with MASLD, but they resemble ALD patients more, especially after adjusting for BMI. Alcohol consumption produces a dissociation between insulin resistance and some cardiometabolic risk factors (blood pressure and HDL-C), which may make the current classification of patients challenging.

Biomarker discovery in hepatocellular carcinoma (HCC) for personalized treatment and enhanced prognosis

Hepatocellular carcinoma (HCC) is a leading contributor to cancer-related deaths worldwide and presents significant challenges in diagnosis and treatment due to its heterogeneous nature. The discovery of biomarkers has become crucial in addressing these challenges, promising early detection, precise diagnosis, and personalized treatment plans. Key biomarkers, such as alpha fetoprotein (AFP) glypican 3 (GPC3) and des gamma carboxy prothrombin (DCP) have shown potential in improving clinical results. Progress in proteomic technologies, including next-generation sequencing (NGS), mass spectrometry, and liquid biopsies detecting circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA), has deepened our understanding of HCC's molecular landscape. Immunological markers, like PD-L1 expression and tumor-infiltrating lymphocytes (TILs), also play a crucial role in guiding immunotherapy decisions. Despite these advancements, challenges remain in biomarker validation, standardization, integration into clinical practice, and cost-related barriers. Emerging technologies like single-cell sequencing and machine learning offer promising avenues for further exploration. Continued investment in research and collaboration among researchers, healthcare providers, and policymakers is vital to harness the potential of biomarkers fully, ultimately revolutionizing HCC management and improving patient outcomes through personalized treatment approaches.

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.

From NAFLD to MAFLD and MASLD: a tale of alcohol, stigma and metabolic dysfunction

Liver steatosis is a frequent finding in clinical practice and it is estimated to affect 30% of the general adult population worldwide. It became one of the leading causes of end-stage liver disease and hepatocellular carcinoma. From its first description, a diagnosis of nonalcoholic fatty liver disease (NAFLD) required the exclusion of excessive alcohol consumption and concomitant chronic liver diseases of different origins, making it a diagnosis of exclusion. In recent years, the need to stress the strict association between liver steatosis and metabolic dysfunction (i.e., insulin resistance, overweight/obesity, type 2 diabetes, and metabolic syndrome), as well as the desire to define a condition in a positive rather than negative way, led to new definitions and new diagnostic criteria. Metabolic dysfunction-associated fatty liver disease (MAFLD) was proposed by Eslam et al. in 2020. More recently, a Delphi consensus endorsed by several international hepatologic societies proposed a new terminology [metabolic dysfunction-associated steatotic liver disease (MASLD)] and a new set of diagnostic criteria. The MAFLD and MASLD definitions have a good degree of concordance. They mainly differ in the number of metabolic derangements needed to define “metabolic dysfunction” in normal-weight individuals and in alcohol consumption. Indeed, while MAFLD does not exclude patients with significant alcohol consumption, the recent Delphi consensus included the metabolic dysfunction and alcohol-related liver disease (MetALD) disease entity, a condition in which steatosis, metabolic dysfunction, and moderate alcohol intake coexist. In the present narrative review, we underline the strengths and possible limitations of each definition and summarize available evidence from epidemiologic studies evaluating the clinical usefulness of each set of diagnostic criteria.

Prognostic Impact of Metabolic Syndrome and Steatotic Liver Disease in Hepatocellular Carcinoma Using Machine Learning Techniques

Metabolic dysfunction-associated steatotic liver disease (MASLD) currently represents the predominant cause of chronic liver disease and is closely linked to a significant increase in the risk of hepatocellular carcinoma (HCC), even in the absence of liver cirrhosis. In this retrospective multicenter study, machine learning (ML) methods were employed to investigate the relationship between metabolic profile and prognosis at diagnosis in a total of 219 HCC patients. The eXtreme Gradient Boosting (XGB) method demonstrated superiority in identifying mortality predictors in our patients. Etiology was the most determining prognostic factor followed by Barcelona Clinic Liver Cancer (BCLC) and Eastern Cooperative Oncology Group (ECOG) classifications. Variables related to the development of hepatic steatosis and metabolic syndrome, such as elevated levels of alkaline phosphatase (ALP), uric acid, obesity, alcohol consumption, and high blood pressure (HBP), had a significant impact on mortality prediction. This study underscores the importance of metabolic syndrome as a determining factor in the progression of HCC secondary to MASLD. The use of ML techniques provides an effective tool to improve risk stratification and individualized therapeutic management in these patients.