COMMENTARY

A Future Without Hepatitis C?

The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD)

William F. Balistreri, MD

Disclosures

December 16, 2014

In This Article

Defining the Long-term Benefits of Achieving SVR

van der Meer[19] recently reported that the rates of life expectancy of patients with HCV infection and advanced hepatic fibrosis or cirrhosis who achieved SVR were comparable with those of the general population. The excellent observed rates of survival and SVR in these patients might be explained by the associations between SVR and regression of hepatic inflammation and fibrosis, reduced hepatic venous pressure gradient, reduced occurrence of hepatocellular carcinoma (HCC) and liver failure, as well as reduced occurrence of diabetes mellitus, end-stage renal disease, and cardiovascular events.[19]

Patient-Reported Outcomes; Mental Health Outcomes

Studies presented during the meeting also addressed outcomes. In one study, IFN- and RBV-free treatment regimens with LDV/SOF were shown to improve patient-reported outcomes for patients with genotype 1.[20]

Neurocognitive dysfunction has been reported in patients with HCV and mild histologic disease, with subsequent improvement after SVR with IFN-based treatment. Alsop and colleagues[21] studied the effect of viral suppression on neuronal function using cerebral MR spectroscopy (MRS) following treatment with LDV/SOF with or without RBV in 14 HCV-infected patients, all of whom achieved SVR. This exploratory study suggests that viral suppression can improve spectroscopic measures consistent with an overall improvement in neural health. Furthermore, changes in the metabolite pattern captured by MRS may be associated with changes in patient-reported outcomes related to mental health.

Risk for Liver Transplant, HCC, and Death

The cost-effectiveness of treatment for HCV depends on the extent of reductions in the risk for liver transplantation, HCC, and all-cause mortality for those achieving SVR during long-term follow-up, plus the risk for reinfection with HCV.

In a meta-analysis of 129 studies involving 23,309 patients with HCV infection, Hill and colleagues[22] compared clinical outcomes in patients achieving SVR vs those who did not. During long-term follow-up of patients, the annual absolute risk for death (all cause) was 0.7% for HCV monoinfected patients achieving SVR vs 1.7% for those not achieving SVR. Overall, the 10-year mortality rate was approximately 7% in patients achieving SVR and 16% in those who did not. The risk for liver transplantation was reduced by 90% in patients with SVR. Achieving SVR was associated with a 68%-79% reduction in the risk for HCC, compared with not achieving SVR. However, annual absolute mortality risk reductions were small (1%) in monoinfected patients, and there was a significant risk for reinfection after SVR in some studies. Patients with HCV-associated HCC are at higher risk for adverse post–transplant outcomes.[23]

Given that HCV is the main driver of HCC in the United States, better screening strategies are needed so that aggressive treatment of HCV patients with the newly developed highly effective IFN- and RBV-free regimens will be possible.

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