Current burden of steatotic liver disease and fibrosis among adults in the United States, 2017-2023

Abstract

Background/aims: Multi-society experts proposed the adoption of new terminology, metabolic dysfunctionassociated steatotic liver disease (MASLD) and steatotic liver disease (SLD). We studied the current prevalence of SLD and its subcategories in the US.

Methods: Using the recent National Health and Nutrition Examination Survey from 2017 to 2023, we analyzed data from 12,199 participants (≥18 years) who completed transient elastography. SLD and its subcategories, including MASLD, metabolic and alcohol-related liver disease (MetALD), and alcohol-related liver disease (ALD), were categorized according to consensus nomenclature.

Results: The age-adjusted prevalence of SLD (cut-off: 285 dB/m) was 35.0% (95% confidence interval [CI] 33.4-36.7). Within this category, the age-adjusted prevalence for MASLD was 31.9% (95% CI 30.4-33.4), MetALD 2.2% (95% CI 1.8-2.6), and ALD 0.8% (95% CI 0.6-1.1). The prevalence of SLD and MASLD showed a statistically insignificant decrease during COVID-19, while ALD increased without significance. In contrast, the prevalence of advanced fibrosis in SLD was significantly higher during the COVID-19 era, at 9.8% for 285 dB/m and 7.8% for 263 dB/m, compared to 7.4% (P=0.039) and 6% (P=0.041) in the pre-COVID-19 era. The proportion of advanced fibrosis and cirrhosis in individuals with ALD was two-fold higher than MASLD and MetALD, largely due to increases during the COVID-19 era.

Conclusion: While the prevalence of SLD and its subcategories remained stable, there was a significant increase in advanced fibrosis among SLD individuals during the COVID-19 era, with ALD having a proportion of advanced fibrosis and cirrhosis that was twice as high as MASLD and MetALD.

Keywords: Alcohol-related liver disease; MASLD; MetALD; NHANES.

Figure 1.

Age-adjusted prevalence of SLD subcategories by sex and race/ethnicity in the United States, 2017–2023. (A) Age-adjusted prevalence of MASLD defined as CAP score ≥285 dB/m. (B) Age-adjusted prevalence of MASLD defined as CAP score ≥263 dB/m. (C) Age-adjusted prevalence of MetALD defined as CAP score ≥285 dB/m. (D) Age-adjusted prevalence of MetALD defined as CAP score ≥263 dB/m. (E) Age-adjusted prevalence of ALD defined as CAP score ≥285 dB/m. (F) Age-adjusted prevalence of ALD defined as CAP score ≥263 dB/m. ALD, alcohol-related liver disease; CAP, controlled attenuation parameter; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-related steatotic liver disease; SLD, steatotic liver disease.

Figure 2.

Age-adjusted prevalence of fibrosis and cirrhosis among individuals with SLD subcategories in the United States, 2017–2023. (A) Age-adjusted prevalence of fibrosis and cirrhosis among individuals with SLD subcategories defined as CAP score ≥285 dB/m. (B) Age-adjusted prevalence of fibrosis and cirrhosis among individuals with SLD subcategories defined as CAP score ≥263 dB/m. Transient elastography values of 8 kPa or higher (≥F2), 11.6 kPa or higher (≥F3), and 13.1 kPa or higher (≥F4) were considered to have significant fibrosis, advanced fibrosis, and cirrhosis among individuals with subcategories of SLD. P-value for comparison between MASLD vs. MetALD vs. ALD. ALD, alcohol-related liver disease; CAP, controlled attenuation parameter; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-related steatotic liver disease; SLD, steatotic liver disease.

Figure 3.

Comparison between the Pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) Regarding the Prevalence of SLD and SLD Subcategories and Fibrosis and Cirrhosis among Individuals with SLD in the United States, 2017–2023. (A) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of SLD and SLD subcategories defined as CAP score ≥ 285 dB/m. (B) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of SLD and SLD subcategories defined as CAP score ≥263 dB/m. (C) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of fibrosis and cirrhosis among individuals with SLD defined as CAP score ≥285 dB/m. (D) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of fibrosis and cirrhosis among individuals with SLD defined as CAP score ≥263 dB/m. Transient elastography values of 8 kPa or higher (≥F2), 11.6 kPa or higher (≥F3), and 13.1 kPa or higher (≥F4) were considered to have significant fibrosis, advanced fibrosis, and cirrhosis among individuals with SLD and subcategories of SLD. CAP, controlled attenuation parameter; SLD, steatotic liver disease.

Figure 4.

Comparison between the Pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) Regarding the prevalence of fibrosis and cirrhosis among individuals with MASLD, MetALD, ALD in the United States, 2017–2023. (A) Comparison between the preCOVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with MASLD defined as CAP score ≥285 dB/m. (B) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with MASLD defined as CAP score ≥263 dB/m. (C) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with MetALD defined as CAP score ≥285 dB/m. (D) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with MetALD defined as CAP score ≥263 dB/m. (E) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with ALD defined as CAP score ≥285 dB/m. (F) Comparison between the pre-COVID-19 era (2017–2020) and the COVID-19 era (2021–2023) regarding the prevalence of Fibrosis and Cirrhosis among Individuals with ALD defined as CAP score ≥263 dB/m. Transient elastography values of 8 kPa or higher (≥F2), 11.6 kPa or higher (≥F3), and 13.1 kPa or higher (≥F4) were considered to have significant fibrosis, advanced fibrosis, and cirrhosis among individuals with SLD and subcategories of SLD. ALD, alcohol-related liver disease; CAP, controlled attenuation parameter; MASLD, metabolic dysfunction-associated steatotic liver disease; MetALD, metabolic dysfunction and alcohol-related steatotic liver disease; SLD, steatotic liver disease.