ALDH2 and metabolic dysfunction-associated steatotic liver disease: The progression of ALD, like NAFLD, may involve multiple hits.13 The first hit of ALD may not be alcohol but the liver injury induced by nutritional, environmental, or genetic factors, including chronic consumption of cholesterol-containing Western diets.27 Krishnasamy et al34 reported that mice fed 3 months of ethanol plus cholesterol (0.5%, w/v)-containing Lieber-DeCarli liquid diet developed severe steatohepatitis and early liver fibrosis without altering hepatic protein expression of the ethanol metabolic enzymes ADH1, Cyp2E1, and ALDH2.