title: Elevated AST-to-platelet ratio index is associated with increased all-cause mortality among HIV-infected adults in Zambia.
abstract: OBJECTIVE
  We investigated the association between significant liver fibrosis, determined by AST-to-platelet ratio index (APRI), and all-cause mortality among HIV-infected patients prescribed antiretroviral therapy (ART) in Zambia.
  
  
  METHODS
  Among HIV-infected adults who initiated ART, we categorized baseline APRI scores according to established thresholds for significant hepatic fibrosis (APRI ≥1.5) and cirrhosis (APRI ≥2.0). Using multivariable logistic regression we identified risk factors for elevated APRI including demographic characteristics, body mass index (BMI), HIV clinical and immunological status, and tuberculosis. In the subset tested for hepatitis B surface antigen (HBsAg), we investigated the association of hepatitis B virus co-infection with APRI score. Using Kaplan-Meier analysis and Cox proportional hazards regression we determined the association of elevated APRI with death during ART.
  
  
  RESULTS
  Among 20 308 adults in the analysis cohort, 1027 (5.1%) had significant liver fibrosis at ART initiation including 616 (3.0%) with cirrhosis. Risk factors for significant fibrosis or cirrhosis included male sex, BMI <18, WHO clinical stage 3 or 4, CD4(+) count <200 cells/mm(3) , and tuberculosis. Among the 237 (1.2%) who were tested, HBsAg-positive patients had four times the odds (adjusted odds ratio, 4.15; 95% CI, 1.71-10.04) of significant fibrosis compared HBsAg-negatives. Both significant fibrosis (adjusted hazard ratio 1.41, 95% CI, 1.21-1.64) and cirrhosis (adjusted hazard ratio 1.57, 95% CI, 1.31-1.89) were associated with increased all-cause mortality.
  
  
  CONCLUSIONS
  Liver fibrosis may be a risk factor for mortality during ART among HIV-infected individuals in Africa. APRI is an inexpensive and potentially useful test for liver fibrosis in resource-constrained settings.
authors.affiliation: Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.|Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Vinikoor
authors.affiliation: Department of Medicine, University of Zambia, Lusaka, Zambia.|University Teaching Hospital, Lusaka, Zambia.
authors.forename: Edford
authors.initials: E
authors.lastname: Sinkala
authors.affiliation: Department of Medicine, University of Zambia, Lusaka, Zambia.|University Teaching Hospital, Lusaka, Zambia.
authors.forename: Aggrey
authors.initials: A
authors.lastname: Mweemba
authors.affiliation: Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.|Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Arianna
authors.initials: A
authors.lastname: Zanolini
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.|Department of Medicine, University of Zambia, Lusaka, Zambia.|University Teaching Hospital, Lusaka, Zambia.
authors.forename: Lloyd
authors.initials: L
authors.lastname: Mulenga
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
authors.forename: Izukanji
authors.initials: I
authors.lastname: Sikazwe
authors.affiliation: Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Fried
authors.affiliation: Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Eron
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.|Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland.
authors.forename: Gilles
authors.initials: G
authors.lastname: Wandeler
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.|Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
mesh_terms: D000328:Adult; D000367:Age Factors; D019380:Anti-HIV Agents / Q000009:adverse effects*; D001219:Aspartate Aminotransferases / Q000097:blood*; D015415:Biomarkers / Q000097:blood; D002423:Cause of Death; D056486:Chemical and Drug Induced Liver Injury / Q000097:blood* / Q000175:diagnosis / Q000209:etiology / Q000401:mortality*; D004796:Clinical Enzyme Tests; D005260:Female; D015658:HIV Infections / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000097:blood* / Q000139:chemically induced / Q000175:diagnosis / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D010976:Platelet Count; D011237:Predictive Value of Tests; D015995:Prevalence; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D015024:Zambia / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D015415:Biomarkers; D001219:Aspartate Aminotransferases
keywords: AST-to-platelet ratio index; Africa; FIB-4; HIV/AIDS; hepatitis B virus; liver disease