The future of alcoholic liver disease management

Alcohol-related liver disease (ALD) is one of the most prevalent causes of liver disease. It is the leading cause of cirrhosis, accounting for almost 60%. Moreover, it is the leading cause of liver transplant. Hepatologists are underpreparated to diagnose and treat alcohol use disorder (AUD) despite its high prevalence. The aim of this narrative review is to suggest a cultural and organizational change of a hepatology unit. This narrative review is based on a detailed analysis of the scientific literature published before January 31^st, 2025 and examining the most recent papers on alcohol-related liver disease and hepatology unit organization (PubMed, Web of Science, Scopus, Google Scholar). Hepatology Unit must acquire alcohol and social skills autonomously. In association with liver injury treatment, it is necessary to set up addiction therapy in relation to liver damage severity and manage social vulnerability. The latter significantly influences the therapeutic path (mainly in case of inclusion on the list for a liver transplant). Therefore, in addition to cultural change (AUD skills), it is mandatory that the new organization provides the introduction of an authentic multi-professional activity, the formal caregiver and the self-help groups facilitator. The ability to identify hazardous/harmful alcohol consumption or alcohol use disorder is necessary. This is essential to clinically define steatotic liver disease. If this does not happen, the clinical outcome is compromised. Identification of a low-risk alcohol consumption in case of metabolic associated steatotic liver disease is necessary. In fact, it is known that ethanol in case of metabolic syndrome induces fibrogenesis at low dosage. Competence to manage harmful alcohol consumption and AUD is necessary (pharmacotherapy: intoxication, craving, withdrawal syndrome and psychotherapy). It is necessary to manage family and social problems that may prohibit inclusion in the liver transplantation list. Training and support of informal caregivers is necessary (introduction of the formal caregiver). Collaboration with self-help groups associations is necessary (introduction of the self-help groups facilitator). Collaboration with associations or charities for the management of fragile patients affected by AUD (homeless, migrants, prisoners, etc.).