Sunday, July 17, 2011

Hepatitis C Vasculitis-2011

From Medscape Rheumatology > Viewpoints
Predicting Outcomes in Hep C Vasculitis
Kevin Deane, MD
Authors and Disclosures
Posted: 07/19/2011

Prognostic Factors in Patients With Hepatitis C Virus Infection and Systemic Vasculitis
Terrier B, Semoun O, Saadoun D, Sène D, Resche-Rigon M, Cacoub PArthritis Rheum. 2011;63:1748-1757

Symptomatic vasculitis affects approximately 5%-10% of patients with hepatitis C (HCV) infection, and prior to the introduction of antiviral therapies, such vasculitis led to significant morbidity and increased mortality. However, more widespread use of antiviral therapies over the past decade years has perhaps improved mortality from HCV as well as from associated vasculitis. These authors sought to update our understanding of prognostic factors in HCV-related vasculitis by evaluating the outcomes of patients with this disease in the era of antiviral therapy.

Study Summary
This was a longitudinal, observational study of 151 patients with HCV-related vasculitis evaluated between 1993 and 2009 in France. For enrollment, patients must have had chronic active hepatitis C infection, HCV-related vasculitis, and at least 6 months of follow-up after diagnosis. HCV vasculitis was defined as clinical manifestations of vasculitis (including skin, neurology or other internal organ involvement) as well as biopsy-proven vasculitis, and/or detectable blood levels of mixed cryoglobulins in the setting of purpura.
The 151 subjects were an average age of 60 at diagnosis of HCV-related vasculitis; 46% were men, and the HCV genotype 1 was present in 62%. Overall, these subjects were followed for a median of 54 months after their diagnosis of HCV vasculitis. The overall survival rates in the entire cohort were 1-year, 96%; 5-years, 75%; 10 years, 63%. Specific causes of mortality in these patients included infections, end-stage liver disease (including hepatocellular carcinoma), non-liver cancer (including B and T cell lymphomas), and renal failure. The baseline factors associated with a poorer prognosis were age > 65 years, severe liver fibrosis (a Metavir fibrosis score ≥ 3), and vasculitic involvement of the kidneys, central nervous system, or heart. Additionally, treatment with corticosteroids and immunosuppressive agents was associated with poorer prognosis, although treatment with the specific therapies of plasmapheresis and rituximab did not appear to worsen prognosis. Factors associated with improved prognosis were treatment with pegylated interferon (introduced in 2001) plus ribavirin, although treatment with interferon monotherapy was not associated with improved outcomes. Finally, complete clinical response of vasculitis and a sustained virologic response were also associated with a good prognosis.

This interesting study of patients with HCV-related vasculitis tells us perhaps what we already knew -- that more severe HCV and associated vasculitis are more severe. However, the improvement in outcomes in those undergoing antiviral therapy, especially dual therapy with pegylated interferon plus ribavirin, is encouraging. It is also of interest that treatment with plasmapheresis or rituximab was not associated with worsened mortality. However, this is an observational study with inherent limitations to its conclusions regarding therapies for HCV vasculitis. Because this study focused on patients with HCV vasculitis, we still need to know more about potential changing incidence rates and disease severity of HCV vasculitis now that the use of antiviral therapies is more widespread. Ultimately, for optimal treatment approaches for patients with HCV vasculitis, we’ll need well-designed clinical trials, perhaps guided by findings from this study.

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