Saturday, January 2, 2010

HEP C = Cirrhosis, Right? WRONG!

Only the minority of patients with hepatitis C infection progress to cirrhosis. Studies have shown that 20% to 25% of people with hepatitis C will develop cirrhosis ([1]). There are some individuals that are more likely to progress to cirrhosis than others ([2]). The current or past use of significant amounts of alcohol is the single most important factor in accelerating progression to cirrhosis ([3]). For this reason, we recommend that all patients with chronic hepatitis C abstain totally from alcohol.

Other factors that may increase the likelihood of progression to cirrhosis include co-infection with HIV (human immunodeficiency virus) and/or hepatitis B virus. Recent research suggests that excessive iron in the liver may also accelerate progression to cirrhosis ([4]). In some patients, progression to cirrhosis occurs despite none of these factors being present. Virus-specific factors or the type of immune response to the infection may be responsible for the progression to cirrhosis in these individuals.

More recently it has been observed that progression to fibrosis (scar tissue) and cirrhosis appears to accelerate after age 45. The reasons for this are not clear, but it is suspected that changes in the immune response to the hepatitis C infection may cause increased fibrosis after age 45 ([5]). This is another reason why we are becoming more aggressive in treating hepatitis C in young people, even if fibrosis has not yet developed.

Factors that are associated with a lower likelihood of progression to cirrhosis include young age at time of infection, female gender, no history of alcohol use and past treatment with interferon. It should be noted that the genotype of the virus and the viral load have no relationship whatsoever to the development of cirrhosis.

What are the symptoms of cirrhosis?

In early cases of cirrhosis, there are no specific symptoms that would make the physician suspect cirrhosis. At an early stage, even laboratory tests may not show evidence of cirrhosis. Currently we do not have an accurate way of diagnosing cirrhosis by doing a blood test. Even though there is a commercially-available blood test for detecting advanced fibrosis in the liver, the accuracy of this test in patients with hepatitis C is still unknown, and currently it is unable to differentiate cirrhosis from less-advanced stages of fibrosis.

As the cirrhosis becomes more advanced, symptoms from the complications of cirrhosis may develop. By this time, laboratory test abnormalities suggestive of decreased liver function (abnormal levels of bilirubin and albumin; and abnormal coagulation parameters) also develop. Complications from cirrhosis include ascites, variceal bleeding, encephalopathy and liver cancer.

The severity of the cirrhosis is determined based on laboratory test results and findings on physical exam. The liver biopsy plays no role in determining the severity of the cirrhosis. Factors that are taken into account to determine the severity of cirrhosis include the serum albumin (albumin is a protein produced by the liver), the PT or INR (measures the ability of the blood to clot) and the level of serum bilirubin (bilirubin is a substance excreted by the liver, which, when it accumulates, causes jaundice). In addition, the presence or absence of ascites (fluid accumulation in the abdomen) and encephalopathy (confusion caused by toxins not filtered by the liver) are also used to grade the severity of cirrhosis.

A point system known as the Child’s-Pugh-Turcotte score (CPT score) has been devised to determine the severity of the cirrhosis. Depending on the total score, a patient is classified as Class A (early cirrhosis) through Class C (advanced cirrhosis).

Child-Pugh-Turcotte Criteria

1 Point 2 Points 3 Points
>3.5 2.8-3.5 <2.8
Bilirubin (mg/dL) <2 2-3 >3
Ascites None Minimal Moderate
Encephalo-pathy None Grade 1-2 Grade 3-4
PT (sec
<4> 4-6
Class A: 5-6 points; Class B: 7-9 points; Class C: 10-15 points
As of 9/1/09 Ricki stands at 12 points. (Class C - advanced)

Prognosis of cirrhosis

Patients with early cirrhosis (CPT Class A) from hepatitis C infection who have no complications from cirrhosis have an excellent prognosis. Even without treating the hepatitis C infection, 10 years after diagnosing cirrhosis the majority (>75%) continue to do well with no liver-related complications ([6]). It is believed that treatment of the hepatitis C with interferon will provide an even better prognosis.

The diagnosis of early cirrhosis should not be considered a fatal diagnosis. Most patients will continue to do well for decades. There is no reason to refer a person with cirrhosis to a liver transplant center unless the cirrhosis is advanced (CPT class C) or complications from cirrhosis have developed.

Hepatitis C Support Project

(C) 2003. Hepatitis C Support Project

** Hep C is not a death sentence, get the facts, become your own advocate, and fight! No one else is going to do it for you. ** Ricki

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