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Severe Liver Disease Associated With Prolonged Exposure to Antiretroviral Drugs

Maida, Ivana MD; Núñez, Marina MD, PhD; Ríos, Maria Jose MD; Martín-Carbonero, Luz MD, Phd; Sotgiu, Giovanni MD; Toro, Carlos MD, PhD; Rivas, Pablo MD; Barreiro, Pablo MD, PhD; Mura, Maria Stella MD, PhD; Babudieri, Sergio MD; Garcia-Samaniego, Javier MD, PhD; González-Lahoz, Juan MD, PhD; Soriano, Vincent MD, PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 2006 - Volume 42 - Issue 2 - p 177-182
doi: 10.1097/01.qai.0000221683.44940.62
Clinical Science

Background: Liver damage is frequently seen in HIV-positive subjects, often resulting from coinfection with hepatitis B and/or C viruses (HCV), alcohol abuse, etc. However, the etiology of liver disease still remains unknown for a small subset of individuals.

Methods: Cryptogenic liver disease (CLD) was defined as persistently elevated aminotransferases levels in the absence of hepatitis C and/or B viruses replication and of other common causes of liver disease (alcohol, medications, etc). We identified cases initially meeting this definition by examining all HIV-positive subjects attended during the year 2004 in 2 large HIV clinics in Spain. Their clinical charts were retrospectively reviewed, and their assessment completed when needed to rule out other less frequent causes of liver disease. The stage of liver fibrosis was assessed by liver biopsy and/or elastography. To assess which factors could be associated with CLD, HIV-positive controls were chosen and matched by age, gender, and CD4 status.

Results: CLD was diagnosed in 17 (0.5%) out of 3200 HIV-positive patients. Their mean age was 43 years, 82.4% were male, and 76% had acquired HIV through homosexual relationships. The mean time from HIV diagnosis was >15 years, and all patients had been exposed to antiretroviral therapy. Nevirapine, stavudine, and didanosine were the drugs more frequently used by this subset of patients. None of them had liver function test abnormalities before initiating antiretroviral therapy. Advanced liver fibrosis (F3-F4 Metavir scores) was recognized in 10 (58.8%) individuals, and 9 (52.9%) had developed symptomatic liver complications, including ascites (8), portal thrombosis (6), variceal bleeding (5), and encephalopathy (2). In the case-control analysis, prolonged didanosine exposure was the only independent predictor of developing CLD in this population.

Conclusions: CLD is an uncommon condition in HIV-positive individuals and might be associated with prolonged didanosine exposure. It may evolve causing severe liver complications, with variceal bleeding and portal thrombosis being particularly frequent.

From the *Department of Infectious Diseases and †Hepatology Unit, Hospital Carlos III, Madrid. Spain; ‡Department of Internal Medicine, School of Medicine, University of Sassari, Sassari, Italy; §HIV Unit, Hospital Virgen Macarena, Seville, Spain.

Received for publication October 10, 2005; accepted March 22, 2006.

This work was supported in part by grants from Fundación Investigación y Educación en SIDA (IES), Red de Investigación en SIDA (RIS project 173), Red de Investigación en Hepatitis (RTIC G03/015), and the VIRGIL Network.

The authors have no conflict of interest.

Reprints: Vincent Soriano, MD, PhD, Department of Infectious Diseases, Hospital Carlos III, Calle Sinesio Delgado 10, Madrid 28029, Spain (e-mail:

Highly active antiretroviral therapy (HAART) has dramatically changed the life expectancy of HIV-positive individuals, reducing the risk of opportunistic infections and deaths.1,2 However, other illnesses such as liver cirrhosis have emerged as important causes of morbidity and mortality in this population.3-5 Besides hepatitis B (HBV) or C (HCV) viruses, other multiple factors may cause liver damage in HIV-positive individuals, including opportunistic pathogens, tumors, autoimmune diseases, alcohol abuse, and prescription of potentially hepatotoxic medications. However, persistent liver enzyme elevation in the absence of any recognizable cause is seen only rarely in HIV-positive patients. The role of HIV itself, a new unknown hepatotropic agent, and/or some antiretrovirals has been postulated for these cases.6,7

Herein, we describe a group of HIV-positive individuals with liver disease of unknown origin, in which extensive studies were conducted to rule out potential known causes of liver damage. The frequency of this entity and its clinical presentation and possible causes were assessed.

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Cryptogenic liver disease (CLD) was defined as persistently elevated aminotransferase levels in the absence of replicative HCV and HBV infections or other common causes of liver disease (alcohol abuse, hepatotoxic medications, etc).8 Normal values of liver enzymes were 10 to 55 IU/L for ALT and 10 to 40 IU/L for AST. We identified subjects initially meeting these criteria while examining HIV-positive patients attending 2 large HIV clinics in Spain-one in Madrid and another in Seville-in the year 2004. The clinical charts of these individuals were retrospectively reviewed, and their assessment completed when needed to rule out other less frequent causes of liver disease, including autoimmune hepatitis, nonalcoholic steato-hepatitis (NASH), hemochromatosis, Wilson disease, porfiria, á1-antitrypsin deficiency and syphilis. Moreover, given the nature of this study, further studies were undertaken to exclude any possible known cause of liver damage.

The presence of "occult" HBV and HCV infections was excluded after testing plasma and peripheral blood mononuclear cells for the presence of HBV DNA and/or HCV RNA using sensitive real-time polymerase chain reaction assays, as described elsewhere, which have a detection limit of 6 and 10 IU/mL, respectively.9,10 The presence of genetic sequences of cytomegalovirus and transfusion transmitted virus were excluded in plasma using specific polymerase chain reaction tests.11,12 Patients with significant obesity, grade 3 to 4 dyslipidemias, hyperglycemia, insulin resistance, and/or showing ultrasonographic findings compatible with fatty liver disease were also excluded because these conditions have typically been associated with NASH.

The stage of liver fibrosis was assessed by liver biopsy and/or elastography, the latest using FibroScan (Echosens, Paris, France), a new noninvasive tool recently validated to assess liver fibrosis.13,14 In patients from whom a liver biopsy could be obtained, an experienced pathologist examined the tissue in detail searching for any recognizable cause of liver damage. To investigate which factors could be associated with the development of CLD, a group of HIV-positive controls with normal liver function tests was selected and matched by age, gender, and CD4 status.

A case report form was built in which information on demographics (age, gender, risk category), date of HIV diagnosis, duration of antiretroviral treatment, exposure to different antiretrovirals, and use of other medications was recorded. Information regarding the nadir CD4 count and baseline plasma HIV RNA and the current values for CD4 counts, plasma HIV RNA, transaminase levels, total bilirubin, prothrombin time, albumin, and most recent ultrasonographic findings were also recorded.

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Control Group

Once the CLD cases were identified, we chose a control for each who met the following inclusion criteria: HIV infection, absence of chronic HBV and/or HCV infections, and repeatedly normal transaminases levels. Patients were matched by age, gender, and CD4 counts.

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Statistical Analyses

χ2, Student t, and Mann-Whitney U tests were used to compare categorical and continuous variables between groups, respectively. Univariate and multivariate logistic regression analyses were performed to identify factors associated with CLD. For all analyses, a 2-sided P value of 0.05 was considered significant. All analyses were performed using the statistical software package SPSS, version 10.0 (SPSS Inc, Chicago, IL).

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A total of 17 (0.5%) out of 3200 HIV-positive patients met the CLD criteria. The main demographic characteristics are summarized in Table 1. The majority (14/17, 82.4%) were male and had acquired HIV infection through homosexual relationships (13/17, 76%). Their median age was 42 years (range, 27-57). The median time since HIV diagnosis was over 15 years (range, 5-21).



The median time from the initial diagnosis of CLD was 5 years (range, 1-15). All subjects had been exposed to antiretroviral therapy, and the majority (88.2%) were taking HAART and had undetectable viral load at the time the study was conducted in the year 2004. All except 1 patient had CD4 counts >200 cells/μL (Table 2). The median time of exposure to the most potential hepatotoxic antiretrovirals was 49 months (range, 22-98) for didanosine (ddI), 21 (range, 0-59) for nevirapine (NVP), 36 (range, 8-74) for stavudine (d4T), and 0 (0-5) for ritonavir (RTV). None of these individuals was taking any other potentially hepatotoxic drug.



The main liver-related features are summarized in Table 3. Interestingly, parameters of hepatic function were within normal limits in most patients. The histologic findings based on either liver biopsy and/or elastography were as follows: F0-F1 in 7 (41%), F3 in 5 (29%), and F4 in 5 (29%) patients. A liver biopsy could be obtained from 5 patients and unfortunately did not reveal findings other than different unspecific degrees of liver fibrosis, microvesicular steatosis, and inflammation. For the remaining subjects with or without clinically manifest liver cirrhosis, patients refused a liver biopsy. In them, liver fibrosis was assessed through elastography, a noninvasive procedure.13,14



Nine (52.9%) out of 17 patients developed portal hypertension. Episodes of ascites were recorded in 8 (47%), portal thrombosis in 6 (35.2%), bleeding from grade III-IV esophageal varices in 5 (29.4%), and recurrent episodes of hepatic encephalopathy in 2 (11.7%). None of the patients had died since the time of first diagnosis of CLD until the last control in December 2005. Moreover, removal of ddI and/or d4T was followed by normalization of liver enzymes and steady recovery with no further episodes of liver decompensation in 5 out 7 patients.

Table 4 summarises the main features of the CLD cases and controls. There was a trend toward higher CD4 counts and higher plasma HIV RNA in controls compared with CLD cases. Similarly, CLD cases were more often homosexual men than controls, but the difference did not reach statistical significance. Despite a more extensive exposure to antiretroviral therapy in controls than CLD cases, the length of exposure to ddI was the only independently and significantly associated predictor of CLD. Overall, patients with CLD had received ddI for a median of 49 months compared with 29 months in controls (100% of cases and 94% of controls, respectively). In contrast, exposure to NVP and/or d4T tended to be less frequent and/or shorten in CLD cases than that in controls. Multivariate logistic regression analysis identified longer ddI exposure as the only factor associated with the development of CLD (Table 5).





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We have reported a series of cases of liver disease of unknown origin in HIV-infected individuals. Hepatic complications developed in a substantial proportion (53%) of these patients. Occult chronic hepatitis B and C and other uncommon liver conditions were ruled out reasonably in all patients. To our knowledge, this is the first report of a relatively large group of CLD in HIV-positive individuals. The current prevalence of CLD seems to be low, around 0.5%, but it could be on the rise because exposure to some antiretroviral drugs seems to be involved in its pathogenesis. It will be of interest to know whether similar cases have been identified by other groups.

In the general population, CLD is a rare entity with rates below 0.01%15-17 and NASH accounts for a large proportion of cases. In this way, obesity, hyperglycemia, and hyperlipidemia are frequently associated and predisposing conditions. Although we could not exclude definitively NASH in our patients because a liver biopsy could not be obtained in all cases, we excluded all individuals with signs of fat infiltration in the liver by ultrasonograhy, or having dyslipidemias, increased body mass index, hyperglycemia, and/or insulin resistance. However, it should be highlighted that the hepatic tissue taken from the 5 patients who underwent a liver biopsy uniformly showed microvesicular steatosis, which could reflect mitochondrial damage.7,18

Although HIV itself has been associated to specific organ damage in infected persons, causing HIV-associated dementia,19 nephropathy,20 or enteropathy,21 our findings do no support a direct role of HIV as cause of CLD. First, the duration of HIV infection was longer in controls than CLD cases. Second, there was no evidence of higher plasma viremia and/or lower CD4 counts in CLD cases than controls, even when considering nadir values before initiating antiretroviral therapy. Finally and most importantly, no liver enzyme elevations were noted in CLD cases before initiating antiretroviral drugs.

Although antiretroviral therapy is clearly of benefit in most HIV-infected persons because it provides complete virus suppression and significant immune recovery, the hepatotoxicity of antiretroviral agents is a matter of growing concern.22 Aside from acute episodes of liver toxicity associated with some antiretroviral drugs (ie, NVP and efavirenz),23 long-term consequences of iatrogenic liver damage need to be assessed more carefully in HIV-infected persons. For example, recent reports have highlighted that prolonged NVP exposure could be associated with liver enzymes elevations and/or enhanced liver fibrosis, particularly in subjects with concomitant chronic hepatitis C.24-27 On the other hand, potent antiretroviral therapy may halt the deleterious impact of HIV-related immunodeficiency on the faster liver fibrosis progression seen in HIV/HCV-coinfected patients.28-30 In agreement with those observations, recent clinical findings from large cohorts of HIV-infected individuals have highlighted that although HAART may be generally of benefit to reduce the incidence of liver-related complications in patients with underlying HBV and/or HCV infections,31-33 hepatic morbidity might be increased as a result of antiretroviral exposure.34,35

In the case-control study, the only single predictor of developing CLD in our population was long-term exposure to ddI. This nucleoside analogue is known to produce hepatic mitochondrial damage,36,37 and patients with HCV-related liver cirrhosis may be prone to liver decompensation.38 Moreover, ddI treatment has occasionally been associated with hyperlactatemia and lactic acidosis in which liver damage was a prominent part of the syndrome.39,40 However, in our knowledge, our study is the first to demonstrate that prolonged exposure to ddI could be associated specifically with chronic liver disease and severe hepatic impairment. Of note, 3 of our patients had received ddI along with hydroxyurea, which is known to enhance the intracellular metabolites of ddI and eventually their toxic effects.41

Direct histologic findings could only be collected from 5 of our subjects in whom a liver biopsy was performed. Two showed liver cirrhosis and the others showed mild fibrosis. Besides fibrosis and inflammation, different degrees of microvesicular steatosis were present in all cases. Moreover, most CLD cases showed elevated GGT and alkaline phosphatase, and progressive cholestasis has already been reported in several cases of mitochondrial dysfunction in HIV/HCV-coinfected patients taking ddI along with ribavirin, which enhances the intracellular phosphorylated forms of the former.42-44 Although our patients had not been exposed to ribavirin, 3 of them had taken hydroxyurea along with ddI, as mentioned earlier. No other relevant features could be recognized in these biopsies, including features of severe NASH such as Mallory bodies, zone 3 pericellular fibrosis, hepatocyte ballooning, and/or lobular inflammation. Prior reports have underlined that there are no characteristic histopathologic findings in patients experiencing ddI-related hepatotoxicity.45 Therefore, we are confident that our findings exclude other potential causes of liver damage and may be compatible with ddI-related hepatotoxicity.

One additional striking finding in this series of CLD cases was the frequency of complications related to the portal venous system. Portal thrombosis was recognized in one third of patients. Inasmuch as screening for coagulation disorders yielded negative results in these patients, an alternative explanation is warranted. Some of the CLD cases had normal liver function tests but showed portal thrombosis. Clearly, decompensated liver disease (ascites, bleeding, etc) in these patients could not be explained by either mild fibrosis or microvesicular steatosis. Presinusoidal portal hypertension was the main feature in these patients. Nodular regenerative hyperplasia of the liver is an uncommon hepatic lesion often associated with noncirrhotic portal hypertension.46 It is believed to be associated with some drugs (ie, azathioprine and 6-thioguanine),47,48 immunologic disorders or gastrointestinal pathogens.46 Because autoimmune diseases were excluded in all our CLD patients, a putative drug-related and/or microbial etiology was the most likely cause. This condition is difficult to diagnose,49 often missed in the liver biopsy, and, in some cases, it may evolve to liver cirrhosis. Moreover, the recognition of cholestasis in all but one of the CLD cases is in agreement with such a diagnosis.46

It is noteworthy that most HIV-infected subjects with CLD in our series were men who had sex with men (MSM), whereas this group only represents 41% of our whole HIV-infected study population. Hypothetically, repeated episodes of pylephlebitis caused by gastrointestinal pathogens could be more frequent among MSM. Moreover, septic microtrombophlebitis could be favored by the massive disruption of the intestinal immunologic barrier caused by HIV infection,50 increasing the risk of portal thrombosis in subjects having a reduced portal flow secondary to iatrogenic liver damage.

In summary, we have described a series of HIV-infected individuals with liver damage of unknown etiology, some of whom developed serious liver complications, often derived from portal hypertension. Our preliminary findings suggest that antiretroviral therapy, and in particular prolonged ddI exposure, might be involved in the pathogenesis of this condition. Thus, although antiretroviral therapy may overall ameliorate liver disease progression in most patients coinfected with HCV or HBV, prolonged exposure to some antiretrovirals might be detrimental for the liver in a different subset of individuals.

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We would like to thank Xavier Forns, Mike Youle, Massimo Puoti, Stanislas Pol, and Yves Benhamou for reviewing the manuscript.

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HIV; liver; didanosine; hepatitis; antiretroviral therapy

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