Brief Report: Relationship Between Nonalcoholic Fatty Liver Disease and Cardiovascular Disease in Persons With HIV

Impact of HIV Infection on Liver and Cardiovascular Outcomes in Veterans With Metabolic Dysfunction-Associated Steatotic Liver Disease

INTRODUCTION

Hepatic steatosis is highly prevalent in people living with HIV. It remains unclear whether HIV in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with greater risks of liver disease progression and cardiovascular disease (CVD). We aim to evaluate the impact of HIV infection on risks of liver and CVD outcomes among US Veterans with MASLD.

METHODS

Using national Veterans Administration data from 2010 to 2022, we created a propensity score-matched cohort of MASLD patients with vs without HIV. Primary outcomes were incidence of cirrhosis and hepatocellular carcinoma (HCC) among patients with vs without HIV and patients with MASLD-HIV on antiretroviral therapy (ART) vs not on ART. Secondary outcomes included incidence of major adverse cardiovascular events and overall survival.

RESULTS

The propensity-matched cohort included 920 MASLD patients with HIV and 920 MASLD patients without HIV and was similar in demographics and comorbidities. Compared with MASLD patients without HIV, incidences of cirrhosis and HCC were similar among MASLD with HIV. Compared with MASLD patients without HIV, incidence of major adverse cardiovascular event was higher among MASLD patients with HIV (5.18 vs 4.48 per 100 person-years, P = 0.03). Overall 5-year survival was significantly lower among MASLD patients with HIV and even lower among those not on ART.

DISCUSSION

Among US Veterans with MASLD, concurrent HIV infection, and particularly not being on ART, is associated with greater risks of CVD and decreased overall survival. No differences in risks of cirrhosis or HCC were observed.

Fatty Liver Disease: Enter the Metabolic Era

PURPOSE OF REVIEW

The goal of this review is to summarize the recent literature linking HIV to metabolic dysfunction-associated steatotic liver disease (MASLD). This is a pressing issue due to the scale of the MASLD epidemic and the urgent need for preventive and therapeutic strategies for MASLD in PWH.

RECENT FINDINGS

The prevalence of MASLD in PWH is higher than previously appreciated, approaching 50% depending on the population and definition of MASLD. MASLD in PWH is likely multifactorial due to risk factors present in the general population such as metabolic syndrome, and features unique to HIV including systemic inflammation and ART. Statin therapy results in a significant reduction in major adverse cardiovascular events in PWH. PWH are at high risk for MASLD. Screening PWH with metabolic syndrome features could enable earlier interventions to reduce morbidity and mortality associated with MASLD in PWH.

Prevalence and incidence of stroke among people with HIV

OBJECTIVE

We aimed to obtain more precise estimates of stroke to address the wide variation of stroke burden among people with HIV (PWH) in different clinical settings.

DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched PubMed, EMBASE, and Web of Science for original articles reporting the prevalence and incidence of stroke among PWH up to November 23, 2022. Der Simonian-Laird random effects were used to obtain pooled estimates and 95% confidence intervals (CIs).

RESULTS

We included 17 observational studies covering 1 749 003 PWH on estimation of prevalence, and 17 cohort studies covering 249 606 PWH on estimation of incidence. The pooled prevalence of stroke was 1.30% (95% CI: 1.01%, 1.59%) for PWH aged at least 15 years, and 3.98% (95% CI: 2.45%, 5.51%) for PWH aged at least 50 years. The pooled incidence of stroke was 17.86 per 10 000 person-years (95% CI: 15.96, 19.76), meanwhile, the pooled incidence of ischemic stroke (31.50 per 10 000 person-years; 95% CI: 11.11, 51.89) was higher than hemorrhagic stroke (4.43 per 10 000 person-years; 95% CI: 1.95, 6.91) among PWH aged at least 15 years.

CONCLUSION

The prevalence of stroke was nearly one per hundred among PWH aged ≥15 years, and reached four per hundred for those aged ≥50 years. The occurrence of stroke is common during HIV progression, particularly ischemic stroke. Therefore, more efforts should be made on implementing policies, strategies, and programs aimed at identifying the risk factors, improving treatment, and facilitating rehabilitation for stroke to reduce the disease burden among PWH.

Risk of adverse cardiovascular outcomes among people with HIV and nonalcoholic fatty liver disease

OBJECTIVE

To examine and compare the risk of major adverse cardiovascular events (MACEs) between people with HIV (PWH) with and without nonalcoholic fatty liver disease (NAFLD).

DESIGN

Population-based, multicenter, retrospective cohort study.

METHODS

Data on PWH between January 1, 2008, and December 31, 2020 were extracted from the TriNetX database. Primary outcomes were defined as the first incidence of myocardial infarction (MI), MACE, new-onset heart failure (HF), and a composite of cerebrovascular disease. Cox models were used to obtain hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

A total of 151 868 patients were identified as having HIV. After exclusions, 4969 patients were identified as having NAFLD. Of them, 4463 (90%) were propensity matched to a non-NAFLD control. Patients with NAFLD were older (42.9 versus 40.8 years). Among the NAFLD cohort, most participants were male and had a smoking history (12.3 versus 9.8%) than non-NAFLD. The mean follow-up was 4.8 ± 1.1 years for the NAFLD group and 5.3 ± 1.2 years for the non-NAFLD group. The risk of all outcomes was statistically significantly higher in NAFLD patients compared to those without NAFLD: MI (HR, 1.49; 95% CI, 1.11-2.01) MACE (HR, 1.49; 95% CI, 1.25-1.79), HF (HR, 1.73; 95% CI 1.37-2.19) and, cerebrovascular diseases (HR, 1.25; 95% CI, 1.05-1.48) and sensitivity analysis showed similar magnitude to the one generated in the primary analysis.

CONCLUSIONS

Patients with NAFLD have an elevated risk of adverse cardiovascular events (CVEs). The results indicate the need for targeted efforts to improve awareness of risks factors associated with adverse CVEs risk in PWH with NAFLD.

Impact of nonalcoholic fatty liver disease on clinical outcomes in patients with COVID-19 among persons living with HIV: A multicenter research network study

BACKGROUND

People living with human immunodeficiency virus (PLWH) are at an increased risk of nonalcoholic fatty liver disease (NAFLD) but how these patients react to COVID-19 infection is unclear. We examined the clinical characteristics and outcomes of patients with and without nonalcoholic fatty liver disease (NAFLD) among people living with human immunodeficiency virus (PLWH) diagnosed with COVID-19.

METHODS

A multicenter, retrospective cohort study was conducted using TriNetX. Participants diagnosed with COVID-19 between January 20, 2020, and October 31, 2021, in PLWH were identified and divided into cohorts based on preexisting NAFLD. The primary outcome was all-cause mortality, and secondary outcomes were hospitalization, severe disease, critical care, need for mechanical ventilation, and acute kidney injury(AKI). Propensity score matching (PSM) mitigated the imbalance among group covariates. Risk ratios (RR) with 95 % confidence intervals (CI) were calculated.

RESULTS

Of the 5012 PLWH identified with confirmed COVID-19 during the study period, 563 had a diagnosis of NAFLD. After PSM, both groups were well-matched with 561 patients. The primary outcome did not differ between the cohorts at 30-days, even after a fully adjusted analysis, and the risk of all-cause mortality did not differ at 60 and 90 days. NAFLD had a significantly higher risk for hospitalization rates (RR 1.32; 95 % CI, 1.06-1.63) and AKI (RR 2.55; 95 % CI 1.42-4.57) than the non-NAFLD group at 30 days. No other differences were detected in other secondary outcome measures.

CONCLUSIONS

Preexisting NAFLD is associated with an increased risk for hospitalization and AKI among PLWH infected with COVID-19. The potential role of NAFLD in developing severe COVID-19 among PLWH remains to be elucidated in future studies. Still, this study indicates the need for careful monitoring of this at-risk population.

Uncovering the NAFLD burden in people living with HIV from high- and middle-income nations: a meta-analysis with a data gap from Subsaharan Africa

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) has become a significant concern among people living with HIV (PLHIV), albeit its burden remains unclear. The primary objective of this systematic review (SR) and meta-analysis (MA) was to estimate the prevalence of NAFLD and significant fibrosis in PLHIV. The secondary objective was to determine the risk factors for NAFLD among PLHIV.

METHODS

We searched MEDLINE and Scopus from inception to 30 December 2022 for peer-reviewed studies that included PLHIV and reported the prevalence of NAFLD. MA of proportions was used to estimate the pooled prevalence of NAFLD and significant fibrosis. MA of pre-calculated effect estimates examined risk factors for NAFLD in PLHIV.

RESULTS

We included 24 articles published between 2009 and 2022, encompassing 6326 PLHIV. The pooled prevalence of NAFLD was 38% (95% CI: 31-45%) with high heterogeneity (I² = 96.3%). The pooled prevalence of significant fibrosis was 13% (95% CI: 8-18%) with high heterogeneity (I² = 92.09%). Subgroup analyses showed a NAFLD prevalence of 40% (95% CI: 24-57%) in the United States, 33% (95% CI: 31-36) in Asia, 42% (95% CI: 24-61%) in Europe and 33% (95% CI: 29-37) in South America. When stratifying by income level, NAFLD was 39% (95% CI: 31-48) prevalent in PLHIV from high-income economies and 34% in both upper-middle-income (95% CI: 31-37%) and lower-middle-income economies (95% CI: 28-41%). Higher body mass index (BMI) (OR = 1.32, 95% CI: 1.13-1.55; I² = 89.9%), increasing triglycerides (OR = 1.48, 95% CI: 1.22-2.79; I² = 27.2%) and dyslipidaemia (OR = 1.89, 95% CI: 1.32-2.71; I² = 15.5%) were all associated with higher risk-adjusted odds of NAFLD in PLHIV.

DISCUSSION

The burden of NAFLD and significant fibrosis in PLHIV is significant. Therefore, targeted efforts to screen and diagnose NAFLD in this population are needed. Health services for PLHIV could include ways to target NAFLD risk factors, screen for liver disease and implement interventions to treat those with significant fibrosis or more advanced stages of liver disease. Taking no action to address NAFLD in PLHIV should not be an option.

CONCLUSIONS

This SR and MA found a 38% NAFLD and 13% significant fibrosis prevalence in PLHIV. Increasing triglyceride levels, higher BMI values and dyslipidaemia were associated with higher risk-adjusted odds of NAFLD among PLHIV.

Ectopic Fat and Cardiac Health in People with HIV: Serious as a Heart Attack

PURPOSE OF REVIEW

This study aims to summarize knowledge of alterations in adipose tissue distribution among people with HIV (PWH), with a focus on the cardiac depot and how this relates to the known higher risk of cardiovascular disease in this unique population.

RECENT FINDINGS

Similar to the general population, cardiac fat depots mirror visceral adipose tissue in PWH. However, altered fat distribution, altered fat quality, and higher prevalence of enlarged epicardial adipose tissue depots are associated with increased coronary artery disease among PWH. Adipose tissue disturbances present in PWH ultimately contribute to increased risk of cardiovascular disease beyond traditional risk factors. Future research should aim to understand how regulating adipose tissue quantity and quality can modify cardiovascular risk.

Cardiovascular computed tomography and HIV: The evolving role of imaging biomarkers in enhanced risk prediction

The treatment of human immunodeficiency virus (HIV) with antiretroviral (ARV) medications has revolutionised the care for these patients. The dramatic increase in life expectancy has brought new challenges in treating diseases of aging in this cohort. Cardiovascular disease (CVD) is now a leading cause of morbidity and mortality with risk matched HIV-positive patients having double the risk of MI compared to HIV-negative patients. This enhanced risk is secondary to the interplay the virus (and accessory proteins), ARV medications and traditional risk factors. The culmination of these factors can lead to a hybrid metabolic syndrome characterised by heightened ectopic fat. Cardiovascular computed tomography (CT) is ideal for quantifying epicardial adipose tissue volumes, hepatosteatosis and cardiovascular disease burden. The CVD risk attributed to disease burden and plaque morphology is well established in general populations but is less clear in HIV populations. The purpose of this review article is to appraise the latest data on CVD development in HIV-positive patients and how the use of cardiovascular CT may be used to enhance risk prediction in this population. This may have important implications on individualised treatment decisions and risk reduction strategies which will improve the care of these patients.

Associations of Hepatosteatosis With Cardiovascular Disease in HIV-Positive and HIV-Negative Patients: The Liverpool HIV-Heart Project

BACKGROUND

Hepatosteatosis (HS) has been associated with cardiovascular disorders in the general population. We sought to investigate whether HS is a marker of cardiovascular disease (CVD) risk in HIV-positive individuals, given that metabolic syndrome is implicated in the increasing CVD burden in this population.

AIMS

To investigate the association of HS with CVD in HIV-positive and HIV-negative individuals.

METHODS AND RESULTS

We analyzed computed tomography (CT) images of 1306 subjects of whom 209 (16%) were HIV-positive and 1097 (84%) HIV-negative. CVD was quantified by the presence of coronary calcification from both dedicated cardiac CT and nondedicated thorax CT. HS was diagnosed from CT data sets in those with noncontrast dedicated cardiac CT and those with venous phase liver CT using previously validated techniques. Previous liver ultrasound was also assessed for the presence of HS. The HIV-positive group had lower mean age (P < 0.005), higher proportions of male sex (P < 0.005), and more current smokers (P < 0.005). The HIV-negative group had higher proportions of hypertension (P < 0.005), type II diabetes (P = 0.032), dyslipidemia (P < 0.005), statin use (P = 0.008), and HS (P = 0.018). The prevalence of coronary calcification was not significantly different between the groups. Logistic regression (LR) demonstrated that in the HIV-positive group, increasing age [odds ratio (OR): 1.15, P < 0.005], male sex (OR 3.37, P = 0.022), and HS (OR 3.13, P = 0.005) were independently associated with CVD. In the HIV-negative group, increasing age (OR: 1.11, P < 0.005), male sex (OR 2.97, P < 0.005), current smoking (OR 1.96, P < 0.005), and dyslipidemia (OR 1.66, P = 0.03) were independently associated with CVD. Using a machine learning random forest algorithm to assess the variables of importance, the top 3 variables of importance in the HIV-positive group were age, HS, and male sex. In the HIV-negative group, the top 3 variables were age, hypertension and male sex. The LR models predicted CVD well, with the mean area under the receiver operator curve (AUC) for the HIV-positive and HIV-negative cohorts being 0.831 [95% confidence interval (CI): 0.713 to 0.928] and 0.786 (95% CI: 0.735 to 0.836), respectively. The random forest models outperformed LR models, with a mean AUC in HIV-positive and HIV-negative populations of 0.877 (95% CI: 0.775 to 0.959) and 0.828 (95% CI: 0.780 to 0.873) respectively, with differences between both methods being statistically significant.

CONCLUSION

In contrast to the general population, HS is a strong and independent predictor of CVD in HIV-positive individuals. This suggests that metabolic dysfunction may be attributable to the excess CVD risk seen with these patient groups. Assessment of HS may help accurate quantification of CVD risk in HIV-positive patients.