Prevalence and Impact of Steatotic Liver Disease in Autoimmune Liver Diseases: A Systematic Review and Meta‐Analysis

ABSTRACT Autoimmune liver diseases (AILDs), including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), can coexist with steatotic liver disease (SLD); however, this overlap has not been systematically assessed. We aimed to determine the prevalence, clinical characteristics and outcomes of SLD in patients with AILDs. In this systematic review and meta‐analysis, we searched PubMed and Embase from inception to May 20, 2025 for observational studies reporting on hepatic steatosis in AILDs. Proportions were pooled using a generalized linear mixed model and pairwise meta‐analyses used random‐effects models to obtain pooled odds ratios (ORs) or standardized mean differences. PROSPERO ID: CRD420251057378. Forty‐seven studies ( N = 10 734) were included. SLD prevalence was 29.7% (95% confidence interval [CI] 21.9–39.0, τ 2 = 0.923, I 2 = 94.2%) in AIH, 25.0% (95% CI 16.1–36.6, τ 2 = 1.418, I 2 = 94.7%) in PBC, and 17.1% (95% CI 10.8–26.0, τ 2 = 0.500, I 2 = 90.8%) in PSC. Patients with AILDs and SLD had a higher body mass index and a greater burden of metabolic comorbidities. In AIH, SLD was associated with lower liver enzymes, but increased odds of significant (OR 1.37, 95% CI 1.02–1.84, τ 2 = 0, I 2 = 0%) and advanced fibrosis (OR 1.84, 95% CI 1.37–2.47, τ 2 = 0.024, I 2 = 17.4%). Evidence on the prognostic impact of SLD in AILDs was limited and inconsistent, with no studies reporting on PSC. SLD is common across AILDs and may modify their clinical and prognostic profiles, especially in AIH. These data support potential systematic metabolic screening and multidisciplinary care in this population. Further research is needed to clarify the prognostic significance of SLD and inform risk stratification and management in AILDs.