Misclassified ALD is common in presumed MASLD and highly increases risk for future cirrhosis

BACKGROUND AND AIMS:Alcohol overconsumption is a risk factor for disease progression in patients with presumed metabolic dysfunction-associated steatotic liver disease (MASLD). How commonly this occurs and how it affects progression to major adverse liver outcomes (MALO) is not well known. METHODS:We did a register-based cohort study, including all patients with a diagnosis of MASLD in Sweden between 1987 and 2020. Patients were stratified on co-occurrence of diagnoses of alcohol-related liver disease (ALD) or alcohol use disorder (AUD) prior to MASLD diagnosis. Incident MALO:s were derived from national registers. Cox regression was used to calculate hazard ratios for incident MALO. RESULTS:A total of 15,107 patients with MASLD were identified. Median age was 55 years and 52% were female. 1,843 (12%) had a prior diagnosis of ALD or AUD. During follow-up, a further 787 (5.2%) received a diagnosis of ALD or AUD. Patients with previous ALD or AUD diagnoses at or before baseline had considerably higher rates of MALO compared to patients without (19.5% vs 7.8%, aHR=3.12, 95%CI=2.74-3.55). Acquiring an ALD or AUD diagnosis after MASLD diagnosis was associated with higher rates of MALO (aHR=5.81, 95%CI=4.90-6.88). CONCLUSIONS:ALD or AUD is commonly diagnosed prior to or after MASLD diagnosis. Such patients have considerably higher rates of progression to MALO. Correctly separating between MASLD and ALD is vital to assess prognosis.