A Practical Guide to a Healthy Body for People Living with HIV

 

Liver Health

The liver truly is a vital organ: You can’t live without it. The largest solid internal organ in the human body, it works around the clock to perform more than 500 functions. It metabolizes and stores nutrients from the food we eat. It helps process the medications we take. It removes waste products from our blood, breaking down and detoxifying harmful substances. It regulates our hormones, builds proteins needed by the immune system and helps fight infections, among other things. So it’s well worth it to do what we can to help this powerhouse work smoothly.

If you are living with HIV, especially if you are on antiretroviral therapy (ART), it’s a good idea to have your liver health checked regularly by your doctor or nurse practitioner. That’s because some medications, including some HIV meds, can strain the liver. Also, liver problems are sometimes silent, so many people who have a liver problem initially experience few symptoms or none at all. A person can live with liver disease for years without knowing it. By understanding what can harm and what can help your liver, you’ll see that there is much you can do to protect it.

Risk factors for liver problems

Liver injury has many possible causes, including:

  • hepatitis A, B, C, D or E
  • heavy use of alcohol and/or recreational drugs
  • overuse of acetaminophen (Tylenol)
  • repeated use of antibiotics
  • some medications, including some HIV meds
  • poor diet
  • exposure to harmful chemicals
  • higher-than-normal triglyceride levels
  • having a history of life-threatening infections, such as MAC (Mycobacterium avium complex), tuberculosis or CMV (cytomegalovirus)
  • lymphoma
  • liver conditions such as Wilson disease, Gilbert’s syndrome and primary biliary cirrhosis

Although the liver is generally up to the job of breaking down, or metabolizing, medications, some HIV meds can cause liver injury, especially in people who are co-infected with hepatitis viruses. In particular, nevirapine (Viramune) and abacavir (Ziagen, also in Kivexa, Trizivir and Triumeq) can produce an allergic (hypersensitivity) reaction in some people that can harm the liver. Other antiretrovirals that have been known to cause liver problems in some people include efavirenz (Sustiva), tipranavir (Aptivus) and darunavir (Prezista). While it can be toxic to the liver in larger doses, in the lower doses commonly prescribed to boost other protease inhibitors, ritonavir (Norvir) is much less likely to result in liver injury.

In addition to these risk factors, people who are overweight tend to be at higher risk for developing liver problems.

Because of the risk of severe liver injury (hepato­toxicity) from nevirapine, anyone who starts taking this HIV drug should have their liver health monitored frequently during the first 18 months of therapy, and then every three to four months for as long as test results remain normal.

To reduce the risk of nevirapine-associated liver problems, a lower dose is typically prescribed for the first two weeks that a person takes it. After that, if there are no symptoms and if test results indicate no problems, the dose is increased.

Fatty liver

Another type of liver disease that some people with HIV develop is called fatty liver. Nonalcoholic fatty liver disease (NAFLD)—a term used to differentiate it from the fatty liver that can develop as the result of alcohol consumption—is fairly common among people on ART. With this condition, large amounts of fat gradually build up in liver cells. Often this buildup doesn’t cause harm. However, in a small proportion of people with NAFLD, progressive inflammation of the liver may occur and result in serious scarring (cirrhosis of the liver). Eventually, the cirrhosis caused by fatty liver can become so severe that the liver no longer functions properly (liver failure).

Diagnosing liver damage

Unfortunately, many people remain unaware that they have liver disease until they develop symptoms and feel unwell.

Symptoms that could indicate liver damage include:

  • dark (tea-coloured) urine
  • jaundice (yellowing of the skin or whites of the eyes)
  • light-coloured or bloody stool
  • persistent nausea and/or vomiting
  • flu-like symptoms (fever, aches, pains, feeling generally unwell)
  • pain or tenderness on your right side below your ribs
  • abdominal pain
  • unusual fatigue or weakness
  • loss of appetite
  • itchy skin
  • swollen ankles and feet

Signs and symptoms that could indicate a drug hypersensitivity reaction (which can harm the liver) include:

  • a rash, particularly if it is severe or accompanied by fatigue
  • gastrointestinal symptoms (including nausea, vomiting, diarrhea or belly pain)
  • fatigue, lack of energy, weakness
  • respiratory symptoms (sore throat, shortness of breath, cough, unusual findings on X-rays of the chest)
  • mouth sores
  • “pink eye” (conjunctivitis)
  • swelling of the face, throat, tongue, lips, eyes, hands, feet, lower legs
  • the liver damage symptoms previously listed

If you experience any of these symptoms at any time, particularly during the first eight weeks of HIV treatment, notify your doctor immediately.

Your doctor may recommend blood tests to determine whether an HIV medication you’re taking should be discontinued. If a medication has to be discontinued due to a hypersensitivity reaction, it can never again be used because a fatal reaction could occur within hours.

Various blood tests can help assess liver damage or inflammation. A bilirubin test is a blood test that measures how well your liver is clearing the waste product bilirubin. Other tests measure the levels of certain liver enzymes. The liver uses enzymes to get rid of the waste produced by your body and by the breakdown of drugs, alcohol and other toxins. When the liver is stressed, blood tests may show high levels of certain enzymes, such as:

  • AST (aspartate aminotransferase)
  • ALT (alanine aminotransferase)
  • GGT (gamma-glutamyl transpeptidase)
  • ALP (alkaline phosphatase)
  • LDH (lactic dehydrogenase)

If you take HIV medications, you should have your liver enzymes monitored regularly. It is especially important that people who already have some liver damage—due to hepatitis, for example—get regular blood tests. In this way, any drug causing problems can be discontinued and other problems causing liver damage can be addressed. (Abnormally high enzyme levels can sometimes be caused by problems other than liver disease, so the test results need to be interpreted carefully.)

Nonalcoholic fatty liver disease usually causes no obvious symptoms, but when it does they include fatigue, pain in the upper right abdomen and unintentional weight loss. Diagnosis can involve liver enzyme tests, imaging tests and sometimes liver biopsy.

How to protect your liver

Detoxify

Because a healthy liver is so important to your overall health, and it will help you handle antiretroviral therapy over the long term, detoxifying and repairing it is one of the best things you can do for your long-term health. To prevent or repair liver damage, try to eliminate as many sources of toxicity as possible.

Cut down or eliminate your use of alcohol and street drugs

Heavy drinking can be toxic to the liver. Consuming too much alcohol can cause fatty liver and other forms of liver damage. If you already have some liver damage, the risk from alcohol is greater. In people with hepatitis C, a high alcohol intake has been tied to an increased risk of cirrhosis, more advanced liver fibrosis and a higher rate of death. Try to limit your alcohol consumption to no more than one drink per day, or avoid it altogether.

Quit smoking

Tobacco smoke contains hundreds of extremely toxic chemicals that the liver must try to break down. For someone who already has liver problems, continuing to smoke adds another burden to a liver that is already struggling. Easier said than done but if you can quit smoking, you’ll be doing your liver a big favour.

Eat healthy

Eating a healthy diet helps keep your liver healthy. Cut out junk foods and drinks that are loaded with chemicals and sugar that the liver will have to detoxify. Limit the amount of fat you eat. Another way to give your liver a break is to limit the amount of sugar and fructose you consume.

Get vaccinated against hepatitis A and B

Hepatitis A and B are liver diseases caused by the hepatitis A and B viruses. There are vaccines that can protect you from these viruses. Some people from high-risk groups can get the vaccines free of charge. Talk to your doctor for more information. (To learn more about viral hepatitis, visit www.catie.ca/en/hepatitis-c/key-messages/abcs.)

Avoid activities that carry a risk of hepatitis C

If you inject drugs, avoid sharing needles, syringes, filters, alcohol swabs, water and cookers. If you smoke or snort drugs, avoid sharing crack pipes, straws and bills. Because Hep C can also be passed when people share personal items that could have blood on them, such as razors, nail clippers and toothbrushes, it’s also a good idea to avoid sharing these items. During sex, avoid sharing sex toys or other objects that may have someone else’s blood on them. (To learn more about hepatitis C, visit www.catie.ca/en/basics/hepatitis-c.)

If possible, avoid being exposed to chemicals, or reduce your exposure

In the workplace and elsewhere, avoid being exposed to chemical fumes and vapours, such as gasoline, solvents, pesticides and herbicides. Or reduce your exposure by wearing an appropriate face mask.

Avoid taking antibiotics unnecessarily

Some antibiotics can be toxic to the liver. Antibiotics are overused in our society and sometimes prescribed and taken in situations where they will have no effect. You should, of course, take antibiotics if you have a real need, but they shouldn’t be used for a cold or flu or other infection that is caused by a virus for which an antibiotic will do nothing.

Use acetaminophen with caution

Acetaminophen (Tylenol) overdose is the most common cause of acute liver failure in North America, and alcohol consumption can substantially increase the risk. If you consume alcohol regularly, some experts strongly recommend that you take no more than 1,000 to 2,000 mg of acetaminophen per day and for only a few days at most. That means taking no more than two to four extra-strength pills in a 24-hour period.

Acetaminophen is an active ingredient in more than 200 medications, including many popular over-the-counter headache and cold remedies (such as Dayquil, Buckley’s and NeoCitran). It’s also in some common prescription drugs (such as Percocet and Tylenol 3). To protect the liver, avoid combining acetaminophen-containing products. Talk to your pharmacist for help reading labels.

If you take acetaminophen, do not exceed the maximum daily recommended dose on the label. You might also consider taking N-acetyl-cysteine (NAC) to decrease the risk of liver injury. Talk to your doctor about ways to prevent any negative effects from acetaminophen.

Go for a “brown bag” checkup to review your drugs and supplements

Gather all of the prescription medications, over-the-counter meds and supplements you’re taking and bring them to your doctor’s appointment to determine if anything could cause liver problems and, if so, if you should switch to another drug or supplement. At that time your doctor can also assess whether there’s a possibility of drug interactions. It is possible that drugs that would normally cause no problems when taken alone might interact with one another and cause toxicity.

You might want to also do a “brown bag” checkup with your pharmacist. He or she will look at everything you’re taking to check for possible interactions or other problems. Do not change your HIV meds unless your doctor advises you to do so.

Eat foods that support the liver

A well-balanced diet that includes fruits and vegetables, whole grains and good sources of protein and fats supports your liver by providing it with the nutrients it needs to stay healthy.

Consuming a variety of colourful fruits and vegetables provides the body with antioxidants, which protect the liver. Tea, coffee and dark chocolate are also loaded with antioxidants. Research suggests that polyphenols in green and black tea may help protect the liver from toxins and may help prevent liver cancer when two to four cups of tea are consumed daily. Coffee also contains high levels of antioxidants. If you can, stick to organic coffee because non-organic coffee is one of the crops most heavily sprayed with pesticides, and pesticides are filtered by the liver.

Fruits, vegetables and whole grains are a valuable source of fibre. Fibre can help bind toxins in the intestines and then speed their elimination through the bowel, thereby reducing the liver’s detoxification workload. Taking fibre supplements like psyllium or oat bran can add to your fibre intake.

Certain fruits, vegetables, fatty fishes and other foods are also a source of powerful natural anti-inflammatories. These foods can help reduce the inflammation that can contribute to liver damage.

The good fats from olive oil, nuts and seeds, avocados and wild-caught fish are easier for the liver to process and help the liver to create healthy cell membranes around its cells. On the other hand, bad fats like trans fats place a heavy burden on the liver.

If possible, choose organic foods because they do not contain the pesticides that are sprayed on many fruits, vegetables and grains or the antibiotic residues found in non-organic meats, eggs and farm-raised fish. Organic foods tend to be more expensive and many people can’t afford the higher prices. But if you can afford to buy organic occasionally, you might want to buy those fruits and vegetables that tend to be the most heavily sprayed with pesticides. These are sometimes referred to as “the dirty dozen”: apples, celery, bell peppers, peaches, strawberries, nectarines, grapes, spinach, lettuce, cucumbers, blueberries and potatoes.

Finally, be sure to drink plenty of water to help flush out toxins after they have been processed by your liver.

Avoid foods that could harm the liver

If you have fatty liver, reducing your intake of fructose may help. High-fructose corn syrup (also called glucose/fructose syrup) is a major source of fructose. White sugar, or what is commonly referred to as table sugar, contains 50 percent fructose and 50 percent glucose.

Of the 40 kilograms of sugar consumed by the average Canadian each year (that’s about 26 teaspoons each day), only a small fraction comes straight from the sugar bowl. The vast majority comes from commercial foods such as soft drinks, ice cream, cakes, cookies, chocolate bars and breakfast cereals. Significant quantities are also found in cold cuts, relishes, canned soups and vegetables, mayonnaise-like spreads, salad dressings, ketchup and many commercial breads. So, to cut down your intake of sugar/fructose, you will have to read food labels carefully.

When you read labels, remember that all of these are sugars: corn syrup, high-fructose corn syrup, glucose/fructose syrup, sucrose, glucose, fructose, dextrose, maltose, evaporated cane juice, cane sugar, beet sugar, maltodextrin, corn sugar, barley malt, caramel and carob syrup. If you see several of these on the same label, you know that the food is loaded with sugar!

For people with moderate or severe liver disease, certain dietary restrictions may be necessary. A low-sodium diet is recommended for anyone who has advanced liver disease that has resulted in an abnormal accumulation of fluid. The more the salt intake can be reduced, the better the chances of avoiding this excessive fluid accumulation. In general, liver experts recommend limiting sodium intake to only 500 to 1,000 mg daily. This will require reading food labels carefully. You will want to avoid most prepared foods, which are high in sodium, and choose more fresh foods, as they contain little sodium. Your doctor will be able to determine whether you need to restrict your sodium intake.

The amount of protein you consume might need to be limited. When protein is broken down in the body, one of the byproducts is ammonia. A damaged liver cannot process ammonia as well as a healthy liver can. An overload of ammonia can result in a serious brain condition called encephalopathy, which can affect your ability to think clearly and remember. The exact level of protein intake that is desirable for you will depend on the condition of your liver. Your doctor will be able to determine whether you need to restrict your protein intake.

People who are co-infected with HIV and hepatitis C should avoid high levels of iron. Some iron is good but too much can cause iron overload. This is especially true for people who have had a liver biopsy that showed an abnormal accumulation of iron in the tissue. A daily intake of antioxidants may make iron less problematic. But since it is not known exactly when and in whom iron will be a problem, eliminating excessive iron from your diet appears to be a good idea if you are co-infected with HIV and hepatitis C.

Treat liver-damaging infections and cancers

Liver injury can also be caused by certain infections and certain kinds of cancer. Early diagnosis and treatment can limit their effect on the liver. For example, there are now excellent treatments for hepatitis B. The treatment does not cure the infection but can greatly suppress hepatitis B and prevent it from causing further damage to your liver.

There have also been huge advances in hepatitis C treatment. Hepatitis C treatments are very effective at curing the infection. Everyone who has Hep C should talk to their doctor about their options. Hep C treatment can save your liver and your life.

The liver is an organ that is capable of repairing itself. When hepatitis viruses are suppressed or eliminated, particularly if this is done before serious damage has occurred, the liver may be able to repair itself. So don’t hesitate to talk to your doctor about hepatitis testing and treatment.

Supplements

In addition to removing, as much as possible, anything that might be stressing the liver, taking certain supplements may help. Some naturopathic doctors find the following antioxidants and nutrients useful for helping to protect the liver.

Glutathione (GSH) is an antioxidant made by the body that helps break down drugs and toxins and protect the liver. Taking the following nutrients may help to maintain or increase levels of glutathione:

  • N-acetyl-cysteine (NAC) – 500 mg taken three times per day with food. (The body converts NAC into GSH.)
  • vitamin C – try to eat fresh and colourful fruits and vegetables every day. If you cannot get fresh fruit, then consider taking a vitamin C supplement. Speak to your healthcare provider about the dose that is right for you.
  • alpha-lipoic acid – 300 mg per day.

One well-designed clinical trial that lasted for six months found that the amino acid L-carnitine (1 g taken with a meal once daily) was able to reduce inflammation in people with fatty liver. Carnitine is available by prescription (sold under the brand name Carnitor) or over the counter from some pharmacies and health food stores.

Because inflammation is a major contributor to liver damage in nonalcoholic fatty liver disease, dietary changes and nutritional supplements that reduce inflammation may also be helpful.

A herb called milk thistle (Silybum marianum) contains the compounds silybin, silychristin, silydianin and isosilybin, which, as a group, are commonly referred to as silymarin. Silymarin has powerful effects as both an antioxidant and protector of the liver. Clinical trials have found that intravenous administration of milk thistle and its extracts can sometimes be helpful in managing hepatitis C infection. However, milk thistle and its extracts have the potential to interact with many medications, including various prescription drugs and over-the-counter meds. Early test-tube studies led to a concern that silybin might affect blood levels of some antiretrovirals. A later study in humans led researchers to conclude that at commonly used doses the herb should not interfere. Talk to your doctor or pharmacist if you are considering taking this supplement.

Although people living with HIV have found some supplements to be helpful, certain supplements can seriously harm the liver. Many pre-packaged medicines are labelled inaccurately and may contain herbs that are toxic to the liver. Herbs grown in an environment where they have been exposed to toxic chemicals can also cause liver damage. Always consult a knowledgeable practitioner for advice. And always let your doctor and pharmacist know about any herbs or supplements you are thinking of taking.