Liver muscle bone axis in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) has become one of the most common chronic liver diseases worldwide. With the introduction of the new nomenclature, the management of MASLD is evolving from a conventional liver-centered approach focused primarily on hepatic steatosis, metabolic dysfunction-associated steatohepatitis (MASH), liver fibrosis, and cirrhosis risk toward a broader framework that also addresses heterogeneity in metabolic risk, physical function, tolerance to lifestyle interventions, and long-term prognosis. In recent years, impaired skeletal muscle function, sarcopenia, myosteatosis, vitamin D deficiency, and abnormalities in bone metabolism have increasingly been recognized as clinically relevant conditions associated with MASLD severity, progression risk, and adverse extrahepatic outcomes. Although the underlying biological mechanisms remain incompletely understood, these conditions may serve as clinically meaningful risk markers and potential modifiers of disease progression. This review systematically summarizes the epidemiological associations, proposed shared pathogenic mechanisms, clinical recognition pathways, and integrated intervention strategies linking MASLD, sarcopenia, vitamin D deficiency, and bone metabolic abnormalities. We propose that MASLD complicated by sarcopenia and bone vulnerability may represent a clinically relevant liver-muscle-bone metabolic phenotype. Future management of MASLD should therefore place greater emphasis on preserving muscle function, maintaining bone health, and improving patient-centered outcomes.