Hepatitis C patients who achieve SVR have reduced fibrosis, HCC risk
Individuals with hepatitis C virus (HCV) infection who achieve a sustained virological response (SVR) have improved liver stiffness and a lower risk of hepatocellular carcinoma (HCC), according to a presentation at the Asian Pacific Association for the Study of the Liver annual meeting (APASL 2017) in Shanghai, China.
“Most patients with SVR experience decline in liver stiffness,” said Professor Norah Terrault from the University of California, San Francisco, California, US at a postgraduate course held during APASL 2017. “It is useful also to look at changes in liver stiffness as another way for us to assess for changes with SVR,” she said.
A small study conducted in France showed a significant reduction in liver stiffness in patients who achieved SVR after treatment with pegylated interferon-α and ribavirin, probably due to fibrosis regression and possibly improvements in inflammatory reactions. [Aliment Pharmacol Ther 2011;34:656-663]
Another study found that about 60 percent of patients with advanced fibrosis or cirrhosis who were treated with direct-acting antivirals (DAAs) demonstrated improvement in liver stiffness, as measured by transient elastography, after a median 2.5 years. [AASLD 2015, abstract 108]
“This time to improvement takes months to years, and there’s continuing ... improvement in the liver stiffness values even after 2–3 years,” she said.
Although the improvement in fibrosis appears to be similar regardless of treatment with interferons or DAAs, longer-term data is still needed, said Terrault.
While a majority of patients who have achieved SVR will have improved or stable histology, a small percentage will progress. “Understanding that group that is at risk of progression is ... the future of research specifically related to treatment with DAA therapy,” said Terrault.
In individuals with baseline advanced fibrosis, factors associated with a higher risk of developing decompensating events after SVR include cirrhosis, lower platelet count or lower albumin levels, older age, obesity, or alcohol use, said Terrault. She cautioned that these findings were derived from interferon-era treatment and thus, confirmation in the DAA treatment era is needed.
In terms of HCC risk, a meta-analysis of 2,649 patients with advanced liver disease showed a 77 percent reduction in the risk of HCC among patients who had achieved SVR, with 4.2 percent developing HCC compared with 17.8 percent of those who did not achieve SVR. [Ann Intern Med 2013;158:329-337]
Another study from France (n=1,323) found that lack of SVR during follow-up was independently associated with an increased risk for HCC in patients with HCV-compensated cirrhosis. [Hepatology 2016;64:1136-1147]
According to a Japanese study, the risk of developing HCC is similar regardless if patients achieved SVR through DAA or interferon therapy. [J Med Virol 2017;89:476-483]
As in the case of clinical progression, a study identified older age, higher α-fetoprotein levels, low platelet count, and high fibrotic stage as independent risk factors for HCC. [J Antimicrob Chemother 2012;67:2766-2772]
“The most consistent things identified across studies are older age, presence of cirrhosis, and especially a lower platelet count, and we’re starting to see the importance of comorbidities – diabetes, insulin resistance, and alcohol,” said Terrault, on the predictors of HCC in patients who have achieved SVR.