Tuesday, July 31, 2012

A Debate on Liver Fibrosis Progression in HIV/HCV-Coinfected Patients

A Debate on Liver Fibrosis Progression in HIV/HCV-Coinfected Patients

The rate of fibrosis progression is high early in the course of HCV infection, but whether it later declines is unclear.

In late 2011, Vogel and colleagues published a study showing that HIV-infected men with primary hepatitis C virus (HCV) infection had a higher rate of liver fibrosis progression than would be expected in early HCV infection — but that it declined upon resolution of primary HCV infection.1 Now, Fierer and colleagues have written a letter to the editor, questioning the use of transient elastography to measure fibrosis progression in that study.2

Fierer and colleagues argue that although transient elastography provides an accurate assessment of liver stiffness — and thus fibrosis — in the setting of chronic HCV infection, it might not do so during primary HCV infection, when acute inflammation is present. Inflammation can falsely elevate the liver-stiffness score, making the fibrosis stage appear to drop sharply as the acute inflammation associated with primary HCV infection subsides.

Fierer and colleagues assert that liver biopsy provides a more accurate assessment of fibrosis in the setting of primary HCV infection. In support of this assertion, they report the results of 29 liver biopsies (11 reported previously3) performed in HIV-infected men with primary HCV infection. They noted high histopathologic stages of fibrosis early in the course of primary HCV infection, which persisted through the first 1 to 2 years of infection. Contrary to what was reported by Vogel and colleagues, fibrosis stage correlated with increasing time from initial HCV infection.

Notably, both the Vogel and Fierer cohorts were very small with relatively short follow-up, which means that we still lack definitive data beyond the first 1 to 2 years of primary HCV infection. Nevertheless, these studies are important because they demonstrate that HIV-infected men who acquire HCV infection tend to have an elevated rate of fibrosis progression during the early stages of HCV infection. According to recently published data, this elevated rate is associated with increased risks for end-stage liver disease, hepatocellular carcinoma, and all-cause mortality.4 Whether early treatment of HCV infection with new antivirals will alter the course of incident HCV infection in HIV-coinfected individuals remains to be seen.
Sonia Nagy Chimienti, MD

Published in Journal Watch HIV/AIDS Clinical Care July 30, 2012

1. Vogel M et al. Liver fibrosis progression after acute hepatitis C virus infection in HIV-positive individuals. Clin Infect Dis 2012 Feb 15; 54:556.
2. Fierer DS et al. Early-onset liver fibrosis due to primary hepatitis C virus infection is higher over time in HIV-infected men. Clin Infect Dis 2012 Jul 5; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cis538)

3. Fierer DS et al. Liver fibrosis during an outbreak of acute hepatitis C virus infection in HIV-infected men: A prospective cohort study. J Infect Dis 2008 Sep 1; 198:683.
4. Limketkai BN et al. Relationship of liver disease stage and antiviral therapy with liver-related events and death in adults coinfected with HIV/HCV. JAMA 2012 Jul 25; 308:370.

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