One Spectrum, Not Three Silos: Rethinking Steatotic Liver Disease
New review from the Global NASH/MASH Council (GNC) published in Nature Reviews Gastroenterology & Hepatology
We are pleased to announce the publication of "The dynamic spectrum of steatotic liver disease: the global perspective" in Nature Reviews Gastroenterology & Hepatology. Led by Dr. Zobair M. Younossi and developed with an international group of authors from the GNC spanning six continents, this review offers a new perspective on the way steatotic liver disease (SLD) is currently classified and managed. Rather than treating MASLD, MetALD and ALD as distinct, mutually exclusive diagnostic categories, SLD should be considered a single dynamic spectrum. The evidence is compelling: cardiometabolic risk factors are present across all SLD subtypes, required by definition in MASLD and MetALD and found in roughly 98% of individuals with ALD. Alcohol intake, meanwhile, is routinely under-reported, with objective biomarker studies suggesting that 10 to 40% of people initially classified as having MASLD would be reclassified as MetALD or ALD over time.
The implications reach across clinical practice, research and policy. The review calls for routine, repeated assessment of alcohol intake, cardiometabolic risk and fibrosis in clinical practice, combining structured screening tools such as AUDIT-C with objective biomarkers like phosphatidylethanol and non-invasive fibrosis tests. It also highlights a critical gap in drug development: late-phase MASH trials have systematically excluded patients with significant alcohol use, despite the frequent real-world overlap between metabolic and alcohol-related liver injury, leaving the patients who may need treatment most outside the evidence base. Patient-centred care that matches this reality will require genuinely multidisciplinary models spanning hepatology, primary care, endocrinology, addiction medicine and nutrition, alongside public health measures to address the compounded risks of alcohol and obesity.
Please follow this link to view this publications: https://doi.org/10.1038/s41575-026-01235-3
