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. 2025;15(1):153-163.
doi: 10.1159/000543500. Epub 2025 Jan 21.

Association of Liver Fibrosis Markers with Mortality Outcomes in Patients with Chronic Kidney Disease and Coronary Artery Disease: Insights from the NHANES 1999-2018 Data

Zixiang Ye  1   2 , Enmin Xie  1 , Ziyu Guo  2 , Yanxiang Gao  3 , Zhongwei Han  4 , Kefei Dou, Jingang Zheng
Affiliations

Association of Liver Fibrosis Markers with Mortality Outcomes in Patients with Chronic Kidney Disease and Coronary Artery Disease: Insights from the NHANES 1999-2018 Data

Zixiang Ye et al. Cardiorenal Med. 2025.

Abstract

Introduction: The objective of this research was to explore the possible link between markers of liver fibrosis and survival rates in a group of adults who have been diagnosed with both chronic kidney disease (CKD) and coronary artery disease (CAD).

Methods: The National Health and Nutrition Examination Survey (NHANES) data (1999-2018) for participants with both CAD and CKD were analyzed. The fibrosis-4 index (FIB-4), Nonalcoholic Fatty Liver Score (NFS), Forns index, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio were identified as crucial biomarkers. All-cause and cardiovascular disease (CVD) mortality were primary outcomes, assessed using Cox models, Kaplan-Meier curves, and receiver operating characteristic (ROC) analysis.

Results: A total of 1,192 CKD and CAD patients were included. The Cox regression analysis revealed substantial correlations between elevated FIB-4, NFS, Forns index, and AST/ALT levels and a heightened risk of all-cause (hazard ratio [HR]: 1.188, 95% confidence interval [CI]: 1.108-1.274; HR: 1.145, 95% CI: 1.069-1.227; HR: 1.142, 95% CI: 1.081-1.201; HR: 1.316, 95% CI: 1.056-1.639, respectively) and CVD mortality (HR: 1.133, 95% CI: 1.007-1.275; HR: 1.155, 95% CI: 1.024-1.303; HR: 1.208, 95% CI: 1.109-1.316 and HR: 1.636, 95% CI: 1.203-2.224, respectively). The ROC analysis indicated comparable predictive accuracy for all three biomarkers, with AST/ALT showing slightly superior performance.

Conclusion: Liver fibrosis markers, including AST/ALT, NFS, Forns index and FIB-4, are significant mortality predictors in CAD-CKD patients. The AST/ALT ratio, being easily measurable, may serve as an effective predictive tool for risk stratification in this population.

Keywords: AST/ALT ratios; Chronic kidney disease; Coronary artery disease; Liver fibrosis markers; Mortality.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1.
Fig. 1.
Flowchart of selecting CAD and CKD patients from NHANES dataset. AST, aspartate aminotransferase; ALT, alanine aminotransferase; BMI, body mass index; NHANES, National Health and Nutrition Examination Survey; PLT, platelet.
Fig. 2.
Fig. 2.
Kaplan-Meier survival curves of FIB-4, NFS, AST/ALT for all-cause mortality. FIB-4 (a), NFS (b), AST/ALT (c), Forns index (d). AST, aspartate aminotransferase; ALT, alanine aminotransferase; NFS, nonalcoholic fatty liver score; FIB-4, fibrosis-4 index.
Fig. 3.
Fig. 3.
Subgroup analysis of the association between AST/ALT and all-cause in CAD and CKD patients. DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; HR, hazard ratio; CI, confidence interval.
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