Determinants of MASLD and Liver Fibrosis in Maintenance Hemodialysis: A Prospective Evaluation of Metabolic, Nutritional, and Volume-Related Factors

Background and Aim: Liver disease in patients receiving chronic hemodialysis (HD) is frequently underrecognized and may contribute to adverse outcomes. Its evaluation is complicated by dialysis-related changes in volume status that can influence noninvasive measurements. We aimed to assess the prevalence and determinants of Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) and liver fibrosis using transient elastography (TE), with particular attention to metabolic, volume-related, and dialysis-specific factors, and to examine the effect of a single HD session on Controlled Attenuation Parameter (CAP) and liver stiffness measurement (LSM). Methods: In this prospective cross-sectional study, adult patients receiving maintenance HD for ≥3 months were enrolled. TE (FibroScan®) was performed immediately before (pre-HD) and after (post-HD) a midweek HD session. Steatosis was defined as CAP >257 dB/m and significant fibrosis as LSM ≥8 kPa. Volume status was assessed using interdialytic weight gain (IDWG) and ultrafiltration (UF) volume. Associations with clinical, biochemical, and dialysis-related variables were analyzed. Results: Forty patients were included (mean age, 63.5 ± 17.3 years; 70% male; 30% diabetic). MASLD prevalence was 25% pre-HD and 22.5% post-HD. The prevalence of significant fibrosis decreased from 17.5% pre-HD to 10% post-HD, while mean LSM did not change significantly, suggesting that volume removal may influence fibrosis classification in a subset of patients. CAP correlated positively with body mass index, IDWG, UF volume, and triglyceride levels, and inversely with serum albumin. Post-HD LSM showed a significant inverse association with serum albumin and positive associations with alanine aminotransferase, total cholesterol, and low-density lipoprotein cholesterol, whereas pre-HD LSM was mainly associated with age and bilirubin. The FIB-4 index did not correlate with LSM. Conclusions: In maintenance HD patients, hepatic steatosis is closely associated with metabolic burden and fluid overload, whereas fibrosis assessment is substantially influenced by nutritional status. Dialysis-related volume changes may modify LSM-based fibrosis estimates, supporting post-dialysis TE for more reliable assessment. TE provides clinically informative evaluation and appears superior to surrogate indices such as FIB-4 in this population.