New guidance on the management of non-alcoholic fatty liver
disease (NAFLD) has been added, following the findings that around half of
people with HIV referred for investigation after abnormal liver function tests
turn out to have NAFLD.
NAFLD consists of a spectrum of liver damage caused by
metabolic disorders and lifestyle factors highly prevalent in people living
with HIV, including obesity, high cholesterol and triglyceride levels, diabetes
and other metabolic disorders. These disorders lead to fat accumulation in the
liver and eventually to the development of fibrosis – non-alcoholic
steatohepatitis (NASH) – and cirrhosis in a minority of people. The high
prevalence of NAFLD – up to 30-40% in US cohorts – in people living with HIV means
that the prevalence of fibrosis and cirrhosis in people without risk factors of
viral hepatitis or chronic alcohol abuse will also be higher in this
Diagnosis of NAFLD in people with abnormal liver function
and no viral hepatitis or history of alcohol abuse should be carried out by
ultrasound with the use of biopsy to confirm NASH in more advanced cases.
Ultrasound imaging of the liver should also be considered in people with
metabolic syndrome and no other risk factors for fibrosis and normal liver
enzymes, with repeat follow-up every two to five years depending on the
presence of steatosis (fat accumulation in the liver).
Lifestyle modification to reduce weight and metabolic risk
factors is the cornerstone of treatment. Lipid-neutral antiretroviral regimens
should also be considered as a means of modifying metabolic risk factors.