Steatotic liver disease — the paradigm shift
In September 2024, an interdisciplinary European guideline advised a shift from the previous dichotomy of alcoholic and non-alcoholic fatty liver.1 This change prompts consideration for the complex, overlapping harms between alcohol intake, liver disease, and cardiometabolic risk factors, which can easily be overlooked in primary care.
The new guideline proposes using an overarching term, steatotic liver disease (SLD), defined as radiological or histological evidence of liver steatosis,1 which is split into three main categories: metabolic associated steatotic liver disease (MASLD), alcoholic liver disease (ALD), and the new metabolic alcoholic liver disease (MetALD). Table 1 provides the alcohol consumption thresholds for each, alongside the World Health Organization categories for alcohol consumption used by the National Institute for Health and Care Excellence.2
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Table 1. The alcohol consumption thresholds for the categories of SLD, converted from the g/day used in the European guidelines,1 alongside WHO alcohol consumption2
MetALD describes adults with steatotic liver disease and a history of alcohol use that is below the threshold for ALD. It was introduced because of the presence of a harmful relationship between alcohol intake and cardiometabolic risk factors in SLD. MetALD, when compared with MASLD, not only has an increased risk of progression to cirrhosis1, but also other non-communicable diseases. Studies re-examining prospective cohorts with this new terminology have found a rise in all-cause …
