Hepatitis C virus infection in a resident elderly population: a 10-year follow-up study

Chronic Liver Disease in the Older Patient-Evaluation and Management

PURPOSE OF REVIEW

As our population ages, the number of elderly patients with advanced chronic liver disease (ACLD) will increase. In this review we explore risk factors for liver injury, noninvasive assessment of liver disease, complications of cirrhosis, and management of frailty and sarcopenia in the older patient with ACLD.

RECENT FINDINGS

Multiple guidelines regarding ACLD have been updated over the past few years. New cutoffs for FIB-4 and NAFLD (MASLD - Metabolic Dysfunction Associated Steatotic Liver Disease) fibrosis scores for elderly patients are being validated. Older patients with MASLD benefit from caloric restriction, exercise programs, and GLP-1 agonists. Patients with ACLD need to be screened for alcohol use disorder with modified scoring systems, and if positive, benefit from referral to chemical dependency programs. Carvedilol and diuretics may safely be used in the elderly for portal hypertension and ascites, respectively, with careful monitoring. Malnutrition, frailty, sarcopenia, and bone mineral disease are common in older patients with ACLD, and early intervention may improve outcomes. Early identification of ACLD in elderly patients allows us to manage risk factors for liver injury, screen for complications, and implement lifestyle and pharmacological therapy to reduce decompensation and death. Future studies may clarify the role of noninvasive imaging in assessing liver fibrosis in the elderly and optimal interventions for nutrition, frailty, sarcopenia, bone health in addition to reevaluation of antibiotic prophylaxis for liver conditions with rising antibiotic resistance.

Hepatitis C Infection in the Elderly

Hepatitis C virus (HCV) infection in the elderly population is a global medical burden and healthcare utilization concern. The majority of patients with hepatitis C in the USA are "baby boomers," who were born between 1945 and 1965. Consistently worldwide, HCV infection in elderly population is overrepresented and poses public health concerns. These individuals have been infected now for over two decades and are presenting with advanced liver disease. Traditionally, the use of pegylated interferon-based therapy has been limited in the elderly because of its adverse effects. The sustained virologic responses have also tended to be lower in the elderly than in younger adults. The emergence of non-interferon-based therapy with direct acting antiviral agents has expanded the pool of patients eligible for treatment. These agents have been found to be effective, tolerable, and safe in the elderly population.

Chronic hepatitis C in the aged: much ado about nothing or nothing to do?

Hepatitis C is a common infection worldwide. It is a major cause of cirrhosis and its complications, including hepatocellular carcinoma and liver transplantation. Treatment of hepatitis C has dramatically improved since its discovery. Current treatment includes pegylated interferon and ribavirin, and the addition of the protease inhibitors telaprevir, boceprevir, or simeprevir, or the polymerase inhibitor sofosbuvir. The rate of sustained viral response, considered a cure, now approaches 80 %. These treatments are complex, with multiple morbidities and drug interactions. The majority of patients with chronic hepatitis C are from the birth cohort of the 'baby boomer' years (1945-1965) with the oldest already 68 years old. In spite of this, most hepatitis C patients in clinical trials have been much younger and this is still the case in the ongoing studies. Thus, the group of patients most likely to require treatment in the future will have decisions made with a relative lack of evidence-based medicine. It is the purpose of this article to review the epidemiology, clinical manifestations, and treatment of hepatitis C with the data available in the aged population.

Liver physiology and liver diseases in the elderly

The liver experiences various changes with aging that could affect clinical characteristics and outcomes in patients with liver diseases. Both liver volume and blood flow decrease significantly with age. These changes and decreased cytochrome P450 activity can affect drug metabolism, increasing susceptibility to drug-induced liver injury. Immune responses against pathogens or neoplastic cells are lower in the elderly, although these individuals may be predisposed to autoimmunity through impairment of dendritic cell maturation and reduction of regulatory T cells. These changes in immune functions could alter the pathogenesis of viral hepatitis and autoimmune liver diseases, as well as the development of hepatocellular carcinoma. Moreover, elderly patients have significantly decreased reserve functions of various organs, reducing their tolerability to treatments for liver diseases. Collectively, aged patients show various changes of the liver and other organs that could affect the clinical characteristics and management of liver diseases in these patients.

Viral hepatitis in the elderly

As life expectancy continues to rise, elderly adults represent a rapidly growing proportion of the population. The likelihood of complications of acute and chronic liver disease and overall mortality are higher in elderly populations. Several physiological changes associated with aging, greater prevalence of co-morbid conditions, and cumulative exposure to hepatotropic viruses and environmental hepatotoxins may contribute to worse outcomes of viral hepatitis in the elderly. Although pharmacotherapy for hepatitis B and C continues to evolve, the efficacy, tolerability, and side effects of these agents have not been studied extensively in elderly adults. Immunization against hepatitis A and B in naïve elderly adults is an important public health intervention that needs to be revised and broadened.

Diagnosis and management of chronic liver disease in older people

Chronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.

Seroprevalence of HCV and its co-infection with HBV and HIV among liver disease patients of South Tamil Nadu

AIM

To determine the seroprevalence of hepatitis C virus (HCV) and its co-infection with hepatitis B virus (HBV), hepatitis delta agent (HDV) and human immunodeficiency virus (HIV) among liver disease patients of south Tamil Nadu.

METHODS

A total of 1012 samples comprising 512 clinically diagnosed cases of liver disease patients and 500 apparently healthy age and sex matched individuals were screened for Hepatitis C virus (anti HCV and HCV RNA), Hepatitis B virus (HBsAg), Hepatitis delta agent (anti HDV) and Human immuno virus (antibodies to HIV-1 and HIV-2) using commercially available enzyme linked immunosorbent assay kits. HCV RNA was detected by RT-PCR. Liver function tests like ALT, AST, GGT, ALP, bilirubin and albumin were also studied.

RESULTS

The seroprevalence of HCV was found to be 5.6% among liver disease patients by ELISA. 27/512, 49/512 and 12/512 patients were positive for HIV, HBV & HDV respectively. Co-infection of HCV & HBV was found in 8 patients, with 6 for HCV & HIV and 4 for HCV, HBV & HIV co-infections. Sex-wise analysis showed that HIV, HCV & HBV and HCV & HIV co-infection was high among females whereas for HBV it was high in males. The mean ALT and AST in HCV positive cases were 42.1 ± 8.3 and 49 ± 10.1. In people co-infected with HCV & HBV or HCV & HIV or HCV, HBV & HIV the mean ALT of 58.0 ± 03.16, 56.78 ± 4.401 and 64.37 ± 4.01 respectively.

CONCLUSION

We strongly recommend routine test of the blood for HCV in addition to HBV and HIV. We also recommend individualized counseling to identify those at risk and testing for those who want it. Improved surveillance and periodic epidemiological studies will have to be undertaken to monitor and prevent these blood-borne viruses.

Liver disorders in the elderly

Although there are no specific age-related liver diseases, it is increasingly recognized that the percentage and the actual number of elderly will increase substantially over the next twenty years. Moreover, the developments of new emerging conditions (e.g. non-alcoholic steatohepatitis) and novel therapeutic approaches have provoked increasing enthusiasm among hepatologists. Some liver diseases are particularly frequent in the elderly, e.g. chronic hepatitis C and hepatocellular carcinoma. The clinical course and management of liver disease in the elderly may differ in several aspects from those of younger adults. The problem of whether to offer antiviral treatment to a wide range of patients with chronic hepatitis C has arisen over the last eight to ten years, since the reduction in the risk of hepatocellular carcinoma was analyzed. Selected patients aged 65 and older have a chance of treatment with pegylated interferon plus ribavirin, despite a higher likelihood of side effects. The diagnosis of autoimmune hepatitis should be suspected in a patient over 65 years of age in case of 'acute' presentation with 10-fold increase in transaminases, jaundice and hyper-gammaglobulinemia, to avoid any delay in starting immunosuppressive therapy. The age of an end stage liver disease will increase over the next years, thus we will expects an increasing number of decompensated liver disease and hepatocellular carcinomas.

Chronic liver disease in an ageing population

The prevalence of chronic liver disease is increasing in the elderly population. With a mostly asymptomatic or non-specific presentation, these diseases may easily go undiagnosed. Abnormal liver function tests of unknown cause are a common reason for referral to secondary care. Investigating the older person with abnormal liver function is important; even with mild abnormalities, the same vigilance should be applied to an older person as in a young person. Liver biopsy is safe but often overlooked in this age group and may provide useful information to diagnose, direct therapy and prognosticate. Treatment options are similar for all age groups, with a few subtle differences, although further evidence is frequently required for the older population. Morbidity and age-adjusted mortality are often more severe in older people, and therefore early diagnosis and intervention is important. Presented here are the most common chronic liver diseases that geriatricians are likely to encounter in clinical practise. Their epidemiology, clinical features, investigation, treatment and mortality are described with a particular focus on the elderly population.

Hepatitis C virus infection in the elderly: epidemiology, natural history and management

Hepatitis C virus (HCV) infection frequently occurs in elderly individuals, with a prevalence in individuals aged >60 years of up to approximately 40%. Although progression to cirrhosis is accelerated and occurs more frequently in patients who acquire the infection in old age, this outcome is often not seen because most elderly infected patients acquired HCV when they were young. Data on progression of HCV infection to cirrhosis and eventually to hepatocellular carcinoma are often derived from studies of HCV-infected individuals who present or are referred to hospitals, and which are therefore likely to overestimate the seriousness of the disease; indeed, population-based studies indicate that in many elderly individuals the disease is asymptomatic and runs a fairly benign course. Treatment is based on use of pegylated interferon-alpha and ribavirin, and is overall less effective and more toxic in the elderly. Therefore, treatment should be carefully considered on an individual basis and proposed only in patients up to the age of 75 years with a significant risk of progression of liver disease, no serious co-morbidities and good life expectancy. All treated patients should be followed long term in order to assess the influence of therapy on the evolution of liver disease (decompensated cirrhosis, hepatocellular carcinoma) and survival. It is hoped that liver biopsy, which is still required in order to assess prognosis appropriately, will be replaced in the future by less invasive methods based on combinations of biochemical markers of fibrosis and/or transient elastography, and that newer and less toxic orally administered drugs for HCV infection will become available.

Epidemiological aspects of hepatitis C virus infection among HIV-infected individuals in Mato Grosso State, Central Brazil

The present study has been carried out to estimate the prevalence of HCV among HIV-positive individuals in the state of Mato Grosso, Central Brazil, as well as to identify the associated epidemiological factors. One thousand and eight individuals over 18 years of age bearing HIV/aids and being attended in the reference public health network of the state of Mato Grosso participated in this research. HIV-positive subjects were interviewed and blood samples were taken to be tested for anti-HCV antibodies by enzyme immunoassay (EIA). The anti-HCV antibodies were investigated in all the individuals by immunoenzymatic assay. The reactive samples in duplicate were submitted to a polymerase chain reaction (PCR) to detect HCV-RNA. The positive tests were submitted for genotyping by the LIA method. One hundred and ten (10.9%; CI 95%: 9.1-13.0) HIV-positive individuals presented anti-HCV by EIA. The PCR was positive in 60 (6.0%; CI 95%: 4.6-7.6) individuals. The 1a genotype was the most frequent, followed by the 3a and 1b. The genotype 2 was found in only one individual. There were more male and intravenous drug users among HIV-HCV coinfected individuals when compared to only HIV-infected individuals. Multivariate analysis revealed an association between the HIV-HCV coinfection, regarding either EIA or PCR results, and the use of intravenous drugs, the presence of tattoos, and having received blood transfusions before 1994. There was no association of the coinfection with the variables related to sexual transmission. The relatively low prevalence of HCV infection in the HIV-positive population in that region may be a consequence of a small number of intravenous drug users in the sample, despite a strong association between HCV infection and use of intravenous drugs.