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Despite its rising prevalence, treatment options remain limited, highlighting the need for novel therapeutic strategies. In recent years, ketone metabolism has emerged as a key modulator of hepatic metabolic health. Hepatic ketogenesis provides a mechanism for fatty acid mobilization. Endogenously synthesized ketone metabolites can then provide energy for hepatic nonparenchymal cells and extrahepatic tissues. Ketones also function as signaling molecules that can reduce key pathological drivers of MASLD progression. Impaired ketogenesis is observed in MASLD, contributing to metabolic inflexibility and liver dysfunction. Conversely, ketogenic interventions, including exogenous ketone supplementation and ketogenic diets, have been shown to be hepatoprotective, attenuating steatosis, inflammation, and fibrosis. Ketogenic enzyme loss- and gain-of-function studies have highlighted the roles of ketogenesis, ketolysis, and ketone metabolite conversion in MASLD, providing insights to refine keto-therapeutic strategies for disease management. 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