Key Hepatokines Linking MASLD and Type 2 Diabetes: From Pathophysiological Mechanisms to Therapeutic Modulation

Type 2 diabetes mellitus (T2D) is a major and growing global health burden that is associated with substantial cardiovascular, renal, and metabolic complications and is increasingly recognized as a systemic disorder involving multiple organs, particularly the liver. Metabolic dysfunction-associated steatotic liver disease (MASLD) affects more than half of individuals with T2D, and the two conditions have a bidirectional relationship: T2D promotes the development and progression of MASLD, including advanced fibrosis and increased liver-related mortality, while MASLD worsens insulin resistance and metabolic control, favoring the onset of T2D. In this context, the liver is increasingly viewed not only as a metabolic organ but also as an endocrine one, secreting hepatokines that act on distant tissues to regulate insulin sensitivity, inflammation, glucose metabolism, and lipid homeostasis. Through these actions, hepatokines are thought to represent one of the mechanistic links between MASLD and T2D. This narrative review summarizes current evidence on several of the most extensively studied hepatokines, including fibroblast growth factor 21, fetuin-A, fetuin-B, leukocyte cell-derived chemotaxin-2, selenoprotein P, angiopoietin-like proteins, and retinol-binding protein 4. As a distinctive feature, the review also discusses emerging pharmacological strategies targeting hepatokine pathways and evaluates how commonly used antidiabetic therapies may modulate hepatokine secretion.