Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited. Hepatic steatosis in individuals living with HIV measured by controlled attenuation parameter: a cross-sectional study Mihály Sulyok a , Mihály Makara c , Zsófia Rupnik d , Tamás Ferenci f , Eszter Újhelyi e , Luca Kormos d , Zsuzsanna Gerlei b , János Szlávik d , Gábor Horváth g and István Vályi-Nagy b Objectives Available data on the prevalence of hepatic steatosis in an unselected HIV-infected population are limited. The aim of this study was to determine the prevalence of hepatic steatosis and assess the associated factors in HIV-infected individuals. Patients and methods One hundred and thirty-six HIV-infected individuals were enrolled in this cross-sectional study. Patients underwent transient elastography and controlled attenuation parameter (CAP) measurements. We analyzed the associations between the CAP value and demographic, metabolic, and immunologic parameters. For the first time, in HIV-infected individuals, we used a continuous scale of CAP values to identify significant covariates of hepatic fat accumulation. As a result and compared with other methods, one of the main advantages of CAP was that the quantitative measurement of liver steatosis could be used for analysis. Results Using univariate analysis, CAP was significantly correlated with the following continuous variables: CD4 percentage (P = 0.035), CD8 percentage (P = 0.016), age (P < 0.001), CD4/8 ratio (P = 0.002), BMI (P < 0.001), serum triglyceride (P < 0.001), and serum cholesterol (P = 0.004) levels, the length of known HIV positivity (P < 0.001), and liver stiffness (P = 0.041). With respect to categorical variables, a significant association was found for the presence of diabetes (P = 0.006), hypertension (P < 0.001), facial lipodystrophy (P = 0.031), and the use of lopinavir (P = 0.042). In multivariate analysis using linear regression, BMI (P < 0.001), presence of diabetes (P = 0.026), and hypertension (P = 0.040) were identified as independent significant correlates. Darunavir therapy was associated negatively with the CAP value (P = 0.032). Conclusion Our findings reflect the importance of metabolic factors in hepatic steatosis. The strongest independent covariate was BMI. Eur J Gastroenterol Hepatol 27:679–685 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Introduction Chronic liver disease is considered to be one of the most important causes of morbidity and mortality in people living with HIV (PLWH) [1]. Hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection are still the main causes of chronic liver damage; however, most recently, there has been an increasing concern about the role of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). The pathogenesis of hepatic stea- tosis (HS) is still incompletely understood and multiple factors have been hypothesized to be necessary for its development and progression [2]. Long-term antiretroviral therapy (ART) may also con- tribute toward hepatotoxicity. Older ART drugs (protease inhibitors and dideoxynucleoside analogs) cause hyper- triglyceridemia and lipodystrophy and are considered to be especially harmful [3,4]. Furthermore, PLWH are increasingly vulnerable to environment-related hepato- toxic factors, such as alcohol consumption, illicit drug use, smoking, and mental illnesses, requiring possible psychia- tric medication [5–8]. In addition, HIV-induced metabolic changes and chronic inflammation may also contribute toward HS [9]. It also has to be emphasized that patients with normal liver enzymes can still have significant stea- tosis and fibrosis. Thus, early detection of HS in HIV- infected patients is the cornerstone of prevention of the silent progression of NAFLD to NASH and cirrhosis [10]. To date, the gold standard of diagnosis and assessment of HS is liver biopsy (LB) [11]. Limiting factors of LB are cost and rare but severe complications with additional concerns such as sampling error and difficulties of reproducibility [12, 13]. Furthermore, LB allows only semiquantitative grading. Other noninvasive methods, such as computed tomography and MRI for HS assessment, have also been investigated, but their high cost, limited availability, and lack of standardiza- tion are still in the way of their widespread use [14]. Another noninvasive and recently developed tool is controlled attenuation parameter (CAP), which has enabled accurate and reliable measurements of HS and has been validated a Doctoral School for Clinical Medicine, b Transplantation and Surgical Clinic, Semmelweis University, c Center for Hepatology, d Center for HIV, e Immunology and Molecular Diagnostics Laboratory, St István and St László Hospital, f John von Neumann Faculty of Informatics, Óbuda University, Physiological Controls Group and g Hepatology Center of Buda, Budapest, Hungary Correspondence to Mihály Sulyok, MD, Doctoral School for Clinical Medicine, Semmelweis University, 1085, Üllői str. 26, Budapest, Hungary Tel: + 0036 20 291 8333; fax: + 0036 1 216 1493; e-mail: sulyok.mihaly@gmail.com Received 5 December 2014 Accepted 16 February 2015 European Journal of Gastroenterology & Hepatology 2015, 27:679–685 Keywords: elasticity imaging techniques, fatty liver, HIV infections, multivariate analysis ’ Original article 0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEG.0000000000000339 679