Creatinine-to-cystatin C ratio and all-cause and cardiovascular mortality in U.S. adults with nonalcoholic fatty liver disease: a nationwide cohort study.

Background: The creatinine-to-cystatin C ratio (CCR) is an emerging marker of muscle mass, which influences the progression of nonalcoholic fatty liver disease (NAFLD). However, the relationship between CCR and long-term all-cause and cardiovascular mortality remains unclear in the US NAFLD population. Methods: This nationally representative study analyzed data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004, with mortality follow-up through December 31, 2019 via linkage to the National Death Index (NDI). NAFLD was determined using the Fatty Liver Index (FLI), while CCR was calculated as serum creatinine to cystatin C ratio. We employed multivariable Cox proportional hazards models to assess associations between CCR and mortality risk, expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). The analytical approach included Kaplan-Meier survival analysis, restricted cubic spline regression for non-linear relationship assessment, and comprehensive subgroup and sensitivity analyses to evaluate result robustness. Results: This study included 3,897 participants with NAFLD (53.34% male, mean age 48.98 years), with 1,174 all-cause deaths and 333 cardiovascular deaths over a median follow-up of 206 months. CCR demonstrated significant inverse associations with both all-cause mortality (adjusted HR 0.83; 95% CI 0.78-0.88; Conclusion: In this study of US adults with NAFLD, we identified a significant inverse association between CCR levels and risks of both all-cause and cardiovascular mortality. The stability of this association was confirmed through subgroup and sensitivity analyses, suggesting that CCR may play an important role in long-term prognosis among NAFLD patients.