Determinants of Liver Steatosis Progression in Chinese Children: A Prospective Cohort Study

Background: Liver steatosis in children can be non-invasively assessed by the controlled attenuation parameter (CAP) derived from transient elastography. This study aimed to identify determinants of longitudinal changes in liver steatosis in a Chinese pediatric population. Methods: We established a prospective cohort in Wuxi, China, to investigate risk factors of fatty liver among school-aged children. A total of 1498 children aged 6 to 13 years were enrolled in 2023 and 1195 children completed follow-up assessments in 2024. Biomarkers based on blood, urine, and body composition were measured. The progression of liver steatosis was evaluated using CAP values. Regression analyses were conducted identify determinants of both longitudinal changes in CAP and the progression of liver steatosis. Results: The average CAP of the participants in 2023 was 193.5 dB/m, and in 2024 it was 189.0 dB/m. During the one-year follow-up period, 68 children developed new liver steatosis. Regression analyses revealed 10 biomarkers significantly associated with changes in CAP, which were further categorized into two distinct clusters characterized primarily by metabolic and inflammatory processes. Additionally, the ratio of neutrophils to albumin constituted a separate subgroup. For liver steatosis progression, stepwise logistic regression identified four independent determinants: sex, BMI z-score, lymphocyte count, and trunk body fat mass, and demonstrated good discriminatory power (AUC = 0.80). Conclusion: Several inflammatory and body composition markers were significantly associated with the progression of liver steatosis in Chinese children. These findings underscore the roles of inflammation and fat distribution in the early development of fatty liver disease, which may inform screening strategies for school-aged children.