From the Guidelines
Elevated liver function tests (LFTs) in HIV patients should be promptly evaluated to identify the underlying cause, with a focus on hepatitis coinfection, medication-related toxicity, and other potential causes, as recommended by the 2014 guidelines for management of hepatitis C 1. The evaluation process should include comprehensive testing, such as complete LFTs, viral hepatitis serologies, and ultrasound, to determine the specific cause of the elevated LFTs. According to the 2002 guidelines for preventing opportunistic infections among HIV-infected persons, all HIV-infected patients should be screened for HCV infection, as certain HIV-infected patients are at increased risk for HCV infection and HCV-related disease 1. Key considerations in the management of elevated LFTs in HIV patients include:
- Assessing for medication-related toxicity, particularly from antiretroviral drugs like nevirapine, efavirenz, and protease inhibitors, which commonly cause liver enzyme elevations
- Evaluating for hepatitis coinfection (B, C, or D), which affects 30-90% of HIV patients depending on risk factors
- Considering opportunistic infections like Mycobacterium avium complex, cytomegalovirus, and tuberculosis, which can also impact liver function
- Addressing metabolic factors, such as non-alcoholic fatty liver disease, which is increasingly common in HIV patients on long-term antiretroviral therapy
- Modifying antiretroviral therapy if medication-related, treating underlying infections, and providing regular LFT monitoring, particularly when starting new medications or with known liver disease risk factors, as recommended by the 2014 guidelines for management of hepatitis C 1. In patients coinfected with HIV and HCV, antiretroviral therapy should be recommended regardless of CD4+ lymphocyte count, as the benefits from antiretroviral therapy are bigger than the risk of drug toxicity, and HCV treatment can be safely provided to patients coinfected with HIV and HCV, as stated in the 2002 guidelines for preventing opportunistic infections among HIV-infected persons 1. The treatment of HCV in HIV-coinfected patients may involve the use of peginterferon alpha and ribavirin, with adjusted doses based on body weight and HCV genotype, and the consideration of triple therapy using boceprevir or telaprevir, which has shown higher SVR rates compared to dual combination therapy, as reported in the 2014 guidelines for management of hepatitis C 1. Overall, the management of elevated LFTs in HIV patients requires a comprehensive approach that takes into account the potential causes, the patient's risk factors, and the latest treatment guidelines, with a focus on improving morbidity, mortality, and quality of life outcomes.
From the FDA Drug Label
Hepatotoxicity: Monitor liver function tests before and during treatment in patients with underlying hepatic disease, including hepatitis B or C coinfection, marked transaminase elevations, or who are taking medications associated with liver toxicity. Among reported cases of hepatic failure, a few occurred in patients with no pre-existing hepatic disease. Sometimes allergic reactions can affect body organs, such as your liver Call your doctor right away if you have any of the following signs or symptoms of liver problems: yellowing of your skin or whites of your eyes dark or tea colored urine pale colored stools (bowel movements) nausea or vomiting loss of appetite pain, aching, or tenderness on the right side of your stomach area
Elevated LFT in HIV patients can be a concern when taking certain medications, including efavirenz and raltegravir.
- Monitoring of liver function tests is recommended before and during treatment, especially in patients with underlying hepatic disease.
- Signs and symptoms of liver problems, such as yellowing of the skin or eyes, dark urine, and abdominal pain, should be reported to the doctor immediately.
- Hepatotoxicity is a potential risk associated with these medications, and patients should be closely monitored for any adverse effects. 2 3
From the Research
Elevated Liver Function Tests (LFTs) in HIV Patients
Elevated LFTs are a common occurrence in HIV patients, and several studies have investigated the causes and risk factors associated with this condition.
- The study by 4 found that severe hepatotoxicity was observed in 15.6% of patients prescribed nevirapine and 8.0% of those prescribed efavirenz, with the risk being significantly greater among persons with chronic viral hepatitis and those prescribed concurrent protease inhibitors.
- Another study by 5 demonstrated that abnormalities of liver function tests are common in HIV patients, with 87.6% of patients having abnormalities of their LFTs, and 85.5% being classified as having hepatocellular injury.
- The study by 6 found that acute liver enzyme elevations were associated with a first-line highly active antiretroviral therapy and/or viral hepatitis coinfections in HIV-infected patients, with independent factors for developing acute liver enzyme elevations being HBV and HCV coinfections, antiretroviral therapy, CDC stage C, and high alkaline phosphatase baseline values.
- The research by 7 showed that mild-moderate increased liver enzymes are common in HIV patients without HCV/HBV, and absence of PI use is independently associated with elevations in both AST and ALT, while features typical of hepatic steatosis are only associated with increased ALP.
- The study by 8 examined the long-term safety and efficacy of raltegravir in patients with HIV-1 and hepatitis B and/or C virus coinfection, and found that raltegravir was generally well tolerated and efficacious up to 96 weeks in HIV-infected patients with HBV/HCV coinfection.
Risk Factors for Elevated LFTs in HIV Patients
Several risk factors have been identified as contributing to elevated LFTs in HIV patients, including: