Clinical Gastroenterology and Hepatology
Volume 8, Issue 11 , Pages 924-933, November 2010

Prevalence and Challenges of Liver Diseases in Patients With Chronic Hepatitis C Virus Infection

  • Ira M. Jacobson

      Affiliations

    • Division of Gastroenterology and Hepatology and Center for the Study of Hepatitis C, Joan and Sanford I. Weill Medical College of Cornell University, New York, New York
    • Corresponding Author InformationReprint requests Address requests for reprints to: Ira M. Jacobson, MD, Division of Gastroenterology and Hepatology, Medical Director, Center for the Study of Hepatitis C, Joan and Sanford I. Weill Medical College of Cornell University, 1305 York Avenue, New York, New York 10021. fax: (646) 962-0436
    • ,
  • Gary L. Davis

      Affiliations

    • Division of Hepatology, Baylor Regional Transplant Institute, Baylor University Medical Center, Dallas, Texas
    • ,
  • Hashem El–Serag

      Affiliations

    • Health Services Research, Houston Veterans Affairs, Baylor College of Medicine, Houston, Texas
    • ,
  • Francesco Negro

      Affiliations

    • Divisions of Gastroenterology and Hepatology and Division of Clinical Pathology, University Hospital of Geneva, Geneva, Switzerland
    • ,
  • Christian Trépo

      Affiliations

    • Service de Gastro-entérologie, Service d'Hépatogastroentérologie–Hotel Dieu, Lyon, France

published online 16 August 2010.

Article Outline

Hepatitis C virus (HCV) infections pose a growing challenge to health care systems. Although chronic HCV infection begins as an asymptomatic condition with few short-term effects, it can progress to cirrhosis, hepatic decompensation, hepatocellular carcinoma (HCC), and death. The rate of new HCV infections is decreasing, yet the number of infected people with complications of the disease is increasing. In the United States, people born between 1945 and 1964 (baby boomers) are developing more complications of infection. Men and African Americans have a higher prevalence of HCV infection. Progression of fibrosis can be accelerated by factors such as older age, duration of HCV infection, sex, and alcohol intake. Furthermore, insulin resistance can cause hepatic steatosis and is associated with fibrosis progression and inflammation. If more effective therapies are not adopted for HCV, more than 1 million patients could develop HCV-related cirrhosis, hepatic decompensation, or HCC by 2020, which will impact the US health care system. It is important to recognize the impact of HCV on liver disease progression and apply new therapeutic strategies.

Keywords: Hepatitis C Virus, Burden of Disease, Hepatic Comorbidities, Prevalence

Abbreviations used in this paper: AASLD, American Association for the Study of Liver Diseases, CHC, chronic hepatitis C, ECC, extrahepatic cholangiocarcinoma, HCC, hepatocellular carcinoma, HIV, human immunodeficiency virus, ICC, intrahepatic cholangiocarcinoma, IDU, injection drug use, IOM, Institute of Medicine, MeSH, Medical Subject Headings, NHANES, National Health and Nutrition Examination Survey, SVR, sustained virologic response

 

Approximately 180 million people worldwide are infected with hepatitis C virus (HCV)1 and are at risk of developing serious hepatic complications such as cirrhosis, hepatocellular carcinoma (HCC), or decompensation. In the United States, HCV-related end-stage liver disease is the most common indication for transplantation,2 and HCV markers are frequently found in cases of HCC.3, 4 Although some data suggest that hepatitis C does not increase overall mortality,5 it has been postulated that HCV infection could result in an 8- to 12-year reduction in life expectancy.6 It is estimated that HCV caused more than 86,000 deaths in the European region in 2002.7 The prevalence of hepatitis C–related cirrhosis and its complications is expected to continue to increase through the next decade.8 In addition, demographic changes are expected to result in an increasing incidence of severe HCV-related liver disease as the population ages.

Less than half (42%–46%) of patients infected with HCV genotype 1,9, 10 the major genotype in the USA,11 achieve a sustained virologic response (SVR) with currently available treatment (peginterferon/ribavirin for 48 weeks). There is also evidence to suggest that HCV infection is both underdiagnosed and undertreated.12, 13, 14 The lack of access to effective, well-tolerated therapies has serious implications for the current and future burden of HCV. A recent report commissioned by the Institute of Medicine (IOM) of the National Academies highlighted shortcomings in care for viral hepatitis, including the estimate that up to 75% of HCV-infected persons have not even been diagnosed. The report includes sweeping recommendations for prevention, identification, control, and surveillance of HCV in the general population and identifies major gaps in services for specific populations that are disproportionately affected.15

In light of the public health threat posed by HCV, efforts are needed to heighten awareness of its impact on patients. Numerous extrahepatic morbidities are associated with HCV infection; these and their consequences are reviewed elsewhere.16 Here we summarize the latest evidence for the burden of chronic hepatitis C (CHC) in the United States, focusing on hepatic complications.

Back to Article Outline

Evidence Acquisition 

This review reflects the detailed discussion and opinions of the authors (not the meeting sponsor, Vertex Pharmaceuticals Incorporated) on key articles from the published literature at an advisory board meeting on the burden of liver disease in HCV infection held in Boston, MA, in July 2007. Before the meeting, MEDLINE searches via the PubMed interface were designed and conducted by Paula Michelle del Rosario, a professional medical writer at Gardiner-Caldwell Communications. The searches encompassed the epidemiology and/or burden as a result of HCV-related liver disease by using the Medical Subject Headings (MeSH) [hepatitis C] and either [epidemiology], or [incidence], or [prevalence], or [fibrosis AND epidemiology], or [fibrosis AND mortality], or [liver cirrhosis AND epidemiology], or [liver cirrhosis AND mortality], or [carcinoma, hepatocellular AND epidemiology], or [carcinoma, hepatocellular AND mortality], or [cholangiocarcinoma OR intrahepatic cholangiocarcinoma AND epidemiology], or [fatty liver AND epidemiology], or [fatty liver AND mortality]. Articles not published in the English language and editorials, correspondence, letters, comments, and news articles were excluded. The authors received the search terms and results of the searches in advance of the meeting, and they selected relevant articles for discussion. The authors were responsible for several additions to content and topics covered. Throughout the development of the manuscript, the authors were personally responsible for a marked expansion in the scope of the article, including new references and concepts published since the original advisory board, making this essentially a new article. In addition, the manuscript was thoroughly updated with a repeated PubMed search by Gardiner-Caldwell Communications in September 2009 to capture articles published since the original search was conducted, and relevant publications were selected for inclusion by the authors.

Back to Article Outline

Prevalence, Identification of At-Risk Individuals, and Effects on Life Expectancy 

Various estimates of HCV prevalence in the US population place the number of infected individuals (as defined by anti-HCV antibody positivity) at between 4.1 and 5 million. Of these, 3.2–3.4 million are chronically infected.17, 18 During the first 10–20 years of infection HCV-infected individuals generally experience asymptomatic or mild illness,19 which explains why an estimated 75% of infections remain undiagnosed in the United States.15, 20 Despite a decline in the number of new US cases of HCV infection from a peak of an estimated 262,000/year in 1986 to 17,000/year in 2007,21 the prevalence of individuals infected with HCV for more than 20 years is expected to continue to increase until 2015.22 In the National Health and Nutrition Examination Survey (NHANES; 1999–2002), patients aged 40–49 years accounted for 66% of American HCV-infected patients, and the prevalence of HCV infection in the United States was 2.7 times higher among 40- to 49-year-olds than the general population (Figure 1).17 This “baby boomer” generation is particularly susceptible to blood-borne HCV transmission as a result of an increased lifetime risk of injection drug use (IDU), blood transfusion before 1992, or sexual activity with ≥20 partners, compared with older or younger patients.23, 24 The prevalence of HCV infection varies by age, sex, and race/ethnicity, and early identification of at-risk individuals through routine questioning by clinicians is critical, because management options are limited in late-stage disease.24

Adapted with permission from Armstrong et al 2006.17

After 30 years of infection, an estimated 15%–35% of patients will develop cirrhosis (5-year survival, 75%–80%)6; after 40 years, up to 60% could have cirrhosis. Given the high prevalence of HCV infection among 40- to 49-year-olds17 and that Americans are now expected to live into their mid-70s or beyond, the incidence of complications of HCV infections can be expected to further increase in coming years. In fact, from 1995–2004, US HCV-related mortality already increased 123% from 1.09/100,000 to 2.44/100,000 persons, although this study has some limitations.25 Furthermore, the proportion of CHC patients in the United States with cirrhosis is projected to rise from 25% in 2010 to 45% in 2030.8 Projections also estimate that without effective treatment, the annual number of US patients with cirrhosis, hepatic decompensation, or HCC will roughly double by 2020, and liver-related deaths will almost triple (Table 1).26 Although not all data agree with these estimates,5 several studies have suggested that HCV infection could have a deleterious effect on population mortality rates and life expectancy.27, 28 HCV increased the risk of death in several analyses, irrespective of comorbidities such as coinfection with human immunodeficiency virus (HIV)29 or hepatitis B virus (HBV)30, 31 and even after adjustment for alcohol consumption.32 Furthermore, numerous studies33, 34, 35, 36, 37 and a Cochrane review38 indicated that achievement of an SVR through effective antiviral therapy can significantly reduce mortality in patients with chronic HCV. If all HCV-infected patients were treated with currently available treatment in 2010, liver-related HCV-associated deaths could be reduced by 36% by 2020,8 whereas antiviral treatment rates are currently declining. Improvements in diagnosis and treatment are therefore necessary to reduce the associated public health burden.15, 39

Table 1. Projected Prevalence of HCV Infection and Hepatic Complications in the United States
Reproduced with permission from Davis et al 2003.26
20002010202020302040
HCV infection2,940,6782,870,3912,681,5562,433,7092,177,089
Cirrhosis472,103720,807858,788879,747828,134
Decompensated cirrhosis65,294103,117134,743146,408142,732
HCC727111,18513,18313,39012,528
Liver-related death13,00027,73236,48339,87539,064

Back to Article Outline

Hepatic Consequences 

Individuals with CHC are at increased risk of liver-related morbidity and mortality. HCV infection was associated with 27% of all US liver transplants performed in 2007,2 and US-based studies demonstrated that up to 51%–55% of HCC patients have anti-HCV antibodies.3, 4 There is also a link between steatosis and liver fibrosis in HCV-infected patients,40 as well as a potential association between HCV infection and HCC or, as described more recently, of intrahepatic cholangiocarcinoma (ICC).41, 42, 43, 44, 45 In some ethnic groups such as Latinos the course of HCV infection is more aggressive, with a higher risk of cirrhosis than other ethnic groups.46 Furthermore, disease progression is more rapid in patients who are coinfected with HCV and HIV. Coinfected patients have approximately double the risk of cirrhosis or decompensation than those infected with HCV alone.47

Fibrosis and Cirrhosis 

Progressive hepatic fibrosis leading to cirrhosis is the major complication of chronic HCV infection and accounts for almost all HCV-related morbidity and mortality.26 Early studies suggested little, if any, fibrosis progression during the first decade of infection, followed by a slow, regular progression during the next 15 years, increasing to an intermediate rate during the subsequent decade.48, 49 In a German cohort study of 1833 women infected with HCV-contaminated immunoglobulin, 0.5% of patients developed cirrhosis after 25 years.50 Similarly, in a study of 376 HCV-infected women conducted by the Irish Hepatology Research Group, 51% of patients had fibrosis after 17 years, but only 2% had probable/definite cirrhosis.51 These estimates of cirrhosis rates are considerably lower than those from the US multicohort study8 and the widely cited US military study (approximately 35%).5 Fibrosis outcomes of 184 women from the same cohort were followed up for the subsequent 5 years; 49% showed no change in fibrosis, 24% showed regression, and 27% showed progression.52

Recent data reinforce the potential for severe liver disease to develop in some patients. Among 485 plasma donors infected during the early 1970s, 34% had stage F3/F4 fibrosis (bridging fibrosis), cirrhosis, or HCC after 31 years; their 35-year cumulative survival was 84% versus 91%–95% for the general population.53 Similarly, a study of 300 black and white Americans with untreated HCV infection found that 29% of patients had stage F3/F4 fibrosis after 20 years, and 4.7% had confirmed cirrhosis.54 It should be noted, however, that these studies could have selected patients with severe disease.

The nonlinear progression of fibrosis was recently confirmed in a meta-analysis of 111 HCV studies.55 The mean annual stage-specific transition probabilities were 0.117 for stage F0 to F1, 0.085 for F1 to F2, 0.120 for F2 to F3, and 0.116 for F3 to F4. Although the estimated prevalence of cirrhosis was 16% after 20 years, there was wide variation between studies, suggesting that fibrosis is a highly unpredictable process.

Infection duration is a major risk factor for severe fibrosis,55 with the progression rate in a 50-year-old being almost 3 times that in a 20-year-old.56 Age at time of infection is also important. In a biopsy analysis of 247 treatment-naïve HCV patients, progression rates were 0.13, 0.14, 0.27, and 0.36 fibrosis units/year for patients aged ≤19, 20–24, 25–36, and >36 years at infection, respectively.57 Age >36 years (vs ≤36 years) at time of infection was independently associated with faster progression. Men infected before age 50 have been identified as comprising the majority of cases of cirrhosis today (73.6%), whereas men aged >50 years when infected have faster disease progression compared with other age groups.8

Several other factors, including sex, baseline fibrosis, HCV genotype, HIV/HBV coinfection, and alcohol consumption, also influence fibrosis progression (Table 2).54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69 Identifying these factors can be useful when determining prognosis and advising patients on minimizing liver damage. Indeed, a recent study suggested that HCV genotype 3 might pose a particularly high risk of progressive fibrosis.69 Insulin resistance has been linked with fibrosis,70, 71 and several studies have reported that this relationship remains significant, irrespective of HCV genotype.62, 72, 73 In addition, serum aminotransferase level elevations and the degree of hepatocellular necrosis/inflammation on biopsy have been found to predict fibrosis progression.74 Genetic factors might also play a role in fibrosis progression.75, 76 Recent data indicate that the cirrhosis risk score, which is based on the association of 7 host genes, might help to differentiate HCV patients at high versus low risk of progressing toward cirrhosis, including those with early or mild CHC.76, 77, 78 Steatosis has also been linked to fibrosis progression,40, 67, 79 as has regular cannabis use.68, 80 There is evidence of an association between cigarette smoking and hepatitis fibrosis,81 but not all studies have verified such an association.82

Table 2. Factors Contributing to Fibrotic Progression in CHC53, 54, 55, 56, 68
Established factorsMore recently identified risk factors

Duration of HCV infection

Older age at infection

Male sex

Presence of baseline fibrosis

HIV or HBV coinfection

Long-term high alcohol consumption (>20–50 g/d)


Patient age at biopsy

Infection with genotype 3 HCV

Presence of insulin resistance

Presence of gene polymorphisms involved in inflammation and iron metabolism

Presence of human leukocyte antigen DRB1*1201–3 allele

Latin ethnicity

Steatosis

Daily cannabis use

Hepatocellular Carcinoma 

The greatest increase in US cancer deaths from 1995–2004 was in those caused by cancers of the liver and bile duct, of which HCC comprised about 76%.83 This might be attributed to the increasing incidence of HCV-related HCC because rates for HBV-related and alcohol-related HCC have remained stable during recent years.84, 85 The incidence of HCV-related HCC in the United States is projected to peak in 2019 at 14,000 cases/year.8 In a large US database, the proportion of HCV-related cases of HCC among HCC patients aged ≥65 years doubled from 11% in 1993–1996 to 21% in 1996–1999.84 During the past decade, the fastest increase in HCC incidence has affected Hispanics and whites.86 In multivariate analysis HCV infection was an independent predictor for the development of HCC.87 Furthermore, maintenance therapy with peginterferon did not reduce the 5-year incidence of HCC in the HALT-C cohort.88

Comparisons of US and Japanese HCV strains suggest that the US HCV epidemic began about 2 to 3 decades after that in Japan.89, 90 This has led to speculation that the burden of HCC in the United States might eventually equal that currently seen in Japan as HCV-infected individuals age and their infection duration increases. In Japan, HCV-related HCC accounts for 80% of all HCC cases,91 and the rate of HCC among HCV-infected men has risen from 17.4/100,000 in 1972–1976 (32,335 deaths) to 27.4/100,000 in 1992–1996 (109,365 deaths).92

A recent Italian study of 214 HCV-infected patients with Child–Pugh class A cirrhosis showed that HCC developed at a rate of almost 4%/year.93 HCC was the first complication to occur in 55 (27%) patients; after 17 years, HCC had developed in 68 (32%) patients.93 In another cohort of 416 patients with uncomplicated Child–Pugh class A HCV-related cirrhosis, the incidence of HCC was 13.4% at 5 years, and the 5-year HCC death rate was 15.3%, with the hazard rate of HCC tending to increase over time.94

Several factors influence the risk of HCC in patients with HCV-related cirrhosis. Generally, HCC risk is increased in patients aged >50 years or those infected when aged >50 years, patients with longer duration of infection, men, overweight or diabetic patients, and patients with advanced cirrhosis or elevated alpha-fetoprotein.8, 95, 96 Other possible risk factors include the presence of steatosis,41 HCV genotype 1b,97 Asian/African American race,98 and occult HBV infection.99 As for hepatic fibrosis, an association between cigarette smoking and HCV-related HCC has been suggested in some studies100 but not others.101

Chronic HCV-related inflammation might increase HCC risk by shifting hepatocytic transforming growth factor–beta signaling from tumor suppression to fibrogenesis.102 HCC generally develops after cirrhosis is established, signifying the likely importance of long-standing necrosis and regeneration, an environment of extensive scarring, in its pathogenesis. HCV might influence hepatocarcinogenesis through the oncogenic effects of its core protein, which might augment oxidative stress.103 It might also alter the signaling cascade of mitogen-activated protein kinase and activating factor 1, thereby activating cell-cycle control. Liver angiogenesis and the neovascular response,104, 105 plus genomic changes that deregulate components of the Jak/STAT pathway in early carcinogenesis,106 might also promote HCV-related hepatocarcinogenesis. Additional mechanisms have also been proposed.107

Cholangiocarcinoma 

Various small studies have demonstrated a link between HCV and ICC.42, 43, 44, 45 A recent large cohort study of >140,000 HCV-infected military veterans108 showed a >2-fold increase in ICC risk in HCV-infected patients versus noninfected controls. However, many of these hospital-based, case-control studies are limited by the potential for selection or ascertainment bias,108 and some studies have failed to observe any association between HCV and ICC.109, 110 The association of HCV infection with susceptibility to ICC, and the pathogenetic basis for such an association, warrant further investigation. Chronic HCV infection was not a risk for extrahepatic cholangiocarcinoma (ECC).111

Decompensation 

Patients with HCV-associated cirrhosis are at high risk of developing hepatic decompensation, manifesting as hepatic synthetic dysfunction or complications of portal hypertension. Clinical signs of decompensation include ascites, encephalopathy, and upper gastrointestinal hemorrhage caused by variceal bleeding.93, 112

In an analysis of data from 1000 HCV patients with mild to advanced fibrosis, the incidence of decompensated cirrhosis after 5–7 years of follow-up was 43.5/10,000 person-years or about 1 in 230 patients/year.65 Similarly, a retrospective study reported the 5-year risk of decompensation to be 18% in 384 HCV patients with compensated cirrhosis (incidence, 3.9%/year),112 and a recent estimate suggests decompensation is currently present in 11.7% of CHC patients with cirrhosis.8 Decompensation has become more common since 1995, and because the proportion of CHC patients with cirrhosis is expected to increase through 2030, the incidence of decompensation can be expected to increase accordingly.8 It should be noted, however, that this model estimates that the majority of cirrhotic patients with chronic HCV infection will not develop decompensation during the first 3 decades of infection. Annual incidence rates for ascites (2.9%), jaundice (2.0%), upper gastrointestinal bleeding (0.7%), and encephalopathy (0.1%) were established in a later prospective study of 214 HCV-RNA seropositive patients after 114 months of follow-up.93

Age at HCV acquisition is relevant, with decompensation risk as high as 133/10,000 person-years in patients infected after 39 years of age.65 In addition, the presence of the human leukocyte antigen DRB1*1201–3 allele might be associated with a higher rate of progression toward decompensated cirrhosis and HCC.65 The identification of reliable proteomic/genomic markers for risk of advanced HCV-related liver disease would aid prognostication and therapeutic decision-making.

Steatosis 

Steatosis occurs to some degree in about half of all patients with chronic HCV infection.40, 113 In a meta-analysis of data from >3000 patients, steatosis was independently associated with the presence of fibrosis, diabetes, hepatic inflammation, ongoing alcohol abuse, overweight (body mass index >25), age ≥45 years, and genotype 3 infection.40 Among 101 HCV-infected patients with no factors predisposing to fatty liver, steatosis was found in 41% of patients, irrespective of sex, age, or infection route.114

Two main mechanisms underlie the pathogenesis of steatosis in HCV-infected patients who abstain from alcohol, a direct viral effect and a metabolic mechanism. Viral steatosis is associated with genotype 3 HCV infection,40, 114, 115, 116, 117 where the severity of steatosis correlates with serum71, 115 and intrahepatic113 viral load. This type of steatosis often resolves after viral eradication.116, 117, 118 It is believed that HCV genotype 3 has a direct effect on hepatocyte lipid metabolism, resulting in fat accumulation. Interactions involving the HCV genotype 3 core protein, such as enhanced fatty acid synthase promoter activation119 and increased lipid affinity,120 are being investigated in vitro.

Metabolic steatosis is seen primarily in patients infected with genotype non-3 HCV40, 72 and is largely due to insulin resistance,62, 72, 121 characterized by hyperinsulinemia and free fatty acid overflow to organs and non-adipose tissues.122 These alterations give rise to triglyceride accumulation in hepatocytes, resulting in steatosis.40, 70, 71, 123

Steatosis might reduce the likelihood of achieving SVR with HCV treatment, even when other steatosis-inducing factors are accounted for. In one study, SVR rates were 18%–32% lower in people with steatosis versus those without steatosis after adjusting for other potentially confounding cofactors such as genotype, fibrosis score, and viral load.117

Back to Article Outline

Reducing the Impact of Infection 

About 85% of HCV-positive persons in the United States general population can be identified on the basis of 3 characteristics: IDU history, blood transfusion before 1992, or abnormal serum alanine transaminase levels.17 In selected populations, other characteristics might also be useful for screening. A retrospective study of 5400 US veterans found that the following factors predicted HCV infection: IDU, blood transfusion before 1992, service during the Vietnam war, tattoo, and a history of abnormal liver test results.123 However, HCV risk factor histories are rarely documented in clinical practice.124 Infected patients can thus remain undiagnosed until they present with hepatic complications. Recent guidelines issued by the American Association for the Study of Liver Diseases (AASLD) make recommendations for diagnosis and counseling of HCV-infected patients on alcohol, weight loss, and treatment to prevent the development of cirrhosis and other complications.125

Diagnosis and Screening 

Figure 2 summarizes the clinical management of patients at risk of HCV infection. Asking patients about their transfusion history and high-risk drug/sexual behavior during health care visits should be routine, and high-risk patients (history of IDU, blood transfusion before 1992, or HIV-positive) should be tested, with cognizance of the higher prevalence rates in men, “baby boomers,” and African Americans. The AASLD guidelines promote screening in at-risk populations to reduce HCV transmission rates.125 The recent IOM report on viral hepatitis includes a recommendation that federally funded US health care insurers improve access to HCV screening as part of preventative care for the general population, so people at risk of HCV infection can be identified.15

Once diagnosed, patients should be evaluated for HCV RNA, genotype, and serologic exclusion of common liver diseases. Baseline imaging (ultrasound) might also be useful. Assessing fibrosis by liver biopsy can be used to estimate prognosis, treatment urgency, and necessity of HCC screening. Surrogate methods, including serum fibrosis markers, imaging techniques, and indirect methods to measure liver stiffness such as transient elastography,125 might have a future role.

Because insulin resistance enhances fibrosis progression, monitoring insulin resistance, fasting glucose, or insulin levels is advisable. In addition, lifestyle modifications, including weight loss and dietary changes, might reduce insulin resistance and slow the fibrosis rate. All patients should be assessed for immunity against hepatitis A/B by assessment of disease markers and vaccinated if seronegative.125 Counseling should be offered regarding alcohol consumption, if appropriate.

Treatment 

Currently, the only drugs available to treat HCV are peginterferon and ribavirin. SVR rates associated with peginterferon/ribavirin are suboptimal, particularly for genotype 1–infected patients.9, 10 The AASLD guidelines recommend an individualized treatment approach based on assessment of comorbidities, likelihood of response, and side-effect potential.125 Although more effective options are needed, successful treatment can eradicate the virus and thereby minimize complications and possibly improve mortality rates.126, 127 Nearly all patients (99.2%) maintain undetectable HCV loads 5 years after attaining SVR, representing a “virologic cure.”126 Some patients with fibrosis who achieve SVR demonstrate an improvement in necroinflammatory activity and fibrosis regression.128, 129, 130 Furthermore, the 5-year survival of SVR patients is similar to that of the overall population.130 The role of interferon in preventing HCC is controversial. A reduced risk of HCC has been noted in patients achieving SVR; however, reports of HCC after SVR was achieved in cirrhotic patients indicate a need for surveillance and reinforce the importance of viral eradication before cirrhosis develops.131, 132 Long-term maintenance therapy with peginterferon does not appear to affect the incidence of HCC.133

Davis et al8 extended their multicohort model to include an assessment of treatment effects, predicting that an increase in the proportion of treated patients (or use of treatment with improved viral clearance rate) would result in reduced rates of cirrhosis, liver failure, HCC, and liver-related death.

Education and Counseling 

A lack of knowledge about HCV among health care providers, social service providers, and the public is identified by the IOM as a major challenge to controlling the disease. Education and outreach programs for these audiences feature among the recent IOM recommendations for comprehensive viral hepatitis services aimed at preventing viral transmission, missed diagnosis, and poor health outcomes in HCV.15

Increasing access to treatment and providing support to optimize therapeutic adherence might help to improve outcomes. This requires a greater emphasis on early detection along with careful, individualized diagnostic assessment and therapeutic decision-making. Many physicians have adopted a “watch-and-wait” approach, particularly for patients with minimal liver disease. Although this might sometimes be appropriate, patients should be advised of the possibility of unexpectedly rapid disease progression and the need for regular follow-up, including repeat biopsies every 3–5 years. The pros and cons of deferring therapy should be discussed in the context of the patient's clinical and histologic profile.

Many eligible patients decline antiviral treatment. In a study of 280 US patients, 41% declined treatment, citing no symptoms and concerns about side effects.134 Information provided by health care providers is critical; in 3 US cities, interest in HCV treatment among injection drug users was 7-fold higher among patients who were told that they were at risk for cirrhosis or cancer.135 Patients under regular review are also more likely to be interested in receiving treatment,135 emphasizing the importance of communication and continuity of care. Several promising agents, including HCV protease and polymerase inhibitors (eg, telaprevir, boceprevir, and R7128), are in phase 2 or phase 3 trials, with a hope of availability within 2–3 years and beyond.

Back to Article Outline

Changing Our Views 

The impact of HCV infection on the burden of liver disease is becoming evident as individuals unknowingly infected decades ago age and develop severe sequelae of advanced liver fibrosis. Up to 1 million Americans are predicted to develop HCV-related hepatic complications during the next 2 decades.26 Persons born between the 1940s and 1960s account for most infections, with the highest risk among those with a history of IDU or blood transfusions before 1992. Once chronic infection is established, disease progression is variable and dependent on several factors. Cirrhosis, liver failure, and HCC might occur at a faster rate and in more patients than previously believed.

HCV infection is a health care priority. Increasing access to treatment might significantly reduce the morbidity and mortality burden of HCV infection.136 Other measures to tackle the challenge of HCV include improving surveillance, screening and identifying patients at risk of progression, and optimizing therapy. We now need to capitalize on what we know about HCV and formulate strategies to address the anticipated surge in HCV-related morbidity and mortality. New HCV treatments are in development that might increase SVR and potentially decrease the burden of hepatic complications in populations with significant unmet need.

Back to Article Outline

Acknowledgments 

This review is based partially on studies identified and discussed by the authors during an advisory board meeting sponsored by Vertex Pharmaceuticals Incorporated in 2007. The authors would like to thank Dr Miriam Alter for her valuable discussion during the meeting and Paula Michelle del Rosario, MD, and Magdy Fahmy, PhD, of Gardiner-Caldwell Communications, Macclesfield, UK (supported by Vertex Pharmaceuticals Incorporated) for designing and conducting the PubMed literature search and for their professional medical writing assistance in developing the first draft of the manuscript, based on our recommendations of relevant published papers and our debate and discussion during the meeting.

All authors provided close direction to the medical writers, including significant content additions and redrafts, and commented on each version of the manuscript. Author revisions and comments were collated by Gardiner-Caldwell Communications. All authors substantially contributed to development of the manuscript and have read and approved the final draft. The corresponding author had full access to the source literature and takes full responsibility for the content of the paper.

Back to Article Outline

References 

  1. World Health Organization Initiative for Vaccine Research. Hepatitis C. http://www.who.int/vaccine_research/diseases/viral_cancers/en/index2.htmlAccessed November 13, 2008
  2. OPTN. U.S. liver transplants performed: January 1, 1988-April 30, 2008. http://optn.transplant.hrsa.gov/Accessed November 12, 2009
  3. Snowberger N, Chinnakotla S, Lepe RM, et al. Alpha fetoprotein, ultrasound, computerized tomography and magnetic resonance imaging for detection of hepatocellular carcinoma in patients with advanced cirrhosis. Aliment Pharmacol Ther. 2007;26:1187–1194
  4. Di Bisceglie AM, Lyra AC, Schwartz M, et al. Hepatitis C-related hepatocellular carcinoma in the United States: influence of ethnic status. Am J Gastroenterol. 2003;98:2060–2063
  5. Seeff LB, Hollinger FB, Alter HJ, et al. Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: a National Heart, Lung, and Blood Institute collaborative study. Hepatology. 2001;33:455–463
  6. Ryder SD. Outcome of hepatitis C infection: bleak or benign?. J Hepatol. 2007;47:4–6
  7. Muhlberger N, Schwartzer R, Lettmeier B, et al. HCV-related burden of disease in Europe: a systematic assessment of incidence, prevalence, morbidity, and mortality. BMC Public Health. 2009;22:9–34
  8. Davis GL, Alter MJ, El-Serag H, et al. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression. Gastroenterology. 2010;138:513–521
  9. Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet. 2001;358:958–965
  10. Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002;347:975–982
  11. Nainan OV, Alter MJ, Kruszon-Moran D, et al. Hepatitis C virus genotypes and viral concentrations in participants of a general population survey in the United States. Gastroenterology. 2006;131:478–484
  12. Russmann S, Dowlatshahi EA, Printzen G, et al. Prevalence and associated factors of viral hepatitis and transferrin elevations in 5036 patients admitted to the emergency room of a Swiss university hospital: cross-sectional study. BMC Gastroenterol. 2007;7:5
  13. Irving WL, Smith S, Cater R, et al. Clinical pathways for patients with newly diagnosed hepatitis C: what actually happens. J Viral Hepat. 2006;13:264–271
  14. Morrill JA, Shrestha M, Grant RW. Barriers to the treatment of hepatitis C: patient, provider, and system factors. J Gen Intern Med. 2005;20:754–758
  15. Institute of Medicine of the National Academies consensus report: hepatitis and liver cancer—a national strategy for prevention and control of Hepatitis B and C. January 11, 2010. http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspxAccessed March 2010
  16. Jacobson IM, Cacoub P, Dal Maso L, et al. Chronic hepatitis C infection II: manifestations beyond the liver. Clin Gastroenterol Hepatol. 2010;In press
  17. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705–714
  18. Edlin BR. Five million Americans infected with the hepatitis C virus: a corrected estimate. Hepatology. 2005;42:213A
  19. Dienstag JL. Non-A, non-B hepatitis: I—recognition, epidemiology, and clinical features. Gastroenterology. 1983;85:439–462
  20. Kamal SM. Acute hepatitis C: a systematic review. Am J Gastroenterol. 2008;103:1283–1297
  21. Centers for Disease Control and Prevention (CDC). Disease burden from viral hepatitis A, B, and C in the United States. http://www.cdc.gov/hepatitis/statistics.htmAccessed November 13, 2009
  22. Armstrong GL, Alter MJ, McQuillan GM, et al. The past incidence of hepatitis C virus infection: implications for the future burden of chronic liver disease in the United States. Hepatology. 2000;31:777–782
  23. Armstrong GL. Injection drug users in the United States, 1979-2002: an aging population. Arch Intern Med. 2007;167:166–173
  24. Wasley A, Miller JT, Finelli L. Surveillance for acute viral hepatitis: United States, 2005. MMWR Surveill Summ. 2007;56:1–24
  25. Wise M, Bialek S, Finelli L, et al. Changing trends in hepatitis C-related mortality in the United States, 1995–2004. Hepatology. 2008;47:1128–1135
  26. Davis GL, Albright JE, Cook SF, et al. Projecting future complications of chronic hepatitis C in the United States. Liver Transpl. 2003;9:331–338
  27. Neal KR, Ramsay S, Thomson BJ, et al. Excess mortality rates in a cohort of patients infected with the hepatitis C virus: a prospective study. Gut. 2007;56:1098–1104
  28. Uto H, Stuver SO, Hayashi K, et al. Increased rate of death related to presence of viremia among hepatitis C virus antibody-positive subjects in a community-based cohort study. Hepatology. 2009;50:393–399
  29. McDonald SA, Hutchinson SJ, Bird SM, et al. A population-based record linkage study of mortality in hepatitis C-diagnosed persons with or without HIV coinfection in Scotland. Stat Methods Med Res. 2009;18:271–283
  30. Duberg AS, Törner A, Davidsdóttir L, et al. Cause of death in individuals with chronic HBV and/or HCV infection, a nationwide community-based register study. J Viral Hepat. 2008;15:538–550
  31. Amin J, Law MG, Bartlett M, et al. Causes of death after diagnosis of hepatitis B or hepatitis C infection: a large community-based linkage study. Lancet. 2006;368:938–945
  32. Hisada M, Chatterjee N, Kalaylioglu Z, et al. Hepatitis C virus load and survival among injection drug users in the United States. Hepatology. 2005;42:1446–1452
  33. Berenguer J, Alvarez-Pellicer J, Martín PM, et al. Sustained virological response to interferon plus ribavirin reduces liver-related complications and mortality in patients coinfected with human immunodeficiency virus and hepatitis C virus. Hepatology. 2009;50:407–413
  34. Deuffic-Burban S, Deltenre P, Louvet A, et al. Impact of viral eradication on mortality related to hepatitis C: a modeling approach in France. J Hepatol. 2008;49:175–183
  35. Iacobellis A, Siciliano M, Perri F, et al. Peginterferon alfa-2b and ribavirin in patients with hepatitis C virus and decompensated cirrhosis: a controlled study. J Hepatol. 2007;46:206–212
  36. Lawson A, Hagan S, Rye K, et al. The natural history of hepatitis C with severe hepatic fibrosis. J Hepatol. 2007;47:37–45
  37. Picciotto FP, Tritto G, Lanza AG, et al. Sustained virological response to antiviral therapy reduces mortality in HCV reinfection after liver transplantation. J Hepatol. 2007;46:459–465
  38. Brok J, Gluud LL, Gluud C. Ribavirin plus interferon versus interferon for chronic hepatitis C. Cochrane Database Syst Rev. 2010;Jan 20;CD005445
  39. Volk ML, Tocco R, Saini S, et al. Public health impact of antiviral therapy for hepatitis C in the United States. Hepatology. 2009;50:1750–1755
  40. Leandro G, Mangia A, Hui J, et al. Relationship between steatosis, inflammation, and fibrosis in chronic hepatitis C: a meta-analysis of individual patient data. Gastroenterology. 2006;130:1636–1642
  41. Pekow JR, Bhan AK, Zheng H, et al. Hepatic steatosis is associated with increased frequency of hepatocellular carcinoma in patients with hepatitis C-related cirrhosis. Cancer. 2007;109:2490–2496
  42. Donato F, Gelatti U, Tagger A, et al. Intrahepatic cholangiocarcinoma and hepatitis C and B virus infection, alcohol intake, and hepatolithiasis: a case-control study in Italy. Cancer Causes Control. 2001;12:959–964
  43. Yamamoto S, Kubo S, Hai S, et al. Hepatitis C virus infection as a likely etiology of intrahepatic cholangiocarcinoma. Cancer Sci. 2004;95:592–595
  44. Kobayashi M, Ikeda K, Saitoh S, et al. Incidence of primary cholangiocellular carcinoma of the liver in Japanese patients with hepatitis C virus-related cirrhosis. Cancer. 2000;88:2471–2477
  45. Shin HR, Lee CU, Park HJ, et al. Hepatitis B and C virus, Clonorchis sinensis for the risk of liver cancer: a case-control study in Pusan, Korea. Int J Epidemiol. 1996;25:933–940
  46. Rodriguez-Torres M. Latinos and chronic hepatitis C: a singular population. Clin Gastroenterol Hepatol. 2008;6:484–490
  47. Graham CS, Baden LR, Yu E, et al. Influence of human immunodeficiency virus infection on the course of hepatitis C virus infection: a meta-analysis. Clin Infect Dis. 2001;33:562–569
  48. Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C: the OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet. 1997;349:825–832
  49. Poynard T, Ratziu V, Charlotte F, et al. Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis c. J Hepatol. 2001;34:730–739
  50. Wiese M, Grüngreiff K, Güthoff W, et al. Outcome in a hepatitis C (genotype 1b) single source outbreak in Germany: a 25-year multicenter study. J Hepatol. 2005;43:590–598
  51. Kenny-Walsh E. Clinical outcomes after hepatitis C infection from contaminated anti-D immune globulin: Irish Hepatology Research Group. N Engl J Med. 1999;340:1228–1233
  52. Levine RA, Sanderson SO, Ploutz-Snyder R, et al. Assessment of fibrosis progression in untreated Irish women with chronic hepatitis C contracted from immunoglobulin anti-D. Clin Gastroenterol Hepatol. 2006;4:1271–1277
  53. Ferenci P, Ferenci S, Datz C, et al. Morbidity and mortality in paid Austrian plasma donors infected with hepatitis C at plasma donation in the 1970s. J Hepatol. 2007;47:31–36
  54. Terrault NA, Im K, Boylan R, et al. Fibrosis progression in African Americans and Caucasian Americans with chronic hepatitis C. Clin Gastroenterol Hepatol. 2008;6:1403–1411
  55. Thein HH, Yi Q, Dore GJ, et al. Estimation of stage-specific fibrosis progression rates in chronic hepatitis C virus infection: a meta-analysis and meta-regression. Hepatology. 2008;48:418–431
  56. Ryder SD, Irving WL, Jones DA, et al. Progression of hepatic fibrosis in patients with hepatitis C: a prospective repeat liver biopsy study. Gut. 2004;53:451–455
  57. Pradat P, Voirin N, Tillmann HL, et al. Progression to cirrhosis in hepatitis C patients: an age-dependent process. Liver Int. 2007;27:335–339
  58. Bialek SR, Terrault NA. The changing epidemiology and natural history of hepatitis C virus infection. Clin Liver Dis. 2006;10:697–715
  59. Bonacini M, Groshen MD, Yu MC, et al. Chronic hepatitis C in ethnic minority patients evaluated in Los Angeles County. Am J Gastroenterol. 2001;96:2438–2441
  60. Colletta C, Smirne C, Fabris C, et al. Value of two noninvasive methods to detect progression of fibrosis among HCV carriers with normal aminotransferases. Hepatology. 2005;42:838–845
  61. Erhardt A, Maschner-Olberg A, Mellenthin C, et al. HFE mutations and chronic hepatitis C: H63D and C282Y heterozygosity are independent risk factors for liver fibrosis and cirrhosis. J Hepatol. 2003;38:335–342
  62. Hui JM, Sud A, Farrell GC, et al. Insulin resistance is associated with chronic hepatitis C virus infection and fibrosis progression [corrected]. Gastroenterology. 2003;125:1695–1704
  63. McCaughan GW, George J. Fibrosis progression in chronic hepatitis C virus infection. Gut. 2004;53:318–321
  64. Paladino N, Fainboim H, Theiler G, et al. Gender susceptibility to chronic hepatitis C virus infection associated with interleukin 10 promoter polymorphism. J Virol. 2006;80:9144–9150
  65. Pradat P, Tillmann HL, Sauleda S, et al. Long-term follow-up of the hepatitis C HENCORE cohort: response to therapy and occurrence of liver-related complications. J Viral Hepat. 2007;14:556–563
  66. Verma S, Bonacini M, Govindarajan S, et al. More advanced hepatic fibrosis in Hispanics with chronic hepatitis C infection: role of patient demographics, hepatic necroinflammation, and steatosis. Am J Gastroenterol. 2006;101:1817–1823
  67. Cross TJ, Quaglia A, Hughes S, et al. The impact of hepatic steatosis on the natural history of chronic hepatitis C infection. J Viral Hepat. 2009;16:492–499
  68. Ishida JH, Peters MG, Jin C, et al. Influence of cannabis use on severity of hepatitis C disease. Clin Gastroenterol Hepatol. 2008;6:69–75
  69. Bochud PY, Cai T, Overbeck K, et al. Genotype 3 is associated with accelerated fibrosis progression in chronic hepatitis C. J Hepatol. 2009;51:655–666
  70. Muzzi A, Leandro G, Rubbia-Brandt L, et al. Insulin resistance is associated with liver fibrosis in non-diabetic chronic hepatitis C patients. J Hepatol. 2005;42:41–46
  71. Sanyal AJ, Contos MJ, Sterling RK, et al. Nonalcoholic fatty liver disease in patients with hepatitis C is associated with features of the metabolic syndrome. Am J Gastroenterol. 2003;98:2064–2071
  72. Fartoux L, Poujol-Robert A, Guechot J, et al. Insulin resistance is a cause of steatosis and fibrosis progression in chronic hepatitis C. Gut. 2005;54:1003–1008
  73. Cua IH, Hui JM, Kench JG, et al. Genotype-specific interactions of insulin resistance, steatosis, and fibrosis in chronic hepatitis C. Hepatology. 2008;48:723–731
  74. Ghany MG, Kleiner DE, Alter H, et al. Progression of fibrosis in chronic hepatitis C. Gastroenterology. 2003;124:97–104
  75. Huang H, Shiffman ML, Cheung RC, et al. Identification of two gene variants associated with risk of advanced fibrosis in patients with chronic hepatitis C. Gastroenterology. 2006;130:1679–1687
  76. Huang H, Shiffman ML, Friedman S, et al. A 7 gene signature identifies the risk of developing cirrhosis in patients with chronic hepatitis C. Hepatology. 2007;46:297–306
  77. Marcolongo M, Young B, Dal Pero F, et al. A seven-gene signature (cirrhosis risk score) predicts liver fibrosis progression in patients with initially mild chronic hepatitis C. Hepatology. 2009;50:1038–1044
  78. Pradat P, Trepo E, Potthoff A, et al. The cirrhosis risk score predicts liver fibrosis progression in patients with initially mild chronic hepatitis C. Hepatology. 2010;5:356–357
  79. Lok AS, Everhart JE, Chung RT, et al. Evolution of hepatic steatosis in patients with advanced hepatitis C: results from the hepatitis C antiviral long-term treatment against cirrhosis (HALT-C) trial. Hepatology. 2009;49:1828–1837
  80. Mallat A, Hezode C, Lotersztajn S. Environmental factors as disease accelerators during chronic hepatitis C. J Hepatol. 2008;48:657–665
  81. Dev A, Patel K, Conrad A, et al. Relationship of smoking and fibrosis in patients with chronic hepatitis C. Clin Gastroenterol Hepatol. 2006;4:797–801
  82. De Luca L, De Angelis C, Fagoonee S, et al. Is smoking a prognostic factor in patients with chronic hepatitis C?. Minerva Gastroenterol Dietol. 2009;55:139–143
  83. Surveillance, Epidemiology and End Results SEER Program. SEER Cancer Statistics Review 1975–2004Surveillance, Epidemiology, and End Results (SEER) program. http://seer.cancer.gov/csr/1975_2004/Accessed November 13, 2009
  84. Davila JA, Morgan RO, Shaib Y, et al. Hepatitis C infection and the increasing incidence of hepatocellular carcinoma: a population-based study. Gastroenterology. 2004;127:1372–1380
  85. El-Serag HB. Hepatocellular carcinoma: recent trends in the United States. Gastroenterology. 2004;127:S27–S34
  86. El-Serag HB, Lau M, Eschbach K, et al. Epidemiology of hepatocellular carcinoma in Hispanics in the United States. Arch Intern Med. 2007;167:1983–1989
  87. Ioannou GN, Splan MF, Weiss NS, et al. Incidence and predictors of hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol. 2007;5:938–945
  88. Lok AS, Seeff LB, Morgan TR, et al. Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease. Gastroenterology. 2009;136:138–148
  89. Tanaka Y, Hanada K, Mizokami M, et al. Inaugural article: a comparison of the molecular clock of hepatitis C virus in the United States and Japan predicts that hepatocellular carcinoma incidence in the United States will increase over the next two decades. Proc Natl Acad Sci U S A. 2002;99:15584–15589
  90. Tanaka Y, Kurbanov F, Mano S, et al. Molecular tracing of the global hepatitis C virus epidemic predicts regional patterns of hepatocellular carcinoma mortality. Gastroenterology. 2006;130:703–714
  91. Yoshizawa H. Hepatocellular carcinoma associated with hepatitis C virus infection in Japan: projection to other countries in the foreseeable future. Oncology. 2002;62(Suppl 1):8–17
  92. Shibuya K, Yano E. Regression analysis of trends in mortality from hepatocellular carcinoma in Japan, 1972-2001. Int J Epidemiol. 2005;34:397–402
  93. Sangiovanni A, Prati GM, Fasani P, et al. The natural history of compensated cirrhosis due to hepatitis C virus: a 17-year cohort study of 214 patients. Hepatology. 2006;43:1303–1310
  94. Degos F, Christidis C, Ganne-Carrie N, et al. Hepatitis C virus related cirrhosis: time to occurrence of hepatocellular carcinoma and death. Gut. 2000;47:131–136
  95. Trinchet JC, Ganne-Carrie N, Nahon P, et al. Hepatocellular carcinoma in patients with hepatitis C virus-related chronic liver disease. World J Gastroenterol. 2007;13:2455–2460
  96. Veldt BJ, Chen W, Heathcote EJ, et al. Increased risk of hepatocellular carcinoma among patients with hepatitis C cirrhosis and diabetes mellitus. Hepatology. 2008;47:1856–1862
  97. Raimondi S, Bruno S, Mondelli MU, et al. Hepatitis C virus genotype 1b as a risk factor for hepatocellular carcinoma development: a meta-analysis. J Hepatol. 2009;50:1142–1154
  98. Nguyen MH, Whittemore AS, Garcia RT, et al. Role of ethnicity in risk for hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis. Clin Gastroenterol Hepatol. 2004;2:820–824
  99. Squadrito G, Pollicino T, Cacciola I, et al. Occult hepatitis B virus infection is associated with the development of hepatocellular carcinoma in chronic hepatitis C patients. Cancer. 2006;106:1326–1330
  100. Hassan MM, Spitz MR, Thomas MB, et al. Effect of different types of smoking and synergism with hepatitis C virus on risk of hepatocellular carcinoma in American men and women: case-control study. Int J Cancer. 2008;15:1883–1891
  101. Di Costanzo GG, De Luca M, Tritto G, et al. Effect of alcohol, cigarette, smoking, and diabetes on occurrence of hepatocellular carcinoma in patients with transfusion-acquired hepatitis C virus infection who develop cirrhosis. Eur J Gastroenterol Hepatol. 2008;20:674–679
  102. Matsuzaki K, Murata M, Yoshida K, et al. Chronic inflammation associated with hepatitis C virus infection perturbs hepatic transforming growth factor beta signaling, promoting cirrhosis and hepatocellular carcinoma. Hepatology. 2007;46:48–57
  103. Koike K. Hepatitis C virus contributes to hepatocarcinogenesis by modulating metabolic and intracellular signaling pathways. J Gastroenterol Hepatol. 2007;22(Suppl 1):S108–S111
  104. Huang XX, McCaughan GW, Shackel NA, et al. Up-regulation of proproliferative genes and the ligand/receptor pair placental growth factor and vascular endothelial growth factor receptor 1 in hepatitis C cirrhosis. Liver Int. 2007;27:960–968
  105. Mazzanti R, Messerini L, Comin CE, et al. Liver angiogenesis as a risk factor for hepatocellular carcinoma development in hepatitis C virus cirrhotic patients. World J Gastroenterol. 2007;13:5009–5014
  106. Wurmbach E, Chen YB, Khitrov G, et al. Genome-wide molecular profiles of HCV-induced dysplasia and hepatocellular carcinoma. Hepatology. 2007;45:938–947
  107. McGivern DR, Lemon SM. Tumor suppressors, chromosomal instability, and hepatitis C virus-associated liver cancer. Annu Rev Pathol. 2009;4:399–415
  108. El-Serag H, Engels E, Landgren O, et al. Risk of hepatobiliary and pancreatic cancers following hepatitis C virus infection: a population-based study of US veterans. Hepatology. 2009;49:116–123
  109. Zhou YM, Yin ZF, Yang JM, et al. Risk factors for intrahepatic cholangiocarcinoma: a case-control study in China. World J Gastroenterol. 2008;14:632–635
  110. Lee TY, Lee SS, Jung SW, et al. Hepatitis B virus infection and intrahepatic cholangiocarcinoma in Korea: a case-control study. Am J Gastroenterol. 2008;103:1716–1720
  111. Shaib YH, El-Serag HB, Nooka AK, et al. Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: a hospital-based case-control study. Am J Gastroenterol. 2007;102:1016–1021
  112. Fattovich G, Giustina G, Degos F, et al. Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients. Gastroenterology. 1997;112:463–472
  113. Hourigan LF, Macdonald GA, Purdie D, et al. Fibrosis in chronic hepatitis C correlates significantly with body mass index and steatosis. Hepatology. 1999;29:1215–1219
  114. Rubbia-Brandt L, Quadri R, Abid K, et al. Hepatocyte steatosis is a cytopathic effect of hepatitis C virus genotype 3. J Hepatol. 2000;33:106–115
  115. Adinolfi LE, Gambardella M, Andreana A, et al. Steatosis accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV genotype and visceral obesity. Hepatology. 2001;33:1358–1364
  116. Kumar D, Farrell GC, Fung C, et al. Hepatitis C virus genotype 3 is cytopathic to hepatocytes: reversal of hepatic steatosis after sustained therapeutic response. Hepatology. 2002;36:1266–1272
  117. Poynard T, Ratziu V, McHutchison J, et al. Effect of treatment with peginterferon or interferon alfa-2b and ribavirin on steatosis in patients infected with hepatitis C. Hepatology. 2003;38:75–85
  118. Rubbia-Brandt L, Giostra E, Mentha G, et al. Expression of liver steatosis in hepatitis C virus infection and pattern of response to α-interferon. J Hepatol. 2001;35:307
  119. Jackel-Cram C, Babiuk LA, Liu Q. Up-regulation of fatty acid synthase promoter by hepatitis C virus core protein: genotype-3a core has a stronger effect than genotype-1b core. J Hepatol. 2007;46:999–1008
  120. Hourioux C, Patient R, Morin A, et al. The genotype 3-specific hepatitis C virus core protein residue phenylalanine 164 increases steatosis in an in vitro cellular model. Gut. 2007;56:1302–1308
  121. Ratziu V, Munteanu M, Charlotte F, et al. Fibrogenic impact of high serum glucose in chronic hepatitis C. J Hepatol. 2003;39:1049–1055
  122. Browning JD, Horton JD. Molecular mediators of hepatic steatosis and liver injury. J Clin Invest. 2004;114:147–152
  123. Zuniga IA, Chen JJ, Lane DS, et al. Analysis of a hepatitis C screening programme for US veterans. Epidemiol Infect. 2006;134:249–257
  124. Trooskin SB, Navarro VJ, Winn RJ, et al. Hepatitis C risk assessment, testing and referral for treatment in urban primary care: role of race and ethnicity. World J Gastroenterol. 2007;13:1074–1078
  125. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335–1374
  126. Swain M, Lai M-Y, Shiffman ML, et al. Durable sustained virological response after treatment with peginterferon alfa-2a (Pegasys) alone or in combination with ribavirin (Copegus): 5-year follow-up and the criteria of a cure. J Hepatol. 2007;46:S3
  127. Deuffic-Burban S, Deltenre P, Louvet A, et al. Impact of viral eradication on mortality related to hepatitis C: a modelling approach in France. J Hepatol. 2008;49:175–183
  128. Bruno S, Battezzati PM, Bellati G, et al. Long-term beneficial effects in sustained responders to interferon-alfa therapy for chronic hepatitis C. J Hepatol. 2001;34:748–755
  129. Duchatelle V, Marcellin P, Giostra E, et al. Changes in liver fibrosis at the end of alpha interferon therapy and 6 to 18 months later in patients with chronic hepatitis C: quantitative assessment by a morphometric method. J Hepatol. 1998;29:20–28
  130. Veldt BJ, Saracco G, Boyer N, et al. Long term clinical outcome of chronic hepatitis C patients with sustained virological response to interferon monotherapy. Gut. 2004;53:1504–1508
  131. Buti M, Esteban R. Long-term outcome after interferon therapy in patients with chronic hepatitis C. Ann Hepatol. 2007;6:267–269
  132. Reddy KR, Govindarajan S, Marcellin P, et al. Hepatic steatosis in chronic hepatitis C: baseline host and viral characteristics and influence on response to therapy with peginterferon alpha-2a plus ribavirin. J Viral Hepat. 2008;15:129–136
  133. Lok AS, Seeff LB, Morgan TR, et al. Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease. Gastroenterology. 2009;136:138–148
  134. Khokhar OS, Lewis JH. Reasons why patients infected with chronic hepatitis C virus choose to defer treatment: do they alter their decision with time?. Dig Dis Sci. 2007;52:1168–1176
  135. Strathdee SA, Latka M, Campbell J, et al. Factors associated with interest in initiating treatment for hepatitis C virus (HCV) infection among young HCV-infected injection drug users. Clin Infect Dis. 2005;40(Suppl 5):S304–S312
  136. Deuffic-Burban S, Babany G, Lonjon-Domanec I, et al. Impact of pegylated interferon and ribavirin on morbidity in patients with chronic hepatitis C and normal aminotransferases in France. Hepatology. 2009;50:1351–1359

 This article has an accompanying continuing medical education activity on page e117. Learning Objectives—At the end of this activity, the learner should be able to appreciate the prevalence of HCV virus infection in the United States as well as worldwide, understand the natural history of HCV infection, including the long-term risk of cirrhosis and hepatocellular cancer, and recognize that a sustained viral response represents a virologic cure.

 Conflicts of Interest The authors disclose the following: Ira M Jacobson is a consultant for Abbott, Anadys, Boehringer Ingelheim, Bristol-Meyers Sqibb, Genetech, Gilead Sciences, GlobeImmune, Human Genome Sciences, Merck, Novartis, Pfizer, Pharmasset, Tibotec, Zymogenetics, and Vertex Pharmaceuticals (including advisory board for manuscript); an investigator for Abbott, Anadys, Boehringer Ingelheim, Genetech, Gilead Sciences, GlobeImmune, Human Genome Sciences, Idenix, Merck, Novartis, Pfizer, Pharmasset, Tibotec, Vertex Pharmaceuticals, and Zymogenetics; and a speaker for Bristol-Myers Squibb, Genetech, Gilead Sciences, Merck, and Novartis. Gary L. Davis is an investigator and consultant (including advisory board for manuscript) for Vertex Pharmaceuticals and receives research funding from Human Genome Science, Merck, Roche, Schering-Plough, and Vertex Pharmaceuticals. Hashem El-Serag is a consultant for Vertex Pharmaceuticals (including advisory board for manuscript). Francesco Negro is a consultant for Vertex Pharmaceuticals (including advisory board for manuscript) and receives educational grant support from Roche. Christian Trépo is an investigator and consultant for Vertex Pharmaceuticals (including advisory board for manuscript).

 Funding This report is based on material identified by the authors during an advisory board meeting conducted by Vertex Pharmaceuticals Incorporated.

PII: S1542-3565(10)00780-9

doi:10.1016/j.cgh.2010.06.032

Clinical Gastroenterology and Hepatology
Volume 8, Issue 11 , Pages 924-933, November 2010

Article Tools

* Image Usage & Resolution