The impact of metabolic dysfunction-associated steatotic liver disease (MASH) on the high risk of cardiovascular disease in CKD: interconnections and management

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a major contributor to systemic metabolic dysfunction and is increasingly recognized as a risk enhancer for both cardiovascular disease (CVD) and chronic kidney disease (CKD). This review explores the complex interconnections between MASLD, CVD, and CKD, with emphasis on shared pathophysiological mechanisms and the clinical implications for risk assessment and management. We describe the crosstalk among the liver, heart, and kidneys, focusing on insulin resistance, chronic inflammation, and progressive fibrosis as key mediators. The severity of liver fibrosis in MASLD is independently associated with both cardiovascular and renal outcomes. Conventional cardiovascular risk scores may underestimate risk in MASLD-CKD populations, highlighting the need for integrated approaches that include hepatic, renal, and metabolic profiling. We also review current non-invasive diagnostic tools, including fibrosis scores and cardiovascular biomarkers, as well as emerging genetic and epigenetic markers that may enhance risk stratification. The therapeutic landscape is evolving, with promising results from lifestyle interventions and pharmacological agents such as GLP-1 receptor agonists, SGLT2 inhibitors, and novel antifibrotic compounds. We also propose a practical algorithm for the screening and risk stratification of MASLD in CKD patients, incorporating non-invasive fibrosis assessment and cardiometabolic risk evaluation. This stepwise approach supports early detection and personalized management, particularly in patients with CKD or type 2 diabetes. In conclusion, MASLD significantly amplifies cardiovascular and renal risk. Early, multidisciplinary intervention is essential to improve long-term outcomes in this high-risk population.