Abstract: Objective: To analyze the changing trends in the etiological spectrum of liver cancer in China from 1990 to 2023, and focus on the disease burden, sex differences and temporal variation characteristics of nonalcoholic steatohepatitis(NASH)-related liver cancer. Methods: Data were extracted from the Global Burden of Disease Study(GBD) 2023 database for NASH-related liver cancer in China from 1990 to 2023, including incidence, prevalence, mortality and disability-adjusted life year(DALY). The Joinpoint regression model was employed to examine temporal trends in age-standardized rate(ASR). The composition ratios of the major etiologies of liver cancer in 1990 and 2023-hepatitis B virus(HBV), hepatitis C virus(HCV), alcohol, NASH and others were calculated and compared. Results: Compared with 1990, the incident cases, prevalent cases, deaths and DALY of NASH-related liver cancer in China increased significantly in 2023. In terms of ASR, the female incidence, mortality and DALY rates decreased by 32.7%, 37.0% and 46.5%, respectively. The prevalence increased in males(P<0.05), whereas the changes in incidence and mortality rates were not statistically significant(P>0.05). From 1990 to 2023, all ASR exhibited a decline-first-then-rise pattern: an accelerated decline from 2000 to 2005, reaching a nadir in 2005, followed by a gradual increase, with a marked acceleration in males after 2015. In 2023, the DALY burden was concentrated in the 50-69 age group. In terms of etiological composition, the proportion of HBV-related liver cancer decreased from 65.8% to 64.1%, while that of NASH-related liver cancer increased from 4.9% to 6.1%. The Das Gupta decomposition revealed that the cumulative net increase in the number of deaths was 4,838.01 from 1990 to 2023. Population growth and population ageing contributed 43.84% and 93.29%, respectively, while epidemiological changes contributed-37.13%. Multiple linear regression analysis showed that metabolic risk factors explained 40.27% of the annual variation in mortality(adjusted R² =0.4027, P<0.001), with high fasting plasma glucose being an independent and significant driver(β =38.14, P<0.001). The interaction test of generalized additive model(GAM) revealed that the age-period interaction term was statistically significant(P<0.001). Conclusion: Overall, the age-standardized burden of NASH-related liver cancer in China initially decreased and then increased from 1990 to 2023, with a significant reduction in females but relative stability in males. NASH was the only etiology without a significant decline in males, and its proportion in the etiological composition of liver cancer continued to rise. The increase in absolute burden is mainly driven by population growth and aging, while metabolic risk factors, especially dysglycemia, have become important drivers that offset previous prevention gains and contribute to the rebound in burden, highlighting the urgent need for comprehensive prevention and control strategies targeting males, middle-aged and older populations, and metabolic risk factors.