STEATOTIC liver disease (SLD) is increasingly common, with metabolic dysfunction-associated SLD (MASLD) the predominant subtype. In Sweden, cirrhosis caused by MASLD and alcohol-related liver disease (ALD) is rising, with ALD remaining the leading cause of liver-related deaths, while MASLD is now the most frequent cause of hepatocellular carcinoma (HCC). Distinguishing MASLD from ALD can be challenging, as patients may both meet MASLD criteria and consume excessive alcohol. The new SLD classification introduced MASLD with excessive alcohol intake (MetALD) to bridge this overlap.
PEth Levels in SLD and Alcohol Assessment
Phosphatidylethanol (PEth) is a highly specific biomarker for recent alcohol consumption, providing a more reliable measure than self-reported intake or short-term tests. A recent Danish study demonstrated that PEth predicted hepatic decompensation and death more accurately than self-reported alcohol use, highlighting its clinical value. In the present cohort of over 46,000 individuals, PEth levels above 0.05 μmol/L were found in around one-third of patients with MASLD, indicating that undisclosed alcohol use is common and may worsen outcomes.
Higher PEth levels were associated with more advanced liver disease at baseline and a greater risk of major adverse liver outcomes (MALOs) and liver-related mortality. Importantly, risk increased linearly with PEth up to 1.0 μmol/L and exponentially above this threshold, reinforcing that even moderate alcohol intake can be harmful in SLD. Incorporating PEth testing alongside clinical assessment helps stratify patients into MASLD, MetALD, or ALD categories, guiding interventions and alcohol cessation strategies.
Implications for Clinical Management
This study emphasises that accurate SLD classification is crucial for prognosis and treatment decisions. Using PEth as a complementary biomarker can improve detection of harmful alcohol consumption, reduce misclassification, and identify patients at higher risk for adverse liver events. While longitudinal studies are needed to monitor changes over time, these findings support integrating PEth testing into routine clinical care for patients with MASLD, MetALD, and ALD to inform tailored management and reduce progression to cirrhosis or HCC.
Reference
Vaz J et al. Phosphatidylethanol levels distinguish steatotic liver disease subgroups and are associated with risk of major liver outcomes. J Hepatol. 2025;83(5):1011-22.
