From the Guidelines
For a patient with a history of hepatitis C who achieved sustained virologic response (SVR) after antiviral treatment in 2017, but now shows stage 4 fibrosis on NASH FibroSure testing despite normal liver enzymes, I recommend immediate referral to a hepatologist for comprehensive evaluation and management of advanced fibrosis/cirrhosis. The patient should undergo a liver ultrasound with Doppler to assess for portal hypertension and hepatocellular carcinoma (HCC) surveillance, as recommended by the EASL position paper on clinical follow-up after HCV cure 1. Endoscopic screening for esophageal varices is necessary, and the patient should be monitored for complications of cirrhosis including HCC with ultrasound every 6 months and AFP testing, in line with the AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus 1. Despite HCV cure, the patient has advanced fibrosis likely from non-alcoholic steatohepatitis (NASH), requiring lifestyle modifications including:
- weight loss of 7-10% if overweight
- Mediterranean diet
- regular exercise
- abstinence from alcohol Consider vitamin E 800 IU daily if non-diabetic with biopsy-proven NASH. Regular assessment of liver function with comprehensive metabolic panel every 3-6 months is important. This aggressive approach is necessary because despite viral clearance, the patient has advanced fibrosis that increases risk for liver-related complications including HCC and portal hypertension, and may eventually require evaluation for liver transplantation if decompensation occurs, as highlighted in the EASL position paper 1. The patient's advanced fibrosis stage 4, as indicated by the NASH FibroSure testing, warrants close monitoring and management to prevent further disease progression, in accordance with the recommendations outlined in the EASL position paper 1.
From the Research
Management of History of Hepatitis C
- The patient has a history of hepatitis C with sustained virological response (SVR) in 2017 after antiviral treatment, and liver enzymes remain normal 2.
- Recent NASH FIBROSURE showed fibrosis stage 4, indicating advanced fibrosis.
Fibrosis Progression and Regression
- Fibrosis progression is common in hepatitis C, and both host and viral factors influence its natural history 2.
- Viral eradication decreases liver damage by improving inflammation and regressing fibrosis, irrespective of the treatment regimen 2.
- Fibrosis regression has been demonstrated after the eradication of hepatitis C virus infection and is associated with a lower risk of hepatic cirrhosis and liver cancer 2, 3.
- Non-invasive methods, such as transient elastography, are useful in assessing liver fibrosis and can help predict the degree of liver fibrosis after SVR 3, 4.
Risk of Hepatocellular Carcinoma (HCC)
- Liver fibrosis is an important risk factor for the development of HCC after SVR in patients with persistent hepatitis C virus infection 4.
- The FIB-4 index retains its predictive ability for the risk of HCC when recalculated after SVR, despite the decrease in patients with high FIB-4 index values 4.
- Patients with a FIB-4 index <1.45 did not develop HCC even by the regression from advanced fibrosis after SVR 4.
- Liver steatosis is a major predictor of poor outcomes, including all-cause mortality and HCC, in chronic hepatitis C patients with SVR 5.
Monitoring and Follow-up
- Patients showing advanced fibrosis and cirrhosis must be followed up after SVR, as risks of portal hypertension and HCC remain 2.
- Dynamic assessment of the FIB-4 index can be useful in the surveillance of HCC after SVR 4.
- Patients with liver steatosis should be rigorously screened for HCC, regardless of fibrosis stage 5.