COHORTE DE PACIENTES CON CIRROSIS HEPÁTICA Dr. José R Arribas Unidad VIH Servicio de Medicina Interna

Morbidity and mortality in HIV infected patients with compensated and decompensated cirrhosis: prospective cohort of 373 patients M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, JR Arribas and the GESIDA 37/03- FIPSE /03 Study Group. Oral Presentation at EACS2007 PS8/4

OBJECTIVE To evaluate morbidity/mortality in HIV-infected patients with compensated vs decompensated liver cirrhosis.

STUDY DESIGN (1) Multicenter national prospective cohort. País Vasco H. Virgen de Aranzazu. Valencia H. General Universitario Valencia. Barcelona H. Clinic y Provincial. H. Germans Trias i Pujol. Madrid H. Príncipe de Asturias. H. Gregorio Marañón. H. Ramón y Cajal. H. Doce de Octubre. H. La Paz.

STUDY DESIGN (2) Cirrhosis Diagnosis –Biopsy: (Cirrhosis or advanced bridging fibrosis). –Decompensation Gastrointestinal bleeding, ascites, hepatic encephalopathy. –Bonacini Score > 8 (Am J Gastroenterol 1997;92:1302).

BONACINI SCORE FOR CIRRHOSIS DIAGNOSIS Three-parameter cirrhosis discriminant score: –Platelets – ALT/AST ratio – PT –Cutoff for cirrhosis diagnosis = 8 Sensibility 46% Specifycity 98% Bonacini M, et al. Am J Gastroenterol 1997;92:1302.

STUDY DESIGN (3) Total planned follow-up 48 months. Visits: baseline and then every 6 months. –Each visit: Personal interview. Hematology, Biochemistry, Inmmunology, Virology, alfa- fetoprotein. Abdominal US. –Each year: Endoscopy to detect esophageal varices (according to Schepis criteria*). Schepis et al. Hepatology 2001; 33:471-2.

STUDY DESIGN (4) SURVIVAL: time from the date of entry until the first endpoint occurred. ENDPOINT: death, hepatocarcinoma or liver transplant. STATISTICAL ANALISYS: Kaplan-Meyer analysis, log rank test (comparison of survival between different groups).

BASELINE CHARACTERISITICS (1) AllCompensatedDecompensated N Mean age (years )44 43 Female (%)80 (22)61 (22,2)19 (19,4) Cirrhosis diagnosis - Biopsy (%) - Bonacini Score >8 (%) - Prior decompensation (%) 234 (63) 41 (11) 98 (26) 234 (85,1) 41 (14,9) _ 98 (100) Cirrhosis causes - Hepatitis C (%) - Genotypes 2 or 3 (%) - Hepatitis B (%) - Prior alcohol abuse (%) 370 (99,2) 81 (21,7) 24 (6,4) 115 (31) 274 (99,7) 63 (22,9) 17 (6,2) 74 (26,9) 96 (97,9) 18 (18,4) 7 (7,1) 41 (41,8) Median duration HIV infection (years)15

AllCompensatedDecompensated Median duration HVC infection (years)23 HCV treatment received (%)205 (55)178 (64,7)27 (27,6) CDC stage C (%)143 (39,3)90 (32,8)53 (54,1) Receiving HAART at baseline (%)322 (82,8)244 (88,7)78 (79,6) HIV Transmission route - IVDU (%)328 (88)239 (86,9)89 (90,8) CD4 cell count (median, IQR) - Baseline - Nadir 373 ( ) 145 ( ) 434 ( ) 175 ( ) 239 ( ) 104 ( ) - HIV-RNA - Baseline (median, IQR) - % HIV RNA BLQ* 49 ( ) 72,4 49 ( ) 75,6 49 ( ) 65,2 BASELINE CHARACTERISITICS (2) *Below limit of quantification (50-200) c/ml.

AllCompensatedDescompensated Lost to follow-up (%) 40 (10,7) 21 (7,6) 19 (19,4) Follow-up (median, IQR) 18 (14-20) 18 (15,7-20,2) 16 (6-19) Endpoints, n (%) Any Death Hepatocarcinoma Transplant 63 (18,9) 55 (16,5) 2 (0,6) 9 (2,7) 20 (7,9) 17 (6,7) _ 3 (1,2) 43 (54,4) 38 (48,1) 2 (2,5) 6 (7,6) Deaths, n (%) Hepatic causes Other Unknown 33 (9,9) 14 (1,8) 6 (1,8) 6 (2,4) 5 (2) 27 (34,2) 8 (10,1) 1 (1,3) RESULTS

BaselineInitially compensated Type of Decompensations n (%) Ascites GI bleeding Encephalopathy HRS SBP Unknown 99 (26,5) 51 (51,1) 12 (12,1) 10 (10,1) 15 (15,2) 4 (4) 7 (7,1) 17 (6,2) 6 (2,2) 2 (0,7) 7 (2,6) 2 (0,7)

SURVIVAL N Cumulative probability of survival Months 0.82

SURVIVAL Compensated vs Decompensated Compensated Decompensated p<0,0001 (log-rank) Cumulative probability of survival Months

SURVIVAL (months) COMPENSATEDDECOMPENSATED Mean (IC95%) Median (IC95%) 1 year probability 2 years probability 3 years probability 66 (63-69) NA (15-23) 18 (12-24) _

SURVIVAL Child Pugh Score A B C CP-A CP-B CP-C p<0,0001 (log-rank) Cumulative probability of survival Months

CHILD-PUGH SCORE ABC Mean (IC95%) Median (IC95%) 1 year probability 2 years probability 3 years probability 68 (65-70) NA (18-26) 19 (13-25) _ 10 (6-13) 7 (5-9) 0.32 _ SURVIVAL (months)

N PROBABILITY OF FIRST DECOMPENSATION Percent wiithout decompensation Months Probability of decompensation One year Two years Three years 0.04 (IC95% 0.01 – 0.07)

CONCLUSIONS HIV-infected patients with compensated liver cirrhosis had a relatively high survival with a low per year probability of first decompensation. HIV-infected patients with decompensated cirrhosis have a very poor prognosis. One third of our patients with decompensated liver cirrhosis died during the first year of follow-up. Child Pugh score apears as a good prognostic score for HIV- infected patients with liver cirrhosis. These results emphasize the critical importance of avoiding the development of end-stage liver disease in HIV-infected patients. Analysis of factors associated to survival will be available soon

FACTORS ASSOCIATED WITH SURVIVAL AND FIRST HEPATIC DECOMPENSATION IN A LARGE PROSPECTIVE COHORT OF HIV-HCV CO-INFECTED PATIENTS WITH LIVER CIRRHOSIS. M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, JR Arribas and the GESIDA 37/03-FIPSE /03 Study Group. Poster Presentation at CROI2008 [1057]

clinicaloptions.com/hiv METHODS Prospective multicenter cohort of 331 HIV-HCV coinfected patients with cirrhosis. Median follow-up time: 18 months. Cirrhosis diagnosis (n,%): biopsy (209, 63%), prior decompensation (86, 26%), Bonacini Score 8 (36, 11%). Endpoints: death, hepatocarcinoma or liver transplant. Survival defined as the time from entering in the cohort until first endpoint occurred. The association of survival with different factors was explored in univariate and multivariate Cox proportional hazard models. Variables included: age, sex, time since cirrhosis/HIV diagnosis, alcohol intake, CD4 count (nadir, baseline and <100 at baseline), HIV viremia, suppressed HIV replication, history of anti-HCV therapy, HCV genotype, sustained viral response to anti-HCV therapy, concomitant chronic HBV, history of cirrhosis decompensation, Child Pugh score and HAART (at baseline, continuous/interrupted during follow-up). For patients with no history of prior liver decompensation at baseline we explored variables associated with the development of first decompensation.

BASELINE CHARACTERISTICS Male, N, (%)258 (78) Age, median, (IQR)44 (41 – 47) Months of follow-up, median, (IQR)18 (12 – 20) Years since HIV diagnosis, median, (IQR)16 (11 – 19) Years since cirrhosis diagnosis, median, (IQR)3 (2 – 5) CDC C3, N, (%)93 (28.1) IVDU, N, (%)292 (88.2) HAART, N, (%) at baseline287 (87) non continuous HAART166 (50) Alcohol abuse, N, (%)100 (30.2)

BASELINE CHARACTERISTICS CD4, median, (IQR) at baseline nadir (232 – 589) (71 – 258) HIV-RNA < BLQ*, N, (%)236 (74) HVB co-infection, N, (%)20 (6) HCV genotype 2 or 3, N, (%)71 (27) HCV therapy, N, (%) sustained viral response, N, (%) still non evaluable, N, (%) (57.7) (11.2) (15.7)

clinicaloptions.com/hiv ENDPOINTS Endpoints: 62 (54 deaths, 9 hepatocarcinomas, and 1 liver transplant). Compensated cirrhosis at baseline: 19 (16 deaths, 3 Hepatocarcinomas) Decompensated cirrhosis at baseline: 43 (38 deaths, 6 Hepatocarcinomas, 1 Liver Transplant)

Variables associated to survival. Univariate analysis HR (CI 95%)p Male gender2.37 (1.078 – 5.21)0.032 Alcohol intake0.506 (0.306 – 0.838)0.008 CD4 <100 at baseline3.26 (1.48 – 7.19)0.003 Unsuppressed VL at baseline2.16 (1.27 – 3.65)0.004 No HCV therapy received3.01 (1.76 – 5.14) < No response to HCV therapy7.31 (1.01 – 52.81) Non-Continuous HAART during follow up (6.15 – 38.46) < CD4 nadir0.997 (0.995 – 0.999)0.008 Child Pugh score B Child Pugh score C (6.97 – 29.9) (17.96 – 86.65) <

Multivariate analysis: Hazard ratio of factors associated with decreased survival [HR, (CI), p]

Survival according to Child Pugh Score Child Pugh A Child Pugh B Child Pugh C (N) CP-A CP-B CP-C

Probability of first decompensation according to Child Pugh Score (N) CP-A CP-B Child Pugh A Child Pugh B

clinicaloptions.com/hiv CONCLUSIONS Child-Pugh scores B and C are significantly associated with decreased survival in HIV-HCV coinfected patients with cirrhosis. Maintaining HIV viral suppression and receiving continuous HAART are associated with prolonged survival. Our study supports the continuous use of HAART in this population. Child-Pugh B is significantly associated with the short-term risk of first hepatic decompensation. HIV-HCV coinfected patients with compensated cirrhosis and a Child-Pugh B score should be followed closely for the development of decompensation.

clinicaloptions.com/hiv RESUMEN El estudio GESIDA 37/03 es una de las cohortes más grandes de pacientes infectados por VIH con cirrosis hepática. Hasta el momento esta cohorte nos ha permitido caracterizar mejor la historia natural de la cirrosis hepática en esta población Además hemos podido analizar los factores relacionados con la supervivencia y la primera descompensación. Continuamos el seguimiento activo de esta cohorte (Dra. Marisa Montes)

clinicaloptions.com/hiv AGRADECIMIENTOS M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, Rosario Madero, Herminia Esteban