Liver biopsy findings for HIV-infected patients with chronic hepatitis C and persistently normal levels of alanine aminotransferase

Background. Severe liver fibrosis is common in patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) who have a high alanine aminotransferase (ALT) level. However, little is known about the frequency, liver biopsy findings, and significance of a persistently normal ALT level in coinfected patients. Methods. We analyzed clinical data and histological findings for 256 patients coinfected with HIV and HCV, 24 ( 9.4%) of whom had an ALT level within the normal range on >= 2 separate occasions within a 6-month period. Results. The proportion of patients demonstrating advanced stages of fibrosis (F3 and F4) was 78 (33.7%) of 232 patients in the high ALT level group, compared with 0 (0%) of 24 patients in the persistently normal ALT level group (P < .001). Among patients with persistently normal ALT levels, 23 (96%) had any grade of fibrosis, P < .001 and 7 (29%) had stage F2 of fibrosis. No differences were found between both groups with respect to age, sex, HIV transmission category, Centers for Disease Control and Prevention clinical category, CD4(+) cell count (both nadir and baseline values), type of antiretroviral therapy, years since onset of HCV infection, alcohol use, or HCV load. However, the proportion of patients infected with HCV genotype 3 was significantly higher among patients with high ALT levels than in patients with persistently normal ALT levels (61 [26.9%] of 232 patients vs. 1 [4.2%] of 24 patients; P = .04). Conclusions. Histological abnormalities are significantly milder in patients coinfected with HIV and HCV who have persistently normal ALT levels than those found in patients with high ALT levels. However, a subgroup of patients with persistently normal ALT levels may have significant cases of fibrosis. Liver biopsy may be recommendable in patients coinfected with HIV and HCV who have persistently normal ALT levels, to determine the extent of liver fibrosis and, consequently, to assess suitability for treatment.