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Cardiovascular Disease Independently Associated with NAFLD in People with HIV

Key findings

  • This cross-sectional study identified risk factors for nonalcoholic fatty liver disease in 232 adults with human immunodeficiency virus (HIV), of whom 97 also had nonalcoholic fatty liver disease (NAFLD) and 135 did not
  • A significant association between NAFLD and cardiovascular disease (CVD) persisted even after accounting for traditional CVD risk factors
  • In addition, higher body mass index and a CD4 count >200 cells/mm3 were associated with NAFLD in people with HIV
  • These findings have implications for identifying people with HIV who are at highest risk of developing NAFLD

Because of its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is a growing concern in the treatment and management of people with HIV. The prevalence of NAFLD in this population has been reported to be as high as 40%.

Alyson Kaplan, MD, internal medicine resident at Massachusetts General Hospital, Kathleen E. Corey, MD, MPH, MMSc, director of the Mass General Fatty Liver Program, and colleagues have found that people with human immunodeficiency virus (HIV) who have NAFLD have less favorable cardiometabolic profiles and higher rates of cardiovascular disease than those without NAFLD, even after controlling for traditional cardiovascular disease (CVD) risk factors. Their report appears in the Journal of Acquired Immune Deficiency Syndromes.

Study Details

The subjects in this cross-sectional study were 232 adults diagnosed with HIV between 2010 and 2017, of whom 97 also had NAFLD and 135 did not. There was no significant difference in age, sex, race or tobacco use between the subgroups.

Metabolic Factors

Compared with the non-NAFLD subgroup, the NAFLD subgroup:

  • Had higher average body mass index (31 vs. 28 kg/m2; P <0.001)
  • Was more likely to have hypertension (53% vs. 35%; P = 0.0007)
  • Was more likely to have obstructive sleep apnea (14% vs. 4%; P = 0.008)
  • Was more likely to have diabetes (27% vs. 13%; P = 0.01)
  • Had higher average triglyceride levels (254 vs. 140 mg/dL; P <0.001)
  • Had lower average high-density lipoprotein cholesterol levels (40 vs. 52 mg/dL; P <0.001)

HIV-specific Factors

Compared with the non-NAFLD subgroup, the NAFLD subgroup:

  • Were more likely to have a cluster of differentiation 4 (CD4) count <200 cells/mm3 (18% vs. 7%; P = 0.01)
  • Were more likely to have been diagnosed with HIV in the last 10 years (28% vs. 17%; P = 0.03)

Cardiovascular Disease

People with HIV who had NAFLD were more likely than those without NAFLD to have CVD (30% vs. 10%; P <0.001). CVD was defined as a history of coronary artery disease, congestive heart failure, peripheral vascular disease, stroke, transient ischemic attack, myocardial infarction or coronary revascularization.

On multivariate analysis controlling for traditional CVD risk factors, CD4 <200 cells/mm3 (OR, 4.67), CVD (OR, 3.08) and higher body mass index (OR, 1.10) were significantly associated with NAFLD.

Applying the Findings to Practice

These results require validation in prospective studies, but they suggest that people with HIV who have low CD4+ count or a history of CVD are at highest risk for NAFLD.

There were no differences between the NAFLD and non-NAFLD subgroups in lifetime exposure to the various classes of antiretroviral therapies. However, many of the older classes are strongly associated with components of the metabolic syndrome (e.g., insulin resistance, dyslipidemia) and with hepatocyte injury. Clinicians should be aware that longer exposure to the older agents probably increases the risk of development of NAFLD.

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