Better Cirrhosis Monitoring Methods Needed for Hepatitis C Patients

Recent study results highlight the need to develop better surveillance techniques for whether a patient who achieved a sustained virologic response following treatment for hepatitis C virus (HCV) will develop cirrhosis.

A team, led by Teresa Broquetas, Liver Section, Gastroenterology Department, Hospital del Mar, evaluated the accuracy of transient elastography (TE) at identifying cirrhosis 3 years following HCV-eradication.

The Study

In the prospective, multi-center study, the investigators examined patients with hepatitis C virus and advanced chronic liver disease (HCV-cALD) prior to beginning direct-acting antiviral (DAA) therapy and evaluated the diagnostic accuracy of transient elastography to identify cirrhosis 3 years after sustained virologic response.

There was a total of 746 patients included in the study, 95.4% of which with transient elastography of at least 10 kPa. In addition, 10.2% (n = 76) of patients underwent a liver biopsy 3 years following sustained virologic response.

Prior to beginning treatment, 63% (n = 46) of these patients showed a transient elastography greater than 15 kPa.

Forecasting Cirrhosis

The best variable to predict cirrhosis after sustained virologic response (area under the receiver operating characteristic [AUROC], 0.79) was transient elastography prior to DAA treatment.

In addition, a number of measures, including liver function parameters, serological non-invasive tests, and transient elastography values improved following sustained virologic responses.

Liver biopsies 3 years after the hepatitis C virus has been eliminated with a median time of 38.4 months helped identify cirrhosis in 53.9% (n = 41) of patients.

After the investigators conducted a multivariate analysis, they found HCV genotype 3 (OR, 20.81; 95% CI, 2.12-201.47; P = 0.009) and transient elastography prior to DAA therapy (OR, 1.21; 95% CI, 1.09-1.34; P <0.001) were deemed the only variables linked to cirrhosis following a sustained virologic response.

Despite this, the accuracy of transient elastography following sustained virologic response was considered poor (AUROC, 0.75), with 27.3% (n = 6) of patients with transient elastography less than 8 kPa having cirrhosis. There were similar results found in the serological non-invasive tests of APRI and FIB-4.

“Cirrhosis is present, 3 years after SVR, in more than half of HCV-cACLD patients even the normalization of liver function parameters, serological non-invasive tests, and TE values,” the authors wrote. “The low diagnostic accuracy of non-invasive methods after SVR reinforces the need of long-term surveillance.”

Direct-Acting Antivirals

The advent of direct-acting antivirals has transformed HCV care, lowering the overall mortality rate.

A 2020 study shows DAA treatment was associated with a decrease in mortality among Medicare beneficiaries, regardless of cirrhosis status.

Direct-acting antiviral drugs are effective in treating HCV infections. In previous simulations, investigators discovered extended life as a key advantage of this drug class. However, real-world evidence on the link between DAA treatment and reduced mortality is understudied.

The adjusted hazard ration (AHR) of dying between patients with treatment and those without treatment in the cirrhosis group was 0.51 (95% CI, 0.46-0.57).

The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.53; 95% CI, 0.46-0.60 vs HR, 0.55; 95% CI, 0.50-0.60) among patients without cirrhosis, but the survival advantage associated with DAAs for non—dual-eligible beneficiaries was statistically significantly higher than for dual-eligible beneficiaries among patients without cirrhosis (HR, 0.47; 95% CI, 0.41-0.55 vs HR, 0.57; 95% CI, 0.52-0.62).

The study, “Elastography is unable to exclude cirrhosis after sustained virological response in HCV-infected patients with advanced chronic liver disease,” was published online in Liver International.