Nancy Reau, MD, is Professor of Internal Medicine, Richard B. Capps Chair of Hepatology, Associate Director of Solid Organ Transplantation, and Section Chief of Hepatology at Rush University Medical Center.

Nancy Reau, MD

Recognizing, Treating Alcohol as an Additive Risk Factor in MASLD

, hosts Nancy Reau, MD, and Kimberly Brown, MD, focus on one of the most challenging, and often underappreciated, aspects of managing 

metabolic dysfunction-associated steatotic liver disease (MASLD)

: accurately assessing and addressing alcohol use.

Reau highlights data examining patient reluctance to disclose alcohol consumption, using phosphatidylethanol (PEth) testing as an objective biomarker. Even at a relatively low cutoff, PEth identified alcohol use in a substantial proportion of patients who reported little or no drinking during clinic visits. Of note, many patients who stated they abstained entirely showed biochemical evidence of alcohol exposure, reinforcing a reality many clinicians recognize: self-reported alcohol use is often inaccurate, whether due to stigma, reluctance, or misunderstanding of what constitutes meaningful intake.

The conversation then turns to how PEth testing can be integrated into practice. Reau emphasizes transparency, explaining that she routinely tells patients when PEth is being ordered, framing it as a tool to support honest, nonjudgmental conversations about liver health.

Brown contrasts this with a more routine testing strategy, likening PEth to other standard laboratory assessments. For her, she says the value lies in using objective data to educate patients, showing that even amounts they perceive as minimal may still be harmful in the context of MASLD. She also notes the implications for clinical trials, pointing out that many study populations likely include patients with overlapping metabolic disease and alcohol use, given the limitations of self-reporting.

Both experts emphasize the clinical importance of another study discussed in the segment, which demonstrated that even modest alcohol consumption, including levels considered lower risk by public health standards, was associated with increased fibrosis in patients with MASLD. This risk was compounded by the presence of multiple metabolic factors, with alcohol acting as another “layer” of risk that accelerates disease progression.

Reau and Brown agree that for patients with MASLD, particularly younger individuals with decades of disease risk ahead, no amount of alcohol is truly safe, and addressing this openly is essential to long-term outcomes.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

Daugherty T, Roepke E, Caviness D, et al. Real-world use of PEth in a MASLD Clinic. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Duseja A, Verma N, De A, et al. Any amount of alcohol intake increases the risk of significant fibrosis and fibrotic MASH in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) - Insights from 7189 patients from Indian Consortium on MASLD (ICOM-D). Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Videos

Nancy Reau, MD, and Kimberly Brown, MD, discuss the challenges of accurately assessing and addressing alcohol use in patients with MASLD.

Liver Lineup: Managing MASLD and MASH Amid Limited Awareness, Overlapping Risk Factors

Liver Lineup: Updates and Unfiltered Insights

, Nancy Reau, MD, and Kimberly Brown, MD, turn their attention to 

metabolic dysfunction–associated steatotic liver disease (MASLD) and metabolic dysfunction–associated steatohepatitis (MASH)

, conditions that now dominate hepatology clinics but continue to pose major diagnostic and therapeutic challenges. As new drugs enter the clinic and others advance through the pipeline, the hosts explore what meaningful progress looks like in a disease space defined by heterogeneity, comorbidities, and ongoing uncertainty around long-term outcomes.

The conversation opens with reflections on the transition from NAFLD/NASH to MASLD/MASH. Reau and Brown discuss how the updated terminology better captures the metabolic underpinnings of the disease and may help reduce stigma, while acknowledging that changing nomenclature alone does not solve longstanding issues around diagnosis, risk stratification, or patient engagement. They emphasize that many patients with advanced disease are still being identified late in their clinical course.

A central theme of the episode is how clinicians should think about treatment in MASH today. The hosts discuss the significance of having a therapy available for this patient population and what that means for hepatology practice. They underscore the importance of appropriate patient selection, fibrosis assessment, and setting realistic expectations around treatment goals, particularly given the complexity and heterogeneity of the disease.

Reau and Brown also address the role of weight loss and metabolic management in MASLD and MASH. They discuss how improvements in metabolic parameters can translate into liver-related benefits, while noting that sustained lifestyle change remains difficult to achieve and maintain. Pharmacologic approaches that support weight loss are discussed in the context of their broader metabolic effects, rather than as liver-specific therapies.

The episode concludes with a discussion of system-level challenges, including underdiagnosis, inconsistent use of noninvasive testing, and limited awareness outside of hepatology. As MASLD becomes an increasingly common cause of advanced liver disease, the hosts stress the need for better collaboration across specialties and clearer pathways for identifying patients who would benefit from referral and treatment.

Podcasts

Reau and Brown discuss new data on MASH/MASLD, including awareness, referral patterns, discussions around alcohol, and emerging pharmacotherapies.

Liver Lineup: Advances, Gaps, and What’s Next in Viral Hepatitis

, hosts Nancy Reau, MD, and Kimberly Brown, MD, tackle a paradox that continues to define viral hepatitis care: despite curative therapies for 

 and highly effective suppression for hepatitis B, global and domestic elimination goals remain out of reach. The conversation reframes viral hepatitis not as a “finished” chapter in hepatology, but as an ongoing public health challenge shaped by missed screening, gaps in linkage to care, and uneven adoption of evidence-based interventions.

Reau and Brown begin by emphasizing that hepatitis B and C persist largely because patients are not being identified or connected to treatment. Even in well-resourced health systems, screening often falls to primary care settings where competing priorities can delay testing. Both experts highlight successful but labor-intensive models that rely on universal screening and proactive outreach, underscoring that cure is only possible when diagnosis comes first.

The discussion then shifts to prevention strategies that extend beyond antivirals. Reviewing large population-based datasets, the hosts examine data suggesting statin use is associated with reduced risks of hepatic decompensation and hepatocellular carcinoma in patients with chronic viral hepatitis. Importantly, these benefits appear independent of antiviral therapy, reinforcing the message that statins should not be withheld solely due to compensated liver disease.

Similarly, emerging data on GLP-1 receptor agonists point to improvements in liver-related outcomes, cancer risk, and cardiometabolic complications among patients with viral hepatitis and diabetes. While neither expert advocates prescribing these agents solely for cancer prevention, both agree the findings are reassuring and further support their use when clinically indicated.

A significant portion of the episode focuses on the evolving hepatitis B pipeline, particularly strategies aimed at achieving a functional cure. Reau reviews durability data for antisense oligonucleotide therapies, noting that while response rates remain modest, selected patients with low baseline surface antigen levels may benefit. Both experts stress that durability, safety, and long-term outcomes will ultimately determine the role of these agents alongside well-tolerated lifelong nucleos(t)ide therapy.

The episode concludes with a deep dive into hepatitis D, one of the most aggressive viral liver diseases. Reau and Brown discuss promising combination approaches using monoclonal antibodies and siRNA therapies that have demonstrated substantial viral suppression in clinical trials. While relapse remains common after treatment discontinuation, the data signal meaningful progress in a field with limited therapeutic options.

Across the conversation, one message is clear: viral hepatitis may no longer dominate headlines, but sustained attention, better screening, and thoughtful integration of new therapies are essential to reducing long-term liver-related morbidity and mortality.

Reau and Brown discuss recent research in hepatitis B, C, and D, including use of statins, GLP-1s, and more.

Understanding Missed HCC Screening in Patients With Cirrhosis: Barriers to Care

Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is a cornerstone of liver care, yet real-world adherence to screening remains a persistent challenge. In this segment of Liver Lineup: Updates & Unfiltered Insights, hosts Kim Brown, MD, and Nancy Reau, MD, examine new data on how wide the gap remains between guideline recommendations and clinical practice as well as why that gap exists.

Check out the full episode on advances in liver transplantation and hepatocellular carcinoma 

Brown introduced a prospective, 3-year cohort study of adults with cirrhosis that evaluated adherence to HCC surveillance, along with patient-reported reasons for nonadherence. She explained that the investigators excluded individuals with pre-existing liver lesions or incomplete data and defined full adherence as receiving both ultrasound imaging and alpha-fetoprotein (AFP) testing every 6 months. Brown highlighted how low adherence truly was: fewer than 10% of patients met criteria for full adherence, while even partial adherence, defined as ultrasound alone, remained below 50%.

She emphasized that the reasons for nonadherence were multifactorial, the most striking being that more than a quarter of patients reported that surveillance had not been recommended by their treating physician. Brown described this as particularly disappointing given the well-established association between routine surveillance and earlier tumor detection. She suggested that this gap may be especially relevant in patients with metabolic disease, where clinicians may not consistently recognize cirrhosis-related cancer risk.

Reau expanded on these findings by highlighting practical challenges that arise in everyday clinical care. She noted that the study did not specify how many patients received AFP testing alone, an important omission given how surveillance is often implemented in practice.

Drawing from her own experience, Reau described how patients may resist blood draws, imaging studies, or both. She also pointed to frustrations around ultrasound quality, including inadequate visualization and the frequent need for follow-up imaging, which can lead to patient fatigue and disengagement.

Reau further emphasized that evolving guidelines have added complexity, particularly surrounding AFP, which has long been a point of debate. She pointed out that not all clinicians may be fully aware of updated recommendations re-incorporating it into routine surveillance, complicating how adherence is defined and measured.

Brown closed the discussion by returning to the issue of access and feasibility. While lack of physician recommendation was the leading barrier, resource limitations and geographic access were also significant. She underscored growing interest in blood-based screening strategies, noting that emerging data presented at The Liver Meeting may offer more practical, scalable approaches to HCC surveillance in the future, especially for patients who struggle to access imaging.

Shukla A, Padole V, Vaidya A. NON-ADHERENCE TO SURVEILLANCE PROTOCOL OF HEPATOCELLULAR CANCER IN PATIENTS WITH LIVER CIRRHOSIS: PREVALENCE AND REASONS. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

This segment of Liver Lineup features an in-depth discussion on hepatocellular carcinoma screening in patients with cirrhosis.

Nancy Reau, MD

Articles