Outcome of Targeted Therapy for Obstructive Sleep Apnea in Children with Obesity and Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD).

Background: Obstructive sleep apnea (OSA) and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently coexist in children with obesity, but data on hepatic outcomes following OSA treatment are limited. This study evaluated associations between targeted OSA treatment and longitudinal changes in sleep-disordered breathing and hepatic outcomes. Methods: This retrospective observational cohort included children aged 4-18 years with obesity, polysomnography-confirmed OSA, and ultrasonography-confirmed MASLD who received clinical care between 2018 and 2025. Children received targeted OSA treatment (adenotonsillectomy and/or continuous positive airway pressure [CPAP]) or non-targeted treatment. Polysomnographic parameters, liver enzymes, and ultrasonographic hepatic steatosis were assessed at baseline and 6-12 months. The primary outcome was a ≥30% reduction in alanine aminotransferase (ALT). Results: Among 127 children, 67 received targeted treatment and 60 did not. Targeted treatment was associated with improvements in OSA severity, nocturnal oxygenation, ALT, AST, and ultrasonographic steatosis, whereas less favorable trajectories occurred without targeted treatment. ALT reduction differed significantly among treatment modalities, with the greatest reduction observed with CPAP. In multivariable analyses, CPAP was associated with both ≥30% ALT reduction (OR 14.54, 95% CI 3.87-54.69; p < 0.01) and ultrasonographic improvement (OR 3.33, 95% CI 1.16-9.59; p = 0.03). A BMI z-score reduction of ≥0.25 was not independently associated with either hepatic outcome. Conclusions: Targeted OSA treatment was associated with more favorable sleep and hepatic outcomes, with the strongest associations observed for CPAP. Prospective studies are needed to determine whether these associations represent causal treatment effects.