Liver and Kidney Impact Comparison
Comparative analysis of hepatic and renal effects across compound classes.
Introduction
Organ toxicity profiles differ markedly between performance-enhancing compounds, and so does the evidence. On paper, peptides show a favorable safety profile for liver and kidney compared to oral steroids, mainly because almost nothing has been studied. This page is part of our long-term effects comparison.
Liver Impact Comparison
Hepatotoxicity Risk
| Compound Type | Risk Level | Mechanism | Markers |
|---|---|---|---|
| 17-alpha alkylated steroids | High | Direct toxicity (cholestasis) | Elevated liver enzymes, bilirubin |
| Injectable steroids | Lower | Minimal first-pass hepatic metabolism | Usually normal |
| SARMs | Variable | Hepatic metabolism | Variable ALT elevation |
| Peptides | Not established | Non-hepatic metabolism | Little human data |
Most oral steroids carry a 17-alpha alkyl group (usually methyl) so they survive the first pass through the liver. In a 2020 review of 52 published drug-induced liver injury (DILI) cases (BMJ Open Gastroenterology), the compound most often taken was methyldrostanolone, a 17-alpha-methylated oral. Biopsies showed "bland" cholestasis, and no one died.
For SARMs, a 2023 systematic review (Journal of Xenobiotics) found 15 DILI case reports and raised ALT in about 7% of trial participants on average. A 2024 Australian series of 23 DILI cases (Alimentary Pharmacology & Therapeutics) implicated 14 SARMs among 40 products; one patient needed a transplant.
Peptides are mostly broken down by enzymes in blood and tissue, not the liver, but a 2025 BPC-157 review found only three small human pilots.
Liver Effects by Duration
| Compound | Short-term | Medium-term | Long-term |
|---|---|---|---|
| Oral steroids | Enzyme elevation | Cholestasis possible | Adenoma risk |
| Injectable steroids | Minimal | Minimal | Tumors (LiverTox) |
| SARMs | Variable ALT rise | DILI in case reports | Unknown |
| Peptides | None observed (pilots) | Not studied | Not studied |
LiverTox, the NIH liver-injury database, links long-term androgen use to liver tumors and peliosis hepatis (blood-filled liver cysts); see our cancer risk comparison.
Kidney Impact Comparison
Nephrotoxicity Profile
A 2026 review in Nefrología found most steroid-related acute kidney injury is indirect, with unknown prevalence. Kidney injury often accompanies cholestatic liver injury: 43% of patients in the 52-case review developed it.
A 2010 Columbia series (Journal of the American Society of Nephrology) found focal segmental glomerulosclerosis (FSGS) in 10 bodybuilders after long-term steroid use, and proteinuria fell in those who stopped. Blood pressure effects are in our cardiovascular comparison.
Kidney Function Markers
| Marker | Steroids | SARMs | Peptides |
|---|---|---|---|
| Creatinine | May raise (muscle mass) | Little data | Little data |
| Proteinuria | Heavy in FSGS cases | Not documented | Not documented |
The Columbia authors argued that because creatinine rises with muscle mass, kidney damage in bodybuilders is likely underrecognized.
Protective Strategies
Most liver cases improve after stopping, though median recovery in the Australian series was 175 days and a 2022 review (World Journal of Gastroenterology) notes some damage is irreversible. The SARM review's authors suggested ALT monitoring for continuing users.
What we still don't know
- How common any of this is; case series can't give rates.
- How much SARM injury comes from the labeled compound; causality was only "possible" in 17 of 23 Australian cases.
- Whether peptides affect the liver or kidneys over months of use.
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References
- Androgenic anabolic steroid-induced liver injury: two case reports and review of 50 further cases (BMJ Open Gastroenterology, 2020)
- Androgenic Steroids (LiverTox, NIDDK, updated 2020)
- Systematic review of safety of selective androgen receptor modulators in healthy adults (Journal of Xenobiotics, 2023)
- Drug-induced liver injury from SARMs, anabolic-androgenic steroids and bodybuilding supplements in Australia (Alimentary Pharmacology & Therapeutics, 2024)
- Regeneration or risk? A narrative review of BPC-157 for musculoskeletal healing (Current Reviews in Musculoskeletal Medicine, 2025)
- Testosterone and anabolic androgenic steroids: impact on acute kidney injury (Nefrología, 2026)
- Development of focal segmental glomerulosclerosis after anabolic steroid abuse (Journal of the American Society of Nephrology, 2010)
- Anabolic androgenic steroid-induced liver injury: an update (World Journal of Gastroenterology, 2022)