MetALD in Clinical Practice: Diagnosis, Non-Invasive Risk Stratification, and Management

Metabolic dysfunction-associated steatotic liver disease with increased alcohol consumption (MetALD) is a newly defined category within the spectrum of steatotic liver disease. It captures patients who have both cardiometabolic risk factors and alcohol intake above the thresholds accepted for metabolic dysfunction-associated steatotic liver disease (MASLD). This overlap matters clinically, as the coexistence of metabolic dysfunction and increased alcohol exposure is associated with a higher risk of progressive liver disease. In this narrative review, we bring together current evidence on the diagnosis, non-invasive risk stratification, and management of MetALD, with particular attention to serum-based fibrosis scores such as the Fibrosis-4 (FIB-4) index and imaging-based methods including vibration-controlled transient elastography and controlled attenuation parameter. We also consider the factors that can complicate the interpretation of these non-invasive tests when alcohol use is ongoing. Management has to address both components of the disease at once: reducing alcohol exposure, treating alcohol use disorder where present, managing weight, and controlling cardiometabolic risk factors. Incretin-based therapies are attracting growing interest given their established metabolic effects and the emerging hepatic and alcohol-related data, though no randomized trial has yet tested their efficacy specifically in MetALD. In advanced disease, liver transplantation remains the definitive option for appropriately selected patients, but it requires careful assessment of cardiometabolic comorbidities, alcohol-related risk, and frailty. Further prospective studies are needed to clarify the natural history of MetALD, define optimal risk-stratification strategies, and establish treatment outcomes in this population.