Letter: HIV-associated NAFLD--more questions than answers?

Abstract

We read with great interest the article by Vodkin et al.1 In this study, they found HIV-associated non-alcoholic 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 HIV-associated 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 HIV-infected patients than in the general population.4 However, the impact of viral factors on NAFLD in HIV-infected 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. Declaration of personal and funding interests: None.