Progress of Hepatitis C elimination in Viennese people living with HIV after two decades of increasing cure rates

BACKGROUND & AIMS

Interferon(IFN)-based hepatitis C virus (HCV) therapy has been replaced by direct-acting antivirals (DAAs). We assessed temporal trends in patient characteristics, transmission risks, treatment initiation, and cure rates in eras of IFN, restricted DAA-access, and unrestricted DAA-access in Viennese HCV/HIV-coinfected patients (HIV/HCV).

METHODS

Consecutive HIV/HCV-coinfected patients starting HCV treatment at the Vienna General Hospital between 2002 and 2020 were retrospectively enrolled.

RESULTS

Of all N = 508 HIV/HCV, 78% (398/508) were male and the mean age was 41.8 ± 9.5 years. 'People-who-inject-drugs' (PWID) accounted for 61% (311/508), while 31% (156/508) were 'men who have sex with men' (MSM). In the IFN-era, restricted DAA-era and unrestricted DAA-era, N = 152, N = 129, and N = 227 HCV treatments were started and 49% (74/152), 95% (122/129), and 88% (200/227) achieved sustained virologic response, respectively. Treatment during the IFN-era was a strong predictor for virologic non-response (aOR 12.69; 6.93-23.24) and loss-to-follow-up (aOR 6.12; 2.99-12.54), while virologic non-response was less common in 'MSM' (aOR 0.28; 0.13-0.62). Ninety three percent (50/54) of the observed HCV reinfections occurred in the unrestricted DAA-era. A substantial increase in 'MSM' transmission was observed since 2010 with 66% (107/161) in the DAA-era versus 15% (49/330) prior to the DAA-era.

CONCLUSIONS

HCV cure rates in Viennese HIV patients increased from 49% in the IFN-era to 88-95% in the DAA-era. MSM-related risk behaviour and reinfections became the key challenges towards HCV elimination in HIV-coinfected patients.

[Intractable renal and enteral loss of potassium in a case of Turner's syndrome (author's transl)]

A case of Turner's syndrome is presented; many congenital defects were detected. Predominant clinical findings were cheilognatoschisis, respiratory distress, caused by congenital bronchiektasis and chronic hypokalemia with paroxysmal attacks of paralysis and tetania. Hypokalemia was mainly due to gastrointestinal losses as a consequence of permanent vomiting in the presence of stomach atonia and hiatus insufficiency or because of "third space losses", while a subileus persisted chronically. Furthermore also a renal loss of serum potassium was evident in the patient's predialytic time. Basic renal diseases were pyelonephritis, renal damage from phenacetine abuse, or probably even a nephropathy due to potassium depletion. Uraemia was controlled by dialysis treatment and by a dialysate consisting of 7 and 6 mmol/l potassium respectively. The result of this intense therapy was physical rehabilitation and the patient finally could resume her professional work again.

How to identify the genetic basis of gastrointestinal and liver diseases?

New insights into the genetic basis of disease are being generated at an ever increasing rate. This explosion of information was ignited by technological advances, such as the polymerase chain reaction and automated DNA sequencing. Although its promise is great, the integration of genetics into the everyday practice of medicine remains challenging. This review discusses the application of molecular genetics in general with a specific focus on hereditary diseases of the digestive organs. The application of molecular genetics in everyday clinical routine is hampered by the difficult interpretation of test results. These difficulties include the prediction of disease penetrance, the presence of multiple mutations of a particular gene with varying functional consequences, and the importance of exogenous factors modulating disease expression. To date, the most significant impact of genetics has been to increase our understanding of disease aetiology and pathogenesis and to reliably identify siblings of affected patients with the risk to develop symptomatic disease.

[Parenteral feeding of patients with liver cirrhosis with hepatic encephalopathy]

The amino acid solution, Aminofusin hepar, was evaluated for treatment of hepatic encephalopathy and for parenteral nutrition of patients with liver cirrhosis in correlation to changes in amino acid levels. In contrast to amino acid solutions used for the parenteral nutrition of patients without liver disease, this solution contains an increased proportion of branch chained amino acids and of arginine and ornithine, and a reduced proportion of phenylalanine, methionine, glycine and threonine. The changes in the plasma amino acid levels after infusion of this solution were measured in 4 cirrhotics. The concentration of leucine, isoleucine, valine, ornithine and arginine increased markedly, whereas phenylalanine, methionine, tyrosine, glycine and threonine decreased. The ammonia level in venous blood increased slightly. 4 cirrhotics with encephalopathy were treated for 7 days. In 3 of them the neuropsychiatric symptoms were completely reversed, whereas in the remaining 1 no clinical improvement was achieved in spite of normalization of the plasma aminogramm. In this patient a constant rise of blood ammonia was noted. The indications for special amino acid solutions in liver diseases are discussed.

Pegylated interferon plus ribavirin for chronic hepatitis C: the role of combination therapy today, tomorrow and in the future

Approximately 123 million people worldwide are infected with hepatitis C virus (HCV). The majority of those infected with the virus develop chronic progressive liver disease that over time can result in cirrhosis, end-stage liver disease, hepatocellular carcinoma and death. The goal of treatment is viral eradication. The recognised standard of care for chronic hepatitis C is the combination of pegylated interferon plus ribavirin, which has been shown to be effective in treatment-naïve patients, including those with persistently normal ALT levels, and in patients with HIV-HCV coinfection. Two pegylated interferons are commercially available, both of which have distinct pharmacokinetic properties that necessitate different dosing strategies. With the standard of care, overall virological response rates have exceeded 50% in randomised, multinational phase III studies. Viral response rates are heterogenous and are influenced by a range of viral and host-specific factors. By far, the most important factors influencing treatment outcomes are HCV genotype and baseline HCV RNA level. Customisation of therapy based on baseline factors is recommended in treatment guidelines in order to maximise cure rates. Pegylated interferon plus ribavirin has been shown to be effective and safe in patients with HIV-HCV coinfection and is now recommended in this important and growing subpopulation. Ongoing efforts to improve treatment outcomes are focused on dynamic customisation of therapy based on the on-treatment response to therapy. Treatment of nonresponders to previous interferon-based therapies is an important area under investigation. Although several promising oral agents have been identified and are currently in clinical development, it seems likely that pegylated interferon will remain the backbone of therapy for years to come.

[Psychosomatic treatment of patients with Crohn disease]

Only few clinical reports must suffice at present to assume that in patients with Crohn's disease like in those with ulcerative colitis psychotherapy--regardless how intensive it might be--has not been proven to cure the underlying biologic disturbance. Therefore the hope of complete cure by psychotherapy is not warranted. While improvement and even freedom of all symptoms may take place, psychotherapy cannot prevent stress-related relapse.

The GABA hypothesis of the pathogenesis of hepatic encephalopathy: current status

Gamma-aminobutyric acid (GABA), the principal inhibitory neurotransmitter of the mammalian brain, can induce coma. Outside the central nervous system it is synthesized by gut bacteria and catabolized largely in the liver. GABA and its agonists, as well as benzodiazepines and barbiturates, induce neural inhibition as a consequence of their interaction with specific binding sites for each of these classes of neuroactive substances on the GABA receptor complex of postsynaptic neurons. In a rabbit model of acute liver failure: (i) the pattern of postsynaptic neuronal activity in hepatic coma, as assessed by visual evoked potentials, is identical to that associated with coma induced by drugs which activate the GABA neurotransmitter system (benzodiazepines, barbiturates, and GABA agonists); (ii) the levels of GABA-like activity in peripheral blood plasma increase appreciably before the onset of hepatic encephalopathy, due at least in part to impaired hepatic extraction of gut-derived GABA from portal venous blood; (iii) the blood-brain barrier becomes abnormally permeable to an isomer of GABA, alpha-amino-isobutyric acid, before the onset of hepatic encephalopathy; and (iv) hepatic coma is associated with an increase in the density of receptors for GABA and benzodiazepines in the brain. These findings are the bases of the following hypotheses: (i) when the liver fails, gut-derived GABA in plasma crosses an abnormally permeable blood-brain barrier and by mediating neural inhibition contributes to hepatic encephalopathy; (ii) an increased number of GABA receptors in the brain found in liver failure increases the sensitivity of the brain to GABA-ergic neural inhibition; and (iii) an increased number of drug binding sites mediates the increased sensitivity to benzodiazepines and barbiturates observed in liver failure by permitting increased drug effect.

IL28B polymorphism cannot predict response to interferon alpha treatment in patients with melanoma

BACKGROUND

Recent genome-wide association studies revealed the rs12979860 single nucleotide polymorphism (SNP) of the IL28B gene (CC genotype) to be the strongest pre-therapeutic predictor of therapy response to interferon alpha in patients with chronic hepatitis C infection. The favorable CC genotype is associated with significantly higher rates of sustained virologic response. No data exist on the role of IL28B polymorphism in interferon therapy of diseases other than viral hepatitis.

METHODS

A retrospective study involving 106 patients with melanoma who received low- or high-dose interferon therapy was performed. The CC and non-CC genotype of IL28B rs12979860 SNP were correlated with progression-free and overall survival.

RESULTS

44 (41.5%) patients were CC and 62 (58.5%) non-CC. There was no statistically significant difference in age at diagnosis, melanoma type or localization, Breslow level or AJCC stage between CC and non-CC patients. During the observation period (6.43±4.66 years) disease progression occurred in 36 (34%) patients after 5.5±4.3 years. 43.2% (19) of patients with CC and 27.4% (17) of patients with non-CC genotype were affected (p = 0.091). Disease progression was more frequent in patients on high dose interferon therapy and with a worse AJCC stage.

CONCLUSION

In contrast to classical risk factors like tumor thickness and clinical stage, IL28B polymorphism was not associated with progression-free or overall survival in patients with melanoma treated with interferon alpha.