REVIEWS

Alcoholic liver disease: pathogenesis and new

targets for therapy
José Altamirano and Ramón Bataller
Abstract | Alcoholic liver disease (ALD) is a major cause of morbidity and mortality worldwide. The spectrum
of disease ranges from fatty liver to hepatic inflammation, necrosis, progressive fibrosis and hepatocellular
carcinoma. In developed countries, ALD is a major cause of end-stage liver disease that requires
transplantation. The most effective therapy for ALD is alcohol abstinence. However, for patients with severe
forms of ALD (that is, alcoholic hepatitis) and for those who do not achieve abstinence from alcohol, targeted
therapies are urgently needed. The development of new drugs for ALD is hampered by the scarcity of studies
and the drawbacks of existing animal models, which do not reflect all the features of the human disease.
However, translational research using liver samples from patients with ALD has identified new potential
therapeutic targets, such as CXC chemokines, osteopontin and tumor necrosis factor receptor superfamily
member 12A. The pathogenetic roles of these targets, however, remain to be confirmed in animal models. This
Review summarizes the epidemiology, natural history, risk factors and current knowledge of the pathogenetic
mechanisms of ALD. In addition, this article provides a detailed description of the findings of these
translational studies and of the animal models used to study ALD.
Altamirano, J. & Bataller, R. Nat. Rev. Gastroenterol. Hepatol. 8, 491–501 (2011); published online 9 August 2011; doi:10.1038/nrgastro.2011.134

Introduction
Sustained, excessive alcohol consumption is an addictive
behavior disorder that occurs in all ethnicities and age
groups, and in both sexes.1,2 In many individuals, consis­
tently high levels of alcohol intake leads to alcoholic liver
disease (ALD), a major cause of morbidity and mortal­
ity worldwide. Heavy alcohol drinking is also associated
with disorders unrelated to the liver, such as infections,
malignancies, cardiovascular events and diseases of the
nervous system, pancreas and kidneys.3
The spectrum of ALD encompasses fatty liver, hepatic
inflammation and necrosis, progressive fibrosis and
hepatocellular carcinoma.2 Furthermore, a sustained,
excessive alcohol intake favors the progression of other
liver diseases, such as chronic viral hepatitis (hepa­
titis C and B) and other metabolic liver diseases, such as
hemochromatosis, Wilson disease and fatty liver associ­
ated with the metabolic syndrome.4–8 Despite the eco­
nomic burden of ALD and its severe effect on health,
few advances have been made in the management of
patients with this condition.2 No modern diagnostic tools
can assess an individuals’ susceptibility to ALD, and the
pathogenesis of this disease in humans is poorly under­
stood. This scenario is in marked contrast to the spec­
tacular leaps forward made in the treatment of other liver
diseases, such as hepatitis B and C. The lack of advances
in the field of ALD are mainly related to the difficulties
of conducting clinical trials in patients with an active
alcohol addiction, the lack of interest in this field from
Competing interests
The authors declare no competing interests.
drug companies and the drawbacks of current experi­
mental models of ALD. Moreover, public funding for
research into alcohol-related disorders has been scarce,
especially in the field of hepatology.
In this Review, we describe the epidemiology and
natural history of ALD, as well as the risk factors associ­
ated with this disease. In addition, we present the current
knowledge of the pathogenetic mechanisms underlying
ALD. This article also includes detailed descriptions
of translational studies conducted using human tissue
samples, which have identified potential new therapeutic
targets for ALD, and the animal models currently used
to study this disease.
Epidemiology of ALD
Prevalence
Alcohol abuse is a major cause of preventable morbid­
Liver Unit, Hospital
ity and mortality worldwide. According to the WHO, Clínic, Institut
morbidity from alcohol misuse in developed countries d’Investigacions
Biomèdiques August Pi
accounts for 10.3% of disability-adjusted life-years i Sunyer (IDIBAPS),
(DALYs—a measure of overall disease burden that CIBER de
reflects the years of healthy life lost owing to both pre­ Enfermedades
Hepáticas y Digestivas
mature mortality and prolonged poor health), a figure (CIBERehd), Center
that comes second only to the morbidity associated with Esther Koplowitz,
Laboratory of Liver
tobacco use in developed countries (11.7% of DALYs).9 Fibrosis, Rosellón 149,
Alcohol misuse also affects individuals in develop­ 3rd Floor, 08036
ing countries, where it is responsible for almost 9% of Barcelona, Spain
(J. Altamirano,
DALYs.10,11 Worldwide, ALD is responsible for about 4% R. Bataller).
of DALYs.9
Correspondence to:
ALD is probably the main cause of death among people R. Bataller
with severe alcohol abuse and is responsible for about bataller@clinic.ub.es

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Key points
■■ Alcohol abuse is a major cause of preventable morbidity and mortality 80–90%
worldwide, and a major health problem in both the EU and the USA
■■ Alcoholic liver disease is a major cause of end-stage liver disease requiring liver
Healthy liver
transplantation
■■ The spectrum of alcoholic liver disease encompasses simple steatosis, Steatosis 20–40%
steatohepatitis, progressive fibrosis, cirrhosis and hepatocellular carcinoma
■■ The basic mechanisms of alcoholic liver disease have been evaluated in both
animal models and translational studies, but further research is needed to
confirm the results
■■ Studies in human liver samples have identified novel therapeutic targets for
alcoholic liver disease, including CXC chemokines, osteopontin, tumor necrosis
factor receptor superfamily member 12A receptor and nostrin
Alcoholic Fibrosis
■■ New experimental models of severe alcoholic liver disease that include 8–20%
steatohepatitis
profound hepatocellular damage and fibrosis should be developed

3.8% of global mortality.9 Moreover, ALD remains one 20–40%

of the most important causes of liver-related deaths in

the USA, with a mortality of 4.4 deaths per 100,000 of the
population—even higher than that of hepatitis C (2.9
deaths per 100,000 people).12 Remarkably, data from the
European Liver Transplant Registry show that ALD was
recorded as the indication for liver transplantation in
almost half (41.6%) of procedures performed between
1996 and 2005.13,14 ALD is, therefore, the second most
common indication for liver transplantation in Europe
and North America.15,16
Natural history
ALD comprises a broad spectrum of disease: asymptom­
atic fatty liver, steatohepatitis, progressive fibrosis,
end-stage cirrhosis and superimposed hepatocellular
carcinoma (Figure 1). Up to 90% of patients with heavy
alcohol intake have some degree of steatosis,17 which is
usually asymptomatic and rapidly reversible with absti­
nence. Continued heavy alcohol consumption, however,
leads to inflammation of the liver characterized by the
infiltration of polymorphonuclear leukocytes and hepato­
cellular damage, both of which define alcoholic hepa­titis.18
Eventually, patients develop liver fibrosis deposition (20–
40%) and cirrhosis (8–20%), which confers a high risk of
complications (such as ascites, variceal bleeding, hepatic
encephalo­pathy, renal failure and bacterial infections).19,20
Severe forms of alcoholic hepatitis have a very high short-
term mortality.20 The prognosis of patients with alcoholic
hepatitis can be estimated by several predictive models,
such as Maddrey’s discriminant function, the model for
end-stage liver disease (MELD), Glasgow scores and a
composite albumin, bilirubin, international normalized
ratio and creatinine (ABIC) score (Figure 2).21–25 These
scores can help clinicians to manage these patients.21–25
In addition, response to corticosteroids could be evalu­
ated with the Lille model, which utilizes age, severity
of renal impairment, albumin level, prothrombin time,
initial bilirubin level, and change in bilirubin level after
7 days of treatment: a value ≥0.45 identifies patients who
do not respond to corticosteroids and is associated with
a 25% probability of 6‑month survival, whereas a value
<0.45 reflects an 85% probability of 6‑month survival.
Cirrhosis
3–10%
Clinical Hepatocellular
decompensations carcinoma
Figure 1 | The spectrum of alcoholic liver disease. The
percentages represent the patients who progress from one
stage to the next.
This model, therefore, enables the early identification of
patients who do not respond to corticosteroid therapy
and who could be considered for inclusion in clinical
trials (Figure 2).24
As alcohol abuse can lead to severe damage in the
nervous system, heart, kidney and pancreas, patients
with ALD may also develop a variety of symptoms unre­
lated to the liver, such as psychiatric manifestations, heart
failure, renal failure and abdominal pain.
Diagnosis and treatment
The diagnosis of alcohol abuse is based on self-
reporting, but collection of objective data is advisable.
Among the various biomarkers of chronic alcohol
abuse, carbohydrate-­d eficient transferrin (CDT) is
probably the most reliable.26 A combined index based
on γ‑glutamyltransferase and CDT measurements
has a good sensitivity for detecting excessive ethanol
consumption.27
The cornerstone of management of patients with ALD
is to stop them from drinking alcohol, as continued
alcohol intake is the single most important risk factor
for progression of ALD.28–30 Abstinence is also critical for
patients with advanced ALD, who may eventually require
liver transplantation, because patients who continue to
drink alcohol are not eligible for most transplantation

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programs. Referral to rehabilitation programs, together Clinical and biochemical suspicion of alcoholic liver disease
with family support, is usually necessary to achieve absti­
nence in patients with ALD (Figure 3). Although studies
showed that drugs, such as disulfiram, naltrexone, acam­ Noninvasive diagnostic tests:
prosate and baclofen, can help some patients achieve sus­ ultrasonography, ASHtest, carbohydrate-deficient
transferrin, elastography
tained abstinence,31–34 drug treatment is not successful in versus
all patients. For those who find alcohol cessation impos­ Liver biopsy to rule out other etiologies

sible, treatments that attenuate the progression of liver

disease and reduce mortality are urgently needed.
Psychiatric evaluation
Parenteral and enteral feeding improve the nutritional
status of patients with alcoholic hepatitis without influ­
encing short-term survival.35 Several pharmacological
Group and supportive psychotherapy to
therapies have been tried in patients with severe alcoholic promote abstinence from alcohol
hepatitis, albeit with limited success (Figure 3). Studies
of anabolic–androgenic steroids36 and antioxidant drugs Failure Success
(such as vitamin E and silibinin37,38) showed that these Pharmacological therapy Consider an
agents did not improve survival. Other ineffective thera­ for alcoholism antifibrogenic therapy
(disulfiram, baclofen, naltrexone) (losartan, pentoxifylline)
pies include colchicine, propylthiouracil and combined
intravenous administration of glucagon and insulin.39–41 Figure 2 | Proposed algorithm for the treatment of
By contrast, treatment with corticosteroids (such as alcoholic hepatitis. The algorithm is based on current
evidence, AASLD Clinical Guidelines and experience in the
prednisolone) and pentoxifylline can prolong survival
Liver Unit of the Hospital Clinic of Barcelona.49 A value of
in some patients with alcoholic hepatitis, although nearly ≥0.45 in the Lille model is associated with a 25%
half of treated patients do not respond to this therapy.42–44 probability of survival for 6 months, whereas a value of
Corticosteroid treatment for patients with alcoholic <0.45 is associated with an 85% probability of 6‑month
hepa­titis, the most severe form of ALD, has been the survival.24 Abbreviations: ABIC, age, bilirubin, international
standard of care for the past 40 years. normalized ratio and creatinine; MARS, molecular
In addition, although some studies have investigated adsorbent recirculating system; MELD, model for end-stage
the potential role of agents that interfere with the bio­ liver disease.
logical effects of tumor necrosis factor (TNF), such
as the monoclonal antibody infliximab and the TNF
Clinical and biochemical suspicion of alcoholic hepatitis
inhibitor etanercept, in the treatment of patients with
severe alcoholic hepatitis, these two agents were associ­
ated with increased mortality owing to severe bacterial
Consider transjugular liver biopsy for histological confirmation
infections.45–48 As a result, novel targeted therapies are
needed for alcoholic hepatitis. Treatment algorithms for
ALD and alcoholic hepatitis based on current evidence,
Severity stratification
AASLD Clinical Guidelines and experience in the Liver (Maddrey’s discriminant function, MELD, ABIC and Glasgow scores)
Unit of the Hospital Clinic of Barcelona are proposed
(Figures 2 and 3).49
Intermediate and high risk Low risk
Disease progression
Steatosis
Alcoholic steatosis is a complex process manifested Severe infection No or Nutrition assessment and
controlled infection standard supportive care
through several mechanisms. The main pathogenetic
factors underlying this process are increased fatty acid
and triglyceride synthesis, enhanced hepatic influx of
Pentoxifylline Corticosteroids
free fatty acids from adipose tissue and of chylo­microns (400 mg three times (prednisone 40 mg)
daily for 4 weeks)
from the intestinal mucosa, increased hepatic lipo­ Lille model score at 7 days
genesis, inhibited lipolysis, and damaged mitochondria <0.45 ≥0.45
and microtubules, all of which result in accumula­tion of Stop corticosteroids
4 weeks of corticosteroids
VLDL.50–55 The molecular mechanisms involved in ste­ followed by a 2-week taper Consider for clinical trials
Consider for MARS
atosis are largely unknown, although overexpression of
lipogenic enzymes results from the down­regulation Figure 3 | Proposed algorithm for the treatment of alcoholic liver disease. The
of peroxisome proliferator activated receptor α (PPARα) algorithm is based on current evidence, AASLD Clinical Guidelines and experience
and the induction of sterol regulatory element-binding in the Liver Unit of the Hospital Clinic of Barcelona.49 The ASHtest (BioPredictive,
Paris, France) estimates the severity of alcoholic liver disease from the levels of
protein (SREBP).56,57 AMP-activated protein kinase,
α2-macroglobulin, haptoglobin, apolipoprotein A1, total bilirubin,
which regulates the relative concentrations of intra­ γ‑glutamyltransferase, alanine aminotransferase and aspartate aminotransferase.
cellular malonyl coenzyme A and long-chain acyl- Some parameters are adjusted for the patient’s age and sex. Abbreviations: ABIC,
­coenzyme A—the key metab­olites responsible for the age, bilirubin, international normalized ratio and creatinine; MARS, molecular
balance between fat synthesis and fat degradation adsorbent recirculating system; MELD, model for end-stage liver disease.

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Continuous alcohol intake
ADH, ALDH, CYP2E1
Gut permeability Antioxidants Acetaldehyde
Hepatocytes Kupffer cells
Hepatic
stellate cells
Serum lipopolysaccharide ROS ROS
Cytokines
CD14 Kupffer cells TGF-β
TLR4 Hepatic stellate cells
Lipid
NOx Mitochondrial
damage peroxidation
NFκB, JNK
STATs Cytokines
Regeneration Inflammation Apoptosis Fibrosis
Figure 4 | Pathogenetic pathways leading to progression of alcoholic liver disease.
Ethanol promotes the translocation of lipopolysaccharide from the gastrointestinal
lumen to the portal vein, where it binds to the lipopolysaccharide-binding protein. In
the Kupffer cells, lipopolysaccharide binds to CD14, which combines with TLR4
activating multiple cytokine genes with inflammatory cytokine production and
decreasing the expression of STATs leading to reduced liver regeneration. Long-
term alcohol consumption alters the intracellular balance of antioxidants with
subsequent decrease in the release of mitochondrial cytochrome c and expression
of Fas ligand, leading to hepatic apoptosis through the caspase‑3 activation
pathway. Studies in rats and mice suggest that activated Kupffer cells and
hepatocytes are sources of free radicals (especially ROS), which are responsible
for lipid peroxidation and further apoptotic damage. Activation of hepatic stellate
cells also contributes to the production of cytokines, ROS and TGF‑β exacerbating
liver fibrosis. Abbreviations: ADH, alcohol dehydrogenase; ALDH, aldehyde
dehydrogenase; CYP2E1, cytochrome P450 2E1; JNK, c‑Jun N‑terminal kinase;
NFκB, nuclear factor κB; NOx, nitrogen oxides; ROS, reactive oxygen species; STAT,
signal transducer and activator of transcription; TGF‑β, transforming growth
factor β; TLR4, Toll-like receptor 4.
pathways—is also implicated in hepatic fat metabolism.58
In addition, changes in NADH reduction–­oxidation
potential in the liver might promote lipogenesis
through inhibition of fatty acid oxidation. Furthermore,
microsomal tri­g lyceride transfer protein activity is
reduced by long-term ethanol administration, which
also causes fat accumula­tion in the liver.59
Steatohepatitis
Steatohepatitis is defined by the presence of fatty liver,
an inflammatory infiltrate (which mainly consists of
polymorphonuclear leukocytes) and hepatocellular
damage. This stage of ALD is a prerequisite for progres­
sion to fibrosis and cirrhosis.60 The histological subtypes
of steatohepatitis are not well defined and the severity of
disease might depend on the amount of alcohol intake
and other environmental factors, such as diet and life­
style, as well as the genetic background of patient.61–63
When the inflammation and hepatocellular injury are
severe, the condition is called alcoholic hepatitis.
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Various molecular mechanisms probably contribute
to the development of steatohepatitis (Figure 4). For
example, acetaldehyde (the major product of alcohol
metabolism) binds to both proteins and DNA, resulting
in functional alterations and the formation of protein
adducts. In turn, these adducts form autoantigens that
activate the adaptive immune system 64,65 and recruit
lympho­c ytes to the damaged liver. Acetaldehyde also
induces mitochondrial damage and impairs glutathione
function, leading to oxidative stress and apoptosis.66–68
Oxidative stress, and the resulting protein nitrosyla­
tion and lipid peroxidation, are believed to have a
major pathogenetic role in ALD.69 Nonparenchymal
liver cells are the major producers of reactive oxygen
species (ROS) in patients with ALD.70 The enzymes and
pathways involved in ROS generation include the cyto­
chrome P450 2E1 (CYP2E1)-dependent microsomal
electron transport system of the respiratory chain,
NADH-dependent cytochrome reductase and xanthine
oxidase.71–73 Moreover, chronic alcohol intake mark­
edly upregulates CYP2E1 activity, because this enzyme
(in addition to alcohol dehydrogenase and aldehyde
dehydro­genase), metabolizes ethanol to acetaldehyde;
thus alcohol ingestion stimulates the generation of ROS
and hydroxyl-ethyl radicals.70 Alcohol metabolites and
ROS stimulate signaling pathways that involve nuclear
factor κB (NFκB), signal transducer and activator of
transcription (STAT)–Janus kinase (JAK) and c‑Jun
N‑terminal kinase (JNK) in hepatic resident cells, leading
to local synthesis of inflammatory mediators, such as
tumor necrosis factor (TNF), IL‑17, CXC chemokines
(including IL‑8), as well as osteopontin.74–80
Alcohol abuse also results in changes in the colonic
microbiota and increased permeability of the intestine
to bacterial endotoxin, which leads to elevated serum
levels of lipopolysaccharide. This increase in lipopoly­
saccahride induces inflammatory actions in Kupffer cells
via the CD14–Toll-like receptor (TLR) 4 pathway.3,81 The
resulting inflammatory milieu in the alcoholic liver then
leads to polymorphonuclear leukocyte infiltration, ROS
formation and hepatocellular damage. Finally, impaired
protein degradation through the ubiquitin–proteasome
pathway, increased endoplasmic reticulum stress and
altered autophagy also promote hepatocellular injury
and development of hepatic inclusions of aggregated
cytokeratins (termed Mallory-Denk bodies).82
Fibrosis
Patients with alcoholic steatohepatitis can develop pro­
gressive fibrosis. In livers affected by ALD, the fibrotic
tissue is typically located in pericentral and peri­
sinusoidal areas.83 In advanced stages of ALD, colla­gen
bands are evident and bridging fibrosis develops, which
precedes the development of regeneration nodules and
liver cirrhosis. The cellular and mol­ecular mechanisms of
fibrosis in ALD are not completely understood. Alcohol
metab­olites, such as acetaldehyde, can directly activate
hepatic stellate cells, the main collagen-­producing cells
in the injured liver.84 Hepatic stellate cells can also be
activated in a paracrine fashion by damaged hepatocytes,

activated Kupffer cells and polymorphonuclear leuko­
cytes.85 The damaged hepatocytes, activated Kupffer cells
and polymorphonuclear leukocytes release a wide range
of fibrogenic mediators: growth factors, such as trans­
forming growth factor (TGF)‑β and platelet-derived
growth factor; cytokines, including leptin, angiotensin II,
IL‑8 and TNF; nitric oxide; and ROS (super­oxide,
hydrogen peroxide and hydroxyl anion radicals). 86,87
Importantly, ROS stimulate profibrogenic intracellular
signaling pathways in hepatic stellate cells, including
extracellular signal-­regulated kinases (ERK1 and ERK2),
phosphoinositide 3 kinase–Akt and JNK.88,89 ROS also
upregulate tissue inhibitor of metallo­proteinases 1
and decrease the action of metallo­proteinases, which
jointly promote collagen accumulation.90,91 Cells other
than hepatic stellate cells, including portal fibroblasts
and bone-marrow-derived cells, can also synthesize
collagen in patients with ALD. Whether other novel
mechanisms, such as epi­thelial-to-mesenchymal trans­
ition of hepatocytes, also have a role in liver fibrosis is
under investigation.92
Environmental and genetic factors
ALD results from a complex interaction of behavioral,
environmental and genetic factors. Although a posi­
tive correlation between cumulative alcohol intake and
degrees of liver fibrosis has been reported, extensive
variability in the histological response to alcohol abuse
exists in individuals.93,94 At similar levels of ethanol con­
sumption, some patients only develop macrovesicular
steatosis, while others develop progressive fibrosis and
cirrhosis. The main environmental factors that promote
the progression of liver fibrosis in patients with alcohol
abuse include obesity and cigarette smoking. 87,95 The
role of metabolic factors, including insulin resistance, is
unclear, although some reports suggest that such factors
might also favor progression of fibrosis.96
Genetic factors are also known to influence the organ
specificity of alcohol-related harmful effects. While
some patients with heavy alcohol consumption develop
ALD, others mainly suffer from alcohol-related dis­
orders of the pancreas, heart and nervous system.
Studies in families showed variations in the suscepti­
bility to ALD between different ethnic groups, suggest­
ing that genetic factors are important determinants of
disease risk. Twin studies also suggest a major role for
genetic pre­d isposition in the susceptibility to ALD;
concordance rates for alcoholism and alcohol-induced
liver fibrosis in monozygotic twins were 26.3 and 14.6,
respectively. 97 Epidemiological studies suggest that
several genetic factors influence the severity of steatosis
and oxidative stress, and that the cytokine milieu, the
magnitude of the immune response, and/or the severity
of fibrosis also modulate an indivi­duals’ propensity to
progress to advanced ALD.98
Genes encoding the main alcohol-metabolizing
enzymes (alcohol dehydrogenase, aldehyde dehydrogenase
and CYP2E1) and proteins involved in the toxic effects
of alcohol and its metabolites on the liver, such as anti­
oxidants and proinflammatory cytokines, have been the
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focus of investigation. Genetic factors that influence the
activity of these enzymes and the rate of alcohol metab­
olism have also been extensively studied. Owing to its
fibrogenic potential, variations in the rate of genera­
tion of acetaldehyde could explain the differences in the
suscepti­bility of individuals to ALD after abusive alcohol
consumption. Most genetic epidemiological studies of
ALD have been performed in Asia, where the preva­
lence of polymorphisms in the genes encoding enzymes
involved in alcohol metabolism, such as ADH1B, ADH1C
and ALDH2, is very high. Although polymorphisms in
these genes and in the 5'-flanking region of CYP2E1 are
accepted to be involved in an individual’s susceptibility to
alcoholism, their role in the progression of ALD remains
controversial.99 A meta-analysis of studies on the associa­
tion between alcoholism and alcohol-induced liver
damage highlighted the heterogeneity of the case–control
studies that investigated ADH1B, ADH1C, CYP2E1 and
ADLH2 polymorphisms.100
Polymorphisms in genes that encode pro­inflammatory
cytokines involved in the pathogenesis of ALD have
also been examined. Although a single nucleotide
poly­morphism located in the promoter region of TNF
(which increases production of this cytokine) is associ­
ated with severe steatohepatitis, no studies have yet
confirmed this finding. Polymorphisms in the genes
encoding NFκB subunits, IL‑1β and IL‑1 receptor
antagonists, IL‑2, IL‑6 and IL‑10 also modify the pro­
gression of ALD.98 Moreover, studies have also investi­
gated the role of genetic variation in factors involved
in lipopolysaccharide-­induced intracellular pathways,
including CD14 and TLR4, as potential risk factors for
ALD. Differential expression of genes belonging to these
pathways could alter the inflammatory and fibrogenic
response of the liver after prolonged alcohol intake.101
Patients with polymorphisms that result in low activity
of superoxide dismutase and gluthatione‑S-transferase—
two powerful antioxidant enzymes—are also at risk of
developing severe ALD. Finally, three studies indicated
that variations in PNPLA3, which encodes patatin-like
phospholipase domain-­containing protein 3, strongly
influence the development of advanced liver fibrosis
among Mexican and Caucasian populations. 61,102,103
Importantly, PNPLA3 polymorphisms can be consid­
ered to be the only confirmed and replicated genetic risk
factor for ALD.
Despite the large number of studies that have assessed
the role of genetic variation in susceptibility to ALD, a
large-scale, well-designed, genome-wide association
study of factors associated with ALD remains to be
performed. Most published reports include a limited
number of patients who lack a well-defined phenotype,
have only investigated a few genes and have important
methodological weaknesses. Consequently, a genetic
test capable of identifying patients with the propensity
to develop advanced ALD has not yet been developed.
Such a genetic test could be useful in clinical settings,
as it would help to identify the main genetic determi­
nants of ALD, which would assist in the development of
new therapies.
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Table 1 | Potential therapeutic targets for alcoholic liver disease*

Target molecule Biological function Disease
IL‑8 and GRO‑α75,76 Inflammation, hepatocellular death Alcoholic hepatitis
NFκB, TLR3 and TLR7141 Fibrogenesis, inflammation, hepatocellular death Alcoholic liver disease (various stages)
Osteopontin 77
Inflammation, hepatocellular death Alcoholic liver disease (various stages)
IL‑17142 Inflammation, hepatocellular death Alcoholic hepatitis
P90SRK 143
Fibrogenesis, hepatocellular death Alcoholic hepatitis
TNF receptor superfamily Fibrogenesis, inflammation, hepatocellular death Alcoholic liver disease (various stages)
member 12A107
ADAMTS13 and von Fibrinolysis, coagulation Alcoholic hepatitis
Willebrand factor111,112
Nostrin113 Endoplasmic reticulum stress Alcoholic cirrhosis
Dimethylarginines 144,145
Endoplasmic reticulum stress, endothelial dysfunction Alcoholic hepatitis
IL‑22 and STAT379,106 Inflammation, hepatocellular death Alcoholic hepatitis
Fas108 Hepatocellular death, cellular apoptosis Alcoholic hepatitis
Bcl‑2109
Hepatocellular death, cellular apoptosis Alcoholic hepatitis
IL‑6146 Inflammation Alcoholic liver disease (various stages)
TNF105 Inflammation Alcoholic hepatitis
*All were identified in in vitro studies that used human liver samples. Abbreviations: ADAMTS13, a disintegrin and metalloproteinase with a thrombospondin
type 1 motif, member 13; GRO‑α, growth-regulated α‑protein; P90SRK, p90 ribosomal S6 kinase; TNF, tumor necrosis factor.

New therapeutic targets in humans CXC chemokines: IL‑18 and GRO‑α

As animal models do not accurately mimic the main find­
ings in advanced ALD in humans, studies using human
tissue are needed to identify new therapeutic targets. As
discussed above, epidemiological studies have revealed
several genes that mediate injury and fibrosis in ALD.
However, the key genes involved in the pathogenesis
of ALD are unclear. Studies have also investigated the
correla­tion between serum levels of molecular media­
tors of ALD (such as TNF) and disease severity,104 but
the pathogenetic significance of the associations identi­
fied in these studies is similarly unclear, since increased
serum levels of cyto­kines could result from impaired
liver clearance or ongoing bacterial infections. A more
rational approach would be to investigate the expression
and/or activation of different mediators of ALD in liver
tissue from patients with ALD, and to correlate these
findings with disease severity and the patient’s outcome.
This approach has already been used to identify poten­
tial targets for therapy in patients with severe ALD
(Table 1). However, the pathogenesis of ALD involves
interactions between multiple genes and environmental
factors. The results of gene-array studies that identified
single genetic determinants of ALD should, therefore, be
considered cautiously.75,105
A wide variety of cytokines, immune modulators and
markers of fibrogenesis are altered in patients with ALD.
However, the fact that their tissue expression or serum
levels are altered in this setting might not render these
specific mediators useful as therapeutic targets. Although
some of these molecules take part in the physiopathol­
ogy of ALD, others might be more useful as indicators
of disease activity and inflammation than for their role
as disease mediators. The most relevant mediators for
ALD identified in human samples are discussed in
detail below.
This family of chemokines mainly attracts polymorpho­
nuclear leukocytes, the main infiltrating inflammatory
cells in ALD. In patients with alcoholic hepatitis, the
baseline levels of expression of some of these chemokines
in the liver correlated with the patient’s survival duration
and the degree of portal hypertension.75,76
IL‑22–STAT3 pathway
IL‑22 has been identified as a member of the IL‑10 family
of cytokines, which are produced by T helper type 17 cells
and natural killer cells. This interleukin has important
roles in the control of bacterial infection, homeo­stasis
and tissue repair.106 Treatment with IL‑22 ameliorates
experimental ALD in rodent models through activa­
tion of STAT3. Moreover, IL‑22 receptor 1 expression is
upregulated, whereas IL‑22 expression is undetectable,
in patients with alcoholic hepatitis.79
TNF superfamily receptors
In patients with alcoholic hepatitis, TNF is not over­
expressed. By contrast, several members of the TNF
receptor superfamily are markedly upregulated. In par­
ticular, TNF receptor superfamily member 12A (also
known as Fn14 or the Tweak receptor) is markedly over­
expressed in these patients and its expression correlates
with the severity of alcoholic hepatitis.107 Interestingly,
TNFRSF12A is mainly expressed in hepatic progenitor
cells, which accumulate in patients with severe forms of
alcoholic hepatitis.
Osteopontin
The extracellular matrix protein osteopontin is highly
expressed in patients with alcoholic hepatitis. The basal
level of expression of osteopontin correlates with the
severity of this disease and its expression is upregulated

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Table 2 | The most important experimental models of alcoholic liver disease

Outline of model
Direct ethanol administration
via upper gastrointestinal tract
intubation (esophageal or
gastric)
Tsukamoto–French model of
ethanol administration via
permanent intragastric
gastrostomy
Lieber–De Carli liquid nutrient
diet: ethanol accounts for
36%* of total calories
Control littermates receive
carbohydrates as substitute
Combination of Lieber–De Carli
diet and jejunoileal bypass, or
combination of Lieber–De Carli
diet plus endotoxin
administration
Knockout and transgenic
animals
Voluntary oral ethanol intake: a
diet containing 8% ethanol, fish
oil (30% of calories), protein
and dextrose is administered
for 8 weeks
Chronic–binge ethanol intake:
a 5% liquid ethanol diet is
administered for 10 days,
followed by a force-fed single
dose of 20% ethanol (5 g/kg
body weight)
*In the minipig nutrient diet ethanol accounts for 40% of total calories.
Species Liver damage Advantages Disadvantages References
Rats, Steatosis Controlled ethanol dose Lack of utility as a model of 110–113
mice, Mild polymorphonuclear chronic ethanol administration
rabbits leukocyte infiltration Stressful
Not physiological
Rats, mice Severe steatosis Good control of ethanol Expensive maintenance 141–144
Scattered hepatocyte necrosis intake Surgical expertise needed
Mild polymorphonuclear Possibility of high blood Not suitable for acute
leukocyte and mononuclear ethanol levels exposure studies
infiltration
Rats, Steatosis No bias resulting from Important differences between 145, 146
mice, Mild inflammation nonalcoholic nutrient animal and human pathology
baboons, Baboons: alcoholic hepatitis intake, owing to exactly Baboons: high cost and
minipigs features and cirrhosis equivalent caloric intake methodologically difficult
Minipigs: resembles the by littermate controls Minipigs: high cost and lack of
histological features of human long-term results
alcoholic liver disease
Rats, mice Marked steatosis No bias resulting from Important differences between 114, 115
Focal polymorphonuclear nonalcoholic nutrient animal and human pathology
leukocyte infiltration intake, owing to exactly Methodologically difficult
Occasional hepatocyte necrosis equivalent caloric intake Not physiological
by littermate controls
Mice Depends on the function of the Enables specific and Findings are difficult to 120–123
manipulated gene systematic analysis of translate to human diseases
Mostly affects macrovesicular genes and their products, Not physiological
and microvesicular fat as well as their relation Methodologically difficult
deposition to ethanol administration
Rats Marked steatosis Resembles human Important differences between 124
Focal polymorphonuclear drinking habits animal and human pathology
leukocyte infiltration Possibility of high blood
Occasional hepatocyte necrosis ethanol levels and
Pericentral liver collagen considerable liver injury,
deposition including mild fibrosis
Mice Marked steatosis Resembles human Methodologically difficult 119
Focal polymorphonuclear drinking habits Force-feeding (gavage)
leukocyte infiltration Possibility of high blood procedure requires technical
Focal hepatocyte necrosis ethanol levels and expertise
considerable liver injury

by fibrogenic mediators, such as TGF‑β. Importantly, which result in microcirculatory disturbances. In

mice that lack osteopontin develop attenuated liver
injury after prolonged exposure to alcohol.77
Proapoptotic molecules: Fas and Bcl‑2
Several studies have demonstrated that proapoptotic
mediators, such as Fas and Bcl‑2, are upregulated in the
livers of patients with ALD.108,109 Oxidative stress stimu­
lates the expression of these proteins, and thereby pro­
motes the induction of apoptotic pathways. Although
these mediators are appealing targets for the treatment
of patients with ALD, prolonged inhibition of their
expression could favor cancer development, which is
already a major complication in patients with chronic
liver diseases.110
patients with alcoholic hepatitis, the imbalance between
ADAMTS13 activity and these unusually large von
Willebrand factor multimers caused by proinflammatory
cytokines could contribute to sinusoidal micro­circulatory
disturbances and subsequent liver injury.111,112
Nostrin
Nostrin, also known as nitric oxide synthase traffic
inducer, regulates nitric oxide (NO) synthesis and is a key
effector in chronic liver diseases. A marked increase in
the expression of nostrin protein and mRNA is evident
in the livers of patients with ALD, which could contrib­
ute to the decreased enzymatic activity of endothelial NO
synthase in diseased livers.113

ADAMTS13: von Willebrand factor cleaving protease Animal models of ALD

Decreased plasma activity of ADAMTS13 (a disintegrin
and metalloproteinase with a thrombospondin type 1
motif, member 13), which is produced by hepatic stel­
late cells, leads to accumulation of unusually large von
Willebrand factor multimers and subsequent thrombi,
A number of strategies have been proposed to induce
ALD in rodents and other animals by continuous expo­
sure to ethanol or ethanol-containing diets (Table 2).114–119
The first limitation of this approach is the reluctance of
most rodents to drink ethanol-containing diets. Only

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REVIEWS
some genetically selected rats (Marchigian Sardinan
alcohol-preferring rats) will spontaneously ingest ethanol
at high concentrations and display a binge-like drinking
behavior.120 Moreover, most studies are usually designed
to induce ALD within few weeks, and consequently the
extent of liver disease is modest.
Administration of ethanol in these animal models
ranges from voluntary oral intake via drinking water
or a liquid diet (Lieber–De Carli model) to direct
gastric administration via a nasogastric tube or perm­
anent gastro­stomy (Tsukamoto–French model).121–124
Experiments using these models are usually performed
under controlled nutritional conditions. Solutions of
5–20% ethanol are used, and very high blood alcohol
levels can be achieved. Hepatic steatosis, a mild
inflamma­tory infiltrate and modest liver injury develop
after 4–12 weeks of alcohol administration. However, the
main histological findings in patients with severe ALD
(massive fibrosis and hepatocellular damage) are not
always present, which limits the value of these models.
An additional limitation is the rapid circadian changes in
ethanol metabolism in rodents, which should be closely
monitored to avoid acute intoxication.
The histological findings in baboons and minipigs
fed with ethanol-containing diets closely mimic those of
ALD, with sequential development of fatty liver disease,
alcoholic steatohepatitis and cirrhosis (Table 2). 125–127
However, none of the currently used animal models of
ALD results in portal hypertension, which is a major
determinant of mortality in patients with severe ALD.
A widely used strategy to increase the patho­
genic effects of ethanol in rodents is simultaneous
administra­tion of other agents known to contribute to
its deleterious effect on the liver. Intraperitoneal injec­
tions of lipo­p olysaccharide and supplementation of
iron in the diet both increase liver inflammation and
injury.128–130 Similarly, a diet containing high levels of
poly­unsaturated fatty acids exacerbates fatty liver and
resultant hepatic injury after ethanol exposure. The data
from these studies should be considered with caution,
however, as the adjuvant agents administered in conjunc­
tion with ethanol can themselves induce patho­logical
effects in the liver.
The role of specific genes in the development of ALD
has been investigated using genetically manipulated
mice (transgenic models). These genes include Ppar,
Rxr, Srebf1, Cyp2e1, Tnfrsf1a and Tnfrsf1b, Ncf1 (which
encodes p47-phox), Cd14, Tlr4, Icam1, Serpine1, IL6 and
Nfe2l2, among others.131–139 For instance, transgenic mice
overexpressing Cyp2e1 that were given an alcohol-rich
diet had significantly higher serum alanine transaminase
levels and showed higher histological injury to liver than
wild-type mice.140
Another mouse model that combines chronic alcohol
exposure and binge ethanol administration has been pro­
posed. Binge drinking is the most common pattern of
alcohol consumption in adolescents. Although animal
models of ethanol binges might not completely mimic
the liver injury observed in humans, some studies indi­
cate a substantial contribution of binge drinking to the
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© 2011 Macmillan Publishers Limited. All rights reserved
incidence of cirrhosis seen in patients with ALD.79 This
model could, therefore, closely reproduce the drinking
behaviors of humans.
New animal models that mimic the pathological find­
ings induced by ethanol exposure in humans are clearly
needed. Future studies will need to test whether, when
combined with excessive alcohol intake, other factors,
such as obesity and cigarette smoking, participate in the
pathogenesis of ALD. Additionally, studying the effects
of ethanol exposure in animal models of comorbidities
are required to investigate the observed synergy between
alcohol abuse and other factors that promote liver
disease (such as an adipogenic diet and viral hepatitis)
and to study the increased liver oncogenesis caused by
ethanol abuse.
Conclusions
Excessive alcohol consumption is a major preventable
cause of morbidity and mortality worldwide, and ALD is
a frequent indication for liver transplantation. However,
despite its high prevalence, ALD has received little atten­
tion in the past two decades and no major advance has
been made in the management of these patients since
the introduction of corticosteroid therapy. The develop­
ment of targeted therapies for ALD is hampered by poor
knowledge of the molecular mechanisms involved in its
development, particularly in humans, and by the percep­
tion that it is an addictive and a self-inflicting disease.
Most studies of the mechanisms underlying ALD have
been conducted in animal models, which do not repro­
duce all the pathological changes found in humans with
severe forms of the disease.
In addition to these animal studies, however, trans­
lational research using tissue samples from patients
with ALD have identified novel potential therapeutic
targets for this disease. However, most of the data so
far obtained are preliminary and the roles of the identi­
fied molecules will need to be characterized in trans­
genic and other animal models. In the future, studies of
biological systems that integrate the existing informa­
tion at different levels (such as genetic, metabolic and
proteomic data) will be required to delineate the pre­
vailing pathogenetic pathways in ALD. The potential
value of drugs that target these molecules will need
to be initially evaluated in preclinical settings, before
clinical implementation.
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“translational”, “experimental models”, “classification”,
“prognosis”, “diagnosis” and “treatment”. Data from
full-text articles and abstracts published in the English
language were reviewed. Relevant articles were also
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Acknowledgments
The authors of this article are supported by grants
from Fondo de Investigación Sanitaria (FIS PI080237
and FIS PS09/01164). J. Altamirano also holds a
grant from Fundación Banco Bilbao Vizcaya Argentaria
(FBBVA). CIBERehd is funded by the Instituto de Salud
Carlos III.
Author contributions
Both authors contributed equally to all aspects of this
Review.