Follow-Up Care for Patients with History of Hepatitis C
Patients who have achieved sustained virologic response (SVR) after hepatitis C treatment require ongoing surveillance only if they have advanced fibrosis (F3) or cirrhosis (F4), while those without advanced fibrosis need no additional liver-related follow-up. 1
Post-Treatment Assessment of Cure
All patients must undergo confirmation testing at 12 weeks or later after completing therapy, which includes: 1
- Quantitative HCV RNA testing to confirm undetectable virus (virologic cure)
- Hepatic function panel to document transaminase normalization
- Monitoring for hypoglycemia in patients taking diabetes medications
- INR monitoring for patients taking warfarin
Risk Stratification Based on Fibrosis Stage
The follow-up strategy depends entirely on whether the patient had advanced fibrosis before achieving SVR. 1, 2
Patients WITHOUT Advanced Fibrosis (F0-F2)
No additional liver-related follow-up is recommended for patients who achieved SVR without advanced fibrosis. 1, 2 This represents a critical decision point—these patients can be discharged from hepatology care after confirming SVR.
Patients WITH Advanced Fibrosis or Cirrhosis (F3-F4)
Lifelong surveillance is mandatory even after achieving SVR, as these patients remain at risk for hepatocellular carcinoma (HCC) and complications of portal hypertension: 1, 3, 2
- HCC surveillance with abdominal ultrasound every 6 months (with or without alpha-fetoprotein) 1, 2
- Upper endoscopy every 2-3 years to screen for esophageal varices 1, 2
- Continue endoscopy surveillance if varices are already present, with treatment as indicated 1
Assessment for Persistent Liver Disease
If transaminases remain elevated after achieving SVR, evaluate for other causes of liver disease, including: 1
- Non-alcoholic fatty liver disease
- Alcohol-related liver disease
- Autoimmune hepatitis
- Hemochromatosis
- Other viral hepatitis
Reinfection Monitoring
HCV RNA testing for reinfection is only necessary if the patient has ongoing risk factors (such as active injection drug use) or develops unexplained hepatic dysfunction. 1
- Use quantitative HCV RNA assay, not anti-HCV antibody testing, to detect reinfection 1
- Annual HCV RNA testing is recommended for patients with ongoing risk factors 4
- Routine prospective monitoring is NOT recommended for patients on immunosuppressive therapy who achieved SVR 1
Special Considerations for Treatment Failures
Patients who did not achieve SVR should be evaluated for retreatment by a specialist according to AASLD/IDSA guidance. 1
For patients unable to be retreated: 1
- Assessment for disease progression every 6-12 months with hepatic function panel, CBC, and INR
- Counsel to avoid excess alcohol use
Common Pitfalls to Avoid
A critical gap identified in real-world practice is that 20% of patients with advanced fibrosis receive no HCC screening post-SVR, while 35% without advanced fibrosis undergo unnecessary liver imaging. 3 This highlights the importance of clear risk stratification based on fibrosis stage.
Do not discontinue HCC surveillance in cirrhotic patients who achieve SVR—new HCC cases continue to occur post-treatment, though at reduced rates compared to untreated patients. 3 The sustained virologic response aborts progression of liver injury and causes regression of fibrosis in most patients, but does not eliminate HCC risk in those with established cirrhosis. 1