Misclassification of Alcohol Use Disorder in MASLD and MetALD: Prevalence, Clinical Characteristics, and Outcomes

Abstract

Background/Aims: Within metabolic dysfunction and alcohol-associated liver disease (Met-ALD), there exists a continuum where the condition can conceptually shift between being metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease. However, alcohol use disorder (AUD) can be included in these diagnoses. The aim of this study was to investigate the prevalence and clinical characteristics of misclassified AUD among patients with MASLD and MetALD. Methods: The study included a total of 3,362,552 participants from the 2011 to 2012 National Health Screening Program. Steatotic liver disease was defined as having a hepatic steatosis index score of 36 or higher. Significant alcohol intake was calculated on the basis of self-report questionnaire responses. AUD was defined as having received medical care for an alcohol-related condition at least once during the study period. The mean follow-up period for participants was 9.8 years. Results: MASLD and MetALD prevalence were 23.8% and 1.9%, respectively. AUD was identified in 1.1% (8,481 individuals) of MASLD and 4.7% (2,989 individuals) of MetALD cases. Misclassified AUD was associated with significantly higher all-cause and liver-related mortality. Adjusted hazard ratios for liver-related mortality were 6.53 for AUD misclassified as MASLD and 6.98 forAUD misclassified as MetALD. Extrahepatic cancer mortality risk was also elevated (adjusted hazard ratio: 1.33 in MASLD and 1.44 in MetALD). Conclusions: A significant number of AUD cases were misclassified as MASLD and MetALD in cross-sectional assessment of alcohol consumption. Patients with AUD misclassified as MASLD or MetALD had higher liver-related mortality than the pure MASLD and MetALD groups. (Gut Liver, 2025;19:735-745)