Summary Background and Aims Despite the development of transient elastography (TE)‐based Agile scores for diagnosing fibrotic burden in patients with metabolic dysfunction‐associated steatotic liver disease (MASLD), their applicability in predicting kidney outcomes remains unclear. We aimed to investigate the association between liver fibrotic burden, as assessed by Agile scores, and the risk of incident chronic kidney disease (CKD) in patients with MASLD. Methods A total of 3240 participants with MASLD but without pre‐existing CKD who underwent TE between July 2006 and October 2018 were selected. The primary outcome was incident CKD, defined as estimated glomerular filtration rate (eGFR) &lt;60 mL/min/1.73 m 2 or proteinuria (≥1+ on dipstick) on two consecutive measurements. The secondary outcome was a 25% decline in eGFR measured on two consecutive visits. Results During a median follow‐up of 3.6 years, 187 participants (5.8%) developed incident CKD. When stratified into three groups according to Agile 3+ scores, multivariable Cox models revealed that risk of incident CKD was 2.77‐fold (95% confidence interval [CI], 1.89–4.07; p &lt; 0.001) higher in the high‐risk group (Agile 3+ &gt;0.68), compared to the low‐risk group (Agile 3+ &lt;0.45). During a median follow‐up of 3.4 years, the high‐risk group had a 2.41‐fold higher risk (95% CI, 1.86–3.12; p &lt; 0.001) of experiencing the secondary outcome, compared to the low‐risk group. Similar findings were observed for Agile 4 scores. Prediction testing revealed that Agile scores were better predictors of kidney outcomes, compared to liver stiffness measured by TE. Conclusions In patients with MASLD, but without CKD, advanced liver fibrosis measured by Agile scores was significantly associated with a higher risk of incident CKD.

Agile 3+ and Agile 4 scores predict chronic kidney disease development in metabolic dysfunction‐associated steatotic liver disease