Read HCV Cirrhosis Is a Life Threatening Disease text version

Medical Writers' Circle

About the Writer

Bennet Cecil, MD Assistant Clinical Professor of Medicine University of Louisville School of Medicine Corporate Medical Director Hepatitis C Treatment Centers Inc. Louisville, Kentucky

The reason that HCV is a serious infection is that it causes cirrhosis. Cirrhosis occurs when the normally soft liver is converted by a disease into a hard organ full of scar tissue. Hepatitis C and alcoholism are the most common causes of cirrhosis in the US. Chronic liver disease with cirrhosis is the 12th most common cause of death in the US. Cirrhosis from HCV does not happen overnight. It takes many years of liver injury followed by fibrosis. This provides many years to identify persons infected with HCV and successfully treat them. The success rate of antiviral therapy is lower in persons who have cirrhosis.

The HCV Advocate

February 2009

a series of articles written by medical professionals about the management and treatment of hepatitis C

HCV Cirrhosis Is a Life Threatening Disease

Often, patients with mild or moderate fibrosis in their 40s will for unknown reasons accelerate fibrosis progression and develop cirrhosis over 5-10 years.

HCV cirrhosis develop liver cancer each year and liver cancer cases and deaths in the US are spiking because of our HCV epidemic. About 2-3% of patients with HCV cirrhosis develop liver failure each year. Patients with liver failure accumulate fluid in the abdomen, called ascites. This fluid can become infected, (spontaneous bacterial peritonitis). Jaundice is another sign of liver failure where the skin and eyes become yellow because the liver cannot excrete bilirubin normally. Patients with cirrhosis develop portal hypertension. Their veins in the esophagus and stomach become enlarged and can rupture with a risk of death. Some cirrhotic patients develop hepatic encephalopathy with sleepiness, difficulty in concentration and confusion. This can progress to hepatic coma especially if they have bleeding or


People with cirrhosis die prematurely. Even though they are often in their 40s or 50s, cirrhotic patients die at a rate similar to people in their 80s. Cirrhotic patients get liver failure and liver cancer, which in turn lead to death. About 1-2% of patients with

HCV Cirrhosis Is a Life Threatening Disease

Medical Writers' Circle --a series of articles written by medical professionals about the management and treatment of hepatitis C


February 2009

infection. The level of ammonia in their blood is often elevated. Hepatitis C causes inflammation, injury and fibrosis (scar tissue). As the years roll by, more and more fibrosis occurs. Fibrosis can be staged by a liver biopsy; stage 0 (no fibrosis), stage 1 (mild fibrosis), stage 2 (moderate fibrosis), stage 3 (severe fibrosis) and finally stage 4 (cirrhosis). Young patients do not usually develop HCV cirrhosis. It becomes more common in patients who are forty or older. Many patients mistakenly reason that since they have had HCV for 20 years and have only stage 1 or 2 fibrosis that it will be another 20 or 30 years before they get cirrhosis and start getting into trouble. Often, patients with mild or moderate fibrosis in their 40s will for unknown reasons accelerate fibrosis progression and develop cirrhosis over 5-10 years. Cirrhosis is a common finding in patients infected with HCV who are 65 and older. Elderly patients do not tolerate treatment easily, and successful treatment of an elderly patient may not prolong survival. This is because older persons have other diseases that cause death, especially cardiovascular disease. Cirrhotic elderly patients who eradicate HCV still have risk of liver cancer even though curing HCV reduces that risk. It is not clear when a patient is too old to undergo antiviral therapy. Patients with early cirrhosis do not look any different than patients with mild liver damage. They have compensated cirrhosis; there is severe damage but the liver is functioning well. As the cirrhoThe HCV advocate

sis progresses changes occur. Spider angiomas, small blood vessels appear on the neck chest and back. Muscles in the chest and shoulders shrink and the skin becomes thin. Large veins are often visible under the skin of the abdomen. The spleen enlarges and can be felt on physical examination and measured by ultrasound. Fetor hepatis, a musty smell to the breath, becomes present. Sex hormone imbalances reduce testosterone in men causing sexual problems, and young cirrhotic women stop having normal menstrual cycles. Blood tests help to clarify the severity of cirrhosis and the need for liver transplant. As the cirrhosis progresses, the platelet count tends to fall. Elevation of bilirubin signifies that cirrhosis is progressing to liver failure. As the bilirubin rises the sclera (whites of the eyes) and skin turn yellow. Another blood test, prothrombin time INR, measures the clotting ability of the blood. Since the liver produces clotting proteins, as it fails the blood clots more slowly. Bilirubin, prothrombin INR, a test for renal function and age are the variables in the MELD score. This is the numeric score that determines a patient's place on the liver transplant list. The higher the MELD score, the higher the chance of dying without a liver transplant. Liver biopsy is the gold standard test for cirrhosis. HCV Fibrosure is a non-invasive test from LabCorp that estimates that amount of liver damage without a biopsy. Ultrasound or CT exam of the abdomen image the liver and spleen

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giving clues about cirrhosis and can detect liver cancer. Upper endoscopy in a sedated patient is a procedure that examines the esophagus and stomach for enlarged veins called varices. Esophageal varices can be treated with medicines like nadolol or propranolol. Large or bleeding varices can be ligated (tied off) during upper endoscopy using small rubber bands. The best strategy is to permanently eradicate HCV before it causes cirrhosis. The liver can then heal and the patient will avoid liver cancer and liver failure. The liver has a strong ability to heal and regenerate once HCV has been permanently eliminated by successful antiviral therapy. Since it is not possible to accurately select individuals who 5, 10 or 20 years later will develop cirrhosis, the best course of action is to offer antiviral therapy to all patients with HCV. This is a challenge with patients who have medical, psychiatric and social problems. Antiviral therapy may need to be delayed, but too often it is put on permanent hold. Before you know it, we are all a few years older. The patient still has the same medical, psychiatric and social problems, and in addition a cirrhotic liver. Many of them will not be offered a liver transplant, and therefore die prematurely from HCV. Even patients who receive a transplant still die at a faster rate than normal. Patients transplanted for HCV have about 25% chance of death within five years. That is about 5% chance of death per year


HCV Cirrhosis Is a Life Threatening Disease

Medical Writers' Circle --a series of articles written by medical professionals about the management and treatment of hepatitis C


February 2009

like an 80-year-old American. Prevention of cirrhosis by curing HCV is much preferred to treating a cirrhotic patient with HCV. Patients with compensated cirrhosis from HCV have been included in many published clinical trials. Cirrhotic patients have a lower chance of successful eradication of HCV than patients with less liver damage, but benefit from successful treatment. Multiple studies from around the world have demonstrated that cirrhotic patients with HCV improve their survival and lower their chance of liver cancer if they eliminate HCV. Liver biopsy and noninvasive serum markers usually show improvement in cirrhosis with permanent viral eradication. Actual reversal of cirrhosis has been demonstrated, but the proportion of patients who are able to accomplish this is unknown. Some physicians thought interferon might help patients even if the HCV was not eliminated, but the HALT C trial refuted that theory. The HALT C study randomized nonresponding patients with HCV who had stage 3 or stage 4 fibrosis to either no treatment or maintenance low dose Pegasys. Pegasys did

not reduce liver cancer or death in these patients who were not able to clear their HCV infection. The clear link between permanent eradication of HCV and better clinical outcome emphasizes the importance of doing everything possible to successfully treat HCV including patients with cirrhosis. Patients who do not respond to initial therapy using pegylated interferon plus ribavirin, or relapse after completion should consider retreatment with a different regimen. Studies like the DIRECT trial using Infergen plus ribavirin or REPEAT using a longer duration of Pegasys plus ribavirin have demonstrated that some who initially fail can succeed with a new attempt at cure. Hepatitis C protease inhibitors in phase 3 trials will improve our success in viral eradication. Patients can find information about enrolling in HCV trials at Cirrhosis is a life threatening condition, and HCV cirrhosis is preventable by curing the HCV infection before there is severe liver damage. Patients with HCV cirrhosis can be treated with antiviral therapy successfully. If initial treatment is not successful, consideration of retreatment or participation in a clinical trial should be seriously considered.

HCSP FactSheets: HCV Disease Progression

HCSP Easy Facts · What is Cirrhosis? · What is Steatosis?

HCSP Hepatitis C Basics · What is Fibrosis / Cirrhosis?

HCSP Factsheet Series · Acute Hepatitis C · Cirrhosis · Fibrosis · Steatosis · Liver Transplantation

A publication of the Hepatitis C Support Project

The Mission of the Hepatitis C Support Project is to offer support to those who are affected by the hepatitis C Virus (HCV), hepatitis B Virus (HBV) and HCV coinfections. Support is provided broadly, through information and education, as well as access to support groups. The Project seeks to serve the HCV community as well as the general public. Executive Director, Editor-in-Chief, HCSP Publications Alan Franciscus Managing Editor / Webmaster C.D. Mazoff, PhD This information is provided by the Hepatitis C Support Project a nonprofit organization for HCV education, support and advocacy ©2009 Hepatitis C Support Project Reprint permission is granted and encouraged with credit to the Hepatitis C Support Project.


HCV Cirrhosis Is a Life Threatening Disease

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