Impact of Longitudinal Alcohol Use Patterns on Long-Term Risk of Cirrhosis Among US Veterans With Steatotic Liver Disease

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.

Steatotic Liver Disease Classification is Dynamic, Affecting Clinical Trial Eligibility and Subclass-Specific Treatments

BACKGROUND & AIMS

Steatotic liver disease (SLD) includes the subclasses metabolic-dysfunction-associated steatotic liver disease, metabolic and alcohol-related liver disease, and alcohol-related liver disease. We investigated the robustness of the SLD diagnoses after 2 years.

METHODS

We performed a prospective cohort study among individuals from the general population and individuals at risk of SLD. Participants were classified according to the diagnostic criteria of the SLD nomenclature at baseline and after 2 years.

RESULTS

We included 1042 participants, mean age was 57 ± 10 years, 663 were male (64%) and 379 (36%) female, and 70 (7%) had advanced fibrosis. At baseline, 595 (57%) had SLD, hereof 371 (62%) met the criteria for metabolic-dysfunction-associated steatotic liver disease, 140 (24%) for metabolic and alcohol-related liver disease, and 83 (14%) for alcohol-related liver disease, and 1 (<1%) was classified as cryptogenic SLD. Median time between the baseline and follow-up visit was 25 months (interquartile range, 24-31). Overall, 399 (38%) of the 1042 participants changed SLD classification from baseline to follow-up. In the group without SLD at baseline, 25% had SLD at follow-up. In comparison, 38% with metabolic-dysfunction-associated steatotic liver disease at baseline were classified differently at follow-up, whereas 62% and 69% of participants with baseline metabolic and alcohol-related liver disease and alcohol-related liver disease were classified differently at follow-up. The primary reasons for changing classification were that individuals no longer met the criteria for having SLD or had altered their alcohol intake.

CONCLUSIONS

SLD and the subclassification hereof is highly dynamic, especially driven by changes in alcohol use and hepatic steatosis. This affects eligibility for clinical trials and clinical management of patients with 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.

Focused Recommendations for the Management of Metabolic Dysfunction-Associated Steatohepatitis (MASH) by Advanced Practice Providers in the United States

Metabolic dysfunction-associated steatohepatitis (MASH) has become the dominant cause of liver disease in the United States. With the growing burden of this disease in gastroenterology practices, the identification and treatment of those at risk of developing adverse outcomes (cirrhosis, hepatocellular carcinoma, or liver-related death) has become urgent. In recent years, the development of noninvasive tests (NITs) to identify "at-risk MASH" patients have provided cost-effective algorithms to identify these patients. Although treatment has historically been limited to lifestyle modification, recent FDA approval of resmetirom for noncirrhosis MASH with stages 2 and 3 fibrosis has provided a new opportunity in the United States to provide these patients with novel treatment options. Other new effective treatment regimens are on the horizon. Given that gastroenterology and hepatology practices in the United States heavily rely on advanced practice providers (APPs) to manage patients with MASLD, the APP Committee of the Global NASH/MASH Council has curated the essentials of day-to-day MASH management for our busy gastrohepatology providers and their APP colleagues. The goal of this document is to equip and mobilize more GI providers with the requisite competencies for the management of at-risk MASH, given the rapidly evolving MASH treatment landscape.

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.