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Calza L, Giglia M, Viale P. Relationship Between Vitamin D Deficiency and Nonalcoholic Fatty Liver Disease in Patients With HIV-1 Infection. J Acquir Immune Defic Syndr 2024; 95:e5-e7. [PMID: 38408219 DOI: 10.1097/qai.0000000000003359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Leonardo Calza
- Department of Medical and Surgical Sciences, Unit of Infectious Diseases, "Alma Mater Studiorum" University of Bologna, IRCCS S. Orsola Hospital, Bologna, Italy
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2
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Jin D, Jin S, Zhou T, Cui Z, Guo B, Li G, Zhang C. Regional variation in NAFLD prevalence and risk factors among people living with HIV in Europe: a meta-analysis. Front Public Health 2024; 11:1295165. [PMID: 38259755 PMCID: PMC10802187 DOI: 10.3389/fpubh.2023.1295165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024] Open
Abstract
Background and Aim Europe faces an elevated risk of nonalcoholic fatty liver disease (NAFLD) among people living with HIV (PLWH), contributing to the region's highest global burden of NAFLD. However, the prevalence of NAFLD across various European countries and regions remains unclear. This study aims to investigate the prevalence and risk factors associated with NAFLD among PLWH across European countries. Methods A systematic search was conducted across four databases: PubMed, Embase, Web of Science, and Cochrane Library. Data on the prevalence of NAFLD, nonalcoholic steatohepatitis (NASH), and fibrosis, as well as the associated risk factors, were collected among PLWH in Europe. Results Thirty-six studies from 13 European nations were included. The prevalence of NAFLD, NASH, and fibrosis were 42% (95%CI 37-48), 35% (95%CI 21-50) and 13% (95%CI 10-15), respectively. Male gender, BMI, waist circumference, Diabetes, hypertension, metabolic syndrome, dyslipidemia, triglycerides, HDL, LDL, ALT, AST, and years on antiretroviral therapy (ART) were found to be risk factors for NAFLD. High BMI and triglycerides were associated with NASH. Patients with high BMI and triglycerides are at increased risk of significant liver fibrosis. Conclusion The high prevalence of NAFLD, NASH, and fibrosis among PLWH in Europe highlights the need for early screening, intervention, and increased research focus on adolescents living with HIV. Furthermore, the significant variations observed between countries and regions underscore the influence of related risk factors.
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Affiliation(s)
- Dachuan Jin
- Clinical Laboratory, Sixth People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Shunqin Jin
- Department of Radiology, Hebei Medical University, Shijiazhuang, China
| | - Tao Zhou
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
| | - Zhongfeng Cui
- Clinical Laboratory, Sixth People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Baoqiang Guo
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | - Guangming Li
- Department of Liver Disease, Sixth People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Chunming Zhang
- Department of General Surgery, Sixth People’s Hospital of Zhengzhou, Zhengzhou, China
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3
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Wegermann K, Moylan C, Naggie S. Fatty Liver Disease: Enter the Metabolic Era. Curr HIV/AIDS Rep 2023; 20:405-418. [PMID: 37882965 DOI: 10.1007/s11904-023-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize the recent literature linking HIV to metabolic dysfunction-associated steatotic liver disease (MASLD). This is a pressing issue due to the scale of the MASLD epidemic and the urgent need for preventive and therapeutic strategies for MASLD in PWH. RECENT FINDINGS The prevalence of MASLD in PWH is higher than previously appreciated, approaching 50% depending on the population and definition of MASLD. MASLD in PWH is likely multifactorial due to risk factors present in the general population such as metabolic syndrome, and features unique to HIV including systemic inflammation and ART. Statin therapy results in a significant reduction in major adverse cardiovascular events in PWH. PWH are at high risk for MASLD. Screening PWH with metabolic syndrome features could enable earlier interventions to reduce morbidity and mortality associated with MASLD in PWH.
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Affiliation(s)
- Kara Wegermann
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC, USA
| | - Cynthia Moylan
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC, USA
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Susanna Naggie
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Division of Infectious Diseases, Department of Medicine, Duke University Health System, Durham, NC, USA.
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Kalligeros M, Vassilopoulos A, Shehadeh F, Vassilopoulos S, Lazaridou I, Mylonakis E, Promrat K, Wands JR. Prevalence and Characteristics of Nonalcoholic Fatty Liver Disease and Fibrosis in People Living With HIV Monoinfection: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2023; 21:1708-1722. [PMID: 36642292 DOI: 10.1016/j.cgh.2023.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/28/2022] [Accepted: 01/01/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Liver disease remains a leading cause of morbidity and mortality among people living with HIV (PLWH). Emerging data suggest that PLWH are at high risk for developing nonalcoholic fatty liver disease (NAFLD). The aim of this review is to examine the current literature and provide an accurate estimate of the prevalence of NAFLD, nonalcoholic steatohepatitis (NASH), and fibrosis, and identify potential risk factors for NAFLD in PLWH. METHODS We searched PubMed and Embase databases to identify studies reporting the prevalence of NAFLD and/or fibrosis in PLWH monoinfection. We performed a random effects meta-analysis of proportions to estimate the pooled prevalence of NAFLD, NASH, and fibrosis among PLWH monoinfection. We also examined potential risk factors for NAFLD by comparing characteristics of PLWH monoinfection with and without NAFLD. RESULTS A total of 43 studies, reporting data for 8230 patients, met our eligibility criteria and were included in the meta-analysis. Based on imaging studies the overall pooled prevalence of NAFLD and moderate liver fibrosis (METAVIR ≥ F2) among PLWH monoinfection was 33.9% (95% confidence interval [CI], 29.67%-38.39%), and 12.00% (95% CI, 10.02%-14.12%), respectively. Based on biopsy studies, prevalence of NASH and significant liver fibrosis (stage ≥F2 on histology) was 48.77% (95% CI, 34.30%-63.34%) and 23.34% (95% CI, 14.98%-32.75%), respectively. Traditional metabolic syndrome and HIV-related factors were associated with NAFLD in PLWH. CONCLUSIONS Our study confirms that the burden of NAFLD, NASH, and fibrosis is high among PLWH monoinfection. Prospective longitudinal studies are needed to delineate NAFLD, NASH, and fibrosis risk factors, and identify early interventions and new therapies for NAFLD in this population.
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Affiliation(s)
- Markos Kalligeros
- Division of Internal Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Athanasios Vassilopoulos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Fadi Shehadeh
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island; Department of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Stephanos Vassilopoulos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Ingrid Lazaridou
- Division of Internal Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kittichai Promrat
- Division of Gastroenterology and Hepatology, Providence VA Medical Center, Providence, Rhode Island
| | - Jack R Wands
- Liver Research Center, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Cinque F, Cespiati A, Lombardi R, Guaraldi G, Sebastiani G. Nutritional and Lifestyle Therapy for NAFLD in People with HIV. Nutrients 2023; 15:nu15081990. [PMID: 37111209 PMCID: PMC10140991 DOI: 10.3390/nu15081990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
HIV infection and nonalcoholic fatty liver disease (NAFLD) are two major epidemics affecting millions of people worldwide. As people with HIV (PWH) age, there is an increased prevalence of metabolic comorbidities, along with unique HIV factors, such as HIV chronic inflammation and life-long exposure to antiretroviral therapy, which leads to a high prevalence of NAFLD. An unhealthy lifestyle, with a high dietary intake of refined carbohydrates, saturated fatty acids, fructose added beverages, and processed red meat, as well as physical inactivity, are known to trigger and promote the progression of NAFLD to nonalcoholic steatohepatitis, liver fibrosis, and hepatocellular carcinoma. Furthermore, with no currently approved pharmacotherapy and a lack of clinical trials that are inclusive of HIV, nutritional and lifestyle approaches still represent the most recommended treatments for PWH with NAFLD. While sharing common features with the general population, NAFLD in PWH displays its own peculiarities that may also reflect different impacts of nutrition and exercise on its onset and treatment. Therefore, in this narrative review, we aimed to explore the role of nutrients in the development of NAFLD in PWH. In addition, we discussed the nutritional and lifestyle approaches to managing NAFLD in the setting of HIV, with insights into the role of gut microbiota and lean NAFLD.
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Affiliation(s)
- Felice Cinque
- Division of Gastroenterology and Hepatology, and Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Annalisa Cespiati
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Rosa Lombardi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Medicine and Metabolic Disease Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Giovanni Guaraldi
- Modena HIV Metabolic Clinic, Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria di Modena, 41124 Modena, Italy
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, and Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
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Hari A. Ultrasound-Based Diagnostic Methods: Possible Use in Fatty Liver Disease Area. Diagnostics (Basel) 2022; 12:diagnostics12112822. [PMID: 36428882 PMCID: PMC9689357 DOI: 10.3390/diagnostics12112822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Liver steatosis is a chronic liver disease that is becoming one of the most important global health problems, due to its direct connection with metabolic syndrome, its significant impact on patients' socioeconomic status and frailty, and the occurrence of advanced chronic liver disease. In recent years, there has been rapid technological progress in the ultrasound-based diagnostics field that can help us to quantitatively assess liver steatosis, including continuous attenuation parameters in A and B ultrasound modes, backscatter coefficients (e.g., speed of sound) and ultrasound envelope statistic parametric imaging. The methods used in this field are widely available, have favorable time and financial profiles, and are well accepted by patients. Less is known about their reliability in defining the presence and degree of liver steatosis. Numerous study reports have shown the methods' favorable negative and positive predictive values in comparison with reference investigations (liver biopsy and MRI). Important research has also evaluated the role of these methods in diagnosing and monitoring non-alcoholic fatty liver disease (NAFLD). Since NAFLD is becoming the dominant global cause of liver cirrhosis, and due to the close but complex interplay of liver steatosis with the coexistence of liver fibrosis, knowledge regarding NAFLD's influence on the progression of liver fibrosis is of crucial importance. Study findings, therefore, indicate the possibility of using these same diagnostic methods to evaluate the impact of NAFLD on the patient's liver fibrosis progression risk, metabolic risk factors, cardiovascular complications, and the occurrence of hepatocellular carcinoma. The mentioned areas are particularly important in light of the fact that most of the known chronic liver disease etiologies are increasingly intertwined with the simultaneous presence of NAFLD.
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Affiliation(s)
- Andrej Hari
- Oddelek za Bolezni Prebavil, Splošna Bolnišnica Celje, Oblakova Cesta 3, 3000 Celje, Slovenia
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Abstract
PURPOSE OF REVIEW The HIV population is ageing with rising rates of frailty though strategies of how best to manage it remain ill-defined. It also remains unclear what the prevalence of frailty is within this cohort, how best to diagnose it and what factors are associated. RECENT FINDINGS The prevalence of frailty remains unclear because of heterogenous results. Routine screening in those 50+ is recommended and whilst the Fried Frailty Phenotype is currently preferred the Clinical Frailty Scale could be considered. No biomarkers are currently recommended. Looking at associated factors, HIV neurocognitive impairment and long-term alcohol usage has been shown to be associated with developing frailty whilst those who are frail have been shown to be less active and more likely to fall. NAFLD with fibrosis has been shown to be an indicator of metabolic age and the Pooled Cohort Equations has been shown to be more effective in diagnosing cardiovascular risk in frail people living with HIV. SUMMARY Whilst the prevalence of frailty differs between countries, with the addition of prefrailty, this represents a large proportion of people living with HIV. Services must ensure strategies are in place to support those living with HIV and frailty. Further longitudinal studies are required.
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Affiliation(s)
- Howell T Jones
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Tom Levett
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - Tristan J Barber
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
- Institute for Global Health, UCL, London, Institute of Child Health, London, UK
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Kwong J. Frailty in Adults With HIV: Identification, Assessment, and Management. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Predictors of Transition to Frailty in Middle-Aged and Older People With HIV: A Prospective Cohort Study. J Acquir Immune Defic Syndr 2021; 88:518-527. [PMID: 34757975 DOI: 10.1097/qai.0000000000002810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/31/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND People with HIV (PWH) have increased frailty risk at younger ages compared with the general population. Multimorbidity is associated with frailty, yet effects of specific comorbidities on transition to frailty in PWH are unknown. SETTING Prospective study of 219 PWH age 45 years or older in the National NeuroAIDS Tissue Consortium. METHODS Frailty status was categorized using Fried frailty phenotype criteria. Comorbidities [bone disease, cardiovascular disease, cerebrovascular disease, liver disease, renal disease, diabetes, chronic obstructive pulmonary disease (COPD), hypertension, obesity, cancers, neuropsychiatric conditions] were assessed from longitudinal data. Associations between baseline comorbidities and transition to frailty within 30 months were analyzed using Kaplan-Meier and Cox regression models. Grip strength was assessed using mixed-effects models. RESULTS At baseline, the median age was 61 years, 73% were male 98% were on antiretroviral therapy, 29% had ≥3 comorbidities, 27% were robust, and 73% were pre-frail. Cerebrovascular disease, diabetes, and COPD were independent predictors of transition to frailty within 30 months in models adjusted for age, sex, and multimorbidity (≥3 additional comorbidities) [hazard ratios (95% confidence intervals) 2.52 (1.29 to 4.93), 2.31 (1.12 to 4.76), and 1.82 (0.95 to 3.48), respectively]. Furthermore, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity was associated with substantially increased frailty hazards compared with multimorbidity alone (hazard ratios 4.75-7.46). Cerebrovascular disease was associated with decreased baseline grip strength (P = 0.0001), whereas multimorbidity, diabetes, and COPD were associated with declining grip strength (P < 0.10). CONCLUSIONS In older PWH, cerebrovascular disease, diabetes, COPD, or liver disease co-occurring with multimorbidity is associated with substantially increased risk of becoming frail within 30 months. Interventions targeting these comorbidities may ameliorate frailty and age-related functional decline in PWH.
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Kamkwalala AR, Garg A, Roy U, Matthews A, Castillo-Mancilla J, Lake JE, Sebastiani G, Yin M, Brown TT, Kamer AR, Jabs DA, Ellis RJ, Boffito M, Greene M, Schmalzle S, Siegler E, Erlandson KM, Moore DJ. Current Considerations for Clinical Management and Care of People with HIV: Findings from the 11th Annual International HIV and Aging Workshop. AIDS Res Hum Retroviruses 2021; 37:807-820. [PMID: 34405689 DOI: 10.1089/aid.2021.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The number of people with HIV (PWH) aged 50 years or older continues to steadily increase. The convergence of age- and HIV-related complications in these individuals presents a challenge for both patients and clinicians alike. New findings continue to emerge, as numerous researchers evaluate the combined impact of these two factors on quality of life, physiological systems, and mental health in PWH. Since its first occurrence in 2009, the International Workshop on HIV and Aging has served as a multidisciplinary meeting to share basic biomedical data, clinical trial results, treatment strategies, and epidemiological recommendations, toward better understanding and outcomes among like-minded scientific professionals. In this article, we share a selection of key findings presented in plenary talks at the 11th Annual International Workshop on HIV and Aging, held virtually from September 30, 2020 to October 2, 2020. We will also address the future directions of HIV and aging research, to further assess how the aging process intersects with chronic HIV.
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Affiliation(s)
| | - Ankita Garg
- Department of Infectious Diseases, University of Georgia, Athens, Georgia, USA
| | - Upal Roy
- Department of Health and Biomedical Sciences, The University of Texas Rio Grande Valley, Brownsville, Texas, USA
| | - Avery Matthews
- Department of Psychiatry, South Texas Veteran Health Care System, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jose Castillo-Mancilla
- Department of Medicine, Division of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jordan E. Lake
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Giada Sebastiani
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Michael Yin
- Department of Infectious Disease, Columbia University, New York, New York, USA
| | - Todd T. Brown
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Angela R. Kamer
- Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA
| | - Douglas A. Jabs
- Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Ophthalmology, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald J. Ellis
- Department of Neurosciences, University of California San Diego, La Jolla, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Marta Boffito
- Department of HIV Services, Chelsea and Westminster Hospital, London, United Kingdom
| | - Meredith Greene
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sarah Schmalzle
- Department of Infectious Disease, University of Maryland, Baltimore, Maryland, USA
| | - Eugenia Siegler
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Kristine M. Erlandson
- Department of Medicine, Division of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David J. Moore
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
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Guaraldi G, Milic J, Sebastiani G, Raggi P. Sarcopenic obesity at the crossroad of pathogenesis of cardiometabolic diseases. Atherosclerosis 2021; 335:84-86. [PMID: 34563339 DOI: 10.1016/j.atherosclerosis.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Italy.
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Italy.
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada
| | - Paolo Raggi
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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