Sleep disorders as an emerging risk factor for liver cirrhosis and hepatocellular carcinoma: a systematic review and meta-analysis of cohort studies

Sleep disorders are increasingly recognized as contributors to metabolic dysfunction and chronic liver disease, but their associations with hepatocellular carcinoma (HCC) and cirrhosis remain unclear. We conducted a systematic review and meta-analysis to evaluate the relationship between sleep disorders and liver-related outcomes. Following PRISMA guidelines (PROSPERO: CRD420261342781), we searched PubMed, Embase, Web of Science, and the Cochrane Library through February 2026 for cohort studies assessing sleep disorders and liver outcomes. Adjusted hazard ratios (HRs) or odds ratios (ORs) were pooled using random-effects models. Subgroup and sensitivity analyses were performed, and risk of bias was assessed using ROBINS-I. Thirteen cohort studies were included. Overall, sleep disorders were associated with an increased risk of liver-related outcomes (HR 1.49; 95% CI 1.22–1.81; I² = 96%). Insomnia was significantly associated with increased risk (HR 1.39; 95% CI 1.28–1.49), whereas obstructive sleep apnea showed a non-significant trend (HR 1.80; 95% CI 0.91–3.58). Sleep disorders were linked to higher risks of HCC (HR 1.42; 95% CI 1.15–1.77) and unspecified liver cancer (HR 1.26; 95% CI 1.01–1.57), but not cirrhosis. Findings were robust in sensitivity analyses, with no significant publication bias. Sleep disorders, particularly insomnia, are associated with increased risks of HCC and liver-related outcomes. These findings highlight sleep disturbances as potentially modifiable risk factors in liver disease progression.