cirrhosis

Patients with cirrhosis are the ones in danger of premature death from HCV. After infection with HCV for

20 years about 20% of patients have cirrhosis. After 50 years of infection, about half of HCV patients have

cirrhosis. About 4% of patients with HCV cirrhosis develop liver failure each year and about 1% develop liver

cancer. Cirrhotic patients therefore have about 95% chance of remaining stable each year. Once liver

failure or liver cancer occurs, about half of the patients die in one or two years. Liver transplantation can

be done but the list is long and patients still have an appreciable death rate. About 15% of transplanted

patients die the first year and 30% die by five years. The new liver is infected with HCV and sometimes

progresses to cirrhosis very quickly. Some transplant patients are cured of HCV before or after transplant,

using antiviral therapy. Be sure to read my page on survival about the benefits of curing HCV in patients

with cirrhosis and even those with liver failure.

The HALT-C Trial Group reported their results treating patients with cirrhosis or bridging fibrosis (stage 4

or 3). Thirty-five percent of patients had no detectable HCV RNA in serum at treatment week

20, and 18% achieved sustained virologic response (SVR). To get into the study, you had to fail regular

interferon or interferon plus ribavirin. They used Pegasys plus ribavirin.

Look at the chart below, and see what is happening.

	Number	week 20 response (%)	week 48 response(%)	sustained virologic response(%)
All patients	604	35%	32%	18%
genotype 1	539	30%	27%	14%
genotype 2	31	81%	81%	65%
genotype 3	26	81%	77%	54%
White	466	38%	35%	20%
Black	84	11%	10%	6%
Hispanic	39	49%	41%	18%
>2 log fall HCV RNA at week 12	309	66%	61%	34%

Genotype 2 patients and genotype 3 patients did not do too bad. They were treated for 48 weeks instead of the

commonly used 24 weeks. Genotype 1 patients did poorly. 30% responded initially and 27% were negative at the end

of treatment. Only 14% achieved sustained virologic response. The rest relapsed. Patients who failed treatment in the

Halt C study were then randomized to maintenance Pegasys 90 mcg per week or no treatment. At AASLD 2007 the

results were released showing no benefit from interferon treatment for nonresponders. Antiviral therapy has no

measurable benefit unless the HCV is permanently eradicated. Patients with advanced fibrosis (stage 3 and 4) need

longer treatment to reduce relapse. When you fall from 27% of your patients being negative to only 14% being

negative, it means that nearly half of the curable patients did not get cured!!!! To reduce the relapse

rate, we treat stage 3 and 4 patients for about 2 years if they have genotype one and they are responding.