Chronic kidney disease in nonalcoholic fatty liver disease at primary healthcare centers in Korea

PLOS ONE RESEARCH ARTICLE Chronic kidney disease in nonalcoholic fatty liver disease at primary healthcare centers in Korea Eun-Hee Nah ID1‡*, Sug Kyun Shin2‡, Seon Cho1, Hyeran Park1, Suyoung Kim1, Eunjoo Kwon1, Han-Ik Cho3 1 Health Promotion Research Institute, Korea Association of Health Promotion, Seoul, Korea, 2 Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea, 3 MEDIcheck LAB, Korea Association of Health Promotion, Seoul, Korea ‡ E-HN and SKS are contributed equally to this work as co-first authors * , a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Abstract Background OPEN ACCESS Citation: Nah E-H, Shin SK, Cho S, Park H, Kim S, Kwon E, et al. (2022) Chronic kidney disease in nonalcoholic fatty liver disease at primary healthcare centers in Korea. PLoS ONE 17(12): e0279367. https://doi.org/10.1371/journal. pone.0279367 Editor: Gulali Aktas, Bolu Abant İzzet Baysal University: Bolu Abant Izzet Baysal Universitesi, TURKEY Received: September 29, 2022 Accepted: December 5, 2022 Published: December 20, 2022 Copyright: © 2022 Nah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and supporting information. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. The prevalence rates of nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are expected to increase with the rising trends in diabetes and obesity associated with aging populations. Considering the impacts of coexistent NAFLD and CKD on morbidity and mortality rates, screening strategies for groups at high-risk of CKD are needed in community-dwelling individuals with NAFLD. The aims of this study were to determine the prevalence and distribution of CKD in NAFLD, as well as the risk factors for CKD and the correlation with liver fibrosis in asymptomatic individuals with NAFLD at primary healthcare centers in Korea. Methods This retrospective cross-sectional study used data from 13 health-promotion centers in 10 Korean cities. Liver steatosis and stiffness were assessed using ultrasonography and magnetic resonance elastography (MRE), respectively. CKD was defined as an estimated glomerular filtration rate of <60 mL/min/1.73m2, and urine albumin-to-creatinine ratio or proteinuria. CKD was categorized into four stages: no CKD, mild, moderate, and severe. Comparisons according to the CKD stages in NAFLD were performed using Student’s t-test or the chi-square test. Multivariable logistic regression analyses were performed to identify the risk factors for CKD and the correlation with liver fibrosis in NAFLD. Results The prevalence of CKD was 12.4% in NAFLD. Albuminuria (16.2%) and proteinuria (8.0%) were more prevalent in NAFLD. NAFLD (odd ratio = 1.27, 95% CI = 1.09–1.48, P = 0.003) was independently associated with CKD of at least mild stage. However, there was no significant association between CKD of at least moderate stage and NAFLD after adjusting for PLOS ONE | https://doi.org/10.1371/journal.pone.0279367 December 20, 2022 1 / 12 PLOS ONE Chronic kidney disease in NAFLD age and a metabolically unhealthy status. CKD was associated with significant liver fibrosis as measured by MRE in NAFLD. Conclusion The presence of NAFLD and liver fibrosis were independent risk factors for CKD, but NAFLD was not an independent risk factor for the later stages of CKD. Introduction Nonalcoholic fatty liver disease (NAFLD) is a growing global health concern whose reported prevalence has ranged from 8% to 45% among the general population [1]. Its increasing prevalence is expected to continue with the rising trends in obesity and diabetes in aging societies. Although cirrhosis and its complications are the most common liver-related causes of morbidity, cardiovascular diseases (CVDs) are the leading cause of overall morbidity and mortality in NAFLD [2]. In addition, some studies have shown that NAFLD is the underlying cause not only for a wide spectrum of liver damage, but also for several extrahepatic manifestations including chronic kidney diseases (CKD) [3,4]. CKD is expected to be one of the leading causes of death globally in the near future [5]. The prevalence of CKD has been estimated at 9–15% [6,7]. Some studies found that the prevalence and risk of CKD were significantly increased among patients with NAFLD and that CKD was independently associated with an increased overall mortality in NAFLD [8–10]. However, there are also controversies on the relationship between NAFLD and CKD according to regions, races, and other characteristics of study populations [11–13]. NAFLD and CKD share some cardiometabolic risk factors that lead to CVD events in both diseases [14,15]. Furthermore, more advanced NAFLD has a greater impact on incident CKD. Considering the impacts of coexistent NAFLD and CKD on morbidity and mortality rates, screening strategies for groups at high-risk of CKD are needed in community-dwelling individuals with NAFLD. The aims of this study were to determine the prevalence and distribution of CKD in NAFLD, as well as the risk factors for CKD and the correlation with liver fibrosis in asymptomatic individuals with NAFLD at primary healthcare centers in Korea. Materials and methods Study subjects This cross-sectional, retrospective study consecutively selected subjects who underwent health checkups including magnetic resonance elastography (MRE), abdominal ultrasonography (US), and renal function tests at 13 health-promotion centers in 10 Korean cities between 2018 and 2021. The Korea Association of Health Promotion is running a health checkup program that includes those provided by the Korean National Health Insurance Service (NHIS) but also programs that are paid for privately. This program involves 17 health-promotion centers in 13 cities, and the 13 of these health-promotion centers that have MRE facilities were selected for inclusion in the current study. The medical records and lifestyle information of the subjects were also reviewed. The exclusion criteria were a history of viral hepatitis or hepatocellular malignancy, secondary causes of fatty liver or high alcohol consumption (>210 g for males and > 140 g for females weekly). Analyses were applied to 8,909 eligible subjects. The study protocol was reviewed and approved by the institutional review board of the Korea Association PLOS ONE | https://doi.org/10.1371/journal.pone.0279367 December 20, 2022 2 / 12 PLOS ONE Chronic kidney disease in NAFLD of Health Promotion (approval no.: 130750-202206-HR-002). The requirement for informed consent was waived due to the retrospective design of the study, and the anal (...truncated)