Chronic Hepatitis C Teaching Topic

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TEACHING TOPICS from the New England Journal of Medicine Teaching Topics | June

23, 2011Hepatitis C: Approximately what percentage of patients with chronic

hepatitis C virus infection have progression to cirrhosis? Teaching

TopicHepatitis CClinical PracticeChronic Hepatitis C InfectionH.R. Rosen

Infection with HCV affects an estimated 180 million people globally. It is a

leading cause of chronic hepatitis, cirrhosis, and liver cancer and a primary

indication for liver transplantation in the Western world.Clinical Pearls What

are the predominant risk factors for hepatitis C virus infection?The predominant

risk factor for HCV acquisition is injection-drug use; among U.S. adults 20 to

59 years of age with any history of illicit injection-drug use, the prevalence

of HCV infection is greater than 45%. Other risk factors include blood

transfusion before 1992, high lifetime number of sexual partners, and iatrogenic

transmission, including through dialysis; in large series, 15 to 30% of patients

report no risk factors. Approximately what percentage of patients with chronic

hepatitis C virus infection have progression to cirrhosis?Although the natural

history of HCV infection is highly variable, an estimated 15 to 30% of patients

in whom chronic infection develops have progression to cirrhosis over the

ensuing three decades. A number of factors, including a longer duration of

infection, an older age at the time of exposure, male sex, coinfection with

other viruses such as HIV, and daily alcohol consumption, but not viral level or

genotype, have been consistently associated with an increased risk of

fibrosis.Table 1. Predictors of a Favorable Response to Treatment with

Peginterferon and Ribavirin.Morning Report QuestionsQ. What methods can be used

to quantify hepatic fibrosis?A. Several methods have been used to quantify

hepatic fibrosis, including the simple aspartate aminotransferase:platelet ratio

index and commercially available assays of some or most of the following

biomarkers: á2-macroglobulin, á2-globulin, ã-globulin, apolipoprotein A-I,

ã-glutamyltransferase, total bilirubin, and hyaluronic acid.Q. What treatment is

the standard of care for all HCV genotypes?A. Over the past decade, on the basis

of considerable data from randomized trials, pegylated interferon

(peginterferon) plus ribavirin became the standard of care for all HCV

genotypes. Regardless of the infecting genotype, the likelihood of a sustained

virologic response is lower among patients with a high pretreatment HCV RNA

level and higher among patients with better adherence to antiviral therapy.