Metabolic dysfunction–associated steatotic liver disease and obstructive sleep apnea: A cohort analysis of prevalence and hepatic outcomes

BACKGROUND Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and often coexists with obstructive sleep apnea (OSA). Emerging evidence suggests that OSA may independently accelerate liver injury in MASLD. Despite this the epidemiology and clinical significance of OSA within the population with MASLD remain incompletely understood. AIM To estimate the prevalence of OSA among MASLD and determine the impact of OSA on hepatic complications. METHODS This was a large, multicenter, population-based retrospective cohort study conducted using the TriNetX Global Health Research Network from 2010 to 2024. We identified adults with MASLD with International Classification of Diseases, Tenth Revision codes and propensity score matched (PSM) them 1:1 with adults without MASLD. Patients with any record of prior liver disease other than MASLD or OSA (G47.3x) before the MASLD index date were excluded from the study. RESULTS After PSM there were 364283 pairs analyzed with balanced covariates. From 2010-2024 OSA incidence and prevalence in MASLD increased more than 400-fold (P < 0.001). MASLD was associated with 54% higher odds of OSA vs matched controls (odds ratio: 1.54), and patients with MASLD developed OSA earlier (median 189 days vs 358 days; P < 0.001). OSA markedly worsened hepatic outcomes. The odds of fibrosis were 1.78-fold higher at 1 year and 2.12-fold higher at 10 years while cirrhosis risk was 50%-55% higher at the 1-year and 10-year follow-ups (P < 0.001). Independent predictors of OSA in MASLD included male sex, obesity, older age, hypertension, and nicotine dependence. CONCLUSION MASLD was associated with a significantly higher risk of OSA, and coexisting OSA substantially amplified long-term hepatic complications. In addition, MASLD was associated with an earlier onset of OSA, highlighting the need for integrated hepatology-sleep medicine approaches and early identification and treatment of OSA in MASLD cohort may prevent the development of complications such as hepatic fibrosis and cirrhosis.