Statins and the Lifetime Outcomes of MASLD: From Evidence Asymmetry to Outcome Convergence

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a systemic disorder in which cardiovascular, hepatic and oncological outcomes shape long-term prognosis. Statins are particularly relevant because their cardiovascular benefit is firmly established, yet they remain underused in MASLD, while their potential liver-related effects remain uncertain. Observational studies consistently associate statin exposure with slower fibrosis progression, fewer major adverse liver outcomes, lower hepatocellular carcinoma incidence and reduced liver-related mortality. However, direct randomized evidence in MASLD remains limited, and available studies differ substantially in disease stage, exposure, endpoint and follow-up. In this narrative review, we critically examine the cardiovascular, hepatic, oncological, randomized, observational, genetic and pharmacological evidence on statin therapy in MASLD. We aim to clarify the apparent discordance between evidence sources, assess whether statins may modify liver-related outcomes beyond their established cardiovascular benefit, and propose a framework for evaluating multidomain therapeutic effects. We propose outcome convergence as a framework for assessing whether a therapy can improve more than one clinically relevant disease domain while preserving independent causal evaluation of each outcome. Statins should therefore be regarded as a candidate, rather than an established, outcome-convergent therapy.