Table 1. Comparison and summary of quality standards and guideline statements on alcohol-related liver disease from various global regions.

Recommendations	BASL/BSG [2023] (5)	EASL [2018] (7)	AASLD [2020] (6)	ALEH [2019] (8)
Alcohol consumption
Standard drink (grams)	8	10	14^d	14
Daily consumption	NP	M: ≤30 g/day	M: ≤28 g/day	M: (BMI <30 kg/m²): ≤42 g/day
		F: ≤20 g/day	F: ≤14 g/day	F: (BMI <30 kg/m²): ≤28 g/day
				M: (BMI ≥30 kg/m²): ≤28 g/day
				F: (BMI ≥30 kg/m²): ≤14 g/day
Weekly consumption	M & F: <112 g/week	NP	NP	NP
“Binge” drinking	NP	M: ≥50 g within 2 hours	M: >70 g within 2 hours	M: >70 g within 2 hours
“Binge” drinking	NP	F: ≥40 g within 2 hours	F: >56 g within 2 hours	F: >56 g within 2 hours
High-risk consumption^a	M^b: ≥400 g/week	M & F: >30 g/day	M: >28 g/day	M: (BMI <30 kg/m²): >42 g/day
	F^b: ≥280 g/week	M: >112 g/week	F: >14 g/day	F: (BMI <30 kg/m²): >28 g/day
	M & F^c: ≥112 g/week	F: >56 g/week		M: (BMI ≥30 kg/m²): >28 g/day
				F: (BMI ≥30 kg/m²): >14 g/day
AUD
Screening	AUDIT-C or FAST	AUDIT/AUDIT-C	AUDIT/AUDIT-C	AUDIT/AUDIT-C or CAGE
Diagnosis	NP	Based on DSM-V criteria	Based on DSM-V criteria	M: >3 standard drinks/day; F: >2 standard drinks/day
				Or M & F: binge drinking
				Or AUDIT score >8
Management	Early, longitudinal, and multidisciplinary approach involving addiction specialists and brief interventions	Early, longitudinal, and multidisciplinary approach involving addiction specialist and brief interventions	Early, longitudinal, and multidisciplinary approach involving addiction specialist and brief interventions	Early, longitudinal, and multidisciplinary approach involving addiction specialist and brief interventions
Pharmacologic management in patients with concurrent ALD	Acamprosate and baclofen	Acamprosate and baclofen	Acamprosate and baclofen	Baclofen
Management of alcohol Withdrawal	CIWA protocol with prn benzodiazepines	CIWA protocol with prn benzodiazepines	NP	NP
ALD
Screening	Assessment of liver fibrosis should be offered based on alcohol consumption: M^b: ≥400 g/week; F^b: ≥280 g/week; M & F^c: ≥112 g/week	Should be performed in high-risk populations such as those in alcohol rehabilitation clinics, or as identified in primary care	NP	NP
Diagnosis	NP	Suspected in females consuming >20 g/day and males >30 g/day of alcohol with clinical and/or biological abnormalities suggestive of liver injury. ALD should also be considered in patients with extrahepatic manifestations of AUD including peripheral neuropathy, pancreatitis, cardiomyopathy, and others	There is no unique presentation of ALD that can be distinguished with confidence from other forms of liver disease. Careful evaluation of drinking history and exclusion of other causes of liver disease is required	Relies on a history of significant alcohol intake clinical features, laboratory abnormalities and exclusion of other causes of liver disease
Fibrosis assessment	Validated, non-invasive liver fibrosis markers including FIB-4, APRI, ELF, TE	TE +/− liver biopsy in cases of diagnostic uncertainty. No specific recommendations on FIB-4, APRI or ELF	NP	TE +/− liver biopsy in cases of diagnostic uncertainty. No specific recommendations on FIB-4, APRI or ELF
Management	Patients admitted to hospital with ALD should be reviewed by a clinician trained in hepatology within 24 hours of admission and followed up within 6 weeks of discharge. Community-based management of AUD with access to addictions specialists including pharmacologic treatment of AUD recommended. Nutritional support for those with advanced ALD. Complete alcohol abstinence recommended	Treatment of comorbid conditions such as obesity, insulin resistance, malnutrition, cigarette smoking, iron overload, and viral hepatitis. Community-based management of AUD with access to addictions specialist including pharmacologic treatment of AUD. Complete alcohol abstinence recommended	Treatment of comorbid conditions such as obesity are often needed. Community-based management of AUD with access to addictions specialists including pharmacologic treatment of AUD recommended. Complete alcohol abstinence recommended	Performed by multidisciplinary teams with access to addictions specialist including pharmacologic treatment of AUD. Adequate food intake with proper protein and caloric content should be considered. Complete alcohol abstinence recommended
LT	Should be considered for patients with ALD and ongoing hepatic failure with a UKELD score >49 and alcohol abstinence. A definite 6-month abstinence period is not required	Should be considered for patients with ALD with a MELD ≥15 and/or Child-Pugh C classification. Selection of LT should not be based on a 6-month criterion of abstinence alone	Should be considered for patients with ALD with decompensated cirrhosis, MELD ≥21, Child-Pugh C classification, an episode of SBP or HCC. Selection should not be based on a fixed abstinence interval	Should be considered for patients with end-stage ALD. Selection of LT should not be based on a 6-month criterion of abstinence alone
AH
Diagnosis	NIAAA criteria +/− liver biopsy if confounding factors	NIAAA criteria +/− liver biopsy if confounding factors	NIAAA criteria +/− liver biopsy if confounding factors	NIAAA criteria +/− liver biopsy if confounding factors
Treatment indications	MELD ≥21, GAHS ≥9, NLR ≥5	mDF ≥32, GAHS ≥9	mDF ≥32, GAHS ≥9, MELD ≥21	mDF ≥31, MELD ≥21
Management
Alcohol abstinence	Yes	Yes	Yes	Yes
Corticosteroids^e	Yes	Yes	Yes	Yes
NAC^f	NP	Consider	Consider	Consider
Pentoxifylline	NP	No	No	No
G-CSF	NP	No	No	No
B-complex vitamins	NP	Yes	NP	Yes
Preventing AKI^g	NP	Yes	Yes	NP
Nutritional	Assessment by dietician with hepatology experience and malnutrition optimized	35–40 kcal/kg/day of body weight with a daily protein intake of 1.2–1.5 g/kg	Malnutrition should be addressed and treated, preferably with enteral nutrition. Consider therapeutic doses of zinc	Oral intake should be started as soon as possible and a daily intake of 1.5 g/kg of ideal body weight of protein is recommended
Treatment response	Day 4/7 Lille score <0.45	Day 7 Lille score <0.45	Day 7 Lille score <0.45	Day 4/7 Lille score <0.45
Early LT	NP	Early LT in highly select patients should be considered in patients without a treatment response to corticosteroids	LT may be considered in carefully selected patients with favorable psychosocial profiles in severe AH not responding to medical therapy	Should be considered in patients with severe AH
Corticosteroid use in AH
Contraindications	Uncontrolled infection	Uncontrolled infection	Uncontrolled infection, AKI with serum creatinine >2.5 mg/dL, uncontrolled gastrointestinal bleeding, concomitant disease including HBV, HCV, DILI, HCC, acute pancreatitis, HIV, TB, and multiorgan failure or shock	Sepsis, active gastrointestinal bleeding, acute pancreatitis, active tuberculosis, uncontrolled diabetes, and psychosis
Infectious screening recommendations	Patients presenting with decompensated ALD or AH should be screened for infection	Systematic screening for infection should be performed before initiating therapy, during corticosteroids treatment and during the follow up period	Chest X-ray, blood, urine, and ascites cultures should be performed in all patients with AH	Diagnostic paracentesis, blood, urine, and sputum cultures should be obtained
Palliative care assessment	Recommended for those with ALD an expected survival of <12 months	NP	NP	NP

^a, high-risk consumption is defined by the amount of alcohol consumed at which the risk of alcohol-related liver disease, including liver fibrosis is felt to increase; ^b, increased risk of “advanced” fibrosis; ^c, in patients with cofactors for liver disease including obesity and diabetes; ^d, the AASLD acknowledges that a simplification in the quantification of a standard drink would be to adopt the European standard that one started drink is defined by 10 g of pure alcohol; ^e, prednisolone 40 mg p.o; daily (or equivalent) administered for up to 28 days depending on treatment response; ^f, N-acetylcysteine for 5 days intravenously may be combined with corticosteroids; ^g, avoidance of diuretics/nephrotoxic drugs with volume expansion if needed. BASL/BSG, British Association for the Study of the Liver/British Society of Gastroenterology; EASL, European Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; ALEH, Latin American Association for the Study of the Liver; NP, not provided; M, male; F, female; BMI, body mass index; AUD, alcohol use disorder; AUDIT, alcohol use disorders identification test; AUDIT-C, alcohol use disorders identification test-consumption; FAST, fast alcohol screening test; CAGE, Cut down, Annoyed, Guilty, Eye-opener; DSM-V, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; CIWA, Clinical Institute Withdrawal Assessment for Alcohol; ALD, alcohol-associated liver disease; FIB-4, fibrosis-4; APRI, AST to platelet ratio index; ELF, enhanced liver fibrosis test; TE, transient elastography; LT, liver transplant; UKELD, UK Model for End-Stage Liver Disease; MELD, model for end-stage liver disease score; SBP, spontaneous bacterial peritonitis; HCC, hepatocellular carcinoma; NIAAA, National Institute on Alcohol Abuse and Alcoholism; GAHS, Glasgow Alcoholic Hepatitis Score; NLR, neutrophil-to-lymphocyte ratio; mDF, Maddrey’s Discriminant Function; NAC, N-acetylcysteine; G-CSF, granulocyte colony stimulating factor; AKI, acute kidney injury; AH, alcohol-associated hepatitis; HBV, hepatitis B virus; HCV, hepatitis C virus; DILI, drug-induced liver injury; HIV, human immunodeficiency virus; TB, tuberculosis.