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The recent availability of non-invasive tools to measure liver fibrosis has allowed examination of its extent and determination of predictors in all patients with chronic hepatitis C virus (HCV) infection. On the other hand, most information on hepatic fibrosis in HCV/human immunodeficiency virus (HIV)-coinfected patients has been derived from liver biopsies taken before highly active antiretroviral therapy (HAART) was widely available. All consecutive HCV patients with elevated aminotransferases seen during the last 3 years were evaluated and liver fibrosis measured using transient elastography (FibroScan®) and biochemical indexes. Patients were split according to their HIV serostatus. A total of 656 (69.6%) HCV-monoinfected and 287 (30.4%) HIV/HCV-coinfected patients were assessed. Mean CD4 count of coinfected patients was 493 cells/µL and 88% were under HAART (mean time, 4.2 ± 2.4 years). Advanced liver fibrosis or cirrhosis was recognized in 39% of the coinfected and 18% of the monoinfected patients (P < 0.005). A good correlation was found between FibroScan® and biochemical indexes [AST to platelet ratio index (r = 0.405, P < 0.0001), FIB-4 (r = 0.393, P < 0.0001) and Forns (r = 0.407, P < 0.0001)], regardless of the HIV status. In the multivariate analysis, age >45 years, body mass index (BMI) >25 kg/m, and HIV infection were independently associated with advanced liver fibrosis or cirrhosis. HIV/HCV-coinfected patients have more advanced liver fibrosis than HCV-monoinfected patients despite the immunologic benefit of HAART.
Before the advent of highly active antiretroviral therapy (HAART), most deaths in HIV-infected patients were on account of acquired immunodeficiency syndrome (AIDS)-related illnesses. The improved life expectancy of HIV-infected persons receiving HAART has permitted those complications on account of other concurrent diseases to become manifest. In this regard, no doubt chronic hepatitis C virus (HCV) coinfection has attracted considerable attention within the last few years. Progressive hepatic fibrosis, up to the development of cirrhosis, is a feature of almost all chronic liver diseases. HIV-coinfection accelerates the progression of HCV-related fibrosis, particularly in patients with elevated alcohol consumption and/or severe immune suppression. A growing number of deaths in HIV-infected persons are currently on account of complications of end-stage liver disease secondary to chronic hepatitis C, including the development of hepatocellular carcinoma. Fortunately, HIV/HCV-coinfected patients under effective HAART seem to benefit from slower liver fibrosis progression compared with patients with uncontrolled HIV disease. However, this assessment has been derived from a selected group of patients, as those who accepted a liver biopsy in the workup for interferon-based therapies, and therefore may not apply to all HIV/HCV-coinfected patients. Moreover, it is unclear whether long-term exposure to HAART may enhance liver fibrosis by other mechanisms, including hepatic steatosis, and whether the expected benefit of HAART on HCV-related liver fibrosis throughout immune recovery may be blunted.
Liver biopsy is considered the 'gold standard' for assessing hepatic fibrosis. However, this is an invasive and potentially life-threatening procedure and its accuracy in assessing hepatic fibrosis has been questioned because of sampling error and inter-observer variability. Of note, histologic understaging is particularly common in patients with compensated cirrhosis. For all these reasons, non-invasive tools to measure liver fibrosis have been developed and are entering rapidly into the clinical practice. They are mainly represented by serum fibrosis markers and imaging techniques. Among the latest, transient elastography (FibroScan®, Echosens, Paris, France) is a rapid tool that reliably measures liver stiffness by means of wave emission. The correlation between the extent of hepatic fibrosis assessed both by histology and FibroScan® has proven to be relatively good in patients with chronic hepatitis C, regardless of the HIV infection.
The aim of this study was to assess the prevalence of advanced liver fibrosis and cirrhosis using transient elastography and biochemical markers in a large group of patients with chronic hepatitis C seen within the last 3 years at two large European clinics, and to identify such of those factors that are associated with the severity of liver damage.
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