Alimentary Pharmacology and Therapeutics Letters to the Editors

Letter: HIV-associated NAFLD – more questions than answers? C.-C. Wang & Y.-C. Chao Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, New Taipei City, Taiwan. E-mail: [email protected] doi:10.1111/apt.13133

SIRS, We read with great interest the article by Vodkin et al.1 In this study, they found HIV-associated nonalcoholic fatty liver disease (NAFLD) has a higher prevalence of non-alcoholic steatohepatitis (NASH) and increased severity of liver disease than primary NAFLD. In terms of histopathology, HIV-associated NAFLD demonstrated increased lobular inflammation and acidophil bodies compared to primary NAFLD, but there was no difference in grade of steatosis or stage of fibrosis between two groups. In addition, duration of HIV infection was the only risk factor for NASH in HIV-associated NAFLD patients, instead of viral load and the use of anti-retroviral treatment. Although these results provide the first detailed clinical, biochemical and histological description of HIVassociated NAFLD, several issues deserve further discussion. Chronic viral infections are associated with hepatic steatosis. For example, chronic hepatitis C virus infection increases the risk of hepatic steatosis especially in genotype 3.2 In contrast, chronic hepatitis B virus infection seems to protect against, instead of promote, hepatic steatosis.3 The prevalence of NAFLD is higher in

Letter: HIV-associated NAFLD – more questions than answers? 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.13158

SIRS, We thank Drs Wang and Chao for their thoughtful comments1 on our article regarding the clinical, bio912

HIV-infected patients than in the general population.4 However, the impact of viral factors on NAFLD in HIVinfected patients is still unclear. In this study, 86 biopsies in HIV-infected patients without viral hepatitis were identified and 33 (38%) were found to have NAFLD. If the authors could perform further comparison between HIV-infected patients with NAFLD and those without, especially with respect to viral or metabolic factors, and the use of anti-retroviral treatment, we could understand more about the risk factors for NAFLD in HIV-infected patients. In addition, longer duration of HIV infection was found to be associated with NASH in this study. Other than the effects of the virus itself or the use of anti-retroviral treatment, metabolic changes such as increasing obesity or hypertriglyceridaemia during long-term HIV infection could be another explanation for this finding.

ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. 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. 2. Sharma P, Balan V, Hernandez J, et al. Hepatic steatosis in hepatitis C virus genotype 3 infection: does it correlate with body mass index, fibrosis, and HCV risk factors? Dig Dis Sci 2004; 49: 25–9. 3. Wang CC, Tseng TC, Kao JH. Hepatitis B virus infection and metabolic syndrome: fact or fiction? J Gastroenterol Hepatol 2015; 30: 14–20. 4. Crum-Cianflone N, Dilay A, Collins G, et al. Nonalcoholic fatty liver disease among HIV-infected persons. J Acquir Immune Defic Syndr 2009; 50: 464–73.

chemical and histological characteristics of HIV-associated nonalcoholic fatty liver disease (NAFLD) compared to primary NAFLD.2 The authors note that chronic viral infections may be associated with hepatic steatosis. HIV is not a traditional hepatotrophic virus, but HIV can be detected in liver cells.3Although HIV viraemia is linked to an increased risk of renal and cardiovascular disease, its effect on liver fibrosis remains uncertain.4, 5 CD4 T-cell count may play a greater role in liver disease, with several groups showing CD4 T-cell count of

Letter: HIV-associated NAFLD--more questions than answers? Authors' reply.

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