Antiretroviral Therapy Improves Poor Prognosis among HIV-HCV and HIV-HBV Coinfected Patients with Liver Cirrhosis

Antiretroviral Therapy Improves Poor Prognosis among HIV-HCV and HIV-HBV Coinfected Patients with Liver Cirrhosis

In a proportion of individuals with chronic hepatitis B or C, liver disease progresses to the stage of cirrhosis, an extensive buildup of scar tissue in the liver that interferes with blood flow through the organ. The liver can compensate for considerable damage, but cirrhosis can ultimately progress to decompensated disease (in which the liver cannot carry out its normal functions) and end-stage liver disease (liver failure).

The natural history of cirrhosis in patients with HIV-HBV and HIV-HCV coinfection has not been extensively studied, but there is evidence that HIV positive people may experience more rapid liver disease progression.

As reported in the November 1, 2007 Journal of Acquired Immune Deficiency Syndromes, Italian researchers conducted a study to investigate the incidence and type of liver-related complications and mortality in coinfected cirrhotic patients.

The investigators retrospectively identified a cohort of HIV positive patients at San Matteo hospital in Pavia. Between 1999 and 2004, 392 HIV positive individuals were followed for at least 6 months. Of these, 69 (18%) initially had compensated cirrhosis: 7 with HBV, 59 with HCV, and 3 with both HBV and HCV (none were receiving treatment for hepatitis C). In addition, 140 subjects with HIV monoinfection and 183 with HIV-HCV coinfection but no cirrhosis served as controls.

Most of the study participants were men and the median age was about 36 years. A majority had CD4 cell counts below 350 cells/mm3, and this was more common among the cirrhotic patients; conversely, non-cirrhotic patients were more likely to be taking antiretroviral therapy (about 60% vs about 75%).

Study subjects received liver biopsies at the start of the study. They underwent routine clinical exams every 3 months, and received abdominal ultrasounds every 6 months. Time to decompensation and mortality due to liver-related causes were recorded.

Results

• Among the coinfected cohort, the most frequent complications were ascites (abdominal fluid accumulation) at 39%, jaundice (yellowing of the skin due to excess bilirubin) at 39%, and hepatic encephalopathy (brain damage) at 22%.

• 13% developed hepatocellular carcinoma, including all 3 HIV-HBV-HCV triple-infected patients.

• The survival rate at 5 years was 72% for cirrhotic patients and 97% for subjects without cirrhosis.

• Overall, 32% of the patients with cirrhosis died (all due to liver-related causes), compared with about 4% in the control groups.

• The overall mortality rate was 71.3 per 1000 person-years (PY) for the coinfected subjects with cirrhosis, 8.0 per 1000 PY for the HIV-HCV coinfected patients without cirrhosis, and 6.5 per 1000 PY for the HIV monoinfected individuals.

• Among the cirrhotic patients, after the first decompensation event, the survival rate was 48% at 1 year and 18% at 3 years.

• Lower CD4 count and higher HIV viral load did not predict a greater likelihood of hepatic decompensation or death.

• Nevertheless, treatment with antiretroviral therapy after the first decompensation event was associated with an increased survival rate (61% and 26% at 1 and 3 years, respectively, vs 27% and 0% for untreated patients; P < 0.0001).

Conclusion

In conclusion, the authors wrote, "The results indicate significant morbidity and mortality during the 6 years after the diagnosis of compensated cirrhosis due to HBV and/or HCV in HIV infected patients, identifying ascites as the most frequent complication."

12/14/07

Reference
R Bruno, P Sacchi, M Puoti, and others. Natural history of compensated viral cirrhosis in a cohort of patients with HIV infection. Journal of Acquired Immune Deficiency Syndromes 46(3): 297-303. November 1, 2007.