Edited by Kenneth E. Sherman 209 pp, $189 New York, NY, Springer, 2012 ISBN-13: 978-1-4419-1711-9 In HIV and Liver Disease, Kenneth Sherman and contributors attempt to improve understanding of liver dysfunction in patients with human immunodeficiency virus (HIV), an entity that has evolved from an acute to a chronic illness. Chapter 1 sketches current trends of the HIV epidemic, although the most recent data are from 2010. In the chapter on liver disease in HIV, Butt addresses well-recognized factors of drug-related liver injury: ethanol use and coinfection with hepatitis B virus (HBV) and hepatitis C virus (HCV). It is generally less appreciated that nonalcoholic fatty liver disease is relatively common, with magnetic resonance imaging and computed tomography studies reporting a 37% to 42% rate of steatosis among patients with HIV alone, increasing to 67% to 69% among those coinfected with HBV or HCV (pp 10-11). The degree of steatosis correlates with the risk of fibrosis. A special notation is also made of “nodular regenerative hyperplasia,” a newer entity perhaps 3 times more common in patients with vs without HIV. The chapter on pathology of HIV-associated liver disease paints a broader picture. Early on, HIV liver pathology was primarily related to opportunistic infections; this has evolved to a point at which chronic viral hepatitis now comprises the majority. In addition to HBV and HCV, members of the herpes family are implicated. Adenovirus hepatitis can be seen in children and young adults. Biliary tract disease can present as ascending bacterial cholangitis and sclerosing cholangitis. Malignancies primarily include Kaposi sarcoma, hepatocellular carcinoma, and lymphoma. Smith and Sterling likewise review the development of nonbiopsy tools to evaluate liver fibrosis, particularly in determining the need for HCV therapy. Use of common and nonstandard laboratory assays as well as imaging modalities are described. A useful chart summarizes studies conducted among patients coinfected with HIV and HCV. In their chapter, Zhou, Jones, and McClain—building on Butt's emphasis on the increasing awareness of steatosis and steatohepatitis—provide a useful review of mechanisms of alcohol-induced disorders of hepatic lipid metabolism, including the role of zinc (and zinc deficiency), together with the effects of ethanol on altering gut flora and increasing intestinal permeability. The physician involved with detoxification of the alcohol-abusing patient would do well to review the therapies available for managing alcoholic hepatitis. The review by Shata describes the cells involved with the immunopathology of the liver, with multiple colored diagrams showing relationships. Shata shows the liver as the critical organ receiving and processing the multitude of gut-associated antigens delivered by the portal vein. The early and devastating damage done to the gut-associated lymphoid tissue (GALT) by both simian immunodeficiency virus and HIV make eminent teleological sense, with the loss of gut TH17 cells being associated with microbial translocation. This leads to increased levels of lipopolysaccharide in the liver and the chronic stimulation required for HIV replication. Kupfer cells, the resident hepatic macrophages that clear most microbial translocation products, can be HIV infected and are characteristically decreased in patients with HIV. This loss of Kupfer cell function further augments the deleterious effect of microbial translocation, including the favoring of TH2 cell production, induction of tolerance, and progression of hepatic fibrosis. Bansal and Blackard cover similar material, emphasizing the differing cell types within the liver and their interaction with HIV, HBV, and HCV. They emphasize the early depletion of the GALT CD4 population, leading to disruption of gut epithelial integrity and of the proinflammatory cytokine milieu. A chapter providing a brief but detailed description of HIV replication is followed by 6 chapters devoted to hepatitis: 3 review HBV and therapy, 2 review HCV and therapy, and 1 summarizes hepatitis A, D, and E. Overton and Aberg devote a chapter to discussing standard measures for prevention of hepatitis. Shire provides a concise, well-done review of liver-related effects of retroviral therapy, with a useful summary table. The text is rounded out with chapters on management of end-stage liver disease, assessment and treatment of alcohol and substance-abuse disorders, racial disparities in HIV and liver disease, and quality of life in patients with HIV and liver disease. HIV and Liver Disease is well timed, because many patients coinfected with HIV and HCV have effective, stable control of their HIV but have not been so fortunate in controlling their HCV. The text can be appreciated by a wide audience, but perhaps most stimulating are the reviews describing the immunophysiology of the liver, with this organ functioning as “Grand Central Station” for the antigen traffic from the portal vein resulting from disrupted intestinal epithelial integrity. The effects discussed in this text suggest that early decimation of the CD4 GALT, long before damage to the peripheral CD4 compartment is evident, was an evolutionary “stroke of genius” to maintain a lifetime of activated lymphocytes necessary for replication. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
JAMA – American Medical Association
Published: Jul 25, 2012