Is Cirrhosis an Inevitable Consequence of Chronic Hepatitis C Virus Infection?

Knowledge of the natural history of any disease is of great importance to the person with the illness, who obviously wishes information on what the future holds, as well as to the person’s physician, who must assess the need for and the intensity of management and treatment. Also important is knowledge of patient and disease characteristics that might modify the course of illness, features that help to predict, in a given patient, what the risk is for having a good or bad outcome. This is particularly relevant for infection with HCV. Hepatitis C begins generally as a silent acute infection, advances equally silently to a chronic phase characterized by persistence of the viral infection and usually raised serum aminotransferase levels, and after a variable period, ranging from about 10–30 years, progresses in a proportion of instances to cirrhosis. A fraction of the patients with HCV-related cirrhosis will develop end-stage liver disease or hepatocellular carcinoma (HCC).¹ Although this is a generally accepted scenario in persons infected with HCV, there remains uncertainty about the true frequency of evolution of the liver disease as well as its rate of progression.² This should not be surprising because of the obvious difficulty in studying a disease whose onset is rarely identified, which progresses with such high frequency to chronicity, and which commonly, but not invariably, advances extremely slowly and usually without symptoms to a potentially fatal end point. Indeed, the condition is most often identified unexpectedly in its mid-course when laboratory tests are performed for routine evaluation or when persons are screened for high-risk behaviors and then tested for the virus, or late in the course of the disease when end-stage liver disease declares itself.