Letters to the Editor
To the Editor:
Nunes et al1 tested the performance of noninvasive fibrosis markers in patients coinfected with HIV and hepatitis C virus (HCV). This is an important issue, because biopsy has risks, discomforts, and limitations as a diagnostic method.2,3 Although the study shows promising results, we are concerned about the authors' conclusions that “the performance of the evaluated noninvasive markers of liver fibrosis is equivalent in HCV/HIV-coinfected and HCV-infected subjects.” We believe that the authors could not reach this conclusion, because the 97 subjects studied represent only 26% of the original 370 HCV-infected participants of the Hepatitis C, HIV and Related Morbidity CHARM cohort.
There are many reasons to believe that these two groups are distinct. Data comparing characteristics of the subjects submitted to biopsy with those not submitted were not shown. The role of liver biopsy in HIV/HCV-coinfected patients is controversial.4 Some groups argue that liver biopsy should be performed before treatment, and others argue that HIV patients with immunologic status preserved can be treated for HCV without liver biopsy.4 We do not know which belief prevailed in the cohort from which the patients were selected.
Therefore, we believe that the conclusions about the performance of the methods tested by Nunes et al1 still cannot be generalized to the whole HCV/HIV population, because the sample included in the study is not representative of all HCV/HIV-coinfected patients. Conclusions should be restricted to those patients with the immunologic profile shown in Table 1 of the study: patients with regular to good immunologic conditions, a mean CD4 count of 499 cells/μL, and most with an undetectable HIV viral load.
Fernando H. Wolff, MD
Regis Kreitchmman, MD
Sandra C. Fuchs, MD, PhD
Postgraduate Program in Medical Sciences Faculdade de Medicina (Medical School) Universidade Federal do Rio Grande do Sul Porto Alegre, RS, Brazil
1. Nunes D, Fleming C, Offner G, et al. HIV infection does not affect the performance of noninvasive markers of fibrosis for the diagnosis of hepatitis C virus-related liver disease. J Acquir Immune Defic Syndr
2. Afdhal NH, Nunes D. Evaluation of liver fibrosis: a concise review. Am J Gastroenterol
3. Regev A, Berho M, Jeffers LJ, et al. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection. Am J Gastroenterol
4. Soriano V, Puotib M, Sulkowski M. Care of patients with hepatitis C and HIV co-infection. AIDS