Among 2,049,641 Korean health-checkup participants, fatty liver (Fatty Liver Index ≥30) raised all-cause mortality in every subtype versus no steatosis: MASLD HR 1.28, MetALD 1.40, ALD 1.70. Liver-related death climbed steepest, with HRs of 2.57, 4.34 and 6.23 respectively, while extrahepatic cancer and cardiovascular deaths also rose. Mortality increased with each additional cardiometabolic risk factor, and that gradient was strongest in MASLD and weakest in ALD.
The pattern is coherent: alcohol appears to act as a dose-dependent accelerant on top of metabolic injury, so liver mortality scales from MASLD to MetALD to ALD. The MASLD finding carries the practical message. Where alcohol is not the dominant driver, the number of metabolic risks (obesity, glucose, blood pressure, lipids) largely determines outcome, which means treatable risk factors are the lever. In ALD, drinking itself overwhelms the other contributors. Caveats matter, though. The Fatty Liver Index is a blood-and-anthropometry proxy, not imaging or biopsy, so misclassification is likely. Alcohol intake was self-reported at checkup, and a single baseline measure cannot capture changes over time. Residual confounding by smoking, diet and fitness is probable in an observational design. The headline associations largely confirm earlier MASLD work, but the scale and the subtype-by-risk-factor stratification are useful. For adults with fatty liver, the takeaway is to reduce alcohol and manage weight, glucose, blood pressure and lipids together, and to discuss liver and cardiovascular risk with a clinician.