To the Editor:
Elevated liver enzyme levels, detected through a liver function test (LFT), are markers of liver or biliary tract diseases. Alanine aminotransferase (ALT) is a more specific indicator of liver inflammation. These abnormal findings are frequent in HIV-infected patients, and their diagnosis and management may be difficult because of intricacies of the pathogenic mechanism involved.1 Recently, Sterling et al2 evaluated the prevalence and factors associated with abnormal LFT results, particularly focusing on patients without viral hepatitis coinfection. They reported a higher prevalence of elevated LFT results in HIV-positive patients without hepatitis C virus (HCV)/hepatitis B virus (HBV) infection (15% to 20%) than in the general population (8%). Increased ALT was associated in this study with hypertension, HIV viral load (VL), Lymphocytes T-CD4+ count lower than 200 cells/mL, metabolic syndrome, and absence of protease inhibitor (PI) use. They did not study the presence of occult HCV and/or HBV infection in those patients with negative serology.2
During a 7-month period (September 2004 to March 2005), all HIV-positive patients ≥18 years old at a general hospital in Buenos Aires who have their scheduled control of HIV VL followed up at the National Reference Center for AIDS were asked to provide consent for the use of their serum samples to evaluate HBV and HCV serology status and ALT level. Only the first blood sample of patients with more than 1 control of HIV VL during this period was included. Diagnostic procedures included HCV antibody (Ab) by microparticle enzyme immunoassay (MEIA) (AXSYM; Abbott Diagnostics, Chicago, IL) and HCV 3.0 Murex (Abbott Diagnostics, Chicago, IL) and hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis B e antigen (HBeAg), hepatitis B e specific antibodies (HBeAb) and hepatitis B core antibody (HBcAb) (immunoglobulin M [IgM] and total) by MEIA. ALT levels were determined by Biosystem (BioSystems S.A. Costa Brava 30, Barcelona, Spain) (normal value of 41 IU/mL). The presence of HCV RNA was determined for all samples proven to be reactive in any of the serologic tests or with abnormal LFT results. Two different reverse transcriptase polymerase chain reaction (RT-PCR) qualitative approaches were used: an in-house assay previously described3 and a commercial assay (AMPLICOR HCV test kit, version 2.0, lower detection level of 50 IU/mL; Roche Molecular Systems, Pleasanton, CA). Specimens containing detectable HCV RNA were genotyped by using the restriction fragment length polymorphism (RFLP) method previously described.4
For quantitative purposes, a commercial assay (Bayer VERSANT HCV RNA 3.0 Assay bDNA test kit [Bayer Diagnostics, Berkeley, CA]; ranging from 615 to 7700,000 HCV RNA IU/mL) was carried out.
The presence of HBV DNA was studied by PCR reaching an amplicon (585 nt, from nucleotide 203 to 787) of the HBV surface (S) gene, as described by Zeng et al.5 The HBV genotype was determined by phylogenetic analysis of the PCR product corresponding to the partial sequence of the S gene. For this purpose, the amplification products were sequenced directly on both strands, using the BigDye Terminator Cycle Sequencing Ready Reaction Kit (Applied Biosystems, Foster City, CA) on an ABI PRISM 3100 Genetic Analyzer (Applied Biosystems, Foster City, CA).
A total of 593 consecutive patients were included. Overall, 41.6% (n = 246) had markers of HBV infection and 20% (n = 129) had markers of HCV infection; 65 cases (11%) showed markers for both. Abnormal LFT results were found in 104 (17.5%) of the samples: 77 (74%) between 1 and 2 times greater than the upper normal limit (grade 0 to 1 according to the National Institutes of Health [NIH] National Institute of Allergy and Infectious Diseases [NIAID]6) and 27 (26%) >2 times the upper normal limit (grade 2). Clinical records were reviewed, and in 75% of these cases, a persistent abnormal ALT level was observed (ie, presented 2 of 3 determinations greater than the normal level during a 12-month period7). Among those with abnormal LFT results, 58 (56%) showed serologic markers for HBV (9 chronic carriers, 27 with an “isolated core” pattern, and 22 positive for HBcAb and HBsAb) and 54 (52%) had positive HCV serology (45 with detectable HCV RNA). Thirty-one patients presented with triple infection (HCV/HBV/HIV). Twenty-three patients (22%) presented with negative HBV and HCV serology (Fig. 1).
Among patients with serologic markers of HBV infection, 9 were positive for HBsAg (with positivity for HBeAg in 8 of them) and a median HBV VL of 5,200,000 copies/mL (range: <1000 to >40,000,000 copies/mL); all presented with an ALT grade of 0 to 1. Of the 27 samples with an isolated core pattern, HBV DNA was found in 1 sample; after sequencing, no mutations were found. None of the samples with detectable HBcAb and HBsAb were positive for HBV DNA. In the 23 samples with negative serology results for HBV and HCV coinfections, the presence of HCV RNA and HBV DNA was investigated. None of the samples exhibited HCV RNA, and only 1 was positive for HBV DNA.
Abnormal ALT was more frequent in the group of intravenous drug users, which was probably related to the higher risk of hepatitis coinfection in this population.
Among the patients in whom their antiretroviral scheme was known, 75% (81 of 104) were receiving a nonnucleoside reverse transcriptase inhibitor (NNRTI), and in 69%, the absence of PI (protease inhibitors) use was recorded, in concordance with the results of Sterling et al.2
Despite the fact that we could not find a statistically significant association between elevated ALT and CD4 cell count, we can estimate that it was a trend to have a lower CD4 count among patients with this abnormality (328 vs. 383 cells/mL; P = 0.055).
Our data show that most of the cases with abnormal ALT in our population are generally mild and are associated with active HBV/HCV infection, with many of them being detectable by means of serology assays. Considering the results of our study, the routine search for HBV DNA and/or HCV RNA in HIV-positive patients, even in the setting of elevated ALT, would not be recommended and should be implemented on a case-by-case basis.
Natalia Laufer, MD
Lucila Cassino, MSc
Federico Bolcic, MSc
Franco Moretti, MSc
Rita Reynoso, MD
Maria Belen Bouzas, Bqco
Pedro Cahn, PhD
Horacio Salomón, PhD
Jorge Quarleri, PhD
Centro Nacional de Referencia para el SIDA Departamento de Microbiologica Facultad de Medicine Universidad de Buenos Aires Buenos Aires, Argentina
1. Pol S, Lebray P, Vallet-Pichard A. HIV infection and hepatic enzyme abnormalities: intricacies of the pathogenic mechanisms. Clin Infect Dis
. 2004; 38(Suppl 2):S65-S72.
2. Sterling RK, Chiu S, Snider K, et al. The prevalence and risk factors for abnormal liver enzymes in HIV-positive patients without hepatitis B or C coinfections. Dig Dis Sci
. 2007; Oct 16 [Epub ahead of print].
3. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999-2002. Ann Intern Med
4. Quarleri JF, Robertson BH, Mathet VL, et al. Genomic and phylogenetic analysis of hepatitis C virus isolates from Argentine patients: a 6 year-retrospective study. J Clin Microbiol
5. Zeng GB, Wen SJ, Wang ZH, et al. A novel hepatitis B virus genotyping system by using restriction fragment length polymorphism patterns of S gene amplicons. World J Gastroenterol
6. ACTG Clinical Group. Division of AIDS table for grading the severity of adult and pediatric adverse events. NIH-NIAID; 2004.
7. Soriano V, Puoti M, Sulkowski M, et al. Care of patients coinfected with HIV and hepatitis C virus: 2007 updated recommendations from the HCV-HIV International Panel. AIDS