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Cirrhosis and decompensation are common among people with chronic hepatitis C
Liz Highleyman, 2015-08-11 07:00:00
More than one-quarter of people with chronic hepatitis C at Kaiser-Permanente developed liver cirrhosis over 12 years and 40% of these experienced decompensation – higher rates than expected, according to a presentation at the recent Digestive Disease Week 2015 meeting in Washington, DC. The study also found that cirrhosis and decompensation were associated with comorbid conditions, supporting the idea of hepatitis C as a systemic disease.
Over years or decades, chronic hepatitis C virus (HCV) infection can lead to serious liver disease including advanced fibrosis, cirrhosis, liver cancer, decompensated liver failure and the need for a liver transplant. People with decompensation – which occurs when the liver can no longer carry out its vital functions – may develop ascites (abdominal fluid accumulation), bleeding varices (enlarged veins) in the oesophagus or stomach and hepatic encephalopathy (brain impairment).
Lisa Nyberg and colleagues analysed outcomes among people with hepatitis C who received care through Kaiser Permanente Southern California, a large, integrated health maintenance organisation with approximately 3.5 million members, between January 2002 and December 2013.
The projected public health burden of hepatitis C is based on old natural history studies that may not reflect the current patient population, the researchers noted as background. Hepatitis C is most common among ‘baby boomers’ born during 1945-1965. Compared with these earlier studies, the current cohort of people with hepatitis C is older and has a higher prevalence of obesity and other comorbid conditions that may affect the natural history of the disease.
This retrospective analysis included 54,383 people with a relevant diagnosis code or a positive HCV RNA lab test. Those who had liver cancer or had already had a liver transplant were excluded. Of these, 24,968 adults with HCV had been Kaiser-Permanente members for at least a year and met the inclusion criteria. About 60% were men, more than 40% were white, more than a quarter were Hispanic and the mean age was approximately 53 years.
Among these 24,968 eligible hepatitis C patients, 19% were found to have prevalent or pre-existing cirrhosis, 23% developed incident or new cirrhosis during follow-up and 58% did not have cirrhosis. Among people with pre-existing cirrhosis, 17% already had a decompensation diagnosis, 41% developed new decompensation and 42% did not experience decompensation.
Among 20,285 people without cirrhosis, 28% received a new diagnosis of cirrhosis over the entire 12-year study period, or an annual rate of 5.6%. Among people with new cirrhosis, 20% had decompensation when they were diagnosed with cirrhosis, 46% later developed decompensation and 34% did not have decompensation.
People who developed incident cirrhosis were significantly more likely than people without cirrhosis to have cardiovascular disease (18% vs 13%; crude hazard ratio [HR] 1.21) and diabetes (26% vs 20%; crude HR 1.18). People with cirrhosis were also more likely to have HIV, but this was not a significant difference (2.3% vs 1.9%; crude HR 1.14).
Among 7680 hepatitis C patients with initially compensated cirrhosis, 40% developed new decompensation over the 12-year study period, or an annual rate of 9.9%. Decompensation was significantly associated with cardiovascular disease, diabetes, chronic kidney disease and obesity.
People with cirrhosis who developed decompensation had a 19% likelihood of developing hepatocellular carcinoma, compared to 3.1% for people with compensated cirrhosis and 0.1% for people without cirrhosis (annual rates of 3.31%, 0.47% and 0.02%, respectively).
People with cirrhosis who had decompensation were much more likely to require liver transplants (14%) than either people with compensated cirrhosis (0.03%) or people without cirrhosis (0.03%). People with decompensated cirrhosis also were twice as likely to die as people with compensated cirrhosis (55% vs 21%), who in turn were more likely to die than people without cirrhosis (7.8%).
"Selected comorbid conditions are seen [at] higher prevalence in patients with HCV and cirrhosis and are associated with an increased risk of decompensation," the researchers concluded, "support[ing] the idea of HCV as a systemic illness."
"Our study lends support for early diagnosis and treatment of chronic hepatitis C to reduce morbidity and mortality," they added. The findings also support "aggressive management of comorbid conditions."
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