Liver stiffness is a strong predictor of
hepatic complications and all-cause mortality in people co-infected with HIV
and hepatitis C virus (HCV), Spanish investigators report in the online edition of AIDS. Liver stiffness was assessed using
an ultrasound-based technique called transient elastometry (FibroScan). This can assess liver
stiffness, an accurate proxy for fibrosis without the need for a liver biopsy.
“We found that baseline liver stiffness was
the strongest predictor of developing hepatic events and of all-cause mortality
and death in HIV/HCV-coinfected patients,” write the investigators. “The
strength of our study is the large size of the study population…and the long
The availability of safe and potent
antiretroviral therapy means that the prognosis for many people with HIV is
now a normal life expectancy. However, people co-infected with HIV and hepatitis C continue to
have markedly elevated mortality rates and liver disease is an important cause
of death in these patients.
Liver fibrosis is a predictor of the risk
of liver disease and death in co-infected people. The standard assessment
tool for fibrosis is liver biopsy. However, this is an invasive procedure, has
a risk of complications and is unpopular with patients. Therefore, alternative
tests have been developed, one of which is FibroScan. This test uses a handheld ultrasound scanning device to measure the stiffness of the liver. A liver scarred by fibrosis is stiffer than a healthy liver.
Investigators at the Hospital Carlos III in
Madrid wanted to see if liver stiffness as assessed by FibroScan was a predictor of liver disease and death in their
co-infected patients. FibroScan has
been in routine use at their centre since 2004.
Their observational, retrospective study
involved 545 co-infected patients. Most (71%) were men, their mean age was 41
years, 81% had a history of injecting drug use and 4% were also infected with
hepatitis B. All but three of the participants were taking antiretroviral therapy
and 88% had an undetectable viral load. The mean duration of follow-up was 71
Liver stiffness below 7.5 kPa was
considered to equate to the Metavir F0-F1 stages (no or very mild fibrosis);
7.5-9.4 to Metavir F2 (mild fibrosis); 9.5-12.4 kPa to Metavir 3; and above
14.5 kPa as Metavir F4. Advanced fibrosis was classified Metavir F3-F4.
The investigators explored the relationship
between baseline liver stiffness and the incidence of death and liver-related
events (defined as ascites – fluid in the abdominal cavity; encephalopathy –
damage to the brain; oesophageal varices – enlarged veins in the oesophagus; and
Over a third of participants (34%) had advanced
fibrosis at baseline. Almost two-thirds of individuals received hepatitis C
therapy during follow-up and 39% achieved a sustained virological response. Twelve
participants (2%) died. Four deaths were attributed to liver disease. Liver-related
events occurred in 53% participants (10%).
After taking into account potential
confounders, the investigators established that baseline liver stiffness was
the strongest predictor of liver-complications (OR = 1.12; 95% CI, 1.08-1.16; p
< 0.0001). Moreover, liver stiffness was the only factor associated with
all-cause mortality (OR = 1.09; 95% CI, 1.01-1.19; p = 0.02).
Other factors associated with liver-related
events were male gender (p = 0.01), CD4 cell count (p = 0.02) and glucose
levels (p = 0.006).
Hepatitis C therapy that achieved a
sustained virological response was protective against liver events (p = 0.01).
“Baseline liver stiffness is the strongest
predictor of liver-related complications and of all-cause mortality in
HIV/HCV-coinfected patients on antiretroviral therapy,” conclude the authors.
“Clearance of HCV with antiviral therapy significantly reduces the risk of
developing liver decompensation events in this population.”