BMC Gastroenterol. 2026 Jun 4. doi: 10.1186/s12876-026-04987-z. Online ahead of print.
ABSTRACT
BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing global health burden. Identifying robust prognostic biomarkers is crucial for early risk stratification. The red blood cell distribution width to albumin ratio (RAR) has emerged as a potential biomarker reflecting inflammation and nutritional status. This study aimed to evaluate the association between RAR and both all-cause and cardiovascular mortality among adults with MASLD.
METHODS: Data from the National Health and Nutrition Examination Survey 1999-2018 were analyzed. MASLD was defined using the United States Fatty Liver Index (USFLI ≥ 30), combined with cardiometabolic criteria. Participants were categorized into RAR quartiles. Weighted Cox proportional hazards models, Fine-Gray competing risk models, and restricted cubic splines were employed to the association between RAR and mortality. Stratified and sensitivity analyses were conducted to test robustness.
RESULTS: Among 6,287 MASLD patients (mean age 51.39 years, 42.69% female), there were 1,161 all-cause deaths and 324 cardiovascular deaths over a median follow-up of 9.2 years. In the fully adjusted Model 3, individuals in the highest RAR quartile had a higher risk of all-cause mortality (hazard ratio [HR] = 2.41, 95% confidence interval [CI] = 1.87-3.10, P < 0.001) and cardiovascular mortality (HR = 3.39, 95% CI = 2.17-5.31, P < 0.001) compared to those in the lowest quartile. Each unit increase in RAR was associated with a 93% increase in all-cause mortality (HR = 1.93, 95% CI = 1.62-2.30, P < 0.001) and a 130% increase in cardiovascular mortality (HR = 2.30, 95% CI = 1.83-2.90, P < 0.001). No significant nonlinear associations were found. A significant age interaction was observed in all-cause mortality (P for interaction < 0.05), with stronger associations seen among younger individuals. Sensitivity analyses confirmed the robustness of these findings.
CONCLUSIONS: Higher RAR levels were significantly associated with increased all-cause and cardiovascular mortality in adults with MASLD. RAR holds potential as a risk stratification tool for MASLD adults in clinical practice.
PMID:42243742 | DOI:10.1186/s12876-026-04987-z