Spotlight on steatotic liver disease types

Metabolic dysfunction-associated steatotic liver disease (MASLD) alone is far more common than alcohol-related liver disease (ALD) or the combination of both (metabolic alcohol-related liver disease or MetALD) but appears less deadly, according to recent studies.

One study, published by the Journal of Clinical Gastroenterology on May 28, estimated the age-standardized prevalence of the three subtypes among U.S. adults, using 2017 to 2023 data from the National Health and Nutrition Examination Survey. Overall, the prevalence of MASLD was 32.42%, MetALD was 2.20%, and ALD was 1.29%. Men had higher prevalence of all three compared to women. The highest prevalence of MASLD was in Mexican-Americans (43.96%) and the lowest in Black Americans (27.39%). MetALD was most prevalent among Whites (2.56%). Between 2017-2020 and 2021-2023, there was a significant rise in ALD prevalence, from 0.93% to 1.68%, an 80.6% increase. The prevalence of advanced fibrosis with any of the subtypes also rose between the surveys, from 2.47% to 3.30%. “Although steatosis prevalence seems stable, the increasing burden of advanced fibrosis—particularly among those with severe obesity and high alcohol use—signals a worsening disease trajectory,” said the study authors, adding that the findings highlight “the urgent need for public health strategies focused on obesity prevention, metabolic health optimization, and liver fibrosis screening to mitigate the rising toll of chronic liver disease.”

The next study, published by the Journal of Hepatology on May 24, focused on patients with imaging-confirmed hepatic steatosis receiving outpatient care from the Veterans Administration in 2010 to 2021. Of the 366,433 patients, 77.9% had MASLD, 17.5% had MetALD, and 4.6% had ALD. With a median follow-up of 5.4 years, the researchers calculated that for patients without cirrhosis, the 10-year cumulative incidence of death from cardiovascular disease was 8.1% with MASLD, 7.5% with MetALD, and 8.1% wit ALD. For deaths from non-hepatic cancers, the rates were 7.5%, 7.4%, and 7.4%, respectively. Liver-related mortality was significantly lower with non-cirrhotic MASLD (0.04 per 100 person-years) than MetALD (0.19 per 100 person-years; hazard ratio [HR], 3.38 [95% CI, 3.02 to 3.78]) or ALD (0.40 per 100 person-years; HR, 6.99 [95% CI, 6.08 to 8.04]). The same trend was true, but less pronounced, in patients with cirrhosis. “The progressively increasing risk of liver-related mortality from MASLD to MetALD to ALD underscores the critical role of alcohol use in disease prognosis,” said the study authors. “Taken altogether, our findings highlight the need for an integrated care model that simultaneously addresses liver disease, increased alcohol consumption, and cardiovascular risk to reduce mortality in SLD throughout the disease spectrum.”

Another study, by the same authors and based on the same patient population, was published by JAMA Internal Medicine on June 16. It focused on the outcomes of adverse liver events (cirrhosis, decompensation, hepatocellular carcinoma, liver transplant, liver-related death), major adverse cardiovascular events (MACE), and all-cause mortality across the subtypes. It found that those with MetALD had a higher incidence of the liver outcomes (1.12 vs. 0.61 per 100 person-years; hazard ratio [HR], 1.56 [95% CI, 1.50 to 1.62) and all-cause mortality (2.74 vs. 2.60 per 100 person-years; HR, 1.08 [95% CI, 1.05 to 1.10]) as those with MASLD, but similar incidence of MACE. ALD was associated with higher risk of liver events and mortality, but similar risk of MACE, compared to MASLD. Risk of adverse liver outcomes increased with fibrosis-4 score across all subtypes. “These findings underscore the role of alcohol and fibrosis assessments in clinical practice for risk stratification,” the study authors said.