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Bhattacharya D, Gupta A, Tierney C, Huang S, Peters MG, Chipato T, Martinson F, Mohtashemi N, Dula D, George K, Chaktoura N, Klingman KL, Gnanashanmugam D, Currier JS, Fowler MG. Hepatotoxicity and Liver-Related Mortality in Women of Childbearing Potential Living With Human Immunodeficiency Virus and High CD4 Cell Counts Initiating Efavirenz-Containing Regimens. Clin Infect Dis 2021; 72:1342-1349. [PMID: 32161944 DOI: 10.1093/cid/ciaa244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 03/08/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Severe hepatotoxicity in people with human immunodeficiency virus (HIV) receiving efavirenz (EFV) has been reported. We assessed the incidence and risk factors of hepatotoxicity in women of childbearing age initiating EFV-containing regimens. METHODS In the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, ART-naive pregnant women with HIV and CD4 count ≥ 350 cells/μL and alanine aminotransferase ≤ 2.5 the upper limit of normal were randomized during the antepartum and postpartum periods to antiretroviral therapy (ART) strategies to assess HIV vertical transmission, safety, and maternal disease progression. Hepatotoxicity was defined per the Division of AIDS Toxicity Tables. Cox proportional hazards models were constructed with covariates including participant characteristics, ART regimens, and timing of EFV initiation. RESULTS Among 3576 women, 2435 (68%) initiated EFV at a median 121.1 weeks post delivery. After EFV initiation, 2.5% (61/2435) had severe (grade 3 or higher) hepatotoxicity with an incidence of 2.3 (95% confidence interval [CI], 2.0-2.6) per 100 person-years. Events occurred between 1 and 132 weeks postpartum. Of those with severe hepatotoxicity, 8.2% (5/61) were symptomatic, and 3.3% (2/61) of those with severe hepatotoxicity died from EFV-related hepatotoxicity, 1 of whom was symptomatic. The incidence of liver-related mortality was 0.07 (95% CI, .06-.08) per 100 person-years. In multivariable analysis, older age was associated with severe hepatotoxicity (adjusted hazard ratio per 5 years, 1.35 [95% CI, 1.06-1.70]). CONCLUSIONS Severe hepatotoxicity after EFV initiation occurred in 2.5% of women and liver-related mortality occurred in 3% of those with severe hepatotoxicity. The occurrence of fatal events underscores the need for safer treatments for women of childbearing age.
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Affiliation(s)
| | - Amita Gupta
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Camlin Tierney
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sharon Huang
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Marion G Peters
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Neaka Mohtashemi
- University of California, Los Angeles, Los Angeles, California, USA
| | - Dingase Dula
- College of Medicine, Johns Hopkins Research Project, Blantyre, Malawi
| | | | | | | | | | - Judith S Currier
- University of California, Los Angeles, Los Angeles, California, USA
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Brunet L, Moodie EEM, Young J, Cox J, Hull M, Cooper C, Walmsley S, Martel-Laferrière V, Rachlis A, Klein MB, Cohen J, Conway B, Cooper C, Côté P, Cox J, Gill J, Haider S, Sadr A, Johnston L, Hull M, Montaner J, Moodie E, Pick N, Rachlis A, Rouleau D, Sandre R, Tyndall JM, Vachon ML, Sanche S, Skinner S, Wong D. Progression of Liver Fibrosis and Modern Combination Antiretroviral Therapy Regimens in HIV-Hepatitis C-Coinfected Persons. Clin Infect Dis 2015; 62:242-249. [PMID: 26400998 PMCID: PMC4690484 DOI: 10.1093/cid/civ838] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/10/2015] [Indexed: 12/04/2022] Open
Abstract
In human immunodeficiency virus–hepatitis C-coinfected, both protease inhibitor- and nonnucleoside reverse transcriptase inhibitor-based regimens were associated with progression of liver fibrosis over time when paired with a backbone of abacavir/lamivudine but not tenofovir/emtricitabine. Background. Liver diseases progress faster in human immunodeficiency virus (HIV)–hepatitis C virus (HCV)-coinfected persons than HIV-monoinfected persons. The aim of this study was to compare rates of liver fibrosis progression (measured by the aspartate-to-platelet ratio index [APRI]) among HIV-HCV–coinfected users of modern protease inhibitor (PI)- and nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens with a backbone of tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC). Methods. Data from a Canadian multicenter cohort study were analyzed, including 315 HCV polymerase chain reaction–positive persons who initiated antiretroviral therapy with a PI or NNRTI and a backbone containing either TDF/FTC or ABC/3TC. Multivariate linear regression analyses with generalized estimating equations were performed after propensity score matching to balance covariates across classes of anchor agent. Results. A backbone of TDF/FTC was received by 67% of PI users and 69% of NNRTI users. Both PI and NNRTI use was associated with increases in APRI over time when paired with a backbone of ABC/3TC: 16% per 5 years (95% confidence interval [CI], 4%, 29%) and 11% per 5 years (95% CI, 2%, 20%), respectively. With TDF/FTC use, no clear association was found among PI users (8% per 5 years, 95% CI, −3%, 19%) or NNRTI users (3% per 5 years, 95% CI, −7%, 12%). Conclusions. Liver fibrosis progression was more influenced by the backbone than by the class of anchor agent in HIV-HCV–coinfected persons. Only ABC/3TC-containing regimens were associated with an increase of APRI score over time, regardless of the class of anchor agent used.
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Affiliation(s)
- Laurence Brunet
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jim Young
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland
| | - Joseph Cox
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mark Hull
- British Columbia Centre for Excellence in HIV/AIDS.,Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia
| | - Curtis Cooper
- Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia.,The Ottawa Hospital-General Campus
| | - Sharon Walmsley
- Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia.,University Health Network, University of Toronto, Ontario
| | | | - Anita Rachlis
- Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia.,Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Ontario
| | - Marina B Klein
- Canadian Institutes of Health Research Canadian HIV Trials Network, Vancouver, British Columbia.,Chronic Viral Illness Service, Montreal Chest Institute, McGill University Health Centre, Quebec, Canada
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3
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Chalermchai T, Hiransuthikul N, Tangkijvanich P, Pinyakorn S, Avihingsanon A, Ananworanich J. Risk factors of chronic hepatitis in antiretroviral-treated HIV infection, without hepatitis B or C viral infection. AIDS Res Ther 2013; 10:21. [PMID: 23885958 PMCID: PMC3727961 DOI: 10.1186/1742-6405-10-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 07/23/2013] [Indexed: 12/15/2022] Open
Abstract
Background Increasing rates of non-AIDS defining illnesses, and in particular liver diseases, have been found after the initiation of highly active antiretroviral therapy. However, there is little evidence concerning the risk factors for and clinical characteristics of liver disease in antiretroviral (ARV)-treated HIV infection, in the absence of hepatitis B or C viral co-infection. Methods A nested case–control study of HIV infected volunteers, matched by starting date of anti-retroviral treatment, was conducted in a Thai cohort studied from Nov 2002 - July 2012. Cases were defined as those subjects with an elevated alanine aminotransferase (ALT ≥ 40 IU/L) at two consecutive visits six months apart, while controls were defined as individuals who never demonstrated two consecutive elevated ALT results and had a normal ALT result (< 40 IU/L) at their last visit. Both groups had normal ALT levels prior to ARV initiation. Clinical demographics and risk factors for chronic hepatitis including HIV-related illness, ARV treatment and metabolic diseases were collected and analyzed. Conditional logistic regression was used to determine risk factors for chronic hepatitis in HIV infection. Results A total of 124 matched pairs with HIV infection were followed over 3,195 person-years. The mean age (±SD) was 33.0 ± 7.3 years, with 41.1% of subjects being male. The incidence of chronic hepatitis was 5.4 per 100 person-years. The median time from initiation of ARV to chronic hepatitis was 1.3 years (IQR, 0.5-3.5). From univariate analysis; male sex, plasma HIV-1 RNA level > 5 log 10 copies/ml, metabolic syndrome at baseline visit, high BMI > 23 kg/m2, abnormal HDL cholesterol at time of ALT elevation and treatment experience with NNRTI plus boosted PI were selected (p value < 0.2) to the final model of multivariate analysis. Male sex had 3.1 times greater risk of chronic hepatitis than the females by multivariate analysis (adjusted OR, 95% CI: 3.1, 1.5-6.3, p =0.002). High BMI ≥ 23 kg/m2 was also associated with 2.4 times greater risk of chronic hepatitis (adjusted OR, 95% CI: 2.4, 1.2-4.8, p = 0.01). Conclusions Chronic hepatitis in ARV-treated HIV-infected patients is common and may lead to a major health care problem. Male sex and high BMI ≥ 23 kg/m2 carry higher risks for developing chronic hepatitis in this study. Therefore, these patients should be closely monitored for long-term hepatotoxicity.
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4
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Hunt CM, Forster JK, Papay JI, Stirnadel HA. Evidence-Based Liver Chemistry Monitoring in Drug Development. Pharmaceut Med 2012. [DOI: 10.1007/bf03256763] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Snijdewind IJM, Smit C, Godfried MH, Nellen JFJB, de Wolf F, Boer K, van der Ende ME. Hcv coinfection, an important risk factor for hepatotoxicity in pregnant women starting antiretroviral therapy. J Infect 2011; 64:409-16. [PMID: 22227465 DOI: 10.1016/j.jinf.2011.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 12/19/2011] [Accepted: 12/20/2011] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This retrospective cohort study evaluated the risk of hepatotoxicity in HIV-1 positive pregnant and non-pregnant women starting combined ART. METHODS Data were used from the ATHENA observational cohort. The study population consisted of HIV-1 infected, therapy naïve, pregnant and non-pregnant women, followed between January 1997 and February 2008. Demographic, treatment and pregnancy related data were collected. Risk of hepatotoxicity was determined using univariate and multivariate logistic regression. Analyses were adjusted for age, region of origin, baseline HIV-RNA levels and CD4 cell counts, cART regimen and hepatitis B and C coinfection. ALT and AST values of more than 5 times ULN were considered as hepatotoxicity. RESULTS Four-hundred and twenty-five pregnant and 1121 non-pregnant women were included. Independent risk factors of hepatotoxicity in all women were the presence of detectable HCV RNA (OR 5.48, 95% CI 2.25-13.38, p<0.001) and NVP use (OR 2.63, 95% CI 1.54-4.55, p<0.001). Stratified for pregnancy, the adjusted risk of hepatotoxicity was significantly associated with HCV coinfection only during pregnancy (OR 23.53, 95% CI 4.69-118.01, p<0.001). NVP use is related to hepatotoxicity in pregnant (OR 5.26, 95% CI 1.61-16.67, p<0.005) as well as in non-pregnant women (OR 2.13, 95% CI 1.11-4.00, p=0.02). CONCLUSION HCV coinfection and NVP use are associated with a higher risk of cART induced hepatotoxicity in pregnant women.
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Affiliation(s)
- Ingrid J M Snijdewind
- Erasmus University Medical Centre, 's Gravendijkwal 230, Rotterdam, The Netherlands.
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Obuseh FA, Jolly PE, Kulczycki A, Ehiri J, Waterbor J, Desmond RA, Preko PO, Jiang Y, Piyathilake CJ. Aflatoxin levels, plasma vitamins A and E concentrations, and their association with HIV and hepatitis B virus infections in Ghanaians: a cross-sectional study. J Int AIDS Soc 2011; 14:53. [PMID: 22078415 PMCID: PMC3228661 DOI: 10.1186/1758-2652-14-53] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 11/11/2011] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Micronutrient deficiencies occur commonly in people infected with the human immunodeficiency virus. Since aflatoxin exposure also results in reduced levels of several micronutrients, HIV and aflatoxin may work synergistically to increase micronutrient deficiencies. However, there has been no report on the association between aflatoxin exposure and micronutrient deficiencies in HIV-infected people. We measured aflatoxin B1 albumin (AF-ALB) adduct levels and vitamins A and E concentrations in the plasma of HIV-positive and HIV-negative Ghanaians and examined the association of vitamins A and E with HIV status, aflatoxin levels and hepatitis B virus (HBV) infection. METHODS A cross-sectional study was conducted in which participants completed a demographic survey and gave a 20 mL blood sample for analysis of AF-ALB levels, vitamins A and E concentrations, CD4 counts, HIV viral load and HBV infection. RESULTS HIV-infected participants had significantly higher AF-ALB levels (median for HIV-positive and HIV-negative participants was 0.93 and 0.80 pmol/mg albumin, respectively; p <0.01) and significantly lower levels of vitamin A (-16.94 μg/dL; p <0.0001) and vitamin E (-0.22 mg/dL; p <0.001). For the total study group, higher AF-ALB was associated with significantly lower vitamin A (-4.83 μg/dL for every 0.1 pmol/mg increase in AF-ALB). HBV-infected people had significantly lower vitamin A (-5.66 μg/dL; p = 0.01). Vitamins A and E levels were inversely associated with HIV viral load (p = 0.02 for each), and low vitamin E was associated with lower CD4 counts (p = 0.004). CONCLUSIONS Our finding of the significant decrease in vitamin A associated with AF-ALB suggests that aflatoxin exposure significantly compromises the micronutrient status of people who are already facing overwhelming health problems, including HIV infection.
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Affiliation(s)
- Francis A Obuseh
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pauline E Jolly
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrzej Kulczycki
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John Ehiri
- Division of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - John Waterbor
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Renee A Desmond
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Yi Jiang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chandrika J Piyathilake
- Department of Nutrition Sciences - Nutritional Biochemistry and Genomics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Therapeutic monitoring and variability of atazanavir in HIV-infected patients, with and without HCV coinfection, receiving boosted or unboosted regimens. Ther Drug Monit 2011; 33:303-8. [PMID: 21544015 DOI: 10.1097/ftd.0b013e31821c2772] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adequate plasma trough concentrations (Ctrough) of protease inhibitors are required to maintain antiviral activity throughout the dosing interval. Therapeutic drug monitoring is used in clinical practice to optimize dosage and avoid toxic or subtherapeutic drug exposure. The pharmacokinetic variability of Atazanavir (ATV) can be relatively large, as a result of several factors. One of the affecting factors may be hepatic impairment due to hepatitis C virus (HCV) coinfection. METHODS We collected trough plasma samples from human immunodeficiency virus (HIV)-1-infected outpatients, with and without HCV coinfection and/or cirrhosis, receiving stable highly active antiretroviral therapy containing ATV. In the total population, we mainly compared the 2 regimens: 300ATV + 100RTV OD [ritonavir (RTV), once daily (OD)] versus 400ATV OD. We used a threshold value of 0.15 μg/mL, based on the proposed therapeutic range (0.15-0.85 μg/mL). Plasma concentrations of ATV were determined by a validated assay using high-performance liquid chromatography with ultraviolet detection. A total of 214 HIV-infected outpatients were included. For each regimen, we compared 3 groups of subjects: HIV+/HCV-, HIV+/HCV+, and HIV+/HCV+ with cirrhosis. RESULTS In the whole study population, we observed a large variability and found suboptimal Ctrough levels (<0.15 μg/mL) in 23 subjects (2 belonging to the 300/100 OD group and 21 to the 400 OD group). For the standard dosage regimen of 300ATV + 100RTV OD, we did not find a statistical difference between HIV-infected patients without HCV coinfection versus HIV-infected patients with HCV coinfection: median 0.85 (interquartile range 0.53-1.34) and 0.95 (0.70-1.36) μg/mL, respectively. In HIV+/HCV+-infected patients with cirrhosis, we found a median Ctrough of 0.70 (0.43-1.0) μg/mL, with no statistical difference when compared with HIV+/HCV- infected patients. For the 400ATV OD (n=90) dosage regimen, the total median ATV Ctrough was 0.40 (0.23-1.0) μg/mL. In this group, we found a statistically significant difference between HIV+/HCV- and HIV+/HCV+-infected patients: median Ctrough was 0.23 (0.11-0.42) and 0.52 (0.20-1.0) μg/mL, respectively. In HIV+/HCV+ subjects with cirrhosis, the Ctrough median value was 0.42 (0.13-0.75) μg/mL, and there was a significant difference when compared with HIV patients without coinfection. CONCLUSIONS Therapeutic drug monitoring of ATV in patients receiving unboosted regimen may be useful to identify those HIV-infected subjects, with or without HCV coinfection, who may benefit from adding low RTV doses, or the subset of patients in whom removal of RTV could be attempted without the risk of suboptimal plasma ATV exposure.
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Jolly PE, Shuaib FM, Jiang Y, Preko P, Baidoo J, Stiles JK, Wang JS, Phillips TD, Williams JH. Association of high viral load and abnormal liver function with high aflatoxin B1-albumin adduct levels in HIV-positive Ghanaians: preliminary observations. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2011; 28:1224-34. [PMID: 21749228 PMCID: PMC3381352 DOI: 10.1080/19440049.2011.581698] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
We examined the association between certain clinical factors and aflatoxin B(1)-albumin adduct (AF-ALB) levels in HIV-positive people. Plasma samples collected from 314 (155 HIV-positive and 159 HIV-negative) people were tested for AF-ALB levels, viral load, CD4+ T-cell count, liver function profile, malaria parasitaemia, and hepatitis B and C virus infections. HIV-positive participants were divided into high and low groups based on their median AF-ALB of 0.93 pmol mg(-1) albumin and multivariable logistic and linear regression methods used to assess relationships between clinical conditions and AF-ALB levels. Multivariable logistic regression showed statistically significant increased odds of having higher HIV viral loads (OR=2.84; 95% CI=1.17-7.78) and higher direct bilirubin levels (OR=5.47; 95% CI=1.03-22.85) among HIV-positive participants in the high AF-ALB group. There were also higher levels of total bilirubin and lower levels of albumin in association with high AF-ALB. Thus, aflatoxin exposure may contribute to high viral loads and abnormal liver function in HIV-positive people and so promote disease progression.
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Affiliation(s)
- P E Jolly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
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The use of atazanavir in HIV-infected patients with liver cirrhosis: lack of hepatotoxicity and no significant changes in bilirubin values or model for end-stage liver disease score. AIDS 2011; 25:1006-9. [PMID: 21422988 DOI: 10.1097/qad.0b013e3283466f85] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although atazanavir is widely used in hepatitis C virus (HCV)-HIV-1 patients, little is known about its safety in advanced liver disease. We studied 34 HCV-HIV-1 patients with cirrhosis receiving atazanavir. After 551.2 patient-months of follow-up, there were no cases of serious liver toxicity or cirrhosis decompensation, and only 18.5% discontinued the drug. Despite median bilirubin level at inclusion was 1.5 mg/ml, increases in bilirubin level were mild. Model for end-stage liver disease score (MELD) increased to 1.35 points (95% confidence interval 0.13-2.6), but no patient changed their pretreatment situation after atazanavir introduction. Atazanavir is a well tolerated option in cirrhosis, and significant alterations in bilirubin or MELD were not observed.
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Huruy K, Kassu A, Mulu A, Wondie Y. Immune restoration disease and changes in CD4+ T-cell count in HIV- infected patients during highly active antiretroviral therapy at Zewditu memorial hospital, Addis Ababa, Ethiopia. AIDS Res Ther 2010; 7:46. [PMID: 21176160 PMCID: PMC3022664 DOI: 10.1186/1742-6405-7-46] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 12/21/2010] [Indexed: 01/28/2023] Open
Abstract
Background Highly active antiretroviral therapy (HAART) improves the immune function and decreases morbidity, mortality and opportunistic infections (OIs) in HIV-infected patients. However, since the use of HAART, immune restoration disease (IRD) has been described in association with many OIs. Our objective was to determine the proportion of IRD, changes in CD4+ T-cell count and possible risk factors of IRD in HIV-infected patients. Methods A retrospective study of all HIV- infected patients starting HAART between September 1, 2005 and August 31, 2006 at Zewditu memorial hospital HIV clinic, Addis Ababa, Ethiopia was conducted. All laboratory and clinical data were extracted from computerized clinic records and patient charts. Results A total of 1166 HIV- infected patients with mean ± SD age of 36 ± 9.3 years were on HAART. IRD was identified in 170 (14.6%) patients. OIs diagnosed in the IRD patients were tuberculosis (66.5%, 113/170), toxoplasmosis (12.9%, 22/170), herpes zoster rash (12.9%, 22/170), Pneumocystis jirovecii pneumonia (4.1%, 7/170), and cryptococcosis (3.5%, 6/170). Of the 170 patients with IRD, 124 (72.9%) patients developed IRD within the first 3 months of HAART initiation. Low baseline CD4+ T-cell count (odds ratio [OR], 3.16, 95% confidence interval [CI], 2.19-4.58) and baseline extra pulmonary tuberculosis (OR, 7.7, 95% CI, 3.36-17.65) were associated with development of IRD. Twenty nine (17.1%) of the IRD patients needed to use systemic anti-inflammatory treatment where as 19(11.2%) patients required hospitalization associated to the IRD occurrence. There was a total of 8 (4.7%) deaths attributable to IRD. Conclusions The proportion and risk factors of IRD and the pattern of OIs mirrored reports from other countries. Close monitoring of patients during the first three months of HAART initiation is important to minimize clinical deterioration related to IRD.
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Mikl J, Sulkowski MS, Benhamou Y, Dieterich D, Pol S, Rockstroh J, Robinson PA, Ranga M, Stern JO. Hepatic profile analyses of tipranavir in Phase II and III clinical trials. BMC Infect Dis 2009; 9:203. [PMID: 20003457 PMCID: PMC2803791 DOI: 10.1186/1471-2334-9-203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 12/14/2009] [Indexed: 11/17/2022] Open
Abstract
Background The risk and course of serum transaminase elevations (TEs) and clinical hepatic serious adverse event (SAE) development in ritonavir-boosted tipranavir (TPV/r) 500/200 mg BID recipients, who also received additional combination antiretroviral treatment agents in clinical trials (TPV/r-based cART), was determined. Methods Aggregated transaminase and hepatic SAE data through 96 weeks of TPV/r-based cART from five Phase IIb/III trials were analyzed. Patients were categorized by the presence or absence of underlying liver disease (+LD or -LD). Kaplan-Meier (K-M) probability estimates for time-to-first US National Institutes of Health, Division of AIDS (DAIDS) Grade 3/4 TE and clinical hepatic SAE were determined and clinical actions/outcomes evaluated. Risk factors for DAIDS Grade 3/4 TE were identified through multivariate Cox regression statistical modeling. Results Grade 3/4 TEs occurred in 144/1299 (11.1%) patients; 123/144 (85%) of these were asymptomatic; 84% of these patients only temporarily interrupted treatment or continued, with transaminase levels returning to Grade ≤ 2. At 96 weeks of study treatment, the incidence of Grade 3/4 TEs was higher among the +LD (16.8%) than among the -LD (10.1%) patients. K-M analysis revealed an incremental risk for developing DAIDS Grade 3/4 TEs; risk was greatest through 24 weeks (6.1%), and decreasing thereafter (>24-48 weeks: 3.4%, >48 weeks-72 weeks: 2.0%, >72-96 weeks: 2.2%), and higher in +LD than -LD patients at each 24-week interval. Treatment with TPV/r, co-infection with hepatitis B and/or C, DAIDS grade >1 TE and CD4+ > 200 cells/mm3 at baseline were found to be independent risk factors for development of DAIDS Grade 3/4 TE; the hazard ratios (HR) were 2.8, 2.0, 2.1 and 1.5, respectively. Four of the 144 (2.7%) patients with Grade 3/4 TEs developed hepatic SAEs; overall, 14/1299 (1.1%) patients had hepatic SAEs including six with hepatic failure (0.5%). The K-M risk of developing hepatic SAEs through 96 weeks was 1.4%; highest risk was observed during the first 24 weeks and decreased thereafter; the risk was similar between +LD and -LD patients for the first 24 weeks (0.6% and 0.5%, respectively) and was higher for +LD patients, thereafter. Conclusion Through 96 weeks of TPV/r-based cART, DAIDS Grade 3/4 TEs and hepatic SAEs occurred in approximately 11% and 1% of TPV/r patients, respectively; most (84%) had no significant clinical implications and were managed without permanent treatment discontinuation. Among the 14 patients with hepatic SAE, 6 experienced hepatic failure (0.5%); these patients had profound immunosuppression and the rate appears higher among hepatitis co-infected patients. The overall probability of experiencing a hepatic SAE in this patient cohort was 1.4% through 96 weeks of treatment. Independent risk factors for DAIDS Grade 3/4 TEs include TPV/r treatment, co-infection with hepatitis B and/or C, DAIDS grade >1 TE and CD4+ > 200 cells/mm3 at baseline. Trial registration US-NIH Trial registration number: NCT00144170
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Affiliation(s)
- Jaromir Mikl
- SUNY at Albany, School of Public Health, Rensselaer NY, USA.
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Endo T, Fujimoto K, Nishio M, Yamamoto S, Obara M, Sato N, Koike T. Case report: clearance of hepatitis C virus after changing the HAART regimen in a patient infected with hepatitis C virus and the human immunodeficiency virus. J Med Virol 2009; 81:979-82. [PMID: 19382259 DOI: 10.1002/jmv.21489] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The effect of highly active antiretroviral therapy (HAART) on hepatitis C virus (HCV) infection remains uncertain. This report describes the case of a man with hemophilia with HIV-HCV coinfection with persistent disappearance of HCV RNA after changing the HAART regimen. He had been treated with zidovudine, lamivudine, and indinavir for initial HAART and the HIV RNA level had been undetectable for more than 8 years. He had suffered from chronic active hepatitis. The HAART regimen was changed to emtricitabine/tenofovir, atazanavir, and ritonavir because the patient preferred a once daily regimen. The HCV RNA level fell immediately and thereafter became undetectable by quantitative and qualitative assay at 5 and 7 months after the change of the HAART regimen, respectively. In contrast to other reported cases, he experienced neither increase of CD4+ T cells count nor ALT flare-ups before HCV RNA clearance. The HCV RNA disappearance in this case may be due to the direct effect of HAART against HCV rather than restoration of cellular immunity to HCV.
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Affiliation(s)
- Tomoyuki Endo
- Department of Internal Medicine II, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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14
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Liver enzymes elevation and immune reconstitution among treatment-naïve HIV-infected patients instituting antiretroviral therapy. Am J Med Sci 2008; 334:334-41. [PMID: 18004087 DOI: 10.1097/maj.0b013e31811ec780] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Because liver enzymes elevation (LEE) complicates antiretroviral (ARV) therapy, and because the strongest risk factor for ARV-related LEE is HBV/HCV coinfection, it is speculated that ARV-related LEE may be a form of immune reconstitution disease. This study summarizes the relation between immune reconstitution, ARV-induced LEE, and HBV/HCV coinfection. METHODS Medical records of ARV-naïve HIV-infected patients initiating ARV were reviewed for hepatitis coinfection, LEE (grade > or =2 AST/ALT) and changes in CD4 T-cell counts over time in an urban HIV clinic. Risk factors for LEE were statistically evaluated, and changes in CD4 T-cell counts were estimated by a mixed-effects linear model. RESULTS Predictors of LEE included HBV/HCV coinfection (OR = 6.44) and stavudine use (OR = 2.33). Nelfinavir use was protective (OR = 0.45). The mean rate of change in CD4 T-cell counts was higher in HBV/HCV coinfected subjects who developed LEE (99 cells/microL per month) compared with non-coinfected subjects who did not develop LEE (59 cells/microL per month, P = 0.03), non-coinfected subjects who developed LEE (36 cells/microL per month, P =0.01), and coinfected subjects who did not develop LEE, 38% higher (62 cells/microL per month; P =0.11) CONCLUSIONS A more robust immune restoration was observed among HBV/HCV coinfected subjects who developed liver enzyme elevation after antiretroviral initiation compared with other groups. This finding suggests that ARV-related liver enzyme elevation may be related in part to immune reconstitution, as measured by changes in CD4 T-cell counts.
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Phanuphak N, Apornpong T, Teeratakulpisarn S, Chaithongwongwatthana S, Taweepolcharoen C, Mangclaviraj S, Limpongsanurak S, Jadwattanakul T, Eiamapichart P, Luesomboon W, Apisarnthanarak A, Kamudhamas A, Tangsathapornpong A, Vitavasiri C, Singhakowinta N, Attakornwattana V, Kriengsinyot R, Methajittiphun P, Chunloy K, Preetiyathorn W, Aumchantr T, Toro P, Abrams EJ, El-Sadr W, Phanuphak P. Nevirapine-associated toxicity in HIV-infected Thai men and women, including pregnant women. HIV Med 2007; 8:357-66. [PMID: 17661843 DOI: 10.1111/j.1468-1293.2007.00477.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of the study was to determine the incidence of, and risk factors for, nevirapine (NVP)-associated hepatotoxicity and rash in HIV-infected Thai men and women, including pregnant women, receiving NVP-containing highly active antiretroviral therapy (HAART). METHODS NVP-containing HAART was prescribed to eligible men and women enrolled in the Prevention of Mother-To-Child Transmission of HIV (PMTCT) and MTCT-Plus programmes. All pregnant women received zidovudine (ZDV)/lamivudine (3TC)/NVP from >14 weeks of gestational age if their CD4 cell count was <or=200 cells/microL or from >28 weeks if their CD4 cell count was >200 cells/microL. Patients followed for at least 8 weeks after starting HAART or until delivery were included in the analyses. RESULTS Of 409 patients, 244 were pregnant women, 87 were nonpregnant women and 78 were men. Hepatotoxicity occurred in 15.6% of all patients. Men had a significantly higher rate of asymptomatic hepatotoxicity (P=0.021). Pregnant women receiving HAART for PMTCT (92% had CD4 cell counts >250 cells/microL) had a significantly higher rate of symptomatic hepatotoxicity (P=0.0003) than pregnant women receiving HAART for therapy. Rash occurred in 16.1% of all patients. The patients' sex and baseline CD4 cell count were not associated with the risk of hepatotoxicity or rash. NVP was discontinued in 4.2% and 6.8% of patients because of hepatotoxicity and rash, respectively. CONCLUSIONS The incidence of NVP-related hepatotoxicity and rash in Thai adults is similar to incidences reported for other populations. While larger studies are needed, our data support continued use of NVP-containing regimens as first-line treatment in developing countries for HIV-infected patients, including pregnant women. Pregnant women with high CD4 cell counts may experience higher rates of symptomatic hepatotoxicity and thus require careful clinical and laboratory monitoring.
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Affiliation(s)
- N Phanuphak
- The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.
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16
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Chauvel O, Lacombe K, Bonnard P, Lascoux-Combe C, Molina JM, Miailhes P, Girard PM, Carrat F. Risk Factors for Acute Liver Enzyme Abnormalities in HIV-Hepatitis B Virus-Coinfected Patients on Antiretroviral Therapy. Antivir Ther 2007. [DOI: 10.1177/135965350701200706] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Little is known about the prognostic factors of acute liver enzyme variations in HIV-hepatitis B virus (HBV)-coinfected patients. Objectives To identify prognostic factors of acute liver enzyme abnormalities in HIV-HBV-coinfected patients with a focus on the putative role of antiretroviral drugs. Design Data from a 3-year, prospective, multicentre cohort study involving HIV-HBV patients were used. Methods A Markov model was used to identify prognostic factors of acute episodes of cytolysis and cholestasis in 300 HIV-HBV-coinfected patients. The effect of antiretroviral therapy was analysed according to the classes of drugs, duration of treatment and treatment modifications. Results The incidence rates of acute episodes of cytolysis and cholestasis were 13.4 per 100 patient-years (95% confidence interval [CI] 9.5–17.3) and 7.1 per 100 patient-years (95% CI 4.2–10.0), respectively (median follow up 34.1 months). Independent risk factors for cytolysis were a high level of HBV or HIV replication, as well as a low of CD4+ T-cell count. No antiretroviral drug was associated with cytolysis, whereas protease inhibitors seemed to be independently associated with cholestasis, along with treatment modifications and the duration of HIV infection. Conclusion Acute and reversible episodes of cytolysis or cholestasis were common and associated with virus- and host-related determinants. The choice of the optimal antiretroviral combination in HIV-HBV-coinfected patients must take into account the necessity of exerting an efficient control of HIV and HBV replication (associated with transient cytolysis) and the risk of inducing cholestasis (associated with the use of protease inhibitors and treatment modifications).
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Affiliation(s)
- Olivia Chauvel
- AP-HP, Hôpital Saint-Antoine, Service de Maladies Infectieuses et Tropicales, Paris, France
- Université Pierre et Marie Curie, Paris, France
- Inserm, U707, Paris, France
| | - Karine Lacombe
- AP-HP, Hôpital Saint-Antoine, Service de Maladies Infectieuses et Tropicales, Paris, France
- Université Pierre et Marie Curie, Paris, France
- Inserm, U707, Paris, France
| | - Philippe Bonnard
- AP-HP, Hôpital Tenon, Service de Maladies Infectieuses et Tropicales, Paris, France
| | | | - Jean-Michel Molina
- AP-HP, Hôpital Saint-Louis, Service de Maladies Infectieuses et Tropicales, Paris, France
| | - Patrick Miailhes
- Hospices Civils de Lyon, Service d'hépatologie, Hôtel-Dieu, Lyon, France
| | - Pierre-Marie Girard
- AP-HP, Hôpital Saint-Antoine, Service de Maladies Infectieuses et Tropicales, Paris, France
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Markowitz M, Slater LN, Schwartz R, Kazanjian PH, Hathaway B, Wheeler D, Goldman M, Neubacher D, Mayers D, Valdez H, McCallister S. Long-Term Efficacy and Safety of Tipranavir Boosted With Ritonavir in HIV-1-Infected Patients Failing Multiple Protease Inhibitor Regimens. J Acquir Immune Defic Syndr 2007; 45:401-10. [PMID: 17554217 DOI: 10.1097/qai.0b013e318074eff5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND BI 1182.2, an open-label, randomized, multicenter, phase 2 study, evaluated efficacy and tolerability of the protease inhibitor (PI) tipranavir (TPV; 500 mg twice daily or 1000 mg twice daily) administered with ritonavir (100 mg twice daily) in combination with 1 nucleoside reverse transcriptase inhibitor and 1 nonnucleoside reverse transcriptase inhibitor in multiple PI-experienced HIV-1-infected patients. METHODS Forty-one patients were evaluated in 2 arms: low-dose (19 patients) or high-dose (22 patients) ritonavir-boosted tipranavir (TPV/r). Primary endpoints were change from baseline in HIV-1 RNA concentrations at weeks 16, 24, 48, and 80 and percentage of patients with plasma HIV-1 RNA levels lower than the limit of quantitation. Safety was evaluated by adverse events (AEs), grade 3/4 abnormalities, and serious AEs. RESULTS Of all patients, 59% were still receiving TPV/r (14 in low-dose arm and 10 in high-dose arm) at week 80. Patients in both arms had a median >2.0-log10 reduction in plasma viral load. Intent-to-treat analysis demonstrated that a similar proportion of patients in the high-dose and low-dose groups achieved plasma HIV-1 RNA levels <50 copies/mL at week 80 (43% vs. 32%; P = 0.527). The most frequently observed AEs were diarrhea, headache, and nausea. CONCLUSION TPV/r combined with other active antiretroviral agents can provide a durable treatment response for highly treatment-experienced patients.
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Affiliation(s)
- Martin Markowitz
- Aaron Diamond AIDS Research Center, Rockefeller University, 455 First Avenue, New York, NY 10016, USA.
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Liver-Related Complications in HIV-Infected Individuals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2007. [DOI: 10.1097/01.idc.0000246152.78893.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Servoss JC, Kitch DW, Andersen JW, Reisler RB, Chung RT, Robbins GK. Predictors of antiretroviral-related hepatotoxicity in the adult AIDS Clinical Trial Group (1989-1999). J Acquir Immune Defic Syndr 2006; 43:320-3. [PMID: 16967041 DOI: 10.1097/01.qai.0000243054.58074.59] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
HIV antiretroviral therapy (ART)-related hepatotoxicity is a significant clinical problem, resulting in severe elevations of liver enzymes and, potentially, liver failure and death. We retrospectively determined baseline clinical predictors of severe hepatotoxicity (SH; serum aminotransferases or total bilirubin >5 times and >2.5 times the upper limit of normal [ULN], respectively) among 8,851 subjects enrolled in 16 Adult AIDS Clinical Trial Group studies from October 1989 to June 1999. Subjects were divided into the following treatment categories: single nucleoside reverse transcriptase inhibitors (NRTIs), multiple NRTIs, nonnucleoside reverse transcriptase inhibitors (NNRTIs) combined with NRTIs, and the protease inhibitor (PI) indinavir (IDV) combined with NRTIs. SH occurred in 824 (9.3%) subjects, in 613 (6.92%) in the first 6 months and in another 211(2.38%) in the subsequent 6 months of study ART. Consistent with other reports, baseline elevation in serum aminotransferases was a significant risk factor for SH for all regimens. Risk factors not previously identified included concomitant hepatotoxic medications, thrombocytopenia, and renal insufficiency. Hepatitis C virus coinfection was associated with an increased risk of SH (odds ratio [OR] = 2.7; P < 0.003). In conclusion, this study identified known and previously unreported risk factors for severe hepatotoxicity that should be considered before the initiation of ART.
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Affiliation(s)
- Julie C Servoss
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, 02114, USA
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De Rosa FG, Audagnotto S, Bargiacchi O, Garazzino S, Aguilar Marucco D, Veronese L, Canta F, Bonora S, Sinicco A, Di Perri G. Resolution of HCV infection after highly active antiretroviral therapy in a HIV–HCV coinfected patient. J Infect 2006; 53:e215-8. [PMID: 16549201 DOI: 10.1016/j.jinf.2006.01.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Revised: 01/30/2006] [Accepted: 01/30/2006] [Indexed: 11/30/2022]
Abstract
The effect of HAART on HCV infection and HCV-RNA plasma levels is controversial. We describe a patient with HIV-HCV coinfection with persistent disappearance of HCV-RNA after immunological and virological response to HAART, and we briefly discuss similar cases reported in the literature.
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Affiliation(s)
- Francesco G De Rosa
- Department of Infectious Diseases, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera 164, 10149, Turin, Italy.
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Gonzalez SA, Liu RC, Edlin BR, Jacobson IM, Talal AH. HIV/Hepatitis C Virus-Coinfected Patients With Normal Alanine Aminotransferase Levels. J Acquir Immune Defic Syndr 2006; 41:582-9. [PMID: 16652026 DOI: 10.1097/01.qai.0000214806.90841.c8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The significance of normal alanine aminotransferase (ALT) levels in patients with HIV/hepatitis C virus (HCV) coinfection is not well understood. METHODS We performed a cross-sectional retrospective analysis on consecutive HIV/HCV-coinfected patients (n = 89) who underwent a liver biopsy during a 2-year period. Similar data were also collected on HCV-monoinfected patients (n = 117). RESULTS Mean ALT levels and the percentage of patients with normal ALT (< or =40 U/L) levels were similar in HIV/HCV-coinfected (mean +/- SD, 81.7 +/- 56.1 U/L; 21%) and HCV-monoinfected patients (97.3 +/- 100.7 U/L; 18%; P = 0.19 and 0.54, respectively). Coinfected patients, however, had significantly advanced necroinflammation (P= 0.001) and fibrosis (P = 0.02) compared with monoinfected patients. The percentage of patients with advanced necroinflammation (grades 3 or 4) was lower in HCV-monoinfected patients with normal ALT levels compared with those with elevated ALT (5% vs 20%, respectively). In contrast, the percentage of coinfected patients with advanced necroinflammation was similar whether the patient had normal or elevated ALT levels (32% vs 37%, respectively). CONCLUSIONS In coinfected patients, normal ALT levels are not an indicator of mild necroinflammation and may not portend a more benign disease course.
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Affiliation(s)
- Stevan A Gonzalez
- Center for the Study of Hepatitis C and Division of Gastroenterology and Hepatology, Department of Medicine, Weill Medical College of Columbia University, 525 East 68th Street, New York, NY 10021, USA
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22
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Hughes CA, Shafran SD. Treatment of hepatitis C in HIV-coinfected patients. Ann Pharmacother 2006; 40:479-89; quiz 582-3. [PMID: 16507622 DOI: 10.1345/aph.1g427] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To review the current management of hepatitis C virus (HCV) in persons coinfected with HIV. DATA SOURCES A MEDLINE search (1966-February 2006) was conducted, using key words such as HIV, human immunodeficiency virus, hepatitis C, interferon, pegylated interferon, and therapy. Article bibliographies and conference abstracts were also reviewed to identify relevant studies. STUDY SELECTION AND DATA EXTRACTION Studies that examined HCV treatment in individuals coinfected with HIV and articles that focused on HCV/HIV coinfection were considered for this review. DATA SYNTHESIS Coinfection with HIV leads to a more rapid and severe course of HCV-related liver disease. Treatment of HCV with pegylated interferon (PEG-IFN) and ribavirin therapy is relatively well tolerated in individuals coinfected with HIV, with overall sustained virologic response (SVR) rates of 27-40%. High relapse rates and poor response in HCV-genotype 1 contribute to the lower SVR in coinfected individuals compared with HCV monoinfection. Treatment of HCV is more complicated in HIV-infected persons due to increased risk of myelosuppression, drug interactions, hepatotoxicity of antiretroviral therapy, and the relative contraindication to interferon therapy in advanced HIV disease. Current guidelines recommend that all HIV-positive patients with chronic HCV infection be considered as treatment candidates for anti-HCV therapy due to the higher risk of liver disease progression. Further studies are needed, however, to define the appropriate dose and duration of therapy in HCV/HIV-coinfected individuals. CONCLUSIONS Response to treatment with PEG-IFN and ribavirin is poorer in patients coinfected with HCV/HIV than in those infected with HCV alone. The benefits of anti-HCV therapy, including viral eradication, need to be weighed against the risks of adverse effects and drug-drug interactions between anti-HCV and antiretroviral medications.
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Affiliation(s)
- Christine A Hughes
- Faculty of Pharmacy and Pharmaceutical Sciences, HIV, Capital Health Region, Edmonton, Alberta, Canada.
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Lagrange-Xélot M, Molina JM. [Adverse effects of antiretroviral treatments]. Presse Med 2005; 34:1571-8. [PMID: 16314816 DOI: 10.1016/s0755-4982(05)84227-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The efficacy of antiretroviral drugs has improved the prognosis for infection by human immunodeficiency virus (HIV); it is nonetheless accompanied by toxicity specific to these agents. Adverse effects of these treatments are a major cause of poor compliance as well as of the cessation or change of treatment. Knowledge of these effects allows physicians to choose an individualized and effective treatment for each patient, one that is well tolerated and appropriate to the patient's sometimes complex medical history. Although some of these adverse effects can be life-threatening (drug eruptions with nevirapine and abacavir, pancreatitis with didanosine, or lactic acidosis with nucleoside analogs), most are reversible. Lipodystrophies, sometimes combining morphologic and metabolic disorders, are observed in some patients after several years of treatment and appear to increase cardiovascular risk. They are one of the major disadvantages of combined treatments.
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Affiliation(s)
- M Lagrange-Xélot
- Service des maladies infectieuses et tropicales, Hôpital Saint-Louis, Paris.
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Cengiz C, Park JS, Saraf N, Dieterich DT. HIV and liver diseases: recent clinical advances. Clin Liver Dis 2005; 9:647-66, vii. [PMID: 16207569 DOI: 10.1016/j.cld.2005.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Because the life expectancy of patients infected with HIV has been prolonged, liver diseases have assumed far greater importance as a cause of morbidity and mortality in these patients. Given the shared risks of transmission, patients who have HIV often are coinfected with hepatotrophic viruses such as hepatitis C and hepatitis B. Further, antiretroviral therapy (ART) used by patients who have HIV is often hepatotoxic, contributing to liver damage. With increasing immunosuppression caused by AIDS, patients who have HIV have to deal with these issues and the increased risk of infection with opportunistic viral, fungal, bacterial, and protozoal pathogens. In addition, steatosis and lipodystrophy now are recognized more commonly in patients who have HIV, particularly in the setting of ART. Thus, understanding of liver diseases in the setting of HIV infection becomes an important focus in caring these individuals. There have been numerous advances in the treatment of liver disease in patients who have HIV, particularly in treating viral hepatitis C and B. This article reviews various liver manifestations in patients who have HIV and the recent advances in diagnostic and therapeutic options.
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Affiliation(s)
- Cem Cengiz
- Division of Liver Diseases, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
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Abstract
PURPOSE OF REVIEW To summarize the salient reviews, studies and case reports and series that dealt with clinical, pathological, methodological, and epidemiological descriptions of drug-induced liver disease in the calendar year 2004. RECENT FINDINGS While no new causes of drug-induced liver injury were reported for 2004, several new reports of previously recognized hepatotoxins, including herbal products, were published. These include the antiretroviral drugs for HIV and agents to manage tuberculosis. Acetaminophen (APAP) retained its preeminent position as the leading cause of drug-induced acute liver failure, currently accounting for nearly 50% of cases according to the latest figures from the U.S. Acute Liver Failure Study Group. Not surprisingly, APAP also heads the list of drugs and toxins leading to liver transplantation for acute hepatic failure. Efforts to reduce the number of cases of intentional APAP poisonings by restricting the number of tablets sold at any one time in the UK are ongoing, but the success of the program may be lessening, as was pointed out this year. The use of potentially hepatotoxic medications in patients with underlying liver disease was examined with the statins, and they emerged as a safe class for use in this setting. SUMMARY Given the apparent increasing incidence of acute liver failure attributable to APAP in the US, additional efforts are still needed to better define the risks associated with its use and to further reduce the incidence of severe liver injury from this widely used agent.
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Affiliation(s)
- Susan K Lazerow
- Division of Gastroenterology, Section of Hepatology, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
The use of highly active antiretroviral therapy has dramatically reduced HIV-associated morbidity and mortality. As a result, patients are often being treated longer and with more complex medical regimens than ever before, increasing the risk for drug interactions and toxicities. In particular, hepatotoxicity caused by antiretroviral use has become an increasingly appreciated potential complication of drug treatment. All classes of antiretrovirals have been reported to induce liver enzyme abnormalities. However, certain antiretrovirals appear much more likely to be associated with drug-induced hepatotoxicity. The risk of antiretroviral-related hepatotoxicity may be associated with patient-specific risk factors, including pre-existing viral hepatitis, baseline elevated liver function test results, female gender, and substance abuse. In addition, complex drug-drug interactions may potentate the risk of antiretroviral-associated hepatotoxicity. Coinfection with hepatitis B or hepatitis C appears to increase the risk of antiretroviral-related hepatotoxicity.
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Affiliation(s)
- Kendra D Kress
- Roche Laboratories Inc., 340 Kingsland Street, Nutley, NJ 07110, USA.
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Braitstein P, Palepu A, Dieterich D, Benhamou Y, Montaner JSG. Special considerations in the initiation and management of antiretroviral therapy in individuals coinfected with HIV and hepatitis C. AIDS 2004; 18:2221-34. [PMID: 15577534 DOI: 10.1097/00002030-200411190-00002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although hepatitis C (HCV) treatment efficacy has improved in recent years, the majority of HIV/HCV-coinfected individuals may not enjoy the full benefits of these treatments and appropriate HIV management is crucial. Evidence is accumulating regarding the impact of HIV/HCV coinfection on the response to, and safety and tolerability of, antiretroviral therapy (ART) in this population. METHODS Computerized, English-language literature searches of MEDLINE and PubMed databases (January 1985 to May 2004) for studies of HIV and HCV infection in humans to examine critically (a) the impact of HCV on the HIV virologic and immunologic response to ART; (b) the safety and tolerability of ART in coinfected individuals; and (c) the relationship between immune suppression and immune restoration on hepatic injury. RESULTS Three key messages emerged regarding the use of ART in HIV/HCV-coinfected individuals: (a) although HCV appeared to have no impact on HIV virologic response, the data are equivocal regarding immunologic response; (b) morbidities associated with HCV infection, such as insulin resistance, diabetes, mitochondrial dysfunction, and liver inflammation, are also associated toxicities of ART, and (c) both immune suppression and restoration can contribute to the onset and acceleration of HCV-related liver disease. CONCLUSIONS The CD4 cell count threshold for initiating ART in HIV/HCV-coinfected patients may be higher because of the impact of immune suppression and restoration on the onset of HCV-associated liver disease and the possibility of a blunted immune response to ART at lower CD4 cell counts. Further, overlapping morbidity between HCV-related mitochondrial and metabolic disease manifestations and ART toxicities warrant careful attention by clinicians.
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Affiliation(s)
- Paula Braitstein
- British Columbia Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.
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Bonacini M. Liver injury during highly active antiretroviral therapy: the effect of hepatitis C coinfection. Clin Infect Dis 2004; 38 Suppl 2:S104-8. [PMID: 14986282 DOI: 10.1086/381453] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Drug-induced liver injury (DILI) is the elevation of liver enzyme and/or bilirubin levels caused by the use of a medication or drug. In patients with human immunodeficiency virus (HIV) infection, some of these events may not be directly caused by medication. Acute viral hepatitis, reactivation of hepatitis B virus or hepatitis C virus (HCV) infection, and/or alcohol use may play roles. Elevated transaminase levels are a signal of liver injury, but most cases improve despite continuation of drug therapy. Approximately 33% of patients with HIV infection are coinfected with HCV. Patients with HIV or HCV infection are more prone to DILI, possibly because of impaired hepatocyte defense mechanisms. HCV coinfection is associated with a 2-10-fold chance of developing elevated transaminase levels during highly active antiretroviral therapy (HAART). Patients with HIV/HCV coinfection should not be denied HAART. Instead, they should be followed-up with monthly liver function tests and referred to specialists if grade 3 or 4 liver enzyme elevations occur.
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Affiliation(s)
- Maurizio Bonacini
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA, USA.
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