Rising risk of NAFLD-related mortality in HIV+ individuals

Roshini Claire Anthony
07 May 2019

The trend in liver disease-related mortality in individuals with HIV has changed, with a reduction in the incidence of viral hepatitis-related deaths and an increase in non-alcoholic fatty liver disease (NAFLD)-related deaths, according to a study presented at the International Liver Congress (ILC 2019).

Researchers used data of Medicare beneficiaries in the US between 2006 and 2016 to identify 47,062 individuals who were HIV-positive, of whom 10,474 had liver disease. Causes of liver disease included hepatitis C virus (HCV; n=5,628), hepatitis B virus (HBV; n=1,374), both HBV and HCV (n=645), NAFLD (n=2,629), and other liver diseases (n=198).

The prevalence rate of viral hepatitis among HIV-positive individuals decreased over the 10-year period, from 27.75 to 24.17 per 100,000 population (p=0.009). [ILC 2019, abstract PS-062]

Conversely, the rates of NAFLD in HIV-positive individuals doubled over the same period, from 5.32 to 11.62 per 100,000 population (p<0.001).

A total of 2,882 deaths occurred over the study period, 36.2 percent of which were due to liver disease. Of these, 49.5 percent were due to HCV, 14.4 percent due to HBV, 11.9 percent due to HCV and HBV, 20.3 percent due to NAFLD, and 3.9 percent due to other liver diseases.

The mortality rate due to viral hepatitis declined over the study period, from 3.78 to 2.58 per 100,000 population (p=0.006), while mortality due to NAFLD increased, from 0.18 to 0.80 per 100,000 population (p=0.041).

“Our study shows that, as highly effective treatments for HBV and HCV infections lead to reduced associated mortality in HIV-infected populations, NAFLD is becoming an increasingly important cause of liver disease,” said study author Professor Zobair Younossi from the Inova Fairfax Medical Campus in Falls Church, Virginia, US.

After adjusting for age, sex, ethnicity, region, beneficiary entitlement, and year, HIV-positive patients with liver disease had a higher 1-year mortality rate than those without liver disease (odds ratio [OR], 1.89, 95 percent confidence interval [CI], 1.69–2.11 for HCV, OR, 2.25, 95 percent CI, 1.85–2.72 for HBV, OR, 4.17, 95 percent CI, 3.31–5.24 for HCV and HBV, and OR, 1.54, 95 percent CI, 1.33–1.80 for NAFLD).

A separate study conducted using two cohorts – The LIVEr disease in HIV (LIVEHIV) and Modena HIV Metabolic Clinic (MHMC) cohorts – found that certain factors increase the risk of progressive liver disease among HIV-positive patients with NAFLD. [ILC 2019, abstract SAT-286]

This study comprised 1,228 HIV-positive (mono-infected) individuals (mean age 50 years, 73 percent male) without viral hepatitis or significant alcohol consumption, of whom 31.8 percent had NAFLD. Of these, 25.2 percent were considered at risk for liver disease progression based on elevated ALT levels, compared with 18.4 percent of patients without NAFLD.

After adjusting for BMI, hypertension, CD4 cell count, and protease inhibitor use, men (OR, 1.57, 95 percent CI, 1.08–2.28), individuals with diabetes (OR, 1.52, 95 percent CI, 1.04–2.24), and those with a longer duration of HIV infection (OR, 1.26, 95 percent CI, 1.02–1.58) had an elevated risk of liver disease progression.

“[A] significant proportion of HIV mono-infected patients is at risk of progressive liver disease,” said study author Dr Sila Cocciolillo from the Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada, and co-authors.

“[T]his supports the need for dedicated monitoring of these patients, with referral to hepatology services when required,” she added.

Despite viral hepatitis remaining a significant cause of liver disease among HIV-positive individuals, the rise in NAFLD cases highlights the importance of investigating treatment strategies for patients with both HIV and NAFLD, said Professor Philip Newsome, vice-secretary of the European Association for the Study of the Liver, who was not affiliated with the study.

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