Diseases and Procedures

Hepatitis C

By Peter G. Mavrelis, M.D.

Hepatitis C is the most common cause of chronic hepatitis in the U.S. affecting 1.5% of the population. One of every five people seen in the inner city E.R.'s is infected. The incidence of new cases peaked in 1989 just before a serological test was devised to screen blood products before transfusion. Today the risk of HCV from blood transfusion is .001%. Most new cases are now contacted by IV drug use, having multiple sexual partners, maternal infant transmission, or occupational exposure.

During acute infection only 25% of patients have symptoms of typical viral hepatitis. During the chronic phase, 30% have no symptoms and normal liver functions, 50% have no symptoms and elevated liver tests, and 20% have clinical liver disease with fatigue and malaise. Factors that lead to a worse prognosis are unclear but alcohol consumption makes matters worse. Twenty percent of patients develop cirrhosis after 20 years and hepatocellular carcinoma can develop in cirrhotics after 30 years.

The diagnosis of hepatitis C is made by using the antibody screening test. This is a sensitive test and indicates active or chronic infection. Screening tests should be followed by a confirming test called RIBA test. Since 85% of cases develop chronic infection having antibody usually means having the infection. Hepatitis C RNA can be measured directly from blood samples and is the gold standard proving active virus circulation. Liver biopsy is the gold standard for determining the severity and stage of the disease.

Treatment of hepatitis C is aimed at preventing the progression of the disease to cirrhosis. Patients should stop all alcohol consumption. They should maintain a balanced diet and get plenty of rest. Vaccination should be given for hepatitis B and A. In a household with an infected member, sharing of toothbrushes and razors should be avoided. Sexual partners of infected patients should be checked but no changes in sexual practices with partners in long-term relationships is necessary.

Interferon alfa-2b is a recombinant protein that has shown effectiveness against HCV in 25% of patients. Treatment is recommended for patients whose disease is most likely to progress to cirrhosis, those with persistent increases of serum ALT level, presence of HCV RNA in the blood, and biopsy specimen showing moderately severe hepatitis. After 12 weeks of treatment if the serum remains positive for HCV RNA, the likelihood of a subsequent response is extremely low. The factors most closely associated with a response to treatment are the absence of cirrhosis on liver biopsy and low serum HCV RNA (less than 1 million viruses/ml). Combination therapy with ribavirin, a nucleoside analogue, has increased the sustained viral disappearance rate to 50%. We are finding that treating hepatitis C is like treating the AIDS virus, we need multiple drugs to eradicate the organism. As a last resort if end stage liver failure occurs, transplantation can be performed.

We are offering treatment with interferon as well as treatment with ribavirin through a study with Indiana University. The medications are funded by the research project.