Metabolic dysfunction and alcohol-related liver disease (MetALD) represents a newly defined and rapidly evolving disease spectrum that bridges metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD). This cover article provides a timely and comprehensive overview of the application and interpretation of non-invasive tests (NITs) in MetALD, covering key domains including steatosis, inflammation, fibrosis, and disease prognostication.

The authors highlight that while current NITs developed for MASLD remain broadly applicable to MetALD, alcohol consumption patterns - particularly episodic binge drinking - may significantly confound test performance and interpretation. This underscores the importance of integrating structured alcohol-use assessment tools and emerging biomarkers into routine clinical evaluation.

Importantly, the review also explores the expanding role of NITs in clinical trial design for MetALD. The authors emphasize the urgent need to move beyond liver biopsy–based surrogate endpoints and advocate for the development and validation of non-invasive biomarkers to support safer, more scalable, and patient-friendly drug development strategies.

Overall, this article provides a forward-looking framework for non-invasive assessment in MetALD, offering critical insights for both clinical practice and future therapeutic innovation in this emerging field.