Letter: Addressing the Growing Disparities in Alcohol-Associated Liver Disease—A Call for Equitable Healthcare Strategies: Authors' Reply

Abstract

On behalf of our coauthors, we appreciate the insightful commentary by El-Kassas et al. on our study examining disparities among a diverse Texas-based alcohol-associated liver disease (ALD) inpatient cohort [1]. Their letter highlights important social and biological contributors to these disparities, which merit further exploration [2].

El-Kassas et al. emphasised the potential role of genetic predisposition, particularly due to polymorphisms in PNPLA3 and TM6SF2, in modulating ALD severity across racial and ethnic groups. These variants not only contribute to ALD disease progression, as El-Kassas et al. noted, but are also associated with an increased risk of hepatocellular carcinoma [3, 4]. Moreover, alcohol use patterns, obesity and type 2 diabetes can amplify this known genetic effect [5]. The extent to which these environmental and metabolic risk factors modulate genetic risk across different racial and ethnic groups remains poorly understood. To this end, our research team is prospectively studying how these factors interact and influence prognosis in the racially, ethnically and socioeconomically diverse ‘Dallas Dionysus Study’ early-stage ALD cohort.

Most ALD patients are diagnosed late (i.e., decompensated cirrhosis), often with no efficacious treatments beyond liver transplantation [6]. Importantly, El-Kassas et al. highlight important systemic barriers to timely ALD diagnosis, such as health literacy, implicit biases and fragmented healthcare systems. Our findings support these concerns, revealing disproportionate increases in ALD hospital encounters among racial and ethnic minorities, which may suggest these populations tend to present later in the disease's progression. Schneider et al. (2024) further emphasise the role of ethnic disparities in liver disease, showing significant variations in the prevalence of liver disease phenotypes across different ethnic groups and sexes [7]. Guided by a comprehensive conceptual framework, our ‘Dallas Dionysus Study’ cohort undergoes baseline assessments of health literacy, barriers to care and medical mistrust (focusing on perceived disparities in treatment based on ethnicity or race). Understanding how these social determinants of health disproportionately affect outcomes may help guide interventions to address diagnostic delays in disadvantaged populations.

El-Kassas et al. propose several multi-level interventions to address disparities in ALD diagnosis and treatment, including Medicaid expansion, enhanced provider education on implicit biases, and targeted early alcohol use disorder (AUD) and ALD screening for high-risk groups. We strongly support these initiatives and advocate for comprehensive policy efforts that address both upstream social determinants and downstream clinical interventions to mitigate ALD disparities [8]. In alignment with these recommendations, our ongoing ‘Dallas Dionysus study’ includes baseline phosphatidylethanol (PEth) testing to objectively assess alcohol consumption, particularly in patients with metabolic dysfunction-associated alcohol-related liver disease (MetALD). As shown by Tavaglione et al. (2025), PEth has demonstrated superior diagnostic accuracy in distinguishing MetALD from metabolic dysfunction-associated steatotic liver disease (MASLD) compared to previously used indirect alcohol biomarkers [9].

In conclusion, we greatly appreciate the valuable insights from El-Kassas et al. Their commentary highlights the complex interplay of genetic, healthcare access and social determinants of health in ALD disparities. This reinforces the need for a comprehensive, multidisciplinary approach to tackling these disparities. Future research should focus on integrating these factors to develop targeted prevention and treatment strategies for underserved populations.