Abstract
Background and aims
Alcohol use disorder (AUD) follows a chronic, relapsing course but is often overlooked when alcohol consumption is minimal at the time of evaluation. We aimed to assess the prognostic impact of a prior AUD diagnosis on liver-related outcomes in patients with presumed metabolic dysfunction-associated steatotic liver disease (MASLD).
Design
Retrospective cohort study utilizing 1:1 propensity score matching to balance demographics, comorbidities, and laboratory data.
Setting
A multi-institutional network of 73 healthcare organizations in the United States, from January 2010 to January 2024.
Participants
82 472 adults with newly diagnosed MASLD, comprising 41 236 patients with a documented prior diagnosis of AUD and 41 236 matched controls without AUD. Patients with pre-existing liver disease (other than MASLD) or subsequent diagnoses of alcohol-associated liver disease were excluded.
Measurements
Incidence rates and hazard ratios (HRs) for cirrhosis, hepatic decompensation, hepatocellular carcinoma and the composite of liver transplantation or all-cause mortality.
Findings
Over a median follow-up of 3 years, patients with prior AUD had statistically significantly higher risks of cirrhosis [HR = 1.38; 95% confidence interval (CI) = 1.20–1.59], hepatic decompensation (HR = 1.12; 95% CI = 1.01–1.24) and liver transplantation or mortality (HR = 1.39; 95% CI = 1.31–1.47) compared with non-AUD controls. This excess risk was attenuated among patients with high metabolic burden (≥3 cardiometabolic risk factors).
Conclusions
Among patients with presumed metabolic dysfunction-associated steatotic liver disease (MASLD), a history of alcohol use disorder appears to be independently associated with adverse clinical outcomes, particularly in those with fewer metabolic risk factors. These findings highlight a missed clinical opportunity and support the integration of longitudinal alcohol assessments and behavioral interventions into the care of patients with presumed MASLD.