Circulating FGF21 and Ketone Bodies Modify the Risk of MASLD and Mortality: Insights from the PREVEND Cohort Study

TL;DR

This study shows that FGF21 and ketone bodies interact to influence the risk of liver disease and mortality in a large cohort.

Contribution

The study reveals a novel interaction between FGF21 and ketone bodies in predicting MASLD and mortality.

Findings

FGF21 and ketone bodies independently increase the risk of MASLD with a positive interaction.

Higher levels of FGF21 and ketone bodies are linked to increased all-cause mortality.

Ketone bodies remain independently associated with mortality after adjusting for confounders.

Abstract

Fibroblast growth factor 21 (FGF21) and ketone bodies are markers of metabolic dysregulation, independently associated with metabolic-dysfunction-associated steatotic liver disease (MASLD) and mortality. We studied their interaction with MASLD and all-cause mortality in 6025 participants from the Prevention of Renal and Vascular End-stage Disease (PREVEND) cohort. Plasma FGF21 (immunoassay) and ketone body concentrations (nuclear magnetic resonance spectroscopy) were measured at baseline. A Fatty Liver Index ≥60 was used as a proxy of MASLD. Logistic regression assessed associations with MASLD, and Cox models evaluated all-cause mortality over a median follow-up of 10.3 years. FGF21 and ketone bodies were not correlated (r = 0.02, p = 0.06), but FGF21 (OR: 1.93 [1.81–2.05], p < 0.001) and ketone bodies (OR: 1.29 [1.19–2.05], p < 0.001) were independent of each other associated with MASLD, with a positive interaction (p = 0.004). Higher FGF21 (HR: 1.24, 95% CI: 1.16–1.32, p < 0.001) and ketone bodies (HR: 1.46, 95% CI: 1.34–1.59, p < 0.001) were associated with mortality, as well as with a positive interaction (p = 0.038). After adjustment for potential confounders, only ketone bodies remained independently associated, while the association of FGF21 became dependent on ketone body levels (interaction p = 0.005). These biomarkers may serve as integrated metabolic stress markers, improving risk stratification for MASLD and adverse outcomes.

Figures