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

Noninvasive pathway for stratifying fibrosis in suspected metabolic dysfunction and alcohol-associated liver disease (MetALD)

BACKGROUND

Metabolic dysfunction and alcohol-associated liver disease (MetALD) may increase liver fibrosis progression, but data on screening are scarce. We aimed to assess the performance of noninvasive tests (NITs) for detecting significant fibrosis in individuals with suspected MetALD.

METHODS

This is a cross-sectional study of prospectively enrolled adults identified as overweight or obese. We included adults with suspected MetALD defined by ≥1 of 5 cardiometabolic criteria and self-reported alcohol use within MetALD ranges or lower self-reported alcohol use but with phosphatidylethanol (PEth) levels ≥25 ng/mL. Clinical assessment included contemporaneous magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE). Significant fibrosis was defined as MRE ≥3.14 kPa (or VCTE ≥7.6 kPa if MRE was missing). Analyses included AUROCs.

RESULTS

Among 617 individuals screened, we identified 97 (15.7%) with suspected MetALD. The mean age was 50.6±12.8 years, 67% were men, the mean body mass index was 31.4±6.5 kg/m2, 12.4% had diabetes, and 8% had significant fibrosis. Fibrosis-4 ≥1.3 demonstrated good performance for significant fibrosis (AUROC: 0.78, 95% CI: 0.58-0.98, sensitivity 80%, specificity 76%, positive predictive value 17%, and negative predictive value 98%). VCTE ≥8 kPa also had good performance (AUROC: 0.85, 95% CI: 0.66-1.00, sensitivity 80%, specificity 91%, positive predictive value 36%, and negative predictive value 99%). A stepwise approach using fibrosis-4 followed by VCTE yielded a low false negative rate (2% misclassified as low risk).

CONCLUSIONS

A clinical care algorithm utilizing a stepwise approach with fibrosis-4 and VCTE shows adequate performance in detecting significant fibrosis in individuals with suspected MetALD.

Advances in identifying risk factors of metabolic dysfunction-associated alcohol-related liver disease

Metabolic dysfunction-associated alcohol-related liver disease (MetALD) is an emerging clinical entity that reflects the coexistence of metabolic dysfunction and alcohol-related liver injury. Unlike classical alcoholic liver disease (ALD), MetALD patients often present with lower to moderate alcohol consumption alongside metabolic risk factors such as obesity, insulin resistance, and dyslipidemia. These factors can synergistically worsen liver injury even at lower alcohol intake levels. Alcohol abuse remains a major global health concern, with the liver being the primary target of alcohol's toxic effects. Long-term alcohol exposure, especially when compounded by metabolic dysfunction, can accelerate the progression from steatosis to inflammation, fibrosis, cirrhosis, and hepatocellular carcinoma. Besides alcohol itself, various factors, including genetic predispositions, gender, type of alcoholic beverage, drinking patterns, and co-morbidities such as viral infections (HBV, HCV) modulate disease susceptibility and severity. This review summarizes current knowledge of risk factors contributing to MetALD, highlights the synergistic interactions between metabolic dysfunction and alcohol consumption, and discusses potential strategies for disease prevention and management.

Milpa Diet for MASLD in Mesoamerican Populations: Feasibility, Advantages, and Future Perspectives

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease, linked closely to metabolic syndrome and rising obesity rates. Affecting up to 37% of the global adult population, MASLD prevalence is exceptionally high among individuals of Hispanic descent, with genetic factors such as the PNPLA3 gene mutation playing a significant role. The subject of this review is the traditional Mesoamerican "milpa" diet, which includes unprocessed local crops like maize, beans, pumpkins, chili, and tomatoes and may represent a strategy to combat MASLD. Current treatment recommendations emphasize weight loss; a reduced intake of saturated fats, processed meats, and added sugars; and increased physical activity. The milpa diet, rich in protein, fiber, vitamins, and bioactive compounds, aligns with these recommendations and could potentially mitigate MASLD by preventing liver fat accumulation and fibrosis. This narrative review focuses on available preclinical and clinical studies adopting the milpa diet as a culturally relevant, nutritious, and sustainable dietary approach in preventing and treating MASLD. More clinical studies are needed to develop precise nutritional quantitative recommendations and guidelines.

High Global Prevalence of Steatotic Liver Disease and Associated Subtypes: A Meta-analysis

BACKGROUND & AIMS

Steatotic liver disease (SLD) encompasses various forms of hepatic steatosis and has become a significant global health concern. Despite its growing burden, a comprehensive understanding of its prevalence is lacking. Thus, this meta-analysis aims to provide a detailed estimation of the global prevalence of SLD and its subtypes.

METHODS

A systematic review and meta-analysis was conducted, examining studies published between January 2023 and August 2024 from MEDLINE and EMBASE that reported on the prevalence of SLD and its subtypes.

RESULTS

A total of 44 studies encompassing 11,282,575 participants were included. Among them, 3,826,283 individuals were diagnosed with SLD. The pooled global prevalence of SLD was 37.5% (95% confidence interval [CI], 31.4%-44.1%; I2 = 99.8%). Subtype analysis showed a prevalence of 33.6% (95% CI, 28.1%-39.5%; I2 = 99.9%) for metabolic dysfunction-associated steatotic liver disease, 4.1% (95% CI, 3.1%-5.3%; I2 = 100%) for metabolic alcohol-related liver disease, and 2.2% (95% CI, 1.5%-3.1%; I2 = 98.0%) for alcohol-related liver disease in the population. Prevalence was notably elevated in individuals with type 2 diabetes (70.2%; 95% CI, 66.1%-73.9%; I2 = 65.4%) and in overweight/obese populations (70.7%; 95% CI, 43.2%-88.4%; I2 = 99.0%).

CONCLUSION

The high prevalence of SLD shows that there remains an urgent need for targeted public health interventions and policies to address the modifiable risk factors contributing to the global burden of SLD.

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.

A call to action to address the steatotic liver disease public health threat in Barcelona

Despite their high prevalence worldwide, steatotic liver diseases (SLDs) are largely excluded from most non-communicable disease (NCD) guidelines and strategies. We propose policies and strategies to achieve the United Nations Sustainable Development Goal of reducing NCD premature mortality by one-third by 2030. To assess this gap-the exclusion of SLDs from NCD policies-in urban areas, we reviewed Barcelona's strategies for NCD risks (e.g., alcohol, tobacco, healthy food access). We then explored applications of geo-spatial visualisation and whole-of-society approaches (e.g., citizen science engagement) aligned with the World Health Organization (WHO) Best Buys to provide recommendations to address NCDs, generally, and SLDs specifically.

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.

MetALD: New Perspectives on an Old Overlooked Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD) are the major contributors to the liver disease burden globally. The rise in these conditions is linked to obesity, type 2 diabetes, metabolic syndrome and increased alcohol consumption. MASLD and ALD share risk factors, pathophysiology and histological features but differ in their thresholds for alcohol use, and the ALD definition does not require the presence of metabolic dysfunction. A recent multi-society consensus overhauled the nomenclature of liver steatosis and introduced the term MetALD to describe patients with metabolic dysfunction who drink more than those with MASLD and less than those with ALD. This new terminology aims to enhance the understanding and management of liver disease but poses challenges, such as the need to accurately measure alcohol consumption in research and clinical practice settings. Recent studies show that MetALD has significant implications for patient management, as it is associated with increased mortality risks and more severe liver outcomes compared to MASLD alone. MetALD patients face increased risks of liver disease progression, cancer and cardiovascular disease. The diagnosis of MetALD involves the adequate quantification of alcohol use through standardised questionnaires and/or biomarkers as well as proper assessment of liver disease stage and progression risk using non-invasive tools including serologic markers, imaging, elastography techniques and genetic testing. Effective management requires addressing both metabolic and alcohol-related factors to improve outcomes. This review intends to provide a comprehensive overview of MetALD, covering pathogenesis, potential diagnostic approaches, management strategies and emerging therapies.

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.

Intestinal failure-associated steatosis and fibroblast growth factor 21 plasma levels among adult chronic intestinal failure patients

BACKGROUND & AIMS

Adult patients with chronic intestinal failure (CIF) may develop intestinal failure-associated steatosis. Asymptomatic steatosis can lead to steatohepatitis and its downstream complications. Monitoring steatosis in daily practice in adult CIF patients is hampered by limited, reliable, accessible, non-invasive methods to measure liver fat content (LFC). Fibroblast growth factor 21 (FGF21) is a hormone that is mainly produced by hepatocytes, and higher plasma levels are associated with the presence and the degree of liver steatosis in several clinical conditions. Furthermore, FGF21 analogues have been shown to reduce fatty liver. FGF21 has previously been suggested as a biomarker for liver steatosis. The aim of this study was to assess the diagnostic performance of FGF21 plasma levels to detect steatosis and steatosis severity in adult CIF patients.

METHODS

FGF21 plasma levels were quantified using enzyme-linked immunosorbent assay (ELISA) in 48 adult CIF patients who had been receiving home parenteral nutrition (HPN) or intravenous fluids for ≥3 months for ≥2 times per week. Liver fat content (LFC, %) was assessed with proton magnetic resonance spectroscopy (1H-MRS). Patient characteristics of patients with steatosis (LFC >5.5 %) and without steatosis (LFC ≤5.5 %) were compared using the Mann-Whitney U test or Fisher's exact test. The diagnostic value of FGF21 levels to diagnose the presence of steatosis (LFC >5.5 %) was performed by determining the area under the receiver operating characteristics curve (AUC), and the optimal cut-off value was determined. Furthermore, Spearman's rho correlation coefficient was calculated to evaluate the association between FGF21 levels and LFC.

RESULTS

FGF21 plasma levels were measured in 48 patients (median age of 56 years, 71 % female) with a median duration of HPN use of 57 months. Steatosis was diagnosed in 8/48 (17 %) patients, with a median LFC of 8.4 % (range 5.7-39.9 %). CIF patients with steatosis had higher median FGF21 plasma levels (658 pg/mL) than patients without steatosis (299 pg/mL). The area under the curve (AUC) of FGF21 to predict steatosis (LFC >5.5 %) was 0.80 [95 % CI 0.63, 0.96]. With the optimal FGF21 cut-off point at 453 pg/mL, the sensitivity as well as the specificity was 75 %. The calculated Spearman rho correlation found a significant positive correlation (ρ = 0.65, p < 0.001) between FGF21 plasma levels and LFC (%).

CONCLUSION

Adult CIF patients with steatosis had higher FGF21 plasma levels than CIF patients without steatosis. FGF21 is a good predictor for diagnosing steatosis and has a good correlation with LFC. FGF21 should be considered as a biomarker for steatosis in adult patients with CIF.

Metabolic Syndrome and Liver Disease: Re-Appraisal of Screening, Diagnosis, and Treatment Through the Paradigm Shift from NAFLD to MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), encompasses a spectrum of liver diseases characterized by hepatic steatosis, the presence of at least one cardiometabolic risk factor, and no other apparent cause. Metabolic syndrome (MetS) is a cluster of clinical conditions associated with increased risk of cardiovascular disease, type 2 diabetes, and overall morbidity and mortality. This narrative review summarizes the changes in the management of people with MetS and NAFLD/MASLD from screening to therapeutic strategies that have occurred in the last decades. Specifically, we underline the clinical importance of considering the different impacts of simple steatosis and advanced fibrosis and provide an up-to-date overview on non-invasive diagnostic tests (i.e., imaging and serum biomarkers), which now offer acceptable accuracy and are globally more accessible. Early detection of MetS and MASLD is a top priority as it allows for timely interventions, primarily through lifestyle modification. The liver and cardiovascular benefits of a global and multidimensional approach are not negligible. Therefore, a holistic approach to both conditions, MetS and related chronic liver disease, should be applied to improve overall health and longevity.

Multidisciplinary clinical practice guideline on the management of metabolic hepatic steatosis

Metabolic hepatic steatosis (MetHS) is a clinically heterogeneous, multisystemic, dynamic, and complex disease, whose progression is one of the main causes of cirrhosis and hepatocarcinoma. This clinical practice guideline aims to respond to its main challenges, both in terms of disease burden and complexity. To this end, recommendations have been proposed to experts through the Delphi method. The consensus was optimal in recommendations regarding type 2 diabetes as a risk factor (1.5.1, 4.5.1), in which cases early detection of MetHS should be carried out (4.5.2). Its results also emphasize the importance of the use of non-invasive tests (FIB-4, NFS, HFS) for the exclusion of significant fibrosis in patients with suspected MetHS (2.3.1, 2.3.3). Diagnosis should be carried out through the sequential combination of non-invasive indices and transient elastography by FibroScan® for its risk stratification (2.3.3). A nearly unanimous consensus was reached regarding the role of early prevention in the impact on the quality of life and survival of patients (5.1.2), as well as on the effectiveness of the Mediterranean diet and physical exercise in relation to the improvement of steatosis, steatohepatitis and fibrosis in MetHS patients (5.2.2) and on the positive results offered by resmiterom and semaglutide in promoting fibrosis regression (5.4.1). Finally, a great consensus has been reached regarding the importance of multidisciplinary management in MetHS, for which it is essential to agree on multidisciplinary protocols for referral between levels in each health area (6.2.1), as well as ensuring that referrals to Hepatology/Digestive and Endocrinology or Internal Medicine services are effective and beneficial to prevent the risk of disease progression (6.2.3, 6.3.1).

Clinical and Economic Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) in a Spanish Mediterranean Region: A Population-Based Study

Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent condition worldwide, with significant regional variability in prevalence estimates. This study aimed to determine the prevalence, demographic characteristics, and economic burden of MASLD, metabolic dysfunction-associated steatotic liver (MASL), and metabolic dysfunction-associated steatohepatitis (MASH) in the Valencian Community region of Spain. Methods: We conducted a retrospective analysis of electronic medical records from the Valencian public healthcare database of individuals aged over 24 years from 2012 to 2019. Results: Of the 3,411,069 individuals included in the database in 2019, 75,565 were diagnosed with MASLD, 74,065 with MASL, and 1504 with MASH based on the International Classification of Diseases (ICD), corresponding to a prevalence of 2.22%, 2.17%, and 0.04%, respectively. Among individuals with type 2 diabetes mellitus (T2DM) or obesity, the prevalence of MASLD was approximately three times and 2.5 times higher, respectively, compared to the overall population. The prevalence of MASLD, MASL, and MASH increased from 2012 to 2019 in all the populations studied. The highest risk of hospitalization was associated with liver-related causes, followed by all-cause hospitalization. The highest cost per subject in 2019 was observed in individuals with concomitant MASH and T2DM. Conclusions: Our findings indicate a rising prevalence of MASLD, MASL, and MASH, despite their potential underdiagnosis during the study period. The presence of MASLD or MASH was associated with high healthcare costs, particularly in patients with MASH and T2DM. Our results underline the need for more effective strategies to enhance disease awareness and improve resource allocation.

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.

Insights into the results of Resmetirom trials: Can a thyroid hormone receptor agonist be the holy grail of MASH therapy?

Despite the heavy individual patient and socioeconomic burden of metabolic dysfunction-associated steatohepatitis (MASH), until recently, no pharmacological therapy for MASH was approved, with available treatment options geared towards associated cardiometabolic risk factors. Accelerated approval of resmetirom, a thyroid hormone receptor-β agonist to be used in conjunction with diet and exercise, marks a significant step forward in the treatment of MASH, offering tempered optimism to healthcare providers and millions of patients around the world for more effective management. Evidence from phase 2 and 3 clinical trials suggests that resmetirom has the potential to alleviate hepatic fibrosis and inflammation and significantly reduce liver lipid content. Notwithstanding this landmark event, the clinical implementation of resmetirom comes with important challenges, for example, ensuring patient access to treatment and demonstrating effects on hard MASH-related outcomes, such as progression to cirrhosis and hepatocellular carcinoma. Additional considerations include the evaluation of co-administration with other hepatoprotective treatments and the assessment of the efficacy in specific MASH sub-phenotypes. Furthermore, the accumulation of real-world data and experience is expected to help answer the remaining questions about the (long-term) effectiveness and safety profile of the drug. The purpose of this article is to provide an updated and critical review of the mechanisms of action, efficacy, and safety of resmetirom based on the latest clinical trials, to define its place within the broader landscape of MASH management, and to highlight current knowledge gaps and opportunities for future research in the field.

Exploring the impact of graded alcohol use on atherogenic lipid profiles among Latinos with underlying chronic liver disease

BACKGROUND

Alcohol use and hepatitis C virus (HCV) often coexist and are associated with cardiovascular disease. One of the underlying drivers is dyslipidemia. We assessed lipid and lipoprotein levels and the relationship between alcohol use and atherogenic lipid profiles, specifically small dense low-density lipoprotein cholesterol (sdLDL-C), in Latinos with and without HCV.

METHODS

From June 1, 2002, to January 1, 2016, 150 Latino adults underwent demographic, clinical, metabolic, lipid/lipoprotein, and genetic evaluations. Linear regression (adjusted for age, sex, and recent alcohol use) assessed factors associated with sdLDL-C.

RESULTS

Participant characteristics were as follows: median age 44 years, 64% male, 39% HCV+, and alcohol use in the last 12 months was 19% heavy and 47% moderate. Ancestries were as follows: 52% European, 40% Native American (NA), and 4.3% African. 29% had non-CC PNPLA3, 89% non-CC TM6SF2, and 73% non-CC IL-28b genotypes. High-density lipoprotein (HDL) cholesterol, HDL-3, apolipoprotein A-1, and lipoprotein-associated phospholipase A2 levels differed by alcohol use groups (p < 0.05). On multivariable analysis, female sex (est. -6.08, p < 0.001), HCV+ status (est. -8.49, p < 0.001), and heavy alcohol use (vs. none) (est. -4.32, p = 0.03) were associated with lower, while NA ancestry (est. 0.92; p = 0.01) and adipose tissue insulin resistance (est. 3.30, p < 0.001) were associated with higher sdLDL-C levels. The positive association between NA ancestry and sdLDL-C was dampened by the presence of a non-CC IL28b genotype (interaction est. -1.95, p = 0.01).

CONCLUSIONS

In this Latino cohort, ancestry and metabolic dysfunction, independent of alcohol use and HCV, were associated with atherogenic risk. In addition to HCV treatment in this population, cardiometabolic health should be optimized.

Lifestyle and Pharmacologic Approaches to Prevention of Metabolic Dysfunction-associated Steatotic Liver Disease-related Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major concern for public health. Fatty liver disease, related to alcohol misuse or metabolic syndrome, has become the leading cause of chronic liver disease and HCC. The strong association between type 2 diabetes mellitus and HCC can be partly attributed to the development of metabolic dysfunction-associated steatotic liver disease (MASLD). There is a strong interest in strategies that may mitigate HCC risk and reduce HCC incidence in this growing population of at-risk individuals. In this review, we describe the pathogenesis of HCC in patients with MASLD and discuss potential emerging pharmacological and lifestyle interventions for MASLD-related HCC. HCC risk has been observed to be lower with healthy lifestyle behaviors, such as healthy dietary patterns (eg, high consumption of vegetables, whole grains, fish and poultry, yogurt, and olive oil, and low consumption of red and processed meats and dietary sugar) and increased physical activity. Selecting an appropriate pharmacologic approach for individuals with MASLD may also decrease the occurrence of HCC. Metformin, PPAR activators, sodium-glucose cotransporter 2 inhibitors, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, aspirin, and statins have all shown promise to reduce the risk of HCC, although guidelines do not recommend their use for the sole purpose of chemoprevention at this time, given a dearth of data defining their risk-benefit ratio.

Body mass index and diabetes predict severity of liver fibrosis across the spectrum of steatotic liver disease

INTRODUCTION AND OBJECTIVES

Recent evidence indicates that metabolic dysfunction and alcohol-associated steatotic liver disease (MetALD), a newly defined subgroup of steatotic liver disease (SLD), may have a worse prognosis than metabolic dysfunction-associated steatotic liver disease (MASLD). This study examines the clinical factors influencing the severity of MetALD to inform and improve future management strategies.

PATIENTS AND METHODS

Data from the 2017-2020 National Health and Nutrition Examination Surveys (NHANES), involving 7745 adults with valid elastography measurements, were utilized to define and estimate the prevalence of MASLD, MetALD, and alcohol liver disease (ALD). Controlled attenuation parameter (CAP) ≥285 dB/m, liver stiffness measurement (LSM) ≥8 kPa, and ≥12 kPa indicated the presence of hepatic steatosis, clinically significant fibrosis, and advanced fibrosis, respectively.

RESULTS

The prevalence of MetALD was 4 % (N=287), compared to 24 % (N=2049) for MASLD and 7 % (N=486) for ALD. The prevalence of significant fibrosis and advanced fibrosis in MetALD was 10.8 % and 3.1 %, respectively, compared to 24.7 % and 9.8 % in MASLD, and 15 % and 8 % in ALD. Logistic regression analysis among MetALD patients showed that higher body mass index (BMI) (odds ratio [OR]: 1.15, 95 % CI: 1.08-1.23, P<0.01) and diabetes mellitus (DM) (OR: 3.0, 95 % CI: 1.06-6.2, P<0.01) were associated with an increased risk of fibrosis. These factors were also identified as independent risk factors for fibrosis in patients with MASLD and ALD.

CONCLUSIONS

MetALD had the lowest prevalence and fibrosis severity among the three groups of SLD. Elevated BMI and DM were associated with the severity of liver disease, and these findings provide a rationale for the use of obesity- and diabetes-targeted medications in these individuals.

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.

The role of cytochrome P4502E1 in ethanol mediated diseases: a narrative update

Cytochrome P450 (CYPs) superfamily of enzymes metabolize thousands of endogenous and exogenous substrates including ethanol. Results: Cytochrome P4502E1 (CYP2E1) is involved in ethanol metabolism as part of the so-called microsomal ethanol metabolizing system, in the metabolism of fatty acids and some drugs such as acetaminophen and isoniazid, and in the activation of a variety of procarcinogens (PCs). Chronic ethanol consumption induces CYP2E1 which may result in an enhanced metabolism of these drugs to their toxic intermediates, and in the generation of carcinogens. In addition, ethanol oxidation increases and is associated with the generation of reactive oxygen species (ROS). This oxidative stress is an important driver for the development of alcohol-associated liver disease (AALD) and alcohol-mediated cancer (AMC). ROS may bind directly to proteins and to DNA. ROS may also lead to lipid peroxidation (LPO) with the generation of LPO products. These LPO products may bind to DNA forming etheno-DNA adducts. Cell culture studies as well as animal experiments have shown that CYP2E1 knock-out animals or the inhibition of CYP2E1 by chemicals results in a significant improvement of liver histology. CYP2E1 is also involved in pathogenesis of hepatic steatosis and fibrosis. More recent studies in patients with AALD have demonstrated an improvement of serum transaminase activities when CYP2E1 was inhibited by clomethiazole. In addition to its role in the generation of ROS, CYP2E1 also enhances the activation of PCs and decreases the level of retinol and retinoic acid in the liver. Conclusion: Inhibition of CYP2E1 may improve AALD and may inhibit AMC.

Effect of luseogliflozin on liver fibrosis differs depending on alcohol consumption in patients with type 2 diabetes

AIM

Changes in FIB-4 levels after the initiation of luseogliflozin therapy were compared between patients with type 2 diabetes according to the presence or absence of alcohol consumption.

METHODS

A total of 192 patients with type 2 diabetes who continued luseogliflozin therapy for over 12 months were retrospectively investigated. The primary outcome was the change in FIB-4. The secondary outcomes were changes in HbA1c, body weight, and serum albumin concentration. A current drinker was defined as an individual consuming >20 g ethanol equivalent/day. Patients were classified according to their risk of developing liver fibrosis into the low-risk (FIB-4 < 1.3) and intermediate/high-risk (FIB-4 ≥ 1.3) groups.

RESULTS

In the low-risk group, while FIB-4 increased dramatically from 0.91 ± 0.30 at the baseline to 1.14 ± 0.34 at 12 months in drinkers (n = 27), non-drinkers (n = 79) showed no significant change (0.87 ± 0.22-0.91 ± 0.26). In the intermediate/high-risk group (n = 63), although the FIB-4 in drinkers (n = 23) showed no significant change (2.18 ± 1.00-2.16 ± 0.93), it significantly decreased from 2.10 ± 0.87 to 1.80 ± 0.68 in non-drinkers (n = 63). In both the low- and intermediate/high-risk groups, HbA1c and body weight significantly decreased in both drinkers and non-drinkers. Serum albumin concentrations significantly increased in both drinkers and non-drinkers in the low-risk group. Although serum albumin concentration did not significantly change in drinkers, it dramatically increased in non-drinkers in the intermediate/high-risk group.

CONCLUSIONS

HbA1c levels and body weight decreased in patients with type 2 diabetes after initiating luseogliflozin therapy, regardless of drinking habits. However, it is desirable to limit alcohol consumption when considering its effects on liver fibrosis.

Updated recommendations for the management of metabolic dysfunction-associated steatotic liver disease (MASLD) by the Latin American working group

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the leading causes of chronic liver disease globally. Based on the 2023 definition, MASLD is characterized by the presence of metabolic dysfunction and limited alcohol consumption (<140 grams/week for women, <210 grams/week for men). Given the significant burden of MASLD in Latin America, this guidance was developed by the Latin American Association for the Study of the Liver (ALEH) Working Group to address key aspects of its clinical assessment and therapeutic strategies. In Latin America, ultrasonography is recommended as the initial screening tool for hepatic steatosis due to its accessibility, while Fibrosis-4 (FIB-4) is preferred for fibrosis risk stratification, with further evaluation using more specific techniques (i.e., vibration-controlled transient elastography or Enhanced Liver Fibrosis [ELF] test). A Mediterranean diet is advised for all MASLD patients, with a target of 7-10% weight loss for those with excess weight. Complete alcohol abstinence is recommended for patients with significant fibrosis, and smoking cessation is encouraged regardless of fibrosis stage. Pharmacological options should be tailored based on the presence of steatohepatitis, liver fibrosis, excess weight, and diabetes, including resmetirom, incretin-based therapies, pioglitazone, and sodium-glucose cotransporter-2 inhibitors. Bariatric surgery may be considered for MASLD patients with obesity unresponsive to lifestyle and medical interventions. Hepatocellular carcinoma screening is advised for all cirrhotic patients, with consideration given to those with advanced fibrosis based on individual risk. Finally, routine cardiovascular risk assessment and proper diabetes prevention and management remain crucial for all patients with MASLD.

Head-to-Head Comparison Between Phosphatidylethanol Versus Indirect Alcohol Biomarkers for Diagnosis of MetALD Versus MASLD: A Prospective Study

BACKGROUND

The current subclassification of steatotic liver disease (SLD) relies on validated questionnaires, such as Alcohol Use Disorders Identification Test (AUDIT) and Lifetime Drinking History (LDH), which, while useful, are impractical and lack precision for their use in routine clinical practice. Phosphatidylethanol (PEth) is a quantitative, objective alcohol biomarker with high sensitivity and specificity.

AIMS

To assess the diagnostic accuracy of PEth for differentiating metabolic dysfunction and alcohol-associated liver disease (MetALD) from metabolic dysfunction-associated steatotic liver disease (MASLD) in a large, population-based, prospective, multiethnic cohort of individuals with overweight or obesity.

METHODS

This is a cross-sectional analysis of a prospective study including 374 adults with overweight or obesity residing in Southern California who had SLD as defined by MRI-PDFF ≥ 5%. The clinical research visit included medical history, biochemical and PEth testing, standardised validated questionnaires (including AUDIT and LDH), physical examination, and advanced imaging using MRI-PDFF and MRE.

RESULTS

Among 374 adults with SLD, the prevalence of MASLD, MetALD, and ALD was 90.1%, 6.4%, and 3.5%, respectively. PEth had a robust diagnostic accuracy in the detection of MetALD (AUROC 0.81, 95%CI 0.73-0.89) and the Youden cut-off was 25 ng/mL. In head-to-head comparative efficacy analysis, PEth was both statistically and clinically superior to all previously used indirect alcohol biomarkers for diagnosing MetALD, including aspartate aminotransferase/alanine aminotransferase ratio, mean corpuscular volume, gamma glutamyltransferase, and ALD/NAFLD index (p < 0.05).

CONCLUSIONS

PEth outperforms previously used non-invasive tests in differentiating MetALD from MASLD and has the potential to change clinical practice by enhancing the subclassification of SLD.

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.

Prevalence, characteristics and outcomes of patients with metabolic and alcohol related/associated liver disease (MetALD): a systematic review and meta-analysis

BACKGROUND

In light of the new nomenclature of steatotic liver disease (SLD), we aimed to enhance the existing knowledge on the epidemiology and clinical outcomes of metabolic and alcohol related/associated liver disease (MetALD).

METHODS

A systematic review and meta-analysis were performed in Medline/PubMed, Embase, Scopus and Cochrane databases to evaluate the prevalence and outcomes of MetALD within the SLD population and to compare the characteristics between MetALD patients and those with metabolic dysfunction associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD). Nineteen studies from nine countries that evaluated 4,543,341 adult participants with SLD were included.

RESULTS

The pooled overall prevalence of MetALD among the SLD population was 10 % (95%CI:7-13 %) without significant difference between Asian and non-Asian populations. However, MetALD was more frequent in men than women (86 % vs 14 %, p < 0.01), while Asian MetALD patients, were more frequent men (92 % vs 66 %, p < 0.01) compared to non-Asians. Additionally, in terms of metabolic characteristics there were no significant differences between MetALD, MASLD and ALD patients. Regarding outcomes, patients with MetALD, compared to non-SLD, were at increased risk of all-cause [HR 1.44 (95%CI:1.24-1.66)], cardiovascular disease (CVD) [HR 1.17 (95%CI:1.12-1.21)] and cancer-related mortality [HR 2.07 (95%CI:1.32-3.25)]. Finally, patients with MetALD, had increased incidence of CVD and liver decompensating events, compared to non-SLD participants [HR 1.49 (95%CI:1.03-2.15); HR 10.55 (95%CI:3.46-32.16) respectively].

CONCLUSIONS

Based on the existing literature, patients with MetALD consist a significant part of the SLD population, with high all-cause, CVD and cancer-related mortality and increased risk for CVD and hepatic decompensation.

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.

Current Status of Glucagon-like Peptide-1 Receptor Agonists in Metabolic Dysfunction-associated Steatotic Liver Disease: A Clinical Perspective

Metabolic dysfunction-associated steatotic liver disease (MASLD) is currently a pressing public health issue associated with adverse outcomes such as cirrhosis, malignancy, transplantation, and mortality. Lifestyle modifications constitute the most effective and fundamental management approach, but they often pose challenges in sustaining long-term clinical benefits. Hence, there is a critical need to enhance our understanding through pharmacological management, which unfortunately remains limited. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a leading treatment in the fields of diabetes and obesity, with recent preclinical and clinical studies indicating significant benefits in the management and treatment of MASLD. Our article begins by reviewing the beneficial therapeutic components of GLP-1RAs in MASLD. Subsequently, from a clinical research perspective, we concluded with the liver outcomes of current primary GLP-1RAs and co-agonists. Finally, we presented our insights on clinical concerns such as appropriate trial endpoints, management of comorbidities, and future developments. In conclusion, the benefits of GLP-1RAs in MASLD are promising, and background therapy involving metabolic modulation may represent one of the future therapeutic paradigms.

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.

Lights and shadows in the new definition of steatotic liver disease

The presence of marked hepatic steatosis in patients with high alcohol consumption was first described in 1836 by Addison et al.1 Many years later, in 1980, Ludwig and colleagues described a histological picture very similar to that seen in patients with alcoholic hepatitis but who did not consume alcohol, coining the term non-alcoholic steatohepatitis (NASH).2 In recent years, the terminology used to describe conditions related to hepatic steatosis has undergone significant evolution. In 2020, Eslam et al.3 subsequently modified it to MAFLD (Metabolic Associated Fatty Liver Disease) to better reflect its association with metabolic dysfunction, a nomenclature that, from the beginning, generated some reluctance due to the absence of clear international consensus.