One-third of HIV/HCV Coinfected Patients with Normal
ALT Have Liver Fibrosis that Indicates Treatment
Research has shown that HIV positive individuals
with chronic hepatitis C -- especially those with
advanced immune suppression -- experience more rapid
liver disease progression than people with HCV alone,
and therefore may benefit from earlier hepatitis
the present study, L. Martin-Carbonero from Hospital
Carlos III in Madrid, Spain, and colleagues compared
liver fibrosis progression in patients with persistent
normal and elevated ALT.
is a liver enzyme released during liver injury. Though
often measured as a overall sign of liver health,
it is marker of liver inflammation, and may not be
a good indicator of fibrosis. Studies of HCV monoinfected
individuals have shown that advanced fibrosis can
occur with persistently normal ALT, but this has not
been extensively studied in HIV/HCV coinfected patients.
analysis included all previously untreated HCV RNA
positive patients with persistently normal ALT who
underwent liver fibrosis assessment using transient
elastometry (FibroScan) -- a non-invasive method of
estimating fibrosis based on liver "stiffness"
-- since 2004 at 3 European hospitals; those who had
received interferon-based therapy were excluded.
normal ALT was defined as ALT below the upper limit
of normal on at least 3 consecutive measurements within
the past 12 months. Fibrosis stage was defined as
mild (corresponding to Metavir stage F0-F1) if liver
stiffness was <7.1 kiloPascals (kPa), moderate
(stage F2) if 7.2-9.4 kPa, severe (stage F3) if 9.5-14
kPa, and cirrhosis (stage F4) if > 14 kPa. Moderate
or greater liver fibrosis is generally considered
an indication for hepatitis C treatment.
total of 449 HIV negative and 133 HIV positive patients
were evaluated. The HIV negative participants were
more likely to be women (63%vs 37%) and were older
on average (mean 51.8 vs 43.5 years) than the HIV
positive group. About 80% of the HIV patients were
on combination antiretroviral therapy and their mean
CD4 count was 525 cells/mm3.
serum HCV RNA levels were similar in the HIV negative
and HIV positive groups (5.9 vs 5.8 log IU/mL).
HIV negative patients, 84.6% had mild liver fibrosis,
8.7% had moderate fibrosis, 3.3% had severe fibrosis,
and 3.3% had cirrhosis.
HIV positive participants, the corresponding proportions
were 70.7%, 18.8%, 6%, and 4.5%, respectively.
together, 6.6% of HCV monoinfected patients and
10.5% of HCV/HIV coinfected patients had severe
liver fibrosis or cirrhosis.
a multivariate analysis, older age (odds ratio
[OR] 1.04) and being HIV positive (OR 2.6) were
significantly associated with severe liver fibrosis
or cirrhosis (stage F3-F4).
on these findings, the study authors concluded, "Some
degree of liver fibrosis that justifies treatment
is seen in 15% of the HCV monoinfected but doubles
to nearly 30% in HIV/HCV coinfected patients with
persistently normal ALT."
Infectious Diseases Department, Hospital Carlos
III, Madrid, Spain; Hepato-Gastroenterology Department,
Hôpital Haut-Leveque, Bordeaux, France; Hepatology
Unit and CIBEREDH, Hospital Carlos III, Madrid, Spain;
Infectious Diseases Department, University of Sassari,
Martin-Carbonero, V de Ledinghen, A Moreno, and others.
Liver fibrosis in patients with chronic hepatitis
C and persistently normal liver enzymes: influence
of HIV infection. Journal of Viral Hepatitis
16(11): 790-795 (Abstract).