Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2019; 11(10): 710-718
Published online Oct 27, 2019. doi: 10.4254/wjh.v11.i10.710
Characterization of patients with both alcoholic and nonalcoholic fatty liver disease in a large United States cohort
George Khoudari, Amandeep Singh, Mazen Noureddin, Danielle Fritze, Rocio Lopez, Imad Asaad, Eric Lawitz, Fred Poordad, Kris V Kowdley, Naim Alkhouri
George Khoudari, Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Amandeep Singh, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
Mazen Noureddin, Department of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Los Angeles, CA 90048, United States
Danielle Fritze, Department of General Surgery, Texas Liver Institute and University of Texas Health, San Antonio, TX 78215, United States
Rocio Lopez, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
Imad Asaad, Department of Gastroenterology, Metro Health System, Cleveland, OH 44109, United States
Eric Lawitz, Fred Poordad, Naim Alkhouri, Texas Liver Institute and University of Texas Health, San Antonio, TX 78215, United States
Kris V Kowdley, Swedish Liver Care Network, Swedish Medical Center, Seattle, WA 98122, United States
Author contributions: All authors have contributed to this manuscript and have agreed on the content; Alkhoury N, Fritze D, and Noureddin M were involved in the study design; Khoudari G, Alkhoury N, and Singh A were involved with data analysis; Lopez R provided statistical support; Khoudari G, Kowdley K V, Singh A, Poordad F, Lawitz E, and Asaad I were involved with data interpretation, drafting and revising the work; All authors provided approval for the final version to be published.
Institutional review board statement: NHANES was approved by the Institutional Review Board at the Center for Disease Control and Prevention. This study does not require IRB approval.
Informed consent statement: Informed consent was obtained from all participants.
Conflict-of-interest statement: All authors have no conflict of interest and nothing to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: George Khoudari, MD, Associate Professor, Department of Hospital Medicine, Cleveland Clinic Foundation, 29401 Hummingbird Cir, Westlake, Cleveland, OH 44195, United States. gkhoudary@gmail.com
Telephone: +1-909-5382118
Received: May 13, 2019
Peer-review started: May 14, 2019
First decision: June 13, 2019
Revised: August 3, 2019
Accepted: October 15, 2019
Article in press: October 15, 2019
Published online: October 27, 2019
Processing time: 166 Days and 2 Hours

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome (MetS) and is characterized by steatosis in the absence of significant alcohol consumption. However, MetS and significant alcohol intake coexist in certain individuals which may lead to the development of BAFLD.


To assess the clinical characteristics of patients with both alcoholic and NAFLD (BAFLD) in a large cohort in the United States.


Adults from the National Health and Nutrition Examination Survey between 2003-2014 were included. NAFLD was diagnosed based on elevated alanine aminotransferase (ALT) and being overweight or obese in the absence of other liver diseases. BAFLD patients met the criteria for NAFLD but also had either MetS or type 2 diabetes and consumed excessive amounts of alcohol. Univariable and multivariable analysis were performed to assess differences between NAFLD and BAFLD and to compare severity based on a validated fibrosis score (FIB4 index).


The prevalence of NAFLD was at 25.9% (95%CI; 25.1-26.8) and that of BAFLD was 0.84% (0.67, 1.02) which corresponds to an estimated 1.24 million Americans affected by BAFLD. Compared to NAFLD, patients with BAFLD were more likely to be male, smokers, have higher ALT, aspartate aminotransferase, triglycerides, and lower platelets; P < 0.01 for all. More importantly, after adjusting for MetS components, BAFLD patients were significantly more likely to have advanced fibrosis [adjusted OR (95%CI) based on FIB4 index > 2.67 was 3.2 (1.4, 7.0), P = 0.004].


A significant percentage of the American general population is afflicted by BAFLD and these patients tend to have more advanced liver fibrosis.

Keywords: Non-alcoholic fatty liver disease, Alcoholic liver disease, Fatty liver disease

Core tip: Using the National Health and Nutrition Examination Survey dataset, we studied a new classification of fatty liver disease that we believe is due to risk factors for both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease occurring in the same individual. We propose to call this entity Both Alcoholic and NAFLD (BAFLD). As most of the risk factors that lead to BAFLD are potentially modifiable, understanding their reciprocal association and combined effect on the liver may aid in understanding, treating, and preventing BAFLD.