Editorial: Has MetALD met the presumption? Authors’ reply

The new nomenclature for steatotic liver disease classifies metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol intake (MetALD) and alcoholic liver disease (ALD) according to alcohol consumption.1 Because the concordance rate between nonalcoholic fatty liver disease (NAFLD) and MASLD is over 95%–99%, it could be assumed that the risk of complications and prognosis in patients with MASLD is almost the same as those with NAFLD.2,3 However, as there has been no equivalent classification for MetALD, it is necessary to first examine the prognosis and risk of complications in MetALD. If the risk of complications and prognosis in MetALD is equivalent to those in MASLD or ALD, there is no point in stratifying MetALD from MASLD and ALD. In this context, we examined a nationwide, population-based database including 761,400 patients with MASLD, MetALD and ALD and demonstrated that liver-related events and all-cause mortality increased significantly from MASLD to MetALD to ALD and cardiovascular events increased significantly from ALD to MetALD to MASLD.4 The results confirm the importance of the new nomenclature. As Tan pointed out, alcohol consumption changes over time and these changes may be associated with changes in complication risk and we agree with this view.5 As the results of questionnaires on alcohol consumption every year are also available in the database used for this study, we would like to investigate the relationship between changes in alcohol consumption and changes in complication risk in future research. The data set includes annual health check-up data, even for cases who have not been seen by any healthcare provider. In addition, because all claims were integrated by the health insurance association, diagnosis and treatment were tracked even when patients switched care providers. These are the advantages of this database, which allows a more accurate long-term assessment.6,7 SLD is a risk for liver-related events, but with a lower incidence than cardiovascular events.4 Therefore, the identification of cases at high risk of liver-related events in SLD and the development of surveillance strategies for liver-related complications are also important future tasks.