TreatmentUpdate78 - Vol. 7, No. 8;- June 1997
Sean Hosein

Although initial infection with hepatitis C virus (HCV) does not immediately destroy the liver, the virus slowly spreads through that organ as infected liver cells produce more HCV. This state of continual production of HCV is called chronic infection and occurs in about 50% of HCV-infected people. Symptoms of HCV are mild, fatigue being the most common. About 20% of HCV-infected people develop severe liver damage after about 20 years of chronic infection when eventually their liver stops working (or fails). About 10% of these people will develop liver cancer.

For some people with HIV infection, HCV can cause further complications. Reports on treatments for HCV infection have appeared in TreatmentUpdate 68. Researchers in Germany have been studying the effect of HCV infection in people with and without HIV infection, trying to find out which people are at high risk for liver failure and death. It appears that measuring levels of certain liver enzymes in the blood can be useful in predicting which people are at risk of liver failure.

Study details

Doctors recruited 240 male subjects and divided them into 4 groups:

* Group A - 49 hemophiliacs with both HIV and HCV infections whose CD4+ counts were declining rapidly (from an average of 233 cells to 50 cells in a 4 year period);

* Group B - 95 hemophiliacs infected with both viruses with a more stable immune system (CD4+ counts declined from an average of 500 cells to 400 cell over a year period);

* Group C - 72 hemophiliacs infected with HCV alone;

* Group D - 24 Bisexual/gay men infected with HIV but not HCV. This group's CD4+ cell counts were similar to group A and declined at the same rate.

Most subjects were monitored for about 5 years and with the exception of the non-HIV-infected subjects used AZT and/or ddC or ddI.

Results -- who developed AIDS?

No one infected with HCV alone died during the study. About half the subjects in group A (HCV and HIV) developed AIDS, as did over 90% of subjects in group D (HIV).

Focus on liver failure

About half the deaths (10/20) in group A were due to severe liver damage and failure.

Lab tests

In general, while liver enzyme levels were higher than normal in subjects infected with HCV, researchers focussed on two particular enzymes; gamma-GT (gamma-glutamyltransferase) and AP (alkaline phosphatase). Among hemophiliacs with both HCV and HIV infections, the level of AP rose over a 4 year period by 46% (from 144 units/Litre to 210 U/L) and that of gamma-GT rose by 65% (from 58 U/L to 96 U/L). Normal ranges were 60-170 U/L for AP and 6-28 U/L for gamma-GT. These increases in liver enzymes were statistically significant. The researchers think that checking the levels of these enzymes is a useful way to predict which patients might experience liver failure.

Why does liver failure occur?

As the CD4+ cell count falls, the immune system is increasingly unable to keep HCV infection under control. Indeed, the amount of HCV in hemophiliacs with HIV is about 3 times higher than in hemophiliacs with HCV infection alone. Liver failure usually occurs in hemophiliacs with high levels of HCV.

REFERENCES:

1. Rockstroh JK, Spengler U, Sudhop T, et al. Immunosuppression may lead to progression of hepatitis C virus-associated liver disease in hemophiliacs coinfected with HIV. American Journal of Gastroenterology 1996;91(12):2563

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