Hepatitis C Virus - The Case
for Selective Treatment
Robert G. Gish MD
Hepatitis C: Natural History and Independent Predictors of
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
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