{
  "abstract": "Obstructive sleep apnea (OSA) and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently coexist and share a common cardiometabolic substrate through a shared cardiometabolic substrate. This narrative review critically appraises the epidemiological, experimental, and interventional evidence proposed to link chronic intermittent hypoxia (CIH) and sleep fragmentation to hepatic steatosis, steatohepatitis, and fibrosis. We summarize the candidate mechanisms, including mitochondrial oxidative stress, hypoxia-inducible factor 1-alpha signaling, sympathetically driven lipolysis, and Kupffer and stellate cell activation and then examine the limits of the evidence supporting them: hypoxia-induced hypophagia and the scarcity of pair-fed controls in rodent models, species differences in the physiological response to hypoxia, publication bias, common-cause confounding by age and systemic inflammation, and the rarity of progressive liver disease in lean patients with anatomically driven OSA. We further review non-invasive diagnostic tools, polysomnographic hypoxemia indices, transient elastography, METS-IR, FIB-4, and emerging biomarkers, such as omentin-1 and follistatin-like 1, that enable bidirectional screening between sleep and hepatology clinics. Finally, we discuss therapeutic strategies, including continuous positive airway pressure, structured weight loss, and incretin-based pharmacotherapy (GLP-1 and dual GIP/GLP-1 receptor agonists), highlighting recent phase 3 evidence for tirzepatide in OSA and semaglutide in metabolic dysfunction-associated steatohepatitis. Current evidence supports CIH as a context-dependent amplifier of liver injury in patients with pre-existing metabolic dysfunction rather than as an established independent cause of MASH. This interpretation still justifies integrated screening and treatment pathways, while identifying the study designs needed to test causality directly.",
  "abstract_shown": true,
  "affiliations": [
    "Doctoral School, University of Medicine and Pharmacy, 200349 Craiova, Romania",
    "Department of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Department of Diabetes, Nutrition and Metabolic Diseases, Faculty of Midwives and Nursing, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Department of Internal Medicine—Internal Medicine, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Department of Oro-Dental Prevention and Oral Health, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Research Centre in Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Haţieganu” Cluj-Napoca, 400012 Cluj-Napoca, Romania",
    "Department of Obstetrics-Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania",
    "Department of Medical Semiology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania"
  ],
  "article_type": "review article",
  "arxiv": null,
  "author_total": 18,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Georgiana-Mihaela Cebuc Simeanu",
      "orcid": "0000-0002-9618-9500"
    },
    {
      "affs": [
        0
      ],
      "name": "Ioana-Gabriela Dragne",
      "orcid": "0009-0004-8957-690X"
    },
    {
      "affs": [
        1
      ],
      "name": "Adina Mitrea"
    },
    {
      "affs": [
        1
      ],
      "name": "Diana Clenciu"
    },
    {
      "affs": [
        2
      ],
      "name": "Diana-Cristina Protasiewicz-Timofticiuc"
    },
    {
      "affs": [
        0
      ],
      "name": "Alina-Liliana Popa"
    },
    {
      "affs": [
        0
      ],
      "name": "Denisa-Maria Mitroi",
      "orcid": "0009-0006-5130-6757"
    },
    {
      "affs": [
        0
      ],
      "name": "Bianca-Florentina Pîrvu",
      "orcid": "0009-0001-1431-9915"
    },
    {
      "affs": [
        3
      ],
      "name": "Ion-Cristian Efrem",
      "orcid": "0000-0001-8563-347X"
    },
    {
      "affs": [
        3
      ],
      "name": "Adina Dorina Glodeanu"
    },
    {
      "affs": [
        4,
        5
      ],
      "name": "Adina-Andreea Mirea",
      "orcid": "0009-0001-4039-0811"
    },
    {
      "affs": [
        1
      ],
      "name": "Adela-Gabriela Ștefan",
      "orcid": "0000-0003-1159-3617"
    },
    {
      "affs": [
        2
      ],
      "name": "Maria-Magdalena Roșu"
    },
    {
      "affs": [
        1
      ],
      "name": "Theodora-Claudia Radu-Gheonea"
    },
    {
      "affs": [
        6
      ],
      "name": "Beatrice-Elena Vladu"
    },
    {
      "affs": [
        7
      ],
      "name": "Ana-Maria Efrem"
    },
    {
      "affs": [
        8
      ],
      "name": "Lorena-Anda Dijmarescu"
    },
    {
      "affs": [
        0,
        9
      ],
      "name": "Mircea-Catalin Fortofoiu",
      "orcid": "0000-0002-3341-1442"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/54tvpp40kkn1b.bib",
  "cited_by": 0,
  "doi": "10.3390/ijms27209372",
  "fulltext_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13705259/?tool=EBI",
  "id": "54tvpp40kkn1b",
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    "1422-0067"
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  "landing_url": "https://www.mdpi.com/1422-0067/27/20/9372",
  "language": "eng",
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
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      "2737|Obstructive Sleep Apnea Research"
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  "pdf_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13705259/pdf/?tool=EBI",
  "pmcid": "PMC13705259",
  "pmid": null,
  "published": "2026-10-01",
  "publisher": "MDPI AG",
  "ris": "https://research.draconitic.com/paper/54tvpp40kkn1b.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:18:57Z",
      "native_id": "10.3390/ijms27209372",
      "source": "crossref",
      "url": "https://www.mdpi.com/1422-0067/27/20/9372"
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  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2737|Obstructive Sleep Apnea Research",
      "subfield": "physiology"
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  ],
  "title": "Chronic Intermittent Hypoxia and MASLD in Obstructive Sleep Apnea: A Critical Appraisal of Mechanistic and Causal Evidence",
  "title_text": "Chronic Intermittent Hypoxia and MASLD in Obstructive Sleep Apnea: A Critical Appraisal of Mechanistic and Causal Evidence",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:21:44Z",
  "url": "https://research.draconitic.com/paper/54tvpp40kkn1b",
  "venue": "International Journal of Molecular Sciences",
  "versions": []
}