Alcohol use and hepatitis C

Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents

BACKGROUND

It is unclear whether alcohol use negatively impacts HCV treatment outcomes in the era of direct antiviral agents (DAAs). We aimed to evaluate the associations between current levels of drinking and treatment response among persons treated for HCV with DAAs in the national Veterans Affairs (VA) healthcare system.

METHODS

We identified patients who initiated HCV DAAs over 18 months (1/1/14-6/30/15) and had documented alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire within one year prior to initiating therapy. DAAs included: sofosbuvir (SOF), ledipasvir/sofosbuvir (LDV/SOF) or ombitasvir-paritaprevir-ritonavir, and dasabuvir (PrOD). AUDIT-C scores were categorized as 0 (abstinence), 1-3 (low-level drinking) and 4-12 (unhealthy drinking) in men or 0, 1-2 and 3-12 in women.

RESULTS

Among 17,487 patients who initiated DAAs, 15,151 (87%) completed AUDIT-C screening: 10,387 (68.5%) were categorized as abstinent, 3422 (22.6%) as low-level drinking and 1342 (8.9%) as unhealthy drinking. There were no significant differences in sustained virologic response (SVR) rates between abstinent (SVR 91%; 95% CI: 91-92%), low-level drinking (SVR 93%; 95% CI 92-94%) or unhealthy drinking (SVR 91%; 95% 89-92) categories in univariable analysis or in multivariable logistic regression models. However, after imputing missing SVR data, unhealthy drinkers were less likely to achieve SVR in multivariable analysis (AOR 0.75, 95% CI 0.60-0.92).

CONCLUSION

Absolute SVR rates were uniformly high among all persons regardless of alcohol use, with only minor differences in those who report unhealthy drinking, which supports clinical guidelines that do not recommend excluding persons with alcohol use.

Moderate Alcohol Use and Insulin Action in Chronic Hepatitis C Infection

BACKGROUND AND AIM

Chronic hepatitis C (HCV) is associated with metabolic abnormalities including insulin resistance (IR) and diabetes. While moderate alcohol consumption is known to have beneficial metabolic effects in the general population, such potential effects in HCV are unknown. We aimed to assess the association between graded alcohol intake and IR, insulin secretion, and metabolic syndrome in HCV.

METHODS

Ninety-five non-diabetic HCV-infected patients underwent detailed metabolic testing. IR was directly measured via steady-state plasma glucose (SSPG) during a 240-min insulin suppression test. Total insulin secretion and insulinogenic index were determined by 75-g oral glucose tolerance test. Genotyping of CYP2E1 was performed to detect genetic polymorphisms influencing alcohol metabolism.

RESULTS

In this cohort, 61 % were abstinent from alcohol for the past 12 months, while 22 % were moderate, and 17 % heavy drinkers. Obesity and nonwhite ethnicity were the strongest predictors of IR. Moderate alcohol intake (vs none) was significantly associated with lower SSPG only among those with normal BMI (coef -72.9, 95 % CI -128.1 to -17.6, p = 0.01). Alcohol use was not associated with insulin secretion parameters when controlling for IR and other factors. Heavy alcohol intake (OR 3.2, 95 % CI 0.86-12.3) and nonwhite ethnicity (OR 7.1, 95 % CI 1.5-33.3) were associated with metabolic syndrome. Among nonwhites, the odds of metabolic syndrome were fivefold higher for heavy drinkers.

CONCLUSIONS

Moderate alcohol intake is associated with improved insulin sensitivity in HCV, although this benefit was limited to normal-weight individuals. The potential benefit of moderate alcohol on IR and its metabolic consequences in HCV warrants further longitudinal investigation.

Retinoid regulation of antiviral innate immunity in hepatocytes

Persistent infection of hepatitis C virus (HCV) is one of the leading causes of end-stage liver disease (ESLD), such as decompensated cirrhosis and liver cancer. Of particular note, nearly half of HCV-infected people in the United States are reported to be heavy drinkers. This particular group of patients is known to rapidly progress to the ESLD. Although accelerated disease progression among alcohol abusers infected with HCV is clinically well recognized, the molecular pathophysiology behind this manifestation has not been well elucidated. Hepatocytes metabolize ethanol (EtOH) primarily through two steps of oxidative catabolism in which alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) play central roles. The ADH-ALDH pathway also governs the metabolism of retinol (vitamin A) to its transcriptionally active metabolite, retinoic acid (RA). In this study, we defined that the ADH-ALDH pathway serves as a potent antiviral host factor in hepatocytes, which regulates the expression of interferon (IFN)-stimulated genes (ISGs) by biogenesis of RA. ISGs constitute over 300 antiviral effectors, which cooperatively govern intracellular antiviral innate immunity. Our study revealed that intracellular RA levels greatly influence ISG expression under basal conditions. Moreover, RA augments ISG induction in response to viral infection or exposure to IFN in a gene-specific manner. Lastly, our results demonstrated that EtOH attenuates the antiviral function of the ADH-ALDH pathway, which suggests the possibility that EtOH-retinol metabolic competition is one of the molecular mechanisms for the synergism between HCV and alcohol abuse in liver disease progression.

CONCLUSIONS

RA plays a critical role in the regulation of intracellular antiviral innate immunity in hepatocytes. (Hepatology 2016;63:1783-1795).

Cigarette smoking increases risk of early morbidity after hepatic resection in patients with hepatocellular carcinoma

AIMS

Cigarette smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. The objective of this study was to investigate whether preoperative smoking has any impact on early morbidity after liver resection for hepatocellular carcinoma (HCC).

METHODS

Data of 425 consecutive patients undergoing partial hepatectomy for HCC was retrospectively reviewed. Smoking and drinking habits, biochemical tests, tumor status, operation data, and any postoperative complications occurring before discharge from the hospital were documented. The risk factors promoting postoperative complications were analyzed by univariate and multivariate methods.

RESULTS

The overall morbidity rate was 40% (170 of 425). 166 patients were current smokers (39%). By multivariate analysis, liver cirrhosis (Risk Ratio (RR) 4.0, 95% confidence interval (CI) 2.0-8.0), smoking status (RR 3.0, 95% CI 1.7-5.1), PY of smoking (RR 1.3, 95% CI 1.1-1.9), preoperative platelet count (RR 1.6, 95% CI 1.4-2.0) and major hepatectomy (RR 1.4, 95% CI 1.1-1.8) were independent risk factors of postoperative morbidity (all p < 0.05). Liver failure, bile leakage, intractable ascites, chest and wound infection were more frequently occurred in smokers than non-smokers. Current smokers had higher postoperative morbidity than non- & former smokers in patients with normal liver and those with liver cirrhosis (p = 0.047 and p < 0.001, respectively).

CONCLUSIONS

Cigarette smoking is an independent risk factor for the development of liver-related and infectious complications in patients undergoing partial hepatectomy for HCC, especially in those with liver cirrhosis.

Impact of cigarette smoking on outcome of hepatocellular carcinoma after surgery in patients with hepatitis B

BACKGROUND AND OBJECTIVES

Cigarette smoking is a potential risk factor for hepatocellular carcinoma (HCC) initiation, partially through interaction with hepatitis B virus (HBV). We examined the hypothesis that cigarette smoking might be associated with HBV-related HCC recurrence and patient survival after curative surgery.

PATIENTS AND METHODS

Data of 302 patients with HBV infection who had undergone curative resection for HCC were prospectively collected from 2008 to 2011. Smoking status and smoking quantity (pack-years, PY) were asked at admission. Factors affecting recurrence-free survival (RFS) were examined. RFS and liver-specific mortality (LSM) stratified by risk factors were compared with log-rank test.

RESULTS

109 were current smokers. Current smokers were not different from non-smokers in tumor burden and surgical procedure. Univariate and multivariate analysis identified that heavy smoking (PY ≥ 20) was the most significant factor associated with HBV-related HCC recurrence after curative surgical resection (p = 0.001), followed by anti-HBV treatment (p<0.01), current smoking (p = 0.028), surgical margin <1 cm (p = 0.048) and blood transfusion >600 ml (p = 0.028). The median RFS in non-smokers, ex-smokers and current smokers was 34 months, 24 months and 26 months, respectively (p = 0.033). Current smokers had significantly worse RFS rate and increased 5-year cumulative LSM than non-smokers (p = 0.024, and p<0.001, respectively). Heavy smokers had significantly worse RFS than non- and light smokers (0

CONCLUSIONS

Smoking history and quantity appears to be risk factors for HBV-related HCC recurrence and LSM of patients after surgery. For smokers, continued smoking postoperatively might accelerate tumor recurrence and patient death. Therefore, smoking abstinence should be strongly recommended to patients pre- and postoperatively.

Collapse

Key Words Collapse

MESH Headings

• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/physiopathology
• Carcinoma, Hepatocellular/surgery
• Female
• Hepatitis B/complications
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/physiopathology
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Prognosis
• Recurrence
• Smoking/physiopathology
• Nicotiana

Collapse

Grants Collapse

Affiliation(s)

Xu-Feng Zhang Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
Tao Wei Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
Xue-Min Liu Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
Chang Liu Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China
Yi Lv Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China

Collapse

Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection

BACKGROUND

The effect of alcohol on liver disease in HIV infection has not been well characterized.

METHODS

We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with 2 noninvasive indices, "FIB-4," which includes platelets, liver enzymes, and age; and aspartate aminotransferase/platelet ratio index ("APRI"), which includes platelets and liver enzymes. FIB-4 <1.45 and APRI <0.5 defined the absence of liver fibrosis. FIB-4 >3.25 and APRI >1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150 to 600 kg, >600 kg).

RESULTS

Subjects (n = 308) were 73% men, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load <1,000 copies/ml, and 18.7% with a CD4 count <200 cells/mm(3) . Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150 to 600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses, controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and the absence of liver fibrosis (FIB-4 <1.45) (adjusted odds ratio [AOR] = 1.12 [95% CI: 0.25 to 2.52] for 150 to 600 kg vs. <150 kg; AOR = 1.11 [95% CI: 0.52 to 2.36] for >600 kg vs. <150 kg; global p = 0.95). Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4 >3.25). Results were similar using APRI, and among those with and without HCV infection.

CONCLUSIONS

In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and the absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.

Tumor-initiating stem-like cells and drug resistance: carcinogenesis through Toll-like receptors, environmental factors, and virus

Neoplasms contain distinct subpopulations of cells known as tumor-initiating stem-like cells (TICs) that have been identified as key drivers of tumor growth and malignant progression with drug resistance. Stem cells normally proliferate through self-renewing divisions in which the two daughter cells differ markedly in their proliferative potential, with one displaying the differentiation phenotypes and another retaining self-renewing activity. Therefore, understanding the molecular mechanisms of hepatocarcinogenesis will be required for the eventual development of improved therapeutic modalities for treating hepatocellular carcinoma (HCC). Hepatitis C virus (HCV) and hepatitis B virus is a major cause of HCC. Compelling epidemiologic evidence identifies obesity and alcohol as co-morbidity factors that can increase the risk of HCV patients for HCC, especially in alcoholics or obese patients. The mechanisms underlying liver oncogenesis, and how environmental factors contribute to this process, are not yet understood. The HCV-Toll-like receptor 4 (TLR4)-Nanog signaling network is established since alcohol/obesity-associated endotoxemia then activates TLR4 signaling, resulting in the induction of the stem cell marker Nanog expression and liver tumors. Liver TICs are highly sensitized to leptin and exposure of TICs to leptin increases the expression and activity of an intrinsic pluripotency-associated transcriptional network comprised of signal transducer and activator of transcription 3, SOX2, OCT4, and Nanog. Stimulation of the pluripotency network may have significant implications for hepatocellular oncogenesis via genesis and maintenance of TICs. It is important to understand how HCV induces liver cancer through genesis of TICs so that better prevention and treatment can be found. This article reviews the oncogenic pathways to generate TICs.

Outcome of hepatitis C virus infection in Chinese paid plasma donors: a 12-19-year cohort study

BACKGROUND AND AIMS

Commercial plasma donation was introduced in China in the 1970s. Cases of non-A, non-B hepatitis (hepatitis C) continued to occur, with multiple outbreaks among plasma donors in Guan county, Hebei province between 1972 and 1990. The outcomes of hepatitis C virus (HCV) infection in these paid plasma donors from six villages of Guan county were followed up for 12-19 years.

METHODS

A total of 402 plasma donors with HCV infection were enrolled since anti-HCV-positive in 1991 or 1998. Follow up was maintained until death or the end of the observation period. No antiviral treatment was applied during the period of infection.

RESULTS

Follow up was lost in 23 cases. After a 12-19-year follow up, 31 donors died, with the cause of death directly related to liver disease in 15 cases, and an overall mortality of 8.18% (31/379). The incidence of liver cirrhosis was 10.03%, and hepatocellular carcinoma (HCC) was 2.90%. The rate of viral spontaneous clearing was 20.32% (77/379), and 13.69% (23/168) in males and 25.59% (54/211) in females. In May 2010, detections were performed in 348 cases. Abnormality of liver function was related to HCV viremia. Sex and alcohol intake impacted the outcome of HCV infection. There was no correlation between the viral spontaneous clearance with age of infection and genotype.

CONCLUSIONS

This area has a high rate of chronicity in HCV infection due to plasma donation. Twenty-five years after virus infection, liver cirrhosis or HCC developed in one-tenth of patients, with an overall mortality of 8.18%.

Cancer stem cells generated by alcohol, diabetes, and hepatitis C virus

Cancer stem cells (tumor-initiating stem-like cells: TISCs) are resistant to chemotherapy and are associated with metastatic hepatocellular carcinoma (HCC), which is commonly observed in hepatitis C virus (HCV)-infected patients with obesity or alcohol abuse. However, it is unknown whether the TLR4-NANOG pathway serves as a universal oncogenic signaling in the genesis of TISCs and HCC. We aimed to determine whether Tlr4 is a putative proto-oncogene for TISCs in liver oncogenesis due to different etiologies and how Tlr4 is regulated at the transcriptional and epigenetic levels. CD133+/CD49f+ TISCs were isolated using FACS from HCC developed in HCV Core Tg mice fed alcohol, diethylnitrosamine-treated mice, and alcoholic patients with or without HCV infection. CD133+/CD49f+ cells isolated from the animal models and patients are tumorigenic both in vitro and in a xenograft model, and Tlr4 or Nanog silencing with shRNA attenuates their tumor initiating property. Functional oncogene screening of a cDNA library identified the organ size control pathway targets Yap1 and AKT activator Igf2bp3 as NANOG-dependent genes that inhibit transforming growth factor-β signaling in TISCs. Tlr4 expression is higher in TISCs compared with CD133-/CD49f+ cells. Taken together, Tlr4 may be a universal proto-oncogene responsible for the genesis of TLR4-NANOG dependent TISCs, and this pathway serves as a novel therapeutic target for HCC.

Examining hepatitis C virus testing practices in primary care clinics

Prior studies found that hepatitis C virus (HCV) risk assessment and testing in primary care clinics were suboptimal. We aimed to determine the actual HCV testing rate among patients with HCV risk factors and to identify variables predictive of testing. In order to do so, we performed a prospective cohort study among patients seen in four urban primary care clinics. At the initial visit, patients were given a questionnaire that listed HCV risk factors and they were instructed to check 'yes' or 'no' if they did or did not have a risk factor, respectively. Patients then handed this questionnaire to their physician during their initial visit. Among those who acknowledged having a HCV risk factor via the questionnaire, we determined the subsequent HCV testing rate and calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) to identify variables predictive of testing. Of the 578 individuals who acknowledged having a HCV risk factor via the questionnaire, only 8% (46/578) were tested for HCV within 2 months of their initial visit. Among those tested, 11% (5/46) had a positive HCV antibody test result. The only variable predictive of HCV testing after adjusting for confounders was having a specific HCV risk factor identified and documented in the chart by physicians [16% (26/159) vs 5% (20/419); aOR 4.5, 95% CI 2.1-9.5]. In summary, 92% of patients with a HCV risk factor were not tested for HCV in the primary care setting, and efforts to improve such rates are clearly warranted.

Impact of HCV genetic differences on pathobiology of disease

Multiple HCV genotypes have been isolated worldwide. Genotype seems to be involved in the main pathological aspects of HCV infection. Insulin resistance, steatosis and progression toward cirrhosis, fibrosis and hepatocellular carcinoma establish and develop following genotype-specific mechanisms. Moreover genotype influences pharmacological treatment in term of dose and duration. Pathways involved in cell proliferation, apoptosis, lipid metabolism, insulin and interferon signaling are impaired to a different extent among genotypes, leading to distinct pathological settings. Genotype 1 is associated with a more aggressive disease with increased insulin resistance, worst response to therapy, higher risk of cirrhosis and hepatocellular carcinoma development, while genotype 3 is associated with increased steatosis and fibrosis. The identification and characterization of HCV types and subtypes provides insight into the different outcome of HCV infection and responsiveness to therapy. In the present article, we focused on the pathogenicity of HCV genotypes and their effect on disease progression and treatment.

Correlates of hazardous drinking among Veterans with and without hepatitis C

Hazardous drinking is a major barrier to antiviral treatment eligibility among hepatitis C (HCV) patients. We evaluated differences in substance-related coping, drinking-related consequences, and importance and confidence in ability to change alcohol use among hazardous drinkers with and without HCV (N = 554; 93.5% male). We examined group differences between HCV+ patients (n = 43) and their negative HCV counterparts (n = 511). Results indicate a higher percentage of HCV+ patients report using substances to cope with possible symptoms of PTSD (P < .05) and depression (P < .01), and endorse more lifetime drinking-related negative consequences than HCV patients (P < .01). Furthermore, HCV+ patients place greater importance on changing alcohol use (P < .01) but report less confidence in their ability to change (P < .01). Use of brief assessment and feedback with skills-based interventions to decrease alcohol use may be well-received by HCV+ patients.

Alteration of hepatic nuclear receptor-mediated signaling pathways in hepatitis C virus patients with and without a history of alcohol drinking

The current study tests a hypothesis that nuclear receptor signaling is altered in chronic hepatitis C patients and that the altered pattern is specific to alcohol drinking history. The expression of a panel of more than 100 genes encoding nuclear receptors, coregulators, and their direct/indirect targets was studied in human livers. Gene expression pattern was compared between 15 normal donor livers and 23 hepatitis C virus (HCV) genotype 1-positive livers from patients without a drinking history (matched for age, sex, and body mass index). HCV infection increased the expression of nuclear receptors small heterodimer partner and constitutive androstane receptor (CAR) as well as genes involved in fatty acid trafficking, bile acid synthesis and uptake, and inflammatory response. However, the expression of retinoid X receptor (RXR) α, peroxisomal proliferator-activated receptor (PPAR) α and β as well as steroid regulatory element-binding protein (SREBP)-1c was decreased in HCV-infected livers. Gene expression pattern was compared in chronic hepatitis C patients with and without a drinking history. Alcohol drinking increased the expression of genes involved in fatty acid uptake, trafficking, and oxidation, but decreased the expression of genes responsible for gluconeogenesis. These changes were consistent with reduced fasting plasma glucose levels and altered expression of upstream regulators that include RXRα, PPARα, and CAR. The messenger RNA levels of fibroblast growth factor 21, interleukin-10, and fatty acid synthase, which are all regulated by nuclear receptors, showed independent correlation with hepatic HCV RNA levels.

CONCLUSION

Our findings suggest that those genes and pathways that showed altered expression could potentially be therapeutic targets for HCV infection and/or alcohol drinking-induced liver injury.

Determinants of the underreporting of alcohol consumption by HIV/HCV co-infected patients during face-to-face medical interviews: the role of the physician

OBJECTIVES

The objective of this study was to assess to what extent HIV/HCV co-infected patients underreport alcohol use to their physician with respect to self-reports from self-administered questionnaires (SAQ) and identify correlates of alcohol underreporting during face-to-face medical interviews (FMI).

DESIGN

ANRS-CO13-HEPAVIH is a French multi-center cohort of HIV/HCV co-infected patients.

METHODS

Data were collected at enrolment using both SAQ and FMI while clinical data were retrieved from medical records. Alcohol consumption was assessed through SAQ and compared with FMI patient reports. Correlates of underreporting alcohol consumption during FMI with respect to SAQ were identified using logistic regression analysis.

RESULTS

Among 544 patients, 37% were classified as alcohol abusers according to AUDIT-C in the SAQ. During FMI, 14% underreported alcohol consumption. The following correlates were independently associated with underreporting alcohol consumption in FMI: not receiving HIV treatment, being followed up by a hepatologist for HCV infection and reporting a history of injecting drug use.

CONCLUSIONS

These results highlight the difficulties in alcohol consumption assessment which HCV specialists may face when suggesting to their HIV/HCV co-infected patients that they cease drinking completely. Patient awareness about the real need to reduce their alcohol use before starting HCV therapy may also contribute to underreporting. Innovative strategies for alcohol risk-reduction, including the promotion of controlled consumption and access to multidisciplinary teams, should be implemented for HIV/HCV co-infected patients in order to reduce barriers to HCV treatment.

Optimizing heroin-assisted treatment (HAT): assessment of the contribution of direct ethanol metabolites in identifying hazardous and harmful alcohol use

BACKGROUND

Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites.

METHOD

Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair.

RESULTS

Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake.

CONCLUSIONS

The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.

Fibrosis in chronic viral hepatitis

In the last years, several studies have been performed with the aim to evaluate the real impact of antiviral treatments on fibrosis progression in patients with chronic viral hepatitis. The main goal of therapy in patients with chronic hepatitis B is viral suppression. This outcome leads to an important improvement in both hepatic inflammation and fibrosis and reduces the HCC occurrence. An histological improvement has been largely demonstrated in patient treated with oral nucleoside and nucleotide analogs achieving the rate of 72% with entecavir and tenofovir. Similarly, in patients with chronic hepatitis C, sustained virologic response to interferon therapy is associated with regression of fibrosis and lower liver decompensation and HCC occurrence. In the next future further studies will assess the real impact of the new directly anti-viral agents on liver necroinflammation and fibrosis in chronic hepatitis C.

Alcohol consumption among HIV-infected women: impact on time to antiretroviral therapy and survival

OBJECTIVE

Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to combination antiretroviral therapy (cART) and death in this population.

METHODS

In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected covariates and their association with baseline alcohol consumption. We then examined the association between alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards regression.

RESULTS

Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than nondrinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug (RRR 3.51, 95% CI 2.09-5.91) and tobacco use (RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97, p < 0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34)

CONCLUSIONS

Among this cohort of HIV-infected women, heavy alcohol consumption was independently associated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C, and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.

Early interferon-based treatment after detection of persistent hepatitis C virus infection: a critical decision

Approximately 170 million people are infected with the hepatitis C virus (HCV) worldwide. Infection with this pathogen is persistent in more than 80% of cases, frequently developing severe forms of liver damage such as cirrhosis and hepatocellular carcinoma. No preventive vaccine is available against HCV, and current treatment based on the combination of pegylated interferon and ribavirin is effective in ∼55% of patients infected with genotype 1, the most prevalent genotype. This review analyzes several factors influencing the achievement of a sustained virological response, namely undetectable HCV RNA at 6 months after conclusion of therapy. Particularly, the relevant issue of age and duration of infection is discussed in detail. Indeed, the final decision for starting treatment should be a case-by-case point. However, the cost-benefit analysis seems to indicate that in patients who are motivated and without contraindications, starting the treatment as early as possible is probably the best choice for success.

Pleasure and guilt: alcohol use and hepatitis C

One hundred and seventy million people worldwide live with chronic hepatitis C. Heavy alcohol use plays a key role in progression of the illness and is a contraindication to hepatitis C treatment. Despite the ubiquity of alcohol in Western society as a marker of celebration and sociability, there has been little research addressing the meanings of alcohol use and the dilemmas involved in ceasing or limiting consumption for affected people. This article fills a gap in the literature by addressing the meanings and practices of alcohol use for people with hepatitis C. Data are drawn from a qualitative study exploring the experiences of 40 people living with hepatitis C in New Zealand and Australia. Participants described a number of tensions and dilemmas involved in their relationship with alcohol, illustrating a complex and under-researched interplay of factors that inform drinking practice.

Hepatocellular carcinoma: prevalence and molecular pathogenesis of Helicobacter spp

Helicobacter pylori infection is one of the most common chronic bacterial infections in humans. The association of other Helicobacter spp. with extragastric diseases in animals is well established, and a role of these bacteria in human liver disease is becoming clearer. Several case-control studies have reported possible associations of Helicobacter spp. with various liver diseases, including hepatocellular carcinoma, which is the fifth most common type of carcinoma among men worldwide, and the eighth most common among women. Thus, it is important to understand molecular mechanisms that may lead to hepatotoxicity or hepatocellular dysfunction in which Helicobacter spp. may play a role in inducing malignant transformation of liver cells.

Alcohol and coffee drinking and smoking habit among subjects with HCV infection

BACKGROUND/AIMS

The aims were to estimate among patients with hepatitis C virus (HCV) infection the prevalence of alcohol and coffee intake and smoking habit, the reliability of these self-reported data and the possible change of patients' habit after their first contact with a Viral Hepatitis Service.

METHODS

229 patients were initially interviewed personally at the Viral Hepatitis Service and after 6 months they were re-interviewed by phone in regard to their alcohol, coffee drinking and smoking habits.

RESULTS

Alcohol drinkers were 55.5% of males and 35.3% of females. Most subjects drank coffee daily, both men (90.0%) and women (84.9%). The proportion of current smokers was higher in males (43.6%) than females (26.9%). We found a fair to good reliability of self-reported data regarding patients' habits, alcohol and coffee intake, and number of cigarettes smoked daily. We observed a statistically significant decrease in alcohol and coffee intake and cigarettes smoked between baseline and follow-up interviews.

CONCLUSION

We found a fairly high proportion of HCV-infected patients who regularly drink alcohol and coffee beverages and smoke cigarettes, especially among males. The reliability of self-reported data on these habits seems satisfactory. More decisive action to modify these habits, especially alcohol intake, is required in these patients.

Health maintenance issues in cirrhosis

Caring for patients with cirrhosis requires special consideration. The role of the hepatologist is to assist the primary care physician in caring for such patients. This involves an active role in immunizations, lifestyle modifications, and providing instructions on when to go to the emergency room (ER). There are also specific recommendations geared toward the patient with cirrhosis relating to slowing down the disease process, maintaining quality of life, and improving survival.

HCV-related burden of disease in Europe: a systematic assessment of incidence, prevalence, morbidity, and mortality

Background

Hepatitis C virus (HCV) is a leading cause of chronic liver disease, end-stage cirrhosis, and liver cancer, but little is known about the burden of disease caused by the virus. We summarised burden of disease data presently available for Europe, compared the data to current expert estimates, and identified areas in which better data are needed.

Methods

Literature and international health databases were systematically searched for HCV-specific burden of disease data, including incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and liver transplantation. Data were collected for the WHO European region with emphasis on 22 countries. If HCV-specific data were unavailable, these were calculated via HCV-attributable fractions.

Results

HCV-specific burden of disease data for Europe are scarce. Incidence data provided by national surveillance are not fully comparable and need to be standardised. HCV prevalence data are often inconclusive. According to available data, an estimated 7.3–8.8 million people (1.1–1.3%) are infected in our 22 focus countries. HCV-specific mortality, DALY, and transplantation data are unavailable. Estimations via HCV-attributable fractions indicate that HCV caused more than 86000 deaths and 1.2 million DALYs in the WHO European region in 2002. Most of the DALYs (95%) were accumulated by patients in preventable disease stages. About one-quarter of the liver transplants performed in 25 European countries in 2004 were attributable to HCV.

Conclusion

Our results indicate that hepatitis C is a major health problem and highlight the importance of timely antiviral treatment. However, data on the burden of disease of hepatitis C in Europe are scarce, outdated or inconclusive, which indicates that hepatitis C is still a neglected disease in many countries. What is needed are public awareness, co-ordinated action plans, and better data. European physicians should be aware that many infections are still undetected, provide timely testing and antiviral treatment, and avoid iatrogenic transmission.

Alcohol metabolism increases the replication of hepatitis C virus and attenuates the antiviral action of interferon

The interactions between hepatitis C virus (HCV) and alcohol metabolism are not well understood. To determine the effect that alcohol metabolism has on HCV replication and the antiviral action of interferon (IFN), Huh-7 cells that harbor HCV replication and metabolize ethanol via the introduced expression of cytochrome P450 2E1 (Cyp2e1) were treated with ethanol and IFN-alpha. Treatment of these cells with ethanol (0-100 mmol/L) significantly increased HCV replication. This effect was dependent on Cyp2e1 expression and alcohol-metabolized oxidative stress (OS), because the antioxidant N-acetylcysteine blocked this effect. Furthermore, the anti-HCV action of IFN-alpha was attenuated in the presence of ethanol metabolism, most likely via attenuation of Stat1 tyrosine-701 phosphorylation. These in vitro results mimic what is often noted clinically, and further dissection of this model system will aid in our understanding of interactions between HCV and alcohol metabolism.

Treatment options for patients with hepatitis C: role of pharmacists in optimizing treatment response and managing adverse events

Chronic hepatitis C is associated with substantial morbidity and mortality and poses a considerable socioeconomic burden. Improved treatment regimens, including the standard of care pegylated interferon alfa and ribavirin, have increased sustained virologic response rates; however, treatment has a long duration and is often associated with adverse events that may affect adherence. The goal of therapy is viral eradication and reduced disease-related complications such as fibrosis, cirrhosis, and hepatocellular carcinoma. The clinical outcome of hepatitis C virus infection is altered with antiviral treatment, which can be influenced by host (e.g., weight, ethnicity, health) and viral (e.g., genotype, baseline viremia) factors. Overall, sustained virologic response was attained by 54-63% of patients in clinical trials treated with pegylated interferon alfa-2a or -2b and ribavirin. However, this benefit is not without risk. Interferon-induced adverse events include flu-like symptoms, bone marrow suppression, and emotional or cognitive effects, whereas hemolytic anemia accounts for most ribavirin dosage reductions. These adverse events may be ameliorated with dosage adjustments, symptom therapy, and judicious use of preventive strategies (e.g., antidepressants, hematopoietic growth factors). Appropriate management of adverse events can increase treatment adherence, thereby enhancing outcomes and improving quality of life. Pharmacists are in an ideal position to improve the treatment of patients with chronic hepatitis C by providing education about the disease and its treatments and associated adverse events and by emphasizing the importance of treatment adherence for successful outcomes.

Hepatocellular carcinoma and other primary liver cancers in hepatitis C patients in Sweden - a low endemic country

The aim of this study was to assess the risk of hepatocellular carcinoma (HCC) and other primary liver cancers (PLC) in the nationwide cohort of hepatitis C virus (HCV) infected patients in Sweden. The basis was the total HCV-cohort notified in 1990-2004, after excluding 3238 people also reported with hepatitis B, the study cohort consisted of 36 126 people contributing an observation time of 246 105 person-years. The most common route of transmission was intravenous drug use (57%). The national Cancer Registry was used for follow-up, and 354 developed PLC (mainly HCC), of whom 234 were eligible for statistical analysis. The PLC incidence in the HCV cohort was compared with the incidence in the general population, and a standardized incidence ratio (SIR) was calculated for six different strata according to estimated duration of infection. The highest relative risk, SIR: 46 (95% CI: 36-56) was found in the stratum 25-30 years with HCV infection and SIR: 40 (95% CI: 31-51) in the stratum 30-35 years with infection. In the entire community-based HCV cohort in Sweden we found a highly increased risk of liver cancer compared to the general population. The highest relative risk was among people who had been infected for more than 25 years.

Human immunodeficiency virus-related microbial translocation and progression of hepatitis C

BACKGROUND & AIMS

Human immunodeficiency virus (HIV)-1 infection has been associated with enhanced microbial translocation, and microbial translocation is a mechanism through which alcohol and some enteric conditions cause liver disease. We hypothesized that HIV promotes liver disease by enhancing microbial translocation.

METHODS

We studied human cohorts in which hepatitis C virus (HCV) and HIV outcomes were carefully characterized.

RESULTS

HIV-related CD4(+) lymphocyte depletion was strongly associated with microbial translocation as indicated by elevated levels of circulating lipopolysaccharide (LPS), LPS-binding protein, soluble CD14, and fucose-binding lectin (AAL) reactive to immunoglobulin G specific for the alpha-galactose epitope and suppressed levels of endotoxin core antibodies (EndoCAb IgM) in HIV-infected subjects compared with the same persons before they had HIV infection and compared with HIV-uninfected subjects. The same measures of microbial translocation were strongly associated with HCV-related liver disease progression (cirrhosis), eg, LPS, odds ratio, 19.0 (P = .002); AAL, odds ratio, 27.8 (P < .0001); in addition, levels of LPS were elevated prior to recognition of cirrhosis.

CONCLUSIONS

Microbial translocation may be a fundamental mechanism through which HIV accelerates progression of chronic liver disease.

Approach to the management of patients with chronic hepatitis C who failed to achieve sustained virologic response

The combination of PEGIFN and RBV is the most effective therapy for patients with chronic hepatitis C. Although more than half of all patients are able to achieve SVR, a significant proportion of patients, particularly those with genotype 1, fail to have undetectable HCV RNA during treatment or relapse after completing therapy with return of detectable HCV RNA. An approach in the management of these patients is to identify factors that could have led to the NR or relapse and that could be corrected before or during a second course of therapy. Because fibrosis progression occurs slowly over decades for many patients with chronic hepatitis C, avoiding alcohol or other factors that could lead to fibrosis progression may be sufficient for the vast majority of patients. Other options that could be considered in patients who have more advanced disease include retreating with one of several new antiviral agents; retreating with higher doses of IFN or PEGIFN and RBV; or using IFN, PEGIFN, or RBV monotherapy long-term as maintenance therapy. The safety and efficacy of these approaches is being evaluated in numerous clinical trials.

Traveling young injection drug users at high risk for acquisition and transmission of viral infections

BACKGROUND

Young injection drug users (IDU) are highly mobile. It is not known how mobility affects their risk of acquiring and transmitting viral infections.

METHODS

We conducted a cross-sectional study of young (under age 30) IDU in San Francisco (2004-2006). Participants completed a semi-structured interview and testing for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV infection. We examined whether travel was independently associated with drug, alcohol, sexual risk behaviors, and infection status, after adjusting for demographic characteristics and years injecting.

RESULTS

Two-thirds (62%) reported past (3 months) travel outside of San Francisco (n=355). Travelers, as compared to non-travelers, were more likely to be under age 20, female, and planned to leave San Francisco in the coming months. Travel was independently associated with heavy alcohol consumption, drinking alcohol until blackout, poly-substance use, more sexual and injecting partners, and receptive needle/syringe sharing, sharing drug preparation equipment, backloading syringes and pooling money to buy drugs. In an analysis of interactions with travel, younger travelers were more likely to be HCV positive than younger non-travelers.

DISCUSSION

Traveling young IDU are at exceptionally high risk for acquiring and transmitting viral infections, while their mobility makes it challenging to effectively deliver interventions.

Abrogation of the antifibrotic effects of natural killer cells/interferon-gamma contributes to alcohol acceleration of liver fibrosis

BACKGROUND & AIMS

Chronic alcohol drinking accelerates liver fibrosis in patients with viral hepatitis that cannot be fully explained by ethanol-enhanced liver damage. Here, we identified a novel mechanism by which alcohol accelerates liver fibrosis: inhibition of the antifibrotic effects of natural killer (NK) cells and interferon-gamma (IFN-gamma).

METHODS

Alcohol administration was achieved by feeding mice with a liquid diet containing 5% ethanol for 8 weeks. Liver fibrosis was induced by administration of carbon tetrachloride (CCl(4)) for 2 weeks. Hepatic stellate cells (HSCs) were also isolated and cultured for in vitro studies.

RESULTS

CCl(4) treatment induced greater fibrosis and less apoptosis of HSCs in ethanol-fed mice compared with pair-fed mice. Polyinosinic-polycytidylic acid (Poly I:C) or IFN-gamma treatment inhibited liver fibrosis in pair-fed but not in ethanol-fed mice. Poly I:C activation of NK cell cytotoxicity against HSCs was attenuated in ethanol-fed mice compared with pair-fed mice, which was due to reduced natural killer group 2 member D (NKG2D), tumor necrosis factor-related apoptosis-inducing ligand, and IFN-gamma expression on NK cells from ethanol-fed mice. In vitro, HSCs from ethanol-fed mice were resistant to IFN-gamma-induced cell cycle arrest and apoptosis compared with pair-fed mice. Such resistance was due to diminished IFN-gamma activation of signal transducer and activator of transcription 1 (STAT1) in HSCs from ethanol-fed mice caused by the induction of suppressors of cytokine signaling proteins and the production of oxidative stress. Finally, HSCs from ethanol-fed mice were resistant to NK cell killing, which can be reversed by transforming growth factor-beta1 (TGF-beta1) neutralizing antibody.

CONCLUSIONS

Chronic ethanol consumption attenuates the antifibrotic effects of NK/IFN-gamma/STAT1 in the liver, representing new and different therapeutic targets with which to treat alcoholic liver fibrosis.

Influence of cannabis use on severity of hepatitis C disease

BACKGROUND & AIMS

Complications of HCV infection are primarily related to the development of advanced fibrosis and whether cannabis use is a risk factor for more severe fibrosis is controversial.

METHODS

Baseline data from a prospective cohort study of 204 persons with chronic HCV infection were used for analysis. The outcome was fibrosis score on biopsy, and the primary predictor evaluated was daily cannabis use.

RESULTS

The median age of the cohort was 46.8 years, 69.1% were male, 49.0% were white, and the presumed route of infection was injection drug use in 70.1%. The median lifetime duration and average daily use of alcohol were 29.1 years and 1.94 drink equivalents per day, respectively. Cannabis use frequency (within prior 12 months) was daily in 13.7%, occasional in 45.1%, and never in 41.2%. Fibrosis stage, assessed by the Ishak method, was F0, F1-2, and F3-6 in 27.5%, 55.4%, and 17.2% of subjects, respectively. Daily compared with non-daily cannabis use was significantly associated with moderate to severe fibrosis (F3-6 vs F1-2) in univariate (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.20-8.56, P = .020) and multivariate analyses (OR, 6.78; 95% CI, 1.89-24.31, P = .003). Other independent predictors of F3-6 were >or=11 portal tracts (compared with <5, OR, 6.92; 95% CI, 1.34-35.7, P = .021) and lifetime duration of moderate to heavy alcohol use (OR per decade, 1.72; 95% CI, 1.02-2.90, P = .044).

CONCLUSIONS

Daily cannabis use is strongly associated with moderate to severe fibrosis, and HCV-infected individuals should be counseled to reduce or abstain from cannabis use.

Outcome of screening for hepatitis C virus infection based on risk factors

OBJECTIVES

Screening for hepatitis C virus (HCV) infection in individuals at increased risk is currently recommended by most, but not all, health authorities. This study identifies outcomes of individuals diagnosed through a screening program targeting high-risk patients.

METHODS

Veterans presenting for care in VA facilities are assessed for HCV risk factors by a questionnaire. Those with a risk factor are offered anti-HCV testing. Between October 1998 and May 2004, 25,701 patients were assessed and 8,471 patients had a risk factor for HCV. Patients diagnosed through the screening program were assessed per study protocol.

RESULTS

The prevalence of a positive HCV antibody in veterans who identified a risk factor was 7.3% (95% CI 6.6-8.0%). Among those diagnosed through the screening program (N = 260), 47% had chronic hepatitis C. Among patients with chronic HCV, 18% had evidence of advanced liver disease (stage III/IV on biopsy or clinical cirrhosis) while 34% had persistently normal alanine aminotransferase (ALT). Two-thirds of individuals who underwent liver biopsy had minimal or no fibrosis. About half (47%) of the screen-detected patients with chronic HCV were treatment candidates. Forty-four percent were not immediate candidates secondary to medical or psychiatric comorbidities or active substance abuse. Twenty-two patients (8%) had died after a median follow-up of 911 days. Two were liver-related deaths.

CONCLUSION

Screening for hepatitis C in persons at high risk can lead to early identification of individuals at risk for progressive liver disease who may benefit from antiviral therapy and counseling to reduce HCV-related liver injury.

Morbidity and mortality in paid Austrian plasma donors infected with hepatitis C at plasma donation in the 1970s

BACKGROUND/AIMS

Between 1964 and 1987 several epidemic outbreaks of hepatitis C virus infection linked to plasma donation occurred at plasmapheresis centres in Austria. Data collected by a Foundation to help the victims enabled us to study the natural history of chronic hepatitis C in this cohort.

METHODS

Medical records and charts of donors accepted by the Foundation were analyzed.

RESULTS

Four hundred and eighty-five subjects (439 males; mean age at infection: 22 years) were included. Mean follow-up was 31 years. Thirty-four percent of plasma donors had advanced liver disease; alcohol abuse and diabetes were related to progression. Twenty-one patients developed hepatocellular carcinoma; 36 underwent liver transplantation. Six donors cleared the virus spontaneously. Forty died, with death directly related to liver disease in 25 donors. Overall and transplant-free 35-year cumulative survival rates were 84% and 74%, respectively. Three hundred and nineteen patients received and 291 completed antiviral treatment. All 56 who achieved a sustained virologic response are alive and well; 14 non-responders died and nine underwent liver transplantation.

CONCLUSIONS

Thirty-one years after virus infection, advanced liver disease has developed in a third of patients, with an overall mortality of 7%. These data underline the progressive nature of chronic hepatitis C infection and the need to identify and treat infected subjects.

Awareness of hepatitis C diagnosis is associated with less alcohol use among persons co-infected with HIV

BACKGROUND AND OBJECTIVE

It is unknown whether testing HIV-infected individuals for hepatitis C virus (HCV) and informing them of their HCV status impacts subsequent alcohol use. We hypothesized that HIV-infected individuals with current or past alcohol problems who reported being told they had HCV were more likely to 1) abstain from alcohol and 2) not drink unhealthy amounts compared to individuals who had not been told.

DESIGN, PARTICIPANTS, AND MEASUREMENTS

Data from a prospective, observational cohort study (HIV-Longitudinal Interrelationships of Viruses and Ethanol) were used to assess the association between awareness of having HCV at baseline and subsequent abstinence and not drinking unhealthy amounts as reported at 6-month follow-up intervals. General estimating equations logistic regression was used to account for the correlation from using repeated observations from the same subject over time. We adjusted for age, sex, race, homelessness, injection drug use, depressive symptoms, and having abnormal liver tests.

RESULTS

Participants who reported being told they had HCV were more likely to report abstaining from alcohol (AOR = 1.60; 95% CI: 1.13 to 2.27) and not drinking unhealthy amounts (AOR = 1.46; 95% CI: 1.01 to 2.11).

CONCLUSIONS

Among patients infected with HIV who had a history of alcohol problems, reporting being told one had HCV was associated with greater abstinence from alcohol and less unhealthy amounts of drinking.

Treatment of hepatitis C virus infection

Acute and chronic hepatitis C virus (HCV) infection remains a serious health problem worldwide, however, there has been advancement in the treatment of HCV infection due to standard treatment using pegylated interferon and ribavirin. The literature indicates that therapy for HCV is becoming more individualized. In addition to considering genotype and viral RNA levels before treatment, achievement of an early virologic response (EVR) and a rapid virologic response (RVR) is now possible during therapy. Moreover, problem patients, such as non-responders, relapsers, HIV or HBV co-infected patients, patients with liver cirrhosis, and pre- or post-liver transplantation patients are an increasing fraction of the patients requiring treatment. This article reviews the literature regarding standard treatments and problem patients with acute and chronic HCV infection. It also includes discussion on contraindications and side effects of treatment with interferon and ribavirin, as well as new drug development.

[Expert recommendations for the diagnosis and treatment of chronic hepatitis C infection in the prison setting]

The prevalence of HCV infection in Spanish prisons is very high (38.5%). The characteristics of the infected patients, particularly the high rate of HIV coinfection, makes it very likely that the morbidity and mortality produced by serious liver disease secondary to this infection will increase considerably in the coming years. A group of Spanish experts with experience in patients who are inmates has been invited to establish a series of recommendations for the diagnosis and treatment of chronic hepatitis C infection in Spanish prisons.

Alcohol and hepatitis C mortality among males and females in the United States: a life table analysis

OBJECTIVE

Evidence from previous studies suggests that heavy alcohol use (HAU) exacerbates the rate of fibrosis progression in the liver and results in increased probability for premature death among patients with hepatitis C virus (HCV) infection. The current study uses population-based mortality data to investigate whether heavy drinking affects the age of death among individuals with HCV and, if so, whether this effect differs between men and women.

METHODS

A total of 7,263,163 death records in the United States between 2000 and 2002 were drawn from the Multiple Cause of Death (MCD) public-use data files compiled by the National Center for Health Statistics (NCHS). International Classification of Diseases, Tenth Revision (ICD-10) codes were used to identify the presence of HCV (B17.1 and B18.2) and HAU (as indicated by alcohol-induced medical conditions, F10 and K70) either as the underlying cause or as one of the contributing causes of death. The deaths were divided into 4 distinctive cause-of-death categories: HCV without HAU, HAU without HCV, HCV plus HAU, and all others. The mean ages of death and the cumulative probabilities of death derived from multiple-cause life table were compared across these categories.

RESULTS

Hepatitis C virus deaths showed an excessive prevalence of HAU when compared with non-HCV deaths. Compared with deaths of HCV without HAU, the mean age of death was shortened for deaths of HCV plus HAU (from 55.1 to 50.0 years among males, and from 61.0 to 49.1 years among females). The cumulative probability of death before age 65 was much higher for the latter than the former group (0.91 vs 0.68 among males, and 0.88 vs 0.47 among females). While HCV alone showed a disproportionate effect on premature death in males, HAU presented a stronger effect in females, resulting in a "catching-up" effect that diminished the gender difference in age of HCV death.

CONCLUSIONS

This study provides mortality-based evidence to further establish heavy alcohol consumption as one of the key risk factors contributing to premature deaths from HCV in the United States. More importantly, this study, for the first time, presents empirical evidence that alcohol consumption affects men and women differently in HCV mortality.

Recomendaciones de expertos sobre el diagnóstico y tratamiento de la hepatitis C crónica en el medio penitenciario

The prevalence of HCV infection in Spanish prisons is very high (38.5%). The characteristics of the infected patients, particularly the high rate of HIV coinfection, makes it very likely that the morbidity and mortality produced by serious liver disease secondary to this infection will increase considerably in the coming years. A group of Spanish experts with experience in patients who are inmates has been invited to establish a series of recommendations for the diagnosis and treatment of chronic hepatitis C infection in Spanish prisons.

Barriers to treatment of hepatitis C in HIV/HCV-coinfected adults with alcohol problems

BACKGROUND

Alcohol use and human immune deficiency virus (HIV) infection are both associated with accelerated progression of hepatitis C virus (HCV) disease and reduced response rates to interferon therapy. In this study, we assessed the prevalence of barriers to interferon treatment in a population of HIV/HCV-coinfected patients with current or past alcohol problems and the extent to which they received treatment to address the barriers.

METHODS

This is a cross-sectional, descriptive analysis of baseline data from a prospective study assessing the impact of HCV and alcohol use on HIV disease progression. Using consensus guidelines, subjects were categorized as having absolute, relative, or no contraindications to interferon therapy for HCV. Absolute contraindications to treatment included heavy alcohol use, decompensated liver disease, CD4 cell count <100 cells/microL, recent needle sharing, and suicidal ideation. Relative contraindications included moderate alcohol use, recent injection drug use, depressive symptoms, and CD4 cell count from 100 to 199 cells/microL.

RESULTS

Of 401 HIV-infected subjects, 200 were HCV RNA-positive. Fifty-three percent had an absolute contraindication to interferon therapy, 35% a relative but no absolute contraindication, and only 12% had no contraindication. Of those with an absolute contraindication, 61% reported heavy drinking and the majority (88%) had multiple contraindications. These contraindications were present despite the fact that over 50% were in receipt of substance abuse and mental health treatment.

CONCLUSIONS

Continued alcohol and drug use as well as depressive symptoms are the major barriers to interferon therapy in HCV/HIV-coinfected subjects and these barriers persist despite high treatment rates for these problems. Therefore, more intensive treatments of alcohol, drug, and mental health issues are needed to improve HCV treatment eligibility in HCV/HIV-coinfected persons.

Southern Europe as an example of interaction between various environmental factors: a systematic review of the epidemiologic evidence

Hepatitis B virus (HBV), hepatitis C virus (HCV) and alcohol consumption are major causes of hepatocellular carcinoma (HCC) worldwide. We performed a systematic review of epidemiologic studies carried out on HCC aetiology in Southern Europe, an area with an intermediate-high prevalence of these agents as well as of putative risk factors such as tobacco smoking, diabetes and obesity. To retrieve the articles, we performed a Medline search for titles and abstracts of articles. After the Medline search, we reviewed the papers and reference lists to identify additional articles. A synergism between HCV infection and HBV infection, overt (hepatitis B virus antigen (HbsAg) positivity) or occult (HBsAg negativity with presence of HBV DNA in liver or serum), is suggested by the results of some studies. The pattern of the risk for HCC due to alcohol intake shows a continuous dose-effect curve without a definite threshold, although most studies found that HCC risk increased only for alcohol consumption above 40-60 g of ethanol per day. Some evidence supports a positive interaction of alcohol intake probably with HCV infection and possibly with HBV infection. A few studies found that coffee has a protective effect on HCC risk due to various risk factors. Some data also support a role of tobacco smoking, diabetes and obesity as single agents or preferably co-factors in causing HCC. In countries with a relatively high alcohol consumption and intermediate levels of HCV and HBV infections (1-3% of population infected by each virus), such as Mediterranean countries, the three main risk factors together account for about 85% of the total HCC cases, leaving little space to other known risk factors, such as haemochromatosis, and to new, still unrecognised, factors as independent causes of HCC.

Alcohol use and treatment of hepatitis C virus: results of a national multicenter study

BACKGROUND & AIMS

Patients with hepatitis C virus (HCV) infection who use alcohol have been excluded from clinical trials; therefore, outcomes with antiviral therapy are unknown. The aim of the study was to determine the impact of alcohol use on HCV treatment outcomes.

METHODS

Subjects using alcohol were categorized as follows: no alcohol versus regular alcohol use, quantity consumed (none, <6 drinks/day, >/=6 drinks/day), CAGE score <2 or >/=2, and recent alcohol use (past 12 months). Patients were treated with interferon plus ribavirin.

RESULTS

A total of 4061 subjects were enrolled, and 726 (18%) received treatment. Alcohol use (past and within 12 months) reduced treatment candidacy. Past alcohol use did not affect the end-of-treatment response, sustained virologic response (SVR), and treatment discontinuation rates. However, recent alcohol use resulted in higher treatment discontinuation (40% vs 26%; P = .0002) and tended to reduce the SVR (14% vs 20%; P = .06), but when patients who discontinued treatment were excluded from analysis, the trend in favor of nondrinkers for SVR disappeared (25% vs 23%). These findings were also consistent in subgroup analyses on race and genotype.

CONCLUSIONS

Eligibility for anti-HCV treatment was reduced in past and recent drinkers. Recent alcohol use was associated with increased treatment discontinuation and lower SVR. However, patients who use alcohol and completed the treatment had a response comparable to that of nondrinkers. Patients with a history of alcohol use should not be excluded from HCV therapy. Instead, additional support should be provided to these patients to ensure their ability to complete treatment.

High prevalence of alcohol use among hepatitis C virus antibody positive injection drug users in three US cities

Injection drug users (IDUs) acquire the majority of new hepatitis C virus (HCV) infections and frequently use alcohol. Alcohol abuse accelerates liver disease among HCV-infected persons, can reduce the effectiveness of treatment for HCV infection and may be a contraindication for HCV treatment. HCV seropositive, HIV-negative IDUs aged 18-35 years in Baltimore, New York City and Seattle who were enrolled in a behavioral risk-reduction intervention trial underwent computerized self-interviews to assess baseline alcohol use and dependence and medical history. We measured problem alcohol use using the 10-item Alcohol Use Disorders Identification Test (AUDIT) scale. Of 598 participants, 84% responded "false" to: "it is safe for a person with HCV to drink alcohol". Problem drinking, defined as score > or =8 on AUDIT, was identified in 37%. Correlates of scoring > or =8 on AUDIT included homelessness, male gender, primarily injecting speedballs, having injected with used needles, prior alcohol treatment and depression. Although most HCV seropositive IDUs in our sample appear informed about their increased risk of liver disease from alcohol, two-fifths screened positive for problem alcohol use. These findings underscore the importance of referring HCV-positive persons to effective alcohol treatment programs to reduce future liver damage and improve eligibility for and effectiveness of treatment of HCV.

Eligibility for treatment of hepatitis C virus infection among young injection drug users in 3 US cities

Among 404 injection drug users aged 18-35 who tested positive for hepatitis C virus (HCV) RNA, 96% had conditions that are potentially unwarranted contraindications for HCV treatment (e.g., problem drinking, moderate-to-severe depression, and recent drug injection). Restrictive eligibility criteria may deny treatment to a large proportion of patients who could benefit from it.

Influence of alcohol on the progression of hepatitis C virus infection: a meta-analysis

BACKGROUND & AIMS

A convincing, yet inconsistent, pattern has emerged that demonstrates increased progression of HCV-related liver disease with heavy alcohol use. The aim was to perform a meta-analysis to quantify the effect of alcohol on cirrhosis risk among persons infected with HCV.

METHODS

A meta-analysis of 20 articles, involving more than 15,000 HCV chronically infected persons, published between 1995 and 2004 was undertaken to explore the relationship between advanced liver disease and the consumption of alcohol.

RESULTS

The pooled relative risk of cirrhosis associated with heavy alcohol intake (defined in the range of at least 210-560 g per week) was 2.33 (95% confidence interval, 1.67-3.26) by the random effects model. The risk of HCV-related liver disease associated with heavy alcohol intake increased with severity of the outcome; the lowest (1.63; 95% confidence interval, 1.22-2.17) and highest (3.54; 2.14-5.85) pooled relative risk estimates were obtained for advanced fibrosis and decompensated cirrhosis, respectively. The regression effect of alcohol might, however, be underestimated in studies investigating the risk of HCV-related cirrhosis because they necessarily include patients undergoing liver biopsy and could therefore under-represent heavy alcohol users.

CONCLUSIONS

The evidence overwhelmingly shows a worsened outcome for those with chronic HCV and concurrent alcohol use. Studies varied widely in their definition of significant alcohol intake, and so the true threshold above which alcohol accelerates HCV disease progression remains uncertain. Alcohol consumption should be minimized as much as possible in those who have chronic HCV until a safe threshold is more definitively determined.

A review of entecavir in the treatment of chronic hepatitis B infection

BACKGROUND

Infection with the hepatitis B virus (HBV) affects two billion people worldwide, and an estimated 400 million people are chronically infected. Currently, FDA-approved regimens for the treatment of chronic HBV include interferon-alpha2b, peginterferon-alpha2a, lamivudine, adefovir dipivoxil, and recently, entecavir.

OBJECTIVE

The purpose of this review is to evaluate the pharmacokinetic and pharmacodynamic properties, and the clinical efficacy and safety of entecavir in the treatment of nucleoside-naĩve and nucleoside-resistant HBeAg-positive and HBeAg-negative chronic hepatitis B (CHB). SEARCH METHODOLOGY: Computerized searches of PubMed and International Pharmaceutical Abstracts from 1985 to July 10, 2005, were performed with the search headings: entecavir, BMS-200475, and chronic hepatitis B.

FINDINGS

Entecavir, a new deoxyguanosine analog, represents a third agent within the nucleoside/nucleotide HBV polymerase inhibitor class with distinct advantages over lamivudine and adefovir dipivoxil: it has a three-step mechanism of action, is the most potent inhibitor of HBV DNA polymerase, is not associated with any major adverse effects, and has a limited potential for resistance. In phase II and III clinical trials, entecavir was found to be superior to lamivudine for all primary endpoints evaluated in both nucleoside-naïve and lamivudine-resistant patients. Entecavir was effective in both HBeAg-positive and HBeAg-negative nucleoside-naïve patients. At this time, optimal duration of entecavir therapy is unknown.

CONCLUSION

Entecavir represents a new first- or second-line treatment option for patients chronically infected with HBV. Long-term efficacy and safety studies as well as studies of entecavir in combination with interferon products or other nucleoside/nucleotide analogs are eagerly awaited.

Global epidemiology of hepatitis C virus infection

Hepatitis C virus (HCV) is a major cause of liver disease worldwide and a potential cause of substantial morbidity and mortality in the future. The complexity and uncertainty related to the geographic distribution of HCV infection and chronic hepatitis C, determination of its associated risk factors, and evaluation of cofactors that accelerate its progression, underscore the difficulties in global prevention and control of HCV. Because there is no vaccine and no post-exposure prophylaxis for HCV, the focus of primary prevention efforts should be safer blood supply in the developing world, safe injection practices in health care and other settings, and decreasing the number of people who initiate injection drug use.