Alcohol and metabolic dysfunction interaction: MetALD

In 2023, the concept of metabolic dysfunction-associated steatotic liver disease (MASLD) combined with metabolic dysfunction and alcohol-related liver disease (MetALD) emerged for patients who meet MASLD criteria and have risky alcohol consumption (20-50 g/day in women and 30-60 g/day in men). Although conceptually useful, the new nomenclature faces controversies: alcohol thresholds are variable and poorly supported, the boundary between metabolic and alcohol-related etiology is blurred, and prospective studies defining the specific risks of MetALD are lacking. The prevalence of MetALD is highly variable. Risk is greater in men with visceral obesity and type 2 diabetes, and it is associated with more advanced fibrosis and a higher incidence of hepatocellular carcinoma. In the pathophysiology of MetALD, alcohol metabolism–related injury converges with insulin resistance, lipogenesis, oxidative stress, mitochondrial dysfunction, activation of inflammatory pathways, and hepatic stellate cell activation driving fibrogenesis. Diagnostic evaluation should be comprehensive, documenting the presence of steatosis, confirming MASLD criteria, demonstrating evidence of risky alcohol consumption, and stratifying fibrosis. Treatment focuses on alcohol abstinence, strict control of metabolic risk factors, and surveillance for complications.