Background: Noninvasive tests are well validated in metabolic dysfunction–associated steatotic liver disease, but evidence in metabolic dysfunction and alcohol-associated liver disease (MetALD) and alcohol-associated liver disease (ALD) is limited. We evaluated noninvasive test–based clinical care pathways for fibrosis risk stratification in MetALD and ALD. Methods: This is a multinational, multicenter, cross-sectional study across 35 centers in 16 countries (2013–2025), including adults with MetALD or ALD. Fibrosis was assessed by liver biopsy and/or vibration-controlled transient elastography (VCTE). In biopsy-proven participants, we analyzed the sequential pathway (Fibrosis-4 [FIB-4] first, followed by VCTE for indeterminate FIB-4) to identify advanced fibrosis (≥F3). Diagnostic accuracy was assessed using the AUC. Results: Among 893 participants (41.3% MetALD and 58.7% ALD), the median age was 52 [43.0–61.0] years, and 79.4% were male. The estimated prevalence of advanced fibrosis was 45% (32.2% in MetALD and 54.0% in ALD). Participants with MetALD had a more dysmetabolic profile but lower fibrosis stages than ALD. Among biopsy-proven participants, FIB-4 AUC was 0.720, and VCTE AUC was 0.833. FIB-4 performed better in MetALD than ALD (AUC 0.773 vs. 0.540), while VCTE accuracy was similar across groups. In the sequential pathways, the false-negative rate for advanced fibrosis (misclassified as low risk) was 6.8% (4.9% MetALD and 11.3% ALD). Conclusions: In biopsy-proven patients, FIB-4 performance was acceptable in MetALD but substantially weaker in ALD. The standard 2-step pathway performed adequately in MetALD but missed a clinically meaningful proportion of advanced fibrosis in ALD.

Hepatic cancer is a world health concern due to its high lethality. The main risk factor worldwide is having hepatic cirrhosis. The etiology of hepatic cirrhosis has changed in recent years, with metabolic-associated steatotic liver disease (MASLD) becoming the leading cause, displacing hepatitis C and B viruses and alcoholic liver disease. It is of the utmost importance to develop screening programs in at-risk populations for early detection. The survival rate of HCC, as determined by a group of specialists or an interdisciplinary committee, is a challenge we have taken on in a public health hospital in Ecuador. This retrospective study identified 71 patients diagnosed with hepatocellular carcinoma, mostly middle-aged men with a history of liver cirrhosis. No significant association was found between the presence of cirrhosis, laboratory abnormalities, and survival. However, the identification by imaging vascular invasion and extrahepatic extension were associated. This study highlights that patients with liver lesions identified through HCC screening have a higher survival rate over a one-year follow-up period.