Hepatic Steatosis in Primary Aldosteronism, Cushing’s Syndrome, and Mild Autonomous cortisol secretion: Metabolic and Hormonal Associations

CONTEXT: Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely linked to obesity, diabetes mellitus (DM), and dyslipidemia. Patients with primary aldosteronism (PA), Cushing's syndrome (CS) and mild autonomous cortisol secretion (MACS) exhibit metabolic abnormalities, but the relative contributions of hormonal and metabolic factors to hepatic steatosis remain unclear. OBJECTIVE: To evaluate MASLD prevalence and determinants in PA, CS, and MACS. DESIGN: Single-center retrospective cross-sectional study. METHODS: 243 treatment-naive patients underwent unenhanced abdominal computed tomography: 102 isolated PA, 60 CS, 47 MACS, and 34 PA with cortisol co-secretion. Hepatic steatosis was assessed using liver-to-spleen (L/S) attenuation ratio. Hepatic steatosis index (HSI), and triglyceride-glucose (TyG) index were calculated. RESULTS: MASLD prevalence was 28.4% in isolated PA, 26.6% in CS, 31.9% in MACS and 26.4% in PA with cortisol co-secretion. Liver attenuation and L/S ratio were similar across groups but correlated with visceral adiposity, glucose, HbA1c, triglycerides, HSI, and TyG index (all r>0.5, p<0.05). DM was independently associated with lower liver attenuation after adjustment for age, sex, and BMI (β = -11.10 HU, 95% CI: -16.40 to -5.79). Serum cortisol, cortisol after the 1-mg DST, aldosterone, and renin were not independently associated with hepatic steatosis, whereas UFC was independently associated with the L/S attenuation ratio in the hypercortisolism subgroup. CONCLUSIONS: Hepatic steatosis was similarly prevalent across PA, CS, and MACS, and was associated with metabolic factors, particularly DM, BMI, visceral adiposity, and hypertriglyceridemia. These findings support consideration of hepatic steatosis assessment in patients with functional adrenal disorders and metabolic risk factors.