Association between sleep-disordered breathing and liver outcomes in steatotic liver disease: a systematic review and...

Sleep-disordered breathing (SDB) including obstructive sleep apnea (OSA) has been linked to liver pathology development in patients with steatotic liver disease via pathways of intermittent hypoxia, oxidative stress, inflammation, and metabolic dysfunction. This systematic review and meta-analysis examined the relationship between SDB and liver outcomes in patients with steatotic liver disease (metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH)).

Review was performed according to PRISMA 2020 guidelines. The extensive search strategy was used for searching literature in databases PubMed/MEDLINE, Embase, Scopus, Web of Science Core Collection, Cochrane CENTRAL, CINAHL from inception to 15 May 2026. Bias assessment and grading of evidence were performed by design-specific criteria and using GRADE system correspondingly. The protocol for this review was registered in PROSPERO (CRD420261384244).

Twenty-two articles were included in the final analysis. Pooled prevalence of MASLD or hepatic steatosis among patients with SDB was 75.1% (95% CI 64.1-83.6%), however heterogeneity was moderate (I² = 94.8%). The pooled prevalence of liver fibrosis or fibrosis risk was 13.9% (95% CI 6.0-29.0%, I² = 96.8%). The presence of SDB or an increase in severity of OSA was significantly linked with higher probability of MASLD or steatosis (OR 3.62, 95% CI 1.59-8.25, I² = 84.1%). The continuous positive airway pressure (CPAP) therapy showed reductions in alanine aminotransferase (mean difference -7.15 U/L, 95% CI -9.50 to -4.80; I² = 35.9%) and aspartate aminotransferase (mean difference -3.38 U/L, 95% CI -4.45 to -2.30; I² = 0.0%) levels. Based on qualitative synthesis, the measures of nocturnal hypoxemia were associated with liver damage stronger compared to apnea-hypopnea index (AHI). Meanwhile controlled CPAP trials failed to show consistent effects on structure of liver (steatosis, fibrosis, liver stiffness, and MASH-related parameters). Certainty of evidence ranged from low to very low for all outcomes.

Sleep-disordered breathing was linked to a significant number of liver steatosis cases and higher odds of MASLD, while evidence on fibrosis outcomes was inconsistent. CPAP therapy showed improvements in biochemical liver injury markers, however, effect of CPAP on structure of liver remained inconclusive due to heterogeneity in study design, adherence to CPAP treatment and duration of follow-up. Further high-quality prospective trials are required to assess influence of SDB treatment on steatotic liver disease progression.

PROSPERO, CRD420261384244.