Alcohol use trajectories and liver enzyme changes in adolescents with MASLD: A longitudinal multicenter cohort.

OBJECTIVES: To characterize longitudinal patterns of alcohol use and evaluate associations with liver enzyme changes in youth with metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS: We analyzed 1172 children with biopsy-confirmed MASLD and longitudinal Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) data. Group-based trajectory modeling identified alcohol use patterns over time. Linear mixed models assessed associations between alcohol trajectory groups and alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT). Generalized linear mixed models evaluated predictors of alcohol use, including age, sex, body mass index (BMI), fibrosis stage, and household income. RESULTS: Among participants diagnosed with MASLD in childhood, 206 (17.6%) reported alcohol use during adolescence or early adulthood. Three alcohol-use groups were identified: non-users, adolescent initiators, and adult initiators. Heavy episodic drinking was reported by 48 of 71 adolescent initiators (67.6%) and 53 of 135 adult initiators (39.3%). Compared with non-users, alcohol initiators had lower liver chemistry values at enrollment but greater annual increases during follow-up. Adolescent initiators had a 4% greater annual increase in ALT, while adult initiators had 6%, 4%, and 3% greater annual increases in ALT, AST, and GGT, respectively. CONCLUSIONS: Nearly 1 in 5 youth with MASLD reported alcohol use during adolescence or early adulthood despite ongoing subspecialty care. Alcohol-use trajectories were associated with greater annual increases in liver chemistries, particularly among participants with heavy episodic drinking. These findings support routine alcohol screening and developmentally tailored anticipatory guidance in pediatric MASLD care.