Therefore, a high baseline weight and 80 mg of d4T daily are directly correlated and difficult to untangle in analysis. In light of

this, it is important to consider that cases with SHLA were more likely to have a baseline weight of ≥60 kg but were at even greater risk if their baseline weight was ≥75 kg in multivariate regression. These findings are consistent with those of a smaller cohort study in the same setting [17]. The rapid increase in risk with increasing weight cannot be explained by dose escalation at 60 kg alone, and suggests a biological phenomenon peculiar to women with high BMIs. Obesity and rapid weight gain are closely linked to both insulin resistance and nonalcoholic fatty liver disease selleck kinase inhibitor (NAFLD) [25,26]. Once NAFLD is present, other factors including oxidative stress and mitochondrial dysfunction (which has been shown to be caused by NRTI drugs [27,28]) may cause progression from NAFLD to nonalcoholic steatohepatitis (NASH; inflammation of and damage to the liver) [25,26,28,29]. In the setting of this study, there is a high prevalence selleck chemical of obesity [30] and metabolic syndrome in African women [31], which could result in many patients having or being predisposed to NAFLD or NASH at the start of ART. Rapid weight gain on ART and the mitochondrial toxicity caused

by NRTIs are likely to exacerbate this. As lactate is cleared predominantly by the liver and kidneys [22], a metabolically dysfunctional fatty liver may be unable to clear excess lactate, potentially contributing to SHLA [25,32]. The clinical utility of

low-grade increases in ALT serving as an early marker for progressive NAFLD warrants further exploration. The well-recognized major symptoms of SHLA (abdominal pain and vomiting) were frequently observed early manifestations of SHLA. These associations were expected, given the a priori anticipated association, and because they are amongst the symptoms that prompt clinicians to measure lactates. Less frequently described early symptoms were poor appetite and weight loss. An important finding was the independent Thalidomide association of symptoms of peripheral neuropathy with development of SHLA. This was probably attributable to their shared underlying pathogenesis of NRTI mitochondrial toxicity. Symptoms of peripheral neuropathy should be a further prompt for clinicians to assess for SHLA. This study has a number of strengths. The universal use of d4T, combined with the matching on duration of therapy, provided a unique opportunity to explore other associations in greater depth. The concentration of 71 cases in a single service setting enabled the collection of clinical follow-up data that facilitated the exploration of early signs of progressive disease. The incompleteness of some clinical data was, however, an important limitation in this study.