Puri Pankaj, Kaur Navjyot, Pathania Sunny, Kumar Sandeep, Sharma P K, Sashindran V K
Professor & Head, Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India.
Assistant Professor (Medicine), Command Hospital (Southern Command), Pune 411040, India.
Med J Armed Forces India. 2017 Jan;73(1):12-17. doi: 10.1016/j.mjafi.2016.12.003. Epub 2017 Jan 7.
Both antitubercular therapy (ATT) and antiretroviral therapy (ART) can cause drug induced liver injury (DILI) in tuberculosis (TB) and human immunodeficiency virus (HIV) coinfection. The aim of this research was to study ATT-induced liver function test (LFT) abnormalities in HIV-infected patients.
HIV-infected patients diagnosed with TB were evaluated with baseline LFT and CD4 counts. ATT regimen was modified if baseline LFT was significantly abnormal. Patients on protease inhibitors were given rifabutin instead of rifampicin. In patients on nevirapine-based ART, efavirenz was substituted for nevirapine. In ART-naive patients, the timing of introduction of ART was according to CD4 cell counts. LFT were repeated fortnightly or as clinically indicated for 10 weeks.
We studied 100 patients with HIV ([M - 67, F - 23], mean age: 40.05 ± 10.75 years, mean CD4 cell count: 239.157 ± 228.49 cells/dL). Sixty-one patients were on ART prior to diagnosis of TB. Baseline LFT abnormalities ( = 40) were similar in ART and non-ART group (28/61 vs 12/39, = 0.13). After starting ATT, derangement of LFT was observed in majority of patients (99/100). However, liver sparing ATT was required only in 15 patients. Bilirubin >2.5 mg/dL was seen only in 9 patients. Significant rise in transaminases was commoner in patients on concurrent ART and ATT ( = 0.044) and with baseline LFT abnormalities ( = 0.00016). There was no case of acute liver failure or mortality.
Mild LFT abnormalities are common in HIV-infected individuals on ATT. Concomitant use of ATT and ART and baseline LFT abnormalities increase the risk of significant DILI. However, with closer follow-up, serious liver injury can be prevented.
抗结核治疗（ATT）和抗逆转录病毒治疗（ART）均可在结核病（TB）合并人类免疫缺陷病毒（HIV）感染患者中导致药物性肝损伤（DILI）。本研究旨在探讨HIV感染患者中ATT引起的肝功能检查（LFT）异常情况。
对诊断为TB的HIV感染患者进行基线LFT和CD4细胞计数评估。若基线LFT显著异常，则调整ATT方案。服用蛋白酶抑制剂的患者给予利福布汀而非利福平。对于接受基于奈韦拉平的ART治疗的患者，用依非韦伦替代奈韦拉平。对于未接受过ART治疗的患者，根据CD4细胞计数确定开始ART的时机。每两周或根据临床指征重复进行LFT检查，持续10周。
我们研究了100例HIV患者（男性67例，女性23例，平均年龄：40.05±10.75岁，平均CD4细胞计数：239.157±228.49细胞/ dL）。61例患者在诊断TB之前已接受ART治疗。ART组和未接受ART组的基线LFT异常情况（n = 40）相似（28/61 vs 12/39，P = 0.13）。开始ATT治疗后，大多数患者（99/100）出现LFT紊乱。然而，仅15例患者需要采用肝脏保护型ATT方案。仅9例患者出现胆红素>2.5mg/dL。同时接受ART和ATT治疗的患者以及基线LFT异常的患者中，转氨酶显著升高更为常见（P = 0.044）和（P = 0.00016）。未发生急性肝衰竭或死亡病例。
接受ATT治疗的HIV感染个体中轻度LFT异常较为常见。同时使用ATT和ART以及基线LFT异常会增加发生严重DILI的风险。然而，通过密切随访，可以预防严重肝损伤。
