Alcohol-Associated Liver Disease
Risk Factors for Alcohol-Associated Liver Disease
Key Concepts/Statements
- ALD is a major cause of advanced liver disease and liver-related mortality globally, including the United States.
- ALD prevalence has increased since 2014, with an accelerated trajectory in recent years, producing substantial healthcare and economic burden.
- Younger adults, women, and minorities have seen the largest increase in AUD and ALD, highlighting key populations in need of targeted prevention and treatment efforts.
- Amount and duration of alcohol use are the primary risk factors for the development of ALD, and the potential harms of alcohol use should be an integral part of education on liver health.
- Daily use and binging of alcohol increase the risk of advanced liver disease in those with underlying liver disease other than ALD. Thus, patients with known liver disease should be counseled on the potential harms of any alcohol use.
- There are insufficient data to determine whether binge drinking without daily heavy use predisposes to advanced forms of ALD.
- All types of alcohol increase the risk of liver disease; however, limited data suggest that risk may be higher with liquor as opposed to beer or wine.
- Genetic variants of α-1 antitrypsin, PNPLA3, TM6SF2, and MBOAT7 are associated with risk of ALD, but there are insufficient data to support their inclusion in clinical management algorithms.
Diagnosis and Treatment of Alcohol Use Disorder
Key Concepts/Statements
- Standardized screening practices for AUD should be implemented at every medical encounter, across diverse clinical settings, including the primary care setting, with attention to conducting screening in a nonbiased manner.
- Alcohol biomarkers may be a useful adjunct to clinical inquiry and alcohol use surveys. The choice of test should be tailored to the suspected window of alcohol use.
- Alcohol withdrawal syndrome (AWS) in persons with AUD and ALD should be assessed and managed as per the Clinical Institute Withdrawal Assessment-Alcohol-revised protocol. Clinicians should be aware to differentiate AWS from hepatic encephalopathy and acknowledge that the 2 conditions can coexist.
- Noninvasive blood and/or radiological tests (NITs) should be used to assess the severity of fibrosis in persons with asymptomatic ALD. FIB-4 score, a blood-based marker, and hepatic transient elastography are best initial NITs of fibrosis among persons with ALD.
- Persons with heavy drinking who have evidence of ALD detected with NIT should be counseled on the risk of progressive liver disease and referred to a provider with expertise in liver disease.
- Liver biopsy is not required for staging of fibrosis but may be needed if there is diagnostic uncertainty based on noninvasive assessment.
- Screening individuals with heavy drinking using NITs for the detection of early ALD is cost-effective.
Management of Alcohol Use Disorder
Key Concepts/Statements
- Patients with cirrhosis due to ALD should be managed similarly to those with cirrhosis because of other causes.
- Patients with complications of ALD cirrhosis should be referred for LT when it is medically indicated.
Alcohol-Associated Hepatitis
Key Concepts/Statements
- The NIAAA diagnostic criteria are a useful guide for making a probable diagnosis of AH, and those meeting criteria can be treated with corticosteroids, if eligible, or recruited into clinical trials. A liver biopsy is not required to make a diagnosis of AH in the absence of confounding factors.
- Individuals with severe AH, defined by MELD >20, have a high short-term mortality and should preferably be hospitalized for management.
- Individuals with moderate AH, defined by MELD ≤20, have significant morbidity and mortality. Further work is needed to study this phenotype and develop effective therapies.
- Sustained abstinence is associated with long-term survival after severe and moderate AH.
- For patients with AH, the MELD score >20 can be used to stratify disease severity, predict the risk of short-term mortality, and guide the use of corticosteroid therapy.
- A caloric intake goal of 35 kcal/kg/d with 1.2–1.5 g/kg/d of protein is recommended for patients with AH. Those patients consuming <21 kcal/kg/d should receive nutritional support preferably through oral/enteral routes.
- Thiamine, vitamin B12, and zinc deficiencies are common in individuals with AH and should be supplemented.
- Patients with severe AH and MELD scores ranging from 25 to 39 derive maximum benefit from the use of corticosteroids; careful consideration of risks and benefits is warranted if considering corticosteroids for those with MELD >50.
- Response to corticosteroid treatment can be assessed based on the Lille score at day 7 or day 4. Among nonresponders (Lille score >0.45), corticosteroids should be discontinued.
- For patients with severe AH who are nonresponsive to corticosteroids and ineligible for early LT having 4 or more organ failures, palliative therapy would be appropriate.
- Selection for LT in patients with ALD should not be based solely on an arbitrary duration of sobriety. A comprehensive psychosocial evaluation by a social worker and an addiction specialist should be used to inform transplant team decision-making.
- Tools such as Stanford Integrated Psychosocial Assessment Tool, High Risk for Alcohol Relapse Score, Michigan Alcoholism Prognostics Score, Hopkins Psychosocial Score, and Sustained Alcohol Use Posttransplant (SALT) Score may be used in addition to the addiction team's evaluation in assessing LT candidacy.
- LT recipients should be monitored for alcohol use using self-report tools or alcohol biomarkers with the goal of early detection to provide interventions to support return to abstinence.
- Multidisciplinary integrated care model is recommended for LT recipients to reduce recurrent alcohol use and improve long-term outcomes.
- Early and/or heavy alcohol use is a risk for graft loss and long-term patient mortality and requires an aggressive intervention to achieve abstinence.
- Public policy interventions can reduce the burden of AUD and alcohol-associated liver complications and should be more widely used to reduce alcohol-related morbidity and mortality.
Recommendation Grading
Abbreviations
- AH: Alcohol-associated Hepatitis
- ALD: Alcohol-Associated Liver Disease
- AUD: Alcohol Use Disorder
Overview
Title
Alcohol-Associated Liver Disease
Authoring Organization
American College of Gastroenterology
Publication Month/Year
January 4, 2024
Last Updated Month/Year
January 31, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%–50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%–60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.
Target Patient Population
Patients with Alcohol Liver Disease
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D020751 - Alcohol-Induced Disorders, D019973 - Alcohol-Related Disorders, D005235 - Fatty Liver, Alcoholic, D008108 - Liver Diseases, Alcoholic, D005233 - Fatty Alcohols, D006519 - Hepatitis, Alcoholic
Keywords
hepatitis, fatty liver, alcoholic liver disease
Source Citation
Jophlin, Loretta L. MD, PhD1,*; Singal, Ashwani K. MD, MS, FACG2,*; Bataller, Ramon MD, PhD, FACG3; Wong, Robert J. MD, MS, FACG4; Sauer, Bryan G. MD, MSc, FACG5; Terrault, Norah A. MD, MPH, FACG6; Shah, Vijay H. MD, FACG7. ACG Clinical Guideline: Alcohol-Associated Liver Disease. The American Journal of Gastroenterology 119(1):p 30-54, January 2024. | DOI: 10.14309/ajg.0000000000002572