Alimentary Pharmacology and Therapeutics Invited Editorials
Editorial: NAFLD in HIV infection – call for action. Authors’ reply I. Vodkin* & R. Loomba*,† *NAFLD Translational Research Unit, Division of Gastroenterology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA. † Division of Epidemiology, Department of Family Medicine and Public Health, UC San Diego School of Medicine, La Jolla, CA, USA. E-mail: [email protected] doi:10.1111/apt.13087
We thank Dr Naomi Bulteel and Professor Clifford Leen for their thoughtful editorial1 on our article regarding the clinical, biochemical and liver histologic characteristics of HIV-associated non-alcoholic fatty liver disease (NAFLD) compared to primary NAFLD.2 Although some data have linked anti-retroviral therapy (ART) with hepatic steatosis,3, 4 we found no association between non-alcoholic steatohepatitis (NASH) and a specific class of ART. With the suggestion of the editorial’s authors, we re-analyzed our data to examine the relationship between cumulative duration of ART and presence of NASH. We found that patients with NASH had significantly longer cumulative exposure to ART compared to those without NASH (104 months vs. 33.7 months, p = 0.007). HIV treatment guidelines recommend initiation of ART for all patients, regardless of CD4 T-cell count.5 Newer generations of ART have reduced the metabolic burden of these regimens, but traditional drug classes remain the backbone of therapy and continue to increase the risk of NAFLD in this population. Non-invasive markers are needed for diagnosing and monitoring of NAFLD and hepatic fibrosis. Although ultrasound elastography is promising in most other forms of liver disease, it does not perform as well in obese patients, leading to significant failure rates in primary NAFLD.6 Similar technical limitations are expected in HIVassociated NAFLD due to increasing obesity7, 8 in the HIV population. Recent studies have demonstrated that two-dimensional magnetic resonance (MR) elastography (2D-MRE) may be a promising biomarker in the non-
Aliment Pharmacol Ther 2015; 41: 590–592 ª 2015 John Wiley & Sons Ltd
invasive diagnosis of advanced fibrosis in NAFLD, with modest success in the diagnosis of NASH.9, 10 Further studies are needed to evaluate the prevalence of NASH and advanced fibrosis in HIV-associated NAFLD, and to evaluate the performance of non-invasive biomarkers in this population. These are key steps in devising optimal management strategies for NASH in this high-risk group.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Bulteel N, Leen C. Editorial: NAFLD in HIV infection - call for action. Aliment Pharmacol Ther 2015; 41: 590. 2. Vodkin I, Valasek MA, Bettencourt R, Cachay E, Loomba R. Clinical, biochemical and histological differences between HIVassociated NAFLD and primary NAFLD: a case-control study. Aliment Pharmacol Ther 2015; 41: 368–78. 3. Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: contribution to protease inhibitor-related lipodystrophy syndrome. AIDS 2000; 14: F25–32. 4. Guaraldi G, Squillace N, Stentarelli C, et al. Nonalcoholic fatty liver disease in HIV-infected patients referred to a metabolic clinic: prevalence, characteristics, and predictors. Clin Infect Dis 2008; 47: 250–7. 5. PoAGfAa. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Department of Health and Human Services [Internet] 2014. [cited 2014 Jan 3]. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/ adultandadolescentgl.pdf. 6. Myers RP, Pomier-Layrargues G, Kirsch R, et al. Feasibility and diagnostic performance of the FibroScan XL probe for liver stiffness measurement in overweight and obese patients. Hepatology 2012; 55: 199–208. 7. Amorosa V, Synnestvedt M, Gross R, et al. A tale of 2 epidemics: the intersection between obesity and HIV infection in Philadelphia. J Acquir Immune Defic Syndr 2005; 39: 557–61. 8. Keithley JK, Duloy AM, Swanson B, Zeller JM. HIV infection and obesity: a review of the evidence. J Assoc Nurses AIDS Care 2009; 20: 260–74. 9. Loomba R, Wolfson T, Ang B, et al. Magnetic resonance elastography predicts advanced fibrosis in patients with nonalcoholic fatty liver disease: a prospective study. Hepatology 2014; 60: 1920–8. 10. Loomba R, Sirlin CB, Ang B, et al. Ezetimibe for the treatment of nonalcoholic steatohepatitis: assessment by novel MRI and MRE in a randomized trial (MOZART Trial). Hepatology 2014; in press.
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Copyright of Alimentary Pharmacology & Therapeutics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial: NAFLD in HIV infection – call for action. Authors’ reply I. Vodkin* & R. Loomba*,† *NAFLD Translational Research Unit, Division of Gastroenterology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA. † Division of Epidemiology, Department of Family Medicine and Public Health, UC San Diego School of Medicine, La Jolla, CA, USA. E-mail: [email protected] doi:10.1111/apt.13087
We thank Dr Naomi Bulteel and Professor Clifford Leen for their thoughtful editorial1 on our article regarding the clinical, biochemical and liver histologic characteristics of HIV-associated non-alcoholic fatty liver disease (NAFLD) compared to primary NAFLD.2 Although some data have linked anti-retroviral therapy (ART) with hepatic steatosis,3, 4 we found no association between non-alcoholic steatohepatitis (NASH) and a specific class of ART. With the suggestion of the editorial’s authors, we re-analyzed our data to examine the relationship between cumulative duration of ART and presence of NASH. We found that patients with NASH had significantly longer cumulative exposure to ART compared to those without NASH (104 months vs. 33.7 months, p = 0.007). HIV treatment guidelines recommend initiation of ART for all patients, regardless of CD4 T-cell count.5 Newer generations of ART have reduced the metabolic burden of these regimens, but traditional drug classes remain the backbone of therapy and continue to increase the risk of NAFLD in this population. Non-invasive markers are needed for diagnosing and monitoring of NAFLD and hepatic fibrosis. Although ultrasound elastography is promising in most other forms of liver disease, it does not perform as well in obese patients, leading to significant failure rates in primary NAFLD.6 Similar technical limitations are expected in HIVassociated NAFLD due to increasing obesity7, 8 in the HIV population. Recent studies have demonstrated that two-dimensional magnetic resonance (MR) elastography (2D-MRE) may be a promising biomarker in the non-
Aliment Pharmacol Ther 2015; 41: 590–592 ª 2015 John Wiley & Sons Ltd
invasive diagnosis of advanced fibrosis in NAFLD, with modest success in the diagnosis of NASH.9, 10 Further studies are needed to evaluate the prevalence of NASH and advanced fibrosis in HIV-associated NAFLD, and to evaluate the performance of non-invasive biomarkers in this population. These are key steps in devising optimal management strategies for NASH in this high-risk group.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Bulteel N, Leen C. Editorial: NAFLD in HIV infection - call for action. Aliment Pharmacol Ther 2015; 41: 590. 2. Vodkin I, Valasek MA, Bettencourt R, Cachay E, Loomba R. Clinical, biochemical and histological differences between HIVassociated NAFLD and primary NAFLD: a case-control study. Aliment Pharmacol Ther 2015; 41: 368–78. 3. Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: contribution to protease inhibitor-related lipodystrophy syndrome. AIDS 2000; 14: F25–32. 4. Guaraldi G, Squillace N, Stentarelli C, et al. Nonalcoholic fatty liver disease in HIV-infected patients referred to a metabolic clinic: prevalence, characteristics, and predictors. Clin Infect Dis 2008; 47: 250–7. 5. PoAGfAa. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Department of Health and Human Services [Internet] 2014. [cited 2014 Jan 3]. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/ adultandadolescentgl.pdf. 6. Myers RP, Pomier-Layrargues G, Kirsch R, et al. Feasibility and diagnostic performance of the FibroScan XL probe for liver stiffness measurement in overweight and obese patients. Hepatology 2012; 55: 199–208. 7. Amorosa V, Synnestvedt M, Gross R, et al. A tale of 2 epidemics: the intersection between obesity and HIV infection in Philadelphia. J Acquir Immune Defic Syndr 2005; 39: 557–61. 8. Keithley JK, Duloy AM, Swanson B, Zeller JM. HIV infection and obesity: a review of the evidence. J Assoc Nurses AIDS Care 2009; 20: 260–74. 9. Loomba R, Wolfson T, Ang B, et al. Magnetic resonance elastography predicts advanced fibrosis in patients with nonalcoholic fatty liver disease: a prospective study. Hepatology 2014; 60: 1920–8. 10. Loomba R, Sirlin CB, Ang B, et al. Ezetimibe for the treatment of nonalcoholic steatohepatitis: assessment by novel MRI and MRE in a randomized trial (MOZART Trial). Hepatology 2014; in press.
591
Copyright of Alimentary Pharmacology & Therapeutics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
