From the Guidelines
HCV RNA testing is the most appropriate method for monitoring a patient with cirrhosis due to a remote Hepatitis C (HCV) infection, who recalls receiving treatment but has no documented record of it, as it directly detects viral genetic material in the blood, providing definitive evidence of whether the infection is still present or has been successfully eradicated. This approach is supported by the most recent guidelines, including the 2020 EASL recommendations on treatment of hepatitis C, which emphasize the importance of achieving a sustained virological response (SVR) as the primary goal of HCV therapy 1.
Key Considerations
- A negative HCV RNA result would confirm cure, while a positive result would indicate ongoing infection requiring treatment.
- In addition to HCV RNA, consider ordering HCV antibody testing, liver function tests, complete blood count, and imaging studies to fully assess liver status.
- For patients with cirrhosis, regardless of HCV status, regular surveillance for hepatocellular carcinoma with ultrasound every 6 months is recommended, as stated in the 2015 AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus 1.
- If HCV RNA is positive, referral to a hepatologist or infectious disease specialist would be appropriate to initiate direct-acting antiviral therapy, which typically consists of medications like sofosbuvir/velpatasvir or glecaprevir/pibrentasvir for 8-12 weeks, with cure rates exceeding 95% even in patients with cirrhosis.
Additional Recommendations
- Patients who achieve an SVR should receive follow-up care according to their level of fibrosis, with those having advanced fibrosis (Metavir fibrosis stage F3 or F4) undergoing surveillance for HCC with twice-yearly abdominal imaging 1.
- Assessment for HCV recurrence or reinfection is only necessary if the patient has ongoing risk for HCV infection or experiences otherwise unexplained hepatic dysfunction, in which case a quantitative HCV RNA assay is recommended 1.
From the Research
HCV RNA Testing for Monitoring Patients with Cirrhosis
- HCV RNA testing is a crucial tool for monitoring patients with cirrhosis due to HCV infection, as it can detect the presence of the virus in the blood 2, 3.
- However, the presence of HCV RNA in peripheral blood mononuclear cells (PBMCs) may indicate a potential relapse after treatment, even if the virus is undetectable in the serum 4.
- In patients with cirrhosis, the risk of hepatocellular carcinoma (HCC) persists even after cure of HCV infection, and regular surveillance is necessary to detect early stages of HCC 5, 6.
Factors Associated with HCC Risk
- Male sex, diabetes, and non-invasive markers of liver fibrosis, such as liver stiffness measurement (LSM) and fibrosis-4 (FIB-4) score, are independently associated with an increased risk of de novo HCC in patients with cirrhosis treated with direct-acting antivirals (DAAs) for HCV infection 5.
- Diabetes is also independently associated with HCC recurrence in patients with a history of HCC 5.
Monitoring and Treatment
- Patients with cirrhosis due to HCV infection should be monitored regularly for signs of liver disease progression and HCC, even after cure of HCV infection 3, 6.
- Treatment of HCV infection with DAAs has improved response rates in patients with cirrhosis, but optimizing efficacy and reducing the risk of complications remains an important goal 6.