From the Guidelines
Management of advanced liver fibrosis from treated hepatitis C requires ongoing monitoring despite viral cure, with a focus on hepatocellular carcinoma (HCC) surveillance, lifestyle modifications, and management of comorbidities. The goal of therapy is to cure HCV infection to prevent hepatic cirrhosis, decompensation of cirrhosis, HCC, severe extrahepatic manifestations, and death 1. Patients with advanced fibrosis (F3) or cirrhosis (F4) should undergo HCC surveillance with ultrasound every 6 months, even after achieving sustained virologic response (SVR), as HCV eradication reduces but does not abolish the risk of HCC 1.
Key aspects of management include:
- HCC surveillance with ultrasound every 6 months for patients with advanced fibrosis (F3) or cirrhosis (F4) 1
- Endoscopic screening for esophageal varices initially and then periodically based on findings for those with cirrhosis
- Lifestyle modifications such as complete alcohol abstinence, maintaining a healthy weight, and managing comorbidities like diabetes and fatty liver disease that can accelerate fibrosis progression
- Vaccination against hepatitis A and B if not immune
- Regular monitoring of liver function tests every 6-12 months
Assessment of liver disease severity is crucial prior to therapy, and non-invasive methods such as liver stiffness measurement and biomarkers of fibrosis can be used to assess liver disease severity, reducing the need for liver biopsy 1. However, in cases of contradictory results or known/suspected mixed etiologies, liver biopsy may be indicated 1. Ongoing surveillance and monitoring are essential, as the risk of HCC persists even after viral clearance, particularly in those with cirrhosis.
From the Research
Management of Advanced Liver Fibrosis
The management of advanced liver fibrosis from treated hepatitis C involves several key considerations:
- Assessment of liver fibrosis: Non-invasive methods, such as ultrasound elastography, are useful in assessing liver fibrosis and can replace liver biopsy in clinical practice 2, 3.
- Treatment with direct-acting antivirals (DAAs): DAAs have been shown to improve liver fibrosis and reduce the risk of liver-related mortality in individuals with advanced fibrosis 4, 5.
- Monitoring of liver stiffness: Liver stiffness measurements can be used to monitor the improvement of liver fibrosis after treatment with DAAs 5.
- Treatment with pirfenidone: Pirfenidone has been shown to decrease fibrosis, cytokine levels, and enhance CB2 gene expression in patients with chronic hepatitis C 6.
Factors Influencing Fibrosis Progression
Several factors can influence fibrosis progression in patients with hepatitis C, including:
- Host and viral factors: Both host and viral factors can influence the natural history of fibrosis progression 2.
- Treatment regimen: The treatment regimen used can affect the progression of fibrosis, with DAAs showing an excellent efficacy and safety profile 2, 5.
- Pre-treatment fibrosis stage: The pre-treatment fibrosis stage can affect the likelihood of improving liver stiffness after treatment with DAAs 5.
Long-Term Outcomes
Long-term outcomes for patients with advanced liver fibrosis from treated hepatitis C are not yet fully understood:
- Risk of hepatocellular carcinoma (HCC): Patients with advanced fibrosis or cirrhosis remain at risk for HCC, even after successful treatment with DAAs 2, 5.
- Need for ongoing surveillance: Patients with advanced fibrosis or cirrhosis may require ongoing surveillance for HCC, even after successful treatment with DAAs 5.