Prevalence, pattern and factors associated with liver enzyme elevation among HIV-infected patients admitted in Kiruddu National Referral Hospital

Abstract

Background: Globally, mortality and morbidity among Human Immunodeficiency Virus (HIV)-infected patients have tremendously improved over the years in this post- Highly Active Anti-retroviral Therapy (HAART) era. However, these patients face new challenges in the line of non-communicable diseases (NCDs) such as liver-related conditions. Morbidity and mortality due to liver-related conditions continue to rise, with the emergence of new factors on top of the traditionally known etiological factors. Understanding the current implicated factors and timely analysis of LEE in this population may provide an avenue to reduce all-cause mortality among hospitalized HIV-infected patients. In this study, we sought to understand the prevalence, pattern, and factors associated with LEE among HIV-infected patients admitted to Kiruddu National Referral hospital (KNRH), Uganda. Objective: To determine the prevalence, pattern, and factors associated with LEE among HIV-infected patients admitted to the infectious diseases unit of KNRH, Uganda Methods: A cross-sectional study was conducted between November 2021 to March 2022 enrolling HIV-infected patients admitted to the infectious disease unit in KNRH, Uganda. Recruitment was done consecutively in those who fulfilled the eligibility criteria. A semi-structured questionnaire was administered to gather demographic data and clinical manifestations of the participants. Liver disease elevation (LEE) was defined according to the Division of AIDS group (DAIDS) 2017, and the Upper Limit of Normal (ULN) reference values used were those of the laboratory of KNRH- Alanine transferase(ALT)-55 IU/L, Aspartate transferase (AST)-35 IU/L, Gamma-glutamyl transferase(GGT)-64 IU/L and Alkaline phosphatase(ALP)-150 IU/L. The pattern of LEE was according to the R-value [(ALT/ULN) ÷ (ALP/ULN)]. Grading of LEE was according to DAIDS 2017 (classified into mild-moderate elevation that is grade I-II while the severe elevation was graded III-IV). Bivariate analysis using the chi-square test and multivariate logistic regression analyses were performed to evaluate factors associated with LEE among hospitalized HIV-infected patients. Results: A total of 303 participants with a median age of 36 years (interquartile range (IQR): 30-44) were enrolled. 171 (56.4%) were males, and 125(41.3%) were on HAART. Herbal medicine use was admitted to by 185 (61.1%) participants. Overall, 201 (66.3%) had LEE, mostly mild-moderate elevations (ranging from 22.5-75%). Cholestatic pattern (71.6%) was the most common LEE, followed by mixed pattern (22%) and hepatitic pattern in 6.4% of the xiv patients. At bivariate analysis, alcohol use, chronic liver disease, polypharmacy, use of anti-tuberculosis drugs (anti-TBs), jaundice and Right Upper Quadrant (RUQ) pains as well as RUQ tenderness, hepatic encephalopathy, and ascites on physical examination were all significantly associated with LEE. At multivariate analysis, with the level of significance set at p <0.05, LEE was significantly associated with alcohol use and the presence of sonographically confirmed liver cirrhosis in patients with a clinical profile of jaundice, RUQ pains, RUQ tenderness, ascites, and hepatic encephalopathy. Conclusions: Our study found a high prevalence of LEE among admitted HIV-infected population, up to 66.3%. The most encountered pattern of elevation was cholestatic (71.6%) and predominantly mild-moderate elevations. Significant independent factors for LEE in this population were jaundice, RUQ pain on the background of alcohol use, and liver cirrhosis coupled with physical examination findings of RUQ tenderness, ascites, and hepatic encephalopathy. Recommendations: We recommend routine liver function tests done at baseline to establish the liver profile status of all hospitalized HIV-infected patients to identify those who may require further evaluation. A prospective study needs to be conducted to further examine the cholestatic pattern of LEE encountered and the new emerging factors described above. Keywords: Liver enzyme elevation (LEE), HIV patients, Uganda