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We investigated the incidence rates of hepatocellular carcinoma (HCC) in metabolic dysfunction-associated steatotic liver disease (MASLD) categories, focusing on its association with alcohol consumption in patients with type 2 diabetes mellitus (T2DM).

This study included 2,418,858 patients with T2DM aged 20 years and older who underwent a health examination between 2009 and 2012. Participants were categorized into five groups according to hepatic steatosis, cardiometabolic risk factors, other liver diseases, and alcohol consumption. Hepatic steatosis was defined as the fatty liver index ≥30. Cox regression analysis was used to analyze the association between steatotic liver disease and development of HCC.

The MASLD group showed a higher risk of HCC development regardless of alcohol consumption or presence of other liver diseases (adjusted hazard ratio [aHR], 1.38; 95% confidence interval [CI], 1.33 to 1.44). The MASLD with other combined group expressed the highest risk (aHR, 5.02; 95% CI, 4.79 to 5.27). In the metabolic dysfunction and alcohol-related steatotic liver disease and alcohol-related liver disease groups, heavy to excessive alcohol consumption increased the risk of HCC development, with a higher risk associated with greater alcohol intake (aHR, 2.40; 95% CI, 2.27 to 2.53 and aHR, 3.16; 95% CI, 2.93 to 3.41). Fine and Gray analysis also exhibited a consistent trend.

MASLD in patients with T2DM was associated with an increased risk of developing HCC, particularly when accompanied by other liver diseases. Moreover, alcohol consumption proportionally increased the risk of HCC with the amount of alcohol consumed.