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FibroScan Score Predicts Liver Outcomes in HIV+ With NAFLD Risk
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EASL International Liver Congress 2022, London, June 22-26, 2022
Mark Mascolini
FibroScan-AST (FAST) score predicted liver outcomes in 1683 HIV-positive people at risk for nonalcoholic fatty liver disease (NAFLD) in Canada and Italy [1]. This prospective analysis confirmed that people with HIV and without viral hepatitis run a risk of severe NAFLD, a result supporting EACS guidelines advising screening HIV-positive people for liver fibrosis.
Prior research figured NAFLD prevalence at about 35% in people with HIV compared with 25% in the general population. Respective rates of nonalcoholic steatohepatitis (NASH) are 10% versus 5% and of liver fibrosis 15% versus 4%. Prolonged antiretroviral use can be toxic to the liver, while HIV can directly cause liver cell death, Kupffer cell infection, and immune activation. (Kupffer cells are immune cells in the liver.)In addition, people with HIV can endure an array of classic liver risk factors.
Researchers from McGill University in Montreal and the University of Modena and University Hospital of Palermo in Italy noted that the FAST score [2] signals histologic NASH with significant liver fibrosis (F2 or worse) and a high NAFLD activity score (4 or higher). EACS guidelines advise screening for NAFLD-linked fibrosis in people with HIV. Because no longitudinal data support this advice or identify appropriate predictive tools, these investigators planned such a study. Their primary aim was "to estimate prevalence and evolution to outcomes of severe NAFLD defined by FAST score in a multicenter cohort of people with HIV."
Study participants came from 3 prospective cohorts in Canada and Italy, including almost 1700 consecutive people with HIV. The analysis excluded HBsAg-positive people and those with chronic HCV infection or alcohol abuse. The researchers used FAST scores to place participants in a low-risk NASH zone (FAST score at or below 0.35), an intermediate-risk group (0.35 to 0.67), or a high-risk NASH zone (above 0.67).
Of the 1683 study participants, 74% were men and 55% white. Age averaged 50 years, 32% had diabetes, and an average 16 years had passed since HIV diagnosis. A large majority, 91.9%, fell into the low-risk NASH group, 6.5% had intermediate risk, and 1.6% had high risk.
Multivariate logistic regression analysis identified four independent predictors of intermediate or high-risk NASH at the following adjusted odds ratios (aORs) (and 95% confidence intervals [CI]):
-- Each additional kg/m2 body mass index: aOR 1.14 (1.10 to 1.19), P < 0.001
-- Male sex: aOR 1.96 (1.16 to 3.32), P = 0.012
-- Every 10 years since HIV diagnosis: aOR 1.57 (1.26 to 1.997), P < 0.001
-- CD4 count below 200: aOR 3.73 (1.58 to 8.82), P = 0.03
Diabetes did not predict intermediate or high risk in this analysis.
Median follow-up stretched to 3.5 years. During that time incidence of liver-related outcomes was 7%, while incidence of nonliver outcomes was 11.5%. Among people with a FAST score below 0.35, incidence of liver-related outcomes stood at 1.6 (0.7 to 3.4) per 100 person-years versus 7.6 (4.2 to 13.7) for people with a FAST score above 0.35. Among nonliver outcomes, 70% were cardiovascular and 30% nonliver cancer.
Multivariate time-dependent Cox proportional analysis figured that a FAST score above 0.35 more than quadrupled risk of liver outcomes (adjusted hazard ratio 4.44, 95% CI 1.66 to 11.9, P = 0.001) in a model adjusted for sex, body mass index, diabetes, HIV duration, protease inhibitor use, and CD4 count below 200.
Area under the receiver operating characteristic (AUROC) curves indicated that FAST score had greater accuracy in predicting liver outcomes in people with HIV (AUROC 0.77) than FIB-4 (AUROC 0.68) NAFLD fibrosis score (AUROC 0.60), or the AST-to-platelet ratio index (APRI) (AUROC 0.71).
The researchers listed four factors that limit their analysis: few deaths for mortality assessment; no competing risk analysis; relatively few women and limited racial/ethnic diversity; no accounting for individual antiretroviral regimens.
With those limitations in mind, the researchers concluded that people with HIV but without viral hepatitis run a high risk for severe NAFLD and that the FAST score predicts liver outcomes in such people. They believe simple serum biomarkers are inadequate to predict liver complications in people with HIV infection.
EASL: Fibroscan-AST (FAST) score predicts liver-related outcomes in 1683 HIV-infected patients at risk for NAFLD - (06/24/22)
References
1. Sebastiani G, Milic I, Kablawi D, et al. FibroScan-AST (FAST) score predicts liver-related outcomes in 1683 HIV-infected patients at risk for NAFLD. EASL International Liver Congress 2022, London, June 22-26, 2022. Abstract OS029.
2. Newsome PN, Sasso M, Deeks JJ, et al. FibroScan-AST (FAST) score for the non-invasive identification of patients with non-alcoholic steatohepatitis with significant activity and fibrosis: a prospective derivation and global validation study. Lancet Gastroenterol Hepatol. 2020;4:362-373. doi: 10.1016/S2468-1253(19)30383-8.
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