الفهرس 
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Non-alcoholic fatty liver diseaseOnly 14 pages are availabe for public view
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Abstract
Non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are worldwide public health problems. Recently, it has also been established that there is a strong association between NAFLD and CKD, regardless the presence of potential confounding diseases such as obesity, hypertension and T2DM. This study was done to assess the renal changes in patients with NAFLD. A total of 47 patients with NAFLD attended inwards and out-patient clinics of Tropical Medicine and Gastroenterology Department, Al-Rajhi Liver Hospital, Assiut University, and Assiut Liver Center, Ministry of Health, Assiut, Egypt were consecutively included in the study between January 2019 and January 2020 and evaluated for renal changes. Thirty sex- and age-matched healthy individuals served as controls. All individuals were subjected to: - Thorough medical history and physical examination - Liver function tests: serum bilirubin, serum albumin, ALT, AST, ALP, prothrombin time and INR - Hepatitis markers (HBs Ag, Anti-HCV Ab) - Complete blood picture- Serum cholesterol and triglycerides- Urine analysis (dip-stick and microscopic examination). - Urinary micro-albumin. - Urine albumin-creatinine ratio (ACR). - Serum creatinine and blood urea. - Imaging: abdominal ultrasonography searching for the degree of fatty infiltration in the liver and liver stiffness measurement using either point Shear Wave Elastography (pSWE) or Transient elastography (Fibroscan) for hepatic fibrosis assessment. - Calculation of FIB-4 and NAFLD Fibrosis Scores- Estimation of GFR using CKD-EPI and MDRD equations Estimation of GFR using CKD-EPI equation, kidney function was categorized according to the National Kidney Foundation Practice Guidelines: normal kidney function (eGFR ≥ 90 mL/min/1.73 m2 and no proteinuria; stage 1), mild kidney function damage (MKFD) or mild CKD (eGFR= 60–89 mL/min/1.73 m2 or with proteinuria; stage 2) and moderate CKD (eGFR= 30–59 mL/min/1.73 m2; stage 3). The following results were observed: The patients’ mean age was (42.8 ± 10.9 years) and the majority of them were females (55.3%).No/mild, moderate and severe liver fibrosis was present in 26 (55.3%), 19 (40.4%) and 2 (4.3%) patients, respectively. According to eGRF measured by CKD-EPI equation, 19 patients had CKD (40.4%); 17 patients had mild kidney function damage (Stage 2 CKD) and two cases had moderate kidney function damage (Stage 3 CKD) NAFLD patients had significantly higher ACR (22.1 ± 4.3 vs. 14.8 ± 4.2; P< 0.001) and significantly lower CKD-EPI equation (94.6 ± 20.4 vs. 112.6 ± 21.3; P= 0.001) and MDRD equation (95.4 ± 29.3 vs. 117.1 ± 31.1; P= 0.005) in comparison to the control group. Among NAFLD patients, significant correlations were found between serum creatinine and BMI, microalbuminuria and HDL. Negative correlation was found between microalbuminuria and plateletsRegarding scores for GFR estimation, CKD-EPI and MARD were negatively correlated with the age and BMI. CKD-EPI was negatively correlated with NAFLD fibrosis score. Patients with moderate liver fibrosis stage had significantly higher microalbuminuria and lower MDRD equation compared to those with no/mild stage. The majority of NAFLD cases (28/47, 59.5%) had normal kidney function (eGFR ≥90 mL/min/1.73 m2; stage 1), 17 NAFLD cases (36.2%) had mild or slightly decreased eGFR between 60 - 89 mL/min/1.73m2 (Stage 2 CKD) and two cases had moderate decrease in eGFR between 59 - 30 mL/min/1.73 m2 (Stage 3 CKD) No cases had Stage 4 CKD (severe decrease in eGFR between 30-15 mL/min/1.73 m2) or Stage 5 CKD or renal failure (eGFR between < 15 mL/min/1.73 m2). NAFLD patients with mild eGFR impairment (Stage 2 CKD) had higher BMI and serum cholesterol than those with normal kidney function. NAFLD patients with eGFR impairment (< 90 mL/min/1.73 m2) had higher BMI (28.6 ± 2.3 vs. 26.9 ± 2.1, P= 0.013) and serum cholesterol levels (190.3 ± 37.8 vs. 163.5 ± 41.1, P= 0.028) than those with normal kidney function (Stage 1; eGFR ≥ 90 mL/min/1.73 m2). Using ROC curve, ACR had the highest AUC (0.876; 95% CI 0.781 - 0.940), followed by CKD-EPI, and MARD equations in prediction of renal changes in NAFLD patients. At a cut-off value of ACR >17 mg/g, 89.4% sensitivity 73.3% specificity, 84% PPV and 81.6% NPV were achieved for prediction of renal changes in approximately 89.4% of the cases. Renal changes are common in patients with NAFLD. The link between NAFLD and CKD is an emerging association where, the estimation of GFR and assessment of albuminuria through calculation of ACR seem to be currently the most relevant methods for this purpose. Common metabolic risk factors for both diseases can explain the occurrence of this association. Early recognition of impaired kidney function in those patients is mandatory for the effective management of these patients. In addition, identifying patients with established but also with early kidney damage is necessary to prevent disease progression and minimize complications, and hence to promote quality of life and improve survival. Efforts should be made to effectively screen and treat for NAFLD and its associated risk factors to impede the progression of this serious disease, which currently lacks a definite treatment. Lifestyle modification consisting of diet, exercise, and weight loss has been advocated to treat patients with NAFLD. Screening patients with NAFLD (mainly with significant liver fibrosis) for early recognition of impaired kidney function to receive targeted treatment and to prevent disease progression and minimize complications, to promote quality of life and improve survival. More studies should be done to identify the pathogenic pathways of CKD in patients with NAFLD and to study the effect of therapeutic interventions and their outcome.