Bidirectional relationship between nonalcoholic fatty liver disease and serum creatinine-to-body weight ratio as a proxy for skeletal muscle mass index

Background and Aim: Although an association between skeletal muscle mass index and nonalcoholic fatty liver disease (NAFLD) has previously been demonstrated, the causal direction remains unclear. Herein, we investigated the directional association between NAFLD and the serum creatinine-to-body weight ratio (sCr/bw), a surrogate marker of the muscle mass index, using longitudinal data. Methods: We recruited 9662 participants in 2017 and performed follow-up over 4 years. We evaluated whether sCr/bw was related to NAFLD development (Analysis I) and whether NAFLD was associated with a low sCr/bw incidence (Analysis II) using logistic regression models. Furthermore, a random intercept cross-lagged panel model was applied to evaluate the bidirectional association between sCr/bw ratio and NAFLD (Analysis III). Results: Analysis I demonstrated an association between sCr/bw and incident NAFLD (odds ratio [OR] = 0.160, 95% confidence interval [CI]:0.107-0.232). Analysis II indicated a relationship between NAFLD and subsequent low sCr/bw ratio (OR = 1.524, 95% CI: 1.258-1.846). Analysis III indicated that the standard regression coefficient from sCr/bw to subsequent hepatic steatosis (HS) was 0.053 for ss sCr/ bw2017. HS2019 and 0.060 for ss sCr/ bw2019. HS2021 and the coefficient from HS to subsequent sCr/bw was 0.093 for ss HS2017. sCr/bw2019 and 0.112 for ss HS2019. sCr/bw2021 (all P < 0.05). Conclusions: This study indicated mutual causality between sCr/bw and NAFLD. Considering that sCr/bw is a surrogate marker of muscle mass index, the findings emphasize that NAFLD and low muscle mass form a vicious cycle, which should be taken seriously in clinical practice.