Creatine in fatty liver disease: Differential roles, multi-organ lipid regulation, and safety

Metabolic-dysfunction-associated fatty liver disease (MAFLD), formerly known as non-alcoholic fatty liver disease, has emerged as the most prevalent chronic liver disease worldwide. Its pathogenesis is closely associated with obesity, insulin resistance, and abnormalities of lipid metabolism. Currently, clinical pharmacotherapies for MAFLD remain limited; only a select few agents have been approved by the US Food and Drug Administration for patients with moderate-to-advanced disease. Consequently, there is an urgent need to identify effective, safe, and cost-efficient interventions. Creatine, a small molecule naturally present in the body, is widely used as a dietary supplement. In recent years, it has garnered attention for its multifaceted roles in lipid regulation. Preclinical studies demonstrate that creatine exerts protective effects on MAFLD at its initial stage (simple steatosis), progressive stage (inflammation and fibrosis), and in associated complications. Furthermore, it synergistically improves the core pathophysiological pathways of MAFLD by regulating lipid metabolism across various organs, including adipose tissue. Notably, creatine exerts the opposite effect in alcoholic liver disease. Creatine has demonstrated significant potential in the prevention and treatment of MAFLD, offering a safe and promising new option for clinical intervention of this disease. However, it is also important to note the differences in its effect on fatty liver under different etiological backgrounds. This review systematically explores the differential mechanisms of creatine in both MAFLD and alcoholic liver disease, and comprehensively assesses its potential in multiple organs related to MAFLD and the safety of its clinical applications.