Prevalence and outcomes of steatotic liver disease subtypes in older adults

Background: Steatotic liver disease (SLD) is a significant cause of chronic liver disease. However, the relative prevalence and prognostic significance of various disease entities according to recently defined classification systems (MAFLD vs. the SLD-spectrum of MASLD, Met-ALD, and ALD) is understudied in older adults. Methods: Post hoc analysis of the ASPirin in Reducing Events in the Elderly (ASPREE) study involving 16,703 Australian community-dwelling adults aged ≥70 years free from significant disability, prior cardiovascular disease events, and with a life expectancy ≥5 years. Steatosis was identified by Fatty Liver Index (FLI) ≥60. Alcohol intake was self-reported. SLD subtypes were classified according to European Association for the Study of the Liver (EASL)/American Association for the Study of Liver Diseases (AASLD) guidelines. Cox regression was used to estimate hazard ratios for adjudicated outcomes: mortality, major adverse cardiovascular events (MACE), and persistent physical disability. Results: Of 9847 participants with calculable FLI and a median 8.6 years follow-up, 3748 (38.1%) had hepatic steatosis. Substratifying by MAFLD criteria versus the SLD type, 3743 had MAFLD (38.0%), and 3464 (35.2%) met SLD criteria (MASLD 3132 [90.4%], Met-ALD 262 [7.6%], ALD 74 [2.0%]) (excluding steatogenic medication users). There was no increased mortality risk with MAFLD or SLD. MAFLD and MASLD were associated with MACE when adjusted for age and sex (HR 1.42 [95% CI 1.17–1.71] and HR 1.40 [95% CI 1.15–1.71], respectively), but not in the fully adjusted model. MAFLD, MASLD, and ALD were associated with an increased risk of persistent physical disability even when fully adjusted (HR 1.46 [95% CI 1.19–1.79], HR 1.49 [95% CI 1.20–1.83], HR 2.53 [95% CI 1.27–5.05], respectively), but not Met-ALD. Conclusions: MAFLD and the metabolic-SLD spectrum are common in community-dwelling older adults. No subclassification is associated with increased mortality in this group, although there is an association between both MACE and persistent physical disability with SLD.