Metabolic dysfunction-associated fatty liver disease in advanced chronic kidney disease: impact on patient survival

Abstract

Background and Aims Metabolic dysfunction-associated fatty liver disease (MAFLD) is a prevalent liver condition commonly associated with obesity, metabolic syndrome, and type 2 diabetes mellitus. It has also been linked to an increased risk of cardiovascular events and overall mortality. Recent studies have established pathophysiological connections between MAFLD and chronic kidney disease (CKD). This study aimed to determine the prevalence of MAFLD in patients with advanced chronic kidney disease (ACKD), identify associated factors, and evaluate its impact on patient survival.

Method A retrospective longitudinal cohort study was conducted with incident patients diagnosed with stage 4 or 5 CKD, not on dialysis, who initiated care for ACKD between 2011 and 2015. Clinical and laboratory data were collected, and the presence of MAFLD was estimated using the Fatty Liver Index (FLI). To assess the impact of FLI and other variables on survival, Kaplan–Meier univariate analysis and Cox regression multivariate analysis were performed, with follow-up through February 2024.

Results Among 367 patients, 60.2% had diabetes, and 70.8% had an FLI ≥ 60. Patients with an FLI ≥ 60 were older, had a greater prevalence of diabetes, greater history of cardiovascular events, higher PCR levels and a lower serum albumin level. During follow-up, 149 patients (40.6%) died, 178 (48.5%) initiated RRT, 104 of whom died during the study period, 32 (8.7%) were still in treatment and eight (2.2%) were lost to follow-up. Kaplan–Meier univariate survival analysis showed that the FLI ≥ 60 group had lower survival censoring for RRT initiation and lower overall survival, also taking into account survival time to death after RRT initiation.

In multivariate Cox regression analysis FLI was identified as an independent risk factor for decreased survival in patients with diabetes, after adjusting for other variables (HR, 1.015; 95% CI 1.004–1.027; p = 0.009). However, in non-diabetic patients, FLI was not a significant predictor of lower survival in multivariate Cox regression analysis.

Conclusion MAFLD is highly prevalent in patients with ACKD, particularly among those with diabetes, for whom it may represent an independent risk factor for reduced survival. This association was not observed in non-diabetic ACKD patients. These results suggest the need to design preventive and treatment strategies for MAFLD in this population.