The overlap with metabolic dysfunction‐associated steatotic liver disease negatively affects outcomes of primary biliary cholangitis

Summary Background and Aims The relationship between primary biliary cholangitis (PBC) and metabolic dysfunction‐associated steatotic liver disease, and its impact on treatment response and prognosis, remains underexplored. Methods Patient cohort from two centres comprising long‐term follow‐up data. All patients had histologically confirmed PBC. Biopsies were classified according to Non‐Alcoholic Steatohepatitis Clinical Research Network. Diagnosis of metabolic dysfunction‐associated steatotic liver disease was established when steatosis exceeded 5%, along with at least one metabolic risk factor. Patients with specific aetiologies of steatosis, other liver diseases, incomplete results and inadequate treatment with ursodeoxycholic acid were excluded. Data from patients initiating second‐line treatment were censored. Treatment response was assessed using the Toronto, Paris II and AST‐to‐platelet at 12‐month criteria. The UK PBC and Globe scores, and liver events were utilized as outcome measures. Results The study included 129 patients, 36 showing histologically confirmed overlap between PBC and steatosis. Patients with overlap showed worse prognosis according to Paris II (61.1% vs. 33.3%, p = 0.004), Toronto (52.5% vs. 24.7%, p = 0.002), AST‐to‐platelet 12‐month >0.54 (36.1% vs. 17.2%, p = 0.021), Globe >0.30 (49.2% vs. 29.2%, p = 0.033) and UK PBC at 5, 10 and 15 years ( p ≤ 0.001). Liver‐related mortality and liver transplant were more prevalent in the overlap group ( p = 0.001). In the multivariate analysis, steatosis, dyslipidaemia and advanced fibrosis were independently associated to worse outcomes. Conclusions Our findings suggest that metabolic dysfunction‐associated steatotic liver disease worsens the prognosis of PBC.