Clinical trajectories, diagnostic framework and risk-stratified management across the MASLD–MetALD–ALD spectrum. (IMAGE)

First Hospital of Jilin University

Clinical trajectories, diagnostic framework and risk-stratified management across the MASLD–MetALD–ALD spectrum.

Caption

This schematic depicts the continuum of SLD, including MASLD, MetALD and ALD, with dynamic transitions driven by metabolic factors and alcohol use. Diagnosis integrates structured history, validated tools (AUDIT/AUDIT-C) and direct biomarkers such as PEth in blood and EtG in hair to estimate recent alcohol intake. Risk stratification relies on non-invasive fibrosis assessment: low risk (FIB-4 <1.3), moderate risk (FIB-4 of 1.3–2.67 plus VCTE <8 kPa) and high risk (FIB-4 >2.67 or FIB-4 of 1.3–2.67 plus VCTE ≥8 kPa). Management is risk-based, combining alcohol reduction or abstinence and metabolic optimisation. Advanced disease may require pharmacotherapy, bariatric surgery or liver transplantation, whereas disease progression may potentially lead to cirrhosis and hepatocellular carcinoma. *Metabolic dysfunction includes obesity, type 2 diabetes or hyperglycaemia, dyslipidaemia (high triglycerides and/or low high-density lipoprotein cholesterol) and arterial hypertension. **The suggested cut-off values of PEth are: MASLD <20 ng/mL; MetALD: 20–200 ng/mL; ALD >200 ng/mL according to expert review. ***The threshold for FIB-4 is >2.0 in individuals aged >65 years. ****Alcohol intake should be assessed as a cumulative value not only based on the recent self-reports. ALD, alcohol-associated liver disease; AUD, alcohol use disorder; AUDIT, alcohol use disorders identification test; AUDIT-C, alcohol use disorders identification test-consumption; EtG, ethyl glucuronide; FIB-4, fibrosis-4; MASH, metabolic dysfunction-associated steatohepatitis; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-associated liver disease; PEth, phosphatidylethanol; SLD, steatotic liver disease; VCTE, vibration-controlled transient elastography.

Credit

By Lanlan Chen, Paul Horn, Frank Tacke.

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Credit must be given to the creator.

License

CC BY

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