Mezzacappa Catherine, Ochoa-Allemant Pedro, Serper Marina, Taddei Tamar H, John Binu V, Kaplan David E, Mahmud Nadim
Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut.
Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
Clin Gastroenterol Hepatol. 2024 Dec 15. doi: 10.1016/j.cgh.2024.10.035.
BACKGROUND & AIMS: Novel steatotic liver disease (SLD) definitions were introduced in 2023. Accurate and meaningful classifications using clinical data are needed to study interventions and outcomes.
In a national cohort of Veterans with cirrhosis and imaging-confirmed steatosis, 7 algorithms differentially emphasizing cardiometabolic risk factors (CMRFs) and alcohol exposure were developed to define alcohol-associated liver disease (ALD), metabolic dysfunction associated SLD (MASLD), and MASLD with increased alcohol intake (MetALD). The primary outcome was classification of SLD, which was validated using hospitalizations for major acute cardiac events (MACE) and alcohol use disorder (AUD). Secondary outcomes included longitudinal Child-Turcotte-Pugh class, incident hepatocellular carcinoma, and all-cause mortality.
In all, 31,514 patients with cirrhosis (median age 64 years) were included. CMRFs (98.8% ≥ 1) and hazardous alcohol use (65.3%) were highly prevalent. The distributions of MASLD, MetALD, and ALD varied substantially across classification methods with varying CMRF and alcohol criteria. For example, MetALD ranged from 4.7% to 47.2%. Using method 4, incidence rates of MACE hospitalizations in MASLD, MetALD, and ALD were 16.7, 14.5, and 8.4 per 100 person-years, respectively, and incidence rates of AUD hospitalizations were 2.0, 26.1, and 47.6 per 100 person-years, respectively. Hypertriglyceridemia and low high-density lipoprotein were common across SLD subtypes, including ALD (67.3% hypertriglyceridemia; 48.2% low high-density lipoprotein). Patients with ALD (hazard ratio, 1.41; 95% confidence interval, 1.34-1.48) had significantly higher hazards of mortality relative to MASLD.
Classification of SLD is highly sensitive to relative weighting of CMRFs and alcohol use. Clinically relevant definitions should consider data availability on alcohol and the limitations of lipid measurements in distinguishing SLD subtypes.
2023年引入了新型脂肪性肝病（SLD）定义。需要使用临床数据进行准确且有意义的分类，以研究干预措施和结果。
在一个患有肝硬化且经影像学证实有脂肪变性的退伍军人全国队列中，开发了7种算法，这些算法对心脏代谢危险因素（CMRFs）和酒精暴露的强调程度不同，用于定义酒精性肝病（ALD）、代谢功能障碍相关的SLD（MASLD）以及酒精摄入量增加的MASLD（MetALD）。主要结局是SLD的分类，并通过主要急性心脏事件（MACE）和酒精使用障碍（AUD）的住院情况进行验证。次要结局包括纵向Child-Turcotte-Pugh分级、肝细胞癌的发生以及全因死亡率。
总共纳入了31514例肝硬化患者（中位年龄64岁）。CMRFs（98.8%≥1）和有害酒精使用（65.3%）非常普遍。根据不同的CMRF和酒精标准，MASLD、MetALD和ALD在不同分类方法中的分布差异很大。例如，MetALD的比例从4.7%到47.2%不等。使用方法4时，MASLD、MetALD和ALD中MACE住院的发生率分别为每100人年16.7、14.5和8.4次，AUD住院的发生率分别为每100人年2.0、26.1和47.6次。高甘油三酯血症和低高密度脂蛋白在包括ALD在内的SLD亚型中都很常见（67.3%为高甘油三酯血症；48.2%为低高密度脂蛋白）。与MASLD相比，ALD患者的死亡风险显著更高（风险比，1.41；95%置信区间，1.34 - 1.48）。
SLD的分类对CMRFs和酒精使用的相对权重高度敏感。临床相关定义应考虑酒精的数据可用性以及脂质测量在区分SLD亚型方面的局限性。
