Desde la esteatosis al riesgo cardiorrenal

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is now recognized as far more than a hepatic condition. In patients with type 2 diabetes, MASLD frequently coexists and shares a common pathophysiological root: insulin resistance. This overlap has repositioned MASLD as a systemic metabolic disorder with significant implications for cardiovascular and renal health.

The link between MASLD and cardiovascular disease is well established. Hepatic steatosis promotes an atherogenic lipid profile, characterized by elevated triglycerides, small dense LDL particles, and low HDL cholesterol. The inflamed, fatty liver also releases pro-inflammatory cytokines and procoagulant factors, contributing to endothelial dysfunction and accelerated atherosclerosis. Numerous studies confirm that MASLD independently increases the risk of coronary artery disease, heart failure, and arrhythmias, particularly atrial fibrillation, even after adjusting for traditional risk factors.

Less discussed but equally important is the renal dimension. Emerging evidence shows that MASLD is independently associated with chronic kidney disease (CKD), including declining glomerular filtration rate and progressive albuminuria. The mechanisms overlap with those driving cardiovascular damage: chronic low-grade inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone system, and insulin resistance all converge to damage renal microvasculature.

In diabetic patients, these three conditions—MASLD, cardiovascular disease, and CKD—do not exist in isolation but form an interconnected triad often termed the “cardio-hepatic-renal axis.” Recognizing this axis has clinical significance: a patient presenting with fatty liver should prompt screening for cardiovascular and renal complications, not just liver fibrosis progression.

This paradigm shift also affects treatment strategy. Therapies such as GLP-1 receptor agonists and SGLT2 inhibitors, originally developed for glycemic control, have demonstrated benefits across all three domains, thereby improving hepatic steatosis, reducing cardiovascular events, and slowing renal decline. This convergence supports a more integrated, multidisciplinary approach to diabetes management, where hepatologists, endocrinologists, cardiologists, and nephrologists collaborate around a shared understanding of MASLD as an early warning sign of broader cardio-renal-metabolic risk.