Frailty in metabolic dysfunction-associated steatotic liver disease: A cardio-hepatic-geriatric perspective on the liver-muscle-heart axis

Metabolic dysfunction-associated steatotic liver disease (MASLD) is usually assessed by liver disease severity, yet patients with similar hepatic findings may differ markedly in strength, exercise capacity, and independence.Frailty captures this variation and may reveal vulnerability that conventional liver assessment misses.This narrative review examines frailty in MASLD from a cardio-hepatic-geriatric perspective.Evidence links MASLD with sarcopenia, myosteatosis, frailty, disability, cardiovascular disease, and mortality, although most studies are observational and use heterogeneous frailty measures.Insulin resistance, adipose tissue dysfunction, and inflammation may affect the liver, skeletal muscle, and cardiovascular system in parallel.Liver-muscle crosstalk, impaired muscle quality, and subclinical cardiac dysfunction may further reduce physiological reserve.This liver-muscle-heart framework helps explain why functional status may not parallel liver disease severity.Assessing muscle strength, physical performance, nutrition, and independence may complement hepatic and cardiometabolic risk stratification, particularly in older adults, patients with multimorbidity, and those undergoing substantial weight loss.Exercise, nutritional support, and functional monitoring during weight-loss therapy warrant greater attention.Prospective studies should identify the most informative frailty measures and determine whether incorporating frailty assessment into MASLD care improves treatment tolerance, preserves independence, and enhances patient-centered outcomes.