A rational approach to the management of hepatitis C infection

Interferon therapy in hemodialysis patients with chronic hepatitis C: study of tolerance, efficacy and post-transplantation course

BACKGROUND

The potential benefit of pre-transplant treatment of chronic hepatitis C on long-term evolution after renal transplantation is not clear.

METHODS

Fifty successive renal transplant candidates had their sera positive for HCV RNA and a biopsy-proven chronic hepatitis. Out of these, 18 patients received a standard course of interferon-alpha2b (IFN; 3 MU three times weekly after hemodialysis sessions for 6 months).

RESULTS

IFN was discontinued in 2 patients (11%) due to persistent leukopenia. HCV RNA turned negative in 10 patients of the treatment group and in none of the control group. Two patients of the IFN group had a virological relapse post-transplantation. Post-transplant follow-up periods were 41.5 +/- 15 and 50 +/- 16 months for the treated and control groups respectively. Transaminases remained normal in all patients of the IFN group after transplantation. In contrast, biochemical evidence of acute and chronic hepatitis was observed in 5 (p = 0.03) and 13 (p = 0.002) patients, respectively, of the control group. Logistic regression analysis identified non-receiving IFN before transplantation as a risk factor for post-transplant hepatic dysfunction (odds ratio = 11.7, p = 0.003) and for chronic allograft nephropathy (odds ratio = 11.6, p = 0.02).

CONCLUSIONS

IFN-treated patients had a significantly better post-transplant hepatic function and significantly lower rates of chronic allograft nephropathy.

Outcome of an optional HCV screening program for blood transfusion recipients in Ireland

BACKGROUND

An optional (general) HCV testing program for blood and blood component recipients before the introduction of routine donor anti-HCV screening (October 1991) was launched in Ireland in 1995 to complement the targeted lookback program in progress at that time and to identify transfusion-transmitted hepatitis C.

STUDY DESIGN AND METHODS

The public were informed of the opportunity to avail of screening by widespread media coverage. Screening was by an initial ELISA (Abbott 3.0, Abbott Laboratories) at the transfusion center laboratories. Reactive samples were referred to a virus reference laboratory where two additional ELISAs (Ortho 3.0, Ortho Clinical Diagnostics; and Murex 3.0, Murex) were performed. Confirmation of ELISA-positive samples was by a RIBA (RIBA 3.0, Chiron Corp.). All patients found to be anti-HCV- seropositive were tested for HCV RNA by PCR and were referred to a hepatologist.

RESULTS

A total of 14,917 persons have been tested for hepatitis C in this program to date (85% women). Sixty-one people were confirmed positive for HCV by RIBA 3.0 (0.4%). Excluding persons with other risk factors (n = 15), the HCV positivity rate for blood component transfusion recipients (n = 46) was 0.3 percent. Of the 46 confirmed hepatitis C-positive blood component transfusion recipients, 32 were women (70%), 24 of whom received transfusion for obstetric or gynecologic indications (75%). Thirty-eight of 46 (83%) anti-HCV seropositive transfusion recipients tested had detectable HCV RNA by PCR.

CONCLUSION

This program identified 46 transfusion recipients and 10 coagulation factor concentrate recipients, all of whom were previously unaware of their infection. The majority of HCV-positive transfusion recipients identified were women. This may reflect that women are longer living survivors of transfusion therapy or alternatively, in our experience, that Irish women perceive themselves at greater risk of hepatitis C because of the well-publicized association of this virus with recipients (women) of Irish RhIG.

Ribavirin dose modification based on renal function is necessary to reduce hemolysis in liver transplant patients with hepatitis C virus infection

Hepatitis C virus (HCV) is currently the most common etiology for liver transplantation (LTx) in the United States. A significant number of patients develop recurrent HCV after LTx. Although there is no completely satisfactory treatment for recurrent HCV, a combination of interferon-alpha (INF) and ribavirin remains the most widely used. Ribavirin is eliminated through the kidneys and tends to accumulate in the presence of renal dysfunction. The primary side effect of ribavirin is hemolysis. The goal of the present study was to correlate the incidence of hemolysis with renal function in LTx patients with recurrent HCV who were being treated with ribavirin. The incidence of hemolysis and the renal function were examined in 72 liver transplant patients (58 male and 14 female patients) with recurrent HCV receiving INF (3 million units, three times per week) and ribavirin (initial dose of 400 mg twice daily). Patients were grouped according to the decrease in the percentage of hematocrit after the introduction of ribavirin, with their baseline serum creatinine and creatinine clearance calculated using the Cockcroft-Gault formula. The decrease in the percentage of hematocrit after ribavirin treatment was also examined with respect to creatinine clearance as a continuous variable. In addition, for purposes of presentation, patients were analyzed in three groups: creatinine clearance of >/= 70 mL/min (group A), creatinine clearance < 70 mL/min and >/= 40 mL/min (group B), and creatinine clearance < 40 mL/min (group C). Forty-five (62.5%) patients experienced a decrease in hematocrit (Hct) >/=15% after starting INF and ribavirin. The mean serum creatinine was 1.3 +/- 0.5 mg/dL (median, 1.3) in this group, and the mean calculated creatinine clearance was 71 +/- 29 mL/min (median, 66.47). In the 27 patients who did not show a significant decrease (< 15%) in hematocrit, the mean serum creatinine was 1.1 +/- 0.3 mg/dL (median, 1.0) and the mean creatinine clearance was 95 +/- 39 (median, 96) mL/min (P =.018). On continuous variable of calculated creatinine clearance, there was a trend in the decrease in hematocrit after ribavirin treatment compared with pretreatment (P =.09). However, the rate of hemolysis was significantly different in group A (53.7%), group B (70.8%), and group C (100%) (P =.042). Patients on INF and ribavirin therapy who experienced hemolysis had significantly higher serum creatinine levels and lower creatinine clearances compared with those who did not have hemolysis. The incidence of hemolysis was significantly associated with higher serum creatinine and decreased creatinine clearance. Because ribavirin is eliminated by the kidneys, this observation points to the need for adjustments in the dose of this agent in LTx patients, who tend to have some degree of renal dysfunction, to reduce the incidence of hemolysis. Further pharmacokinetic studies of ribavirin in LTx patients with varying degrees of renal function may allow the development of an algorithm for the safer use of ribavirin in HCV-positive LTx patients.

The role of viral load determination for the management of human immunodeficiency virus, hepatitis B virus and hepatitis C virus infection

During the last 5 years, considerable scientific and financial efforts have been made in the development of quantitative nucleic acid detection technology. For detection of human immunodeficiency virus (HIV), quantitative culture is time consuming, cumbersome and requires appropriate laboratory safety equipment. Quantitative determination of p24 antigen by enzyme immunoassay is of limited value due to its relatively poor sensitivity. Therefore, quantitative determination of viral load using nucleic acid amplification techniques is the most accurate, prognostic marker for HIV type 1 infection, independently of the CD4+ cell count. Hepatitis B virus (HBV) is not cultivable in vitro. Serological assays allow an accurate diagnosis and follow-up of acute or chronic infection. Quantification of HBV DNA is used for the monitoring of antiviral therapy, determination of infectivity and for resolution of unclear serological profiles, e.g. isolated anti-HBc reactivity, as well as for patients in which HBV mutants are suspected. Hepatitis C virus (HCV) can only be detected by molecular based assays because no cell culture system, which permits a reliable isolation of clinical specimens, is currently available. Furthermore, early diagnosis and follow-up of infection cannot be achieved with antibody serology. The prognostic relevance of quantitative HCV RNA determination is of limited value for the long-term prognosis of chronic hepatitis C. However, viral load may predict the outcome of antiviral therapy. Genetic diversity is another challenge for HCV RNA quantification.

Performance of the COBAS AMPLICOR HCV MONITOR test, version 2.0, an automated reverse transcription-PCR quantitative system for hepatitis C virus load determination

A clinical evaluation of an automated quantitative PCR assay, the COBAS AMPLICOR HCV MONITOR test, version 2.0 (v2.0), was carried out to assess the performance of this test in comparison with that of the previous, manual version, the AMPLICOR HCV MONITOR test, and with that of nested PCR. Serial dilutions of serum samples infected with genotype 1b, 2a, or 3, as well as synthetic RNA transcripts and serum samples derived from 87 patients with chronic hepatitis C and infected with genotype 1a, 1b, 2a, 2b, 3a, 3b, 4, or 5, were analyzed to determine the ability of the system to efficiently quantify various hepatitis C virus (HCV) genotypes. These experiments showed that the COBAS AMPLICOR HCV MONITOR test, v2.0, has mean intra-assay, interassay, and interoperator coefficients of variation that range from 22 to 34.5% and a 3-logarithm dynamic range, which spans from 10(3) to 10(6) copies/ml. Compared to the previous, manual version of the test, the COBAS AMPLICOR HCV MONITOR test, v2.0, showed an improved efficacy for all genotypes, especially genotypes 2, 3, and 4, whose estimated concentrations were on average 1 logarithm higher. When used to monitor patients under treatment, however, both versions showed the same patterns of viremia, indicating that the COBAS AMPLICOR HCV MONITOR test, v2.0, and the AMPLICOR HCV MONITOR test were equally effective at detecting relative viremia changes in serial samples. As expected, the automated test was less sensitive than nested PCR; among specimens from a cohort of patients treated with interferon, nested PCR identified three more viremic specimens, which probably contained very low concentrations of HCV RNA.

Hepatitis C

Hepatitis C virus infection is responsible for significant morbidity and mortality worldwide. Advances in detection and monitoring of hepatitis C virus infection, as well as treatment protocols, have contributed to the medical focus on this high profile disease. Presence of risk factors should increase the clinicians index of suspicion for this symptomatically nonspecific disease.

Effects of long-term interferon-alpha treatment on glucose tolerance in patients with chronic hepatitis C

BACKGROUND/AIMS

Interferon-a has been reported to acutely induce insulin resistance and glucose intolerance. The effects of long-term treatment with interferon-a on glucose metabolism remain unclear.

METHODS

Thirty-two Japanese patients with chronic hepatitis C were given interferon-a (6x10(6)U/day) daily for 2 weeks and thereafter 3 times weekly up to 6 months. The patients received a 75-g oral glucose tolerance test before the treatment. Fifteen patients also had an intravenous glucose tolerance test for an assessment of insulin sensitivity with Bergman's minimal model. These tests were repeated 3 months after the treatment.

RESULTS

Insulin sensitivity was not affected by the treatment (5.7+/-3.8 vs 5.2+/-3.8 10(-4) x min(-1) x mU(-1) x l , not significant) and a statistically significant but minimum decrease in area under the curve of plasma glucose (1012+/-332 vs 928+/-282 mmol x l(-1) x min, p<0.01) in a 75-g oral glucose tolerance test was noted. Acute insulin response to intravenous glucose tolerance tests (214+/-275 vs 294+/-334 mU x l(-1) x min, p<0.05) increased slightly.

CONCLUSION

Contrary to the known acute metabolic effects, interferon-a therapy for 3 months in patients with chronic hepatitis C did not have deleterious effects on insulin sensitivity and glucose tolerance.

The most prevalent hepatitis C virus genotypes in England and Wales are 3a and 1a

Hepatitis C virus (HCV) genotypes were assigned to 567 individuals by restriction fragment length polymorphism analysis of the 5' noncoding region of the HCV genome following reverse transcription-polymerase chain reaction. The groups of individuals in this study included hemophilia patients, injecting drug users (IDUs), blood donors, antenatal patients, those attending genitourinary medicine (GUM) clinics, and patients with chronic liver disease, all from England and Wales. The majority of HCV infections were types 1a (32%), 1b (15%), or 3a (37%). The genotype distribution in individual groups was similar to the overall genotype distribution except for hemophilia patients, in whom the frequencies were 1a (39%), 1b (23%), and 3a (21%). With the exception of hemophilia patients, subpopulations in England and Wales appear to share common modes of HCV transmission. There is a need for continued surveillance to monitor the spread of possibly more virulent or drug-resistant HCV genotypes.

Exposure to blood borne viruses and the hepatitis B vaccination status among healthcare workers in inner London

Occupational exposure to blood borne viruses was examined during one year at a London teaching hospital. A total of 236 incidents occurred of which 83% were related to sharps, 32% were clearly avoidable, and 7% involved an infected source patient. Overall uptake of hepatitis B vaccine was 78% but it was particularly low in paramedical (70%) and domestic staff (45%). Continued effort needs to be applied to improve uptake of hepatitis B vaccine and to maintain high standards of control of infection.

Hepatitis C virus infection: Review and implications for the dentist

OBJECTIVE

The purpose of this report was to review the current literature on hepatitis C virus infection, with particular attention to the aspects of interest for dental health care staff.

MATERIAL AND METHODS

The authors searched original research and review articles on specific aspects of hepatitis C virus infection, including articles on virology, epidemiology, transmission, diagnosis, natural history, extrahepatic manifestations, therapy and oral aspects of hepatitis C virus infection. The relevant material was evaluated and reviewed.

RESULTS

Hepatitis C virus is an RNA virus that is present throughout the world and has major geographic variations. The virus, transmitted mainly by means of blood contact, causes chronic hepatitis in up to 80% of cases and may give rise to hepatic cirrhosis and hepatocellular carcinoma in a significant proportion of patients. Although it is of limited efficacy, interferon alpha is currently the drug of choice in the treatment of the infection. Hepatitis C virus infection is associated with a number of extrahepatic manifestations that may include oral diseases such as lichen planus or sialadenitis. Although there are documented cases of nosocomial transmission to health care workers after percutaneous exposure, the prevalence of hepatitis C virus among dental staff members is probably similar to that in the general population.

CONCLUSION

Hepatitis C virus infection is a relatively common infection worldwide (1.4% in the US general population) that causes significant chronic hepatic disease. The dentist is thus likely to face a growing number of patients with a diagnosis of hepatitis C virus infection. For this reason it is essential for dental health care workers to be aware of the principal features of the disease and of its oral and dental implications.

Multicenter evaluation of the COBAS AMPLICOR HCV assay, an integrated PCR system for rapid detection of hepatitis C virus RNA in the diagnostic laboratory

The benefits shown by the recent introduction of PCR for the in vitro diagnosis of hepatitis C virus (HCV) infection has prompted the development of standardized, ready-to-use assays that can be implemented in routine clinical laboratories. We have evaluated the clinical performance of COBAS AMPLICOR HCV (COBAS), the first instrument system that allows the automation of HCV RNA amplification and detection, to determine its performance in the routine laboratory setting. More than 2,000 specimens collected at five centers were analyzed in parallel by the COBAS and the manual AMPLICOR HCV (AMPLICOR) tests, and the results were compared with the results for biochemical and serological markers of HCV. In this study the two PCR systems showed the same accuracy, with a concordance rate of 99.8%. As expected, the correlation between serology and PCR was not absolute because the presence of anti-HCV antibodies may be associated with a latent or past infection. On the other hand, if the presence of confirmed anti-HCV antibodies and elevated alanine aminotransferase levels are taken as the "gold standard," indicating an active, ongoing infection, the COBAS and AMPLICOR tests show high and comparable sensitivities (100%) and specificities (98%), with positive and negative predictive values of 100 and 97%, respectively. During the study no false-positive reactions were detected. The use of an internal control allowed the identification of inhibitory substances that prevented amplification for 0.3 and 0.4% of samples tested by the COBAS and AMPLICOR tests, respectively. Compared to the manual system, the COBAS system allowed a significant reduction of hands-on time and could improve the overall laboratory work flow. In conclusion, these results support the use of the COBAS and AMPLICOR tests for the molecular diagnosis of active HCV infections.

Long-term interferon-alpha therapy does not affect sex hormones in males with chronic hepatitis C

The effects of interferon-alpha (IFN-alpha), given at a dosage of 6 MU thrice weekly for 12 months, on gonadal function were investigated in 18 males affected by chronic hepatitis C. Periodically, all patients were clinically monitored and questioned about sexual function. Gonadotropin and serum androgen concentrations (follicle-stimulating hormone, luteinizing hormone, total testosterone, free testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and sex hormone binding globulin) were tested every 3 months. Ten of 18 patients (55%) responded to IFN-alpha therapy. Serum total testosterone and sex hormone binding globulin values decreased slightly at the third month of treatment, then returned to baseline values. Serum free testosterone and other sex hormones remained essentially unchanged during IFN-alpha therapy. Four patients (22.2%) complained of sexual dysfunction (impaired libido, erectile failure, and impaired ejaculation), which was unrelated to any significant hormonal change and resolved after IFN therapy was stopped. Serum sex hormones values did not differ between responders and nonresponders to IFN-alpha. This study indicates that 12 months treatment with 6 MU of IFN-alpha thrice weekly does not significantly affect gonadal function in men with chronic hepatitis C. The sexual dysfunction observed could be ascribed to such other side effects of IFN as asthenia, fatigue, or anxiety, or it could have a psychologic basis.

Interferon therapy for chronic HCV hepatitis: trick or treat?

Chronic hepatitis caused by the hepatitis C virus (HCV) is a common condition that leads to cirrhosis and hepatocellular carcinoma. Current treatment with interferon is unsatisfactory, with a low percentage of patients who respond and uncertain high-term significance; in addition, it is associated with sometimes severe side effects. The increasing sophistication of molecular biology has enabled viral characteristics such as viral load, genotypes, and quasi-species to be identified, which may help predict a patient's response to interferon treatment. We suggest that interferon therapy for hepatitis C virus should be restricted to referral centers in the context of controlled trials.

Hepatitis C virus infection and lichen planus: a short review

OBJECTIVE

To review the current literature regarding the association of lichen planus (LP) and liver disease, with particular attention to the association of the oral variant of the disease with hepatitis C virus (HCV) infection.

MATERIALS AND METHODS

Available literature of the possible association of LP with systemic disorders, in particular chronic hepatic disease, has been reviewed.

RESULTS

LP is sometimes associated with infectious or autoimmune disease and/or neoplasia, however an aetiological association between LP and these disorders seems unlikely. A more consistent association exists between LP and chronic hepatic disease. The precise cause of this association is not known. However, in the last 6 years a notable association between HCV infection and LP has been observed, particularly in patients in Spain, Italy and Japan. The pathogenesis of this possible HCV-associated LP is not known, but it may involve a cell mediated response to an altered epithelial antigen.

CONCLUSION

There is now evidence to suggest a significant association between HCV infection and LP in some groups of patients.

Viral hepatitis in older adults

The objective of this paper is to review the epidemiology, manifestations, therapy, and prevention of viral hepatitis in older people and to discuss issues of prevention and management. In developed countries a significant portion of the adult population is not immune to Hepatitis A virus (HAV). Morbidity and mortality from HAV infection increases with age. A safe and effective hepatitis A vaccine is available and health authorities should consider immunization early in life and for healthy adults as well as for potential high risk groups such as nursing home residents. Acute hepatitis due to Hepatitis B virus (HBV) is rare in older people and is usually a mild disease. Most older patients with chronic HBV infection who suffer from advanced liver disease have no evidence of ongoing viral replication. Therefore, they are not candidates for interferon therapy. Those with evidence of ongoing viral replication and compensated liver disease should be offered interferon or be included in clinical trials with new antiviral drugs such as lamivudine. Since the response rate to hepatitis B vaccination decreases with age, developing vaccines with greater immunogenicity is crucial. Hepatitis C virus (HCV) is the most frequent cause of acute viral hepatitis in older people. Acute hepatitis C is usually a mild disease in this age group. Because many older patients with chronic HCV infection have compensated liver disease, they could benefit from antiviral therapy. In light of the low response rate to interferon in older patients with chronic hepatitis C and the side effects of the drug, interferon therapy should be reserved for those with the best chance of response. "Combination" antiviral therapy should be on trial for older patients with chronic HCV infection who do not respond to interferon. The recently discovered RNA virus, Hepatitis G (HGV), has been associated with liver disease in older people. It's role in the pathogenesis of liver injury remains to be elucidated.

Assessment of commercial enzyme immunoassay for hepatitis C virus serotyping

AIMS

To assess a commercial enzyme immunoassay (EIA) for the serotyping of hepatitis C virus (HCV) for routine use in a diagnostic laboratory setting, as well as for noting the serotype prevalence of selected specimens.

METHODS

Seventy six serum specimens, submitted to the laboratory for routine hepatitis studies between May 1992 and February 1996 and stored at -20 degrees C, were evaluated. These specimens were categorised into specific hepatic, renal, and paediatric clinical conditions. The specimens all tested positive for HCV antibodies on a screening EIA, with confirmation on a recombinant immunoblot assay (RIBA). Certain specimens were also HCV RNA positive by the reverse transcription polymerase chain reaction (RT-PCR). All the specimens were serotyped using the newly developed serotyping EIA.

RESULTS

Twenty seven (35.5%) specimens were typable. Type 5 predominated (56%), followed by type 1 (33%), types 1 and 6 (7%) and type 3 (4%). The serotype 5 specimens showed 85% and 90% reactivity with recombinant antigens c100-3 and c22-3c, respectively; serotype 1 specimens showed 75% and 100% reactivity with these antigens. All serotype 5 specimens reacted with the c33-c antigen, but only 60% of serotype 1 specimens reacted with this antigen. The differences in the reactivity of the serotype 5 and serotype 1 specimens for c33-c antigen in the RIBA were significant, but no significant differences in reactivity for antigens c-1-1, c100-3, and c22-3 were noted. Serotype 3 specimens showed equal reactivity with all four antigens used in the RIBA.

CONCLUSION

The serotyping EIA was easy to use, rapid, and cost effective compared with molecular assays. This assay seems to be ideal for the routine diagnostic laboratory setting, but could not be used for certain clinical specimens. The demonstration of serotypes 5, 1, and 3 was not unexpected in this cohort. The occurrence of serotype 6, although concurrent and more likely to be a false cross reaction with serotype 1 peptides, requires confirmation by molecular genotyping before it can be claimed that this type is present in South Africa.