The albumin-bilirubin grade uncovers the prognostic relationship between hepatic reserve and immune dysfunction in HIV-associated hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of liver-related mortality in people living with HIV, where co-infection with hepatotropic viruses accelerates the course of chronic liver disease. AIM: To evaluate whether the albumin-bilirubin (ALBI) grade, a more accurate marker of liver dysfunction in HCC, might identify patients with progressive liver dysfunction in the context of HIV/hepatitis co-infection. METHODS: Using uni- and multi-variable analyses, we studied the albumin-bilirubin grade as a predictor of overall survival (OS) in a large, multi-center cohort of patients with HIV-associated HCC recruited from 44 centres in 9 countries within the Liver Cancer in HIV study group. Patients who underwent liver transplantation were excluded. RESULTS: A total of 387 patients, predominantly HCV co-infected (78%) with balanced representation of all Barcelona Clinic Liver Cancer (BCLC) stages (A = 33%, B = 18%, C = 37%, D = 12%) were recruited. At HCC diagnosis, 84% had been on anti-retrovirals for a median duration of 8.8 years. The albumin-bilirubin grade identified significant differences in median survival of 97 months for grade 1 (95% CI 13-180 months), 17 months for grade 2 (95% CI 11-22 months) and 6 months for grade 3 (95% CI 4-9 months, P < .001). A more advanced albumin-bilirubin grade correlated with lower CD4 counts (464/373/288 cells/mm3 for grades 1/2/3) and higher HIV viraemia (3.337/8.701/61.845 copies/mL for grades 1/2/3, P < .001). CONCLUSIONS: In this large, multi-center retrospective study, the albumin-bilirubin grade highlights the interplay between liver reserve and immune dysfunction as prognostic determinants in HIV-associated HCC

Presentation and outcome of hepatocellular carcinoma in HIV-infected patients: A U.S.–Canadian multicenter study

HIV-infected patients now live longer and often have complications of liver disease, especially with hepatitis B or C virus coinfection. Limited data are available on those with hepatocellular carcinoma (HCC). A retrospective analysis from 1992 to 2005 in 6 centers identified 63 HIV-infected HCC patients. Controls were 226 consecutive HIV-negative HCC patients from four sites. HIV-positive patients were younger than controls (52 vs. 64 years, p < 0.001), more commonly had chronic hepatitis B or C (97% vs. 73%, p < 0.001), were more frequently symptomatic (51% vs. 38%, p = 0.048), had a higher median alfa-fetoprotein level (227 vs. 51 ng/ml, p = 0.005), but a similar mean Child–Turcotte–Pugh score (7.0 vs. 7.5, p = 0.05) and HCC staging score (Barcelona-Clínic-Liver-Cancer stages C + D in 50% vs. 58%, p = 0.24). HCC developed faster in HIV/HCV-coinfected than in HCV-monoinfected patients (mean, 26 vs. 34 years after HCV infection, p = 0.002). HIV-positive patients received proven therapy more often (48% vs. 31%, p = 0.017), but median survival was similar (6.9 vs. 7.5 months, p = 0.44). Independent factors predicting survival were symptomatic presentation (hazard ratio [HR], 0.437; p < 0.001), any proven therapy (HR, 2.19; p < 0.001), diagnosis after 01-Jan-2002 (HR, 1.52; p = 0.010), Barcelona-Clínic-Liver-Cancer stages C + D (HR, 0.491; p < 0.001), AST/ALT ⩾ 2.00 (HR, 0.597; p = 0.001), AFP ⩾ 400 ng/mL (HR, 0.55, p = 0.003), and platelets ⩾ 100,000/mm 3 (HR, 0.651; p = 0.012), but not HIV-serostatus ( p = 0.19). In HIV-infected patients without HCC therapy ( n = 33), median survival was longer with undetectable HIV RNA (<400 copies/mL) than with HIV viremia (6.5 vs. 2.6 months, p = 0.013). HIV-positive HCC patients are younger and more frequently symptomatic and infected with HCV or HBV than HIV-negative patients. Tumor staging and survival are similar. In untreated patients, undetectable HIV RNA independently predicts better survival