Metabolic Dysfunction-Associated Steatotic Liver Disease, Cardiovascular, and Kidney Disease: Triple Challenges.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized as a central component of cardiovascular-kidney-metabolic (CKM) syndrome, reflecting shared pathways of insulin resistance, inflammation, and fibrotic injury that drive multi-organ disease. Affecting more than one-third of adults worldwide, MASLD frequently coexists with chronic kidney disease (CKD) and cardiovascular disease (CVD) and is associated with higher risks of kidney function decline, cardiovascular events, and mortality. Hepatic steatosis and fibrosis may amplify systemic metabolic stress and endothelial dysfunction, contributing to progressive kidney injury and adverse cardiometabolic outcomes. Despite this biologic and epidemiologic overlap, MASLD remains underrecognized in nephrology and cardiology practice. This gap represents a missed opportunity to identify patients at high risk of multi-organ complications early. Noninvasive liver fibrosis assessment, integrated with kidney and cardiovascular risk stratification, offers a practical approach to identifying patients who may benefit from intensified preventive strategies. Lifestyle modification remains foundational, while emerging pharmacotherapies, including glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, mineralocorticoid receptor antagonists, and liver-directed agents, demonstrate potential cross-organ benefits. Coordinated management targeting metabolic dysfunction may slow the progression of kidney disease while improving hepatic and cardiovascular outcomes. This review highlights the clinical intersection of MASLD, CKD, and CVD and proposes a multidisciplinary framework for screening and management. Recognizing MASLD as part of systemic CKM disease can inform risk stratification, guide therapy selection, and support earlier intervention to mitigate the triple burden of liver, kidney, and cardiovascular complications.