Letter to the editor: Chronic liver disease among adolescents and young adults: Alcohol use disorder identification
Authors: Gianni Testino
Journal: Hepatology (2022)

To the editor, In an excellent paper, Paik et al.[1] describe the global burden of chronic liver disease (CLD) among adolescents and young adults aged 15‐29 years using the Global Burden of Disease (GBD) data. It emerges that, worldwide, the causes of CLD have shifted: the global burden of HBV incidence is decreasing, whereas NAFLD is the main driver for increasing CLD incidence. The authors, however, raise an important problem. Despite the rigorous peer review assessment of the GBD data, alcohol‐associated liver disease (ALD) may have been underreported. It is known that despite widespread alcohol consumption (AC), its identification is insufficient.[2] More than 40% of the world's adult population consumes alcohol, with a wide variation according to countries; the prevalence reaches 60%‐70% in Western Europe. It should also be noted that in the Western world, AC is increasing significantly in people between 11 and 24 years old. In Italy, there is hazardous AC in 3.5% of the male population and 1.9% of the female population in people between 11 and 15 years old, in 24.1% of the male population and 17.4% of the female population in people between 16 and 17 years old, and in 53.2% of the male population and 41.1% of the female population in people between 18 and 24 years old.[2,3] Cohort studies estimate that 20% of patients may have characacteristics of both NAFLD and ALD. It is also important to identify light‐moderate AC. More recently, Decraecker et al.[4] reported that in the NAFLD group, more than one drink weekly was associated with higher overall mortality (HR, 1.9; 1.1‐3.4), and more than seven drinks was associated with higher overal morbidity (OR, 1.89; 1.61‐2.21). From this study, it emerges how in fatty liver diseases, light consumption and metabolic syndrome (MS) are prognosis factors. AC is often self‐reported by direct interview. This is a limitation, as the patient underestimates their consumption. Many adult drinkers may be unaware of their risk of alcohol‐associated harm.[2] Therefore, it is strongly recommended to pay more attention to AC by using Alcohol Use Disorder Identification Test (AUDIT).[2] The test's sensitivity and specificity (92% and 93%, respectively) are very high; this fact allows the identification of patients affected by hazardous or harmful consumption who are not addicted to alcohol.[2] The paper of Paik et al.[1] gives us the opportunity to reiterate the need to use the AUDIT currently used in about 10% of cases on a large scale.[2] This helps in establishing the real level of the AC to inform policy decision‐makers and, at the same time, strengthens the recommendation of the American Association for the Study of Liver Diseases: "the limitation of alcohol use in NAFLD patients and management of MS in ALD patients should be emphasized in clinical practice and in international guidelines."[5] In conclusion, the use of the AUDIT in clinical practice is strongly recommended.[2] The early identification of hazardous/harmful AC and, subsequently, the short intervention and/or the addiction program allow the eventual achievement of alcoholic abstention.[2] Alcohol abstention slows down or stops fibrogenesis, improves the patient's prognosis (hepatic and extrahepatic), and avoids possible pharmacological interferences. CONFLICT OF INTEREST Nothing to report.