The Chronic Hepatitis B and Metabolic Dysfunction-Associated Steatotic Liver Disease Paradox: Friend or Foe?

Chronic hepatitis B (CHB) and metabolic dysfunction-associated steatotic liver disease (MASLD) frequently coexist, yet their interplay remains complex and paradoxical. Emerging evidence suggests that hepatic steatosis may suppress hepatitis B virus replication and lower the risks of cirrhosis, hepatocellular carcinoma, and mortality. In contrast, an accumulation of cardiometabolic risk factors, the defining feature of MASLD, has been consistently associated with relatively poor liver-related outcomes in CHB. This apparent contradiction raises questions about the mechanistic, causal role of steatosis and the optimal strategies for managing CHB patients with metabolic dysfunctions. In this concise review, we summarize current evidence from mechanistic, clinical, and population-based studies on the dual impact of MASLD on the natural history of CHB. We also discuss the potential underlying mechanisms, identify key knowledge gaps, and propose a clinically relevant framework for personalized risk stratification and treatment decision-making that integrates both viral and metabolic factors.