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Multiple animals and  in vitro  studies have demonstrated that perfluoroalkyl and polyfluoroalkyl substances (PFASs) exposure causes liver damage associated with fat metabolism. However, it is lack of population evidence for the correlation between PFAS exposure and nonalcoholic fatty liver disease (NAFLD). A cross-sectional analysis was performed of 1150 participants aged over 20 from the US. Liver ultrasound transient elastography was to identify the participants with NAFLD and multiple biomarkers were the indicators for hepatic steatosis and hepatic fibrosis. Logistics regression and restricted cubic splines models were used to estimate the association between PFASs and NAFLD. PFASs had not a significant association with NAFLD after adjustment. The hepatic steatosis indicators including fatty liver index, NAFLD liver fat score, and Framingham steatosis index were almost not significantly correlated with PFASs exposure respectively. But fibrosis indicators including fibrosis-4 index (FIB-4), NAFLD fibrosis score, and Hepamet fibrosis score were positively correlated with each type of PFASs exposure. After adjustment by gender, age, race, education, and poverty income rate, there was also a significant correlation between PFOS and FIB-4 with 0.07 (0.01, 0.13). The mixed PFASs were associated with FIB-4, with PFOS contributing the most (PIP = 1.000) by the Bayesian kernel machine regression model. The results suggested PFASs exposure appeared to be more closely associated with hepatic fibrosis than steatosis, and PFOS might be the main cause of PFASs associated with hepatic fibrosis.Key messagesCurrent exposure doses of PFAS did not significantly change the risk of developing NAFLD.PFASs exposure appeared to be more closely associated with hepatic fibrosis than steatosis.PFOS might be the main cause of PFASs associated with hepatic fibrosis. Current exposure doses of PFAS did not significantly change the risk of developing NAFLD. PFASs exposure appeared to be more closely associated with hepatic fibrosis than steatosis. PFOS might be the main cause of PFASs associated with hepatic fibrosis.

Close association of PFASs exposure with hepatic fibrosis than steatosis: evidences from NHANES 2017–2018