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Kablawi D, Milic J, Thomas T, Fotsing Tadjo T, Cinque F, Elgretli W, Gioè C, Lebouché B, Tsochatzis E, Finkel J, Bhagani S, Cascio A, Guaraldi G, Mazzola G, Saeed S, Sebastiani G. Metabolic dysfunction-associated steatohepatitis exhibits sex differences in people with HIV. HIV Med 2024. [PMID: 39091015 DOI: 10.1111/hiv.13697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES People with HIV are at increased risk for metabolic dysfunction-associated steatohepatitis (MASH). Although sex differences are documented in the general population, their role in the context of HIV is less understood. METHODS This was a multicentre cohort study including people with HIV without viral hepatitis coinfection. A FibroScan-AST (FAST) score >0.35 was used to diagnose MASH with significant liver fibrosis (stage F2-F4). We investigated sex-based differences in MASH trends as a function of age using a segmented linear mixed-effects model. Random effects accounted for clustering by the four sites. Adjusted models included ethnicity, diabetes, hypertension, and detectable HIV viral load. RESULTS We included 1472 people with HIV (25% women). At baseline, the prevalence of MASH with fibrosis by FAST score was lower in women than in men (4.8% vs. 9.2%, p = 0.008). Based on the adjusted model, male sex (+0.034; p = 0.04), age per year (+0.003; p = 0.05), detectable HIV viral load (+0.034; p = 0.02), and hypertension (+0.03; p = 0.01) were positively associated with MASH with fibrosis. Although men exhibited generally higher FAST scores, FAST scores increased in women during the critical biological age of presumed perimenopause to menopause (between 40 and 50 years), reaching levels similar to those in men by the age of 55 years. CONCLUSION Despite women with HIV having a lower prevalence of MASH with fibrosis than men, they exhibit an acceleration in FAST score increase around the perimenopausal age. Future studies should target adequate consideration of sex differences in clinical investigation of metabolic dysfunction-associated steatotic liver disease to fill current gaps and implement precision medicine for people with HIV.
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Affiliation(s)
- Dana Kablawi
- Chronic Viral Illness Service, Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jovana Milic
- Modena HIV Metabolic Clinic, University of Modena and Reggio Emilia, Modena, Italy
| | - Tyler Thomas
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Thierry Fotsing Tadjo
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Felice Cinque
- Chronic Viral Illness Service, Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wesal Elgretli
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Claudia Gioè
- Infectious and Tropical Diseases Unit, Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Bertrand Lebouché
- Chronic Viral Illness Service, Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | - Antonio Cascio
- Infectious and Tropical Diseases Unit, Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", Palermo, Italy
| | - Giovanni Guaraldi
- Modena HIV Metabolic Clinic, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Mazzola
- Department of Infectious Diseases, Sant'Elia Hospital, Caltanissetta, Italy
| | - Sahar Saeed
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Giada Sebastiani
- Chronic Viral Illness Service, Division of Infectious Disease, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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Sterling RK, Vilar-Gomez E, Wilson LA, Loomba R, Gawrieh S, Price J, Naggie S, Lake JE, Heath S, Tonascia J, Sulkowski M, Chalasani N. Diagnostic Ability of Simple Noninvasive Blood Tests to Predict Increased Liver Stiffness in People Living With HIV and Steatotic Liver Disease. Am J Gastroenterol 2024; 119:1483-1495. [PMID: 38314810 PMCID: PMC11296919 DOI: 10.14309/ajg.0000000000002700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/28/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Steatotic liver disease is common in people with HIV (PWH). Identifying those with advanced fibrosis (AF, bridging fibrosis or cirrhosis), F3-4, is important. We aimed to examine the performance of FIB-4 and nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS) in PWH to identify those with AF assessed by liver stiffness measurement (LSM). METHODS We prospectively collected data on adults participating in 2 National Institute of Health-sponsored HIV NAFLD networks. All had HIV on antiretroviral therapy (ART) ≥6 months with HIV RNA <200 copies/mL. Those with viral hepatitis, other liver disease, excessive alcohol use, or hepatic decompensation were excluded. Vibration-controlled transient elastrography for LSM was performed, and AF defined as ≥11 kPa was compared with FIB-4 and NFS at predefined thresholds (<1.3 and >2.67 for FIB-4 and <-1.455 and >0.675 for NFS). RESULTS A total of 1,065 participants were analyzed: mean age 51.6 years, 74% male, 28% White, 46% Black, 22% Hispanic, with 34% overweight (body mass index 25-29 kg/m 2 ) and 43% obese (body mass index ≥30 kg/m 2 ). Features of the metabolic syndrome were common: hyperlipidemia 35%, type 2 diabetes 17%, and hypertension 48%. The median CD4 + T-cell count was 666 cells/mm 3 , 74% had undetectable HIV RNA, and duration of HIV-1 was 17 years with most taking a nucleoside reverse transcriptase inhibitor (92%) and an integrase inhibitor (83%). The mean LSM was 6.3 kPa, and 6.3% had AF. The area under the receiver characteristic curve for FIB-4 and NFS to identify AF were 0.70 and 0.75, respectively. While both had high negative predictive values (97%-98%), the sensitivity at low thresholds and specificity at high thresholds were 64% and 97% for FIB-4 and 80% and 96% for NFS, respectively. Neither FIB-4 nor NFS at either threshold had good positive predictive value to detect AF. DISCUSSION FIB-4 and NFS have excellent specificity and negative predictive value for detecting AF, and thus can be used as screening tools in PWH to exclude those with AF who do not need further testing (LSM) or referral to hepatologist.
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Shengir M, Lebouche B, Elgretli W, Saeed S, Ramanakumar AV, Giannakis A, De Pokomandy A, Cox J, Costiniuk C, Routy JP, Klein MB, Sebastiani G. Switch to a raltegravir-based antiretroviral regimen in people with HIV and non-alcoholic fatty liver disease: A randomized controlled trial. HIV Med 2024; 25:135-142. [PMID: 37641534 DOI: 10.1111/hiv.13531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION The effect of antiretroviral therapy (ART), particularly integrase strand transfer inhibitors (INSTIs), on non-alcoholic fatty liver disease (NAFLD) in people with HIV remains unclear. We evaluated the effect of switching non-INSTI backbone antiretroviral medications to raltegravir on NAFLD and metabolic parameters. MATERIALS AND METHODS This was a single-centre, phase IV, open-label, randomized controlled clinical trial. People living with HIV with NAFLD and undetectable viral load while receiving a non-INSTI were randomized 1:1 to the switch arm (raltegravir 400 mg twice daily) or the control arm (continuing ART regimens not containing INSTI). NAFLD was defined as hepatic steatosis by controlled attenuation parameter ≥238 dB/m in the absence of significant alcohol use and viral hepatitis co-infections. Cytokeratin 18 was used as a biomarker of non-alcoholic steatohepatitis. Changes over time in outcomes were quantified as standardized mean differences (SMDs), and a generalized linear mixed model was used to compare outcomes between study arms. RESULTS A total of 31 people with HIV (mean age 54 years, 74% male) were randomized and followed for 24 months. Hepatic steatosis improved between baseline and end of follow-up in both the switch (SMD -43.4 dB/m) and the control arm (-26.6 dB/m); the difference between arms was not significant. At the end of follow-up, aspartate aminotransferase significantly decreased in the switch arm compared with the control arm (SMD -9.4 vs. 5.5 IU/L). No changes in cytokeratin 18, body mass index, or lipids were observed between study arms. DISCUSSION Switching to a raltegravir-based regimen improved aspartate aminotransferase but seemed to have no effect on NAFLD, body weight, and lipids compared with remaining on any other ART.
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Affiliation(s)
- Mohamed Shengir
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Bertrand Lebouche
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wesal Elgretli
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Sahar Saeed
- Queen's University, Kingston, Ontario, Canada
| | | | - Andreas Giannakis
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra De Pokomandy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joseph Cox
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Cecilia Costiniuk
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Pierre Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Giada Sebastiani
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
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Wegermann K, Moylan C, Naggie S. Fatty Liver Disease: Enter the Metabolic Era. Curr HIV/AIDS Rep 2023; 20:405-418. [PMID: 37882965 DOI: 10.1007/s11904-023-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Kara Wegermann
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC, USA
| | - Cynthia Moylan
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC, USA
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Susanna Naggie
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Division of Infectious Diseases, Department of Medicine, Duke University Health System, Durham, NC, USA.
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Cinque F, Saeed S, Kablawi D, Ramos Ballesteros L, Elgretli W, Moodie EEM, Price C, Monteith K, Cooper C, Walmsley SL, Pick N, Murray MCM, Cox J, Kronfli N, Costiniuk CT, de Pokomandy A, Routy JP, Lebouché B, Klein MB, Sebastiani G. Role of fatty liver in the epidemic of advanced chronic liver disease among people with HIV: protocol for the Canadian LIVEHIV multicentre prospective cohort. BMJ Open 2023; 13:e076547. [PMID: 37607785 PMCID: PMC10445396 DOI: 10.1136/bmjopen-2023-076547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Advanced chronic liver disease (ACLD) is a major cause of death for people with HIV (PWH). While viral hepatitis coinfections are largely responsible for this trend, metabolic dysfunction-associated steatotic liver disease (MASLD) is an emerging concern for PWH. We aimed to assess the contribution of MASLD to incident ACLD in PWH. METHODS AND ANALYSIS This multicentre prospective observational cohort study will enrol 968 consecutive HIV monoinfected patients from four Canadian sites, excluding subjects with alcohol abuse, liver disease other than MASLD, or ACLD at baseline. Participants will be followed annually for 4 years by clinical evaluation, questionnaires, laboratory testing and Fibroscan to measure liver stiffness measurement (LSM) and controlled attenuation parameter (CAP). The primary outcome will be incidence of ACLD, defined as LSM>10 kPa, by MASLD status, defined as CAP≥285 dB/m with at least one metabolic abnormality, and to develop a score to classify PWH according to their risk of ACLD. Secondary outcomes will include health-related quality of life (HRQoL) and healthcare resource usage. Kaplan-Meier survival method and Cox proportional hazards regression will calculate the incidence and predictors of ACLD, respectively. Propensity score methods and marginal structural models will account for time-varying exposures. We will split the cohort into a training set (to develop the risk score) and a validation set (for validation of the score). HRQoL scores and healthcare resource usage will be compared by MASLD status using generalised linear mixed effects model. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committees of all participating institutions. Written informed consent will be obtained from all study participants. The results of this study will be shared through scientific publications and public presentations to advocate for the inclusion of PWH in clinical trials of MASLD-targeted therapies and case-finding of ACLD in PWH.
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Affiliation(s)
- Felice Cinque
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sahar Saeed
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Dana Kablawi
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luz Ramos Ballesteros
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wesal Elgretli
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Colleen Price
- Canadian HIV/AIDS and Chronic Pain Society, Ottawa, Ontario, Canada
| | | | - Curtis Cooper
- Department of Medicine, Division of Infectious Diseases, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sharon L Walmsley
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Neora Pick
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Melanie C M Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Cox
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Nadine Kronfli
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Alexandra de Pokomandy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Pierre Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | - Marina B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Giada Sebastiani
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Sebastiani G, Milic J, Kablawi D, Gioè C, Al Hinai AS, Lebouché B, Tsochatzis E, Finkel J, Ballesteros LR, Ramanakumar AV, Bhagani S, Benmassaoud A, Mazzola G, Cascio A, Guaraldi G. Fibroscan-Aspartate Aminotransferase Score Predicts Liver-Related Outcomes, but Not Extrahepatic Events, in a Multicenter Cohort of People With Human Immunodeficiency Virus. Clin Infect Dis 2023; 77:396-404. [PMID: 37013396 DOI: 10.1093/cid/ciad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is frequent in people with human immunodeficiency virus (PWH). The Fibroscan-aspartate aminotransferase (FAST) score was developed to identify patients with nonalcoholic steatohepatitis (NASH) and significant fibrosis. We investigated prevalence of NASH with fibrosis and the value of FAST score in predicting clinical outcomes in PWH. METHODS Transient elastography (Fibroscan) was performed in PWH without viral hepatitis coinfection from 4 prospective cohorts. We used FAST >0.35 to diagnose NASH with fibrosis. Incidence and predictors of liver-related outcomes (hepatic decompensation, hepatocellular carcinoma) and extrahepatic events (cancer, cardiovascular disease) were evaluated through survival analysis. RESULTS Of the 1472 PWH included, 8% had FAST >0.35. Higher body mass index (adjusted odds ratio [aOR], 1.21 [95% confidence interval {CI}, 1.14-1.29]), hypertension (aOR, 2.24 [95% CI, 1.16-4.34]), longer time since HIV diagnosis (aOR, 1.82 [95% CI, 1.20-2.76]), and detectable HIV RNA (aOR, 2.22 [95% CI, 1.02-4.85]) were associated with FAST >0.35. A total of 882 patients were followed for a median of 3.8 years (interquartile range, 2.5-4.2 years). Overall, 2.9% and 11.1% developed liver-related and extrahepatic outcomes, respectively. Incidence of liver-related outcomes was higher in patients with FAST >0.35 versus FAST ≤0.35 (45.1 [95% CI, 26.2-77.7] vs 5.0 [95% CI, 2.9-8.6] per 1000 person-years). FAST >0.35 remained an independent predictor of liver-related outcomes (adjusted hazard ratio, 4.97 [95% CI, 1.97-12.51]). Conversely, FAST did not predict extrahepatic events. CONCLUSIONS A significant proportion of PWH may have NASH with significant liver fibrosis. FAST score predicts liver-related outcomes and can help management of this high-risk population.
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Affiliation(s)
- Giada Sebastiani
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Chronic Viral Illness Service, Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Jovana Milic
- Modena HIV Metabolic Clinic, University of Modena and Reggio Emilia, Modena, Italy
| | - Dana Kablawi
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Claudia Gioè
- Infectious and Tropical Disease Unit, Azienda Ospedaliera Universitaria Policlinico "P. Giaccone," Palermo, Italy
| | - Al Shaima Al Hinai
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Bertrand Lebouché
- Chronic Viral Illness Service, Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Canada
| | - Emmanuel Tsochatzis
- Institute for Liver and Digestive Health, Division of Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jemima Finkel
- Institute for Liver and Digestive Health, Division of Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Luz Ramos Ballesteros
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | | | - Sanjay Bhagani
- Institute for Liver and Digestive Health, Division of Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Amine Benmassaoud
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Giovanni Mazzola
- Infectious Diseases Unit, Sant'Elia Hospital, Caltanissetta, Italy
| | - Antonio Cascio
- Infectious and Tropical Disease Unit, Azienda Ospedaliera Universitaria Policlinico "P. Giaccone," Palermo, Italy
- Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro," University of Palermo, Italy
| | - Giovanni Guaraldi
- Modena HIV Metabolic Clinic, University of Modena and Reggio Emilia, Modena, Italy
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Gawrieh S, Lake JE, Debroy P, Sjoquist JA, Robison M, Tann M, Akisik F, Bhamidipalli SS, Saha CK, Zachary K, Robbins GK, Gupta SK, Chung RT, Chalasani N, Corey KE. Burden of fatty liver and hepatic fibrosis in persons with HIV: A diverse cross-sectional US multicenter study. Hepatology 2023; 78:578-591. [PMID: 36805976 PMCID: PMC10496090 DOI: 10.1097/hep.0000000000000313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/02/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND AIMS The current prevalence of fatty liver disease (FLD) due to alcohol-associated (AFLD) and nonalcoholic (NAFLD) origins in US persons with HIV (PWH) is not well defined. We prospectively evaluated the burden of FLD and hepatic fibrosis in a diverse cohort of PWH. APPROACH RESULTS Consenting participants in outpatient HIV clinics in 3 centers in the US underwent detailed phenotyping, including liver ultrasound and vibration-controlled transient elastography for controlled attenuation parameter and liver stiffness measurement. The prevalence of AFLD, NAFLD, and clinically significant and advanced fibrosis was determined. Univariate and multivariate logistic regression models were used to evaluate factors associated with the risk of NAFLD. Of 342 participants, 95.6% were on antiretroviral therapy, 93.9% had adequate viral suppression, 48.7% (95% CI 43%-54%) had steatosis by ultrasound, and 50.6% (95% CI 45%-56%) had steatosis by controlled attenuation parameter ≥263 dB/m. NAFLD accounted for 90% of FLD. In multivariable analysis, old age, higher body mass index, diabetes, and higher alanine aminotransferase, but not antiretroviral therapy or CD4 + cell count, were independently associated with increased NAFLD risk. In all PWH with fatty liver, the frequency of liver stiffness measurement 8-12 kPa was 13.9% (95% CI 9%-20%) and ≥12 kPa 6.4% (95% CI 3%-11%), with a similar frequency of these liver stiffness measurement cutoffs in NAFLD. CONCLUSIONS Nearly half of the virally-suppressed PWH have FLD, 90% of which is due to NAFLD. A fifth of the PWH with FLD has clinically significant fibrosis, and 6% have advanced fibrosis. These data lend support to systematic screening for high-risk NAFLD in PWH.
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Affiliation(s)
- Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jordan E. Lake
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Paula Debroy
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Julia A. Sjoquist
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Montreca Robison
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Mark Tann
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN
| | - Fatih Akisik
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN
| | - Surya S. Bhamidipalli
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Chandan K. Saha
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Kimon Zachary
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gregory K. Robbins
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Samir K. Gupta
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Raymond T. Chung
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Kathleen E. Corey
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Kalligeros M, Vassilopoulos A, Shehadeh F, Vassilopoulos S, Lazaridou I, Mylonakis E, Promrat K, Wands JR. Prevalence and Characteristics of Nonalcoholic Fatty Liver Disease and Fibrosis in People Living With HIV Monoinfection: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2023; 21:1708-1722. [PMID: 36642292 DOI: 10.1016/j.cgh.2023.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/28/2022] [Accepted: 01/01/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Liver disease remains a leading cause of morbidity and mortality among people living with HIV (PLWH). Emerging data suggest that PLWH are at high risk for developing nonalcoholic fatty liver disease (NAFLD). The aim of this review is to examine the current literature and provide an accurate estimate of the prevalence of NAFLD, nonalcoholic steatohepatitis (NASH), and fibrosis, and identify potential risk factors for NAFLD in PLWH. METHODS We searched PubMed and Embase databases to identify studies reporting the prevalence of NAFLD and/or fibrosis in PLWH monoinfection. We performed a random effects meta-analysis of proportions to estimate the pooled prevalence of NAFLD, NASH, and fibrosis among PLWH monoinfection. We also examined potential risk factors for NAFLD by comparing characteristics of PLWH monoinfection with and without NAFLD. RESULTS A total of 43 studies, reporting data for 8230 patients, met our eligibility criteria and were included in the meta-analysis. Based on imaging studies the overall pooled prevalence of NAFLD and moderate liver fibrosis (METAVIR ≥ F2) among PLWH monoinfection was 33.9% (95% confidence interval [CI], 29.67%-38.39%), and 12.00% (95% CI, 10.02%-14.12%), respectively. Based on biopsy studies, prevalence of NASH and significant liver fibrosis (stage ≥F2 on histology) was 48.77% (95% CI, 34.30%-63.34%) and 23.34% (95% CI, 14.98%-32.75%), respectively. Traditional metabolic syndrome and HIV-related factors were associated with NAFLD in PLWH. CONCLUSIONS Our study confirms that the burden of NAFLD, NASH, and fibrosis is high among PLWH monoinfection. Prospective longitudinal studies are needed to delineate NAFLD, NASH, and fibrosis risk factors, and identify early interventions and new therapies for NAFLD in this population.
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Affiliation(s)
- Markos Kalligeros
- Division of Internal Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Athanasios Vassilopoulos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Fadi Shehadeh
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island; Department of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Stephanos Vassilopoulos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ingrid Lazaridou
- Division of Internal Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kittichai Promrat
- Division of Gastroenterology and Hepatology, Providence VA Medical Center, Providence, Rhode Island
| | - Jack R Wands
- Liver Research Center, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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9
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Alonso-Peña M, Del Barrio M, Peleteiro-Vigil A, Jimenez-Gonzalez C, Santos-Laso A, Arias-Loste MT, Iruzubieta P, Crespo J. Innovative Therapeutic Approaches in Non-Alcoholic Fatty Liver Disease: When Knowing Your Patient Is Key. Int J Mol Sci 2023; 24:10718. [PMID: 37445895 DOI: 10.3390/ijms241310718] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of disorders ranging from simple steatosis to non-alcoholic steatohepatitis (NASH). Hepatic steatosis may result from the dysfunction of multiple pathways and thus multiple molecular triggers involved in the disease have been described. The development of NASH entails the activation of inflammatory and fibrotic processes. Furthermore, NAFLD is also strongly associated with several extra-hepatic comorbidities, i.e., metabolic syndrome, type 2 diabetes mellitus, obesity, hypertension, cardiovascular disease and chronic kidney disease. Due to the heterogeneity of NAFLD presentations and the multifactorial etiology of the disease, clinical trials for NAFLD treatment are testing a wide range of interventions and drugs, with little success. Here, we propose a narrative review of the different phenotypic characteristics of NAFLD patients, whose disease may be triggered by different agents and driven along different pathophysiological pathways. Thus, correct phenotyping of NAFLD patients and personalized treatment is an innovative therapeutic approach that may lead to better therapeutic outcomes.
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Affiliation(s)
- Marta Alonso-Peña
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Maria Del Barrio
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Ana Peleteiro-Vigil
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Carolina Jimenez-Gonzalez
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Alvaro Santos-Laso
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Maria Teresa Arias-Loste
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Paula Iruzubieta
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
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10
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Larrey D, D'Erasmo L, O'Brien S, Arca M. Long-term hepatic safety of lomitapide in homozygous familial hypercholesterolaemia. Liver Int 2023; 43:413-423. [PMID: 36520008 PMCID: PMC10107656 DOI: 10.1111/liv.15497] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Lomitapide is a microsomal triglyceride transfer protein inhibitor for patients with homozygous familial hypercholesterolaemia. Due to its mechanism of action, potential hepatic effects of lomitapide are of clinical interest. This study aimed to determine the long-term hepatic safety of lomitapide. METHODS Data were aggregated from the pivotal phase 3 and extension phase clinical trial with lomitapide (median 5.1 years; serum total bilirubin, transaminases, cytokeratin-18 [CK-18] and enhanced liver fibrosis [ELF] score, fat-soluble vitamins and essential fatty acids), 8-year data from the Lomitapide Observational Worldwide Evaluation Registry (LOWER) and real-world evidence from a cohort of patients treated with lomitapide in Italy (hepatic elastography, and FIB-4 score for hepatic fibrosis). RESULTS In the phase 3 trial and the LOWER registry, any asymptomatic excursions in liver transaminase levels were not associated with elevations in bilirubin, and no Hy's law cases were detected in up to 8 years follow-up. There were no clinically relevant increases among hepatic biomarkers CK-18, CK-18 fragments or ELF score and fat-soluble vitamins and essential fatty acids remained above normal levels. In 34 patients treated in Italy with lomita pide for more than 9 years, elevations in hepatic fat were mild-to-moderate; hepatic stiffness remained normal, and the mean FIB-4 score remained below the fibrosis threshold value of 2.67. CONCLUSIONS These data indicate that the hepatic safety of lomitapide remains favourable with no clinically significant elevations in hepatic biomarkers and hepatic stiffness remained normal for more than 9 years follow-up. PHASE 3 TRIAL: NCT00730236; extension phase: NCT00943306; LOWER: NCT02135705.
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Affiliation(s)
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | | | - Marcello Arca
- Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
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11
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De A, Duseja A, Badhala P, Taneja S, Sharma A, Arora S. Indian patients with human immunodeficiency virus infection have high prevalence but mild severity of non-alcoholic fatty liver disease. Diabetes Metab Syndr 2022; 16:102679. [PMID: 36450180 DOI: 10.1016/j.dsx.2022.102679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS Antiretroviral therapy (ART) has substantially decreased AIDS-related mortality. Non-AIDS related diseases like chronic liver disease are becoming more frequent in people living with HIV-AIDS (PLHA). Non-alcoholic fatty live disease (NAFLD) is a common etiology of liver disease in the general population. Our aim was to analyse the prevalence and risk factors of NAFLD in Indian PLHA. METHODS One hundred consecutive adults (age:36.89 ± 10.4 years, males:65%) with HIV infection were prospectively enrolled. Patients with significant alcohol intake, Hepatitis B or Cco-infection, other liver disease, malignancy or HIV stage IV were excluded. Hepatic steatosis was assessed using hepatobiliary ultrasoundand controlled attenuation parameter (CAP). Fibrosis was assessed non-invasively using FIB-4, NAFLD fibrosis score (NFS) and liver stiffness measurement (LSM). Metabolic and HIV-related risk factors were compared between PLHA with and without NAFLD. RESULTS Prevalence of NAFLD using CAP was 60%. Among patients with NAFLD, 27 (45%) were lean. Majority had mild-moderate steatosis. Advanced fibrosis was present in 1 (1.67%) and 4 (6.67%) patients using NFS and LSM and none using FIB-4. PLHA with NAFLD were more likely to be overweight or obese (OR = 4.21,p = 0.002) with a higher proportion of abdominal obesity (OR:25.26,p = 0.001). Other metabolic comorbidities, duration of HIV infection, duration and type of ART, CD4-count or HIV-stagewere not significantly different among PLHA with or without NAFLD. CONCLUSION Prevalence of NAFLD among Indian PLHA is high although most have mild disease. Almost half of these patients are lean. HIV-related factors do not impact the risk of NAFLD.
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Affiliation(s)
- Arka De
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Prayas Badhala
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Arora
- Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Two-Tier Care Pathways for Liver Fibrosis Associated to Non-Alcoholic Fatty Liver Disease in HIV Mono-Infected Patients. J Pers Med 2022; 12:jpm12020282. [PMID: 35207770 PMCID: PMC8874585 DOI: 10.3390/jpm12020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/23/2022] [Accepted: 02/10/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: Developing strategies to identify significant liver fibrosis in people with HIV (PWH) is crucial to prevent complications of non-alcoholic fatty liver disease (NAFLD). We aim to investigate if five simple serum biomarkers applied to PWH can optimize a care pathway to identify significant liver fibrosis defined by transient elastography (TE). (2) Methods: A two-tier fibrosis pathway was applied to three prospective cohorts of PWH undergoing TE with CAP. NAFLD was diagnosed as a controlled attenuation parameter ≥ 248 dB/m. Five simple fibrosis biomarkers (FIB-4 < 1.3, BARD score 0–1, NAFLD fibrosis score < −1.455, AST:ALT ratio < 0.8 and APRI < 0.5) were applied as first-tiers to exclude significant liver fibrosis. We determined the decrease in referral for TE that would have occurred based on biomarker assessment and the discordance between low simple fibrosis biomarkers and high TE (≥7.1 kPa), indicating significant liver fibrosis. (3) Results: Of the 1749 consecutive PWH, 15.1% had significant liver fibrosis by TE and 39.1% had NAFLD. The application of the fibrosis biomarkers as first tiers would have resulted in a decrease in TE referrals between 24.9% (BARD score) and 86.3% (APRI). The lowest discordance rate was with NAFLD fibrosis score (8.5%). After adjustments, BMI (odds ratio (OR) 1.12, 95% CI: 1.08–1.17) and triglycerides (OR 1.26, 95% CI: 1.11–1.44) were independent predictors of discordance for APRI < 0.5 and TE ≥ 7.1. The performance of the two-tier pathways was similar in PWH with and without NAFLD. (4) Conclusions: Implementing a two-tier pathway could save a substantial proportion up of TE examinations, reducing costs and helping resource optimization in HIV care. Patients with metabolic risk factors for NAFLD and low fibrosis biomarker may still be considered for TE referral.
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13
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Lake JE, Overton T, Naggie S, Sulkowski M, Loomba R, Kleiner DE, Price JC, Chew KW, Chung RT, Corey KE. Expert Panel Review on Nonalcoholic Fatty Liver Disease in Persons With Human Immunodeficiency Virus. Clin Gastroenterol Hepatol 2022; 20:256-268. [PMID: 33069882 PMCID: PMC9069630 DOI: 10.1016/j.cgh.2020.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects 25% of adults in the general population and is a disease spectrum ranging from steatosis to nonalcoholic steatohepatitis (NASH) to end-stage liver disease. NAFLD is an independent risk factor for cardiovascular disease, diabetes mellitus, and all-cause mortality, and NASH cirrhosis is a frequent indication for liver transplantation. In persons with human immunodeficiency virus (PWH), chronic liver disease is the second leading cause of non-human immunodeficiency virus-related mortality. Between 20% and 63% of PWH have NASH, and 14% to 63% have NASH with fibrosis. However, little is known about the optimal diagnostic strategies, risk factors for, and treatment of NAFLD in PWH. Here, we review current data on and identify knowledge gaps in the epidemiology, pathophysiology, diagnosis, and management of NAFLD in PWH and highlight priorities for research.
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Affiliation(s)
- Jordan E Lake
- Division of Infectious Disease, University of Texas Health Sciences Center at Houston, Houston, Texas.
| | - Turner Overton
- Division of Infectious Disease, University of Alabama School of Medicine, Birmingham, Alabama
| | - Susanna Naggie
- Division of Infections Disease, Duke University School of Medicine, Durham, North Carolina
| | - Mark Sulkowski
- Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rohit Loomba
- Division of Gastroenterology, University of California San Diego School of Medicine, San Diego, California
| | - David E Kleiner
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Jennifer C Price
- Division of Gastroenterology, University of California San Francisco School of Medicine, San Francisco, California
| | - Kara W Chew
- Division of Infectious Diseases, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Raymond T Chung
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen E Corey
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Chang HH. Weight Gain and Metabolic Syndrome in Human Immunodeficiency Virus Patients. Infect Chemother 2022; 54:220-235. [PMID: 35706080 PMCID: PMC9259920 DOI: 10.3947/ic.2022.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/16/2022] [Indexed: 12/31/2022] Open
Abstract
While human immunodeficiency virus (HIV)-associated wasting has declined with significant advances in antiretroviral therapy (ART), weight gain and metabolic syndrome (MetS) are now becoming a problem for people living with HIV (PLWH) worldwide. The development of a new and more effective ART regimen has increased viral suppression and improved immunologic function recovery, leading to the extension of the lifespan of PLWH. It has recently been reported as one of the significant factors associated with weight gain, obesity, and long-term metabolic consequences in PLWH. This article reviewed the epidemiology of overweight and MetS among PLWH and the known risk factors for weight gain and its major comorbidities, such as dyslipidemia, diabetes mellitus, cardiovascular diseases, neurocognitive disorders, and liver diseases, in PLWH. In addition, reports on the pharmacological and surgical management of overweight and obesity in PLWH has been briefly summarized.
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Affiliation(s)
- Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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15
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Alhinai A, Qayyum-Khan A, Zhang X, Samaha P, Metrakos P, Deschenes M, Wong P, Ghali P, Chen TY, Sebastiani G. Non-alcoholic steatohepatitis in liver transplant recipients diagnosed by serum cytokeratin 18 and transient elastography: A prospective study. World J Hepatol 2021; 13:2179-2191. [PMID: 35070018 PMCID: PMC8727200 DOI: 10.4254/wjh.v13.i12.2179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/25/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) seem common after liver transplantation.
AIM To investigate incidence and predictors of NAFLD and NASH by employing noninvasive testing in liver transplant recipients, namely controlled attenuation parameter (CAP) and the serum biomarker cytokeratin 18 (CK-18). We also evaluated the diagnostic accuracy of CK-18 and CAP compared to liver histology.
METHODS We prospectively recruited consecutive adult patients who received liver transplant at the McGill University Health Centre between 2015-2018. Serial measurements of CK-18 and CAP were recorded. NAFLD and NASH were diagnosed by CAP ≥ 270 dB/m, and a combination of CAP ≥ 270 dB/m with CK-18 > 130.5 U/L, respectively. Incidences and predictors of NAFLD and NASH were investigated using survival analysis and Cox proportional hazards.
RESULTS Overall, 40 liver transplant recipients (mean age 57 years; 70% males) were included. During a median follow-up of 16.8 mo (interquartile range 15.6-18.0), 63.0% and 48.5% of patients developed NAFLD and NASH, respectively. On multivariable analysis, after adjusting for sex and alanine aminotransferase, body mass index was an independent predictor of development of NAFLD [adjusted hazard ratio (aHR): 1.21, 95% confidence interval (CI): 1.04-1.41; P = 0.01] and NASH (aHR: 1.26, 95%CI: 1.06-1.49; P < 0.01). Compared to liver histology, CAP had a 76% accuracy to diagnose NAFLD, while the accuracy of CAP plus CK-18 to diagnose NASH was 82%.
CONCLUSION NAFLD and NASH diagnosed non-invasively are frequent in liver transplant recipients within the first 18 mo. Close follow-up and nutritional counselling should be planned in overweight patients.
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Affiliation(s)
- Alshaima Alhinai
- Experimental Medicine, McGill University, Montreal H4A3J1, Canada
| | | | - Xun Zhang
- Departments of Pediatrics and Epidemiology, McGill University, Montreal H4A3J1, Canada
| | - Patrick Samaha
- Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Peter Metrakos
- Cancer Research Program, The Research Institute of McGill University and The Research Institute of McGill University Health Center, Montreal H4A3J1, Canada
| | - Marc Deschenes
- Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Philip Wong
- Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Peter Ghali
- Medicine, University of Florida, Jacksonville, Florida 32218, United States
| | - Tian-Yan Chen
- Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Giada Sebastiani
- Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
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16
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Cervo A, Milic J, Mazzola G, Schepis F, Petta S, Krahn T, Lebouche B, Deschenes M, Cascio A, Guaraldi G, Sebastiani G. Prevalence, Predictors, and Severity of Lean Nonalcoholic Fatty Liver Disease in Patients Living With Human Immunodeficiency Virus. Clin Infect Dis 2021; 71:e694-e701. [PMID: 32280969 DOI: 10.1093/cid/ciaa430] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The burden of nonalcoholic fatty liver disease (NAFLD) is growing in people living with human immunodeficiency virus (HIV). NAFLD is associated with obesity; however, it can occur in normoweight (lean) patients. We aimed to investigate lean NAFLD in patients living with HIV. METHODS We included patients living with HIV mono-infection from 3 prospective cohorts. NAFLD was diagnosed by transient elastography (TE) and defined as controlled attenuation parameter ≥248 dB/m, in absence of alcohol abuse. Lean NAFLD was defined when a body mass index was <25 kg/m2. Significant liver fibrosis was defined as TE ≥7.1 kPa. The presence of diabetes, hypertension, or hyperlipidemia defined metabolically abnormal patients. RESULTS We included 1511 patients, of whom 57.4% were lean. The prevalence of lean NAFLD patients in the whole cohort was 13.9%. NAFLD affected 24.2% of lean patients. The proportions of lean NAFLD patients who were metabolically abnormal or had elevated alanine aminotransferase (ALT) were higher than among those who were lean patients without NAFLD (61.9% vs 48.9% and 36.7% vs 24.2%, respectively). Lean NAFLD patients had a higher prevalence of significant liver fibrosis than lean patients without NAFLD (15.7% vs 7.6%, respectively). After adjusting for sex, ethnicity, hypertension, CD4 cell count, nadir CD4 <200µ/L, and time since HIV diagnosis, predictors of NAFLD in lean patients were age (adjusted OR [aOR], 1.29; 95% confidence interval [CI], 1.04-1.59), high triglycerides (aOR, 1.34; 95% CI, 1.11-1.63), and high ALT (aOR, 1.15; 95% CI, 1.05-1.26), while a high level of high-density lipoprotein cholesterol was protective (aOR, 0.45; 95% CI, .26-.77). CONCLUSIONS NAFLD affects 1 in 4 lean patients living with HIV mono-infection. Investigations for NAFLD should be proposed in older patients with dyslipidemia and elevated ALT, even if normoweight.
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Affiliation(s)
- Adriana Cervo
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada.,Infectious Diseases Unit, Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro" (PROMISE), University of Palermo, Palermo, Italy
| | - Jovana Milic
- Infectious Diseases Clinic, University of Modena and Reggio Emilia, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Mazzola
- Infectious Diseases Unit, Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro" (PROMISE), University of Palermo, Palermo, Italy
| | - Filippo Schepis
- Hepatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Salvatore Petta
- Gastroenterology and Hepatology Service, Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro" (PROMISE), University of Palermo, Palermo, Italy
| | - Thomas Krahn
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
| | - Bertrand Lebouche
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada.,Department of Family Medicine, McGill University, Montreal, Canada
| | - Marc Deschenes
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
| | - Antonio Cascio
- Infectious Diseases Unit, Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro" (PROMISE), University of Palermo, Palermo, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Clinic, University of Modena and Reggio Emilia, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Sebastiani
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada.,Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
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17
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Abstract
PURPOSE OF REVIEW Aging-related comorbidities, including liver disease, represent the main drivers of morbidity and mortality in people with HIV (PWH). Nonalcoholic fatty liver disease (NAFLD) seems a frequent comorbidity in aging PWH nowadays. NAFLD results from a fat deposition into the liver parenchyma that may evolve to nonalcoholic steatohepatitis (NASH), a state of hepatocellular inflammation and injury in response to the accumulated fat leading to liver fibrosis and cirrhosis. We here review the current status of knowledge regarding this emerging comorbidity in PWH. RECENT FINDINGS Recent studies suggest that PWH are at higher risk for both NASH and NASH-related liver fibrosis. Several hypothesized pathogenic mechanisms may account for this finding, including increased metabolic comorbidities, hepatotoxic effect of lifelong antiretroviral therapy, and chronic HIV infection. In clinical practice, non-invasive diagnostic tests, such as serum biomarkers and elastography, may help identify patients with NASH-related fibrosis, thus improving risk stratification, and enhancing clinical management decisions, including early initiation of interventions such as lifestyle changes and potential pharmacologic interventions. Clinicians should remain informed of the frequency, significance, and diagnostic and management approach to NASH in PWH.
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Affiliation(s)
- Adriana Cervo
- Division of Infectious Diseases, Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
- Department of Health Promotion Sciences and Mother and Child Care "Giuseppe D'Alessandro", University of Palermo, Palermo, Italy
| | - Mohamed Shengir
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Keyur Patel
- Division of Gastroenterology, University Health Network Toronto, Toronto General Hospital, Toronto, Canada
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, Chronic Viral Illness Service Royal Victoria Hospital, McGill University Health Centre, 1001 Blvd. Décarie, Montreal, QC H4A 3J1, Canada.
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18
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Amponsah-Dacosta E, Tchuem CT, Anderson M. Chronic hepatitis B-associated liver disease in the context of human immunodeficiency virus co-infection and underlying metabolic syndrome. World J Virol 2020; 9:54-66. [PMID: 33362998 PMCID: PMC7747023 DOI: 10.5501/wjv.v9.i5.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
Globally, a shift in the epidemiology of chronic liver disease has been observed. This has been mainly driven by a marked decline in the prevalence of chronic hepatitis B virus infection (CHB), with the greatest burden restricted to the Western Pacific and sub-Saharan African regions. Amidst this is a growing burden of metabolic syndrome (MetS) worldwide. A disproportionate co-burden of human immunodeficiency virus (HIV) infection is also reported in sub-Saharan Africa, which poses a further risk of liver-related morbidity and mortality in the region. We reviewed the existing evidence base to improve current understanding of the effect of underlying MetS on the development and progression of chronic liver disease during CHB and HIV co-infection. While the mechanistic association between CHB and MetS remains poorly resolved, the evidence suggests that MetS may have an additive effect on the liver damage caused by CHB. Among HIV infected individuals, MetS-associated liver disease is emerging as an important cause of non-AIDS related morbidity and mortality despite antiretroviral therapy (ART). It is plausible that underlying MetS may lead to adverse outcomes among those with concomitant CHB and HIV co-infection. However, this remains to be explored through rigorous longitudinal studies, especially in sub-Saharan Africa. Ultimately, there is a need for a comprehensive package of care that integrates ART programs with routine screening for MetS and promotion of lifestyle modification to ensure an improved quality of life among CHB and HIV co-infected individuals.
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Affiliation(s)
- Edina Amponsah-Dacosta
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, Western Cape, South Africa
| | - Cynthia Tamandjou Tchuem
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, Western Cape, South Africa
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Shengir M, Krishnamurthy S, Ghali P, Deschenes M, Wong P, Chen T, Sebastiani G. Prevalence and predictors of nonalcoholic fatty liver disease in South Asian women with polycystic ovary syndrome. World J Gastroenterol 2020; 26:7046-7060. [PMID: 33311949 PMCID: PMC7701948 DOI: 10.3748/wjg.v26.i44.7046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/30/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polycystic ovary disease (PCOS) may be a risk factor for nonalcoholic fatty liver disease (NAFLD) due to common pathogenetic pathways, including insulin resistance and obesity. Both PCOS and NAFLD are more severe in South Asian women. Data on NAFLD in South Asian women with PCOS are lacking.
AIM To investigate prevalence and predictors of NAFLD and liver fibrosis in PCOS patients from South Asia.
METHODS We conducted an observational routine screening program by means of transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD was defined as CAP ≥ 288 decibels per meter. Significant liver fibrosis (stage 2 and higher out of 4) was defined as TE measurement ≥ 8.0 kilopascals. Elevated alanine aminotransferase (ALT) was defined as ALT > 24 IU/L, as per upper limit of normal reported in South Asian women. Biochemical hyperandrogenism was defined as free androgen index > 5. Predictors of NAFLD were determined by logistic regression analysis.
RESULTS 101 PCOS patients (mean age 36.3 years) with no significant alcohol intake or viral hepatitis were included. Prevalence of NAFLD and significant liver fibrosis was 39.6% and 6.9%, respectively. Elevated ALT was observed in 40% and 11.5% of patients with and without NAFLD, respectively. After adjusting for duration of PCOS and insulin resistance measured by homeostasis model for assessment of insulin resistance, independent predictors of NAFLD were higher body mass index [adjusted odds ratio (aOR) 1.30, 95% confidence interval (CI): 1.13-1.52], hyperandrogenism (aOR: 5.32, 95%CI: 1.56-18.17) and elevated ALT (aOR: 3.54, 95%CI: 1.10-11.47). Lifetime cardiovascular risk was higher in patients with NAFLD compared to those without NAFLD (0.31 ± 0.11 vs 0.26 ± 0.13).
CONCLUSION Despite their young age, NAFLD diagnosed by TE with CAP is a frequent comorbidity in South Asian women with PCOS and is strongly associated with higher body mass index and hyperandrogenism. Non-invasive screening strategies could help early diagnosis and initiation of interventions, including counselling on weight loss, cardiovascular risk stratification and linkage to hepatology care where appropriate.
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Affiliation(s)
- Mohamed Shengir
- Department of Experimental Medicine, McGill University, Montreal H4A3J1, Canada
| | - Srinivasan Krishnamurthy
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Peter Ghali
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Marc Deschenes
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Philip Wong
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Tianyan Chen
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
| | - Giada Sebastiani
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, Canada
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20
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Benmassaoud A, Nitulescu R, Pembroke T, Halme AS, Ghali P, Deschenes M, Wong P, Klein MB, Sebastiani G. Liver-related Events in Human Immunodeficiency Virus-infected Persons With Occult Cirrhosis. Clin Infect Dis 2020; 69:1422-1430. [PMID: 30561558 DOI: 10.1093/cid/ciy1082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/14/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected patients are at increased risk of liver-related mortality. The effect of occult cirrhosis (OcC), defined as preclinical compensated cirrhosis without any clinical findings, on liver-related events is unknown. METHODS HIV-infected patients from 2 Canadian cohorts underwent transient elastography (TE) examination and were classified as (1) OcC (TE ≥13 kPa with no sign of cirrhosis, including absence of thrombocytopenia and signs of advanced liver disease on ultrasound or gastroscopy); (2) overt cirrhosis (OvC) (TE ≥13 kPa with signs of cirrhosis); or (3) noncirrhotic patients (TE <13 kPa). Incidence and risk factors of liver-related events were investigated through Kaplan-Meier and Cox regression analyses, respectively. We estimated monitoring rates according to screening guidelines for hepatocellular carcinoma (HCC) by OcC and OvC status. RESULTS A total of 1092 HIV-infected patients (51% coinfected with hepatitis C virus) were included. Prevalence of OcC and OvC at baseline was 2.7% and 10.7%, respectively. During a median follow-up of 1.8 (interquartile range, 1.5-2.8) years, the incidence of liver-related events in noncirrhosis, OcC, and OvC was 3.4 (95% confidence interval [CI], 1.2-7.3), 34.0 (95% CI, 6.0-104.0), and 37.0 (95% CI, 17.0-69.1) per 1000 person-years, respectively. Baseline OcC (adjusted hazard ratio [aHR], 7.1 [95% CI, 1.3-38.0]) and OvC (aHR, 8.5 [95% CI, 2.8-26.0]) were independently associated with liver-related events. Monitoring rates for HCC were lower in patients with OcC (24%) compared to those with OvC (40%). CONCLUSIONS HIV-infected patients with OcC have a high incidence of liver-related events. Greater surveillance and earlier recognition with appropriate screening strategies are necessary for improved outcomes.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital
| | - Roy Nitulescu
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
| | - Thomas Pembroke
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital.,Department of Infection and Immunity, Cardiff University, United Kingdom
| | - Alex S Halme
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital
| | - Peter Ghali
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital
| | - Marc Deschenes
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital
| | - Philip Wong
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital
| | - Marina B Klein
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital.,Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
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21
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Benmassaoud A, Deschenes M, Chen T, Ghali P, Sebastiani G. Optimizing patients with non-alcoholic fatty liver disease pre-transplant. CANADIAN LIVER JOURNAL 2020; 3:237-250. [PMID: 35992526 PMCID: PMC9202706 DOI: 10.3138/canlivj-2019-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/17/2019] [Indexed: 06/01/2024]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in Western countries. Non-alcoholic steatohepatitis (NASH), which is the progressive counterpart of the disease, is becoming the leading indication for liver transplantation in North America. Owing to the lack of symptoms, NASH is often an incidental diagnosis, resulting in a significant proportion of patients being diagnosed when advanced liver disease has already developed. NAFLD has recently been characterized as the hepatic manifestation of metabolic syndrome. Consequently, it is a multisystem disease that often co-exists with several other conditions, such as obesity, diabetes, cardiovascular diseases, and extra-hepatic malignancy, which have an impact on selection of transplant recipients. The complexity of diagnostic approach, need for multidisciplinary clinical management, and lack of a specific treatment further complicate the picture of this extremely prevalent liver condition. NAFLD patients with advanced liver disease should be considered for early referral to liver transplant clinics for careful metabolic and cardiovascular risk stratification because they have worse survival rates after liver transplantation than other patients with chronic liver disease. Early referral will also facilitate optimization of metabolic comorbidities before proceeding with transplantation. This review provides an overview of strategies to identify patients with advanced NAFLD, with an emphasis on the management of associated comorbidities and optimal timing of pre-transplant evaluation. Other topics that have been shown to affect recipient optimization, such as the role of lifestyle changes and bariatric surgery in the management of obesity, as well as sarcopenia in decompensated NASH-related cirrhosis, are addressed.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Deschenes
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tianyan Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter Ghali
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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22
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Guaraldi G, Maurice JB, Marzolini C, Monteith K, Milic J, Tsochatzis E, Bhagani S, Morse CG, Price JC, Ingiliz P, Lemoine M, Sebastiani G. New Drugs for NASH and HIV Infection: Great Expectations for a Great Need. Hepatology 2020; 71:1831-1844. [PMID: 32052857 DOI: 10.1002/hep.31177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022]
Abstract
In recent years, there has been an increasing number of clinical trials for the treatment of nonalcoholic steatohepatitis (NASH). People living with human immunodeficiency virus (PLWH) are commonly excluded from these studies, usually due to concerns over drug-drug interactions associated with antiretroviral therapy. The Steatohepatitis in HIV Emerging Research Network, a group of international experts in hepatology and infectious diseases, discusses our current understanding on the interaction between human immunodeficiency virus and NASH, and the issues related to the inclusion of PLWH in NASH clinical trials. Recent trials addressing NASH treatment in PLWH are discussed. The risk of drug-drug interactions between antiretroviral therapy and aramchol, cenicriviroc, elafibranor, obeticholic acid and resmetirom (MGL-3196), which are currently in phase 3 trials for the treatment of NASH, are reviewed. A model for trial design to include PLWH is proposed, strongly advocating for the scientific community to include this group as a subpopulation within studies.
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Affiliation(s)
- Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - James B Maurice
- Hepatology Unit, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Catia Marzolini
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Kenneth Monteith
- Coalition des Organismes Communautaires Québécois de Lutte Contre le Sida, Montréal, QC, Canada
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, University College London, London, United Kingdom
| | - Sanjay Bhagani
- Royal Free London, NHS Foundation Trust, London, United Kingdom
| | - Caryn G Morse
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Jennifer C Price
- Department of Medicine, University of California, San Francisco, CA
| | - Patrick Ingiliz
- Center for Infectiology, Berlin, Germany.,Department of Gastroenterology and Hepatology, Charité University Medical Center, Berlin, Germany
| | - Maud Lemoine
- Department of Surgery and Cancer, Liver Unit, St Mary's Hospital, Imperial College London, London, United Kingdom
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital - Site Glen, Montréal, QC, Canada.,Division of Infectious Diseases, McGill University Health Center, Royal Victoria Hospital-Site Glen, Montréal, QC, Canada
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23
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Vitamin E is an effective treatment for nonalcoholic steatohepatitis in HIV mono-infected patients. AIDS 2020; 34:237-244. [PMID: 31651429 DOI: 10.1097/qad.0000000000002412] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE HIV-infected patients are at increased risk of nonalcoholic steatohepatitis (NASH). Vitamin E is recommended for treatment of NASH in the general population. However, its safety and efficacy among HIV-infected patients remain unknown. DESIGN Single-centre, phase IV, open-label, single arm clinical trial. METHODS HIV mono-infected patients without significant alcohol intake or viral hepatitis coinfection were included. The diagnosis of NASH was based on the co-existence of fatty liver, diagnosed by controlled attenuation parameter (CAP) at least 248 dB/m and significant hepatocyte apoptosis, defined by the serum biomarker cytokeratin 18 (CK-18) greater than 130.5 U/L. Participants were treated with 800 IU daily of oral vitamin E (alpha-tocopherol) for 24 weeks, and followed for an additional 24 weeks postdiscontinuation. Generalized linear mixed effects models were used to evaluate changes in alanine aminotransferase (ALT), CAP and CK-18 at the completion of treatment and end of follow-up, controlling for pretreatment trends. RESULTS A total of 27 patients were included. Four (15%) had a pretreatment liver biopsy, which confirmed the diagnosis of NASH in all cases. Compared with baseline, 24 weeks of vitamin E treatment improved ALT [-27 units/l; 95% confidence interval (CI) -37 to -17], CAP scores (-22 dB/m; 95% CI -42 to -1) and CK-18 (-123 units/l; 95% CI -201 to -46). Conversely, there was no change in BMI. No serious adverse event was reported and no patient was lost to follow-up. CONCLUSION In this first clinical trial, we showed that vitamin E is an effective and well tolerated treatment for NASH in HIV-infected patients.
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24
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Vitamin E as a 'bridge' therapy for nonalcoholic steatohepatits in HIV: what is waiting on the other side of the bridge? AIDS 2020; 34:317-319. [PMID: 31876593 DOI: 10.1097/qad.0000000000002413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Diagnostic Accuracy of Noninvasive Markers of Steatosis, NASH, and Liver Fibrosis in HIV-Monoinfected Individuals at Risk of Nonalcoholic Fatty Liver Disease (NAFLD): Results From the ECHAM Study. J Acquir Immune Defic Syndr 2019; 80:e86-e94. [PMID: 30570529 DOI: 10.1097/qai.0000000000001936] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND HIV-monoinfected individuals are at high risk of nonalcoholic fatty liver disease. Noninvasive tests of steatosis, nonalcoholic steatohepatitis (NASH), and fibrosis have been poorly assessed in this population. Using liver biopsy (LB) as a reference, we assessed the accuracy of noninvasive methods for their respective diagnosis: magnetic resonance imaging proton-density-fat-fraction (MRI-PDFF), FibroScan/controlled attenuation parameter (CAP), and biochemical tests. METHODS We enrolled antiretroviral therapy-controlled participants with persistently elevated transaminases and/or metabolic syndrome, and/or lipodystrophy. All had hepatic MRI-PDFF, FibroScan/CAP, FibroTest/NashTest/SteatoTest, APRI, FIB-4, and nonalcoholic fatty liver disease-fibrosis score. A LB was indicated if suspected significant fibrosis (FibroScan ≥7.1 kPa and/or FibroTest ≥0.49). Performance was considered as good if area under a receiver operating characteristic curves (AUROCs) was >0.80. RESULTS Among the 140 patients with suspected significant fibrosis out of the 402 eligible patients, 49 had had a LB: median age of 54 years (53-65), body mass index: 26 kg/m (24-30), steatosis in 37 (76%), NASH in 23 (47%), and fibrosis in 31 (63%) patients [F2: 7 (14%); F3: 6 (12%); and F4: 2 (4%)]. Regarding steatosis, MRI-PDFF had excellent and CAP good performances with AUROCs at 0.98 (95% confidence interval: 0.96 to 1.00) and 0.88 (0.76 to 0.99), respectively, whereas the AUROCs of SteatoTest was 0.68 (0.51 to 0.85). Regarding fibrosis (≥F2), APRI and FIB-4 had good performance with AUROCs at 0.86 (0.74 to 0.98) and 0.81 (0.67 to 0.95). By contrast, FibroScan and FibroTest had poor AUROCs [0.61 (0.43 to 0.79) and 0.61 (0.44 to 0.78)], with very low specificity. Regarding NASH, alanine aminotransferase ≥36 IU/L had good performance with AUROCs of 0.83 (0.71 to 0.94), whereas the NashTest had an AUROC of 0.60 (0.44 to 0.76). CONCLUSIONS In HIV-monoinfected patients, MRI-PDFF and FibroScan/CAP are highly accurate for the diagnosis of steatosis. The alanine aminotransferase level and APRI should be considered for the detection of NASH and fibrosis.
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Morrison M, Hughes HY, Naggie S, Syn WK. Nonalcoholic Fatty Liver Disease Among Individuals with HIV Mono-infection: A Growing Concern? Dig Dis Sci 2019; 64:3394-3401. [PMID: 31643035 DOI: 10.1007/s10620-019-05861-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Liver disease is a leading cause of non-AIDS-related death in the HIV population since the introduction of highly active antiretroviral treatment (HAART). Recent studies suggest that patients with HIV are at high risk for nonalcoholic fatty liver disease (NAFLD) and progressive liver fibrosis. Evidence for the prevalence, risk factors, and diagnostic methodologies of NAFLD in patients with HIV mono-infection is summarized here. RECENT FINDINGS Although limited, published studies suggest that the prevalence of NAFLD is higher (30-50%) and progresses at an increased rate in patients with HIV compared to the general population. Identifying those at risk for significant liver fibrosis is critical, preferably with non-invasive screening tests. While there is a paucity of evidence in this population, transient elastography (TE) appears to provide a sensitive, non-invasive screening modality. Identifying NAFLD early will allow for dietary and lifestyle interventions, as well as future drug therapies to decrease the risk of progressive liver fibrosis and cirrhosis in the high-risk HIV population. Clinicians should be aware of this risk and consider using TE for NAFLD diagnosis and surveillance.
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Affiliation(s)
- Margaret Morrison
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Heather Y Hughes
- Section of Infectious Diseases, Department of Medicine, Ralph H. Johnson VAMC, Charleston, SC, USA
- Divison of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Susanna Naggie
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Durham VAMC, Durham, NC, USA
| | - Wing-Kin Syn
- Section of Gastroenterology and Hepatology, Ralph H. Johnson VAMC, Charleston, SC, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
- Department of Physiology, Faculty of Medicine and Nursing, University of Basque Country UPV/EHU, Leioa, Spain.
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Sebastiani G, Cocciolillo S, Mazzola G, Malagoli A, Falutz J, Cervo A, Petta S, Pembroke T, Ghali P, Besutti G, Franconi I, Milic J, Cascio A, Guaraldi G. Application of guidelines for the management of nonalcoholic fatty liver disease in three prospective cohorts of HIV-monoinfected patients. HIV Med 2019; 21:96-108. [PMID: 31642599 DOI: 10.1111/hiv.12799] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Current guidelines recommend use of a diagnostic algorithm to assess disease severity in cases of suspected nonalcoholic fatty liver disease (NAFLD). We applied this algorithm to HIV-monoinfected patients. METHODS We analysed three prospective screening programmes for NAFLD carried out in the following cohorts: the Liver Disease in HIV (LIVEHIV) cohort in Montreal, the Modena HIV Metabolic Clinic (MHMC) cohort and the Liver Pathologies in HIV in Palermo (LHivPa) cohort. In the LIVEHIV and LHivPa cohorts, NAFLD was diagnosed if the controlled attenuation parameter (CAP) was ≥ 248 dB/m; in the MHMC cohort, it was diagnosed if the liver/spleen Hounsfield unit (HU) ratio on abdominal computerized tomography scan was < 1.1. Medium/high-risk fibrosis category was defined as fibrosis-4 (FIB-4) ≥ 1.30. Patients requiring specialist referral to hepatology were defined as either having NAFLD and being in the medium/high-risk fibrosis category or having elevated alanine aminotransferase (ALT). RESULTS A total of 1534 HIV-infected adults without significant alcohol intake or viral hepatitis coinfection were included in the study. Of these, 313 (20.4%) patients had the metabolic comorbidities (obesity and/or diabetes) required for entry in the diagnostic algorithm. Among these patients, 123 (39.3%) required specialist referral to hepatology, according to guidelines. A total of 1062 patients with extended metabolic comorbidities (any among obesity, diabetes, hypertension and dyslipidaemia) represented most of the cases of NAFLD (79%), elevated ALT (75.9%) and medium/high-risk fibrosis category (75.4%). When the algorithm was extended to these patients, it was found that 341 (32.1%) would require specialist referral to hepatology. CONCLUSIONS According to current guidelines, one in five HIV-monoinfected patients should undergo detailed assessment for NAFLD and disease severity. Moreover, one in ten should be referred to hepatology. Expansion of the algorithm to patients with any metabolic comorbidities may be considered.
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Affiliation(s)
- G Sebastiani
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada.,Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada
| | - S Cocciolillo
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - G Mazzola
- Department of Health Promotion Sciences and Mother and Child Care 'Giuseppe D'Alessandro', University of Palermo, Palermo, Italy
| | - A Malagoli
- University of Modena and Reggio Emilia, Modena, Italy
| | - J Falutz
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada
| | - A Cervo
- Department of Health Promotion Sciences and Mother and Child Care 'Giuseppe D'Alessandro', University of Palermo, Palermo, Italy
| | - S Petta
- Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - T Pembroke
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada.,School of Medicine, Cardiff University, Cardiff, UK
| | - P Ghali
- Division of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - G Besutti
- Department of Imaging and Laboratory Medicine, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - I Franconi
- University of Modena and Reggio Emilia, Modena, Italy
| | - J Milic
- University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - A Cascio
- Department of Health Promotion Sciences and Mother and Child Care 'Giuseppe D'Alessandro', University of Palermo, Palermo, Italy
| | - G Guaraldi
- University of Modena and Reggio Emilia, Modena, Italy.,University Hospital of Modena, Modena, Italy
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Abstract
: Elevation of liver transaminases is common in patients infected with the HIV. Although this is usually an incidental finding during regular work-up, HIV-infected patients with transaminase elevations require additional visits for laboratory studies and clinical assessments, and often undergo interruptions and changes in antiretroviral therapy (ART). Alanine aminotransferase is present primarily in the liver, thus being a surrogate marker of hepatocellular injury. Aspartate aminotransferase is present in the liver and other organs, namely cardiac and skeletal muscle, kidney and brain. Serum levels of both liver transaminases predict liver-related mortality. Moreover, serum fibrosis biomarkers based on alanine aminotransferase and aspartate aminotransferase predict all-cause mortality. In a busy clinical setting, a diagnostic approach to elevated liver transaminases could be complicated given the frequency and nonspecificity of this finding. Indeed, HIV-infected individuals present multiple risk factors for liver damage and chronic elevation of transaminases, including coinfection with hepatitis B and C viruses, alcohol abuse, hepatotoxicity due to ART, HIV itself and frequent metabolic comorbidities leading to nonalcoholic fatty liver disease. This review provides an update on epidemiology of elevated liver transaminases, summarizes the main etiologic contributors and discusses the prognostic significance and a pragmatic approach to this frequent finding in the clinical practice of HIV medicine. With the aging of the HIV-infected population following the successful implementation of ART in Western countries, liver-related conditions are now a major comorbidity in this setting. As such, clinicians should be aware of the frequency, clinical significance and diagnostic approach to elevated liver transaminases.
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30
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Monocyte-macrophage activation is associated with nonalcoholic fatty liver disease and liver fibrosis in HIV monoinfection independently of the gut microbiome and bacterial translocation. AIDS 2019; 33:805-814. [PMID: 30882489 DOI: 10.1097/qad.0000000000002133] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is common among people living with HIV. There are limited data available on the pathophysiology of NAFLD and the development of fibrosis in this population. OBJECTIVES The aim of this study was to investigate the association of bacterial translocation, adipose tissue dysfunction, monocyte activation and gut dysbiosis in patients with HIV monoinfection and NAFLD. METHODS Cases with biopsy-proven NAFLD and HIV monoinfection were age and sex-matched to HIV-positive and HIV-negative controls. Markers of bacterial translocation [lipopolysaccharide-binding protein (LBP), bacterial DNA and lipopolysaccharide (LPS)], adipose tissue dysfunction (leptin, adiponectin) and monocyte activation (sCD14 and sCD163) were measured by ELISA. Hepatic patterns of macrophage activation were explored with immunohistochemistry. 16 s rRNA sequencing was performed with stool. RESULTS Thirty-three cases were included (≥F2 fibrosis n = 16), matched to HIV-positive (n = 29) and HIV-negative (n = 17) controls. Cases with NAFLD were more obese (BMI 31.0 ± 4.4 vs. 24.1 ± 2.8 kg/m, P < 0.001) and had significantly increased levels of sCD14, sCD163 and higher leptin to adiponectin ratio vs. HIV-positive controls. Cases with ≥F2 verses < F2 fibrosis had increased sCD14 (1.4 ± 0.4 vs. 1.1 ± 0.3 μg/ml, P = 0.023) and sCD163 (1.0 ± 0.3 vs. 0.8 ± 0.3 μg/ml, P = 0.060), which correlated with waist circumference (sCD14 P = 0.022, sCD163 P = 0.011). Immunohistochemistry showed increased hepatic portal macrophage clusters in patients with fibrosis. No markers of bacterial translocation or changes to the microbiome were associated with NAFLD or fibrosis. CONCLUSION NAFLD fibrosis stage in HIV monoinfected patients is associated with monocyte activation in the context of obesity, which may be independent of bacterial translocation and gut microbiome.
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Ganesan M, Poluektova LY, Kharbanda KK, Osna NA. Liver as a target of human immunodeficiency virus infection. World J Gastroenterol 2018; 24:4728-4737. [PMID: 30479460 PMCID: PMC6235802 DOI: 10.3748/wjg.v24.i42.4728] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/10/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023] Open
Abstract
Liver injury is a characteristic feature of human immunodeficiency virus (HIV) infection, which is the second most common cause of mortality in HIV-infected patients. Now it is recognized that liver plays a key role in HIV infection pathogenesis. Antiretroviral therapy (ART), which suppresses HIV infection in permissive immune cells, is less effective in hepatocytes, thereby making these cells a silent reservoir of HIV infection. In addition to direct hepatotoxic effects of HIV, certain ART treatment modalities provide hepatotoxic effects. The exact mechanisms of HIV-triggered chronic hepatitis progression are not elucidated, but the liver is adversely affected by HIV-infection and liver cells are prominently involved in HIV-elicited injury. These effects are potentiated by second hits like alcohol. Here, we will focus on the incidence of HIV, clinical evidence of HIV-related liver damage, interactions between HIV and liver cells and the role of alcohol and co-infection with hepatotropic viruses in liver inflammation and fibrosis progression.
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Affiliation(s)
- Murali Ganesan
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, United States
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68105, United States
| | - Larisa Y Poluektova
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Kusum K Kharbanda
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, United States
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68105, United States
| | - Natalia A Osna
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, United States
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68105, United States
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