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Citation

Arab JP, Díaz LA, Rehm J, Im G, Arrese M, Kamath PS, Lucey MR, Mellinger J, Thiele M, Thursz M, Bataller R, Burton R, Chokshi S, Francque SM & Krag A (2025) Metabolic dysfunction and alcohol-related liver disease (MetALD): Position statement by an expert panel on alcohol-related liver disease. Journal of Hepatology, 82 (4), pp. 744-756. https://doi.org/10.1016/j.jhep.2024.11.028

Abstract
In this position statement, we explore the intricate relationship between alcohol intake and metabolic dysfunction in the context of the 2023 nomenclature update for steatotic liver disease (SLD). Recent and lifetime alcohol use should be accurately assessed in all patients with SLD to facilitate classification of alcohol use in grams of alcohol per week. Alcohol biomarkers (i.e., phosphatidylethanol), use of validated questionnaires (i.e. AUDIT-C [alcohol use disorders identification test consumption]), and collateral information from friends and relatives could help facilitate differentiation between alcohol-related liver disease (ALD) per se and liver disease with both metabolic and alcohol-related components (MetALD). Heavy alcohol use can contribute to cardiometabolic risk factors such as high blood pressure, hypertriglyceridaemia, and hyperglycaemia. As a result, caution should be exercised in the application of only one metabolic dysfunction criterion to diagnose MASLD, as suggested in the 2023 nomenclature document, particularly in individuals exceeding weekly alcohol use thresholds of 140 g for women and 210 g for men. This is particularly important in those individuals with isolated high blood pressure, hypertriglyceridaemia, or hyperglycaemia, where the disease process may be driven by alcohol itself. Additionally, metabolic dysfunction and alcohol use should be reassessed over time, especially after periods of change in risk factor exposure. This approach could ensure a more accurate prognosis and effective management of SLD, addressing both metabolic and alcohol-related factors.

Keywords
MASLD; MetALD; NASH; MASH; non-alcoholic fatty liver disease; alcohol-related liver disease; alcoholic liver disease; alcoholic cirrhosis; public health

Notes
Additional authors: Carolin Lackner, Brian P. Lee, Suthat Liangpunsakul, Craig MacClain, Pranoti Mandrekar, Mack C. Mitchell, Marsha Y. Morgan, Timothy R. Morgan, Elisa Pose, Vijay H. Shah, Debbie Shawcross, Nick Sheron, Ashwani K. Singal, Horia Stefanescu, Norah Terrault, Eric Trépo, Christophe Moreno, Alexandre Louvet, Philippe Mathurin

Journal
Journal of Hepatology: Volume 82, Issue 4