Steatotic liver disease common in people with metabolic, alcohol risk factors

Steatotic liver disease (SLD) appears to be highly prevalent among individuals with cardiometabolic or alcohol risk factors, while elevated liver stiffness and advanced liver fibrosis are not uncommon, reports a recent study.

"Given the high prevalence of metabolic and alcohol-related risk factors, the finding that 1–4 percent of at-risk individuals have undetected severe liver fibrosis suggests a substantial number of affected individuals in the general population,” the investigators said. 

A total of 3,123 participants aged 30–75 years were recruited between October 2017 and November 2022 into the following: a) the metabolic cohort (n=1,599), comprising individuals with BMI >30 kg/m² and/or type 2 diabetes without prolonged increased alcohol consumption, or b) the alcohol cohort (n=1,524), comprising those with ongoing or prior increased alcohol consumption.

The investigators assessed liver steatosis by controlled attenuation parameter (CAP), liver fibrosis by liver stiffness measurements (LSM), and conducted liver biopsies in individuals with LSM ≥8 kPa.

Of the participants, 2,197 (70 percent) were diagnosed with LSD: 1,603 (51 percent) with metabolic dysfunction-associated steatotic liver disease (MASLD), 398 (13 percent) with metabolic- and alcohol-related liver disease (MetALD), and 196 (6.3 percent) with alcohol-related liver disease (ALD). [J Hepatol 2025;83:1278-1291]

In addition, some 307 individuals (9.8 percent) had LSM ≥8 kPa, of whom 169 (55 percent) underwent liver biopsy.

In the metabolic cohort, 1,237 (77 percent) had SLD, 147 (9.2 percent) had LSM ≥8 kPa, and 24 (1.5 percent had biopsy-confirmed liver fibrosis. In the alcohol cohort, 960 (63 percent) had SLD, 160 (10.5 percent) had LSM ≥8 kPa, and 46 (3.1 percent) had biopsy-confirmed advanced liver fibrosis.

Across subgroups, the highest liver disease severity was noted in ALD (LSM ≥8 kPa: 25 percent; biopsy-confirmed advanced fibrosis: 8 percent), while severity did not significantly differ between MASLD and MetALD (LSM ≥8 kPa: 12 percent; biopsy-confirmed advanced fibrosis: 3 percent).

These findings align with the described natural history of disease. [J Hepatol 2022;77:1237-1245; J Hepatol 2021;75:1017-1025]

On the other hand, a recent study from the NHANES cohort showed elevated liver stiffness in 21 percent of individuals with MASLD compared with 14 percent of those with MetALD and ALD. [Clin Gastroenterol Hepatol 2024;22:1330-1332.e4]

"Our study further suggests that liver disease severity is similar between MASLD and MetALD, which conflicts with the evidence of a synergistic or additive effect of alcohol and metabolic dysfunction on the risk of liver fibrosis progression,” the investigators said. [Clin Gastroenterol Hepatol 2022; 20:1784-1794; Public Health 2023;226:39-52; BMJ 2010;340doi]

“Interestingly, individuals with MetALD in our cohort reported higher levels of income, education, and physical activity—factors that may mitigate the harmful effects of alcohol and help explain the protective association of a current high alcohol intake with SLD in our univariate analysis,” they added.

Furthermore, about one in four (24 percent) individuals with current excessive alcohol intake showed no SLD and a more favourable metabolic risk profile.

“Together with the finding that insulin resistance was the most prominent risk factor for liver fibrosis, this emphasizes the importance of metabolic profile assessment and management across all SLD subclasses,” the investigators said.