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Ng M, Carrieri PM, Awendila L, Socías ME, Knight R, Ti L. Hepatitis C Virus Infection and Hospital-Related Outcomes: A Systematic Review. Can J Gastroenterol Hepatol 2024; 2024:3325609. [PMID: 38487594 PMCID: PMC10940031 DOI: 10.1155/2024/3325609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 10/24/2023] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
Background People living with hepatitis C infection (HCV) have a significant impact on the global healthcare system, with high rates of inpatient service use. Direct-acting antivirals (DAAs) have the potential to alleviate this burden; however, the evidence on the impact of HCV infection and hospital outcomes is undetermined. This systematic review aims to assess this research gap, including how DAAs may modify the relationship between HCV infection and hospital-related outcomes. Methods We searched five databases up to August 2022 to identify relevant studies evaluating the impact of HCV infection on hospital-related outcomes. We created an electronic database of potentially eligible articles, removed duplicates, and then independently screened titles, abstracts, and full-text articles. Results A total of 57 studies were included. Analysis of the included studies found an association between HCV infection and increased number of hospitalizations, length of stay, and readmissions. There was less consistent evidence of a relationship between HCV and in-hospital mortality. Only four studies examined the impact of DAAs, which showed that DAAs were associated with a reduction in hospitalizations and mortality. In the 14 studies available among people living with HIV, HCV coinfection similarly increased hospitalization, but there was less evidence for the other hospital-related outcomes. Conclusions There is good to high-quality evidence that HCV negatively impacts hospital-related outcomes, primarily through increased hospitalizations, length of stay, and readmissions. Given the paucity of studies on the effect of DAAs on hospital outcomes, future research is needed to understand their impact on hospital-related outcomes.
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Affiliation(s)
- Michelle Ng
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, Canada V6Z 2A9
| | - Patrizia Maria Carrieri
- Faculté de Médecine, Aix Marseille Université, 27 bd Jean Moulin 13385, Marseille Cedex 5, France
| | - Lindila Awendila
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard St, Vancouver, British Columbia, Canada V6Z 1Y6
| | - Maria Eugenia Socías
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, Canada V6Z 2A9
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia, Canada V5Z 1M9
| | - Rod Knight
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, Canada V6Z 2A9
- École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, Canada H3N 1X9
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, Canada V6Z 2A9
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia, Canada V5Z 1M9
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2
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Shaltiel T, Sarpel U, Branch AD. The adverse characteristics of hepatocellular carcinoma in the non-cirrhotic liver disproportionately disadvantage Black patients. Cancer Med 2024; 13:e6654. [PMID: 38230878 PMCID: PMC10905547 DOI: 10.1002/cam4.6654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/24/2023] [Accepted: 10/12/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Black patients have higher hepatocellular carcinoma (HCC)-related mortality than White patients and more often develop HCC in non-cirrhotic liver. HCC surveillance is primarily directed toward cirrhotic patients. We aimed to characterize HCC in non-cirrhotic patients and to identify factors associated with HCC beyond Milan criteria. METHODS Demographic, imaging, laboratory, and pathology data of HCC patients at our institution, 2003-2018, were reviewed, retrospectively. Race/ethnicity were self-reported. Cirrhosis was defined as a Fibrosis-4 score ≥3.25. RESULTS Compared to 1146 cirrhotic patients, 411 non-cirrhotic patients had larger tumors (median 4.7 cm vs. 3.1 cm, p < 0.01) and were less likely to be within Milan criteria (42.6% vs. 57.7%, p < 0.01). Among non-cirrhotic patients, Black patients had larger tumors (4.9 cm vs. 4.3 cm, p < 0.01) and a higher percentage of poorly differentiated tumors (39.4% vs. 23.1%, p = 0.02). Among cirrhotic patients, Black patients had larger tumors (3.3 cm vs. 3.0 cm, p = 0.03) and were less likely to be within Milan criteria (52.3% vs. 83.2%, p < 0.01). In multivariable analysis, lack of commercial insurance (OR 1.45 [CI 95% 1.19-1.83], p < 0.01), male sex (OR 1.34 [CI 95% 1.05-1.70], p < 0.01), absence of cirrhosis (OR 1.58 [CI 95% 1.27-1.98], p < 0.01) and Black race/ethnicity (OR 1.34 [CI 95% 1.09-1.66], p = 0.01) were associated with HCC beyond Milan criteria. Black patients had lower survival rates than other patients (p < 0.01). CONCLUSIONS Non-cirrhotic patients had more advanced HCC than cirrhotic patients. Black patients (with or without cirrhosis) had more advanced HCC than comparable non-Black patients and higher mortality rates. Improved access to healthcare (commercial insurance) may increase early diagnosis (within Milan criteria) and reduce disparities.
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Affiliation(s)
- Tali Shaltiel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrea D. Branch
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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3
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Kim HN, Nance RM, Lo Re V, Silverberg MJ, Franco R, Sterling TR, Cachay ER, Horberg MA, Althoff KN, Justice AC, Moore RD, Klein M, Crane HM, Delaney JA, Kitahata MM. Development and Validation of a Model for Prediction of End-Stage Liver Disease in People With HIV. J Acquir Immune Defic Syndr 2022; 89:396-404. [PMID: 35202048 PMCID: PMC8887786 DOI: 10.1097/qai.0000000000002886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND End-stage liver disease (ESLD) is a leading cause of non-AIDS-related death among people with HIV (PWH). Factors that increase the progression of liver disease include comorbidities and HIV-specific factors, but we currently lack a tool to apply this evidence into clinical practice. METHODS We developed and validated a risk prediction model for ESLD among PWH who received care in 12 cohorts of the North American AIDS Cohort Collaboration on Research and Design between 2000 and 2016 and had fibrosis-4 index > 1.45. The first occurrence of ascites, variceal bleed, spontaneous bacterial peritonitis, or hepatic encephalopathy was verified by standardized medical record review. The Bayesian model averaging was used to select predictors among biomarkers and diagnoses and the Harrell C statistic to assess model discrimination. RESULTS Among 13,787 PWH in the training set, 82% were men and 54% were Black with a mean age of 48 years. Three hundred ninety ESLD events occurred over a mean 5.4 years. Among the ESLD cases, 52% had hepatitis C virus, 15% hepatitis B virus, and 31% alcohol use disorder. Twelve factors together predicted ESLD risk moderately well (C statistic 0.79, 95% confidence interval: 0.76 to 0.81): age, sex, race/ethnicity, chronic hepatitis B or C, and routinely collected laboratory values reflecting hepatic impairment (serum albumin, aspartate aminotransferase, total bilirubin, and platelets) and lipid metabolism (triglycerides, high-density lipoprotein, and total cholesterol). Our model performed well in the test set (C statistic 0.81, 95% confidence interval: 0.76 to 0.86). CONCLUSION This model of readily accessible clinical parameters predicted ESLD in a large diverse population of PWH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Amy C. Justice
- Yale University Schools of Medicine and Public Health, New Haven, CT, USA and Veterans Administration Connecticut Healthcare System, USA
| | | | - Marina Klein
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Joseph A. Delaney
- University of Washington, Seattle, WA, USA
- University of Manitoba, Winnipeg, Manitoba, Canada
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4
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Sun J, Mehta SH, Astemborski J, Piggott DA, Genberg BL, Woodson-Adu T, Benson EM, Thomas DL, Celentano DD, Vlahov D, Kirk GD. Mortality among people who inject drugs: a prospective cohort followed over three decades in Baltimore, MD, USA. Addiction 2022; 117:646-655. [PMID: 34338374 PMCID: PMC10572098 DOI: 10.1111/add.15659] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/21/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS During the past decades, people who inject drugs (PWID) have been impacted by the development of combination antiretroviral therapy (cART) to combat HIV/AIDS, the prescription opioid crisis and increased use of lethal synthetic opioids. We measured how these dynamics have impacted mortality among PWID in an urban US city. DESIGN Prospective cohort study using data from the AIDS Linked to the Intravenous Experience (ALIVE). SETTING Baltimore, MD, USA from 1988 to 2018. PARTICIPANTS A total of 5506 adult PWIDs (median age at baseline 37 years). MEASUREMENTS Mortality was identified by linkage to National Death Index-Plus (NDI-Plus) and categorized into HIV/infectious disease (HIV/ID) deaths, overdose and violence-related (drug-related) deaths and chronic disease deaths. Person-time at risk accrued from baseline and ended at the earliest of death or study period. All-cause and cause-specific mortality were calculated annually. The Fine & Gray method was used to estimate the subdistribution hazards of cause-specific deaths accounting for competing risks. FINDINGS Among 5506 participants with 84 226 person-years of follow-up, 43.9% were deceased by 2018. Among all deaths, 30.5% were HIV/ID deaths, 24.4% drug-related deaths and 33.3% chronic disease deaths. Age-standardized all-cause mortality increased from 23 to 45 per 1000 person-years from 1988 to 1996, declined from 1996 to 2014, then trended upward to 2018. HIV/ID deaths peaked in 1996 coincident with the availability of cART, then continuously declined. Chronic disease deaths increased continuously as the cohort aged. Drug-related deaths declined until 2011, but increased more than fourfold by 2018. HIV/HCV infection and active injecting were independently associated with HIV/ID and drug-related deaths. Female and black participants had a higher risk of dying from HIV/ID deaths and a lower risk of dying from drug-related deaths than male and non-black participants. CONCLUSIONS Deaths in Baltimore, MD, USA attributable to HIV/ID appear to have declined following the widespread use of combination antiretroviral therapy. Increases in the rates of drug-related deaths in Baltimore were observed prior to and continue in conjunction with national mortality rates associated with the opiate crisis.
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Affiliation(s)
- Jing Sun
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Damani A Piggott
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tanita Woodson-Adu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eve-Marie Benson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David L Thomas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Vlahov
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Yale School of Nursing, Orange, CT, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Elsheikh MEA, McClure CP, Tarr AW, Irving WL. Sero-reactivity to three distinct regions within the hepatitis C virus alternative reading frame protein (ARFP/core+1) in patients with chronic HCV genotype-3 infection. J Gen Virol 2022; 103:001727. [PMID: 35230930 PMCID: PMC9176264 DOI: 10.1099/jgv.0.001727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Hepatitis C virus (HCV) infection affects more than 71 million people worldwide. The disease slowly progresses to chronic, long-term liver injury which leads to hepatocellular carcinoma (HCC) in 5 % of infections. The alternative reading frame protein (ARFP/core+1) is encoded by a sequence overlapping the HCV core gene in the +1 reading frame. Its role in hepatitis C pathogenesis and the viral life cycle is unclear, although some observers have related its production to disease progression and the development of HCC. The aim of this study was to determine whether ARFP is immunogenic in patients with chronic HCV genotype 3 infection and to assess whether sero-reactivity is associated with disease progression, particularly to HCC. Immunogenic epitopes within the protein were predicted by a bioinformatics tool, and three -20 aa length-peptides (ARFP-P1, ARFP-P2 and ARFP-P3) were synthesized and used in an avidin-biotin ARFP/core+1 peptide ELISA. Serum samples from 50 patients with chronic HCV genotype 3 infection, 50 genotype-1 patients, 50 HBV patients and 110 healthy controls were tested. Sero-reactivity to the ARFP peptides was also tested and compared in 114 chronic HCV genotype-3 patients subdivided on the basis of disease severity into non-cirrhotic, cirrhotic and HCC groups. Chronic HCV genotype-3 patients showed noticeable rates of reactivity to ARFP and core peptides. Seropositivity rates were 58% for ARFP-P1, 47 % for ARFP-P2, 5.9 % for ARFP-P3 and 100 % for C22 peptides. There was no significant difference between these seroreactivities between HCV genotype-3 patients with HCC, and HCV genotype-3 patients with and without liver cirrhosis. Patients with chronic HCV genotype-3 infection frequently produce antibodies against ARFP/core+1 protein. ARFP peptide reactivity was not associated with disease severity in patients with HCV genotype-3. These results support the conclusion that ARFP/core+1 is produced during HCV infection, but they do not confirm that antibodies to ARFP can indicate HCV disease progression.
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Affiliation(s)
- Mosaab E A Elsheikh
- School of Life Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK
| | - C Patrick McClure
- School of Life Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Infections, The University of Nottingham, Nottingham, UK
| | - Alexander W Tarr
- School of Life Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Infections, The University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - William L Irving
- School of Life Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Infections, The University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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6
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Lu M, Li J, Zhou Y, Rupp LB, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Trudeau S, Gordon SC. Trends in Cirrhosis and Mortality by Age, Sex, Race, and Antiviral Treatment Status Among US Chronic Hepatitis B Patients (2006-2016). J Clin Gastroenterol 2022; 56:273-279. [PMID: 33780209 PMCID: PMC10257940 DOI: 10.1097/mcg.0000000000001522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/31/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Changing US demographics and evolving chronic hepatitis B (CHB) treatments may affect longitudinal trends in CHB-related complications. We studied trends in the prevalence of cirrhosis (past or present) and incidence of all-cause mortality, stratified by patient age, sex, race, and antiviral treatment status, in a sample from US health care systems. METHODS Joinpoint and Poisson regression (univariate and multivariable) were used to estimate the annual percent change in each outcome from 2006 to 2016. RESULTS Among 5528 CHB patients, cirrhosis prevalence (including decompensated cirrhosis) rose from 6.7% in 2006 to 13.7% in 2016; overall mortality was unchanged. Overall rates of cirrhosis and mortality were higher among treated patients, but adjusted annual percent changes (aAPC) were significantly lower among treated than untreated patients (cirrhosis: aAPC +2.4% vs. +6.2%, mortality: aAPC -3.9% vs. +4.0%). Likewise, among treated patients, the aAPC for mortality declined -3.9% per year whereas among untreated patients, mortality increased +4.0% per year. CONCLUSIONS From 2006 to 2016, the prevalence of cirrhosis among CHB patients doubled. Notably, all-cause mortality increased among untreated patients but decreased among treated patients. These results suggest that antiviral treatment attenuates the progression of cirrhosis and the risk of death among patients with CHB.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences
| | - Jia Li
- Department of Public Health Sciences
| | | | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joseph A. Boscarino
- Department of Epidemiology and Health Research, Geisinger Clinic, Danville, PA
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente—Hawaii, Honolulu, HI
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente—Northwest, Portland, OR
| | | | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System and Wayne State University School of Medicine, Detroit, MI
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7
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De Santis A, Maggi D, Lubrano Lobianco F. Safety and efficacy of directly-acting antiviral therapy for chronic hepatitis C virus in elderly people. Aging Med (Milton) 2021; 4:304-316. [PMID: 34964012 PMCID: PMC8711222 DOI: 10.1002/agm2.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In Italy, the prevalence of hepatitis C virus (HCV) infection is higher in the elderly, although the efficacy and safety of treatment in this population has not been extensively studied. Moreover, little is known about how much pharmacological interaction affects eligibility to treatment and to what extent the treatment affects subsequent outcomes. METHODS We retrospectively analyzed the efficacy and safety of directly acting antivirals (DAAs), drug-to-drug interactions, and post-treatment outcomes in 138 patients with HCV aged 70 years or older, who were consecutively treated in our center between 2015 and 2020. RESULTS The mean age was 77 years old (range = 70-95 years old). The Cumulative Illness Rating Scale of pretherapy severity was classified as moderate to severe in 65% of patients. Fifty-five patients (40%) presented compensated cirrhosis, eight of which were complicated by hepatocellular carcinoma (HCC) and all were cured before treatment. One hundred two patients (74%) were taking two or more drugs (range = 0-5 concomitant drugs registered) and in 29 patients (21%) we found potential drug-to-drug interaction. In 11 of those 29 patients (38%), we were forced to change the chronic therapy, when all therapeutic regimens were equal in terms of efficacy and interactions, to avoid potentially serious drug interactions. One serious adverse event occurred in our sample population (i.e., diverticular bleeding due to interaction with direct oral anticoagulants [DOACs]), whereas mild side effects occurred in 37% of patients. The undetectability of HCV RNA at the end of treatment was achieved in 97% of patients, whereas a sustained virological response (SVR) 12 and SVR 24 were obtained in 98% of patients. When comparing pretherapy with post-therapy data, after a medium follow-up of 15 months (median = 1 year, minimum = 2 months, and maximum = 4 years), we observed a reduction in the incidence of episodes of liver decompensation in patients with cirrhosis and a slight increase in the incidence of HCC (with 6 recurrent and 5 de novo HCC), diagnosed within 13 months from the end of therapy. In all patients, we found a significant improvement in all ultrasound variables and a significant reduction in the elastographic measurements. No significant differences in outcomes were observed dividing the population into patients aged ≥ 80 and < 80 years old. CONCLUSIONS Directly acting antiviral therapy was found to be safe and effective in elderly people, and, despite the large number of concomitant drugs, pharmacological interactions appeared to not affect the adherence to therapy or the incidence of adverse events. Side effects were mostly independent from the type of DAA used and from the burden of comorbidity. In long-term follow-up, the benefit of DAA therapy mainly concerned liver pathology and should be strongly advised in patients with cirrhosis. The therapy was found to not affect extrahepatic comorbidities but allowed to end follow-up in noncirrhotic patients with savings in terms of resources. Finally, patients should not be excluded based on age if they have a good performance status.
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Affiliation(s)
- Adriano De Santis
- Department of Translational and Precision MedicineSapienza UniversityRomeItaly
| | - Daniela Maggi
- Department of Translational and Precision MedicineSapienza UniversityRomeItaly
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8
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Effectiveness of Direct-Acting Antivirals in Treatment of Elderly Egyptian Chronic Hepatitis C Patients. GASTROENTEROLOGY INSIGHTS 2021. [DOI: 10.3390/gastroent12030031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Hepatitis C virus treatment has dramatically improved by direct-acting antiviral (DAA) therapy. The aim of this study was to assess the efficacy and safety of DAA in elderly Egyptian chronic hepatitis C (CHC) patients. Methods: The study was carried out on 327 CHC elderly patients >60 years; patients were divided into 3 age subgroups (<65, 65–75 and >75 years) on DAA therapy for 12 weeks. Ninety-one patients (27.8%) were treated with dual therapy, 234 patients (71.6%) with triple therapy and 2 patients (0.6%) with quadrable therapy. Results: All patients achieved end-of-treatment virological response (100%). ALT levels normalized during therapy. The follow-up rate of sustained virological response at 12 weeks after the end of treatment (SVR12) was 100%. One hundred and two patients had missed SVR12 data due to being lost tofollow-up. Two hundred twenty-two adverse events were reported (67.8%), including anemia in 30 patients (9.1%), leucopenia in 129 patients (39.4%) and thrombocytopenia in 63 patients (19.2%). No serious side effects led to discontinuation of therapy. No hepatic decompensation was observed, and no patients died. Conclusion: Age does not influence the success of DAA treatment and all DAA regimens are well tolerated, safe and highly efficacious, even in those aged 75 years or older.
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9
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Pugliese N, Giorgini A, Maggi D, Capogreco A, Dibenedetto C, Lubrano Lobianco F, Dal Buono A, Monico S, Meli R, Battezzati PM, Lleo A, De Santis A, Zuin M, Aghemo A. Directly acting antivirals are safe and effective in HCV positive patients aged 80 years and older: a multicenter real-life study. Expert Opin Drug Saf 2021; 20:839-843. [PMID: 33881366 DOI: 10.1080/14740338.2021.1921144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Treatment of chronic Hepatitis C with directly acting antivirals (DAAs) can bring to sustained virologic response (SVR) in approximately 95% of patients. Efficacy and safety of DAAs in aging patients has not been widely analyzed. We aimed to determine safety and efficacy of DAA-based regimens in a cohort of elderly patients in a real-life setting.Research Design and Methods: We retrospectively investigated safety and efficacy of DAAs in HCV patients of 80 years or older treated in three Hepatology Units.Results and Expert opinion: During the study period, 170 patients older than 80 years received DAAs. Their mean age was 82,3 years. The predominant HCV genotype was 1 (100 patients, 59%). Among the 93 cirrhotic patients (54,7%), 18 had CPT score > A5. Different DAAs regimens were used. Concomitant drugs were common: 163 patients (95,8%) taking at least one drug. In 11 patients, usual therapy had to be changed to start antiviral treatment. Two serious adverse events occurred. Four patients terminated treatment prematurely. In total, 45 patients (26,5%) testified mild side effects. HCV-RNA undetectability at week 12 of treatment follow-up was achieved in 168/170 patients. DAA treatment in HCV patients of 80 years or older is efficacious and safe. Drug-drug interaction should be judiciously evaluated before starting therapy.
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Affiliation(s)
- Nicola Pugliese
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessia Giorgini
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Daniela Maggi
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonio Capogreco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Clara Dibenedetto
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | | | - Arianna Dal Buono
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Sara Monico
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Rossella Meli
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Massimo Zuin
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Alessio Aghemo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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10
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Su F, Berry K, Ioannou GN. No difference in hepatocellular carcinoma risk between chronic hepatitis B patients treated with entecavir versus tenofovir. Gut 2021; 70:370-378. [PMID: 32229544 DOI: 10.1136/gutjnl-2019-319867] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Entecavir (ETV) and tenofovir disoproxil fumarate (TDF) are first-line agents for the treatment of chronic hepatitis B (CHB). Recent studies have challenged the assumption that these agents are equally effective at preventing hepatocellular carcinoma (HCC). We aimed to determine whether the risk of HCC and mortality differ in patients with CHB treated with ETV and TDF. DESIGN We performed a retrospective cohort study of Veterans Affairs patients with CHB in the USA who initiated treatment with ETV or TDF between the dates of Food and Drug Administration approval of these medications and 1 January 2017. Multivariable Cox proportional hazards regression was used to determine the association between antiviral therapy and HCC risk as well as the risk of death or liver transplantation. Propensity score adjustment and competing risks analysis were performed. RESULTS We identified 2193 ETV-treated and 1094 TDF-treated patients who were followed for a mean of 5.4 years. We found no difference in the risk of HCC in ETV-treated versus TDF-treated patients (adjusted HR (aHR) 1.00, 95% CI 0.76 to 1.32). Results were similar in propensity score adjusted and competing risks analysis, and in multiple sensitivity analyses. We also found no difference in the risk of death or liver transplantation (aHR 1.16, 95% CI 0.98 to 1.39). CONCLUSIONS We found no difference in the risk of HCC between patients with CHB treated with ETV versus TDF. Our results support current guideline recommendations that both agents are appropriate first-line options for the treatment of CHB.
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Affiliation(s)
- Feng Su
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA.,Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA.,Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
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11
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Elkadeem M, Shoman SR. Treatment of Chronic Hepatitis C Virus Using Direct Acting Antivirals in Geriatric Egyptian Patients. RECENT ADVANCES IN ANTI-INFECTIVE DRUG DISCOVERY 2021; 16:157-165. [PMID: 34961434 DOI: 10.2174/2772434416666210716123909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND & AIMS There is high proportion of geriatric patients who acquired chronic hepatitis C virus infection. There is a shortage in evidence- based data as regards direct-acting antivirals in this group of patients. The aim was to assess safety, efficacy, and tolerability of direct acting antiviral drugs in Egyptian geriatric patients. METHODS This prospective study was performed on 177 patients with chronic hepatitis C and administrated different regimens of direct acting antivirals. Patients were divided into two groups: Group I: patients below 65 years old (N = 143), and Group II: patients > 65 years old (N = 34). Pretreatment history taking, baseline characteristics, and investigations were done for both groups. Follow up was made to detect treatment efficacy and adverse effects. RESULTS Geriatric group were found to have more comorbidities (diabetes mellitus, hypertension, and cardiomyopathy); also liver cirrhosis. Minor adverse effects occurred in both groups without significant difference included fatigue, insomnia, headache, and dizziness. Vomiting, diarrhea, and skin rash occurred in group II more than group I. Leucopenia, thrombocytopenia, jaundice, and significant anemia occurred without significant difference between both groups. Eighteen patients (25%) of 72 patients who took ribavirin had to reduce ribavirin dose or to stop it. The overall treatment response in the entire study was 97.7% without significant difference between both groups. CONCLUSION Direct acting antivirals are recommended regardless the age. These drugs are effective and tolerable in elderly patients. Attention to other comorbidities, drug-drug interactions, and follow up are recommended.
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Affiliation(s)
- Mahmoud Elkadeem
- Department of Tropical Medicine & Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
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12
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Aly A, Ronnebaum S, Patel D, Doleh Y, Benavente F. Epidemiologic, humanistic and economic burden of hepatocellular carcinoma in the USA: a systematic literature review. Hepat Oncol 2020; 7:HEP27. [PMID: 32774837 PMCID: PMC7399607 DOI: 10.2217/hep-2020-0024] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/01/2020] [Indexed: 12/24/2022] Open
Abstract
AIM To describe the epidemiologic, humanistic and economic burdens of hepatocellular carcinoma (HCC) in the USA. MATERIALS & METHODS Studies describing the epidemiology and economic burden from national cohorts, any economic models, or any humanistic burden studies published 2008-2018 were systematically searched. RESULTS HCC incidence was 9.5 per 100,000 person-years in most recent data, but was ∼100-times higher among patients with hepatitis/cirrhosis. Approximately a third of patients were diagnosed with advanced disease. Patients with HCC experienced poor quality of life. Direct costs were substantial and varied based on underlying demographics, disease stage and treatment received. Between 25-77% of patients did not receive surgical, locoregional or systemic treatment. CONCLUSION Better treatments are needed to extend survival and improve quality of life for patients with HCC.
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Affiliation(s)
| | | | - Dipen Patel
- Pharmerit – an OPEN Health Company, Bethesda, MD 20814, USA
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13
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Kinoshita A, Koike K, Mizuno Y, Ogata I, Kobayashi Y, Hasegawa K, Shiraishi K, Yoshida H, Nakata R, Yamada N, Yasuda K. Efficacy and safety of glecaprevir/pibrentasvir in patients with hepatitis C virus infection aged ≥75 years. Geriatr Gerontol Int 2020; 20:578-583. [PMID: 32267087 DOI: 10.1111/ggi.13919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 01/24/2023]
Abstract
AIM Opportunities to treat older patients with hepatitis C virus infection have increased. We investigated the efficacy and safety of glecaprevir/pibrentasvir in patients with HCV infection aged ≥75 years. METHODS We retrospectively evaluated 131 patients with hepatitis C virus infection treated with glecaprevir/pibrentasvir at nine institutions in Japan. The patients were divided into two groups according to their age: the elderly group (n = 43, aged ≥75 years) and younger group (n = 88, aged <75 years). We compared the clinical characteristics, virologic response and adverse events between the two groups. The predictive factors for adverse events were also assessed. RESULTS The presence of cirrhosis (27.9%), a history of hepatocellular carcinoma (23.3%) and comorbidities (88.4%) were more frequently observed in the elderly group than in the younger group. Six (14.0%) patients in the elderly group and 19 (21.6%) in the younger group dropped out before the sustained virologic response 12 assessment. In the intention-to-treat population, 86.0% in the elderly group and 78.4% in the younger group achieved sustained virologic response 12 (P = 0.30). In the modified intention-to-treat population, all patients achieved sustained virologic response 12. A total of 27.5% of patients experienced adverse events. The most frequently observed adverse events was pruritus, and was significantly associated with female sex, the presence of hemodialysis and serum albumin at baseline <4.0 g/dL. CONCLUSION Glecaprevir/pibrentasvir therapy was effective and well tolerated, even in elderly patients with hepatitis C virus infection aged ≥75 years. Geriatr Gerontol Int 2020; ••: ••-••.
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Affiliation(s)
- Akiyoshi Kinoshita
- Division of Gastroenterology and Hepatology, The Jikei University Daisan Hospital, Tokyo, Japan.,Department of Internal Medicine, Sakuragaoka Hospital, Shizuoka, Japan.,Department of Internal Medicine, Johsai Hospital, Tokyo, Japan
| | - Kazuhiko Koike
- Division of Gastroenterology and Hepatology, The Jikei University Daisan Hospital, Tokyo, Japan.,Department of Internal Medicine, Sakuragaoka Hospital, Shizuoka, Japan
| | - Yusuke Mizuno
- Division of Gastroenterology and Hepatology, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Itsuro Ogata
- Division of Gastroenterology and Hepatology, Kawakita General Hospital, Tokyo, Japan
| | | | | | - Koichi Shiraishi
- Division of Gastroenterology, Tokai University Tokyo Hospital, Tokyo, Japan
| | - Hideo Yoshida
- Division of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Ryo Nakata
- Division of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Norie Yamada
- Division of Gastroenterology, Kiyokawa Hospital, Tokyo, Japan
| | - Kiyomi Yasuda
- Division of Gastroenterology, Kiyokawa Hospital, Tokyo, Japan
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14
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The Changing Epidemiology of Hepatocellular Carcinoma : Experience of a Single Center. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5309307. [PMID: 32185209 PMCID: PMC7063180 DOI: 10.1155/2020/5309307] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/27/2020] [Indexed: 02/08/2023]
Abstract
Aims To analyze the main etiological factors and some clinical features of patients with hepatocellular carcinoma (HCC) at diagnosis and to compare them with those we described ten years ago. Materials and Methods. We compared two groups of patients with HCC, Group 1 consisting of 132 patients (82 M, 50 F) diagnosed in the 2003–2008 period and Group 2 including 119 patients (82 M, 37 F) diagnosed in the 2013–2018 period. For all patients, age, sex, viral markers, alcohol consumption, serum alpha-fetoprotein (AFP) levels, and the main liver function parameters were recorded. The diagnosis of HCC was based on AASLD, EASL guidelines. The staging was classified according to the “Barcelona Clinic Liver Cancer staging system” (BCLC). Results Mean age was 69.0 ± 8 years in Group 1 and 71.0 ± 9 in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 (P < 0.05). HCV subjects were significantly older in Group 2 ( Conclusions This study shows that over the last decade a number of features of patients with HCC in our region have changed, particularly age at onset, etiological factors, and staging of HCC.
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15
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Huynh T, Hu KQ. Direct acting antiviral-induced dynamic reduction of serum α fetoprotein in hepatitis C patients without hepatocellular carcinoma. Front Med 2019; 13:658-666. [PMID: 31655955 DOI: 10.1007/s11684-019-0707-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/25/2019] [Indexed: 12/14/2022]
Abstract
Direct acting antiviral (DAA) treatments may reduce the elevated α fetoprotein (AFP), but data on how these treatments affect elevated AFP in patients with chronic hepatitis C (CHC) remain insufficient. In the present study, the frequency of baseline AFP elevations and their related factors, AFP dynamics during and after DAA treatment, and factors associated with AFP reduction was assessed. This retrospective study included 141 patients with CHC without hepatocellular carcinoma who received DAA and achieved sustained virological response. The details are as follows: mean post-treatment follow-up was 99 weeks (12-213); mean age, 57.8 years old; 52%, males; 79%, genotype (GT) 1; and 47%, cirrhosis. Pre-treatment AFP elevation (> 5.5 ng/mL) was seen in 48.2% patients. On multivariate analysis, baseline AFP > 5.5 was associated with the presence of cirrhosis (P =0.001), coexisting non-alcoholic steatohepatitis (NASH) (P = 0.035), and GT 1 (P = 0.029). AFP normalization was seen in 28.2% patients at treatment week 2, in 52% at the end of treatment, and in 73.4% at the end of follow-up. Post-treatment week 24 AFP normalization was associated with the absence of cirrhosis (P = 0.003), Child-Pugh score < 6 (P = 0.015), and baseline AFP < 10 (P = 0.015). AFP elevation is common in patients with CHC and independently associated with NASH, cirrhosis, and GT 1. DAA treatment resulted in AFP normalization as early as treatment week 2. Post-treatment week 24 AFP normalization is independently associated with the absence of cirrhosis, Child-Pugh score < 6, and baseline AFP < 10.
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Affiliation(s)
- Tung Huynh
- Department of Pharmacy, University of California, Irvine, School of Medicine, Orange, CA, 92868, USA
| | - Ke-Qin Hu
- Division of Gastroenterology and Hepatology, University of California, Irvine, School of Medicine, Orange, CA, 92868, USA.
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16
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Pan CQ, Gayam V, Rabinovich C, Normatov M, Fidman B, Wang D, Garlapati P. Efficacy of Direct-Acting Antivirals for Chronic Hepatitis C in a Large Cohort of Older Adults in the United States. J Am Geriatr Soc 2019; 68:379-387. [PMID: 31647119 DOI: 10.1111/jgs.16206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Data on the virologic response and tolerability of direct-acting antivirals (DAAs) are lacking in older people because these individuals are underrepresented in clinical trials. This study aimed to assess the effectiveness and tolerability of DAA regimens in older individuals in a large cohort of real-life clinical practice. METHODS In this retrospective study, patients with chronic hepatitis C infection between 2017 and 2018 were divided into patients aged 65 years and older and those younger than 65 years. We evaluated the sustained virologic response rates (SVRs) in both groups. Further subgroup analyses on the SVRs for patients aged 65 to 74, 75 to 84, and 85 years and older were performed. We also analyzed the predictors of treatment response in older individuals. RESULTS Among 1151 eligible patients, 516 were in the older group and 635 were in the younger group. The overall treatment response in the entire cohort was 97.7%. A significantly higher percentage of patients presented with advanced stages of fibrosis in the older group (53.1% vs 39.5%; P = <.001). The SVR rates were similar between the two groups (98.3% vs 97.7%; P = .18). In multivariate models, age was not predictive of SVR after adjusting for confounders. Subgroup analyses in the age groups of 65 to 74, 75 to 84, and older than 85 years showed similar treatment response rates (97.4%, 97.2%, and 86.7, respectively; P = .06) and advanced fibrosis (50.8%, 61.5%, and 53.3%, respectively; P = .14). CONCLUSION Although older people exhibit a significantly higher frequency of fibrosis, DAAs produce high rates of SVR in all age groups, and the age of the patient does not seem to have a significant impact on the efficacy of DAAs including patients in the oldest age category (≥75 y). Treatment should not be withheld in older individuals. J Am Geriatr Soc 68:379-387, 2020.
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Affiliation(s)
- Calvin Q Pan
- Center of Liver Diseases, Capital Medical University Affiliated Beijing Ditan Hospital, Chaoyang District, Beijing, China.,Division of Gastroenterology and Hepatology, NYU Langone Health, New York University School of Medicine, New York, New York
| | - Vijay Gayam
- Interfaith Medical Center, SUNY Downstate University Hospital, Brooklyn, New York
| | | | | | | | - Dan Wang
- St. John's University, Jamaica, New York
| | - Pavani Garlapati
- Interfaith Medical Center, SUNY Downstate University Hospital, Brooklyn, New York
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17
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Qureshi K, Petersen T, Andres J. Hepatitis C Treatment Differences in Elderly Patients: Single-Center Retrospective Study. Ann Pharmacother 2019; 54:113-121. [PMID: 31452381 DOI: 10.1177/1060028019871352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Clinical studies evaluating direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment show sustained virological response at 12 weeks (SVR12) rates >90%. However, there are few elderly patients included in these studies; thus, generalizability of high success rates to patients >70 years old cannot be assumed. Objective: To identify treatment differences between elderly and nonelderly patients. Methods: This is a retrospective cohort study of all patients who were treated with DAAs between June 2014 and September 2016 at our institution. Patients were divided into 2 groups: elderly, age ≥70 years at the time of initiation of DAAs, and nonelderly, <70 years. The primary outcome was achievement of SVR12. Results: Among the 551 patients, 60 with age range 70 to 86 years comprised the elderly group. SVR12 rates were significantly lower in the elderly population, especially in those with liver cirrhosis. SVR12 was achieved in 81% of the elderly group as compared with 95% in the nonelderly group. Among cirrhotic patients, 69.4% in the elderly group, and 94.1% in the nonelderly group achieved SVR12. Binary logistic regression modeling showed age >70 years to be the strongest predictor of treatment failure (odds ratio = 3.4), along with diagnosis of cirrhosis (odds ratio = 2.4), when corrected for gender, race, prior treatment experience, genotype, and presence of hepatocellular carcinoma. Conclusion and Relevance: Lower SVR12 was seen in elderly cirrhotic patients (69.4%), who are at higher risk of complications related to advanced liver disease and untreated HCV infection, highlighting the need to treat patients before cirrhosis develops.
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Affiliation(s)
| | - Tess Petersen
- Temple University School of Medicine, Philadelphia, PA, USA
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18
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Jain MK, Rich NE, Ahn C, Turner BJ, Sanders JM, Adamson B, Quirk L, Perryman P, Santini NO, Singal AG. Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis. Hepatology 2019; 70:40-50. [PMID: 30950085 DOI: 10.1002/hep.30638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/25/2019] [Indexed: 12/30/2022]
Abstract
Hepatitis C virus (HCV) testing in persons born from 1945 to 1965 has had limited adoption despite guidelines, particularly among racial/ethnic minorities and socioeconomically disadvantaged patients, who have a higher prevalence of disease burden. We examined the effectiveness of a multifaceted intervention to improve HCV screening in a large safety-net health system. We performed a multifaceted intervention that included provider and patient education, an electronic medical record-enabled best practice alert, and increased HCV treatment capacity. We characterized HCV screening completion before and after the intervention. To identify correlates of HCV screening, we performed logistic regression for the preintervention and postintervention groups and used a generalized linear mixed model for patients observed in both preintervention and postintervention time frames. Before the intervention, 10.1% of 48,755 eligible baby boomer patients were screened. After the intervention, 34.6% of the 34,093 eligible baby boomers were screened (P < 0.0001). Prior to the intervention, HCV screening was lower among older baby boomers and providers with large patient panels and higher in high-risk subgroups including those with signs of liver disease (e.g., elevated transaminases, thrombocytopenia), human immunodeficiency virus-positive patients, and homeless patients. Postintervention, we observed increased screening uptake in older baby boomers, providers with larger patient panel size, and patients with more than one prior primary care appointment. Conclusion: Our multifaceted intervention significantly increased HCV screening, particularly among older patients, those engaged in primary care, and providers with large patient panels.
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Affiliation(s)
- Mamta K Jain
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Chul Ahn
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Barbara J Turner
- Department of Internal Medicine, UT Health Science Center, San Antonio, TX
| | - Joanne M Sanders
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Brian Adamson
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Lisa Quirk
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Patrice Perryman
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Noel O Santini
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
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19
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Liver-related events and mortality among elderly patients with advanced chronic hepatitis C treated with direct-acting antivirals. PLoS One 2019; 14:e0217052. [PMID: 31158237 PMCID: PMC6546209 DOI: 10.1371/journal.pone.0217052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 05/04/2019] [Indexed: 12/19/2022] Open
Abstract
Background Direct-acting antivirals (DAAs) are effective in patients aged ≥65 years. However, little is known about the effects of DAAs on survival, liver decompensation and development of hepatocellular carcinoma (HCC). Objective To compare the incidence of liver-related events and mortality between patients aged ≥65 and <65 years. Methods Prospective study comparing patients aged ≥65 and <65 years treated with DAAs. The incidence of liver-related events and mortality, and HCC was compared between age groups. Results Five hundred patients (120 aged ≥65 and 380 aged <65 years) were included. The incidence of liver-related events was 2.62 per 100 patient-years (py) in older and 1.41/100 py in younger patients. All-cause mortality was 3.89 and 1.27/100 py in older and younger patients, respectively. The respective liver-related mortality rates were 1.12 and 0.31/100 py. In patients with cirrhosis (stage F4), all-cause mortality (P = 0.283) and liver-related mortality (P = 0.254) did not differ between groups. All five liver-related deaths were related to multifocal HCC. The incidence of HCC was 1.91 and 1.43 per 100 py in the older and younger groups, respectively (P = 0.747). The diagnosis of HCC was 8 months after the end of treatment. Conclusions The incidence of liver-related events and liver-related mortality was low in older people treated with DAAs and was similar to that in younger patients. The extra mortality in people aged ≥65 years treated with DAAs seems to be secondary to non-liver-related causes. These results support the utilization of DAAs in patients aged ≥65 years.
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20
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Elbaz T, Abdo M, Omar H, Hassan EA, Zaghloul AM, Abdel-Samiee M, Moustafa A, Qawzae A, Gamil M, Esmat G. Efficacy and safety of sofosbuvir and daclatasvir with or without ribavirin in elderly patients with chronic hepatitis C virus infection. J Med Virol 2018; 91:272-277. [PMID: 30138531 DOI: 10.1002/jmv.25287] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/25/2018] [Indexed: 12/20/2022]
Abstract
Hepatitis C virus (HCV) infection is considered as a major public health problem that, worldwide, chronically affects 170 million people. Elderly patients are more likely than younger patients to have increased duration of infection, increased rate of disease progression, and subsequently increased incidence of advanced liver disease. Natural history models predicted that the prevalence of HCV infection and its chronic sequelae as well as extrahepatic manifestations will eventually increase through the next decade and will mostly affect those who are greater than 60 years of age. Moreover, polytherapy and polypharmacy are frequent in elderly patients due to associated comorbidities. As advanced age is associated with increasing risk of development of cirrhosis and hepatocellular carcinoma, elderly patients are in special need of safe and effective antiviral therapies. Achievement of sustained viral responses (SVR) is associated with reduced liver-related complications and overall mortality in such patients with the advanced liver disease. With the recent introduction of interferon-free direct-acting antivirals, successful treatment for chronic HCV infection had dramatically improved, with overall cure rates that exceed 90% SVR. In our study, we aimed to study the efficacy and safety of combined sofosbuvir and daclatasvir, with or without ribavirin, in management of chronically infected HCV elderly patients who are more than 60 years old.
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Affiliation(s)
- Tamer Elbaz
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Mahmoud Abdo
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Heba Omar
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Essam A Hassan
- Department of Tropical Medicine, Fayoum University, Faiyum, Egypt
| | - Amr M Zaghloul
- Department of Tropical Medicine and Gastroenterology, Sohag University, Sohag, Egypt
| | - Mohamed Abdel-Samiee
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Ahmed Moustafa
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Abdallah Qawzae
- Hepat-gastroenterology Department, Ahmed Maher Teaching Hospital, Cairo, Egypt
| | - Mostafa Gamil
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Gamal Esmat
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Giza, Egypt
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21
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Buivydiene A, Liakina V, Kashuba E, Norkuniene J, Jokubauskiene S, Gineikiene E, Valantinas J. Impact of the Uridine⁻Cytidine Kinase Like-1 Protein and IL28B rs12979860 and rs8099917 SNPs on the Development of Hepatocellular Carcinoma in Cirrhotic Chronic Hepatitis C Patients-A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2018; 54:E67. [PMID: 30344298 PMCID: PMC6262489 DOI: 10.3390/medicina54050067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/14/2018] [Accepted: 09/21/2018] [Indexed: 12/18/2022]
Abstract
Background and objectives: The hepatitis C virus (HCV) is the major causative agent of hepatocellular carcinoma (HCC) in the western world. The efficacy of surveillance programs for early detection of HCC is not satisfactory: many tumors are diagnosed at the late, incurable stages. Therefore, there is a need in reliable prognostic markers for the proper follow-up of HCV-positive patients. The aim of the present study was to assess the prognostic value of the uridine⁻cytidine kinase-like protein 1 (UCKL-1), a putative oncoprotein, together with genetically determined polymorphisms in the interleukin 28B (IL28B) gene (rs12979860, rs8099917) in the development of HCC in HCV-positive cirrhotic patients. Materials and Methods: We included 32 HCV cirrhotic patients, 21 (65.6%) of whom had HCC. The expression of UCKL-1 was assessed in liver tissue sections, using immunohistochemistry. For IL28B rs12979860 and rs8099917 genotype analysis, the corresponding genomic regions were amplified by polymerase chain reaction (PCR) with appropriate primers. Results: We have found that UCKL-1 expression was significantly increased in HCC (p = 0.003). The presence of rs8099917 TT single-nucleotide polymorphism (SNP) elevated the chances of HCC manifestation more than sevenfold (OR = 7.3, p = 0.0273). The presence of rs12979860 CC SNP also heightened HCC chances more than sevenfold (OR = 7.5, p = 0.0765). Moreover, in the HCC group, a combination of IL28B rs12979860 non-TT and rs8099917 TT genotypes was observed more often, compared with the non-HCC group. Other combinations of IL28B rs12979860 and rs8099917 SNIPs were associated with a reduced risk of HCC development, approximately at the same extent. Conclusions: The presence of IL28B rs8099917 TT and rs12979860 CC SNPs, but not the intensity of UCKL-1 expression, is strongly associated with increased chances of HCC development in HCV-positive cirrhotic patients.
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Affiliation(s)
- Arida Buivydiene
- Center of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, LT-08661 Vilnius, Lithuania.
| | - Valentina Liakina
- Center of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, LT-08661 Vilnius, Lithuania.
- Department of Chemistry and Bioengineering, Faculty of Fundamental Sciences, Vilnius Gediminas Technical University, LT-10223 Vilnius, Lithuania.
| | - Elena Kashuba
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
- RE Kavetsky Institute of Experimental Pathology, Oncology and Radiobiology, UA-03022 Kyiv, Ukraine.
| | - Jolita Norkuniene
- Department of Mathematical Statistics, Faculty of Fundamental Sciences, Vilnius Gediminas Technical University, LT-10223 Vilnius, Lithuania.
- Vilniaus Kolegija/University of Applied Sciences, LT-08105 Vilnius, Lithuania.
| | - Skirmante Jokubauskiene
- Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuanian, .
- National Center of Pathology, LT-08406 Vilnius, Lithuania.
| | - Egle Gineikiene
- Center of Hematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, LT-08661 Vilnius, Lithuania.
- Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania.
| | - Jonas Valantinas
- Center of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, LT-08661 Vilnius, Lithuania.
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22
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Mikolas LA, Jacques K, Huq M, Krasner C, Mambourg SE. Utilizing Clinical Pharmacist Specialist to Manage Hepatitis C Virus Patients on Direct-Acting Antiviral Therapy. J Pharm Pract 2018; 32:655-663. [PMID: 29783912 DOI: 10.1177/0897190018777345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate outcomes of a clinical pharmacist specialist (CPS)-managed hepatitis C virus (HCV) treatment clinic (HCVTC) in treating HCV-infected veterans with direct-acting antivirals (DAAs). METHODS We established a CPS-managed HCVTC under a collaborative practice agreement with our infectious disease physician (IDP). A total of 132 veterans were treated between November 1, 2014, and November 30, 2015. The CPS engaged in pretreatment screening, drug selection, patient education, medication counseling, drug therapy monitoring, drug utilization review, addressing issues on drug adherence, and routine and posttreatment follow-up of patients to assess sustained virologic response (SVR) after 12 weeks of treatment. RESULTS Of 132 patients managed by the CPS, 87 (66%) were treated with ledipasvir/sofosbuvir (LDV/SOF), 29 (22%) with paritaprevir/ritonavir/ombitasvir + dasabuvir (PrOD), and 16 (12%) with sofosbuvir (SOF)-based regimen. The corresponding regimens demonstrated a SVR rate of 92% (n = 80), 100% (n = 29), and 93.8% (n = 15), respectively. We achieved an SVR rate of 94% against HCV genotype 1 (GT-1) and 100% against GT-2 to GT-4. The overall SVR rate was 94% across regimens, showing 93% in treatment-naive patients and 96% in treatment-experienced patients, and 93% in noncirrhotic and 94% in compensated cirrhotic patients. The results were comparable to SVR data reported in pivotal trials for DAAs. CONCLUSION The results suggest that CPS could be effectively utilized in drug therapy management of HCV-infected patients treated with DAAs.
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Affiliation(s)
- Lena A Mikolas
- Pharmacy Services, Department of Veterans Affairs, VA Sierra Nevada Health Care System, Reno, NV, USA
| | - Kimberly Jacques
- Pharmacy Services, Department of Veterans Affairs, VA Sierra Nevada Health Care System, Reno, NV, USA
| | - Mostaqul Huq
- Pharmacy Services, Department of Veterans Affairs, VA Sierra Nevada Health Care System, Reno, NV, USA
| | - Charles Krasner
- Medicine Services, Department of Veterans Affairs, VA Sierra Nevada Health Care System, Reno, NV, USA
| | - Scott E Mambourg
- Pharmacy Services, Department of Veterans Affairs, VA Sierra Nevada Health Care System, Reno, NV, USA
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23
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Abstract
Hepatitis C virus (HCV) is the most common blood-borne infection in the United States and is of concern in older adults. HCV infection is associated with not only hepatic but also extrahepatic comorbidities common to the aging patient including diabetes, kidney and cardiovascular diseases, and neurocognitive impairment. The effect of direct-acting antiviral agents to treat HCV on these outcomes is limited. This article summarizes the literature regarding the epidemiology and natural history of HCV infection; the impact of age on clinical outcomes in HCV-infected persons; and current knowledge regarding safety and efficacy of HCV treatment regimens in the older patient.
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Affiliation(s)
- Michael Reid
- Department of Medicine, University of California, San Francisco, 513 Parnassus Avenue, San Francisco, CA 94122, USA
| | - Jennifer C Price
- Department of Medicine, University of California, San Francisco, 513 Parnassus Avenue, San Francisco, CA 94122, USA
| | - Phyllis C Tien
- Department of Medicine, University of California, San Francisco, 513 Parnassus Avenue, San Francisco, CA 94122, USA; Medical Service, Department of Veteran Affairs Medical Center, San Francisco, CA 94121, USA.
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24
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Bartenschlager R, Baumert TF, Bukh J, Houghton M, Lemon SM, Lindenbach BD, Lohmann V, Moradpour D, Pietschmann T, Rice CM, Thimme R, Wakita T. Critical challenges and emerging opportunities in hepatitis C virus research in an era of potent antiviral therapy: Considerations for scientists and funding agencies. Virus Res 2018; 248:53-62. [PMID: 29477639 DOI: 10.1016/j.virusres.2018.02.016] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 12/19/2022]
Abstract
The development and clinical implementation of direct-acting antivirals (DAAs) has revolutionized the treatment of chronic hepatitis C. Infection with any hepatitis C virus (HCV) genotype can now be eliminated in more than 95% of patients with short courses of all-oral, well-tolerated drugs, even in those with advanced liver disease and liver transplant recipients. DAAs have proven so successful that some now consider HCV amenable to eradication, and continued research on the virus of little remaining medical relevance. However, given 400,000 HCV-related deaths annually important challenges remain, including identifying those who are infected, providing access to treatment and reducing its costs. Moreover, HCV infection rarely induces sterilizing immunity, and those who have been cured with DAAs remain at risk for reinfection. Thus, it is very unlikely that global eradication and elimination of the cancer risk associated with HCV infection can be achieved without a vaccine, yet research in that direction receives little attention. Further, over the past two decades HCV research has spearheaded numerous fundamental discoveries in the fields of molecular and cell biology, immunology and microbiology. It will continue to do so, given the unique opportunities afforded by the reagents and knowledge base that have been generated in the development and clinical application of DAAs. Considering these critical challenges and new opportunities, we conclude that funding for HCV research must be sustained.
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Affiliation(s)
- Ralf Bartenschlager
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; Division Virus-Associated Carcinogenesis, German Cancer Research Center, Heidelberg, Germany; German Centre for Infection Research (DZIF), Partner Sites Heidelberg and Hannover-Braunschweig, Germany.
| | - Thomas F Baumert
- Institut National de la Santé et de la Recherche Médicale, U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France; Université de Strasbourg, Strasbourg, Institut Hospitalo-Universitaire, Pôle Hépato-digestif, Nouvel Hôpital Civil, Strasbourg, France
| | - Jens Bukh
- Copenhagen Hepatitis C Program (CO-HEP), Department of Infectious Diseases and Clinical Research Centre, Hvidovre Hospital and Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Michael Houghton
- Li Ka Shing Institute of Virology, Department of Medical Microbiology & Immunology, University of Alberta, Edmonton, Canada
| | - Stanley M Lemon
- Departments of Medicine and Microbiology & Immunology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Brett D Lindenbach
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT, USA
| | - Volker Lohmann
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland
| | - Thomas Pietschmann
- German Centre for Infection Research (DZIF), Partner Sites Heidelberg and Hannover-Braunschweig, Germany; Institute of Experimental Virology, TWINCORE, Centre for Experimental and Clinical Infection Research (a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI)), Hannover, Germany
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY, USA
| | - Robert Thimme
- Center for Medicine, Department of Medicine II, Medical Center - University of Freiburg, Germany
| | - Takaji Wakita
- Department of Virology II, National Institute of Infectious Diseases, Tokyo, Japan
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The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study. J Hepatol 2018; 68:393-401. [PMID: 29107152 DOI: 10.1016/j.jhep.2017.10.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/21/2017] [Accepted: 10/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings. METHODS HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995-2011/2012/2013, respectively) were linked to hospital admissions (2001-2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed. RESULTS Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76-2.10), New South Wales (aHR 3.68; 95% CI 3.38-4.00) and Scotland (aHR 3.88; 95% CI 3.42-4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively. CONCLUSIONS Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved. LAY SUMMARY The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.
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26
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Lu M, Li J, Rupp LB, Zhou Y, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Trudeau S, Gordon SC. Changing trends in complications of chronic hepatitis C. Liver Int 2018; 38. [PMID: 28636782 PMCID: PMC5777910 DOI: 10.1111/liv.13501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Chronic hepatitis C virus (HCV)-related complications have increased over the past decade. METHODS We used join-point regression modelling to investigate trends in these complications from 2006 to 2015, and the impact of demographics on these trends. Using data from the Chronic Hepatitis Cohort Study (CHeCS), we identified points at which the trend significantly changed, and estimated the annual percent change (APC) in rates of cirrhosis, decompensated cirrhosis and all-cause mortality, adjusted by race, sex and age. RESULTS Among 11,167 adults with chronic HCV infection, prevalence of cirrhosis increased from 20.8% to 27.6% from 2006 to 2015, with adjusted annual percentage change (aAPC) of 1.2 (p <. 01). Although incidence of all-cause mortality increased from 1.8% in 2006 to 2.9% in 2015, a join-point was identified at 2010, with aAPCs of 9.6 before (2006 < 2010; p < .01) and -5.2 after (2010 ≤ 2015; p < .01), indicating a decrease in mortality from 2010 and onward. Likewise, overall prevalence of decompensated cirrhosis increased from 9.3% in 2006 to 10.4% in 2015, but this increase was confined to patients 60 or older (aAPC = 1.5; p = .023). Asian American and Black/African American patients demonstrated significantly higher rates of cirrhosis than White patients, while older patients and men demonstrated higher rates of cirrhosis and mortality. CONCLUSIONS Although cirrhosis and mortality among HCV-infected patients in the US have increased over the past decade, all-cause mortality has decreased in recent years.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit MI
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Joseph A. Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Health System, Danville PA
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente–Hawai’i, Honolulu HI
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente–Northwest, Portland OR
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit MI
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Ippolito AM, Iacobellis A, Milella M, Conti F, Messina V, Valvano MR, Niro GA, Morisco F, Barone M, Termite AP, Brancaccio G, Andriulli A. Hepatitis C Virus Clearance in Older Adults. J Am Geriatr Soc 2018; 66:85-91. [PMID: 29135030 DOI: 10.1111/jgs.15140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine whether older adults with the hepatitis C virus (HCV) achieve a sustained viral response (SVR) after treatment with direct-acting antiviral therapy. PARTICIPANTS Individuals aged 80 and older with chronic HCV infection (N = 253; n = 213 with cirrhosis, n = 40 with advanced fibrosis). MEASUREMENTS We investigated the efficacy, safety, and global clinical effect of treatment with different combinations of direct antiviral agents (DAAs). Participants with cirrhosis were staged according to Child-Pugh-Turcotte class, Model for End-Stage Liver Disease score, and the D'Amico staging system. The type and number of comorbidities at baseline and hepatic and nonhepatic events during follow-up were registered. RESULTS Ninety-five percent of participants with cirrhosis and 95% of those with advanced fibrosis attained SVR. The rate was independent of sex, HCV genotype, and treatment schedule. During a mean follow-up of 14 ± 4 months (range 5-23 months), 34 events occurred in 27 participants: 10 hepatocellular carcinomas, 12 hepatic decompensations, 9 nonhepatic events, 3 deaths. Multivariate analysis of risk factors for experiencing adverse events during follow up showed that participants in D'Amico Stages 4 and 5, with a baseline serum albumin level of 3.5 mg/dL or less, and 3 or more comorbidities were the most at risk. CONCLUSION In a real-world setting, DAAs are safe and effective in older adults with HCV-related advanced fibrosis or cirrhosis. Individuals with preserved albumin synthesis and fewer than 3 comorbidities at baseline have the most to gain from long-term DAA therapy.
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Affiliation(s)
- Antonio Massimo Ippolito
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy
| | - Angelo Iacobellis
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy
| | - Michele Milella
- Clinics of Infectious Diseases, University of Bari, Bari, Italy
| | - Fabio Conti
- Centre for the Study of Hepatitis, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Messina
- Infectious and Tropical Diseases Unit, S. Anna and S. Sebastiano Hospital, Caserta, Italy
| | - Maria Rosa Valvano
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy
| | - Grazia Anna Niro
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy
| | - Filomena Morisco
- Division of Gastroenterology, Department of Clinical Medicine and Surgery, Federico II University of Napoli, Naples, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, Azienda Ospedaliero Universitaria Policlinico, University of Bari, Bari, Italy
| | | | | | - Angelo Andriulli
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy
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28
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Mohsen W, Levy MT. Hepatitis A to E: what's new? Intern Med J 2017; 47:380-389. [PMID: 28401719 DOI: 10.1111/imj.13386] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/27/2016] [Accepted: 11/20/2016] [Indexed: 12/17/2022]
Abstract
Viral hepatitis contributes to significant morbidity and mortality worldwide. While acute infection may be self-limiting, unrecognised chronic infection and under-utilisation of guideline-based approaches to therapy contribute to increasing rates of cirrhosis, hepatocellular carcinoma and death. Our aim was to review the current evidence for screening, diagnosis and treatment in hepatitis A to E. Evidence for this review was sourced from international and Australian guidelines and high-quality clinical trials. MEDLINE was searched using structured key word strategy and retrieved articles were reviewed methodically to inform a brief and up-to-date synopsis of hepatitis A to E. We share some of the recent developments in viral hepatitis, specifically the new therapies for hepatitis C. Direct-acting antiviral therapies are safe, well-tolerated and effective. Subsidies allow access for all Australians with most strains of hepatitis C. We outline evidence underpinning efficacy and safety of treatment for hepatitis B, while clarifying some of the nuances in the setting of pregnancy and immunosuppression. We provide a simplified concept to facilitate understanding of the five phases of hepatitis B; practical for real-world setting. Hepatitis A to E is a broad topic, not all aspects of these viruses can be covered in this short review. We provided suggestions for evidence based guidelines, which are a suitable supplement to this article.
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Affiliation(s)
- Waled Mohsen
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Miriam T Levy
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Direct-acting antivirals are effective for chronic hepatitis C treatment in elderly patients: a real-world study of 17 487 patients. Eur J Gastroenterol Hepatol 2017; 29:686-693. [PMID: 28195877 PMCID: PMC6534142 DOI: 10.1097/meg.0000000000000858] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The mean age of patients with chronic hepatitis C virus (HCV) infection in the USA has been increasing. Despite the increasing proportion of HCV-infected elderly patients, this group is under-represented in clinical trials of HCV treatment. AIM We aimed to describe the real-world effectiveness of direct-acting antivirals (DAAs) among elderly patients. PATIENTS AND METHODS We retrospectively identified 17 487 HCV-infected patients who were started on treatment with sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ombitasvir/ritonavir/dasabuvir-based regimens in the Veterans Affairs Healthcare System between 1 January 2014 and 30 June 2015. We ascertained sustained virologic response (SVR) rates in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older and performed multivariable logistic regression to determine whether age predicted SVR. RESULTS Overall unadjusted SVR rates were 91.2% [95% confidence interval (CI): 89.7-92.4], 89.8% (95% CI: 88.8-90.7), 90.8% (95% CI: 90.1-91.6), 91.1% (95% CI: 90.1-91.9), 90.0% (95% CI: 86.9-92.4), and 93.8% (95% CI: 88.8-96.7) in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older. Unadjusted SVR rates were similar in all age groups after stratifying by genotype, treatment regimen, stage of liver disease, and treatment experience. In multivariate models, age was not predictive of SVR after adjusting for confounders. CONCLUSION DAAs produce high rates of SVR in all age groups, including patients in our oldest age category (≥75 years). Advanced age in and of itself should not be considered a barrier to initiating DAA treatment.
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30
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Effectiveness and Tolerability of Direct Acting Antiviral Therapy for Hepatitis C in a Real World Elderly Cohort. Clin Gastroenterol Hepatol 2017; 15:603-604. [PMID: 27989848 DOI: 10.1016/j.cgh.2016.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 02/07/2023]
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Santambrogio R, Barabino M, Scifo G, Costa M, Giovenzana M, Opocher E. Effect of Age (over 75 Years) on Postoperative Complications and Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma. J Gastrointest Surg 2017; 21:657-665. [PMID: 28083840 DOI: 10.1007/s11605-016-3354-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/31/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Thanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged <75 years (younger). METHOD One hundred sixty-eight patients who underwent HR for HCC from 1998 to 2015 in our Center were analyzed using a prospective database. Complications, disease-free survival rates, and cumulative survival rates were compared between the two groups. RESULTS During the immediate postoperative period, no differences were found about liver-related complications, hospital stay and 90-day mortality. However, older patients had more complications in class II or higher (Clavien classification) (p = 0.017). Although disease-free survival in both groups was similar (p = 0.099), overall survival was worse in the elderly group (p = 0.024). On multivariate analysis, only age ≥75 years was significantly related to overall survival. CONCLUSION If elderly patients with liver cirrhosis and HCC are appropriately selected and evaluated, they might have favorable prognoses after HR.
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Affiliation(s)
- Roberto Santambrogio
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy.
| | - Matteo Barabino
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Giovanna Scifo
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Mara Costa
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Marco Giovenzana
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Enrico Opocher
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
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Nguyen K, Jimenez M, Moghadam N, Wu C, Farid A, Grotts J, Elashoff D, Choi G, Durazo FA, El-Kabany MM, Han SHB, Saab S. Decrease of Alpha-fetoprotein in Patients with Cirrhosis Treated with Direct-acting Antivirals. J Clin Transl Hepatol 2017; 5:43-49. [PMID: 28507926 PMCID: PMC5411356 DOI: 10.14218/jcth.2016.00057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/26/2017] [Accepted: 02/01/2017] [Indexed: 12/11/2022] Open
Abstract
Background and Aims: The lack of specificity has limited the role of serum alpha-fetoprotein (AFP) for hepatocellular carcinoma (HCC) screening among patients with cirrhosis related to hepatitis C virus (HCV) infection. We sought to examine whether AFP may decrease after achieving a sustained virological response (SVR) in patients with HCV-related cirrhosis. Methods: We performed a retrospective study of patients with HCV-related cirrhosis who were cured with direct-acting antiviral (DAA) therapy at the University of California, Los Angeles. Laboratory values, including serum AFP, were measured before and after completing the DAA treatment. Results: Fifty-six patients met the inclusion criteria, with median (interquartile range [IQR]) age of 67 (58-69) years and with 51.8% being male. All patients received DAA therapy without interferon. AFP decreased from median (IQR) 7.2 (4.2-13.4) ng/mL before DAAs to 4.2 (2.7-6.3) ng/mL at the end of treatment and 4.2 (2.9-6.8) ng/mL at 12 weeks after treatment (p < 0.001). Model for end-stage liver disease (MELD), fibrosis-4 (FIB4), and aspartate transaminase (AST) to platelet ratio index (APRI) scores at baseline were not significantly associated with AFP reduction. On multivariate analysis, platelet count, AST and total bilirubin at baseline were significantly correlated to AFP reduction (p = 0.04, 0.009 and 0.04, respectively). The higher the baseline AFP, the greater the reduction in AFP. There was no statistically significant correlation between baseline AFP and MELD, FIB4 or APRI scores. Conclusion: There was a significant decrease in AFP in patients with cirrhosis who achieved a SVR with DAAs. Given a reduction in AFP after DAA treatment, AFP should be further studied as a screening modality for HCC in patients with cirrhosis.
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Affiliation(s)
- Kelvin Nguyen
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Nima Moghadam
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Crystal Wu
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Alex Farid
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Jonathan Grotts
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
| | - David Elashoff
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Biostatistics, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Gina Choi
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Francisco A. Durazo
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohamed M. El-Kabany
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven-Huy B. Han
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
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Atkins D, Kilbourne AM, Shulkin D. Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration. Annu Rev Public Health 2017; 38:467-487. [DOI: 10.1146/annurev-publhealth-031816-044255] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.
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Affiliation(s)
- David Atkins
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
| | - Amy M. Kilbourne
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48109-5624
| | - David Shulkin
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
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White DL, Thrift AP, Kanwal F, Davila J, El-Serag HB. Incidence of Hepatocellular Carcinoma in All 50 United States, From 2000 Through 2012. Gastroenterology 2017; 152:812-820.e5. [PMID: 27889576 PMCID: PMC5346030 DOI: 10.1053/j.gastro.2016.11.020] [Citation(s) in RCA: 303] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/03/2016] [Accepted: 11/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence and mortality of hepatocellular carcinoma (HCC) have been reported to be plateauing in the United States. The United States has large racial, ethnic, and regional variation; we collected data from all 50 states to better analyze changes in HCC incidence in the entire United States. METHODS We collected data from the US Cancer Statistics registry, which covers 97% of the population, and calculated adjusted incidence rates. We assessed annual trends among sociodemographic and geographic subgroups using joinpoint analysis. RESULTS HCC incidence increased from 4.4/100,000 in 2000 to 6.7/100,000 in 2012, increasing by 4.5% (95% confidence interval [CI], 4.3%-4.7%) annually between 2000 and 2009, but only by 0.7% annually (95% CI, -0.2% to 1.6%) from 2010 through 2012. The average annual percentage change (AAPC) between 2000 and 2012 was higher in men (increase, 3.7%) than in women (increase, 2.7%), and highest in 55- to 59-year-old individuals (AAPC, 8.9%; 95% CI, 7.1%-10.7%) and 60- to 64-year-old individuals (AAPC, 6.4%; 95% CI, 4.7%-8.2%). By 2012, rates in Hispanics surpassed those in Asians, and rates in Texas surpassed those in Hawaii (9.71/100,000 vs 9.68/100,000). Geographic variation within individual race and ethnic groups was observed, but rates were highest in all major race and ethnic groups in Texas. CONCLUSIONS In an analysis of the incidence of HCC in all 50 US states, we found the rate of increase in HCC to have slowed from 2010 through 2012. However, incidence is increasing in subgroups such as men ages 55 to 64 years old-especially those born in the peak era of hepatitis C virus infection and among whites/Caucasians. Rates in Hispanics have surpassed those in Asian Americans. We observed geographic differences, with Texas having the highest age-adjusted HCC rates nationwide.
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Affiliation(s)
- Donna L White
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas; Texas Medical Center Digestive Disease Center, Baylor College of Medicine, Houston, Texas; Center for Translational Research in Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas; Texas Medical Center Digestive Disease Center, Baylor College of Medicine, Houston, Texas
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas; Texas Medical Center Digestive Disease Center, Baylor College of Medicine, Houston, Texas
| | - Jessica Davila
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas; Texas Medical Center Digestive Disease Center, Baylor College of Medicine, Houston, Texas.
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