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Salama II, Raslan HM, Abdel-Latif GA, Salama SI, Sami SM, Shaaban FA, Abdelmohsen AM, Fouad WA. Impact of direct-acting antiviral regimens on hepatic and extrahepatic manifestations of hepatitis C virus infection. World J Hepatol 2022; 14:1053-1073. [PMID: 35978668 PMCID: PMC9258264 DOI: 10.4254/wjh.v14.i6.1053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/01/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) is a common cause of liver disease and is associated with various extrahepatic manifestations (EHMs). This mini-review outlines the currently available treatments for HCV infection and their prognostic effect on hepatic manifestations and EHMs. Direct-acting antiviral (DAA) regimens are considered pan-genotypic as they achieve a sustained virological response (SVR) > 85% after 12 wk through all the major HCV genotypes, with high percentages of SVR even in advanced fibrosis and cirrhosis. The risk factors for DAA failure include old males, cirrhosis, and the presence of resistance-associated substitutions (RAS) in the region targeted by the received DAAs. The effectiveness of DAA regimens is reduced in HCV genotype 3 with baseline RAS like A30K, Y93H, and P53del. Moreover, the European Association for the Study of the Liver recommended the identification of baseline RAS for HCV genotype 1a. The higher rate of hepatocellular carcinoma (HCC) after DAA therapy may be related to the fact that DAA regimens are offered to patients with advanced liver fibrosis and cirrhosis, where interferon was contraindicated to those patients. The change in the growth of pre-existing subclinical, undetectable HCC upon DAA treatment might be also a cause. Furthermore, after DAA therapy, the T cell-dependent immune response is much weaker upon HCV clearance, and the down-regulation of TNF-α or the elevated neutrophil to lymphocyte ratio might increase the risk of HCC. DAAs can result in reactivation of hepatitis B virus (HBV) in HCV co-infected patients. DAAs are effective in treating HCV-associated mixed cryoglobulinemia, with clinical and immunological responses, and have rapid and high effectiveness in thrombocytopenia. DAAs improve insulin resistance in 90% of patients, increase glomerular filtration rate, and decrease proteinuria, hematuria and articular manifestations. HCV clearance by DAAs allows a significant improvement in atherosclerosis and metabolic and immunological conditions, with a reduction of major cardiovascular events. They also improve physical function, fatigue, cognitive impairment, and quality of life. Early therapeutic approach with DAAs is recommended as it cure many of the EHMs that are still in a reversible stage and can prevent others that can develop due to delayed treatment.
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Affiliation(s)
- Iman Ibrahim Salama
- Department of Community Medicine Research, National Research Center, Giza 12622, Dokki, Egypt
| | - Hala M Raslan
- Department of Internal Medicine, National Research Center, Giza 12622, Dokki, Egypt
| | - Ghada A Abdel-Latif
- Department of Community Medicine Research, National Research Center, Giza 12622, Dokki, Egypt
| | - Somaia I Salama
- Department of Community Medicine Research, National Research Center, Giza 12622, Dokki, Egypt
| | - Samia M Sami
- Department of Child Health, National Research Center, Giza 12622, Dokki, Egypt
| | - Fatma A Shaaban
- Department of Child Health, National Research Center, Giza 12622, Dokki, Egypt
| | - Aida M Abdelmohsen
- Department of Community Medicine Research, National Research Center, Giza 12622, Dokki, Egypt
| | - Walaa A Fouad
- Department of Community Medicine Research, National Research Center, Giza 12622, Dokki, Egypt
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Chen YC, Tseng CW, Tseng KC. Rapid platelet count improvement in chronic hepatitis C patients with thrombocytopenia receiving direct-acting antiviral agents. Medicine (Baltimore) 2020; 99:e20156. [PMID: 32384505 PMCID: PMC7220127 DOI: 10.1097/md.0000000000020156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The effect of direct-acting antiviral agents (DAAs) on short-term platelet improvement in chronic hepatitis C (CHC) patients with thrombocytopenia is unclear.From December 2015 to March 2018, a total of 249 CHC patients receiving DAA treatment with baseline thrombocytopenia (platelet count <150 × 10 /μL) at Dalin Tzu Chi Hospital were enrolled in this retrospective study. Blood examinations were conducted at baseline (BL), week 4 (W4) after DAA initiation, end of treatment (EOT), and 12 weeks after EOT (P12).Hepatitis C virus (HCV) genotyping revealed that 184 patients (73.9%) carried HCV genotype 1. Of the patients in the cohort, 87 (34.9%) were interferon (IFN)-experienced, and 213 (85.5%) had advanced fibrosis. All but 1 patient achieved SVR12 (sustained virologic response (SVR) rate, 99.6%; 248/249). The platelet count recovered significantly in 104 patients (41.7%; 104/249). The mean baseline platelet count was 102 × 10/μL before DAA, increasing to 116 × 10/μL, 114 × 10/μL, and 113 × 10/μL at W4, EOT, and P12, respectively. Comparison of the mean platelet count at baseline with that at W4, EOT, and P 12 showed statistically significant increases at all time points (W4 vs BL, P < .001; EOT vs BL, P < .001; P12 vs BL, P < .001). Multivariate analyses revealed moderate or severe fatty liver (P = .024) and lower baseline platelet count (P = .005) was significantly associated with platelet count improvement.In conclusion, thrombocytopenia associated with CHC rapidly improves with the administration of DAA. Moderate or severe fatty liver and lower baseline platelet count predict significant improvement of platelet count.
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Affiliation(s)
- Yen-Chun Chen
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
| | - Chih-Wei Tseng
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
- School of Medicine, Tzuchi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi
- School of Medicine, Tzuchi University, Hualien, Taiwan
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Sayyar M, Saidi M, Zapatka S, Deng Y, Ciarleglio M, Garcia-Tsao G. Platelet count increases after viral elimination in chronic HCV, independent of the presence or absence of cirrhosis. Liver Int 2019; 39:2061-2065. [PMID: 31365178 DOI: 10.1111/liv.14203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/02/2019] [Accepted: 07/28/2019] [Indexed: 12/29/2022]
Abstract
UNLABELLED Platelet (PLT) count is included in non-invasive scores assessing liver fibrosis in patients with chronic liver disease. Improvement in fibrosis scores after antiviral treatment for hepatitis C virus (HCV) has been interpreted as indicative of an improvement in fibrosis. HCV itself can lower PLT and, therefore, an increase in PLT would be expected after viral elimination irrespective of pretreatment fibrosis stage. The aim of this study was to investigate this hypothesis by assessing changes in PLT after viral elimination in patients with chronic HCV stratified by the absence or presence of cirrhosis. METHODS Retrospective analysis of patients with chronic HCV infection treated with direct-acting antivirals (DAAs) who achieved viral elimination and in whom PLT were obtained prior to treatment, at first negative HCV-RNA, at treatment completion and at 6 months, and 1 year after treatment completion. Comparisons were made between patients with and without cirrhosis. RESULTS A total of 420 patients with chronic HCV were treated, of which 208 were excluded, leaving 212 patients eligible for analysis (142 without cirrhosis, 70 with cirrhosis). Overall, a significant increase in PLT was observed up to 1 year after antiviral treatment completion (P < .001). Changes in PLT between patients with and without cirrhosis were not significantly different at any of the time points. CONCLUSION Platelet count increased significantly in patients with HCV who achieved viral elimination irrespective of the absence or presence of cirrhosis. This suggests that changes in PLT post-viral elimination should not be interpreted as being reflective of changes in liver fibrosis or portal hypertension.
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Affiliation(s)
- Mubarak Sayyar
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA.,Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Marie Saidi
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA.,Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Susan Zapatka
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Maria Ciarleglio
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA.,Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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Thrombocytopenia in Patients with Chronic Hepatitis C Virus Infection. Mediterr J Hematol Infect Dis 2017; 9:e2017019. [PMID: 28293407 PMCID: PMC5333732 DOI: 10.4084/mjhid.2017.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 12/11/2022] Open
Abstract
Thrombocytopenia in patients with chronic hepatitis C virus (HCV) infection is a major problem. The pathophysiology is multifactorial, with auto-immunogenicity, direct bone marrow suppression, hypersplenism, decreased production of thrombopoietin and therapeutic adverse effect all contributing to thrombocytopenia in different measures. The greatest challenge in the care of chronic HCV patients with thrombocytopenia is the difficulty in initiating or maintaining IFN containing anti-viral therapy. Although at present, it is possible to avoid this challenge with the use of the sole Direct Antiviral Agents (DAAs) as the primary treatment modality, thrombocytopenia remains of particular interest, especially in cases of advanced liver disease. The increased risk of bleeding with thrombocytopenia may also impede the initiation and maintenance of different invasive diagnostic and therapeutic procedures. While eradication of HCV infection itself is the most practical strategy for the remission of thrombocytopenia, various pharmacological and non-pharmacological therapeutic options, which vary in their effectiveness and adverse effect profiles, are available. Sustained increase in platelet count is seen with splenectomy and splenic artery embolization, in contrast to only transient rise with platelet transfusion. However, their routine use is limited by complications. Different thrombopoietin analogues have been tried. The use of synthetic thrombopoietins, such as recombinant human TPO and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMDGF), has been hampered by the development of neutralizing antibodies. Thrombopoietin-mimetic agents, in particular, eltrombopag and romiplostim, have been shown to be safe and effective for HCV-related thrombocytopenia in various studies, and they increase platelet count without eliciting any immunogenicity Other treatment modalities including newer TPO analogues-AMG-51, PEG-TPOmp and AKR-501, recombinant human IL-11 (rhIL-11, Oprelvekin), recombinant human erythropoietin (rhEPO), danazol and L-carnitine have shown promising early result with improving thrombocytopenia. Thrombocytopenia in chronic HCV infection remain a major problem, however the recent change in DAAs without IFN, as the frontline therapy for HCV, permit to avoid the dilemmas associated with initiating or maintaining IFN based anti-viral therapy.
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Rivero-Juarez A, Gonzalez R, Frias M, Manzanares-Martín B, Rodriguez-Cano D, Perez-Camacho I, Gordon A, Cuenca F, Camacho A, Pineda JA, Peña J, Rivero A. KIR2DS2 as predictor of thrombocytopenia secondary to pegylated interferon-alpha therapy. THE PHARMACOGENOMICS JOURNAL 2016; 17:360-365. [PMID: 26975229 DOI: 10.1038/tpj.2016.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/22/2016] [Accepted: 01/27/2016] [Indexed: 12/28/2022]
Abstract
Our aim was to evaluate the killer cell immunoglobulin-like receptors (KIRs) as a marker for the development of thrombocytopenia secondary to Peg-interferon (IFN) therapy in a cohort of human immunodeficiency virus (HIV)/hepatitis C virus (HCV) co-infected patients. Patients were naive to HCV treatment, receiving a first course of Peg-IFN/Ribavirin combination therapy. Total platelet count (cells ml-1) was determined at each visit, determining platelet decline from baseline to weeks 1, 2, 4, 8 and 12 after starting therapy. The end point of the study was development of thrombocytopenia, defined as a platelet count of <1 50 000 cells ml-1. Fifty-eight HIV/HCV co-infected patients were included in the study, of whom 20 (34.4%) developed thrombocytopenia. The absence of KIR2DS2 was associated with higher and faster rate of thrombocytopenia (54.2% vs 22.5%; P=0.012; 6.6 vs 10.3 weeks; P=0.008). The absence of KIR2DS2 was associated with a greater decline in platelet count and development of thrombocytopenia during Peg-IFN treatment in HIV/HCV co-infected patients.
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Affiliation(s)
- A Rivero-Juarez
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - R Gonzalez
- Immunology Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - M Frias
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - B Manzanares-Martín
- Immunology Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - D Rodriguez-Cano
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - I Perez-Camacho
- Service de Medicina Tropical, Hospital de Poniente, El Ejido, Almería, Spain
| | - A Gordon
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - F Cuenca
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - A Camacho
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - J A Pineda
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario de Valme, Seville, Spain
| | - J Peña
- Cellular Biology, Physiology and Immunology Department, Universidad de Córdoba, Córdoba, Spain
| | - A Rivero
- Infectious Diseases Unit, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía de Córdoba, Universidad de Córdoba, Córdoba, Spain
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