Metabolic Dysfunction-Associated Steatotic Liver Disease in the Aging Population: A Narrative Review of Pathophysiological Synergy, Diagnostic Challenges, and Tailored Management.

PURPOSE OF REVIEW: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver condition in older adults, yet its management in the geriatric context remains poorly characterized. This review examines the unique pathophysiology, diagnostic challenges, and tailored therapeutic strategies for MASLD in the aging population. RECENT FINDINGS: The convergence of inflammaging, mitochondrial senescence, and the deteriorating liver-muscle axis drives distinct geriatric MASLD phenotypes, including "Lean MASLD" and post-menopausal sex-reversal. These processes promote progression to metabolic dysfunction-associated steatohepatitis (MASH), the inflammatory stage of the disease. Chronodisruption-potentially mediated by melatonin deficiency and nuclear factor-kappa B activation-has been proposed as a novel driver. Advanced liver fibrosis has been associated with systemic biological aging. Diagnostically, standard Fibrosis-4 index thresholds are unreliable in patients over 65, and "silent cirrhosis" with normal aminotransferases is common. Carbon-ion radiotherapy has emerged as a potentially sarcopenia-friendly treatment option for MASLD-related hepatocellular carcinoma. Managing geriatric MASLD requires a paradigm shift from liver-centric histological targets toward functional longevity. Avoiding the "Sarcopenia Trap," recalibrating non-invasive fibrosis tests with age-adjusted thresholds, promoting alcohol abstinence, and addressing chronodisruption are essential components of a holistic, individualized care framework.