A revisão sistemática foi realizada utilizando instrumentos de busca de material científico indexado, incluindo MEDLINE (pela PubMed), Web of Science, IBECS e LILACS. Estudos elegíveis incluíram o ano de publicação, critérios para diagnostico de DHGNA e HIV, publicados em inglês, português e espanhol, entre 2006 a 2018. Os critérios de exclusão incluíram estudos com pacientes com outras doenças do fígado. Dois revisores foram envolvidos na pesquisa dos artigos e o PRISMA (Preferred Reporting Items for Systematic Reviews and Meta - Analyses) foi utilizado nas análises.

RESULTADOS

Cento e dezesseis artigos foram selecionados, 27 excluídos porque não preencheram critérios de inclusão e assim, 89 foram lidos pelos investigadores. Desses, 13 artigos foram incluídos na revisão. Quatro séries de casos utilizaram métodos por imagens para identificação de DHGNA e nove estudos utilizaram biópsia hepática. A prevalência de DHGNA em pacientes com HIV variou de 30% a 100% e esteato-hepatite não alcoólica (EHNA) entre 20% e 89%. Na avaliação das principais variáveis estudadas, observou-se a associação positiva entre dislipidemia, resistência à insulina e índice de massa corporal. Não houve concordância entre os artigos que avaliaram a relação dos antiretrovirais com a DHGNA.

CONCLUSÕES

A presente revisão sistemática sugere elevada prevalência de DHGNA em pacientes infectados com HIV. DHGNA nesses pacientes foi associada principalmente a fatores metabólicos. A possível associação entre terapia antiretroviral e DHGNA nesses pacientes vem sendo discutida, mas são necessários mais estudos para estabelecer essa associação.

Hepatopatia gordurosa não alcoólica; Infecções pelo HIV; Síndrome de Imunodeficiência Adquirida

Reference	Country	Diagnostic Method	N	Prevalence

				NAFLD	NASH
Perez et al., 2018 ¹⁴14. Moreno-Perez O, Reyes-Garcia R, Muñoz-Torres M, Merino E, Boix V, Reus S, et al. High Irisin levels in nondiabetic HIV-infected males are associated with insulin resistance, nonalcoholic fatty liver disease, and subclinical atherosclerosis. Clin Endocrinol (Oxf). 2018;89(4):414-23.	Spain	Magnetic resonance	72	33,3%	-
Morse et al., 2015 ⁸8. Morse CG, McLaughlin M, Matthews L, Proschan M, Thomas F, Gharib AM, et al. Nonalcoholic steatohepatitis and hepatic fibrosis in HIV-1-monoinfected adults with elevated aminotransferase levels on antiretroviral therapy. Clin Infect Dis. 2015;60(10):1569-78.	USA	Biopsy	62	73%	54%
Vodkin et al., 2015 ²2. Vodkin I, Valasek MA, Bettencourt R, Cachay E, Loomba R. Clinical, biochemical and histological differences between HIV- associated NAFLD and primary NAFLD: a case-control study. Aliment Pharmacol Ther. 2015;41(4):368-78.	USA	Biopsy	86	38%	24%
Nishijima et al., 2014 ¹⁵15. Nishijima T, Gatanaga H, Shimbo T, Komatsu H, Nozaki Y, Nagata N, et al. Traditional but not HIV-related factors are associated with nonalcoholic fatty liver disease in Asian patients with HIV-1 infection. PLoS One. 2014;9(1):e87596.	Japan	Ultrasonography	485	31%	-
Rivero-Juarez et al., 2013 ¹⁷17. Rivero-Juárez A, Camacho A, Merchante N, Pérez-Camacho I, Macias J, Ortiz-Garcia C, et al; Grupo para el estudio de las hepatitis vı´ricas (HEPAVIR) de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI). Incidence of liver damage of uncertain origin in HIV patients not co-infected with HCV/HBV. PLoS One. 2013;8(7):e68953.	Spain	Biopsy	10	100%	20%
Sterling et al., 2013 ⁹9. Sterling RK, Smith PG, Brunt EM. Hepatic steatosis in human immunodeficiency virus: a prospective study in patients without viral hepatitis, diabetes, or alcohol abuse. J Clin Gastroenterol. 2013;47(2):182-7.	USA	Biopsy	14	64%	28%
Arendt et al., 2011 ¹⁰10. Arendt BM, Mohammed SS, Ma DW, Aghdassi E, Salit IE, Wong DK, et al. Non-alcoholic fatty liver disease in HIV infection associated with altered hepatic fatty acid composition. Curr HIV Res. 2011;9(2):128-35.	Canada	Biopsy	20	30%	70%
Crum-Cianflone et al., 2009 ¹¹11. Crum-Cianflone N, Dilay A, Collins G, Asher D, Campin R, Medina S, et al. Nonalcoholic fatty liver disease among HIV-infected persons. J Acquir Immune Defic Syndr. 2009;50(5):464-73.	USA	Ultrasonography	216	31%	20%*
Ingiliz et al., 2009 ¹⁸18. Ingiliz P, Valantin MA, Duvivier C, Medja F, Dominguez S, Charlotte F, et al. Liver damage underlying unexplained transaminase elevation in human immunodeficiency virus-1 mono-infected patients on antiretroviral therapy. Hepatology. 2009;49(2):436-42.	France	Biopsy	30	60%	89%
Akhtar et al., 2008 ¹²12. Akhtar MA, Mathieson K, Arey B, Post J, Prevette R, Hillier A, et al. Hepatic histopathology and clinical characteristics associated with antiretroviral therapy in HIV patients without viral hepatitis. Eur J Gastroenterol Hepatol. 2008;20(12):1194-204.	USA	Biopsy	23	56%	39%
Guaraldi et al., 2008 ¹⁶16. Guaraldi G, Squillace N, Stentarelli C, Orlando G, D’Amico R, Ligabue G, et al. Nonalcoholic fatty liver disease in HIV-infected patients referred to a metabolic clinic: prevalence, characteristics, and predictors. Clin Infect Dis. 2008;47(2):250-7.	Italy	Computer Tomography	225	36%	-
Mohammed et al., 2007 ¹³13. Mohammed SS, Aghdassi E, Salit IE, Avand G, Sherman M, Guindi M, et al. HIV-positive patients with nonalcoholic fatty liver disease have a lower body mass index and are more physically active than HIV-negative patients. J Acquir Immune Defic Syndr. 2007;45(4):432-8.	Canada	Biopsy	26	100%	55%

Reference	Country	Diagnostic Method	N	Clinical Conditions and Laboratory changes
Morse et al., 2015 ⁸8. Morse CG, McLaughlin M, Matthews L, Proschan M, Thomas F, Gharib AM, et al. Nonalcoholic steatohepatitis and hepatic fibrosis in HIV-1-monoinfected adults with elevated aminotransferase levels on antiretroviral therapy. Clin Infect Dis. 2015;60(10):1569-78.	USA	Biopsy	62	IR/DM (+); Hepatic steatosis (+); Aminotransferases elevation (+); Polymorphyms PNPLA3.
Vodkin et al., 2015 ²2. Vodkin I, Valasek MA, Bettencourt R, Cachay E, Loomba R. Clinical, biochemical and histological differences between HIV- associated NAFLD and primary NAFLD: a case-control study. Aliment Pharmacol Ther. 2015;41(4):368-78.	USA	Biopsy	86	Dyslipidemia (+); aminotransferases elevation (+); Canalicular enzymes (+); ART (-); HIV (+)
Nishijima et al., 2014 ¹⁵15. Nishijima T, Gatanaga H, Shimbo T, Komatsu H, Nozaki Y, Nagata N, et al. Traditional but not HIV-related factors are associated with nonalcoholic fatty liver disease in Asian patients with HIV-1 infection. PLoS One. 2014;9(1):e87596.	Japan	Ultrasonography	485	IR/DM (-); BMI/WC (+); Dyslipidemia (+), hypertriglyceridemia and elevated LDL levels; aminotransferases elevation (+), elevated ALT; ART (-);Elevated CD4+ (+)
Price et al., 2014 ¹⁹19. Price JC, Seaberg EC, Latanich R, Budoff MJ, Kingsley LA, Palella FJ Jr, et al. Risk factors for fatty liver in the Multicenter AIDS Cohort Study. Am J Gastroenterol. 2014;109(5):695-704.	USA	Computer Tomography	719	IR/DM (+); BMI/WC (+); Elevation of aminotransferases (+), elevated ALT; ART (+), greater cumulative exposure to Dideoxynucleoside analogues (Stavudina, Didanosine, Zalcitabine); HIV (-); CD4+ (-)
Rivero-Juarez et al., 2013 ¹⁷17. Rivero-Juárez A, Camacho A, Merchante N, Pérez-Camacho I, Macias J, Ortiz-Garcia C, et al; Grupo para el estudio de las hepatitis vı´ricas (HEPAVIR) de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI). Incidence of liver damage of uncertain origin in HIV patients not co-infected with HCV/HBV. PLoS One. 2013;8(7):e68953.	Spain	Biopsy	10	IR/DM (+); BMI/WC (+); Dyslipidemia (+), hypertriglyceridemia; Hepatic steatosis (+); ART (-); CD4+ plus hypertriglyceridemia (+)
Sterling et al., 2013 ⁹9. Sterling RK, Smith PG, Brunt EM. Hepatic steatosis in human immunodeficiency virus: a prospective study in patients without viral hepatitis, diabetes, or alcohol abuse. J Clin Gastroenterol. 2013;47(2):182-7.	USA	Biopsy	14	IR/DM (+); Canalicular enzymes (+) plus hypertriglyceridemia
Crum-Cianflone et al., 2009 ¹¹11. Crum-Cianflone N, Dilay A, Collins G, Asher D, Campin R, Medina S, et al. Nonalcoholic fatty liver disease among HIV-infected persons. J Acquir Immune Defic Syndr. 2009;50(5):464-73.	USA	Ultrasonography	216	BMI/WC plus Hypertriglyceridemia (+); Dyslipidemia (+), hypertriglyceridemia and decreased HDL levels; ART (-); HIV (-); CD4+ (-)
Ingiliz et al., 2009 ¹⁸18. Ingiliz P, Valantin MA, Duvivier C, Medja F, Dominguez S, Charlotte F, et al. Liver damage underlying unexplained transaminase elevation in human immunodeficiency virus-1 mono-infected patients on antiretroviral therapy. Hepatology. 2009;49(2):436-42.	France	Biopsy	30	IR/DM (+); BMI/WC (-); Dyslipidemia (-); ART (-); HIV (-)
Akhtar et al., 2008 ¹²12. Akhtar MA, Mathieson K, Arey B, Post J, Prevette R, Hillier A, et al. Hepatic histopathology and clinical characteristics associated with antiretroviral therapy in HIV patients without viral hepatitis. Eur J Gastroenterol Hepatol. 2008;20(12):1194-204.	USA	Biopsy	23	BMI/WC (+); ART (+), all patients who presented DHGNA were exposed to NRTIs; HIV (+)
Guaraldi et al., 2008 ¹⁶16. Guaraldi G, Squillace N, Stentarelli C, Orlando G, D’Amico R, Ligabue G, et al. Nonalcoholic fatty liver disease in HIV-infected patients referred to a metabolic clinic: prevalence, characteristics, and predictors. Clin Infect Dis. 2008;47(2):250-7.	Italy	Computer Tomography	225	IR/DM (+); BMI/WC and Visceral Adipose Tissue (+); Dyslipidemia (+); aminotransferases elevation (+); ART (+), exposure to NRTIs
Mohammed et al., 2007 ¹³13. Mohammed SS, Aghdassi E, Salit IE, Avand G, Sherman M, Guindi M, et al. HIV-positive patients with nonalcoholic fatty liver disease have a lower body mass index and are more physically active than HIV-negative patients. J Acquir Immune Defic Syndr. 2007;45(4):432-8.	Canada	Biopsy	26	BMI/WC (-); Dyslipidemia (+), hypertriglyceridemia;

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[1] CORRESPONDING AUTHOR: Helma Pinchemel Cotrim Programa de Pós-graduação em Medicina e Saúde, Complexo Hospitalar Universitário Professor Edgard Santos – UFBA Rua Augusto Viana, s/n, 5º andar, Canela, Salvador, Bahia - Brasil, CEP 40110-060 Phone/Fax: +55 71 3276-2373 E-mail: helmacotrim@gmail.com