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News Review

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HEPATITIS JOURNAL REVIEW:
A Bi-Monthly Publication of the Hepatitis Support Project

July 10 , 2005 Volume 2, Issue 10


Liz Highleyman

To download pdf version click here


In This Issue: Hepatitis C

Hepatitis C Treatment and Advanced Liver Disease

Forum Looks at Living-Donor Liver Transplantation

Vertically Transmitted Hepatitis C

Sexual Transmission of HCV

 

Hepatitis C Treatment and Advanced Liver Disease

Because of their overall unstable health, it has traditionally been recommended that people with advanced liver disease should not receive interferon-based treatment for hepatitis C. But with recent improvements in therapy, researchers are seeking ways to safely treat this population. In the July Journal of Viral Hepatitis, F. Marrache and colleagues reported on a study of 80 chronic HCV patients with bridging fibrosis or cirrhosis treated with pegylated interferon (Peg-Intron) plus ribavirin. The researchers observed an overall sustained virological response (SVR) rate of 36%; improvement was seen in all patient groups except those who had previously failed to respond to the same combination therapy. No serious clinical adverse events were observed, but 19% stopped therapy prematurely. Low prothrombin index and low body mass index were associated with treatment discontinuation, but not pre-treatment blood count abnormalities. The researchers noted that, “tolerance [of therapy] seems worse in patients with the most advanced liver disease.” In addition, early virological response at week 8 and week 12 predicted treatment outcomes in this population of subjects with fibrosis or cirrhosis as well as it does for patients without advanced liver damage. The authors concluded that combination therapy with pegylated interferon plus ribavirin “seems effective” in this population, and “is safe with appropriate monitoring.”

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Forum Looks at Living-Donor Liver Transplantation

The July Journal of Hepatology contains an extensive forum on liver transplantation from living donors. While this procedure now accounts for less than 6% of liver transplants, it is an important advance, given the extreme shortage of donated cadaver livers. H. Tan, K. Patel-Tom, and A. Marcos offered an overview of who qualifies as “ideal” donors and recipients. They also proposed guidelines to maximize donor safety and achieve the best possible outcomes. C. Liu, C. Lo, and S. Fan looked at some important technical issues regarding the surgical procedure. S. Todo and colleagues discussed prevention and management of biliary (bile drainage) problems, which is a major complication associated with living donor transplants. M. Sagmeister and B. Mullhaupt analyzed the cost-effectiveness of the procedure, concluding that it can be cost-effective if offered under appropriate circumstances. But as A. Rimola and colleagues reported based on a European study of patients awaiting cadaver livers, “[t]he applicability of adult-to-adult living donor liver transplantation is low, mainly because of reasons related to potential recipients.” After being informed about living donor transplantation as an option, 17% of patients underwent the procedure, 30% refused to receive a partial liver donation from a relative, 20% declined to undergo live-donor transplants for other reasons, 14% had no medically suitable donor, and 13% had no donors willing to give up part of their liver. As it turned out, the waiting time to transplantation ended up being longer for the patients who underwent living donor transplantation than for those who received cadaver livers.

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Vertically Transmitted Hepatitis C
While the rate of mother-to-child transmission of HCV is known to be low (about 5%), little else is known about the natural history of vertically acquired hepatitis C. In the July 1 Clinical Infectious Diseases, the European Paediatric Hepatitis C Virus Network reported on a large, multicenter, prospective study of children who contracted HCV perinatally from their mothers. A total of 266 children with vertical HCV infection were followed from birth for up to 16 years (average follow-up was about four years). Ten percent of the children were coinfected with HIV, adding to the evidence that vertical HCV transmission is more likely when the mother has both HCV and HIV. About one-quarter (21-25%) of the children appear to have cleared HCV (indicated by two negative HCV PCR tests), at a median age of 15 months. One-half had chronic asymptomatic infection and about one-third had chronic active infection (detectable HCV replication). The only clinical sign of liver disease was hepatomegaly (enlarged liver), observed in 10% of the children, which was associated with elevated ALT levels.

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Sexual Transmission of HCV

As reported in the late April journal review, controversy continues to percolate regarding sexual transmission of HCV. Clusters of HCV infections among HIV positive gay men in London and Paris have led some experts to suggest that sexual transmission of HCV may be more common than previously believed, but similar outbreaks have not been seen in North America.

Adding to the evidence that HCV is sexually transmitted, H. Gotz and colleagues reported on a cluster of acute HCV infections among men who have sex with men in the Netherlands; results were reported in the June 10 issue of AIDS. The index patient (the first man that came to the researchers attention), who is HIV positive, is thought to have seroconverted for HCV sometime in the spring of 2003; in May of that year, he suffered a bout of lymphogranuloma venereum (LGV), a previously rare sexually transmitted disease that has recently been reported more frequently among gay men in several European and North American cities. Suspecting that proctitis (rectal inflammation) due to LGV might have facilitated HCV transmission, the researchers screened the man’s sexual partners and others diagnosed with LGV that year for HCV. Within this cluster of 17 mostly HIV positive men with LGV, seven (about 40%) had recently contracted HCV, and several seroconverted around the time they had proctitis. Three different HCV genotypes were seen, indicating “several entries” of the virus into the population. Looking at specific sexual practices, the researchers found that the men with HCV were not more likely to practice unprotected anal sex, leading them to conclude that transmission by semen was unlikely. About 70% of the HCV positive men reported having more than 10 sexual partners, compared with 40% of the HCV negative men. Non-injection recreational drug use was common among both HCV positive and HCV negative men (all the HCV positive men denied injection drug use). All of the seven men with HCV reported unprotected anal fisting (receptive or insertive), compared with just two of the nine HCV negative men. The researchers suggested that damage to the rectal mucosa - whether due to LGV or fisting - seems to increase the risk of HCV transmission. They recommended using gloves for fisting and added that screening gay men for HCV at sexually transmitted disease clinics should be considered.

A report in the May Journal of Viral Hepatitis also looked at sexual activity and HCV transmission. A. Oliveira and colleagues studied 2,691 HIV positive heterosexual and homosexual individuals in Lyon, France, who were exposed to HIV through sexual activity (thus controlling for the potentially confounding factor of injection drug use). They found that among the heterosexual subjects, 13% were coinfected with HCV; among the gay men, 6% also had HCV. Further, t he risk of HCV infection among HIV positive individuals differed according to their sexual behavior, leading the authors to conclude that “[t] he determinants associated with HCV transmission through the sexual route need to be explored further.”


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