Future complications of chronic hepatitis C in a low-risk area: projections from the hepatitis c study in Northern Norway

Treatment of HCV with direct-acting antivirals on reducing mortality related to extrahepatic manifestations: a large population-based study in British Columbia, Canada

Background

HCV infection is associated with mortality due to extrahepatic manifestations (EHM). Sustained virologic response (SVR) following direct-acting antiviral (DAA) therapy has been linked to decreased all-cause and liver-related mortality. However, evidence regarding the impact of DAA on EHM-related deaths is lacking. This study aimed to assess the impact of DAA and SVR on EHM-related mortality.

Methods

The British Columbia Hepatitis Testers Cohort comprises ∼1.7 million people tested for HCV between 1990 and 2015 and is linked with administrative health data. Among individuals diagnosed with HCV by 12/31/2020, those who received at least one DAA treatment were matched to those who never received treatment by the year of their first HCV RNA positive date. We compared three groups: treated & SVR, treated & no-SVR, and untreated; and generated EHM mortality rates and incidence curves. To account for differences in baseline characteristics, we used inverse probability of treatment weights (IPTW). IPTW-weighted multivariable cause-specific Cox regression models were adjusted for competing risk and confounders.

Findings

Study population included 12,815 treated (12,287 SVR, 528 no-SVR) and 12,815 untreated individuals (median follow-up 3.4 years, IQR 2.9). The untreated group had the highest EHM mortality rate (30.9 per 1000 person-years [PY], 95% CI 29.2-32.8), followed by the treated & no-SVR group (21.2 per 1000 PY, 95% CI 14.9-30.1), while the treated & SVR group had the lowest EHM mortality rate (7.9 per 1000 PY, 95% CI 7.1-8.7). In the multivariable model, EHM mortality in the treated & SVR group was significantly decreased (adjusted cause-specific hazard ratio [acsHR] 0.20, 95% CI 0.18-0.23). The treated & SVR group had significant reductions in mortality related to each of the EHMs (78-84%).

Interpretation

Treatment of HCV with DAA was associated with significant reductions in EHM-related mortality. These findings emphasize the critical importance of timely diagnosis and treatment of HCV to prevent deaths associated with EHM, and have important implications for clinical practice and public health.

Funding

This work was supported by the BC Centre for Disease Control and the Canadian Institutes of Health Research (CIHR) [Grant # NHC-348216, PJT-156066, and PHE-337680]. DJ has received Doctoral Research Award (#201910DF1-435705-64343) from the Canadian Institutes of Health Research (CIHR) and Doctoral fellowship from the Canadian Network on Hepatitis C (CanHepC). CanHepC is funded by a joint initiative of the Canadian Institutes of Health Research (CIHR) (NHC-142832) and the Public Health Agency of Canada (PHAC).

Physiomimetic In Vitro Human Models for Viral Infection in the Liver

Viral hepatitis is a leading cause of liver morbidity and mortality globally. The mechanisms underlying acute infection and clearance, versus the development of chronic infection, are poorly understood. In vitro models of viral hepatitis circumvent the high costs and ethical considerations of animal models, which also translate poorly to studying the human-specific hepatitis viruses. However, significant challenges are associated with modeling long-term infection in vitro. Differentiated hepatocytes are best able to sustain chronic viral hepatitis infection, but standard two-dimensional models are limited because they fail to mimic the architecture and cellular microenvironment of the liver, and cannot maintain a differentiated hepatocyte phenotype over extended periods. Alternatively, physiomimetic models facilitate important interactions between hepatocytes and their microenvironment by incorporating liver-specific environmental factors such as three-dimensional ECM interactions and co-culture with non-parenchymal cells. These physiologically relevant interactions help maintain a functional hepatocyte phenotype that is critical for sustaining viral hepatitis infection. In this review, we provide an overview of distinct, novel, and innovative in vitro liver models and discuss their functionality and relevance in modeling viral hepatitis. These platforms may provide novel insight into mechanisms that regulate viral clearance versus progression to chronic infections that can drive subsequent liver disease.

Rifaximin microbial resistance and its efficacy and safety as a secondary prophylaxis of hepatic encephalopathy in patients with hepatitis C virus-related cirrhosis

BACKGROUND AND AIM

Rifaximin is an oral antibiotic with promising efficacy in the reduction of hepatic encephalopathy (HE) recurrence. Development of microbial resistance to rifaximin is not studied yet in HE. The study aim was to assess the microbial resistance, safety and efficacy of rifaximin as secondary prophylaxis of HE.

METHOD

In this open-label parallel, prospective interventional study, 100 patients were randomly allocated either to receive 400 mg rifaximin 3 times/d plus 30-45 mL lactulose 3 times/d (intervention group) or to receive the standard of care only which is lactulose alone (control group) for 6 months. The primary outcome of the study was the difference between minimum inhibitory concentration (MIC) of rifaximin among the two studied groups at the end of treatment. The secondary outcomes included the time to first episode of HE, time to first hospitalisation, and patient's survival.

RESULTS

The MIC did not differ significantly after treatment exposure compared with baseline either between groups or within the same group. The time to new episode of HE was 18.84 ± 6.49 weeks (mean ± SD) in the intervention group and was significantly longer (P = .002) than that in the control group 14 ± 7.52 weeks. Moreover, only 23 (46%) patients developed overt HE in the intervention group compared with 35 patients (70%) in the control group (P = .005). Also, there was an observed 32% reduction in the risk of hospitalisation in intervention group compared with control group.

CONCLUSION

Rifaximin succeeded to maintain remission from new episodes of HE in hepatitis C virus cirrhotic patients with limited potential for development of microbial resistance over the study period. ClinicalTrials.gov Identifier: NCT04736836.

Possible roles of methylenetetrahydrofolate reductase polymorphism and folate status in patients with early hepatitis C virus genotype 4

BACKGROUND AND STUDY AIMS

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease worldwide. In Egypt, 92.5% of HCV infection cases reportedly involve infection with HCV genotype 4. HCV infection may induce liver steatosis directly and indirectly. Host genetic polymorphisms may also contribute to the pathogenesis of steatosis. Folate deficiency indirectly cuase liver damage. Folate status is mostly affected by MTHFR C677T polymorphism. The pathophysiology of thrombocytopenia (TCP) in HCV infection remains unclear. Thus, the present study investigated the roles and consequences of MTHFR C677T SNP and folate status in patients with early HCV genotype 4 infection and their relation with steatosis and thrombocytopenia.

PATIENTS AND METHODS

Fifty patients with the HCV genotype 4 and 50 healthy controls were enrolled in the study. All the participants underwent laboratory, demographic, and anthropomorphic examinations. Serum folate level was determined, and genomic analysis of MTHFR C677T SNP was performed.

RESULTS

No significant difference in allelic frequency of MTHFR C677T was observed between patients and controls. However, significantly lower serum folate level, hemoglobin level, and platelet count were found in patients than controls (p = 0.014, p = 0.005, and p = 0.001, respectively). The cholesterol, triglyceride, and high-density lipoprotein levels were also significantly lower in patients than controls (p < 0.001, p = 0.001, and p < 0.001, respectively), whereas the low-density lipoprotein level was significantly higher in patients (p < 0.001). Patients harboring the MTHFR CT genotype had a significantly lower serum folate level (p = 0.033) than the controls. Among the patients with HCV infection, those with the TT genotype had the highest body mass index (p = 0.003) and levels of cholesterol, triglyceride, and high-density lipoprotein (p = 0.007, p = 0.025, and p = 0.040, respectively).

CONCLUSION

MTHFR C677T SNP may contribute to the development of complications associated with early HCV genotype 4 infection, such as dyslipidemia and decreased folate levels.

APRI and FIB-4 performance to assess liver fibrosis against predefined Fibroscan values in chronic hepatitis C virus infection

Backgrounds and Aims:

Chronic hepatitis C (CHC) infection can leads to chronic liver disease, fibrosis, then cirrhosis, and, finally, hepatocellular carcinoma (HCC); moreover, it is the most common indication for liver transplantation. Liver biopsy is still the gold standard method for the staging of liver fibrosis as it is an invasive procedure with complications. There are some noninvasive methods such as fibroscan that are now the investigation of choice; FIB-4 and aminotransferase to platelet ratio index (APRI) are other noninvasive tools to assess liver fibrosis by using aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count, and age. This study aims to evaluate the efficacy and performance of FIB-4 and APRI against fibroscan in patients infected with the hepatitis C virus.

Method:

It is a cross-sectional study that was conducted in a tertiary health care center in Uttar Pradesh, India, from January 2017 to January 2020. Fibroscan was done for all patients. A blood sample was used to determine AST, ALT, and platelet count. FIB-4 and APRI were calculated from laboratory data.

Result:

187 of the 487 patients in the study have F0-F1 fibrosis, 69 have F2, 53 have F3 fibrosis, and 178 have cirrhosis. Based on receiver operating characteristic (ROC) analysis, single optimum cut-offs for diagnosing significant fibrosis and cirrhosis were 1.2 for APRI and 2.25 for FIB-4.

Conclusions:

Compared with Fibroscan, APRI and FIB-4 showed good performance in detecting the patients without liver fibrosis as well as satisfactory performance in detecting significant fibrosis. These scores should be used in combination with other noninvasive scores for an accurate assessment of liver fibrosis.

Epidemiological trend of hepatitis C-related liver events in Spain (2000-2015): A nationwide population-based study

OBJECTIVE

Analysis the epidemiological trends of hospital admissions, intra-hospital deaths, and costs related to chronic hepatitis C (CHC) taking into account four major clinical stages [compensated cirrhosis (CC), end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver transplantation (LT)] in Spain.

METHODS

Retrospective study in patients with chronic hepatitis C and a hospital admission in the Spanish Minimum Basic Data Set from 2000 to 2015. Outcome variables were admission, death, length of hospital stay and costs.

RESULTS

A total of 868,523 hospital admissions with CHC (25.5% CC, 25.3% ESLD, 8.6% HCC, and 2.5% LT) were identified. Overall rates of admission and mortality increased from 2000-2003 to 2004-2007, but after 2008, these rates stabilized and/or decreased. An upward trend was found for hospitalization percentage in CC (from 22.3% to 30%; p < 0.001), ESLD (from 23.9% to 27.1%; p < 0.001), HCC (from 7.4% to 11%; p < 0.001), and LT (from 0.07% to 0.10%; p = 0.003). An upward trend was also found for case fatality rate, except in ESLD (p = 0.944). Gender and age influenced the evolution of hospitalization rates and mortality differently. The length of hospital stay showed a significant downward trend in all strata analyzed (p < 0.001). Cost per patient had a significant upward trend (p < 0.001), except in LT, and a decrease from 2008-2011 to 2012-2015 in CC (p = 0.025), HCC (p < 0.001), and LT (p = 0.050) was found.

CONCLUSION

The initial upward trend of the disease burden in CHC has changed from 2000 to 2015 in Spain, improving in many parameters after 2004-2007, particularly in the 2012-2015 calendar period.

Screening for hepatitis C in a general adult population in a low-prevalence area: the Tromsø study

Background

Chronic hepatitis C virus (HCV) infection can progress to cirrhosis and end-stage liver disease in a substantial proportion of patients. The infection is frequently asymptomatic, leaving many infected individuals unaware of the diagnosis until complications occur. This advocates the screening of healthy individuals. The aim of this study was to estimate the prevalence of HCV infection in the general adult population of the municipality of Tromsø, Norway, and to evaluate the efficiency of such an approach in a presumed low-prevalence area.

Methods

The study was part of the seventh survey of the Tromsø Study (Tromsø 7) in 2015–2016. Sera from 20,946 individuals aged 40 years and older were analysed for antibodies to HCV (anti-HCV). A positive anti-HCV test was followed up with a new blood test for HCV RNA, and the result of any previous laboratory HCV data were recorded. Samples positive for anti-HCV and negative for HCV RNA were tested with a recombinant immunoblot assay. All HCV RNA positive individuals were offered clinical evaluation.

Results

Among 20,946 participants, HCV RNA was detected in 33 (0.2%; 95% CI: 0.1–0.3), of whom 13 (39.4%; 95% CI: 22.7–56.1) were unaware of their infection. The anti-HCV test was confirmed positive in 134 individuals (0.6%; 95% CI: 0.5–0.7) with the highest prevalence in the age group 50–59 years. Current or treatment-recovered chronic HCV-infection was found in 85 individuals (0.4%; 95% CI: 0.3–0.5) and was associated with an unfavorable psychosocial profile.

Conclusion

In this population-based study, the prevalence of viraemic HCV infection was 0.2%. A substantial proportion (39%) of persons with viraemic disease was not aware of their infectious status, which suggests that the current screening strategy of individuals with high risk of infection may be an inadequate approach to identify chronic HCV infection hidden in the general population.

Liver disease burden and required treatment expenditures for hepatitis C virus (HCV) infection in Thailand: Implications for HCV elimination in the new therapeutic era, a population-based study

The prevalence of hepatitis C virus (HCV) infection has been decreasing globally, but the growing effects of HCV-related morbidity and mortality remain of concern. Advances in curative medicine, involving direct-acting antivirals (DAAs), have led many countries to aim to eradicate HCV. Information on epidemiology and disease burden is essential for national policy development. Thus, this study aimed to determine the HCV-related hepatic disease burden in areas of Thailand with high and average HCV prevalence in order to extrapolate the viral burden across Thailand. Patients previously diagnosed as positive for anti-HCV antibodies were recruited to assess chronic HCV infection (CHC) status, liver function, HCV-RNA level and hepatic fibrosis. The number of patients eligible for Universal Health Coverage (UC) scheme and the approximately required expenditure on interferon (IFN)-based treatment were estimated. In areas of both high (12%) and average (2%) HCV viremic prevalence, over half of the patients (52.2% to 62.5%) had advanced liver fibrosis (F3 and F4). A striking percentage of patients with F4 (38.9%) were found in the high-prevalence area, while comparable proportions of advanced liver fibrosis presented in the two areas and disease burden peaked at 50-59 years. Under the current UC program treatment scenario, 78-83% of CHC patients with stage F2-F4 fibrosis were eligible for treatment. The estimated expenditure required for overall CHC treatment across the whole country was 1,240 million USD at this current status, but the declining cost of generic DAA-based therapy may reduce the requirement to <90 million USD. This study provides information on the estimated number of CHC patients, liver disease burden and expenditure requirements for Thailand. To eliminate HCV by 2030, proactive government strategies raising public health to minimize transmission and emphasizing targeted screen-and-treatment programs, novel therapeutic guideline development for decentralizing treatment, and effective budget allocation are urgently needed.