European Association for the Study of the Liver and French hepatitis C recent guidelines: The paradigm shift

HCV elimination in a Swiss opioid agonist therapy programme - a cohort study

BACKGROUND

In opioid agonist therapy (OAT) programmes, chronic hepatitis C is highly prevalent and directly observed therapy guarantees optimal adherence. Since 2017, all patients with chronic hepatitis C in Switzerland can be treated with pangenotypic direct-acting antivirals irrespective of liver fibrosis stage. Until the end of 2021, however, prescription was restricted to infectious disease specialists, gastroenterologists and certain addiction specialists. Difficult venous access after long-term intravenous drug use and, in the case of referral to a specialist, difficulties keeping appointments are barriers to HCV diagnosis and treatment.

AIMS

To assess whether minimally invasive point-of-care tests and a "test-and-treat / vaccinate on-site" approach can improve human immunodeficiency virus (HIV) / hepatitis C virus (HCV) screening, HCV treatment uptake and immunity against hepatitis A/B.

METHODS

Since September 2018, an infectious disease specialist and a study nurse performed 4-weekly visits in the OAT programme "HAG" (heroin dispensation of the canton Aargau), offering HIV/HCV antibody rapid testing (20 min) and HCV RNA quantification (GeneXpert®, 60 min) from capillary blood, noninvasive liver fibrosis assessment (Fibroscan®, 5-10 min) and HCV treatment prescription on-site. Recommended venous blood draws for HAV/HBV serology and HAV/HBV vaccinations were performed by the staff of the "HAG". Project performance was assessed by annual cross-sectional chart review.

RESULTS

Of the 128 patients registered in April 2018, 79 (62%) were still present in May 2021. With 72 newly registered, a total of 200 patients could be assessed, of whom 129 (65%) were still present in May 2021. Between April 2018 and May 2021, the proportion ever tested for HIV antibodies increased from 79% (101/128) to 91% (117/129), the proportion ever tested for HCV antibodies from 83% (106/128) to 93% (120/129) and the proportion of those HCV antibody positive ever tested for HCV RNA tested from 89% (47/53) to 98% (56/57). The proportion with adequate HCV management (last HCV antibody test ≤1 year ago, if HCV antibody negative or last HCV RNA test ≤1 year ago, if HCV antibody-positive and RNA-negative) improved from 23% ([15 + 15]/128) to 80% ([55 + 48]/129). Overall, HCV treatment uptake increased from 60% (21/35) to 92% (55/60) and HCV RNA prevalence among the HCV antibody positives decreased from 38% (18/47) to 7% (6/84). Between 2018 and 2021, 19 non-cirrhotic chronic hepatitis C patients were successfully treated on-site (18 sustained virological responses [SVR] 12, 1 SVR4), with excellent adherence (≥93%) and, so far, no reinfection. The proportion with known HAV/HBV serostatus increased from 38%/51% to 64%/76%. Immunity against HAV/HBV improved from 19%/23% to 50%/57%.

CONCLUSION

Capillary blood point-of-care tests and a "test-and-treat / vaccinate on-site" approach remove crucial barriers to diagnosis and treatment, making hepatitis elimination in OAT programmes achievable. A high fluctuation rate requires HIV/HCV/HAV/HBV testing at admission, but also allows more patients to be screened.

Combined Use of Transjugular Intrahepatic Portosystemic Shunt and Transarterial Chemoembolization in the Treatment of Esophageal and Gastric Variceal Bleeding: A Retrospective Study of 80 Patients with Hepatocellular Carcinoma and Portal Hypertension

Background

The main cause of death in patients with hepatocellular carcinoma (HCC) with portal hypertension is esophageal and gastric variceal bleeding caused by severe portal hypertension; therefore, the treatment of portal hypertension is particularly important to prolong the survival of patients. The therapeutic efficacy and safety of transarterial chemoembolization (TACE) combined with a transjugular intrahepatic portosystemic shunt (TIPS) for HCC with esophageal and gastric variceal bleeding has been rarely reported. The aim of this study was to analyze the clinical efficacy of TIPS combined with TACE in the treatment of HCC with esophageal and gastric variceal bleeding.

Material/Methods

A total of 80 patients with HCC with esophageal and gastric variceal bleeding from July 2015 to November 2019 were retrospectively investigated. Clinical outcomes, biochemical indexes, and complications were compared between TIPS plus TACE and endoscopy plus TACE treatments.

Results

Gastrointestinal rebleeding and adverse reactions (P<0.05) after TIPS combined with TACE were lower than that after endoscopy combined with TACE treatment. Furthermore, TIPS plus TACE had superior clinical outcomes than endoscopy plus TACE, which was associated with promising progression-free survival, overall survival, objective response rate, and disease control rate, and improved liver function.

Conclusions

TIPS combined with TACE was better than endoscopy combined with TACE in the treatment of patients with HCC and esophageal and gastric variceal bleeding. TIPS combined with TACE had a better therapeutic effect on improving liver function and prolonging patient survival time.

Evaluation of the Benefits of TACE Combined with Sorafenib for Hepatocellular Carcinoma Based on Untreatable TACE (unTACEable) Progression

Purpose

Outcomes after the treatment for unresectable or advanced-stage hepatocellular carcinoma (HCC) are unsatisfied. We evaluated the therapeutic benefits of a combination therapy strategy for these patients through transarterial chemoembolization (TACE) plus sorafenib.

Patients and Methods

In total, 85 patients with HCC classified as intermediate and advanced stage from June 2012 to November 2017 were retrospectively investigated. We divided patients into the monotherapy (n=43; TACE alone) and combined therapy (n=42; TACE plus sorafenib) groups.

Results

Compared with the TACE alone group, the TACE plus sorafenib experienced significantly prolonged progression-free survival (PFS) (mean 21 months vs 12 months; P = 0.0005) and overall survival (OS) (mean 32 months vs 21 months; P = 0.0157). The disease control rate (DCR) of TACE plus sorafenib group was 80.95%, which was significantly increased than the TACE alone group (55.81%) (P<0.05), as well as objective response rate (ORR) (23.81% vs 16.28%). Besides, the rates of liver-related AEs and liver failure in the TACE plus sorafenib group were not increased in contrast to TACE alone group, and there were no new safety concerns. To sum up, the superiority of combination therapy with significantly prolonging progression-free and overall survival was observed, meanwhile finding a significant increase in tumor response rate and manageable safety in the combined therapy in contrast to the monotherapy group.

Conclusion

Based on unTACEble progression, the superiority of the combination therapy is that TACE plus sorafenib has been bringing about significantly better outcomes compared with TACE alone for HCC patients.

Simplification of Care for Chronic Hepatitis C Virus Infection

In 2016, the World Health Organization (WHO) set a target for eliminating viral hepatitis as a major public health threat by 2030. However, while today's highly effective and well-tolerated pangenotypic direct-acting antiviral regimens have maximized simplification of hepatitis C virus (HCV) treatment, there remain a plethora of barriers to HCV screening, diagnosis, and linkage to care. As of 2017, only 19% of the estimated 71 million individuals living with chronic HCV worldwide were diagnosed and in 2015 to 2016, only 21% of diagnosed individuals had accessed treatment. Simplification and decentralization of the HCV care cascade would bolster patient engagement and support the considerable scale-up needed to achieve WHO targets. Recent developments in HCV screening and diagnosis, together with reduced pretreatment assessment and on-treatment monitoring requirements, can further streamline the care continuum, ensuring patients are linked to care quickly and earlier in the disease course, and minimize clinic visits.

Cirrhotic patients and older people

The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities, and age is a risk factor for mortality in cirrhotic patients. The incidence of non-alcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients < 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed. This review suggests that comorbidities have a considerable impact on older cirrhotic patients.