Abstract
(1) Background: Developing strategies to identify significant liver fibrosis in people with HIV (PWH) is crucial to prevent complications of non-alcoholic fatty liver disease (NAFLD). We aim to investigate if five simple serum biomarkers applied to PWH can optimize a care pathway to identify significant liver fibrosis defined by transient elastography (TE). (2) Methods: A two-tier fibrosis pathway was applied to three prospective cohorts of PWH undergoing TE with CAP. NAFLD was diagnosed as a controlled attenuation parameter ≥ 248 dB/m. Five simple fibrosis biomarkers (FIB-4 < 1.3, BARD score 0–1, NAFLD fibrosis score < −1.455, AST:ALT ratio < 0.8 and APRI < 0.5) were applied as first-tiers to exclude significant liver fibrosis. We determined the decrease in referral for TE that would have occurred based on biomarker assessment and the discordance between low simple fibrosis biomarkers and high TE (≥7.1 kPa), indicating significant liver fibrosis. (3) Results: Of the 1749 consecutive PWH, 15.1% had significant liver fibrosis by TE and 39.1% had NAFLD. The application of the fibrosis biomarkers as first tiers would have resulted in a decrease in TE referrals between 24.9% (BARD score) and 86.3% (APRI). The lowest discordance rate was with NAFLD fibrosis score (8.5%). After adjustments, BMI (odds ratio (OR) 1.12, 95% CI: 1.08–1.17) and triglycerides (OR 1.26, 95% CI: 1.11–1.44) were independent predictors of discordance for APRI < 0.5 and TE ≥ 7.1. The performance of the two-tier pathways was similar in PWH with and without NAFLD. (4) Conclusions: Implementing a two-tier pathway could save a substantial proportion up of TE examinations, reducing costs and helping resource optimization in HIV care. Patients with metabolic risk factors for NAFLD and low fibrosis biomarker may still be considered for TE referral.
Highlights
Non-alcoholic fatty liver disease (NAFLD) represents a global epidemic, with a prevalence at 25.24% [1]
We found that AST-to-Platelet Ratio Index (APRI) and FIB-4 reduced the most referral rates and costs, while the non-alcoholic fatty liver disease (NAFLD) fibrosis score had the lowest discordance rate with liver stiffness measurement (LSM)
Our study indicated that discordance rates between FIB-4 or APRI and LSM are associated with overweight and hypertriglyceridemia, as such transient elastography (TE) examination may still be considered in people with HIV (PWH) even in the case of low fibrosis biomarker
Summary
Non-alcoholic fatty liver disease (NAFLD) represents a global epidemic, with a prevalence at 25.24% [1]. NAFLD may be more prevalent in PWH than in the HIV-uninfected population, and more severe: both NASH and significant liver fibrosis seem at least twice more frequent in HIV mono-infected patients than in the general population [10,11,12,13,14]. The guidelines from the European AIDS Clinical Society (EACS) recommend the case-finding of significant liver fibrosis in PWH with metabolic conditions or persistent elevated transaminases [17]. These recommendations are in line with other at-risk populations for NAFLD-related liver fibrosis, such as patients with type-2 diabetes [18,19].
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