Determinants of MASLD and liver fibrosis in maintenance hemodialysis: a prospective evaluation of metabolic, nutritional, and volume-related factors

Metabolic dysfunction associated steatotic liver disease (MASLD) is underrecognized in hemodialysis (HD) patients, yet its evaluation is confounded by volume fluctuations. We aimed to determine the prevalence of MASLD and advanced fibrosis using transient elastography (TE), identify their metabolic, nutritional, and volume-related determinants, and assess the impact of a single HD session on controlled attenuation parameter (CAP) and liver stiffness measurement (LSM). Forty adult patients on maintenance HD for ≥ 3 months were enrolled in this prospective cross-sectional study. TE was performed immediately before and after a midweek dialysis session. Steatosis was defined as CAP > 257 dB/m and advanced fibrosis as LSM ≥ 8 kPa. Volume status was assessed by interdialytic weight gain (IDWG) and ultrafiltration (UF) volume. Associations with clinical, biochemical, and dialysis-related variables were analyzed. The study cohort had a mean age of 63.5 ± 17.3 years, with males comprising 70% and diabetic patients accounting for 30% of the population. MASLD prevalence was 25% pre-HD and 22.5% post-HD; advanced fibrosis prevalence was 17.5% pre-HD and 10% post-HD. CAP and LSM did not change significantly with fluid removal ( p = 0.877 and p = 0.962, respectively). CAP correlated positively with body mass index, IDWG, UF volume, and triglycerides, and negatively with serum albumin. Post-HD LSM showed a strong inverse association with serum albumin and positive associations with alanine aminotransferase, total cholesterol, and LDL-cholesterol, whereas pre-HD LSM was predominantly linked to age and bilirubin. The FIB-4 index did not correlate with LSM. MASLD and advanced fibrosis are highly prevalent in maintenance HD patients. TE provides a clinically valuable, volume-independent assessment of liver disease, outperforming FIB-4 in this setting. Low albumin and dyslipidemia emerge as key correlates of fibrosis, highlighting the interplay between malnutrition, metabolic risk, and liver stiffness in end-stage renal disease.