Ramadan Fasting in Metabolic Dysfunction-Associated Steatotic Liver Disease: Linking the Gut–Mitophagy–Circadian Axis to Endothelial Dysfunction and Hepatic Outcomes

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the predominant etiology of chronic liver disease and the leading factor to liver-related mortality. The endothelial dysfunction is a significant contributor to the onset of cardiovascular disease and is closely linked to MASLD. Previous studies have shown that changes in diet influence both MASLD and endothelial function and modify their risk factors. A small number of studies have evaluated the possible effects of Ramadan fasting on MASLD, related endothelial dysfunction and the gut–mitophagy–circadian axis. The aim of this narrative review is to evaluate the impacts of Ramadan fasting on MASLD, hepatic complications, related endothelial dysfunction and the gut–mitophagy–circadian axis. This review integrates endothelial dysfunction, gut microbiota, mitophagy, and circadian rhythm into a single mechanistic framework. We performed searches of SCOPUS and the PubMed databases using diverse search keywords. The review targeted scholarly English articles from the year 2000 to 2026. The review included seventy-three studies. Ramadan fasting might enhance MASLD, hepatic complications, and associated endothelium dysfunction and alter risk factors by facilitating weight loss, ameliorating insulin resistance, enhancing mitophagy, and inducing alterations in gut microbiota and circadian gene expression. Further studies are necessary to assess safety and efficacy of Ramadan fasting on MASLD, hepatic complications and related endothelial function. Circadian control offers a significant molecular foundation connecting Ramadan fasting to metabolic health.