Alcohol-Use Trajectories and Major Adverse Liver Outcomes in MetALD: A Nationwide Longitudinal Cohort Study

INTRODUCTION: Alcohol contributes to the progression of steatotic liver disease. However, in individuals with MetALD, the impact of changes in drinking behavior on disease progression remains unclear. We investigated whether longitudinal changes in alcohol consumption were associated with the risk of major adverse liver outcomes (MALO) in people with MetALD. METHODS: Data were obtained from the Korean National Health Screening Program. Adults with MetALD who completed three screening examinations (2009-2010, 2011-2012, and 2013-2014) were included (n = 85,554). Participants were categorized by alcohol consumption trajectories: Group 1 (sustained consumption), Group 2 (fluctuating consumption), and Group 3 (consistent reduction). The primary outcome was MALO, with cardiovascular death treated as a competing risk. Changes in cardiometabolic risk factors from baseline to the last examination were also evaluated. RESULTS: Over a median follow-up of 10.1 years, 32.9%, 34.6%, and 32.4% of participants were classified into Groups 1, 2, and 3, respectively. Groups 2 and 3 had lower MALO risks than Group 1 (adjusted subdistribution hazard ratios (95% confidence intervals), 0.80 (0.71-0.91) and 0.70 (0.61-0.79), respectively; both P <0.001). Compared with Group 1, Group 3 had higher rates of resolution of impaired fasting glucose, hypertriglyceridemia, and hypertension. DISCUSSION: Alcohol use in MetALD was highly dynamic, and hepatic risk was better captured using longitudinal drinking trajectories. Both intermittent and consistent alcohol reduction were associated with lower MALO risk, with a stronger association for consistent reduction. Consistent reduction was also accompanied by favorable changes in selected cardiometabolic risk factors.