Hepatic Markers Profile in Cytolysis and Cholestasis during Antiretroviral Treatment at the Charles de Gaulle University Hospital

Introduction

The human immunodeficiency virus (HIV) is responsible for nearly 1,500 new infections in children every day, more than 90% of which are in developing countries and most of which are associated with Mother-to-Child Transmission (MTCT) [1]. In 2016, in Burkina Faso, there were approximately 95,000 people living with HIV, of whom 60% had access to antiretroviral treatment (ARV). Prophylaxis as part of MTCT prevention was effective in 91.60% of pregnant women living with HIV. In addition, early ARV treatment in these children is effective in improving their survival [2]. Thus, the World Health Organization (WHO) recommends ARV treatment for any child tested HIV positive regardless of CD4 count and clinical stage [3]. However, this ARV treatment leads to several types of side effects that can be severe. Given the hepatic metabolism of most of the molecules, hepatotoxicity may be considered. Indeed, several physio-pathogenic mechanisms may be at the origin of this hepatic toxicity of ARVs; in particular an immune reaction to the introduction of ARVs, the mitochondrial toxicity of nucleosides, the immune allergy induced by certain molecules and the direct dose-dependent toxicity of some ARVs with hepatic metabolism [4, 5]. Hence the interest of this study, which aimed to evaluate the hepatic markers of cytolysis and cholestasis in children living with HIV under ARVs at the Charles de Gaulle University Hospital.

Results

A total of 86 children with HIV 1 on ARV treatment were included in the study. The sex ratio M/F was 0.95. The age of the patients ranged from 0 to 180 months and the most represented age group was 61-180 months.

Clinically, 40.70% of the children were in clinical stage 2 and almost 56.97% in advanced disease (clinical stage 3 and 4). The Zidovudine (AZT) + Lamivudine (3TC) + Nevirapine (NVP) regimen was the most used (34.88%). During follow-up, 26.74% (n=23) of children had their treatment changed from the initial regimen. Among the reasons for modification, toxidermia accounted for 17.39%, followed by non-compliance 13.04%. The majority of the treatment regimen related to toxidermia was the combination of AZT+3TC+NVP presented sociodemographic, clinical and therapeutic characteristics (Table 1).

Viral load was less than 500 copies/mL in 65.12% of children on treatment, and 86.05% had a TCD4+ lymphocyte count greater than 400/mL (Table 2). Markers of hepatic cytolysis were elevated in 11.63%, 13.95%, and 26.74% of children on ARV therapy for ALT, AST, and LDH respectively. The majority of children were classified as grade 1 cytolysis for ALT (9.30%) and AST (5.81%). Cholestasis markers showed elevated ALP in 77.91% of children and 12.72% for γGT. Cytolysis and cholestasis markers were higher when TCD4+ lymphocytes were greater than 400/mL, but without a statistically significant relationship (Table 3). These markers were elevated in children with a viral load of less than 500 copies/mL; and when the duration of treatment was greater than 12 months, the proportions of children on ARV therapy with cytolysis and cholestasis were high (Table 4).

Markers of cytolysis and cholestasis by TCD4+ lymphocyte count CD4/mL ≤399 >400 p ALT (%) Normal 12.79 75.58 0.78 High 1.16 10.47 AST (%) Normal 10.46 75.58 0.07 High 3.49 10.47 LDH (%) Normal 10.46 62.8 0.57 High 3.49 23.25 ALP (%) Normal 4.65 17.44 0.14 High 9.3 68.61 γGT (%) Normal 11.62 75.58 0.53 High 2.33 10.47 Markers of cytolysis and cholestasis by viral load Viral load copy/mL <500 ≥500 p ALT (%) High Normal 58.14 30.23 0.99 6.98 4.65

Discussion

The majority of patients were female (51.16%) with a sex ratio of 0.95. Our results were close to those of Djadou KE, et al. [7] in Togo, who found a female predominance of 53%. The most represented age group was 61 to 180 months with 69.77% of children on ARV treatment against only 09.30% for children under 12 months. Children over 5 years of age (60 months) were the most numerous, which shows the need to reinforce diagnosis and early follow-up of mothers in order to avoid mother-fetal transmission. Indeed, mother-to-child transmission of HIV is the main mode of contamination in pediatrics, with an additional risk linked to breastfeeding. The majority of children was followed in the city of Ouagadougou because of its accessibility and enhanced technical facilities compared to other cities in Burkina Faso. Clinically, at inclusion, the majority of children had clinical stage 2 (40.70%), while 18.60% had severe symptoms (clinical stage 4). Our results were comparable to those of Djadou KE, et al. [7] in Togo who found 18.18% of children infected at clinical stage 4 at inclusion; however, our figures were higher than those of Oumar AA ,et al. [8] who found 11.1% of children at clinical stage 4 in Segou [7, 8].

Late diagnosis and management of children, especially at stages when they develop opportunistic diseases, are factors related to these high rates of children with severe symptoms at inclusion.

In first-line treatment, the proposed triple therapy (two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor) complied with national protocols in 75.58% of cases [3]. This combination therapy resulted in sustained inhibition of viral replication in the child, thus promoting immune reconstitution. Combinations of Zidovudine (AZT) + Lamivudine (3TC) + Nevirapine (NVP) and Zidovudine (AZT) + Lamivudine (3TC) + Efavirenz (EFV) were the most used with proportions of 34.88% and 20.93% respectively; as the new therapeutic recommendations in first line treatment replace Stavudine (D4T) by Zidovudine (AZT) due to its toxicity. During the follow-up of the children, the therapeutic regimen was modified in 26.74% of the cases. Among the reasons for these modifications, toxidermia was the most represented with 17.39% of children. A cohort study of children undergoing ARV treatment in Togo showed a 25% incidence of toxidermia [9]. Several authors have shown an involvement of the Nevirapine molecule in this toxidermia, but also the cutaneous sensitivity of young children [10]. Non-compliance with treatment was present in 13.04% of children, which could lead to the appearance of mutations, compromising the use of certain antiretrovirals.

An immune deficiency (13.95%) was observed in children under ARV treatment; while the majority (86.05%) had a CD4 count above 400/mL. Authors found in Togo, 67.7% absence of immune deficiency after 12 months of treatment and 81.9% after 24 months [11]. As most authors believe, there is immune reconstitution after at least six months of effective treatment for patients on triple therapy. The viral load was less than 500 copies/mL in 65.12% of children on ARV treatment. Indeed, several authors have shown a beneficial effect of ARVs on the health of HIV-infected African children, under the condition of a good therapeutic compliance responsible for a durable suppression of viral replication and a very low risk of rebound [12].

The profile of liver cytolysis markers showed elevated levels of ALT, AST and LDH in 11.63%, 13.95% and 26.74% of children on ARV treatment, respectively. This hepatic cytolysis was more pronounced in children who had CD4 counts above 400/mL. In addition, when the viral load was below 500 copies/mL, then the proportions of cytolysis were high. In addition, high rates of cytolysis were observed in children with treatment duration of more than 12 months. The level of hepatic cytolysis was low (grade 1) in 9.30% of children on ARV treatment according to ALT and 5.81% according to AST. Several authors have shown that a good tolerance of the patient to ARV treatment favors a progressive decrease in the grade of liver toxicity over time [13, 14, 15]. However, some authors associated this increase in aminotransferases (ALT and AST) with the increase in viral load [16]. Similarly, asymptomatic elevation of blood lactates was frequent during treatment with nucleoside reverse transcriptase inhibitors, which reflected mitochondrial toxicity related to the combination of Stavudine (d4T) + didanosine (DDI), the early interruption of which allowed clinical and biological recovery [17].

Hepatic cholestasis (intra or extrahepatic) is usually observed in the face of increased ALP, which is the result of increased synthesis of the enzyme by the epithelial cells of the bile ducts and increased γGT. Nearly 77.91% of children on treatment had elevated ALP versus 12.79% who had elevated γGTs. The proportions of children on ARV treatment in whom liver cholestasis could be suspected increased when the CD4 count was above 400/mL (elevated ALP =68.6% and elevated γGT=10.46%). On the other hand, the lower the viral load (less than 500 copies/mL), the higher the rates of children on treatment with hepatic cholestasis (high ALP =50% and high γGT=6.98%). In addition, after 12 months of ARV treatment, markers of hepatic cholestasis increased in children.

Conclusion

The liver marker profile of cytolysis and cholestasis in HIV-positive children on ARV treatment showed a high proportion of liver cytotoxicity for a TCD4+ lymphocyte count above 400/mL, a viral load below 500 copies/mL. This shows the importance of biological monitoring which, in addition to helping in the decision to start the initial treatment, also makes it possible to evaluate its effectiveness and the appearance of any intolerance. The disturbances observed were slight, marked by an increase in most parameters, but without serious clinical consequences.