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Is their anything patients can do to control their liver enzymes?
Aug 27, 2002

Hi Doctor Wohl,

Thank you for your endless endurance in trying to aid people that are afflicted with this disease. You and all you other doctors, are very caring and humane individuals. We are all thankful for the service you provide for us here.

I had to attach the CDC finding something in regards to controlling liver enzymes. The article although informative, is a bit stressful towards patients as myself. Does this finding predict a shorter life expectancy now due to liver toxicity associated with HART therapies? Is there anything we patients can do to help our livers from elevating their enzymes? Are there any drugs in the pipeline now accessing this liver toxicity issues, if so we drug looks promising? What would you say is our prognosis with this discovery, is it drastically shorter?

Thanks a gazillion!

Gina Vogel

Better Control of Liver Enzymes Saves Lives of HIV Patients Hepatitis Weekly 08.05.02

Mild-to-moderate elevations in two liver enzymes -- increments that are commonly ignored by most physicians -- are related to an increased risk of death in people with HIV, according to a University of Pittsburgh researcher who presented the findings at the 14th International AIDS Conference in Barcelona.

The two enzymes are alanine transamine (ALT) and aspartamine transamine (AST) and are mildly elevated in up to one-third of patients with HIV. The enzymes are largely overlooked by physicians "...unless they are two to four times above the normal range," said Amy Justice, MD, associate professor of health services research at the University of Pittsburgh Graduate School of Public Health, and associate professor of medicine at the University of Pittsburgh School of Medicine.

"Our study shows that even patients whose elevations are mild to moderate have a death rate that is nearly twice that of patients with mid-range normal levels. This association with increased mortality suggests that any elevation in ALT and AST should be addressed," Justice said.

Elevations in these enzymes signal injury to liver cells, and in some cases, to other cells in the body. The condition can result from highly active antiretroviral therapy, viral hepatitis or alcohol abuse, all of which are toxic to liver cells. Liver failure is the most common cause of death in people with AIDS.

The Pittsburgh-led study was an analysis of data on more than 5,700 participants from two observational studies: Collaborations in HIV Research-US (CHORUS), composed largely of white men who contracted HIV from homosexual activity and women who contracted HIV from heterosexual activity or intravenous drug use; and the Veterans Aging Cohort Study (VACS), composed mainly of African-American men who contracted HIV from heterosexual activity or intravenous drug use. Study participants with mild-to-moderate elevations had a risk of death that was 1.73 times the risk of those with mid-range normal enzyme levels. Those with two or more times the normal levels had a 5.06 times increased risk of death. The results were consistent in both studies.

"The fact that the findings were similar in two very different cohorts suggests that these results apply to all HIV patients," said Justice. "Furthermore, the fact that the most common current cause of death among people with HIV is liver failure suggests that liver injury may be a major limiting factor in the effectiveness of current HIV treatment."

"Chronic viral hepatitis is known to substantially increase the risk of liver cancer," Justice said. "Additional research must be done to determine whether HAART exacerbates this risk or only helps HIV-positive patients live long enough to suffer the consequences of other chronic diseases such as cancer."

Response from Dr. Wohl

Certainly we must take care that HIV therapies don't do more harm than good and that is what many of spend a great deal of time thinking about. However, before we put away all those bottles of antiretrovirals it is important to recognize that a) most people on HIV therapy do not have elevations in their liver tests and b) that the most common causes of elevated liver enzymes in persons with HIV infection may not be related to HIV therapies but to alcohol and viral hepatitis.

Persons with HIV desiring to live to gray hair (if they don't have them already) should abstain from heavy alcohol use and try to avoid becoming co-infected with hepatitis B or hepatitis C (if they don't have them already). When blood is drawn at your scheduled clinic visit it is almost certainly sent for tests of the liver. Clinicians should pay attention to even mild elevations of these enzymes and treat or eliminate possible non-HIV therapy related causes. When it seems the HIV meds are the culprits, changes in these may be warranted based on the clinical situation. Thanks for your question - DW.



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