Sarcopenic visceral obesity in patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

Sarcopenic visceral obesity (SVO) has emerged as a high-risk metabolic phenotype in metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to define the prevalence and metabolic implications of MRI-defined SVO in MASLD, evaluate its association with liver fibrosis, cardiovascular risk, and introduce a novel tier-based classification for risk stratification. In this cross-sectional study, 334 adults with MASLD underwent comprehensive phenotyping. Sarcopenia was assessed by bioelectrical impedance analysis, while visceral obesity was quantified via MRI-based visceral fat area (VFA ≥ 100 cm²). Liver fibrosis was evaluated using non-invasive indices and confirmed in a subset by magnetic resonance elastography (MRE). Participants were stratified into SVO and non-SVO groups, and further categorized into Red, Yellow, or Green tiers based on fibrosis stage and cardiovascular risk. SVO was present in 42.5% of MASLD patients, with higher prevalence among women and individuals with BMI ≥ 40. SVO was associated with significantly worse metabolic profiles (HOMA-IR: 6.2 ± 2.8, p < 0.001), advanced fibrosis (FIB-4: 2.3 ± 1.4, p = 0.003), and higher cardiovascular risk (ASCVD ≥ 7.5%: 65%, p < 0.001). In multivariate analysis, SVO independently predicted advanced fibrosis (OR = 2.5, p = 0.002). Importantly, a tier-based classification model identified a high-risk "Red Tier" group (100% F3-F4 fibrosis, 100% diabetes). This is the first study in a Middle Eastern MASLD cohort to combine MRI-based adiposity assessment with validated sarcopenia criteria to define SVO and demonstrate its prognostic relevance. The introduction of a tiered risk framework integrating SVO, fibrosis, and ASCVD risk represents a novel approach to personalized MASLD care and support targeted decision-making.