Letter to the Editor: Tuberculosis and Antituberculosis Treatments Cannot Be Ignored when Evaluating Patients with Cirrhosis Who Are Coinfected with HIV or Not

Potential conflict of interest: Nothing to report. To the Editor: The study conducted by Salmon‐Ceron et al.1 shows that in the period of combined antiretroviral therapy, the risks of hepatocellular carcinoma (HCC) and hepatic decompensation are similar between hepatitis C virus (HCV) monoinfected patients with cirrhosis and human immunodeficiency virus (HIV)/HCV coinfected patients with cirrhosis, even though the latter have higher all‐cause mortality. Although rigorously implemented, the study overlooked tuberculosis infections and antituberculosis therapy, which may greatly influence the outcome. First, it is well known that HIV‐infected patients are more susceptible to tuberculosis. Gao et al.2 reported that the prevalence of tuberculosis in HIV‐positive patients ranges from 2.9% to 64.5%, of which 31.25% are in Africa, 17.21% are in Asia, 20.11% are in Europe, and 14.84% are in the United States. Meanwhile, according to the World Health Organization,3 the tuberculosis infection accounted for approximately 26% deaths of HIV‐infected patients. In addition, the prevalence of tuberculosis in people with cirrhosis is 15 times higher than the general population, as cirrhosis is an independent risk factor of tuberculosis.4 Second, antituberculosis drugs can accelerate HCC development and cause acute liver failure in cirrhosis because of their potential hepatotoxicity.4 Lim et al.5 identified that long‐term (more than 12 months) use of isoniazid, rifampicin, or the combination of the two led to significantly higher risk of HCC, with an odds ratio of 3.51 (95% confidence interval [CI], 2.11‐5.84), 4.17 (95% CI, 2.76‐4.31), and 7.17 (95% CI, 4.08‐12.6), respectively. Similarly, higher risk of HCC was also observed in patients with cirrhosis with treatment of high doses (>16,050 mg/year) of isoniazid and rifampicin than those without antituberculosis treatment. Lim et al.’s study demonstrated that patients with cirrhosis receiving long‐term, high‐dose isoniazid and rifampicin treatment, especially the combination of the two, have a higher rise of HCC. In summary, HIV infection and cirrhosis are risk factors of tuberculosis infection. Tuberculosis infection and antituberculosis treatment have a significant impact on the all‐cause mortality, the incidence of HCC, and the decompensation of cirrhosis. From our perspective, the tuberculosis infection and antituberculosis treatment may differ between the HIV‐infected group and the noninfected group. Therefore, the conclusion will be more convincing if the research could provide more detailed information about tuberculosis infection and antituberculosis treatments, and optimize the previous findings.