Intended for healthcare professionals

Clinical Review State of the Art Review

Advances in the understanding and management of alcohol-related liver disease

BMJ 2023; 383 doi: (Published 20 November 2023) Cite this as: BMJ 2023;383:e077090
  1. Mark Thursz, professor of hepatology1,
  2. Anne Lingford-Hughes, professor of addiction biology2
  1. 1Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
  2. 2Department of Brain Sciences, Imperial College London, London, UK
  1. Correspondence to: M Thursz m.thursz{at}


Alcohol-related liver disease (ALD) is a major cause of liver-related morbidity and mortality. Epidemiological trends indicate recent and predicted increases in the burden of disease. Disease progression is driven by continued alcohol exposure on a background of genetic predisposition together with environmental cofactors. Most individuals present with advanced disease despite a long history of excessive alcohol consumption and multiple missed opportunities to intervene. Increasing evidence supports the use of non-invasive tests to screen for and identify disease at earlier stages. There is a definite role for public health measures to reduce the overall burden of disease. At an individual level, however, the ability to influence subsequent disease course by modifying alcohol consumption or the underlying pathogenic mechanisms remains limited due to a comparative lack of effective, disease-modifying medical interventions. Abstinence from alcohol is the key determinant of outcome in established ALD and the cornerstone of clinical management. In those with decompensated ALD, liver transplant has a clear role. There is consensus that abstinence from alcohol for an arbitrary period should not be the sole determinant in a decision to transplant. An increasing understanding of the mechanisms by which alcohol causes liver disease in susceptible individuals offers the prospect of new therapeutic targets for disease-modifying drugs. Successful translation will require significant public and private investment in a disease area which has traditionally been underfunded when compared to its overall prevalence.


  • State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All authors contributed to the planning, writing and review of the article. The corresponding author acts as the guarantor for the article and attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Competing interests: ALH declares honorarium from Lundbeck for lecture/training and royalties from editorship of Edwards' Treatment of Drinking Problems: A Guide for the Helping Professions. MT declares consultancy fees from GSK, Durect, Intercept, and Surrozen.

  • Patient involvement: No patients were asked for input in the creation of this article.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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