Mortality from liver disease increasing in HIV-positive patients

End-stage liver disease has become a major cause of death among patients infected with HIV, according to a report in the February 1st issue of Clinical Infectious Diseases. Many HIV-seropositive patients are coinfected with hepatitis C virus (HCV), the authors explain, and the course of HCV-related liver disease from chronic active hepatitis to end-stage liver disease and death is accelerated in these patients.

Dr Barbara McGovern, and colleagues, from New England Medical Center, Boston, Mass, examined the causes of death among HIV-positive patients who died at their institution, Lemuel Shattuck Hospital in Jamaica Plain, Mass, during 1991 (group 1), 1996 (group 2), and 1998 to 1999 (group 3). Most of the patients likely acquired HCV and/or HIV infection as a result of injection drug use, the report indicates. Along with antiretroviral therapy, most of the individuals received other potentially hepatotoxic agents, the researchers note, and most patients who underwent testing had antibodies to HCV and to hepatitis B virus (HBV).

Only 11.5% of the deaths in group 1, during the years before highly active antiretroviral therapy (HAART), resulted from complications of end-stage liver disease, Dr McGovern and associates found. When HAART was being introduced, during the time of the group 2 patients, the mortality from end-stage liver disease rose only slightly, to 13.9% of the deaths. In group 3, however, well into the era of HAART, 50% the deaths were associated with end-stage liver disease, the authors report, with the remainder distributed among sepsis, cytomegalovirus disease, cryptococcal meningitis, and other causes.

“End-stage liver disease has become the leading cause of death of HIV-seropositive patients at our institution,” the authors conclude. “This trend is occurring in the background of a dramatic decline in the incidence of opportunistic infections and the rate of AIDS-related mortality in the era of HAART.”

“HIV providers need to evaluate HIV and HCV simultaneously,” Dr McGovern suggested. “Just as they get a CD4 cell count and HIV RNA on that first visit, they need to check hepatitis serologies and HCV RNA, and vaccinate as needed and get a liver biopsy in patients who are viraemic.”

Comment

In the majority of abstracts assessing mortality in HIV-infection in the era of HAART presented at the 8th CROI, liver disease was the 2nd largest cause of death after AIDS events.