Rescue therapy for chronic hepatitis C virus infection after repeated treatment failures: Impact on disease progression and risk of hepatocellular carcinoma

Dismal prognosis for cirrhotic patients with hepatitis C after initial failure of direct acting anti-virals, but salvage therapy may be life-saving

BACKGROUND

Effective direct-acting antiviral treatment against hepatitis C virus infection is available in many countries worldwide. Despite good treatment results, a proportion of patients does not respond to treatment. The aim of this study was to investigate the long-term prognosis and the outcome of salvage therapy, after an initial treatment failure, in a nation-wide real-life setting.

METHOD

Data from all adult patients registered in the national Swedish hepatitis C treatment register who did not achieve sustained virological response after initial antiviral treatment, was retrieved from 2014 through 2018.

RESULTS

In total, 288 patients with primary treatment failure were included, of whom 236 underwent a second treatment course as salvage therapy after a median delay of 353 (IQR: 215-650) days. Fifteen patients received a third treatment course as second salvage treatment after a further median delay of 193 (IQR: 160-378) days. One-hundred-eleven out of 124 (90%) non-cirrhotic and 62/79 (78%) cirrhotic patients achieved sustained virological response following the first salvage treatment. Sustained virological response was achieved by 108/112 (96%) patients who received a triple antiviral regimen. In total 69 patients were lost to follow-up or died waiting for salvage treatment. Baseline cirrhosis was associated with poor long-term survival.

CONCLUSION

Our study indicates that salvage therapy was effective in most patients with primary treatment failure, in particular when a triple direct acting antiviral regimen was given. To avoid the risk of death or complications, patients with primary treatment failure should be offered salvage therapy with a triple regimen, as soon as possible.

Diagnostic Accuracy of Red Cell Distribution Width to Platelet Ratio for Detection of Liver Fibrosis Compared with Fibroscan in Chronic Hepatitis B Egyptian patients

Background and Aims:

The decision to treat chronic hepatitis B Virus infection (CHB) may necessitate an assessment of the degree of liver fibrosis. Guidelines recommend Fibroscan examination in such cases. However, it is costly and not widely available. Red cell distribution width (RDW) and platelet count are simple parameters obtained from the blood pictures; and their ratio RDW to platelet ratio (RPR) was claimed to correlate with liver fibrosis. We aimed to assess the ability of RPR to replace the costly fibroscan in the detection of significant fibrosis in chronic hepatitis B patients.

Patients and Methods:

This cross-sectional study was conducted in the Tropical medicine department, Tanta University, Egypt, between December 2018 and September 2019. One hundred and twenty-five patients with CHB were included and divided according to the fibroscan examination into: Group I: patients with no significant fibrosis (n=66), Group II: patients with significant (≥ F2) fibrosis (n=59). RPR was calculated for all patients and tested against Fibroscan results.

Results:

Both groups were matched in regards to age, sex, viral load, and steatosis. There was a significant positive correlation between the degree of stiffness measured by FibroScan in patients with a significant degree of fibrosis and serum bilirubin, a quantitative polymerase chain reaction of hepatitis B virus DNA (HBV DNA PCR), and fibrosis-4 score (FIB-4 score) (P value= 0.020, 0.049, and 0.0402, respectively). However, RPR was not correlated to the degree of fibrosis in fibroscan examination.

Conclusions:

The accuracy of RDW to platelet ratio (RPR) for the detection of fibrosis in CHB patients is questionable. FIB-4 is correlated with liver stiffness measurement (LSM) in patients with significant fibrosis (F2 or more). Neither RPR, AST to Platelet Ratio Index (APRI) or FIB4 can replace fibroscan for grading of fibrosis in CHB patients for evaluation to start therapy.

Results of interferon-free treatment for HCV-infected patients with decompensated cirrhosis from a Brazilian real-life cohort

Real-life data on the HCV treatment with direct-acting agents in patients with decompensated cirrhosis are scarce. Study to investigate the effectiveness and safety of sofosbuvir-containing regimens in a prospective cohort of patients with HCV decompensated cirrhosis. A total of 150 patients were enrolled (64% male, 84% genotype 1 with a mean age of 61 ± 9 years). The median MELD was 12, and 79% were Child-PughB. Most patients were treated with sofosbuvir and daclatasvir (98%) with ribavirin in 27%. The overall intention to treat SVR12 was 91% (137/150). The most frequent adverse event was anemia (17%), 73% associated with ribavirin. Twenty-one (14%) patients experienced renal dysfunction, 81% AKI I, and 1 discontinued treatment. Thirty-five (23%) patients presented at least 1 infectious episode, mainly respiratory tract infection (29%). Thirty-three patients (22%) had at least 1 episode of cirrhosis decompensation throughout treatment, particularly worsening of previous ascites in 19%. Nine patients died, and among those, 7 patients died from sepsis. The probability of decompensation in 28, 90 and 180 days was 4%, 19% and 25%. During treatment, infection (OR 2.24; 95 CI 1.09-4.61; P = .03) was a predictor of cirrhosis decompensation, and baseline MELD and CHILD ≥ B8 were both associated with infection. In decompensated cirrhosis, the overall virological response was high with mild adverse events. However, this population had a high frequency of liver-associated decompensation and infections.

Seroprevalence of hepatitis C virus infection in children: A systematic review and meta-analysis

BACKGROUND AND AIMS

Estimates of paediatric hepatitis C virus (HCV) seroprevalence are needed to aid treatment scaling-up, screening and detection approach in this age range, with the ultimate goal of global HCV eradication. The aim of this study was to gather all of the available information on HCV seroprevalence in children all around the world.

METHODS

We searched PubMed, Scopus, Web of Science (WOS), Wiley and EBSCO databases for all studies evaluating HCV seroprevalence in children; however, studies examining seroprevalence in high-risk children or specific groups were excluded.

RESULTS

Only 20 articles with 48 963 people met our inclusion criteria, with an overall prevalence of 0.904% and a 95% confidence interval (CI) of 0.543 to 1.355. Seroprevalence was higher in research published prior to 2010 than in those published after 2010 (0.77% vs. 0.53%).

CONCLUSION

Few studies were conducted to assess the seroprevalence of HCV in children worldwide. However, the worldwide pooled seroprevalence of HCV in children in these studies is low (less than 1%).

Role of Serum Cystatin C as a Diagnostic Tool for Renal Function in Cirrhotic Patients

Background:

Assessment of cystatin C levels could be valuable in the early detection of renal dysfunction because they increase faster than the creatinine levels as the GFR decreases. The aim of this work was to evaluate serum cystatin C as a diagnostic tool for renal dysfunction in cirrhotic patients with and without hepatorenal syndrome (HRS).

Methods:

This case-control study was conducted on 60 patients from the Tropical Medicine Department of Tanta University Hospitals and 10 people served as healthy control volunteers. Serum cystatin C was measured in the three groups.

Results:

A significant difference was observed among the three groups as cystatin C was higher in patients with HRS compared to the cirrhotic group and healthy controls.

Conclusion:

Serum cystatin C is a good predictor for hepatorenal syndrome with a good correlation with serum creatinine, blood urea, GFR, and creatinine clearance.

Metabolomic biomarkers for hepatocellular carcinoma: A systematic review

Hepatocellular carcinoma (HCC) is a highly malignant cancer which lack of effective diagnosis and prognosis biomarkers, therefore surging studies focused on the metabolite candidates for HCC. The current study was designed to systematically review the metabolic studies for HCC, summarize the current available evidence and provide implication for further studies within this area. By systematically screening Pubmed and Embase, and eligibility assessment, we eventually included 55 pieces of studies. After summarized their characteristics, we reviewed them by 3 parts, regarding to the different biofluid they carried out the experiments. By collecting the candidates from all the included studies, we carried out pathway enrichment to see the representative of the reported candidates, as expected the pathway consistent with the current knowledge of HCC. Next, we conduct quality assessment on the included studies. Only 36% of the current evidence grouped as high quality, indicating the quality of metabolic studies needs further improvement.

Lipid Profiles as Markers for the Severity of Liver Diseases in Cirrhotic Patients

Background

Liver cirrhosis is a diffuse process in which the anatomical structure and function of the liver are disturbed. Lipid metabolism occurs mainly in the hepatocytes. In liver cirrhosis, it is expected to detect abnormal lipid profile and abnormal neutrophil to lymphocyte ratio due to necro-inflammation and hepatocyte dysfunction. This study aimed to estimate the lipid profile in patients with liver cirrhosis and to assess its relation to the severity of the liver disease based on Child-Pugh Turcotte score and Neutrophil to Lymphocyte Ratio (NLR).

Methods:

This study included 500 cirrhotic patients. All patients are subjected to history taking, clinical examination, liver and renal function tests, lipid profile, and also abdomino-pelvic ultrasound. Child -Pugh score, fibrosis-4 score (FIB4), and neutrophil and platelet lymphocyte ratio were calculated.

Results:

A total of 500 patients were enrolled in this study; 12 patients were excluded (two patients were on the immunosuppressive drug, three patients had body mass index (BMI) >30, and seven patients took lipid-lowering drugs). Cholesterol level was significantly higher in patients with Child- Score A than B and C. Cholesterol, Low-Density Lipoprotein (LDL), and very-low-density lipoprotein (VLDL) cholesterol were significantly higher in Child B than C. A significant negative correlation was found between cholesterol level and each of FIB4 and NLR ratios.

Conclusion:

There was a significant negative correlation between the severity of liver cirrhosis and lipid profiles (except triglyceride), FIB4 and NLR ratio.

Study of hepatitis B virus infection, reactivation among patients with chronic hepatitis C infection treated by direct antiviral agents (DAAs)

Background

Hepatitis B virus (HBV) may reactivate when treating chronic hepatitis C (CHC) with direct-acting antivirals (DAA). We aimed to investigate the risk of HBV infection and reactivation during DAA therapy by performing a prospective observational study carried on 200 patients positive for chronic HCV who were candidates for treatment by DAA therapy according to the Egyptian guidelines from February 2019 to December 2019; the patients identified to carry HBsAg at baseline or with positive HBc Abs were further assessed for other HBV markers: hepatitis B e antigen at baseline, and serum HBV DNA quantitative measurement at baseline, week 4 of treatment, end of treatment. On the other hand, recent infection by HBV among those patients was observed.

Results

Of all participants, 49% were males and 51% were females, aged above 18 years. There is a highly statistically significant difference (p-value < 0.05) between HCV RNA PCR (at the beginning, at the end of 4 weeks, and at the end of 12 weeks) in studied patients. There was a highly statistically significant difference found between the liver function tests at the beginning, at the end of 4 weeks, and at the end of 12 weeks of treatment where it shows improvement except for serum albumin. At beginning of the study, there were 34 patients who are co-infected with HCV and HBV with quantitative PCR test for HBV DNA ≥ 20 IU/ml. After 1 month of DAA therapy, reactivation was detected in 6 cases (4 occult cases show reverse seroconversion (became HBs Ag positive), and 2 co-infected cases show increased HBV DNA > 1000 IU/L above the baseline level). In addition, 3 new cases acquired recent infection with the positivity of HBc IgM and detectable levels of HBV DNA. After 3 months of study, reactivation was detected in one patient with co-infection (where increased HBV DNA > 1000 IU/L above the baseline level), and 5 new cases acquired recent infection late in the study.

Conclusion

Screening for HBV infection prior to DAA therapy is required to detect recent infection of reactivation of previous infection during or after DAA therapy.

Effect of Direct-Acting Antiviral Drugs on Erectile Functions among Hepatitis C Patients: A Prospective Interventional Study

BACKGROUND & OBJECTIVE

Erectile dysfunction (ED) is one of the extrahepatic manifestations of hepatitis C virus infection that greatly affects patients' quality of life. Unfortunately, some of the drugs used for HCV treatment may have a negative impact on the patient's erectile function such as the pegylated interferon. Currently, with the introduction of directacting antiviral drugs, there are scarce data in the literature about its potential impact on erectile function. In these settings, we aimed to assess the impact of sofosbuvir-based therapy on male erectile function.

METHODS

This prospective interventional study was carried out in Benha University hospitals between January 2019 and May 2020. The study included all consecutive HCV patients with simultaneous ED coming to the hepatology outpatient clinic. Patients were divided into a study group who received sofosbuvir-based therapy (group A) or a control group who received silymarin therapy (group B). The International Index of Erectile Function-5 (IIEF-5) was used for assessment of erectile function at different time points (pretreatment, 6 months, and 12 months after treatment). Different variables in both groups have been statistically analyzed.

RESULTS

Overall, 75 patients who received sofosbuvir-based therapy and a control group (n = 35) matched for age and pretreatment variables (Child-Turcotte-Pugh score and Fibrosis- 4 score). There was no significant difference between both groups in the pretreatment data. On the other hand, the posttreatment IIEF-5 was significantly higher in the sofosbuvir arm compared to the silymarin arm both at six months (p<0.001) and at 12 months (p<0.001). Furthermore, the age and the stage of liver fibrosis were negatively correlated with IIEF-5 at all-time points.

CONCLUSION

The age and the stage of liver fibrosis are significantly correlated with the degree of ED. Furthermore, sofosbuvir-based therapy may be associated with significant improvement in the patients' erectile function.

Risk of primary liver cancer associated with gallstones and cholecystectomy: A competing risks analysis

Previous research has revealed a positive relationship between GSD, cholecystectomy and primary liver cancer (PLC). However, previous studies had several limitations including the retrospective design, narrow assessment of potential confounders and lack of competing risk models in time-to-event analyses. We conducted a large prospective cohort study to explore the relationship between GSD, cholecystectomy and PLC. A total of 95,021 participants who had not been diagnosed with PLC previously were enrolled from the Kailuan Cohort study. Demographic characteristics and biochemical parameters were recorded at baseline for all participants. We used Cox regression models and competing risk regression models to evaluate the association of GSD and cholecystectomy with the risk PLC. A total of 306 incidental PLC cases were identified during a median follow-up of 9.05 (8.75-9.22) years per participant. Compared with the normal group, the multivariable HRs (95%CI) for the association of GSD and cholecystectomy with PLC were 1.77 (1.05-2.94), 5.25 (1.95-14.17). In the CS model, the multivariable HRs (95%CI) was 1.76 (1.05-2.94) for the association of GSD and cholecystectomy with PLC and 5.25 (1.95-14.17) for GSD and cholecystectomy. Similar results were also obtained in the SD model with corresponding multivariate HRs (95%CI) of 1.75 (1.01-3.00), 5.22 (1.90-14.07) in the GSD group and cholecystectomy group, respectively. GSD and cholecystectomy were associated with an elevated risk of PLC.Registration number: ChiCTR-TNRC-11001489.

Quadruple Therapy Offers High SVR Rates in Patients with HCV Genotype 4 with Previous Treatment Failure

BACKGROUND AND AIMS

Direct-acting antivirals (DAAs) have made a revolution in hepatitis C virus (HCV) treatment with promising reduction of HCV infection and disease morbidities. However, unfortunately, treatment failure still occurs in about 5-15% of patients treated with DAA-based combination regimens. The primary aim of the study was to assess the efficacy and safety of a quadruple regimen of (sofosbuvir, daclatasvir, and simeprevir with a weight-based ribavirin) in chronic HCV DAAs-experienced patients.

METHODS

This observational, open-label prospective study was carried out on 103 genotype 4 hepatitis C virus-infected patients who failed to achieve SVR12 after sofosbuvir-daclatasvir with or without ribavirin. Patients were treated for three months with sofosbuvir (400 mg), daclatasvir (60 mg), and simeprevir (150 mg) with a weight-based ribavirin dosage (1000-1200 mg/d). Response to treatment was determined by quantitative PCR for HCV at 3 months after the end of treatment (SVR12), and adverse events during the treatment were recorded.

RESULTS

SVR was achieved in 100 patients (97.1%) at week 12 after treatment. No dangerous or life-threatening adverse events were recorded.

CONCLUSIONS

Retreatment of HCV genotype 4 patients with quadruple therapy is a good therapeutic option and achieves high response rates with minimal side effects.

TIPS Is Not Associated with a Higher Risk of Developing HCC in Cirrhotic Patients: A Systematic Review and Meta-analysis

Background and Aims: The association between portal-systemic shunt and hepatocellular carcinoma (HCC) development in patients who have cirrhosis is still controversial. This systematic review with meta-analysis was performed to systematically clarify the potential role of portal-systemic shunt in the development of HCC. Methods: The PubMed, Embase, and Cochrane Library databases were searched for potentially eligible literature. Meta-analysis with random-effects model was performed to combine the incidence rates of HCC after portal-systemic shunt. Finally, seven studies were included. In the present review, we mainly focused on 859 patients (365 in the transjugular intrahepatic portal-systemic shunt (TIPS) group and 494 in the non-TIPS group) from five studies to analyze incidence rates after TIPS. Results: At the end of follow-up, there were 66 (18%, 66/365) patients who developed HCC after TIPS intervention and 63 (13%, 63/494) patients who developed HCC after non-TIPS treatments. Pooled estimates with random-effects model did not demonstrate a significant increase of incidence of HCC after TIPS (risk ratio: 1.37 [confidence interval (CI): 0.96 to 1.97]; p = 0.08) compared with non-TIPS treatments. Subgroup analyses for those patients with transplanted liver also did not detect a significant difference between the TIPS group and non-TIPS group (risk ratio: 1.10 [CI: 0.59 to 2.07]; p = 0.75). Conclusions: Current evidence suggests that portal-systemic shunt is not associated with a higher risk of HCC development in cirrhotic patients.