Hidden Burden of Alcohol Use Disorder in MASLD and MetALD: Clinical and Nomenclatural Implications (original) (raw)

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Editorial

Yuri Cho

Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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The recent article by Lee et al.1 provides an important lens through which we may re-examine the new nomenclature of steatotic liver disease (SLD), particularly the challenges arising from the coexistence of metabolic dysfunction and alcohol use disorder (AUD). Their nationwide cohort study of over 3.3 million Korean adults demonstrates that misclassified AUD, when labeled as metabolic dysfunction-associated steatotic liver disease (MASLD) or metabolic and alcohol-associated liver disease (MetALD), is associated with substantially worse liver-related and overall outcomes than MASLD or MetALD without AUD.

This study underscores two critical issues in hepatology today: the limitations of cross-sectional self-reported alcohol intake in defining SLD subtypes, and the under-recognition of AUD as a clinical entity distinct from mere alcohol consumption thresholds. By relying on International Classification of Diseases (ICD-10) codes rather than self-report alone, the authors highlight that AUD identifies a subgroup with markedly higher risks of hepatocellular carcinoma, liver-related complications, and mortality.2 Importantly, the hazard ratios for liver-related death in misclassified AUD groups exceeded those of alcohol-related liver disease (ALD) itself, suggesting that hidden AUD may portend an even graver prognosis than overt heavy alcohol use.3

These findings carry immediate clinical and research implications. First, hepatologists must realize that the presence of AUD cannot be captured by consumption data alone. The MASLD/MetALD nomenclature4 relies heavily on alcohol intake cutoffs, yet AUD is a behavioral diagnosis that spans a spectrum of severity and consequences independent of grams per day. In real-world practice, a patient with MASLD by alcohol threshold but with concurrent AUD may, in fact, follow a disease trajectory more akin to ALD.5 This distinction is not merely semantic; it should influence surveillance strategies, counseling, and therapeutic priorities.

Second, the data emphasize the need for comprehensive alcohol histories and objective biomarkers. Reliance on a single questionnaire at baseline overlooks the dynamic nature of drinking behavior, including periods of abstinence or relapse. Incorporation of biomarkers such as phosphatidylethanol or carbohydrate-deficient transferrin, as well as longitudinal assessments, may help overcome recall bias and underreporting. Until such measures become standard, clinicians should maintain vigilance for “hidden” MetALD patients who deny or understate alcohol intake but manifest clinical features of AUD.6

Third, the results highlight the prognostic overlap between misclassified AUD and ALD. In the cohort, both misclassified MASLD and MetALD with AUD demonstrated nearly seven-fold increased risk of liver-related mortality compared with their counterparts without AUD. These data suggest that, despite nomenclatural efforts to create clarity, the clinical reality of SLD remains entangled with alcohol misuse. As we adopt the MASLD framework, careful attention must be paid to ensure that AUD is not sidelined, but rather systematically identified and integrated into patient risk stratification.

Looking ahead, several avenues merit exploration. Prospective studies should integrate validated AUD screening tools alongside alcohol intake questionnaires, to dissect how behavioral dependence modifies outcomes within SLD categories. Mechanistic studies are also needed to clarify why AUD confers greater mortality than ALD alone, perhaps reflecting synergistic injury from metabolic dysfunction and addictive alcohol use. Importantly, public health strategies must recognize that MASLD and MetALD are not mutually exclusive of AUD, and that early detection of AUD may be as critical as metabolic risk modification in altering prognosis.

In summary, Lee et al.1 bring to light the hidden burden of AUD within MASLD and MetALD, a finding with profound implications for both nomenclature and patient care. Clinicians must advocate for a holistic assessment of alcohol use that extends beyond grams per day, embracing behavioral diagnoses, biomarkers, and longitudinal tracking. Only then can the promise of the new SLD classification be realized without obscuring one of the oldest and most lethal contributors to liver disease: AUD.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

Lee JH, Ahn SH, Park J, et al. Misclassification of alcohol use disorder in MASLD and MetALD: prevalence, clinical characteristics, and outcomes. Gut Liver 2025;19:735-745.
Kim SE. Rising burden of alcohol-associated liver disease and cancers: insights into sex disparities and policy implications. Clin Mol Hepatol. Epub 2025 May 15. https://doi.org/10.3350/cmh.2025.0516
Roldan GA, Tricarico C, Brown RS Jr. Alcohol use disorder and alcohol-associated liver disease: new definitions, screening, and treatment. Gastroenterol Hepatol (N Y) 2024;20:662-671.
Eslam M, Newsome PN, Sarin SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol 2020;73:202-209.
Park JW, Suk KT. The effect of moderate alcohol consumption on nonalcoholic fatty liver disease. Clin Mol Hepatol 2023;29:408-410.
Arab JP, Díaz LA, Rehm J, et al. Metabolic dysfunction and alcohol-related liver disease (MetALD): position statement by an expert panel on alcohol-related liver disease. J Hepatol 2025;82:744-756.

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