In patients with mixed drivers of liver disease (e.g., MASLD risk plus hazardous alcohol use), how do you operationally assign the primary etiology in your clinic, and does that choice change your counseling priorities or timing of transplant referral?

If alcohol use is present, regardless of cardiometabolic risk factors, alcohol use needs to be addressed first. Patients with hazardous alcohol use need to be screened for AUD (using something like the AUDIT-C) and treated for AUD if present (a study on AUD in MetALD found that ~5% had AUD). I explain to my patients that alcohol use with any liver disease is like pouring fuel on a fire--meaning that alcohol use is going to make the liver disease progress much faster. As such, this needs to be th...