Metabolic associated fatty liver disease (MAFLD) has been recently proposed as a new concept to describe nonalcoholic fatty liver disease (NAFLD), based on positive diagnostic criteria rather than exclusionary ones. The ongoing debate regarding NAFLD/MAFLD construct has not yet reached HIV arena. Our objective was to characterize MAFLD in comparison to NAFLD and to determine prevalence and predictors of both conditions in people with HIV (PWH).
This was a cross-sectional study of two prospective cohorts comprising PWH on stable ART, that were screened for fatty liver disease (FLD) defined as controlled attenuation parameter of ?248 dB/m by transient elastography. NAFLD was defined as FLD in absence of significant alcohol intake and HBV or HCV co-infection. MAFLD was defined as the presence of FLD and at least one of the following criteria: 1) overweight/obesity; 2) diabetes; or 3) lean FLD (BMI<25 kg/m2) with at least two immune-metabolic alterations [Eslam M. JHepatol.2020;73(1):202-209]. Significant liver fibrosis was defined as liver stiffness ?7.1 kPa. Predictors for both conditions were explored in logistic regression.
We included 1947 PWH (mean age 54 years, 74% males, median HIV duration 21 years, median current CD4 703, 98% with undetectable HIV viral load, current ART exposure to INSTI 53%, PI/c 25%, 32% NNRTI). Prevalence of overweight/obesity and diabetes was 23.4% and 49.5%. NAFLD was diagnosed in 618/1714 (36.1 %) PWH, after excluding PWH with significant alcohol intake (1.8%), HBV (1.2%), HCV (9.2%). MAFLD was diagnosed in 648 (33.3%) PWH. Prevalence of significant liver fibrosis differed across the groups: 9.9% in no NAFLD-no MAFLD, 9.3% in NAFLD only, 26.5% in NAFLD/MAFLD overlap, 48% in MAFLD with diabetes and overweight/obesity, and 16.7% in lean MAFLD. Figure 1A depicts proportions of PWH with NAFLD, MAFLD and NAFLD/MAFLD overlap. Figure 1B shows that male sex, higher CD4, triglycerides and BMI were associated with NAFLD/MAFLD. Significant liver fibrosis was associated with MAFLD with diabetes and overweight/obesity.
PWH displayed a substantial overlap between NAFLD and MAFLD, but those with MAFLD and diabetes or overweight/obesity had higher probability of significant liver fibrosis. HIV-related and metabolic variables were independent predictors of NAFLD/MAFLD. Change of terminology may help to prioritize PWH requiring surveillance and interventions for the management of FLD and associated liver fibrosis.