Differentiating Metabolic-Associated Fatty Liver Disease (MASLD) and Metabolic-Alcoholic Fatty Liver Disease (MetALD)

Diagnostic Criteria

The American Association for the Study of Liver Diseases recommends diagnosing MetALD when patients have hepatic steatosis with at least one cardiometabolic risk factor and consume 20-50 g/day of alcohol in females or 30-60 g/day in males, whereas MASLD requires alcohol consumption below these thresholds (≤20 g/day in females, ≤30 g/day in males) 1, 2, 3
The European Association for the Study of the Liver suggests confirming hepatic steatosis by imaging (ultrasound, CT, MRI) or liver biopsy 1, 3
The American College of Gastroenterology recommends assessing cardiometabolic risk factors, including overweight/obesity, dysglycemia/type 2 diabetes, hypertriglyceridemia, low HDL-cholesterol, and hypertension 1, 4

The National Institute on Alcohol Abuse and Alcoholism suggests using detailed medical history, validated psychometric instruments, and/or biomarkers to assess current and historical alcohol consumption patterns 1, 3
The American Liver Foundation recommends quantifying alcohol consumption as follows: MASLD (≤20 g/day in females, ≤30 g/day in males), MetALD (20-50 g/day in females, 30-60 g/day in males), and ALD (>50 g/day in females, >60 g/day in males) 1, 2, 3

The American Association for the Study of Liver Diseases notes that MetALD represents a distinct subclass with worse prognosis than MASLD despite sharing identical cardiometabolic risk factor prevalence 1, 4
The European Association for the Study of the Liver reports that MetALD is associated with higher all-cause mortality compared to MASLD 1, 4

The American College of Gastroenterology warns against failing to quantify alcohol consumption accurately and relying solely on patient self-report, recommending the use of validated questionnaires (AUDIT-C) and biomarkers when available 1, 4

The American Diabetes Association and European Association for the Study of Diabetes define Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) as the presence of excess triglyceride storage in the liver in the presence of at least one cardiometabolic risk factor and the absence of harmful alcohol intake, according to the Diabetologia guidelines 5
The European Association for the Study of Diabetes recommends that MASLD diagnosis requires two essential components to be present simultaneously: hepatic steatosis and at least one cardiometabolic risk factor, including overweight or obesity, type 2 diabetes or impaired glucose metabolism, hypertension, and dyslipidemia, as stated in the Diabetologia journal 5, 6

The American Association for the Study of Liver Diseases notes that MASLD encompasses a spectrum of liver conditions ranging from simple steatosis to life-threatening complications, including MASL, MASH, fibrosis, cirrhosis, and hepatocellular carcinoma, as reported in the Diabetologia journal 5, 6, 7
The World Health Organization states that MASLD has become the most common chronic liver disease globally, affecting more than a quarter of the world's population, with prevalence expected to continue rising due to the obesity pandemic, according to the Diabetologia guidelines 5
The American Heart Association reports that the disease carries substantial morbidity and mortality through cardiovascular events, chronic kidney disease, hepatic and extrahepatic malignancies, and liver-related outcomes, including liver failure and HCC, as stated in the Diabetologia journal 5, 7