Prowpanga Udompap

Current and Future Burden of Chronic Nonmalignant Liver Disease

Disease burden is an important indicator of the state of health of a population. It can be measured as the frequency (eg, incidence and prevalence) of a condition or its effects including fatal and non-fatal health loss from disease (eg, disability-adjusted life years) as well as the financial costs (eg, direct healthcare costs and indirect healthcare expenditures related to lost income because of premature death). Accurate disease burden information is essential for policy-making such as prioritization of health interventions and allocation of resources. Chronic liver disease (CLD) causes substantial health and economic burden in the United States, where nearly 2 million deaths annually are attributable to CLD. In the recent past, overall mortality rate of CLD has been increasing. Viral hepatitis and alcoholic liver disease are thought to be the most common etiologies of chronic liver diseases. More recently, the prevalence of nonalcoholic fatty liver disease is rapidly increasing, and nonalcoholic steatohepatitis has become a leading indication for liver transplantation. In this article, we assemble available data on the burden of CLD in the United States, focusing on nonmalignant complications, whereas the impact on mortality and healthcare expenses of hepatocellular carcinoma, an important consequence of CLD, is discussed elsewhere.

Increasing prevalence of cirrhosis among U.S. adults aware or unaware of their chronic hepatitis C virus infection.

BACKGROUND & AIMS Cirrhosis from hepatitis C virus (HCV) infection is a major cause of end-stage liver disease and hepatocellular carcinoma worldwide. We determine the prevalence of cirrhosis among HCV-infected American adults including those unaware of their infection. METHODS Using the National Health and Nutrition Examination Survey (NHANES) data, we identified participants aged ⩾20 years with detectable serum HCV RNA. The prevalence of advanced fibrosis and cirrhosis was determined for eras 1 (1988-94), 2 (1999-2006) and 3 (2007-2012) by using FIB-4 >3.25 and APRI >2.0, respectively. RESULTS Out of 52,644 NHANES examinees, 49,429 were tested for HCV, of whom 725 met the inclusion criteria (positive HCV RNA with available data for FIB-4 and APRI). Based on APRI, 6.6% (95% confidence interval [CI]: 2.2-11.0) of HCV-infected adults in era 1, 7.6% (95% CI: 3.4-11.8) in era 2 and 17.0% (95% CI: 8.0-26.0) in era 3 had cirrhosis. In the multivariable regression analysis, this era effect was attributable to increasing age (odds ratio [OR]:1.04, 95% CI: 1.02-1.07), diabetes (OR: 2.33, 95% CI: 1.01-5.40) and obesity (OR: 2.96, 95% CI: 1.15-7.57). Cirrhosis was as common among respondents who were unaware of their infection as those who were aware (both 11%). Results were identical when FIB-4 was used. CONCLUSIONS Among HCV-infected American adults, the proportion with cirrhosis has increased rapidly. Cirrhosis prevalence remains high in individuals unaware of their HCV infection. These data highlight the urgency for HCV screening regardless of symptoms, systematic assessment for liver fibrosis in those with HCV infection and institution of antivirals to prevent advanced liver disease. LAY SUMMARY Chronic hepatitis C virus (HCV) infection is a major cause of cirrhosis, creating a large public health burden. Based on the U.S. National Health and Nutrition Examination Survey sample, we found the proportion of patients with cirrhosis among Americans with HCV infection increased from 6.6% to 17.0% over the past two decades. Patients who were unaware of their infection were just as likely to have cirrhosis as those who knew about their infection, which highlights the need for screening and treatment for HCV at the population level.

Decreasing mortality and disease severity in hepatitis C patients awaiting liver transplantation in the United States

Hepatitis C virus (HCV) infection has been the leading indication for liver transplantation (LT) in the United States. Since 2013, interferon‐free antiviral therapy has led to sustained virological response in many LT candidates. We compared the wait‐list mortality of HCV patients with that of patients with other chronic liver diseases. Data for primary LT candidates were obtained from the Organ Procurement and Transplantation Network database. Adult wait‐list registrants were divided into 3 cohorts: cohort 1 included patients on the waiting list as of January 1, 2004; cohort 2 as of January 1, 2009; and cohort 3 as of January 1, 2014. The primary outcome was wait‐list mortality, and the secondary outcome was the rate of change in Model for End‐Stage Liver Disease (MELD). Multivariate Cox proportional hazards analysis was performed to evaluate 12‐month wait‐list mortality. The cohorts included 7627 LT candidates with HCV and 13,748 patients without HCV. Compared with cohort 2, HCV patients in cohort 3 had a 21% lower risk of death (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.67‐0.93). Among patients with non‐HCV liver disease, no difference in mortality was seen between cohorts 2 and 3 (HR, 0.97; 95% CI, 0.86‐1.09). Among HCV patients, the mean rate of change in MELD decreased from 2.35 per year for cohort 2 to 1.90 per year for cohort 3, compared with 1.90 and 1.66 in cohorts 2 and 3, respectively, among non‐HCV patients. In this population‐based study, wait‐list mortality and progression of disease severity decreased in recent HCV patients for whom direct‐acting antiviral agents were available. Liver Transplantation 24 735–743 2018 AASLD.

Hepatitis B Virus Reactivation and Management of Patients Undergoing Immunosuppression

Hepatitis B reactivation (HBR) occurs in patients with inactive or resolved hepatitis B virus (HBV) infection, in whom the host immune response is overtaken by the replicative drive of the virus. While HBR may be clinically silent, there is abrupt reappearance or rise of HBV DNA in the serum (usually > 2 log) with or without a flare of alanine aminotransferase (ALT) activities. HBR commonly occurs in the setting of B-cell depleting agents and corticosteroids although cytotoxic chemotherapeutic and other immunosuppressant and immunomodulant agents may precipitate it. The risk of HBR may be determined by host characteristics, viral factors, and the type of medical therapy. For an optimal outcome, screening for patients at risk of HBR is critical. For patients identified to be at risk, strategic utilization of antiviral prophylaxis has been shown to improve outcomes.