Hepatitis C (cont.)
In this Article
What is the role of a liver biopsy in the management of chronic hepatitis C?
Blood tests can tell the clinician whether HCV is present but cannot tell the
level of liver damage that has occurred.
Liver biopsy allows the clinician to
determine how much inflammation and scarring is present in a small sample of
liver tissue. Liver biopsy may be recommended when the clinician is uncertain
about whether to begin treatment or wishes to monitor the response within the
liver to therapy.
Who should receive antiviral therapy for hepatitis C virus?
Patients at risk for cirrhosis should be considered for
treatment of HCV. According to a consensus statement from the National
Institutes of Health (NIH)
these include persons with:
- HCV infection and persistent elevation of ALT (alanine aminotransferase, a liver enzyme in the blood)
- High levels of HCV RNA in the blood
- HCV infection and evidence of fibrosis (scarring) on liver biopsy
- HCV infection and evidence of at least moderate
inflammation and liver cell injury (necrosis) on liver biopsy
These are general guidelines. Patients and providers may decide that
treatment is needed for other reasons. For example, patients with HIV have a
more rapid course of liver injury and may need treatment at an earlier stage.
Newer therapies may be offered to selected patients in research settings.
Individuals who should not be treated with antiviral therapy include those
who are unable to comply with the treatment schedule, should not take the
specific medications (for example,
allergy), and have reversible
serious untreated conditions such as unstable heart disease, uncontrolled
high
blood pressure, or untreated major depression.
Patients with unstable (decompensated) cirrhosis are
at high risk for complications for treatment and usually do not receive medical
treatment, except in research settings. Fundamentally, the decision regarding
antiviral therapy in chronic HCV infection should be tailored to the individual
patient with careful consideration of the risks and benefits.
All patients with HCV should be vaccinated against hepatitis B and hepatitis
A. They also should be counseled on measures to prevent the spread of HCV and
eliminating alcohol use. Finally, risk behaviors for HCV overlap with those of
HIV, and all patients with HCV should be tested for HIV.
What are the different patterns of response to antiviral treatment?
Treatment responses are mainly defined by results of the HCV RNA testing.
Four patterns of response to antiviral treatment have been described:
- sustained
virologic response,
- relapse,
- partial response, and
- non-response.
Sustained virologic response
The optimal response is a sustained virologic response (SVR), defined as the
absence of detectable HCV RNA in serum using a sensitive test at the end of the
treatment and six months later. Most of these individuals will remain in
remission (no signs of the disease) indefinitely, with no detectable hepatitis C
virus RNA in the blood or liver. Moreover, follow-up biopsies show a marked
reduction in inflammation and there even can be regression of scarring. Longer
follow-up of these patients is necessary, however, to evaluate definitively
whether sustained responders will avoid the complications of cirrhosis and live
longer.
Relapse
Relapsers are patients who initially eliminate the RNA from their blood but
then develop detectable RNA again shortly after discontinuing therapy. The RNA
becomes detectable again within six months and usually within the first three
months of stopping treatment.
Partial responders
Patients whose HCV RNA levels decline but never become undetectable are
referred to as partial responders.
No response
Patients who have sustained levels of detectable HCV RNA during
therapy are known as non-responders. Patients in whom HCV RNA becomes
undetectable during the early period of treatment but reappears before the end
of therapy, should probably likewise be considered non-responders. This
reappearance of HCV RNA during therapy is referred to as a 'break through' of
HCV.
Next: What are the goals of therapy for hepatitis C virus? »
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