Good survival rates for HIV/HCV-coinfected patients with compensated cirrhosis

Medium-term survival rates in patients co-infected with HIV and hepatitis C who have compensated cirrhosis are good and comparable to those seen in hepatitis C-mono-infected individuals, Spanish investigators report in the online edition of AIDS.

Their analysis showed that 87% of patients with compensated cirrhosis were still alive after three years. However, co-infected patients with decompensated cirrhosis had a much poorer prognosis and their two-year survival rate was only 50%. “Once decompensation has occurred, prognosis rapidly worsens”, comment the authors.

HIV treatment status and baseline Child-Pugh scores (an assessment of prognosis) were significantly associated with outcomes.

Liver disease is now a major cause of serious illness and death in patients co-infected with HIV and hepatitis C.

Spanish investigators wished to establish a better understanding of the natural history of liver cirrhosis and factors associated with prognosis in co-infected patients.

Between June 2004 and June 2005 the investigators enrolled 340 co-infected patients with liver cirrhosis into a prospective study. The patients were assessed at baseline and then at six-monthly intervals.

The majority of patients (n = 248) had compensated cirrhosis (i.e. even though severe liver damage is present, the liver is still able to compensate or cope with the damage it has sustained).

Patients with compensated cirrhosis had significantly higher CD4 cell counts than individuals with decompensated cirrhosis (p = 0.0001). Predicted prognosis at baseline was much better for patients with compensated cirrhosis, and 90% had a Child Pugh score A (100% one year survival rate; 85% three year survival rate) compared to 28% of patients with decompensated cirrhosis.

The overall mortality rate was 8.55 per 100 person years. Two-thirds of total deaths were attributed to liver disease. The mortality rate for patients with decompensated cirrhosis was 27 deaths per 100 person years compared to 4 deaths per 100 person years for patients with compensated cirrhosis.

After three years of follow-up the overall survival rate was 75%. However, 87% of patients with compensated cirrhosis were alive at this follow-up interval compared to 43% of individuals with decompensated liver disease.

Most (89%) patients with a baseline Child Pugh score A were alive after three years, compared to 50% of individuals with a baseline score B, and 16% of those whose prognosis was assessed as Child Pugh C.

In the complete cohort, factors associated with poorer survival were permanent interruption of antiretroviral therapy (p = 0.0001), nadir CD4 cell count (p = 0.017), and a baseline Child Pugh score B or C (p = 0.0001).

For patients with compensated cirrhosis at baseline, factors associated with poorer survival were progression to decompensated disease, permanent interruption of HIV treatment, and a poorer Child Pugh score at baseline.

Longer duration of infection with hepatitis C, stopping HIV therapy, and a Child Pugh score B or C were all associated with a risk of progressing to decompensated cirrhosis.

“Our study emphasises the clinical utility of the Child Pugh score in this population,” note the investigators.

They also comment on the association between interruption of HIV therapy and poorer prognosis, and suggest “it is possible that HAART [highly active antiretroviral therapy] might be beneficial for co-infected patients due to relative preservation of immune function or even by decreasing HIV-induced progression of liver fibrosis or hepatocyte apoptosis.”

Finally, the investigators conducted an analysis involving patients with compensated cirrhosis at baseline that received hepatitis C therapy during follow-up. A sustained virological response to this treatment did not improve survival.

“It is possible that the reason we have not found a survival benefit…is lack of power and/or insufficient follow-up,” explain the investigators. They add that the probability of patients who responded to hepatitis C therapy dying, developing liver cancer, or needing a transplant was low.

“Our study shows a relatively good three year survival of HIV-hepatitis C-co-infected patients with compensated liver disease,” conclude the authors, adding “further follow-up is needed to confirm a possible survival benefit for patients with cirrhosis who achieve a sustained virologic response.”