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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



Hepatitis C Virus - The Case for Selective Treatment


Robert G. Gish MD

Hepatitis C: Natural History and Independent Predictors of Adverse Outcomes

I will present the case for selective treatment of chronic Hepatitis C (Hepatitis C Virus) infection.

It's important when looking at Hepatitis C Virus to realize there are nearly 5 million patients infected with Hepatitis C Virus in the United States but only 20% of those patients will develop cirrhosis. Patients at increased risk of developing cirrhosis include patients who are coinfected with Hepatitis B (HBV) and HIV, patients with alcohol use, organ transplant recipients who are immunosuppressed, and patients with fatty liver. All patients with a positive Hepatitis C Virus antibody test need molecular testing for Hepatitis C Virus RNA and, if positive, they need to move further through an evaluation process. There is a 3% transmission risk of Hepatitis C Virus from vertical, needlestick, and sexual transmission that you also need to communicate to your patients.


Slide 1. Stages Leading to Cirrhosis



I believe the gold standard for evaluating and selecting patients which chronic Hepatitis C Virus infection is the liver biopsy. You take the liver biopsy in the context of when they acquired their Hepatitis C Virus by taking a thorough medical history, and risk behavior history, specifically, and then you stage their liver disease by fibrosis score. Patients with Stage 0 and 1 fibrosis very rarely progress to cirrhosis. Patients with stages 2, 3, and 4 with advancing fibrosis are the patients that you want to target and treat in your practice.


Slide 2. Chronic Hepatitis C: Progression to Cirrhosis According to Baseline Fibrosis

This slide showing severe, moderate, and mild fibrosis from an article by Yano and coworkers in Hepatology demonstrating that the level of fibrosis on liver biopsy predicts the timeline to cirrhosis and the percentage chance of developing cirrhosis.


I would like to emphasize that there are independent predictors of adverse outcomes, specifically cirrhosis, in patients with chronic Hepatitis C Virus infection specifically, the age of acquiring Hepatitis C Virus, alcohol use, obesity, gender, coinfection with HBV or HIV, and immunosuppression, specifically in organ transplant recipients