Non-invasive identification of severe NAFLD and risk stratification of clinical outcomes using Fibroscan-AST (FAST) score in 1683 people with HIV


BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is very frequent in people with HIV (PWH). Guidelines recommend identification of PWH at high risk for NAFLD-related fibrosis and clinical outcomes. The FibroScan-AST (FAST) score was developed to identify patients with nonalcoholic steatohepatitis (NASH) and significant fibrosis, associated with higher risk of end-stage liver disease. We employed the FAST score to identify PWH with severe NAFLD and for risk stratification of clinical outcomes.
METHODS: FibroScan was performed in PWH without viral hepatitis coinfection or alcohol abuse from three large prospective cohorts. We compared prevalence of FAST>0.35 (90% sensitivity and 50% specificity for NASH with significant fibrosis) and FAST'¥0.67 (50% sensitivity, 90% specificity). Incidence of liver-related outcomes (ascites, encephalopathy, variceal bleeding, hepatocellular carcinoma) and extra-hepatic outcomes (cancer, cardiovascular disease) was evaluated by survival analysis. The performance of FAST score in predicting clinical outcomes was compared with simple fibrosis biomarkers.
RESULTS: We included 1683 PWH (mean age 50.1 years, 74.5% male). Prevalence of FAST>0.35 and FAST>0.67 was 8.1% and 1.5%, respectively. At baseline, on multivariable logistic regression higher BMI (aOR 1.15, 95% CI 1.10-1.20), longer duration of HIV infection (aOR 1.05, 95% CI 1.02-1.07), lower CD4 (aOR 0.99, 95% CI 0.99-0.99) and male sex (2.11, 95% CI 1.22-3.65) were associated with FAST >0.35. During a median follow-up of 3.5 years, incidence of liver-related and extra-hepatic outcomes was 7% and 11.5%, respectively. Incidence of liver-related outcomes increased according to FAST score category (see Figure). On multivariable Cox regression analysis, FAST score >0.35 was an independent predictor of liver-related outcomes (aHR 4.44, 95% CI 1.66-11.9). The area under the curve to predict liver-related outcomes was as follows: FAST score 0.83; FIB-4 0.76; NAFLD fibrosis score 0.77; FibroScan 0.78.

CONCLUSIONS: A significant proportion of PWH are at risk for severe NAFLD. FAST score predicts liver-related events and can help risk stratification.

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