Diagnostic approaches to MetALD in the U.S.

Metabolic dysfunction and alcohol-associated steatotic liver disease, MetALD, is a new disease category within the spectrum of steatotic liver disease (SLD), that identifies individuals with MASLD who consume greater amounts of alcohol, but less than those with ALD. The MetALD criteria were developed empirically by a Delphi consensus process of experts in 2023, with ongoing efforts to study and provide supportive evidence. Despite some ongoing uncertainty about the definition of MetALD, its diagnosis is based on assessment of metabolic and alcohol-associated factors. Meeting the requirements for the metabolic component ("Met") is simpler based on the presence of at least one cardiometabolic risk factor (out of 5) with hepatic steatosis. Meeting the alcohol requirement is more complex given the defined upper and lower thresholds of alcohol use that can be difficult to quantify accurately and can fluctuate over time. Routine use of alcohol biomarkers like phosphatidylethanol (PEth) can be useful in the diagnosis of MetALD and other forms of SLD. Accounting for past history of alcohol use disorder, pathophysiologic changes of variables with advanced fibrosis, and the minimum time with a given MetALD variable to fulfill the requirement for MetALD are unresolved areas in need of future study. These diagnostic challenges have significant impacts on future studies, including epidemiology, early detection strategies, and clinical trial design.