Misclassification of Alcohol Use Disorder in MASLD and MetALD: Prevalence, Clinical Characteristics, and Outcomes - PubMed (original) (raw)

. 2025 Sep 15;19(5):735-745.

doi: 10.5009/gnl250072. Epub 2025 Jul 25.

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Misclassification of Alcohol Use Disorder in MASLD and MetALD: Prevalence, Clinical Characteristics, and Outcomes

Jun-Hyuk Lee et al. Gut Liver. 2025.

Abstract

Background/aims: Within metabolic dysfunction and alcohol-associated liver disease (MetALD), there exists a continuum where the condition can conceptually shift between being metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease. However, alcohol use disorder (AUD) can be included in these diagnoses. The aim of this study was to investigate the prevalence and clinical characteristics of misclassified AUD among patients with MASLD and MetALD.

Methods: The study included a total of 3,362,552 participants from the 2011 to 2012 National Health Screening Program. Steatotic liver disease was defined as having a hepatic steatosis index score of 36 or higher. Significant alcohol intake was calculated on the basis of self-report questionnaire responses. AUD was defined as having received medical care for an alcohol-related condition at least once during the study period. The mean follow-up period for participants was 9.8 years.

Results: MASLD and MetALD prevalence were 23.8% and 1.9%, respectively. AUD was identified in 1.1% (8,481 individuals) of MASLD and 4.7% (2,989 individuals) of MetALD cases. Misclassified AUD was associated with significantly higher all-cause and liver-related mortality. Adjusted hazard ratios for liver-related mortality were 6.53 for AUD misclassified as MASLD and 6.98 for AUD misclassified as MetALD. Extrahepatic cancer mortality risk was also elevated (adjusted hazard ratio: 1.33 in MASLD and 1.44 in MetALD).

Conclusions: A significant number of AUD cases were misclassified as MASLD and MetALD in cross-sectional assessment of alcohol consumption. Patients with AUD misclassified as MASLD or MetALD had higher liver-related mortality than the pure MASLD and MetALD groups.

Keywords: Alcohol use disorder; Alcohols; Metabolic dysfunction and alcohol-associated liver disease; Metabolic dysfunction-associated steatotic liver disease; Mortality.

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Conflict of interest statement

CONFLICTS OF INTEREST

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

Figures

Fig. 1

Fig. 1

Flowchart of the study population selection. HSI, hepatic steatosis index; SLD, steatotic liver disease; ALD, alcoholic liver disease; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic and alcohol-associated liver disease; AUD, alcohol use disorder.

Fig. 2

Fig. 2

Kaplan-Meier survival curve showing cumulative incidence rates of liver-related mortality (A), CVD mortality (B), extrahepatic cancer mortality (C), and all-cause mortality (D) based on MASLD/MetALD with or without AUD status. CVD, cardiovascular disease; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-associated liver disease; AUD, alcohol use disorder.

Fig. 3

Fig. 3

Kaplan-Meier survival curve showing cumulative incidence rates of HCC (A) and LRCs (B) based on MASLD/MetALD with or without AUD status. HCC, hepatocellular carcinoma; LRCs, liver-related complications; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-associated liver disease; AUD, alcohol use disorder.

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