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Advanced Fibrosis Triples All-Cause Mortality With HCV and HIV
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50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), September 12-15, 2010, Boston
Mark Mascolini
Biopsy-determined F3-4 fibrosis was the only factor that independently predicted death in a study of 363 people coinfected with hepatitis C virus (HCV) and HIV [1]. Treatment of HCV infection nonsignificantly lowered the risk of death.
Researchers at the Germans Trias i Pujol University Hospital in Barcelona assessed potential predictors of death in 363 HCV/HIV-infected people who had a liver biopsy between 1997 and 2006. Everyone had stable HIV infection and no other illnesses, and no one reported active illicit drug use or heavy alcohol consumption. Follow-up lasted an average 4.5 years (+/- 2.7).
Biopsy determined that 258 people (71%) had F0-2 fibrosis, while 105 had F3-4 fibrosis. Median CD4 count at biopsy was significantly lower in people with advanced fibrosis (431, interquartile range [IQR] 320 to 604.5) than in those with less advanced fibrosis (520, IQR 381.5 to 735.5) (P = 0.005). People with more advanced fibrosis also had a lower nadir (lowest-ever) CD4 count: median 164 (IQR 96 to 237) versus 208 (IQR 114 to 300) (P = 0.031). And people with F3-4 fibrosis were significantly older: median 39 years (IQR 36 to 42.5) versus 37 (IQR 34 to 41) (P = 0.05). Gender, HIV transmission group, combination antiretroviral therapy at biopsy, HIV load, HCV genotype, interferon during follow-up, and length of follow-up did not differ significantly between the F0-2 group and the F3-4 group.
Twenty-three people (6.3%) died during follow-up for a rate of 1.41 per 100 person-years. End-stage liver disease accounted for most deaths. Liver cancer caused 6 deaths. Mortality was significantly lower in people with F0-2 group (0.85 per 100 person-years) than in those with F3-4 fibrosis (2.86 per 100 person-years) (P = 0.002). Treatment with interferon tended to lower mortality (0.89 versus 1.77 deaths per 100 person-years), but not significantly (P = 0.143).
Multivariate analysis identified F3-4 fibrosis as the only independent predictor of mortality, more than tripling the risk (odds ratio 3.482, 95% confidence interval 1.433 to 8.461, P = 0.006). HCV therapy lowered the risk of death about 60%, but that association was not statistically significant (odds ratio 0.424, 95% confidence interval 0.158 to 1.136, P = 0.088). Age at biopsy, gender, and CD4 count did not affect the risk of death in this analysis.
The investigators urged improved management of HCV/HIV-infected people to prevent fibrosis progression. They called for "intensive screening" of coinfected people to detect liver cancer earlier.
Reference
1. Sanmartin R, Martinez E, De Felipe E, et al. Impact of liver-fibrosis stage on mortality in a cohort of HIV/HCV with a mean follow-up of 4.5 years. 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). September 12-15, 2010. Boston. Abstract H-1672.
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