Kovari, Helen

Ledergerber, Bruno

Weber, Rainer

RERO DOC Digital Library

128 • CID 2010:50 (1 January) • CORRESPONDENCEted to an exhaustive prothrombotic screen[2]. In all patients, the results of thescreening were negative, thus excludingthe role of prothrombotic alterations inthe development of HIV-associated IPH.Demonstration of the absence of pro-thrombotic disorders would further sup-port the causative role of antiretroviraltreatment (eg, didanosine), as shown byKovari et al [1], in the pathogenesis ofHIV-related IPH. In addition, we wouldlike to point out that there is a high prob-ability of HIV-infected patients with IPHdeveloping portal vein thrombosis duringfollow-up, and this may further worsenthe existing portal hypertension.In summary, there are several importantfeatures of HIV-related IPH which mayhelp the physician differentiate betweencirrhotic portal hypertension and IPH inan HIV-infected patient who is receivinghighly active antiretroviral therapy. First,despite clinical evidence of significant por-tal hypertension, the HVPG in most pa-tients with HIV-related IPH is normal oronly mildly elevated (!10 mHg). Second,liver elastography may help to raise thesuspicion of IPH by giving false-negativeresults in the assessment of complicationsof portal hypertension. Third, these pa-tients are prone to developing portal veinthrombosis during follow-up, which callsfor regular screening of portal vein pa-tency and consideration of anticoagula-tion. Clinicians should thus be aware ofthis emerging phenomenon and institutethe appropriate screening and therapeuticmeasures.AcknowledgmentsPotential conflicts of interest. P.E.J.C. andJ.C.G.P.: no conflicts.Pik-Eu Jason Changand Juan-Carlos Garcia-Pagan1Department of Gastroenterology and Hepatology,Singapore General Hospital, Singapore;and 2Hepatic Hemodynamic Laboratory, Liver Unit,Institut de Malalties Digestives i Metabo`liques,Hospital Clinic, Institut d’InvestigacionsBiome`diques August Pi i. Sunyer, Barcelona, SpainReferences1. Kovari H, Ledergerber B, Peter U, et al. As-sociation of noncirrhotic portal hypertensionin HIV-infected persons and antiretroviral ther-apy with didanosine: a nested case-controlstudy. Clin Infect Dis 2009; 49:626–35.2. Chang PE, Miquel R, Blanco JL, et al. Idiopathicportal hypertension in patients with HIV in-fection treated with highly active antiretroviraltherapy. Am J Gastroenterol 2009; 104:1707–14.3. Alvarez-Larran A, Abraldes JG, Cervantes E, etal. Portal hypertension secondary to myelofi-brosis: a study of three cases. Am J Gastroen-terol 2005; 100:2355–8.4. Osada Y, Kanazawa H, Narahara Y, Mamiya Y,Nakatsuka K, Sakamoto C. Wedged hepatic ve-nous pressure does not reflect portal pressurein patients with cirrhosis and hepatic veno-ve-nous communications. Dig Dis Sci 2008; 53:7–13.5. Bosch J, Garcia-Pagan JC, Berzigotti A, Abral-des JG. Measurement of portal pressure and itsrole in the management of chronic liver disease.Semin Liver Dis 2006; 26:348–62.6. Ziol M, Handra-Luca A, Kettaneh A, et al. Non-invasive assessment of liver fibrosis by mea-surement of stiffness in patients with chronichepatitis C. Hepatology 2005; 41:48–54.7. Levine AM, Vigen C, Gravink J, Mack W, WattsCH, Liebman HA. Progressive prothromboticstate in women with advancing HIV disease. JAcquir Immune Defic Syndr 2006; 42:572–7.8. Eyal A, Veller M. HIV and venous thromboticevents. S Afr J Surg 2009; 47:54–6.Reprints or correspondence: Dr Jason Chang, Singapore Gen-eral Hospital, Dept of Gastroenterology, Outram Rd, Singapore169608, Singapore (jason.jan@pacific.net.sg).Clinical Infectious Diseases 2010; 50:127–8 2009 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2010/5001-0029$15.00DOI: 10.1086/649009Reply to Changand Garcia-PaganTo the Editor—We thank Chang andGarcia-Pagan [1] for their interest in ourstudy [2], and we offer the following reply.First, in our case-control study of humanimmunodeficiency virus (HIV)–infectedpatients with noncirrhotic portal hyper-tension (NCPH), inclusion criteria werethe presence of endoscopically docu-mented esophageal varices or hepatic ve-nous pressure gradient (HVPG) 10mmHg, absence of hepatic cirrhosis onliver biopsy, and no common cause of liverdisease. All of our case patients had en-doscopically documented esophageal var-ices, and no patient was excluded becauseof a HVPG !10 mmHg. Eight of 15 casepatients underwent hepatic hemodynamicevaluation; the median HVPG was 24.5mmHg (range, 7–54 mmHg). Except in 1case patient, all HVPG values were 10mmHg. Second, because most case pa-tients received a diagnosis of NCPH at atime before liver elastography was regu-larly conducted, we did not evaluate liverstiffness values systematically. Third, wewere not able to search for prothrombot-ic disorders, because cases were includedretrospectively. However, in contrast toChang et al [3], who did not find coag-ulopathies in their 8 patients, other reportshave noted thrombophilic abnormality inaffected patients [4–6]. This supports amultifactorial pathogenesis of NCPH inHIV infection, with antiretroviral therapyand a prothrombotic state leading to mi-crothrombosis and vascular obstruction.AcknowledgmentsPotential conflicts of interest. All authors: noconflicts.Helen Kovari, Bruno Ledergerber,and Rainer WeberDivision of Infectious Diseases and HospitalEpidemiology, University Hospital, Universityof Zurich, Zurich, SwitzerlandReferences1. Chang P-EJ, Garcia-Pagan J-C. Idiopathic non-cirrhotic portal hypertension in HIV-infectedpatients. Clin Infect Dis 2010; 50:127–8 (in thisissue).2. Kovari H, Ledergerber B, Peter U, et al. As-sociation of noncirrhotic portal hypertensionin HIV-infected persons and antiretroviral ther-apy with didanosine: a nested case-controlstudy. Clin Infect Dis 2009; 49:626–35.3. Chang PE, Miquel R, Blanco JL, et al. Idiopathicportal hypertension in patients with HIV in-fection treated with highly active antiretroviraltherapy. Am J Gastroenterol 2009; 104:1707–14.4. Garvey LJ, Thomson EC, Lloyd J, Cooke GS,Goldin RD, Main J. Response to Mallet et al.,‘Nodular regenerative hyperplasia is a newcause of chronic liver disease in HIV-infectedpatients.’ AIDS 2007; 21:1494–5.5. Saifee S, Joelson D, Braude J, et al. Noncirrhoticportal hypertension in patients with human im-munodeficiency virus-1 infection. Clin Gas-troenterol Hepatol 2008; 6:1167–9.6. Mallet VO, Bralet MP, Pol S. Response to Schi-CORRESPONDENCE • CID 2010:50 (1 January) • 129ano et al. Hepatoportal sclerosis as a cause ofnoncirrhotic portal hypertension in patientswith HIV. Am J Gastroenterol 2008; 103:808–9.Reprints or correspondence: Dr Helen Kovari, Div of InfectiousDiseases and Hospital Epidemiology, University Hospital, CH-8091 Zurich, Switzerland (helen.kovari@usz.ch).Clinical Infectious Diseases 2010; 50:128–9 2009 by the Infectious Diseases Society of America. Allrights reserved. 1058-4838/2010/5001-0030$15.00DOI: 10.1086/649010

Reply to Chang and Garcia-Pagan

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library