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. 2025 Dec;57(1):2551813.
doi: 10.1080/07853890.2025.2551813. Epub 2025 Aug 30.

Low-density lipoprotein cholesterol and clinical outcomes in patients with liver cirrhosis: a nationwide cohort study

Byung Sik Kim  1 , Jiyeong Kim  2   3 , Nayeon Choi  2 , Hyun-Jin Kim  1 , Jeong-Hun Shin  1
Affiliations

Low-density lipoprotein cholesterol and clinical outcomes in patients with liver cirrhosis: a nationwide cohort study

Byung Sik Kim et al. Ann Med. 2025 Dec.

Abstract

Background: The association between low-density lipoprotein cholesterol (LDL-C) levels and clinical outcomes in patients with liver cirrhosis (LC) remains unclear. In this study, we aimed to investigate the association between LDL-C levels and cardiovascular events, along with all-cause death in patients with LC, using a nationwide database.

Materials and methods: This retrospective cohort study included 303,988 patients with LC identified from the Korean National Health Insurance Service database who underwent health examinations between 2009 and 2017. Patients were categorised into six LDL-C groups (<70, 70-99, 100-129, 130-159, 160-189, and ≥190 mg/dL). The primary outcomes were (1) a composite of myocardial infarction and ischaemic stroke and (2) all-cause death.

Results: Higher LDL-C levels were associated with a dose-dependent increase in the risk of cardiovascular events. Compared to the reference group (<70 mg/dL), patients with LDL-C ≥ 190 mg/dL had a 1.77-fold higher risk of a composite outcome and a 2.96-fold increased risk of myocardial infarction. Conversely, a U-shaped relationship was observed between LDL-C levels and all-cause death, with the lowest risk observed in the 130-159 mg/dL group. These findings were consistent across the subgroups with compensated or decompensated LC and various underlying aetiologies.

Conclusion: This large-scale nationwide study demonstrated that elevated LDL-C levels are significantly associated with an increased risk of cardiovascular events in patients with LC, while both low and high LDL-C levels are associated with a higher risk of all-cause death. These findings highlight the need for individualised lipid management strategies in this high-risk population.

Keywords: Cardiovascular disease; liver cirrhosis; low-density lipoprotein cholesterol; outcome; statin.

Plain language summary

Elevated LDL-C levels are significantly associated with an increased risk of myocardial infarction and ischaemic stroke in patients with liver cirrhosis, in a dose-dependent manner.A U-shaped relationship was observed between LDL-C levels and all-cause death, with the lowest risk seen in the 130–159 mg/dL group.These associations were consistent across subgroups stratified by cirrhosis status and aetiologies, underscoring the need for tailored lipid management in this high-risk population.

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Conflict of interest statement

The authors report no conflict of interest.

Figures

Figure 1.
Figure 1.
Flowchart illustrating the study population. LDL, low-density lipoprotein; MI, myocardial infarction.
Figure 2.
Figure 2.
Kaplan–Meier survival curves for clinical outcomes stratified by LDL-C categories (A) composite cardiovascular outcome (myocardial infarction and ischaemic stroke), (B) all-cause death, (C) myocardial infarction, and (D) ischaemic stroke. LDL-C, low-density lipoprotein cholesterol.
Figure 2.
Figure 2.
Kaplan–Meier survival curves for clinical outcomes stratified by LDL-C categories (A) composite cardiovascular outcome (myocardial infarction and ischaemic stroke), (B) all-cause death, (C) myocardial infarction, and (D) ischaemic stroke. LDL-C, low-density lipoprotein cholesterol.
Figure 3.
Figure 3.
Restricted cubic spline curves illustrating consistent association between LDL-C levels and clinical outcomes. (A) composite cardiovascular outcome (myocardial infarction and ischaemic stroke), (B) all-cause death, (C) myocardial infarction, and (D) ischaemic stroke. LDL, low-density lipoprotein; CI, confidence interval.
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