Assessment of Apolipoprotein B, A1, And the Risk of Apo B/Apoa1 Ratio in Metabolic Dysfunction-Associated Steatotic Liver Disease: A Cross-Sectional Study from South India

Abstract

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly associated with dyslipidemia. The apolipoprotein B/A1 ratio may provide superior metabolic risk assessment compared to conventional lipid parameters.

Aim: To assess apolipoprotein B, A1 levels and the B/A1 ratio in MASLD patients and evaluate their association with disease severity.

Methods: This cross-sectional study enrolled 150 MASLD patients at a tertiary care center in South India. Clinical evaluation, anthropometry, conventional lipid profile, apolipoprotein measurements, ultrasonography, and transient elastography (FibroScan) were performed. Correlation analysis, multiple regression, and ROC curve analysis were conducted.

Results: Mean age was 48.31±11.42 years with 61.3% males. Comorbidities included hypertension (88%), diabetes (84%), and dyslipidemia (81.3%). Lean MASLD comprised 23.3% of patients; 34.3% of lean patients had elevated Apo B/A1 ratio. Mean Apo B/A1 ratio was 1.14±0.34, with 60% having high cardiovascular risk (ratio >1.0). The ratio correlated strongly with controlled attenuation parameter (r=0.532, p<0.001) and liver stiffness (r=0.392, p<0.001). Notably, 10.7% had normal conventional lipids but elevated Apo B/A1 ratio. Dyslipidemia was the strongest predictor (OR 3.84, 95% CI 2.12-6.96), while normal lipids with increased ratio independently predicted MASLD risk (OR 2.67, 95% CI 1.23-5.79). ROC analysis showed AUC of 0.682 for moderate-severe steatosis and 0.714 for patients with normal lipids but metabolic risk.

Conclusion: Apo B/A1 ratio is a valuable biomarker for MASLD severity, identifying high-risk phenotypes including lean MASLD and metabolic dysfunction despite normal conventional lipids.