Jophlin, Loretta et al.
Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%–50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%–60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.
Alcohol-associated liver disease (ALD) is a leading cause of preventable liver-related morbidity and mortality worldwide, including the United States. Harmful drinking (≥3 drinks/d or ≥21/wk in men and ≥2 drinks/d or ≥14/wk in women) is a risk factor for liver damage and ALD and often occurs in the setting of alcohol use disorder (AUD) (1,2). This pattern of alcohol use is associated with negative social and/or health consequences. The spectrum of ALD ranges from steatosis and steatohepatitis to progressive fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) and includes the unique presentation of alcohol-associated hepatitis (AH), with development of acute on chronic liver failure (ACLF) in more severe forms (Figure 1). The diagnosis of ALD requires identification of chronic, harmful alcohol use, by patient report or detection of alcohol biomarkers, and exclusion of other diseases affecting the liver. It should be acknowledged that harmful alcohol use can accelerate progression of other hepatic diseases including metabolic dysfunction-associated steatotic liver disease (MASLD). Individuals with early ALD may be asymptomatic, with steatosis or steatohepatitis and early stage fibrosis. Advanced patients with ALD may have advanced fibrosis including cirrhosis, complications of cirrhosis with decompensating events (ascites, hepatic encephalopathy, variceal bleeding, and HCC), or symptomatic AH with jaundice and/or ACLF (1). Treatment of AUD with achievement of sustained abstinence is the most effective strategy to prevent disease progression and improve long-term outcomes at any stage of ALD. Liver transplantation (LT) remains a definitive treatment option for patients with end-stage liver disease due to alcohol-associated cirrhosis and/or HCC.