Effect of a Change in HIV Therapy on Liver Steatosis, Inflammation, and Fibrosis

This study provides a unique opportunity to prospectively assess the relationship of lactic acidemia with liver dysfunction and to determine whether lactic acidemia and liver dysfunction are likely to be secondary to NRTI-induced mitochondrial toxicity. If lactic acidemia and hepatic fatty infiltration (steatosis) in this study population are secondary to NRTI-induced mitochondrial toxicity, withdrawal of NRTI medications can be expected to result in partial improvement or resolution of these findings. Furthermore, this study will examine the possible additive ill effects of NRTI-induced mitochondrial toxicity on liver function in individuals coinfected with hepatitis C. This study is designed both as a stand-alone ACTG protocol providing an NRTI-sparing regimen and as a study coenrollable simultaneously with A5116. Patients enrolling in A5133 as a stand-alone study: Patients on NRTI-containing regimens with elevated lactates and ALTs are enrolled into a single open-label NRTI-sparing treatment regimen of efavirenz (EFV) plus lopinavir/ritonavir (LPV/r), which are provided by the study. These patients follow virologic failure/toxicity management guidelines as detailed in the protocol. Patients coenrolling in A5116: Patients are studied on their assigned A5116 antiretroviral regimens with medication as provided by A5116. Those randomized in A5116 to the NRTI-sparing regimen of EFV and LPV/r identical to that offered by A5133 will be assessed together with patients who entered A5133 as a stand-alone study. Individuals assigned in A5116 to the continued NRTI arm of 2NRTIs plus EFV are enrolled into a separate observational arm of A5133. The impact of continued NRTI therapy on liver histology is assessed in this observational arm. Virologic failure/toxicity management is in accordance with the A5116 protocol. The definition of virologic failure in A5116 is identical to the definition used in A5133. Arm 1 consists of patients assigned to an NRTI-sparing regimen without evidence of HCV coinfection. Arm 2 consists of patients assigned to an NRTI-sparing regimen with evidence of HCV coinfection. Arm 3 consists of patients coenrolled in the NRTI-containing arm of A5116 with or without evidence of HCV coinfection. All patients are evaluated for safety and for virologic and immunologic responses. In addition, individuals undergo liver biopsy and upper abdominal CT scans within 30 days prior to entry and within 30 days prior to week 24. The biopsied tissue is reviewed for evidence of fatty infiltration, inflammation, and fibrosis. The CT scans are assessed for degree of fatty infiltration. If sufficient liver tissue is available, the biopsied tissue will be assessed for other parameters. Plasma, PBMCs, and sera are collected to explore the role of oxidative stress and other parameters in the development of hepatic fatty infiltration (steatosis) and hyperlactatemia. The effect of changes in liver fatty infiltration and plasma lactate on lipoproteins will be explored. Finally, PBMC mtDNA content will be correlated with liver mtDNA content.