Downloaded from http://journals.lww.com/jaids by BhDMf5ePHKbH4TTImqenVAHxkFJp/XpPk1L/H3vMGwqMxG9jwOd8eJPG+b4DlKuAX44qu/vwzmc= on 07/29/2018 CLINICAL SCIENCE Liver Stiffness as a Predictor of Esophageal Varices Requiring Therapy in HIV/Hepatitis C Virus–Coinfected Patients With Cirrhosis Juan A. Pineda, MD, PhD,* Eva Recio, MD,* A ´ ngela Camacho, MD, PhD,† Juan Macı ´as, MD, PhD,* Carmen Almodo ´var, MD,† Mercedes Gonza ´lez-Serrano, MD,‡ Dolores Merino, MD,§ Francisco Tellez, MD, k Maria Jose ´ Rı ´os, MD,¶ and Antonio Rivero, MD, PhD† for the Grupo Andaluz de Hepatitis Vı ´rica (HEPAVIR) de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) Background: Liver stiffness (LS) measured by transient elastom- etry is associated with portal pressure in hepatitis C virus (HCV)– monoinfected patients and could predict the presence of esophageal varices in these subjects. The aim of this study was to assess the ability of LS to predict esophageal varices requiring preventive therapy for bleeding in HIV/HCV-coinfected patients. Methods: One hundred two HIV/HCV-coinfected patients with liver cirrhosis (LS $ 14 kPa) underwent an upper gastrointestinal endoscopy (UGE) examination. The diagnostic performance of LS for esophageal varices requiring therapy ($F2 or F1 with red signs or Child–Pugh–Turcotte class C) was assessed by receiver operating receptor characteristic curves. Results: Nineteen patients (19%) harbored varices requiring therapy. LS in patients with and without varices needing treatment was 48 (33–71) kPa and 32 (18–48) kPa (P = 0.004). The area under the receptor operating characteristic curve (95% confidence interval) of LS for the occurrence of varices that should be treated was 0.71 (0.60 to 0.82). There was no cutoff level of LS with good positive predictive value for the presence of varices requiring therapy, but LS of 21 kPa had a negative predictive value of 100%. Twenty- six percent of patients with LS measurement and UGE showed LS ,21 KPa. Conclusions: LS is higher in HIV/HCV-coinfected patients with cirrhosis who show esophageal varices requiring therapy than in those who do not. A cutoff value of LS of 21 kPa could be useful to identify patients with very low probability of varices at risk for bleeding. UGE for screening could be spared in these patients until LS increases above 21 kPa. Key Words: cirrhosis, esophageal varices, hepatitis C, HIV, portal hypertensive gastrointestinal bleeding, transient elastometry (J Acquir Immune Defic Syndr 2009;51:445–449) INTRODUCTION Transient elastometry (FibroScan) is a useful procedure to assess liver stiffness (LS). A good correlation between LS and liver fibrosis has been found in patients with chronic hepatitis C. 1–6 Therefore, transient elastometry is used as an alternative to biopsy for noninvasive assessment of liver fibrosis in this setting. 5,6 In addition, in HIV-uninfected patients with hepatitis C virus (HCV)–related liver cirrhosis, LS measured by transient elastometry also correlates with hepatic vein pressure gradient, the most reliable data for portal hypertension evaluation. 6–8 An LS value of 21 kPa predicts significant portal hypertension (hepatic vein pressure gradient equal to or greater than 10 mm Hg) with positive and negative predictive values of 92.5% and 90.7%, respectively. 8 HCV-related liver cirrhosis and its complications are major challenges in the management of HIV-infected patients, particularly in specific areas as western Mediterranean countries. Indeed, HCV coinfection involves as many as 50% HIV-infected patients in our area, 9 and 20% of HIV/HCV- coinfected patients show cirrhosis at the time of diagnosis. 10 Gastrointestinal bleeding due to esophageal varices is a common and life-threatening complication in patients with HCV-related cirrhosis, both in those with and without HIV coinfection. 11,12 Due to that, an upper gastrointestinal endoscopy (UGE) examination should be carried out in every HIV/HCV-coinfected patient with cirrhosis, once such a di- agnosis is made, to search for varices. 13,14 After screening, patients with medium or large varices should be treated to prevent bleeding. 13,14 As a consequence of the correlation between LS and portal pressure, increased LS seems to be a marker of the presence of large esophageal varices in HCV- monoinfected subjects with cirrhosis. 2,8,15 Therefore, transient elastometry could be used to identify patients with cirrhosis in Received for publication August 31, 2008; accepted January 13, 2009. From the *Unit of Infectious Diseases, Hospital Universitario de Valme, Seville, Spain; †Unit of Infectious Diseases, Hospital Reina Sofı ´a, Cordoba, Spain; ‡Unit of Infectious Diseases, Internal Medicine Department, Hospital Virgen de la Victoria, Malaga, Spain; §Department of Internal Medicine, Hospital Juan Ramon Jime ´nez, Huelva, Spain; k Unit of Infectious Diseases, Hospital La Lı ´nea de la Concepcio ´ n, Cadiz, Spain; and {Unit of Infectious Diseases, Hospital Universitario Virgen Macarena, Seville, Spain. This study has been partly supported by a grant from the Spanish Health Ministry: ISCIII-RETIC RD06/006. Conflicts of interest: none to declare. Correspondence to: Dr. Juan A. Pineda, MD, PhD, Unidad de Enfermedades Infecciosas, Hospital Universitario de Valme, Carretera de Ca ´diz s/n, Sevilla 41014, Spain (e-mail: japineda@telefonica.net). Copyright Ó 2009 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr  Volume 51, Number 4, August 1, 2009 www.jaids.com | 445