Heavy drinking tied to increased fibrosis risk in MASLD

In a recent cross-sectional analysis, investigators evaluated how patterns of alcohol consumption, specifically episodic heavy drinking, influence risk stratification and nomenclature in steatotic liver disease (SLD). Published in Clinical Gastroenterology and Hepatology, the study findings highlight the limitations of relying solely on average alcohol intake when classifying liver disease.

Study design and population

Using data from the 2017–2023 National Health and Nutrition Examination Survey, investigators conducted a nationally representative cross-sectional study of 8,006 US adults with vibration-controlled transient elastography data. Among these, 4,571 individuals met criteria for SLD, including metabolic dysfunction–associated steatotic liver disease (MASLD), metabolic and alcohol-associated liver disease (MetALD), and alcohol-associated liver disease (ALD), noted Yinan Su, BA, of the Keck School of Medicine at the University of Southern California, in Los Angeles, and colleagues

Episodic heavy drinking was defined according to National Institute on Alcohol Abuse and Alcoholism criteria as 4 or more drinks for women or 5 or more drinks for men on any day, at least once per month. Liver fibrosis was assessed using liver stiffness measurements, with 8 kPa or greater indicating significant fibrosis and 12 kPa or more indicating advanced fibrosis, investigators noted.  

Key findings

The study demonstrated that episodic heavy drinking is common, even among patients categorized as MASLD. “Among MASLD, 632 (15.9%) had episodic heavy drinking,” noted Su and colleagues, highlighting a substantial subgroup not captured by current nomenclature.

Importantly, episodic heavy drinking was independently associated with worse liver outcomes. In MASLD patients, it was linked to increased odds of both significant fibrosis and advanced fibrosis. The authors reported that “episodic heavy drinking is prevalent in MASLD and associated with three-fold higher odds of advanced liver fibrosis.”

The adjusted prevalence of significant fibrosis was 23.6% in MASLD patients with episodic heavy drinking compared with 15.6% in those without. These findings suggest that even intermittent high-intensity alcohol exposure may be associated with greater liver disease severity.

The study also explored how incorporating episodic heavy drinking into SLD classification would alter epidemiologic estimates. Reclassifying MASLD patients with episodic heavy drinking as MetALD reduced the estimated prevalence of MASLD from 48% to 40.4%, while increasing MetALD from 5.3% to 12.9%.

“Reclassifying these patients to MetALD would more than double the estimated prevalence of MetALD,” the authors said.

Clinical interpretation

This study highlights a gap in the current classification of steatotic liver disease, where reliance on average weekly alcohol intake may miss risky drinking patterns. Even patients who don’t drink much overall may potentially still harm their liver if they occasionally drink heavily, the study noted.

Brian P. Lee, M.D., study author and hepatologist and liver transplant specialist with Keck Medicine of USC, emphasized this paradigm shift in an interview with GI & Hepatology News.

“Patients often ask how much they can drink. In the liver world, we’re used to thinking about this as an average. For example, in the liver nomenclature, we categorize patients based on alcohol consumption per week,” he said. “We sought to answer whether it mattered not only how much, but also whether the pattern of drinking affected the risk of having liver disease. The key takeaway is that the pattern matters very much, and that episodic heavy drinking is an incredibly common pattern right now among US adults that even when it’s occasional, can be especially harmful.”

The findings highlight the importance of incorporating drinking patterns, including episodic heavy use, into alcohol assessments in clinical practice, rather than relying solely on average weekly intake.

Limitations

The study had several limitations worth noting. Its cross-sectional design precludes causal inference, and alcohol use was self-reported, introducing potential recall and reporting bias. Additionally, transient elastography, while widely used, may be influenced by recent alcohol intake. The absence of viral hepatitis data for part of the cohort and relatively small subgroup sizes for MetALD and ALD further limited precision.

The authors had no relevant conflicts of interest. The National Institute on Alcohol Abuse and Alcoholism supported the research.