Extrahepatic manifestations of chronic viral hepatitis

Hepatitis B (HBV) and C (HCV) viruses are well-recognized causes for chronic hepatitis, cirrhosis, and even for hepatocellular carcinoma. Apart from liver disease, these viral infections are known to be associated with a spectrum of extrahepatic manifestations. The prevalence of clinically significant extrahepatic manifestations is relatively low, but it can be associated with significant morbidity and even mortality. An awareness and recognition of these manifestations is of paramount importance in facilitating early diagnosis and in offering treatment. However, treatments are not necessarily effective, and patients may continue with disabling extrahepatic manifestations. Hepatitis B virus has been well recognized as causing a variety of manifestations that include skin rash, arthritis, arthralgia, glomerulonephritis, polyarteritis nodosa, and papular acrodermatitis. More recently, infection with hepatitis C virus has elicited considerable interest for its role in a spectrum of extrahepatic manifestations. Among the best-reported are cryoglobulinemia, glomerulonephritis, high titer of autoantibodies, idiopathic thrombocytopenic purpura, lichen planus, Mooren's corneal ulcer, Sjögren's syndrome, porphyria cutanea tarda, and necrotizing cutaneous vasculitis. The precise pathogenesis of these extrahepatic complications has not been determined, although the majority represent the clinical expression of autoimmune phenomena.

Hepatitis C in African Americans

Hepatitis C is one of the most common etiologies for chronic liver disease, cirrhosis, and hepatocellular carcinoma. The majority of liver transplants performed today are due to end stage liver disease induced by chronic hepatitis C. The prevalence of the disease is not the same across various races and a great epidemiologic disparity exists. Hepatitis C virus is more prevalent in the African American population with a higher rate of detectable viremia, predominance of genotype 1, and a higher viral load. Paradoxically the natural history of the disease and the progression to cirrhosis is less accelerated, although the development of hepatocellular carcinoma is more evident. African Americans in particular are resistant to antiviral regimens and the response to treatment with interferon monotherapy, a combination of interferon and ribavirin or pegylated interferon and ribavirin is significantly less. There are on going studies that determine the mechanisms in the lack of response in African Americans. An underrepresentation of African Americans in various study trials that are consequently on a list for a liver transplant have been noted and is postulated that the survival after liver transplantation is not equivalent to the one reported for other races, for unclear reasons.

Chronic hepatitis C in African Americans

The prevalence of hepatitis C virus infection is higher in the African American population in comparison with Caucasians and Hispanics. The majority of African Americans are infected with genotype 1 and have a high viral load, but the rate of progression to cirrhosis is lower. After the development of cirrhosis, the chance of developing hepatocellular carcinoma is higher. African Americans have been under-represented in clinical trials, and the initial preliminary observations pointing toward a lower sustained virologic response with interferon monotherapy has been confirmed in larger studies. A lower response to antiviral therapy has been demonstrated in African Americans receiving combination interferon plus ribavirin and combination peginterferon plus ribavirin. The reasons for these differences in natural history and outcomes of therapy are not understood but are the subject of ongoing study.

The safety and efficacy of ledipasvir/sofosbuvir with or without ribavirin in the treatment of orthotopic liver transplant recipients with recurrent hepatitis C: real-world data

BACKGROUND

Recurrent hepatitis C (RHC) in orthotopic liver transplantation (OLT) population is associated with accelerated rates of fibrosis, low efficacy and decreased tolerability with traditional therapies.

AIM

The aim of this study was to evaluate the safety and efficacy of ledipasvir/sofosbuvir (LED/SOF) with or without ribavirin (RBV) in OLT patients with RHC.

PATIENTS AND METHODS

Patients at least 3 months post-OLT and with documented RHC were treated with LED/SOF with or without RBV for either 12 or 24 weeks. End-of-treatment and sustained virological response 12 weeks after the completion of treatment were documented. Patients were closely monitored for treatment-related adverse effects and the potential need for adjustment in their immunosuppression.

RESULTS

Seventy-one patients were included in the study. Median age was 62 years. Median time from OLT was 55 months. Twenty-six (36.6%) patients were treatment-naive and 45 (63.4%) had previously failed interferon-based therapies. The majority of patients (57.7%) had stage F0-F2 fibrosis. Sixty-seven (94.3%) patients completed 12 weeks of LED/SOF with RBV, three patients completed 12 or 24 weeks of LED/SOF without RBV, and one patient completed only 8 weeks of LED/SOF without RBV owing to severe allograft dysfunction. Sustained virological response was near universal in our cohort (98.5%) regardless of genotype, fibrosis stage, and regimen or treatment duration. Most commonly reported side effects were malaise and gastrointestinal upset. No patient required adjustment in immunosuppression and no episodes of rejection were documented during treatment.

CONCLUSION

The combination of LED/SOF with RBV for 12 weeks or LED/SOF for 24 weeks is very effective and safe in treating OLT recipients with RHC.