Background:  Liver biopsy in HIV/HCV coinfected patients is under debate for the low proportion of patients with minimal or absent liver fibrosis and for the accelerated progression of fibrosis. However the majority of the studies are limited to patients with abnormal alanineaminotransferase (ALT); aim of this study was to describe the spectrum of liver disease in coinfected patients with normal and abnormal ALT.

Methods:  A retrospective analysis of 354 consecutive liver biopsies performed from 1997 to 2003 in coinfected patients was assessed. Patients were selected for liver biopsy after three consecutive persistently normal ALT (PNAL) during a follow-up of 12 months. Liver histology was classified by using the modified Ishak score. HIV and HCV-related virological and immunological parameters were concomitantly evaluated. The Mann-Whitney rank sum test for non-parametric data was used to compare mean indipendent values of continuous variables. Associations between discrete variables were tested by Chi-square test or Fisher exact test, as appropriate.

Results:  At the time of biopsy, 26 subjects had normal (group A) and 328 (group B) abnormal ALT. Mean±SD CD4 count and Log HIV-RNA didn’t show a significant difference between the 2 groups: 488±191 cells/µL and 3.12 (1.9 to 4.2) copies/mL for patients of group A, 526±266 cells/µL and 3.4 (1.9 to 4.2) copies/mL for those of group B. Mean±SD HCV RNA Log was 5.7 (5.4 to 6.3) and 5.9 (4.62 to 6.02) IU/mL for each group respectively (p = NS). HCV genotype 1 was detected in 14 (52%) subjects of group A and in 102(31%) of group B (p = 0.01). No significant difference was detected in the distribution of the type of antiretroviral regimen:no drugs, mono or dual therapy and HAART. Liver fibrosis scores for grading and staging were respectively 4.12±1.64 and 1±1.69 for group A, 7.35±2.7 and 2.24±1.79 for group B (p = 0.0007 for grading and = 0.0147 for staging). Liver fibrosis was stage 0-1 in 18 (75%) of patients with normal and in 133 (42.9%) with abnormal ALT , stage 2-3 in 3 (12.5%) and in 105 (33.8%), stage 4-6 in 3 (12.5) and 72 (23.2%) of group A and B respectively (p = 0.039).

Conclusions: Absent or minimal liver fibrosis was evidenced in 75% of coinfected subjects with PNAL, similarly as that of HCV monoinfected subjects, a population less prone to develop fibrosis progression . Prospective studies are needed to evaluate the outcome of the liver disease in this subset before to treat all HCV-RNA positive patients indipendently from liver disease.

Keywords: normal ALT; liver fibrosis; HCV-HIV coinfection