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Gambato M, Canini L, Lens S, Graw F, Perpiñan E, Londoño MC, Uprichard SL, Mariño Z, Reverter E, Bartres C, González P, Pla A, Costa J, Burra P, Cotler SJ, Forns X, Dahari H. Early HCV viral kinetics under DAAs may optimize duration of therapy in patients with compensated cirrhosis. Liver Int 2019; 39:826-834. [PMID: 30499631 PMCID: PMC6483833 DOI: 10.1111/liv.14014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/21/2018] [Accepted: 11/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Detailed hepatitis C virus (HCV) kinetics modelling is scarce in patients with advanced liver disease receiving direct-acting antivirals (DAAs). Due to budget restrictions, patients and health systems would benefit from the shortest possible treatment course. We investigated whether modelling very early HCV kinetics in cirrhotic patients under DAAs therapy could be used to individualize care and reduce treatment duration to achieve cure. METHODS We included 74 patients with HCV-related cirrhosis who received interferon-free treatments for 12-24 weeks. HCV genotype, liver disease stage and treatment regimen were recorded. Viral load was determined prospectively at very frequent intervals until target not detected (TND, <15 IU/mL). A viral kinetic model was used to predict time to cure based on HCV clearance in extracellular body fluid (CL-EF). RESULTS Sixty-eight patients (92%) achieved cure. Thirteen (18%) had MELD ≥15, 35 (47%) were Child-Pugh (CTP) ≥7. Median time to reach TND was 2 weeks (IQR: 1-4 weeks). Modelling indicated an average DAAs efficacy in blocking viral production of ε = 99.1%. HCV half-life (t1/2 ) was significantly shorter in patients with CTP <7, LSM <21 kPa or MELD <15 (1.5 vs 2.5 hours; P = 0.0057). The overall median CL-EF was 5.6 weeks (4.1-7.8). A CTP >7 and a LSM ≥21 kPa were significantly (P = 0.016) associated with longer CL-EF. CONCLUSIONS The study provides insights into HCV dynamics during DAAs therapy in patients with compensated and decompensated cirrhosis. Viral kinetics modelling suggests that treatment duration may be optimized in patients with compensated cirrhosis.
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Affiliation(s)
- Martina Gambato
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
- Multivisceral Transplant Unit, Padua University Hospital, Italy
| | - Laetitia Canini
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Loyola University Medical Center, Maywood, Illinois, United States
- Centre for Immunity, Infection and Evolution, University of Edinburgh, Edinburgh, United Kingdom
| | - Sabela Lens
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Frederik Graw
- Center for Modeling and Simulation in the Biosciences, BioQuant Center, Heidelberg University, Heidelberg, Germany
| | - Elena Perpiñan
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Susan L. Uprichard
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Zoe Mariño
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Enric Reverter
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Concepcio Bartres
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Patricia González
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Anna Pla
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Josep Costa
- Microbiology Service, Hospital Clínic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Patrizia Burra
- Multivisceral Transplant Unit, Padua University Hospital, Italy
| | - Scott J. Cotler
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Xavier Forns
- Liver Unit, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Harel Dahari
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Loyola University Medical Center, Maywood, Illinois, United States
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Abstract
Chronic hepatitis C virus (HCV) infection is a leading cause of death, especially in immunocompromised patients. The lack of clear prevalence data in the Middle East makes it difficult to estimate the true morbidity and mortality burden of HCV. In Kuwait, estimating the burden of disease is complicated by the constant flow of expatriates, many of whom are from HCV-endemic areas. The development of new and revolutionary treatments for HCV necessitates the standardization of clinical practice across all healthcare institutions. While international guidelines from the American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL) do address this evolving treatment landscape, the cost-driven treatment prioritization of patients by these guidelines and unique HCV genotype presentation in the Kuwaiti population prompted the development of a more tailored approach. The predominant HCV genotypes prevalent in Kuwait are genotypes 4 and 1. The Kuwait Hepatology Club (KHC), comprising hepatologists across all major institutions in Kuwait, conducted several consensus meetings to develop the scoring criteria, evaluate all current evidence, and propose screening, diagnosis, and treatment suggestions for the management of HCV in this population. While these treatment suggestions were largely consistent with the 2016 AASLD and 2015 EASL guidelines, they also addressed gaps in the unmet needs of the Kuwaiti population with HCV.
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Affiliation(s)
- Motaz Fathy Saad
- Haya Al-Habib Gastroenterology and Hepatology Center, Mubarak Alkabir Hospital, Hawaly, Kuwait,
| | - Saleh Alenezi
- Unit of Gastroenterology and Hepatology, Department of Medicine, Farwaniya Hospital, Kuwait City, Kuwait
| | - Haifaa Asker
- Thunayan Al-Ghanim Gastroenterology and Hepatology Center, Al-Amiri Hospital, Kuwait City, Kuwait
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Loggi E, Vukotic R, Conti F, Gitto S, Andreone P. Gold standard assays for the monitoring of patients with chronic hepatitis C. Future Virol 2018. [DOI: 10.2217/fvl-2018-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Chronic HCV infection continues to be an important concern of public health, with still a high mortality from HCV-related disease. The landscape of chronic HCV infection has been dramatically changed by the introduction of the new antiviral agents, able to cure the infection in the large majority of patients. The laboratory management of HCV infection relies on serological and molecular tests, which have undergone significant technological advancements, able to ameliorate the performance both in diagnosis of infection and in the treatment monitoring. This article describes the main laboratory tools in the chronic HCV infection, with particular emphasis on the recent changes coming along with the new therapeutic approaches.
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Affiliation(s)
- Elisabetta Loggi
- Dipartimento di Scienze Mediche e Chirurgiche, Centro di Ricerca per lo Studio delle Epatiti, Università degli Studi di Bologna, Bologna, Italy
- Current address: UOC Patologia Clinica, ASUR Area Vasta 4, Fermo (FM), Italy
| | - Ranka Vukotic
- Dipartimento di Scienze Mediche e Chirurgiche, Centro di Ricerca per lo Studio delle Epatiti, Università degli Studi di Bologna, Bologna, Italy
| | - Fabio Conti
- Dipartimento di Scienze Mediche e Chirurgiche, Centro di Ricerca per lo Studio delle Epatiti, Università degli Studi di Bologna, Bologna, Italy
| | - Stefano Gitto
- Dipartimento di Scienze Mediche e Chirurgiche, Centro di Ricerca per lo Studio delle Epatiti, Università degli Studi di Bologna, Bologna, Italy
| | - Pietro Andreone
- Dipartimento di Scienze Mediche e Chirurgiche, Centro di Ricerca per lo Studio delle Epatiti, Università degli Studi di Bologna, Bologna, Italy
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Hussein MH, Peedikayil MC, Zamir ZA, Alfadda A. Resolution of refractory hepatic hydrothorax in patients with hepatitis C virus cirrhosis after treatment with direct-acting antiviral agents. Ann Thorac Med 2018; 13:117-121. [PMID: 29675064 PMCID: PMC5892087 DOI: 10.4103/atm.atm_194_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Hepatic hydrothorax (HH) is a transudative pleural effusion that complicates advanced liver cirrhosis. Cases refractory to medical treatment in the form of salt restriction and diuretics are labeled refractory hepatic hydrothorax (RHH) and may require transjugular intrahepatic portosystemic shunts (TIPSS) or even liver transplantation. Renal impairment is common in advanced liver disease, worsens its prognosis, and makes the management of HH more challenging. Successful antiviral therapy reduces some of the complications of cirrhosis secondary to hepatitis C virus (HCV) infection. We herein report two cirrhotic patients with chronic kidney disease who developed RHH which resolved after the successful treatment of their HCV infection with direct-acting antivirals (DAAs). In cases of RHH associated with HCV cirrhosis, a trial of DAAs is warranted before resorting to TIPSs or liver transplantation.
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Affiliation(s)
- Maged H Hussein
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Musthafa Chalikandy Peedikayil
- Department of Medicine, Section of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Zamir Ahmed Zamir
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman Alfadda
- Department of Medicine, Section of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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McCaughan GW, Thwaites PA, Roberts SK, Strasser SI, Mitchell J, Morales B, Mason S, Gow P, Wigg A, Tallis C, Jeffrey G, George J, Thompson AJ, Parker FC, Angus PW. Sofosbuvir and daclatasvir therapy in patients with hepatitis C-related advanced decompensated liver disease (MELD ≥ 15). Aliment Pharmacol Ther 2018; 47:401-411. [PMID: 29205432 DOI: 10.1111/apt.14404] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/14/2017] [Accepted: 10/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antiviral therapy for hepatitis C has the potential to improve liver function in patients with decompensated cirrhosis. AIMS To examine the virological response and effect of viral clearance in patients with decompensated hepatitis C cirrhosis all with MELD scores ≥15 following sofosbuvir/daclatasvir ± ribavirin. METHODS We prospectively collected data on patients who commenced sofosbuvir/daclatasvir for 24-weeks under the Australian patient supply program (TOSCAR) and analysed outcomes including sustained viral response at 12 weeks (SVR12), death and transplant. RESULTS 108 patients (M/F, 79/29; median age 56years; Child-Pugh 10; MELD 16; genotype 1/3, 55/47) received sofosbuvir/daclatasvir and two also received ribavirin. On intention-to-treat, the SVR12 rate was 70% (76/108). Seventy-eight patients completed 24-weeks therapy. SVR12 was achieved in 56 of these patients on per-protocol-analysis (76%). SVR12 was 80% in genotype 1 compared to 69% in genotype 3. Thirty patients failed to complete therapy. In patients achieving SVR12, median MELD and Child-Pugh fell from 16(IQR15-17) to 14(12-17) and 10(9-11) to 8(7-9), respectively (P<.001). In those who died, MELD increased from 16 to 23 at death (P=.036). Patients who required transplantation had a significantly higher baseline MELD (20) compared to those patients completing treatment (16) (P=.0010). The odds ratio for transplant in patients with baseline MELD ≥20 was 13.8(95%CI 2.78-69.04). CONCLUSIONS SVR12 rates with sofosbuvir/daclatasvir in advanced liver disease are lower than in compensated disease. Although treatment improves MELD and Child-Pugh in most patients, a significant proportion will die or require transplantation. In those with MELD ≥20, it may be better to delay treatment until post-transplant.
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Affiliation(s)
- G W McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P A Thwaites
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - S K Roberts
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Vic., Australia
| | - S I Strasser
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - J Mitchell
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Vic., Australia
| | - B Morales
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - S Mason
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P Gow
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - A Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - C Tallis
- Queensland Liver Transplant Unit, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - G Jeffrey
- Western Australian Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - J George
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia
| | - A J Thompson
- St Vincent's Hospital, University of Melbourne, Melbourne, Vic., Australia
| | - F C Parker
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - P W Angus
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
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Rezaee-Zavareh MS, Hesamizadeh K, Sharafi H, Alavian SM. Treatment of Hepatitis C Infection with Direct-Acting Antiviral Agents in Liver-Transplant Patients: A Systematic Review and Meta-Analysis. HEPATITIS MONTHLY 2017; 17. [DOI: 10.5812/hepatmon.12324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
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Maasoumy B, Vermehren J. Diagnostics in hepatitis C: The end of response-guided therapy? J Hepatol 2016; 65:S67-S81. [PMID: 27641989 DOI: 10.1016/j.jhep.2016.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
On-treatment hepatitis C virus (HCV) RNA has been used to predict response to interferon (IFN)-based therapy. The concept of response-guided treatment (RGT) was established to determine optimal treatment duration and to early identify patients not responding to futile therapies. RGT helped to improve sustained virologic response (SVR) rates and lower the rates of adverse effects. RGT was of particular importance for telaprevir- and boceprevir-based triple therapies. RGT strategies are dependent on highly sensitive and reproducible HCV RNA quantification. However, different HCV RNA assays are used in routine clinical practice and these differ significantly in their performance characteristics. The development of IFN-free therapies has fundamentally changed the role of on-treatment HCV RNA for SVR prediction. Given the high efficacy and excellent tolerability of IFN-free regimens, the interest in treatment individualization has decreased. However, shorter treatment durations may still be desirable, particularly with respect to the high costs of current IFN-free direct-acting antiviral agents (DAAs). Moreover, some difficult-to-treat patients remain, e.g., those infected with HCV genotype 3 in whom the current standard of care may not always be sufficient to achieve SVR, especially in treatment-experienced patients with cirrhosis. Here, a RGT extension may be feasible. However, current data on the predictive value of on-treatment HCV RNA are limited and have shown conflicting results. As more potent DAAs become available, the role of response prediction may diminish further. Currently, shorter treatment duration is only based on baseline HCV RNA whereas no RGT strategy is recommended for any of the approved DAA regimens available.
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Affiliation(s)
- Benjamin Maasoumy
- Medizinische Hochschule Hannover, Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Hannover, Germany
| | - Johannes Vermehren
- Universitätsklinikum Frankfurt, Medizinische Klinik 1, Frankfurt am Main, Germany.
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