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  IAS 2017: Conference on HIV Pathogenesis
Treatment and Prevention
Paris, France
July 23-26 2017
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Fatty Liver in HIV+ at IAS
  ....from Jules: the main concern is that fatty liver [steatosis] can lead to advanced liver disease [without having HCV, HBV or excessive alcohol consumption]....metabolic syndrome & history use of certain ARTs can increase fatty liver and risk for developing liver disease, Fibroscan is used to evaluate liver disease (LSM) & fatty liver (CAP score). HIV+ have higher rates of fatty liver than HIV-negatives. It's estimated that fatty liver is present in from 35-65% of HIV-infected.
NATAP Section dedicated to Fatty Liver http://www.natap.org/liver.htm

from Jules: There were 2 studies at IAS on fatty liver (NAFLD) in HIV+. The first study linked to below looked at HIV+ with and without metabolic syndrome, without HCV or HBV or excessive alcohol consumption: diabetes, abnormal lipids, glucose/diabetes, they also looked at ALT/ASTs and inflammation markers. They found that of the HIV+ patients with metabolic syndrome 25% had advanced liver disease, and of the HIV+ without metabolic syndrome 8% had advanced liver disease, as measured by Fibroscan. Inflammation markers were increased for all but were higher among those with more advanced liver disease. In this study they found obesity BMI>30 & metabolic syndrome associated with advanced liver disease, but not elevated liver enzymes. The study authors mention "liver fibrosis and its pathophysiology have been poorly assessed in HIV-monoinfected patients", in other words HIV clinicians are not considering the possibility that patients could have fatty liver. The 2nd study listed below at IAS used Fibroscan to evaluate 395 HIV+ individuals in Brazil. Average age was only 45 [35-51]. 60% were females. 10% had diabetes, 61% dyslipidemia, 30% hypertension, 32% metabolic syndrome. The duration of HIV infection was from 0 to 16 years. The CAP score is attained by a Fibroscan test & reflects if fatty liver disease is present, and 35% had a high CAP score of >250 dB/m. 9% of patients had LSM [liver stiffness] over 8.0 kPa reflecting liver disease. Associated with fibrosis (advancing liver disease) - Older age was associated with having fibrosis, liver disease. So was having a CD4 count <200. Type 2 diabetes was also strongly associated with more advanced liver disease. All these were found in multivariate analysis, but in Univariate Analysis associated with liver disease were duration of cART & duration of HIV infection, current & prior AZT use vs TDF, protease inhibitor use, central obesity, hypertension, ALT >/= 1.5 upper limit of normal, GGT >/= 1.5 ULN, alkaline pho sphatases >/= 1.5 ULN, all liver enzyme tests. AND associated with steatosis (fatty liver) were being a male vs female; older age, duration of HIV infection, for every 10 years of infection risk was 76% higher, duration of cART & HIV infection, current or prior AZT use (vs TDF); central obesity, type 2 diabetes, dyslipidemia, hypertension, metabolic syndrome. and ALT & GGT elevations of only 1.5 ULN or greater; the metabolic features just listed were all found in multivariate analysis.
Its estimated 20-30% of the general population has fatty liver (NAFLD: non-alcoholic fatty liver disease), but among HIV+ the rates are higher, an estimated 30-40% with some studies finding higher rates of 50-60%, it depends on the characteristics if the HIV+ patients in the study. History of use of the old nukes - d4T, AZT etc - have been found to contribute to fatty liver. Fatty liver is an accumulation of lipids in the liver which over many years can lead to cirrhosis & severe liver disease, and fatty liver can develop without having HCV or HBV. Lipid abnormalities & metabolic abnormalities as we see in HIV can contribute to fatty liver. Fatty liver goes mostly unrecognized and receives little attention from primary care doctors. Unfortunately HIV clinicians and primary care doctors are not very familiar with fatty liver so it rarely gets evaluated. Elevated liver enzymes can mean one has fatty liver, but all too often primary care doctors including HIV clinicians do not pay attention to these elevations, they do not equate these ALT/AST elevations with the possibility that a patient may have fatty liver, they assume the elevated liver enzymes are merely caused by HIV or ARTs which intact they may be but the person may also have fatty liver, which as I mentioned can over many years develop into cirrhosis and severe liver disease. It is only recently getting attention, FATTY LIVER, in the HIV world, at CROI 2017 was a plenary talk by Rohit Loomba linked to below showing the raised concern about fatty liver. The ACTG is beginning to discuss fatty liver and design studies.
IAS: Metabolic syndrome and obesity are the cornerstones of liver fibrosis in HIV-monoinfected patients: results of the METAFIB study - (07/25/17)
IAS: Predictor factors associated with liver fibrosis and steatosis by transient elastography in HIV mono-infected patients under long-term combined antiretroviral therapy - (07/26/17)
Its estimated 30-40% of HIV+ have fatty liver (NAFLD) and studies suggest these rates may be higher than in HIV-negatives. BUT here is a study finding 67% fatty liver in HCV/HIV coinfected .....67% Steatosis in HCV/HIV Coinfected: : Liver inflammation, HCV genotype 3, and BMI are associated with steatosis, a common finding in HCV-HIV-coinfected patients http://www.natap.org/2007/HIV/062007_02.htm
NATAP Section dedicated to Fatty Liver http://www.natap.org/liver.htm
Fatty Liver in HIV+ / HIV Research Politics, Aging - Increased fat accumulation in the liver in HIV-infected patients with antiretroviral therapy-associated lipodystrophy - (07/03/17)
CROI: FATTY LIVER DISEASE: A GROWING CONCERN - - (04/12/17) a plenary talk by noted fatty liver expert Rohit Loomba from UCSD
CROI: Changes in Liver Fibrosis and Steatosis in HIV Mono-Infected patients over 24 months - 50% have fatty liver at average age of 46 - (03/28/17)
CROI: LIVER STEATOSIS AND FIBROSIS IN AT-RISK EUROPEAN HIV-MONOINFECTED PATIENTS - 64% with steatosis among those who had elevated LFTs and/or metabolic syndrome and/or lipodystrophy - (03/28/17)
IAS: Predictor factors associated with liver fibrosis and steatosis by transient elastography in HIV mono-infected patients under long-term combined antiretroviral therapy - (07/26/17)