Staging fatty liver, transplanting the sickest, and a shorter hepatitis C course

The edition in brief

An AGA Clinical Practice Update sets out best-practice advice for metabolic dysfunction- and alcohol-associated liver disease (MetALD): classify steatotic liver disease by cardiometabolic risk and weekly alcohol intake, assess alcohol use at least annually, stage fibrosis with a tiered non-invasive strategy starting from the Fibrosis-4 index, advise abstinence, and avoid bariatric surgery for lack of safety data — while noting GLP-1-based drugs may reduce alcohol cravings. A prospective study across 63 centres found that transplanting patients with severe acute-on-chronic liver failure sharply improved survival: among those declined, 73% with ACLF-2 and 88% with ACLF-3 died within a year, whereas one-year case-fatality after transplantation was 10.5% (ACLF-2) and 21% (ACLF-3) — though 42% with five or six organ failures died, cautioning against routine transplantation there, and this is a non-randomised comparison. A meta-analysis of 162 children with IBD switched from intravenous to subcutaneous infliximab found about 90% treatment persistence and remission with roughly doubled drug levels and rare antidrug antibodies, though it cannot show subcutaneous dosing induces remission de novo. A clinic pearl: enrol every patient with cirrhosis in six-monthly ultrasound surveillance for hepatocellular carcinoma and act promptly on any new nodule. Finally, a single-arm phase 2 study of an 8-week pan-genotypic regimen of bemnifosbuvir and ruzasvir in treatment-naïve chronic hepatitis C achieved sustained virologic response in 90% by intention-to-treat and 95–98% per protocol, across genotypes and regardless of baseline resistance substitutions, with good tolerability — a potential shorter option where access allows, alongside the cheap generic regimens already available in India.