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  • Perspective
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The steatotic liver disease burden paradox: unravelling the key role of alcohol

Nature Reviews Gastroenterology & Hepatology volume 22, pages 281–292 (2025)Cite this article

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Abstract

The classification of steatotic liver disease (SLD) has evolved, incorporating all conditions characterized by hepatic lipid accumulation. SLD represents a continuum of disorders that are shaped by the dynamic factors of alcohol intake and cardiometabolic risk factors. This updated classification has profound implications for both the management and research of SLD, especially with the new distinct category of patients with both metabolic and alcohol-related liver disease. In this Perspective, we highlight the pivotal role of alcohol within the SLD framework. We introduce the ‘SLD burden paradox’: a concept illustrating the disparity in which metabolic dysfunction-associated steatotic liver disease is more prevalent, yet individuals with SLD and excessive alcohol intake (such as in metabolic and alcohol-related liver disease and in alcohol-related liver disease) account for greater global liver-related morbidity and mortality. We explore strategies to mitigate the effect of SLD on morbidity and mortality, emphasizing the importance of early detection and reducing stigma associated with alcohol intake. Our discussion extends to methods for assessing and monitoring alcohol intake together with the critical role of managing cardiometabolic risk factors in patients across the SLD spectrum. Conclusively, we advocate for a coordinated care framework that adopts a person-centric approach when managing SLD, aiming to improve outcomes and patient care.

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Fig. 1: Historic acknowledgement of disease drivers in steatotic liver disease and disease definitions.
Fig. 2: Steatotic liver disease burden paradox.
Fig. 3: Natural history of patients in the steatotic liver disease spectrum.
Fig. 4: The bidirectional linking of factors that predispose to steatotic liver disease.
Fig. 5: Focus of treatment for patients with steatotic liver disease and an excessive alcohol intake.
Fig. 6: Treatment targets and potential disease modifiers in patients with steatotic liver disease and excessive alcohol intake.

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Data availability

Prevalence and liver-related mortality estimates referred to in Fig. 2 are from previous works5,6,7,8,11,12,13. Figure 3 is adapted with permission from Thiele et al.99.

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Acknowledgements

During the preparation of this work, the authors used ChatGTP to improve language and readability. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

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  1. Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark

    Nikolaj Torp, Mads Israelsen & Aleksander Krag

  2. Department of Clinical Research, University of Southern Denmark, Odense, Denmark

    Nikolaj Torp, Mads Israelsen & Aleksander Krag

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The authors contributed equally to all aspects of the article.

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Correspondence to Aleksander Krag.

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A.K. has served as speaker for Novo Nordisk, Norgine, Siemens and Nordic Bioscience; participated in advisory boards for Siemens, Boehringer Ingelheim and Novo Nordisk, all outside the submitted work; has received research support from Norgine, Siemens, Nordic Bioscience, Astra and Echosense; and is a board member and co-founder of Evido. N.T. and M.I. declare no competing interests.

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Torp, N., Israelsen, M. & Krag, A. The steatotic liver disease burden paradox: unravelling the key role of alcohol. Nat Rev Gastroenterol Hepatol 22, 281–292 (2025). https://doi.org/10.1038/s41575-024-01022-y

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