Non-Viral Liver Disease Service In HIV Positive Individuals
Research type
Research Study
Full title
Evaluation of a non-Viral Liver Disease Service In HIV Positive Individuals
IRAS ID
160964
Contact name
Sumita Verma
Contact email
Sponsor organisation
Brighton and Sussex Univerisity Hospitals
Duration of Study in the UK
2 years, 11 months, 30 days
Research summary
Summary of Research
Since the era of highly active antiretroviral therapy, liver disease has emerged as a major contributor to morbidity and mortality amongst individuals with human immunodeficiency virus (HIV), mostly due to hepatitis B and C. However, the discovery of potent antivirals has resulted in a paradigm shift in management of viral hepatitis. Therefore the future liver disease burden in HIV-positive individuals is likely to be due to other aetiologies including alcohol related liver disease (ARLD), non alcoholic fatty liver disease (NAFLD) and/or anti-retroviral (ARV) related hepatotoxicity.
Currently at our institute, all HIV positive individuals with non-viral related liver disease receive a standard of care service which includes blood tests,imaging,fibroscan, assessment of alcohol use (AUDIT questionnaire), with referral to community alcohol team and referral to a combined HIV/Liver clinic if appropriate.
The aim of this research is to evaluate this service by data collection to include demographics, drug use, antiretroviral data, routine clinical blood tests, and uptake/results of liver ultrasound, fibroscan, AUDIT questionnaire, and referral to the community alcohol services and combined HIV/Liver Clinic.
Summary of Results
Background:
Liver disease in the absence of viral hepatitis co-infection is a growing problem in people living with HIV (PLWH). Likely contributors include alcohol excess, metabolic syndrome (MS), and hepatotoxic antiretrovirals (ARV). We aimed to assess the prevalence of hepatic fibrosis and associated risk factors in HIV mono-infected individuals with abnormal liver tests.Methods:
PLWH with persistently elevated alanine aminotransferase (ALT) for >6 months were prospectively assessed using transient elastography, AUDIT questionnaire, and screening for MS. Thresholds for clinically significant hepatic fibrosis (CSHF) and cirrhosis were >7.1kPa and >12.5kPa respectively, and hepatic steatosis (HS) by a controlled attenuation parameter (CAP) >237dB/m. Study duration was from Dec 2016 to Nov 2021
Results: Of the total eligible participants (n=429), 278 were approached of whom 274 (99%) were recruited, indicating high service uptake. The median age was 52yrs (IQR 45-59), 93% men, median HIV duration 15yrs (IQR 10-20), and undetectable viral load in 96%. Overall, HS was seen in 169 (61.7%) and CSHF was seen in 54 (19.7%), of whom 19 (35.2%) had cirrhosis and 40 (74.1%) had HS. Alcohol, MS and ARV were implicated in 24 (44.4%), 31 (57.4%), and 15 (27.8%) of patients with CSHF, respectively. No risk factors were identified in 10 (18.5%) with CSHF. In those with CSHF (n=54) versus those without (n=220), no significant differences were seen in baseline demographic or metabolic co-factors, nor ARV use. On binary and multinomial logistic regression lower HDL cholesterol (HR 0.255, 95% CI 0.103-0.629, P=0.003) and diabetes (HR 2.558, 95% CI 1.175-5.571, P=0.018) were independent predictors of CSHF. Both FIB-4 and APRI performed poorly in identifying CSHF (AUROC 0.556 and 0.603 respectively; Figure 1).Conclusion:
There was near universal uptake of the liver service amongst PLWH. In these PLWH and elevated ALT, ~20% had CSHF and ~60% had HS. Lower HDL and diabetes were independent predictor of CSHF. Hazardous drinking or MS were identified in most patients with CSHF, however no risk factors were identified in almost 20%. This raises the intriguing possibility that CSHF may be caused directly by the HIV infection.REC name
London - Queen Square Research Ethics Committee
REC reference
15/LO/0600
Date of REC Opinion
19 Feb 2015
REC opinion
Favourable Opinion