for Health Care Providers
1: A decompensated cirrhotic with HIV/HCV coinfection: What can we do and what can't we do?
The patient is a 44-year-old man who is coinfected with HIV and hepatitis C. He is currently asymptomatic. He has cirrhosis and a history of heavy alcohol use, although he no longer drinks. An EGD performed 1 year ago (February 2005) showed grade III esophageal varices. Ascites has improved significantly with diuretic treatment.
The patient tested positive for HCV (genotype 1a) 4 years ago (May 2002). He was tested at that time because his girlfriend had just tested HCV positive. However, 5 years earlier (1997), he had tested HCV negative.
He tested positive for HIV 13 years ago (1993), and is receiving antiretroviral therapy. His current regimen is composed of abacavir, tenofovir, lamivudine, and efavirenz. His viral load is undetectable and recent CD4 counts have been between 145 and 225 cells/µL.
The patient has not used alcohol for 10 years (since 1996), and he stopped intravenous drug use 13 years ago (1993). He smokes tobacco and marijuana regularly, but does not use any other illicit drug. Unfortunately, his girlfriend is also HIV/HCV coinfected.
A physical examination revealed nothing remarkable. His blood pressure was 120/70 and pulse was 70 beats per minute. His weight is 225 lbs with a BMI of 31.6.
His white blood cell count is slightly low at 3,200 cells/uL. Other laboratory values included:
- Hematocrit (Hct): 33%
- Platelets: 57,000 cells/µL
- Albumin: 3.5 g/dL
- Total bilirubin: 2.6 mg/dL
- Direct bilirubin: 0.9 mg/dL
- Alpha-fetoprotein (AFP): 15.4 ng/mL
- CD4 count: 210 cells/µL
- HIV viral load: <50 copies/µL
Question 1: What is the optimal management for patients with cirrhosis who are not quite candidates for transplant but already have portal hypertension and intermittent ascites and have blood counts (severe thrombocytopenia in this case) that make treatment with peginterferon and ribavirin problematic?
Speaker 1: Unfortunately, most of us have patients just like this gentleman in our clinics. Right? Does anybody have suggestions about how to manage this patient?
Participant: Weight loss for one. His body mass index is high.
Participant: And he also needs management of the portal hypertension.
Speaker 2: Yes, and we see he's on a beta-blocker.
Speaker 1: This is a difficult situation because the patient is already pretty sick. I feel he is too sick to treat with interferon, not only because his low platelet count of 57,000 cells/µL is problematic, but also because of the ascites, the large varices, and the bilirubin level, which is already at 2.6 mg/dL. We want to be very aggressive in trying to treat patients but, unfortunately, I would describe his condition as "too sick to treat."
However, I do believe that he should be screened for hepatocellular carcinoma (HCC), because he is a cirrhotic patient. I would discuss with him the role of HCC surveillance. Some patients, depending on where they live or what they're interested in, may not want to be in a screening program. Whatever methods you use for HCC screening, they should be considered for patients who are clearly cirrhotic.
Any thoughts about liver transplant referral, which is another controversial subject in regard to coinfected patients?
Speaker 2: Yes, two of the VA transplant centers are currently accepting HIV-infected patients for consideration of liver transplant. Some centers will not accept a candidate with a CD4 count in this patient's range. It is already pushing the envelope to perform transplants in patients with HIV infection. It is very hard to convince our surgeons to do a transplant in an HIV/HCV-coinfected patient. We're a lot more comfortable with HBV-infected patients, because the natural history of HCV is quite aggressive after transplant in patients who are coinfected with HIV. If this were our patient, we would treat him for cirrhosis and follow him as we would an end-stage cirrhotic patient.
Speaker 1: I'd like to bring up a few other points about cirrhotic patients such as this one. First, we should carefully limit the use of NSAIDs. Cirrhotic patients are quite predisposed to liver failure and renal failure. They depend on renal artery perfusion. It is important to be careful with ibuprofen and aspirin in these patients--and many VA patients take aspirin. This is the kind of issue that should be given strong consideration in decompensated cirrhotic patients because limiting the use of NSAIDs may help prevent bleeding from the portal hypertensive gastropathy or varices. At the same time, we see so many patients who have been told to avoid Tylenol completely. However, it is OK for these patients to take up to 2 grams of Tylenol a day, and Tylenol is an important medicine to have as an option for pain control. So Tylenol is alright, but I definitely would limit NSAIDs, though this is not the common thinking. Finally, we see that this patient is still smoking cigarettes and marijuana. Again, we've all seen patients for whom this is an issue. I think that it is often productive to have a frank conversation with them and help them realize that they may need a transplant in the future and that smoking marijuana will eliminate that option. I would address the smoking issue in that context.
Participant: Even if this patient stops using marijuana and becomes eligible for transplant, what about his girlfriend, who is also coinfected? It is extremely unlikely that she would be able to receive a transplant as well.
Speaker 2: That's very reasonable point. You'd have to discuss it with your transplant center.
Speaker 1: So, performing transplants in HIV-positive patients involves several controversial issues. It is important to discuss these issues and get to know the policies of the transplant centers to which you are referring patients. All these things are evolving a bit.
Participant: You mentioned avoiding NSAIDs, but with HIV/HCV-coinfected patients, you also have to look at the antiretrovirals they're on and be very careful, because some of these drugs can be hepatotoxic and a lot of them can cause lipid levels to rise. So, you would consider putting these patients on a statin, but if they're hepatitis C infected, managing them can become really tricky. You have to learn to juggle a lot of things.
Speaker 1: Absolutely. These issues are complex. On our website, we have a set of recommendations, Management and Treatment of Hepatitis C Virus Infection in HIV-Infected Adults, that the HCRC programs put together to help all of us with these patients. You can download a PDF version of this from our website, and it was published in Am J Gastroenterol. 2005 Oct;100(10):2338-54. Erratum in: Am J Gastroenterol. 2005 Nov;100(11):2609. .
- There are patients who have cirrhosis but cannot be treated with pegylated interferon and ribavirin because of their ascites, hyperbilirubinemia, or thrombocytopenia.
- Management of a decompensated cirrhotic can include screening for hepatocellular carcinoma, avoiding NSAIDs, avoiding alcohol, managing ascites with diuretics, preventing variceal bleeds with beta-blockers, treating HIV with ART but avoiding hepatotoxicity, avoiding use of drugs (including marijuana), and promoting weight loss.
- Some centers will perform liver transplants for HIV-infected patients. The policies of the transplant referral center should be investigated to see if the management of a patient who may need a transplant evaluation can be optimized.
- In an HIV-infected patient, transplant readiness may include optimal HIV control with adequate CD4 counts. The cutoffs may vary across different transplant centers.
- Ann Busch, Liver Transplant Clinical Nurse Specialist, Portland VAMC
- Sue Currie, Associate Director, HCRC, San Francisco VAMC
- Guadalupe Garcia-Tsao, Director, HCRC, Connecticut VAMC
- Douglas Heuman, Liver Transplant Program Director, Richmond VAMC
- Alexander Monto, Director, HCRC, San Francisco VAMC
- Roberta Ruimy, Manager, Liver/Kidney Transplant Programs, Portland VAMC
- Brenda Salvas, Health System Specialist, Manager, Liver and Kidney Transplant Program, VA Transplant Program, VA Central Office, Washington, DC
- Anna Sasaki, Staff Physician, Portland VAMC
- Kristine Stick, Nurse Practitioner for Hepatology, San Francisco VAMC
- Suchat Wongcharatrawee, Associate Director HCRC, Connecticut VAMC
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