![]() Liver Disease, Cirrhosis and HIVPrimary Care of Veterans with HIVOrgan Systems and Metabolic. April 2. 00. 9. Last reviewed/updated: October 2. Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. ![]() Consult VA pharmacists for alternatives. Key Points. Chronic liver disease is common among HIV- infected patients, and is increasingly a cause of mortality and morbidity as effective ART allows persons with HIV to live longer. HIV infection may accelerate liver damage caused by HCV or HBV infection. HCV infection is particularly common among HIV- infected patients, especially those who acquired HIV through injection drug use (IDU). Long- term complications of HBV and HCV infection include cirrhosis, end- stage liver disease (ESLD), and hepatocellular carcinoma (HCC). It is essential that providers working with HIV patients be able to identify liver disease and determine whether cirrhosis has developed. Long- term management of cirrhosis is important to providing optimal prevention and treatment of complications. Extension publications including fact sheets, GardenNotes, and publications for sale. Topics include: agriculture crops, agriculture and farm management, agriculture. This diet is used to help reduce discomfort in the esophagus caused by Gastroesophageal Reflux Disease (GERD). Symptoms such as heartburn, chest discomfort. What are the signs and symptoms of breast cancer? Here are seven things that you may observe and why you should discuss them with your doctor. A lump or a thickening. Find information about diet and nutrition in UPMC's Patient Education Materials.![]() Unfortunately, there's no specific diet that's been proven to relieve depression. Still, while certain eating plans or foods may not ease your symptoms or put you. Some ARVs may cause liver toxicity (hepatotoxicity) but most can be used safely by patients with liver disease, with proper monitoring. Patients should not be undertreated for HIV because of concurrent liver disease. Note: Current information on VHA policy, guidelines, and tools related to liver disease can be found on the VA Hepatitis C website. Background. Any disease or injury that chronically affects the liver can cause fibrosis (scarring); this process ultimately may progress to cirrhosis. Cirrhosis is characterized by diffuse interlacing bands of fibrous tissue dividing the hepatic parenchyma into micronodular or macronodular areas. Veterans with HIV*Cirrhosis: 2%Decompensated liver disease: 1%HCC: 0. HCV: 2. 8%HBV: 1. Epidemiology of HIV and Liver Diseases. High morbidity and mortality: In the U. S. ESLD is now a leading cause of death in patients with HIV/HCV or HIV/HBV coinfection. HIV infection accelerates progression of liver disease associated with HCV or HBV. Other factors that cause more severe liver disease, including alcohol misuse, drug- associated hepatotoxicity, male gender, and fatty liver (steatosis), are also more common in the HIV- infected population. Potential Causes of Liver Disease, Especially among HIV- Infected Patients. Alcoholic hepatitis. Alcoholic cirrhosis. Chronic hepatitis BChronic hepatitis CNonalcoholic fatty liver disease. Drug- induced liver injury. Autoimmune hepatitis. Primary biliary cirrhosis. Primary sclerosing cholangitis. Hemochromatosis. Wilson disease. Alpha- 1 antitrypsin deficiency. Prevalence of viral hepatitis among HIV- infected individuals in the United States. HCV. 9- 2. 7% of heterosexuals. HBV. 4- 6% of heterosexuals. Risk factors for liver diseases other than viral hepatitis are common in the HIV- infected population. Abnormalities in liver enzyme levels are common among HIV- infected persons, even in the absence of HCV or HBV infection. Cross- sectional studies have shown a high prevalence of elevated AST (2. ALT (1. 5%), and alkaline phosphatase (4. Alcohol consumption is common among people with HIV infection. Rates of heavy drinking among people with HIV are almost twice those found in the general population. Approximately 8% of persons with HIV report heavy drinking in the past month. Alcohol use disorders were diagnosed in 3. HIV- infected veterans in VA care in 2. Other comorbidities associated with liver disease. Diabetes mellitus. Hyperlipidemia. Obesity. Hemophilia. Ulcerative colitis. Evaluation. At initial assessment, HIV- infected patients should be evaluated for clinical, biochemical, and virologic evidence of chronic liver disease. Frequency of reassessments depends on the presence and severity of existing disease, risk factors for liver disease (eg, IDU, alcohol misuse), and prescription of potentially hepatotoxic medications (eg, NVP). Clinical Features of Liver Diseases(see below for features of decompensated cirrhosis)History. More than 4. 0% of patients with cirrhosis are asymptomatic. Fatigue. Weight loss. Inability to concentrate. Decreased libido. Pruritus (in cholestatic liver diseases)Physical examination. Perform a thorough physical examination with special attention to the abdomen, skin, and neurologic system. Note that patients may display no abnormalities. Abnormal findings suggestive of cirrhosis include. Jaundice. Spider angiomata. Palmar erythema. Caput medusa. Palpable left lobe of the liver. Splenomegaly. Ascites. Clubbing. Asterixis. Gynecomastia. Testicular atrophy. Temporal wasting. Hypertrophic osteoarthropathy. Dupuytren contracture. Fetor hepaticus. ARVs and Hepatotoxicity. Many ARVs may cause liver damage, particularly in patients with preexisting liver disease. These include. NVP*Most PIs, particularly DRV, TPVd. T, dd. INote: ATV and IDV may cause isolated hyperbilirubinemia through inhibition of uridine diphosphate- glucuronosyltransferase (UGT) activity; this does not indicate liver disease. Biochemical Features of Liver Disease and Common Causes. Laboratory Findings and Specific Liver Diseases. Disease. Typical Findings (may not be present)Abbreviations: ANA = antinuclear antibodies; ASMA = antismooth muscle antibodies; GGT = gamma- glutamyltransferase; LKM = liver/kidney microsomes. Alcoholic liver disease. History of alcohol abuse. AST/ALT ratio often > 2: 1. AST and ALT both < 5. IU/m. L (if no other injurious processes)GGT may be . Findings that suggest the presence of cirrhosis include. The major use of abdominal imaging is for detecting complications of cirrhosis (eg, ascites, HCC, and hepatic or portal vein thrombosis) in cirrhotic patients. In patients with chronic liver disease but without cirrhosis, abdominal imaging can be completely normal or can show fatty liver, a nonspecific finding. Useful radiology studies include abdominal ultrasound, abdominal CT scan, and abdominal MRI. Staging and Classification of Cirrhosis. Child- Turcotte- Pugh Score. Originally developed to estimate the risk of death after portacaval shunt surgery; this modified version was intended to assess the risk of nonshunt operations. The score is determined by assessing clinical (subjective) complications of cirrhosis and laboratory (objective) abnormalities indicative of liver dysfunction. Child- Turcotte- Pugh Classification of Liver Disease. Points Assigned. Grade A = Total score 5- 6. Grade B = Total score 7- 9. Grade C = Total score 1. Parameter. 12. 3Ascites. Absent. Slight (or diuretic responsive)Moderate/Tense (or refractory to diuretics)Encephalopathy. None. Grade 1- 2 (or precipitant induced)Grade 3- 4 (or chronic)Bilirubin (mg/d. L)< 2. 2- 3> 3. Albumin (mg/d. L)> 3. Prothrombin time (seconds over control) or INRPT: 1- 3or. INR: < 1. 7. PT: 4- 6or. INR: 1. 7- 2. 3. PT: > 6or. INR: > 2. 3. Print table. Model for End- Stage Liver Disease (MELD) Score. The MELD score is a newer method for predicting 3- month survival. It is used for liver allocation (transplant) by the United Network for Organ Sharing (UNOS) and has been adopted for use in the nontransplant setting. It is used to determine how urgently a patient needs a liver transplant within the coming 3 months. It is the strongest predictor of mortality in HIV- infected patients with ESLD. Another ARV, FTC, is also active against HBV, but is not approved for treatment of HBV. In coinfected patients, the HBV medications must be used as combination therapy within a multidrug, fully suppressive HIV regimen to avoid development of HIV resistance. Treatment of autoimmune hepatitis: can include prednisone or immunosuppressive agents. Management of Complications of Cirrhosis and Chronic Liver Disease: Detection, Prevention, Treatment(Note: Patients with cirrhosis are best managed in collaboration with a GI specialist, particularly those with severe or recurrent complications, based on the 2. VA Hepatitis C Resource Center recommendations on management and treatment of cirrhosis. A summary of these recommendations can be found in Cirrhosis Quicknotes.)Ascites. Overview: The most common complication of cirrhosis. Primary prophylaxis: none recommended, other a than low- salt diet (1- 2 g Na/day); may liberalize salt intake if salt restriction results in poor food intake. Treatment: Diuretics (eg, spironolactone alone or together with furosemide). Start with spironolactone 5. Avoid NSAIDs because of risk of hepatorenal syndrome. Patients with massive ascites may require therapeutic large- volume paracenteses, often with albumin supplementation; should be treated in consultation with a GI/hepatology specialist. Refractory ascites may require placement of a transjugular intrahepatic portosystemic shunt (TIPS)Spontaneous Bacterial Peritonitis (SBP)Overview: Bacterial infection of ascitic fluid that occurs in the absence of an intraabdominal source of infection. Diagnosis: Polymorphonuclear leukocyte (PMN) count of > 2. Because ultrasound is particularly operator dependent, some centers where ultrasound reliability is low may choose to use either CT or MRI for surveillance imaging. Alpha- fetoprotein (AFP) should not be used alone as a screening tool for HCC unless ultrasound is not available: it has poor sensitivity and specificity. See also Liver Transplant resources for providers. Background. Chronic hepatitis C with progression to ESLD or HCC is the most common reason for liver transplantation, both within the VA system and in the United States general patient population. VA patients may be referred for liver transplantation within the VA system or at affiliated academic medical centers. Currently, approximately 1. VA system, with survival rates that meet or exceed UNOS averages. HIV- infected patients are eligible for consideration for liver transplantation at selected VA transplant centers. Referral for liver transplantation involves submission of a transplantation package to the VA Central Office; if approved, the package is forwarded to one of the national VA liver transplant centers for further evaluation.
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