Metabolic dysfunction–associated steatotic liver disease and obstructive sleep apnea: A cohort analysis of prevalence and hepatic outcomes

Table 1 Baseline characteristics before and after propensity score matching, n (%)/mean ± SD

Characteristics	Before PSM				After PSM
	MASLD with OSA	MASLD without OSA	P value	SD	MASLD with OSA	MASLD without OSA	P value	SD
Total	403008	1222421			364283	364283		0.021
Age, years	55.6 ± 13.3	52.3 ± 15.3	< 0.001	0.229	55.3 ± 13.4	55.6 ± 13.9	< 0.001	0.014
Sex
Male	211174 (52.4)	573207 (46.9)	< 0.001	0.111	188288 (51.7)	185011 (50.8)	< 0.001	0.018
Female	191713 (47.6)	649214 (53.1)	< 0.001	0.111	175995 (48.3)	179272 (49.2)	< 0.001	0.018
Race/ethnicity
White	308039 (76.5)	866921 (70.9)	< 0.001	0.126	276739 (76.0)	278846 (76.5)	< 0.001	0.014
Hispanic or Latino	37325 (9.3)	178649 (14.6)	< 0.001	0.166	35576 (9.8)	3346 (9.2)	< 0.001	0.021
Not Hispanic or Latino	303603 (75.4)	834983 (68.3)	< 0.001	0.157	271870 (74.6)	275494 (74.6)	< 0.001	0.023
Black or African American	41535 (10.3)	110525 (9.0)	< 0.001	0.043	36865 (10.1)	37170 (10.2)	0.237	0.003
Asian	11546 (2.9)	60485 (4.9)	< 0.001	0.108	11286 (3.1)	10761 (3.0)	< 0.001	0.008
American Indian or Alaska native	2264 (0.6)	7879 (0.6)	< 0.001	0.011	2080 (0.6)	1756 (0.5)	< 0.001	0.012
Native Hawaiian or other Pacific Islander	2745 (0.7)	6543 (0.5)	< 0.001	0.019	2395 (0.7)	2326 (0.6)	< 0.001	0.002
BMI	37.5 ± 8.4	32.2 ± 7.2	< 0.001	0.671	36.9 ± 8.4	34.9 ± 7.6	< 0.001	0.026
BMI categories by kg/m2
30-35	152703 (37.9)	322388 (26.4)	< 0.001	0.249	135568 (37.2)	141766 (38.9)	< 0.001	0.035
35-40	144999 (36.0)	198160 (16.2)	< 0.001	0.462	116641 (32.0)	119757 (32.9)	< 0.001	0.018
> 40	133046 (33.0)	127239 (10.4)	< 0.001	0.57	99003 (27.2)	96295 (26.4)	< 0.001	0.017
Comorbidities
Diabetes mellitus type 2	157762 (39.2)	226779 (18.6)	< 0.001	0.467	129485 (35.5)	129766 (35.6)	0.492	0.002
Hypertensive diseases	277537 (68.9)	461297 (37.7)	< 0.001	0.657	239666 (65.8)	241545 (66.3)	< 0.001	0.011
Chronic kidney disease	48146 (12.0)	58410 (4.8)	< 0.001	0.261	37269 (10.2)	36589 (10.0)	0.008	0.006
Heart failure	47743 (11.9)	38808 (3.2)	< 0.001	0.334	32445 (8.9)	30314 (8.3)	< 0.001	0.021
Hyperlipidemia	205319 (51.0)	312041 (25.5)	< 0.001	0.542	172507 (47.4)	173106 (47.5)	0.160	0.003
Nicotine dependence	71558 (17.8)	147476 (12.1)	< 0.001	0.160	61281 (16.8)	60543 (16.6)	0.021	0.005
Alcohol abuse	14672 (3.6)	38466 (3.1)	< 0.001	2.027	12975 (3.6)	11750 (3.2)	< 0.001	0.019

Baseline demographic and clinical characteristics of adults with metabolic dysfunction-associated steatotic liver disease with and without obstructive sleep apnea before propensity score matching. Standardized differences quantify covariable imbalance with values > 0.1 indicating clinically meaningful differences. The P values represent group comparisons using χ² tests for categorical variables and t tests for continuous variables. Body mass index categories reflect World Health Organization obesity classifications. Note: After propensity score matching, covariate balance was primarily assessed using standardized mean differences, with values < 0.1 indicating adequate balance. Statistically significant P values for some variables may persist due to the very large sample size and do not necessarily indicate meaningful residual imbalance. BMI: Body mass index; MASLD: Metabolic dysfunction-associated steatotic liver disease; OSA: Obstructive sleep apnea; PSM: Propensity score matched.

Table 2 Annual incidence and prevalence of obstructive sleep apnea among patients with metabolic dysfunction-associated steatotic liver disease (2010-2024)

Year	Incidence (%)	Incidence (n)	Prevalence (%)	Prevalence (n)
2010	0.029	13	0.029	13
2011	0.048	24	0.072	36
2012	0.113	63	0.177	99
2013	0.128	78	0.281	171
2014	0.203	136	0.450	303
2015	0.388	284	0.781	575
2016	0.678	535	1.376	1094
2017	0.824	682	2.024	1696
2018	1.097	935	2.889	2507
2019	1.266	1089	3.846	3398
2020	1.290	1098	4.806	4242
2021	1.700	1420	6.062	5297
2022	2.086	1666	7.702	6526
2023	2.519	1880	9.747	7857
2024	3.237	2151	12.425	9122

Yearly incidence and prevalence proportions of newly diagnosed obstructive sleep apnea (OSA) among patients with metabolic dysfunction-associated steatotic liver disease (MASLD) from 2010 to 2024. Incidence represents new OSA diagnoses per year divided by the MASLD population at risk; prevalence reflects all existing OSA cases each year among patients with MASLD. Both raw counts (n) and population percentages are shown. These trends were subsequently analyzed using Mann-Kendall monotonic trend testing and Sen’s slope estimates.

Table 3 Primary outcomes comparing patients with metabolic dysfunction-associated steatotic liver disease and with and without obstructive sleep apnea after propensity score matching

Cohort for primary outcomes	MASLD with OSA, n = 364283	MASLD without OSA, n = 364283	Odds ratio (95%CI)	P value
Hepatic fibrosis
1 year	1895	1069	1.777 (1.648-1.915)	< 0.0001
3 years	2796	1384	2.028 (1.901-2.163)	< 0.0001
5 years	3243	1544	2.110 (1.986-2.243)	< 0.0001
10 years	3675	1740	2.123 (2.005-2.248)	< 0.0001
Hepatic cirrhosis
1 year	2914	1911	1.529 (1.443-1.620)	< 0.0001
3 years	4158	2716	1.537 (1.464-1.514)	< 0.0001
5 years	4822	3149	1.538 (1.471-1.609)	< 0.0001
10 years	5506	3620	1.529 (1.466-1.595)	< 0.0001

Incidence of hepatic fibrosis and hepatic cirrhosis at the 1-year, 3-year, 5-year, and 10-year follow-up among propensity score-matched cohorts with metabolic dysfunction-associated steatotic liver disease with and without obstructive sleep apnea. Outcomes are presented as event counts and corresponding odds ratios with 95%CIs. All analyses reflect matched sample sizes of 364283 per group. Logistic regression models were used to calculate odds ratios at each time point. MASLD: Metabolic dysfunction-associated steatotic liver disease; OSA: Obstructive sleep apnea.

Table 4 Multivariable cox proportional hazards model assessing predictors of progression to hepatic disease

Covariate	HR	95%CI	P value
Age at index	1.008	(1.007-1.008)	< 0.0001
Male	1.449	(1.436-1.463)	< 0.0001
Race/ethnicity
White	1.143	(1.123-1.163)	< 0.0001
Black or African American	1.054	(1.033-1.076)	< 0.0001
Asian	1.01	(0.981-1.041)	0.4884
American Indian or Alaska Native	0.968	(0.908-1.031)	0.3110
Native Hawaiian or Other Pacific Islander	1.074	(1.026-1.125)	0.0022
Hispanic or Latino	1.062	(1.040-1.084)	< 0.0001
Not Hispanic or Latino	0.939	(0.928-0.951)	< 0.0001
Comorbidities
Type 2 diabetes mellitus	0.989	(0.976-1.002)	0.0832
Hypertension	1.246	(1.232-1.26)	< 0.0001
Heart failure	1.009	(0.991-1.028)	0.3288
Chronic kidney disease	0.996	(0.977-1.016)	0.6856
Overweight and obesity	1.828	(1.809-1.847)	< 0.0001
Nicotine dependence	1.031	(1.017-1.046)	< 0.0001
Alcohol abuse	1.025	(0.995-1.055)	0.0983

Hazard ratios (HRs) with 95%CIs from a multivariable Cox proportional hazards model evaluating demographic factors, race/ethnicity, and comorbidities associated with progression to hepatic outcomes in patients with metabolic dysfunction-associated steatotic liver disease. Covariables include age, sex, race/ethnicity categories, cardiometabolic conditions, substance use, and obesity status. An HR > 1 indicates increased risk while an HR < 1 indicates reduced risk of hepatic progression. All variables were included in the fully adjusted model. HR: Hazard ratios.