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Metabolic Syndrome Associated Fatty Liver Disease (MAFLD)
Decompensated Liver Disease
Acute Liver Failure
Asymptomatic Raised Transaminases (ALT & AST)
Ascites in Cirrhosis
Alcohol Related Liver Disease
Hepatitis C
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Hepatitis C
Last updated 10th October 2022
Last updated on 4th December 2013 by Calum Murray
What is Hepatitis C?
- Bloodborne virus discovered in 1989. UK prevalence 0.5-1%; Over 700 identified cases D&G. Six genotypes: types 1 & 3 common locally.
- Scotland has a national programme to identify and treat people with HCV to reduce the future burden of patients with chronic liver disease/failure
Who Should Be Screened?
- Patients with persistently elevated ALT
- Any patient with jaundice or liver failure
- Past or present injecting drug users
- Recipients of blood products pre-screening in 1991
- Children of mothers known to be infected with HCV – risk <5%
- Healthcare professionals following needlestick injury in patient known or suspected to be infected with HCV – risk 3%
- People who received medical or dental treatment in countries where HCV is common
- People who have had tattoos or body piercing in circumstances where infection control is thought to be suboptimal
- Sexual partners of patients with HCV. Risk of sexual transmission ~ 3% in 10 year relationship. Be aware of recent outbreaks of HCV infection in men who have sex with men
- Blood/tissue donors
- Haemodialysis patients
- Healthcare professionals pursuing careers in specialties requiring them
- Consider testing patients with chronic fatigue
Principles of Testing
- HCV-RNA indicates current infection – can be detected from as early as one or two weeks post infection
- HCV antibody indicates past or current infection – can be detected at seven to eight weeks post infection, persists even after spontaneous viral clearance or successful trweatment.
- Healthcare professionals with needlestick injuries should have HCV-RNA at 6, 12 and 24 weeks, and HCV antibody at 12 and 24 weeks
- Individuals with positive antibody and repeatedly negative HCV-RNA do not require further active management of their infection, but do need to be advised about lifestyle risks as presence of antibody doesnt protect against reinfection
- Specialist clinic only – should have HCV genotyping if considering antiviral therapy.
Clinical Presentation
- Acute infection usually asymptomatic but if associated with jaundice the likelihood of spontaneous viral clearance is higher (ie good prognosis).
- Early chronic disease; fatigue, myalgia and arthralgia, depression, memory impairment, reduced alcohol tolerance.
- Late disease; features of cirrhosis.
- Extra-hepatic features often mediated through cryoglobulins include rashes, renal impairment.
Investigations
- Jaundice is rare and usually only appears in decompensated cirrhosis
- Transaminases usually raised in range 50-200u/l with ALT>AST
- Around 25% patients with chronic hepatitis C have persistently normal serum ALT – such patients more likely to be women and to have mild disease.
- Liver biopsy is not an essential test prior to antiviral therapy – now only considered after treatment failure or high likelihood of other liver disease
Progression of Untreated Disease
- Around 20% patients will clear the virus spontaneously
- The rest have significant risk of progression to cirrhosis and HCC
- Progression to cirrhosis is around 20% after 20 years for patients attending liver clinic with around 20% cirrhotics developing HCC
- Male sex, older age, smoking, alcohol and coinfection with HAV, HBV or HIV can all accelerate progression of liver disease
- No association between HCV genotype and disease progression
Management
- Always offer to screen for HBV & HIV
- Always offer Hepatitis A and B immunisation.
- Offer to test sexual partners, children and injecting contacts
Antiviral Therapy
- All patients with CHC should be considered for antiviral therapy.
- Benefits have been shown right across the spectrum of HCV infection from mild disease including patients with persistently normal ALT up to those with compensated cirrhosis
- Treatment naive patients with HCV genotype 1 should be considered for Pegylated Interferon SC with Ribavirin orally plus a Protease Inhibitor as triple therapy. Optimal treatment duration is 48 weeks
- For patients with HCV genotypes 2 or 3 standard treatment should be Pegylated Interferon and Ribavirin for 24 weeks
- Treatment regimens, which are complex, are changing rapidly as new oral medications become available. Current recommendations given in more detail in the SIGN guideline – click on link below
- Drug users may require support to remember to attend clinic – contact Claire Starr (Dr Jones’ Secretary for Tuesday pm clinic 33787)
Management of Adverse Effects
- These are common and usually managed by Clinical Nurse Specialists Marie Murray and Liz Scotney
- Flu-like symptoms – minimise by paracetamol and increased fluids
- Anaemia and neutropenia – consider dose reduction Ribavirin, EPO, G-CSF on a case by case basis
- Depression – consider treatment with antidepressant
- The new protease inhibitors can cause life threatening rash but if treatment is stopped then it cannot be restarted. Must discuss with specialist.
- Other side effects include skin reactions, thyroid dysfunction, weight loss, dyspnoea, retinopathy, alopecia – click on link below
Response Rates
- Sustained viral response (SVR), defined as HCV-RNA negative 6 months after end of therapy, should be used as marker of viral clearance – relapse thereafter is very uncommon
- SVR is currently 70% for genotype 1 (triple therapy) and 70-80% for genotype 2 or 3 (dual therapy)
Screening for Hepatocellular Carcinoma
- The rate of development of HCC in patients with HCV who are not cirrhotic is extremely low so screening should be limited to those with cirrhosis
- Serum AFP and liver ultrasound every 6 months is recommended