HIV and LIVER

1. HIV and LIVER Dr.Bujji Babu

2. HIV & LIVER LIVER IS THE COMMONEST SITE OF DISEASE IN PATIENTS OF HIV INFECTION SYMPTOMS OF HEPATOBILIARY DISEASE AND / OR BIOCHEMICAL ABNORMALITIES OCCUR IN THE MAJORITY OF PATIENTS WITH HIV DISEASE 80% HAVE ABNORMAL LFT AT SOME POINT DURING THE COURSE OF HIV DISEASE 61% HAVE > ALT & 51% ALPHOS LIVER DISEASE IS THE LEADING CAUSE OF DEATH ClinInfDis 2001 J Acq Immun 2001

3. HIV &LIVER HEPATIC INVOLVEMENT BY HIV OPPERTUNISTIC INFECTIONS OF LIVER IN HIV HIV RELATED BILIARY TRACT DISEASE COINFECTION OF DISEASES IN TROPICS DRUG INDUCED LIVER DISEASE (HAART) LIVER NEOPLASMS IN HIV

4. HIV HEPATITIS RECOGNIZED AS DISTINCT CLINICAL ENTITIY DIRECT VIRAL INVOLVEMENT NO SPECIFIC CLINICAL PATTERN DEMO OF +HIV MESSENGER RNA IN HEPATOCYTES DIAGNOSIS MANAGEMENT

5. HIV-LIVER INFECTIONS BACTERIAL MYCOBACTERIAL my av int(MAC) my tub FUNGAL Crypto Histo Coccoid Sporoth PROTOZOA Amoebic Leishmania

6. HIV- LIVER -TUBERCULOSIS Late event in the natural history MAC-38% Poorly formed granuloma/76% + AFB Culture diagnostic MT occurs early Well formed granuloma Liver abscess/ portal adenopathy Often aggressive clinical course Therapy Anti microbial sensitivity Long term outcome-? Drug induced toxicity

7. HIV—FUNGAL INFECTIONS As a part of disseminated disease Crypto= associated meningeal disease Candidiasis– multiple microabsces+ splenic ab Histoplasm—PUO. round oval budding yeast Coccoido– Pulm involvement/liver granuloma Liver Bx/ FNAC Diagnostic Specific therapy

8. HIV== PROTOZOAL Pneumocystis carnii pulmonary & liver(most common ext pulm) Liver Bx= nodules. Foamy eosinophilic exudates Amoebic liver abscess Ind j GE 1999 J CliGE 2001

9. HIV– VIRAL INFECTIONS MANY VIRAL INFECTIONS HEP-B & HEP-C MOST IMPORTANT (40%) PROPHYLAXIS AGAINST HEP –B WITH VACCINE

10. HIV- INFECTIONS Ind J GE 1999 74 patients 45% alcoholics 81% HBV+ 29% ANTI HCV + 5—Hep Tuberculosis 2– Liver abscess MedScin Monit 2001 SouthEastAsianJ TropMed 2000 117 cases Crypt– 21.4% Tub --16.2% CMV– 5.1% Nno secific-49.6% 2001 48.8% HEP .B 56.8% HEP.C

11. HIV- NEOPLASMS VISCERAL KAPOSIS SARCOMA/ 33-40% METS NON HODGKINS LYMPHOMA (EBV) often correlates with CD4 counts Aggressive Poor prognosis Median survival about 6 mths HAART THERAPY REDUCED INCIDENCE Int J Can2003

12. HIV—BILIARY INVOLVEMENT NON HIV RELATED BILIARY CONDITIONS Biliary Calculi/CBD diseases ACALCULOUS CHOLECYSTITIS Associated with low CD4 US diagnostic CMV infection vasculitis/sec infection HIV CHOLANGIOPATHY Specific entity

13. HIV CHOLANGIOPATHY Middle aged RUQ pain alphos Dilated biliary tract Distal CBD tapering Biopsy – nonspecific CMV/CRYPTO Paillary stenosis----------------- 15% Sclerosing cholangitis alone----20% Papillry sten+ScleroCholan --- 50% Long Ext Bile duct stricture---- 15% (AmJnMed1989)

14. HIV- CHOLANGIOPATHY PATHOGENISIS HIV INFECTION MULTIPLE INFECTIONS DIARRHOEA+BILIARY (ULCERATIVE COLITIS) UNIQUE HLA HAPLOTYPE ASYMPTOMATIC –12/26 ? SIGNIFICANCE SPHINCTEROTAMY ? BENEFIT

15. HIV- ANTIVIRAL DRUGS---HAART PROTEASE INHIBITORS Indinavir Nelfinavir Amprenavir Ritanavir Saquinavir Lopinavir ritonovir NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS Zidovudine Didanosine Lamivudine Stavudine Zalcitabine Abcavir NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS Delaviridine Efavirenz Nevirapine

16. HIV-ANTIVIRAL DRUG TOXICITY • 6 TO 10% CHOLESTASIS • AC LIVER FAILURE • POTENTIAL MITOCHONDRIAL TOXICITY • TOXICITY TAKES 6Months • NNRTI DRUGS CAUSE IMMUNE MEDIATED • DURING PREGNANCY DRUG INTERACTIONS NNRTI+PI INTERACT- P450 ASSOCITED ANTIBIOTICS COINFECTION WITH VIRAL HEPATITIS OLDER AGE ALCOHOL

17. HIV—ANTIVIRAL DRUGS THE BENEFIT OF HAART THERAPY OUTWEIGHS THE RISK OF TOXICITY MONITOR LIVER ENZYMES EARLY RECOGNITION/HOLD CHECK DRUG-DRUG INTERACTION ALCOHOL

18. HIV-LIVER CONCLUSIONS LIVER INVOLVEMENT IS COMMON INFECTIONS ARE MAIN INVOLVEMENT IS SECONDARY/ OR PART OF DISSEMINATED DISEASE LIVER BIOPSY CONFIRMS DIAGNOSIS BILIARY CHOLANGIOPATHY IS A DISTINCT ENTITY DRUGS PLAY AN IMPORTANT ITEOLOGICAL CAUSE WHICH NEEDS CLOSE FOLLOWUP THANK YOU