Monday, August 28, 2017

HCV Disease Progression - Alcohol Consumption

HCV Disease Progression
When newly diagnosed with HCV the first thing on a patients mind (it was on mine) is how much liver damage do I have, and how will this virus progress overtime. Only by research into the natural history of hepatitis C can this be estimated. However, because the time of acute HCV infection is often impossible to establish, disease progression is difficult to determine. There is a general consensus after acquiring the virus it takes 10 to 15 years before evidence of the disease appears on biopsy or noninvasive tests used to measure fibrosis, 20 or so years to develop cirrhosis, and around another decade to develop liver cancer, but is influenced by several host factors, especially alcohol consumption.

Alcohol consumption
Researchers often reference a unique cohort of HCV patients when describing the natural history of hepatitis C. Never has there been a more perfect natural history study, in that, the known dates of infection were precise. The famous and tragic cohort include 704 Irish women and 917 German women exposed to hepatitis C from contaminated Anti-D immunoglobulin in 1977 and 1979. In the following cohort study published in Journal of Hepatology 2017 Aug 23, researchers looked at host and treatment factors to estimate the effect of disease progression in 682 Irish women mentioned in the above cohort. The authors wrote;

In the mid 1990s, a group of women were diagnosed with chronic hepatitis C virus (HCV) infection following receipt of contaminated anti-D immunoglobulin between 1977 and 1979 in Ireland. Seventy-two (19%) developed cirrhosis and 18 had died from liver-related causes (5%) after 36 years of infection. Disease progression accelerated in the latest five years of follow-up, particularly in women with diabetes mellitus and high alcohol consumption. We recommend that patients with chronic HCV infection be advised of the additive harmful effect of high alcohol consumption.
View abstract, here.

2013 - German cohort of women after 35 years of infection
Going back to a study in 2013, in the German cohort of women after 35 years of infection, published in Hepatology, mild but significant disease progression at 35 years after infection is suggested, noting patients with self-limited HCV infection or who achieved SVR after antiviral treatment were protected from progressive liver disease and showed the best clinical long-term outcome.

2005 - German cohort of women after 25 years of infection
In 2005 a slow rate of disease progression in the German women after 25 years of infection is again suggested, given the high rate of spontaneous clearance (undetectable levels of the virus without initiating drug therapy.) as published in Journal of Hepatology. Comment on the study:

In sum, from the study of Wiese et al. [10] and a similar study in Ireland [11], one can conclude that a woman infected with HCV in her mid-20's has a near 50% chance of spontaneous recovery and in those with persistent infection, there is only a 5% probability of developing bridging fibrosis, cirrhosis or HCC during the first 25 years of infection. These relatively benign outcomes are quite encouraging, but this population represents a best-case scenario because of the young age and general good health at the onset of infection, and the rarity of co-morbid factors. Risk might increase slightly in males and would increase significantly in those infected at ages beyond 40, those with immunodeficiency states, those with excessive alcohol intake and perhaps those with high body mass index. Nonetheless, the 25-year outcome in the natural history of HCV infection is one of higher than expected spontaneous recovery and lower than predicted morbidity and mortality. Comment published in Journal of Hepatology.

Recommended Reading
Read more about alcohol use and disease progression.

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