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News Review

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

January 31, 2006
Volume 3, Issue 2


Liz Highleyman

To download pdf version click here


In This Issue: Hepatitis C


Noninvasive Fibrosis Prediction

FibroScan Works for Coinfected Patients

Hepatocellular Carcinoma

Journal of Hepatology Looks at Coinfection

HCV Transmission Through Sharing Piercing Jewelry


Noninvasive Fibrosis Prediction

Researchers continue to study techniques for predicting liver disease progression without repeated invasive biopsies. Most such methods involve blood tests for various biochemical markers, liver imaging, or techniques that assess the elasticity of the liver. In the January 2006 European Journal of Gastroenterology & Hepatology, Blai Dalmau Obrador and colleagues described a predictive index for diagnosing cirrhosis using a combination of clinical, laboratory, and ultrasound findings. First, the researchers performed a multivariate regression analysis of data from 332 chronic hepatitis C patients, 20% of whom had biopsy evidence of cirrhosis. They determined seven variables that predicted cirrhosis: age 60 years or older, low platelet count, AST/ALT ratio of 1 or greater, prolonged prothrombin time, caudate lobe hypertrophy (enlargement), right lobe atrophy (shrinkage), and splenomegaly (enlarged spleen). The authors created an index using these seven factors, and found that hepatitis C patients who scored 22 or higher were significantly more likely to have cirrhosis. They concluded that, “The index will be useful for the management and follow-up of hepatitis C patients, drastically reducing the indications for biopsy in this context.” In a related report in the January 2006 Journal of Hepatology, Yamada Hiroyuki and colleagues described a study validating the use of ultrasound as a technique for diagnosing liver fibrosis.

 

Further in the future, genetic analysis may also be used to assess fibrosis progression. As Tarik Asselah and colleagues reported in the December 2005 issue of Gastroenterology, a set of 11 genes – including several involved in immune response and extracellular matrix remodeling – were differentially expressed in liver specimens with greater degrees of fibrosis. Likewise, Maria Smith and colleagues reported in the January 2006 issue of the same journal that unique patterns of gene “upregulation” were observed in hepatitis C patients who developed early fibrosis after liver transplantation. Data from both studies suggest that gene expression patterns may one day help assess liver damage and predict the risk of cirrhosis or liver cancer.

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FibroScan Works for Coinfected Patients

According to a study in the February 1, 2006 Journal of Acquired Immune Deficiency Syndromes (JAIDS), an ultrasound method known as transient elastography, or FibroScan, can be used to diagnose liver damage in HIV/HCV coinfected patients, as has already been demonstrated in individuals with hepatitis C alone. Victor de Ledinghen and colleagues used FibroScan to measure liver stiffness in 72 coinfected subjects. Stiffness was correlated with fibrosis stage and predicted cirrhosis significantly better than platelet count, AST/ALT ratio, AST-to-platelet ratio index (APRI), and FIB-4 (a noninvasive index designed for coinfected patients). The authors concluded that FibroScan is “a promising noninvasive method” for the assessment of fibrosis and diagnosis of cirrhosis in coinfected patients.

Unlike biochemical measures such as ALT and AST levels or platelet counts, liver stiffness is not likely to be affected by antiretroviral medications or HIV infection itself. In a study by David Nunes and colleagues, however, concurrent HIV infection did not seem to negatively affect the performance of blood tests for fibrosis. As reported in the December 15, 2005 issue of JAIDS, various noninvasive serum marker tests (including AST/ALT ratio, APRI, and the Forns index) were as good – or, in some cases, as bad – at detecting liver damage in 40 HIV/HCV patients and 57 subjects with hepatitis C alone.

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Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC, a type of liver cancer) remains one of the most devastating manifestations of advanced liver damage, although therapies have improved in recent years. As reported in the January 2006 Journal of Hepatology, Hashem El-Serag and colleagues used the large SEER-Medicare database to examine management of HCC patients diagnosed between 1992 and 1999. The median age at diagnosis was 74 years and more than 90% were older than 65. Just 13% received potentially curative therapy such as surgical tumor removal (resection) or liver transplantation, while about 60% received palliative therapy and 26% received no specific treatment. Only about one-third of patients with early-stage liver cancer (a single lesion or tumors smaller than 3 cm) received potentially curative therapy; at the same time, curative therapy was attempted in nearly 20% of patients with less favorable prognosis (tumors 10 cm or larger). Survival was longest in patients receiving transplants (median 852 days) and shortest among those receiving no treatment (median 58 days). The likelihood of receiving appropriate therapy varied significantly by geographic region. The authors concluded that, “There is underutilization of potentially curative therapy, even among those with favorable tumor features.” Discussing El-Serag’s findings in an accompanying editorial, Maria Varela and Jordi Bruix noted that HCC therapy often does not adhere to the most recent state-of-the-art recommendations, leading to outcomes worse than those seen in clinical trials. “As a whole,” they wrote, “it appears that some individuals who could have benefited from therapy were not treated and some who were treated would have been better served if they had been left untreated.” On a related note, the American Association for the Study of Liver Diseases (AASLD) published new “Practice Guidelines for the Management of HCC” in the November 2005 issue of Hepatology.

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Journal of Hepatology Looks at Coinfection

In other hepatocellular carcinoma news, Raffaele Bruno and colleagues from Italy offered an overview of HCC management in HIV positive individuals in a Journal of Hepatology supplement devoted to the 1st European Consensus Conference on the Treatment of Chronic Hepatitis B and C in HIV Coinfected Patients, held March 2005 in Paris. Liver cancer is a growing cause of mortality among HIV positive people. In France, for example, HCC deaths in this population increased from 4.7% of all deaths in 1995 to 25% in 2000. HIV/HCV coinfected patients may be at greater risk for liver cancer at younger ages since they appear to progress more rapidly to advanced liver disease. While the same methods of HCC diagnosis and treatment are appropriate for patients with and without HIV, the authors noted that “[n]umerous issues in HCC prevention, diagnosis, and management still remain to be resolved through large-scale, randomized clinical trials.”

 

Other articles in the coinfection supplement examined the virology of hepatitis B and C, natural history and predictors of hepatitis C disease severity, epidemiology of HIV/HCV and HIV/HBV coinfection, prevention of viral hepatitis in HIV positive individuals, how viral hepatitis affects HIV disease, options for treating HIV/HCV coinfected patients, how to select which coinfected patients will benefit from hepatitis C treatment, and interactions between antiviral hepatitis therapies and anti-HIV drugs.

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HCV Transmission Through Sharing Piercing Jewelry

 

Finally, a report in the November 5, 2005 issue of Pediatrics suggested that HCV may be transmitted by sharing jewelry for body piercings. According to this case report, a 17-year old woman who had repeatedly tested HCV negative prior to donating blood became HCV positive about a year after receiving a navel (bellybutton) piercing. The piercing was performed under sterile conditions and the young woman reported no sexual or drug-related transmission risk factors. However, she swapped piercing jewelry about 2-3 times per week with a female friend who had several transmission risk factors, including intranasal cocaine use and multiple sex partners. Testing revealed that both young women had the same genotype 3a HCV strain. Some 15-20% of people with hepatitis C have no recognized traditional transmission risk factors. This case demonstrates that prevention educators should include sharing piercing jewelry in the list of less common potential routes of HCV transmission, along with sharing personal hygiene items.

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