Prevalence of MASLD in End-Stage Kidney Disease Patients and Evaluation of Tocotrienol as a Therapeutic Agent - PMET Study

Abraham G, Jayaraman GV, Mathew M, Prakash A and Kumaraswamy L

Published on: 2025-10-22

Abstract

Background: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), formerly termed Non-Alcoholic Fatty Liver Disease (NAFLD), is increasingly recognized among patients with End-Stage Kidney Disease (ESKD) undergoing dialysis. However, data on the prevalence of MASLD in ESKD patients in India is currently unavailable. Diagnostic challenges and limited therapeutic options further complicate its management in this population. The American Association for the Study of Liver Diseases (AASLD) recommends lifestyle modification and vitamin E for MASLD, particularly in non-diabetic patients. This study aims to evaluate the prevalence of MASLD among ESKD patients in India and represents the first clinical evaluation of tocotrienol, a potent vitamin E isomer, as a potential therapeutic intervention in this group.

Objective: To determine the prevalence of MASLD / NAFLD in ESKD patients undergoing maintenance hemodialysis and to evaluate the therapeutic efficacy of Tocotrienol in improving hepatic parameters using advanced Transient Elastography (TE) technique.

Methods: This prospective, dual-center study enrolled 120 ESKD patients at the Tanker Medical Foundation Dialysis Center, Chennai, India, and 20 patients from the MGM Hospitals Dialysis Center, Chennai, India. Hepatic steatosis and fibrosis were assessed using transient elastography (Fibrotouch FT100-HISKY), measuring ultrasound attenuation parameter (UAP) and liver stiffness. Liver size & other biochemical parameters were checked.

Participants with UAP > 250 dB/m (n = 39), indicative of moderate hepatic steatosis, received tocotrienol (200 mg, twice daily) for three months. UAP, Liver stiffness and liver enzymes were compared pre- and post-intervention. Multivariate regression was used to adjust for confounders.

Results: NAFLD can progress from simple steatosis, steatohepatitis, and fibrosis to eventually cirrhosis. At the Tanker Foundation, 35.8% of patients had a UAP value >238 db/m, indicative of hepatic steatosis. Interestingly, 47.5% with no previous hepatitis B and C had liver stiffness scores >7 kPa, indicating more advanced liver disease in ESKD patients. In addition, 71.7% of the patients had some form of occult liver disease with UAP >238 db/m or liver stiffness >7 kPa or SGPT (ALT) >40. At the MGM center, 50% of patients had some form of occult liver disease. Liver size was in the range of 9.86 cm to 16.1 cm. Tocotrienol significantly improved UAP scores in 3 months, reducing the level by -27.96 (p < 0.001), suggesting a reduction in hepatic steatosis. Tocotrienol treatment also reduced SGPT (ALT) levels with a coefficient of -9.69 (p = 0.045). The effect on liver stiffness was not statistically significant with a time point coefficient of 1.65 (p= 0.063) indicating only a minor change. Regression analysis confirmed tocotrienol as an independent predictor of hepatic improvement.

Conclusion: MASLD is highly prevalent in ESKD patients and is often underdiagnosed. Tocotrienol appears to be a safe and effective treatment option for reducing hepatic steatosis and liver enzyme levels in dialysis patients.