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ACTHIV 2018: A State-of-the-Science Conference for Frontline Health ProfessionalsACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Pre-TreatmentEvaluationofHepatitisC
OluwatoyinAdeyemi,MDAssociateProfessorofMedicineDivisionofInfectiousDiseases
CCHHSandRushUniversityMedicalCenter,Chicago
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
LearningObjectivesUponcompletionofthispresentation,learnersshouldbebetterableto:
• ReviewthestepsthehealthcareteamshouldfollowfromHCVdiagnosistotreatment
• DiscusstheimportanceoffibrosisassessmentinHCVmanagementandhowtoassessfibrosis.
• Describewhenhepatocellularcancer(HCC)screeningisanessentialpartofpost-curecare.
HCVguidelines.org(AASLD/IDSA)
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
FacultyandPlanningCommitteeDisclosuresPleaseconsultyourprogrambook.
Therewillbenooff-label/investigationalusesdiscussedinthispresentation.
Off-LabelDisclosure
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
DoyoutreatHCVpatients?• A.yes,ItreatHCVinmyHIV/HCVco-infectedpatients
• B.Yes,ItreatHCVmonoandHIV/HCVco-infectedpatientsinmypractice
• C.IdonottreatHCVandrefertootherspecialists
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
01234567
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rateper100
,000
Persons
HepatitisCHIV
16,600deaths
8369deaths
Deaths From Hepatitis C Have Surpassed Deaths From HIV Infection
LyK.Netal.,AnnalsofInt.Med,2012:157(9)
Age-adjusted Mortality Rates of HIV and Hepatitis C: United States, 1999-2010
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Source: CDC, National Notifiable Diseases Surveillance System (NNDSS)
0
0.5
1
1.5
2
2.5
3
Repo
rted
cases/10
0,00
0po
pulatio
n
Year
0-19yrs
20-29yrs
30-39yrs
40-49yrs
50-59yrs
>60yrs
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ProjectedCasesofHepatocellularCarcinomaandDecompensatedCirrhosisDuetoHCV
Davis GL, et al. Gastroenterology. 2010;138(2):513-521
1950 1960 1970 1980 1990 2000 2010 2020 2030Year
Num
ber o
f cas
es160,000
0
140,000
120,000
100,000
80,000
60,000
40,000
20,000
Decompensated cirrhosis
Hepatocellular cancer
Peak incidence:145,000 cases/year in 2020
Peak incidence:14,000 cases/year in 2019
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
PathogenesisofHIV/HCVCo-infection
cations in the setting of coinfection, are summarized inFig. 1 and described below.
HIV Disease Progression in the Setting of HCVCo-infection
Although most studies demonstrate increased mortalityamong co-infected individuals, a recent meta-analysis ofover 30 studies with over 100,000 patients found noincrease in mortality in co-infected patients in the pre-HAART era. Post-HAART, co-infection increased risk ofoverall mortality but not of AIDS-defining conditions [22].In contrast, an Italian cohort study found a twofoldincreased AIDS risk among co-infected patients [23]. TheWomen’s Interagency HIV Study (WIHS) found an almosttwofold increased AIDS risk among co-infected womenwithout a CD4 count <200 cells/μL and for ART-naïvewomen [24••]. The Italian cohort showed increases inbacterial and mycotic infections and WIHS found increases
in bacterial pneumonia, HIV encephalopathy, and wastingsyndrome, suggesting the need for earlier and moreaggressive HIV and HCV treatment in co-infected individ-uals [23, 24••].
Recent studies found high levels of T-cell activation inco-infected compared to HIV monoinfected individualseven following HAART [24••, 25, 26]. Chronic immuneactivation may lead to immune dysfunction and cytokineproduction, causing enhanced HIV and HCV replicationand lower T-cell counts [25]. The WIHS study showed thathigh levels of activated CD8 T cells are associated withincident AIDS among HCV-viremic women but not HCV-uninfected women, and CD4 activation predicted AIDS inboth groups [24••, 25]. Suppression of HCV with therapyreduces activation [26]. These results again support earlytreatment of HIV and HCV.
Several pathways for active HCV infection impactingHIV infection have been proposed (Table 1). HCV co-infection may increase immune activation, leading to CD4T-cell apoptosis in HIV-untreated patients and more rapid
Fig. 1 Pathogenesis of HIV/HCV co-infection: Immune activation and dysregulation, effects on HIV and HCV disease progression, andcomplications in multiple organ systems
Curr HIV/AIDS Rep (2011) 8:12–22 13
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
RiskFactorsAssociatedwithFasterFibrosisProgressioninChronicHCV
Poynard A.AntivirTher.2010;15(3):281-291;Poynard,etal.Lancet.1997;349(9055):825-832.
HCC
DiseaseStateFactorsHost/ViralFactors
• Malegender• Age• Obesity• Diabetes• Metabolicsyndrome• HIV,HBVco-infection• Immunesystemcompromise• Steatosis• Ironoverload• Genotype3
• Heavyalcoholconsumption• Tobaccouse
LifestyleFactors
• Fibrosisstage• Inflammationgrade• PersistentlyelevatedALT
CirrhosisNormalLiver
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ExtrahepaticManifestationsofHCV
§ Mixedcryoglobulinemia§ Sjögren (sicca)syndrome§ Lymphoproliferativedisorders
§ Porphyriacutanea tarda§ Neuropathy§ Membranoproliferativeglomerulonephritis
§ Cryoglobulinemic vasculitis
§ Cornealulcers(Mooren ulcers)
§ Thyroiddisease§ Lichenplanus§ Pulmonaryfibrosis§ Type2diabetes§ Systemicvasculitis(polyarteritis nodosa,microscopicpolyangiitis)
§ Arthralgias,myalgias,inflammatorypolyarthritis
§ Autoimmunethrombocytopenia
AdaptedfromAliA,Zein NN.CleveClinJ Med. 2005;72:1005-1008.
Strongly associated Possibly associated
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
STEP1:SCREENING
-HCVSCREENINGATENTRYINTOCARE(A1)AND….RecommendationforHCVTestingforPersonsWithOngoingRiskFactors
RECOMMENDED RATING
AnnualHCVtestingisrecommendedforpersonswhoinjectdrugsandforHIV-infectedmenwhohaveunprotectedsexwithmen.
PeriodictestingshouldbeofferedtootherpersonswithongoingriskfactorsforHCVexposure.
IIa,C
www.hcvguidelines.orgpril 28, 2016.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Mr HK• 58y/oAAMwellcontrolledHIV+/HCV+.Newtoyourpractice.Hyperlipidemia,DM.HCV- treatmentnaïve.
• Socialhx:hashistoryofrecreationalmarijuanauseandoccasional“otherdrugs”;deniessignificantetoh
• Meds:Darunavir/cobi+Dolutegravir+FTC/TDF,Metformin,atorvastatin,pantoprazoleforheartburn
• PE:normal• Labs:ALT45,AST78,TB1.8,GFR90.Plts 138K• Imaging:ultrasoundshowshyperechoicliverconsistentwithsteatosis• Has“great”privateinsuranceandwantstostartHCVtherapyASAP
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Case(cont’d)
• ViraltestingisdoneforpatientandhisHCVRNAis3.2millionIU/ml
• HewantstreatmentforHCVbutwhatothercounselingdoyouneedtodo?
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
HCVguidelines.orgRecommendations for Counseling Those with Current (Active) HCV Infection
RECOMMENDED RATING
Personswithcurrent(active)HCVinfectionshouldreceiveeducationandinterventionsaimedatreducingprogressionofliverdiseaseandpreventingtransmissionofHCV. IIa,B
1.Abstinencefromalcoholand,whenappropriate,interventionstofacilitatecessationofalcoholconsumptionshouldbeadvisedforallpersonswithHCVinfection. IIa,B
2.Evaluationforotherconditionsthatmayaccelerateliverfibrosis,includingHBVandHIVinfections,isrecommendedforallpersonswithHCVinfection. IIb,B
3.Evaluationforadvancedfibrosisusingliverbiopsy,imaging,and/ornoninvasivemarkersisrecommendedforallpersonswithHCVinfection,tofacilitateanappropriatedecisionregardingHCVtreatmentstrategyandtodeterminetheneedforinitiatingadditionalmeasuresforthemanagementofcirrhosis(eg,hepatocellularcarcinomascreening)(seeWhenandinWhomtoInitiateHCVTherapy).
I,A
4.VaccinationagainsthepatitisAandhepatitisBisrecommendedforallsusceptiblepersonswithHCVinfection. IIa,C
5.Vaccinationagainstpneumococcalinfectionisrecommendedtoallpatientswithcirrhosis(Marrie,2011). IIa,C
6.AllpersonswithHCVinfectionshouldbeprovidededucationonhowtoavoidHCVtransmissiontoothers. I,C
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
The AASLD/IDSA Recommendations for Patients with Active HCV
• Abstinence from alcohol• Evaluation for other conditions that may lead to fibrosis (e.g. HIV, HBV, NASH)• Evaluation for advanced fibrosis
– APRI, Fib4, imaging• Vaccination against HAV, HBV and pneumococcal infection (in patients with
cirrhosis)• Education on avoidance of transmission
Available at: www.hcvguidelines.org Accessed April 28, 2016.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
STEP2:LINKAGETOCAREANDFIBROSISASSESSMENT
RecommendationforLinkagetoCare
RECOMMENDED RATING
AllpersonswithactiveHCVinfectionshouldbelinkedtoaclinicianwhoispreparedtoprovidecomprehensivemanagement. IIa
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Whatmoreinformationdoyouneedbeforeyoutreathim?
• A.Confirmgenotypeandstarttreatmentsincehisinsurancecoversthepayment?
• B.Assessfibrosisseveritybeforetreatmentinitiation
• C.OrderbaselineresistancetesttocheckforRAVswithgenotypeorder
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
HCVRNApositive—Whatdoyouneedtoknow?• HCVGenotype• HepatitisBstatus- BsAg,cAb,sAb• Alcoholuse?• Activesubstanceuse?• Liverfibrosisseverity.• Ifcirrhotic-child’sclass.Compensatedordecompensated?• Priortreatmentexperience• Renalfunction• Medicationlist• Insurancestatus
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Stateofhepc.org
Courtesy : NVHRNational Viral Hepatitis Roundtable. nvhr.org
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
FDAWarning:RiskofHBVReactivationinHCV-PatientsTreatedwithDAAs• 29casesfromNovember2013– Oct2016
• 2deaths,1livertransplant• Reactivationtypically4–8weeksafterHCVtreatmentinitiation• BaselineHBVcharacteristics:
• 9 +HBsAg andHBVDNA• 7 +HBsAg;undetectableHBVDNA.• 3HBsAgandHBVDNAnegative;presumedisolatedcore+• 10HBVtestingnotreported/available• HCVpatientsshouldbescreenedforHBVinfectionbeforestartingDAAtreatmentandshouldbemonitoredforHBVflare-upsorreactivationduringandfollowing treatment
FDA. Drug Safety Communication published –Ann Intern Med 2017; 166 (11):792-798
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
SuggestionsforchronicHBVManagement/Monitoring
1. +sAganddetectableHBVDNA• HBVtreatmentpriortoHCVtherapy
2. +sAg,undetectableHBVDNA• Closemonitoring(ALT/ASTq2weeks;HBVDNAmonthly)• Duration?
3. Isolatedcore+,HBVDNAnegative• Closemonitoring• Doubledosevaccine?
Slide courtesy of David L Wyles, MD.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Whataboutroutineresistancetesting?
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
MutationProtease(Linear)
Protease(Macrocyclic)
NS5AInhibitor
NS5BNucleoside
NS5BPalm
NS5BThumb
NS5BFinger Interferon Ribavirin
V36M
T54A
R155K
A156T
D168V
L28V
Y93H
S282T
C136Y
M414T
R422K
M423T
P495S
•HCV DrAG ResisSS. 2012;1.2. http://www.hivforum.org= Resistance mutation
Occurrence of Resistance Mutations
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Regimen-SpecificRecommendationsforUseofRASTestinginClinicalPractice
RECOMMENDED RATING
Elbasvir/grazoprevirNS5ARAStestingisrecommended forgenotype1a-infected,treatment-naiveor-experiencedpatientsbeingconsideredforelbasvir/grazoprevir.Ifpresent,weight-basedribavirinshouldbeaddedandtreatmentshouldbeextendedto16weeks,oradifferentrecommendedtherapyused.
I,A
Ledipasvir/sofosbuvirNS5ARAStestingcanbeconsideredforgenotype1a-infected,treatment-experiencedpatientswithoutcirrhosisbeingconsideredforledipasvir/sofosbuvir.If>100-foldresistanceispresent,treatmentshouldinclude12weeksoftherapywithweight-basedribavirin,oradifferentrecommendedtherapy.
I,A
NS5ARAStestingcanbeconsideredforgenotype1a-infected,treatment-experiencedpatientswithcirrhosisbeingconsideredforledipasvir/sofosbuvir.If>100-foldresistanceispresent,treatmentshouldinclude24weeksoftherapywithweight-basedribavirin,oradifferentrecommendedtherapyused.
I,A
Sofosbuvir/velpatasvirNS5ARAStestingisrecommendedforgenotype3-infected,treatment-experiencedpatients(withorwithoutcirrhosis)andtreatment-naivepatientswithcirrhosisbeingconsideredfor12weeksofsofosbuvir/velpatasvir.IfY93Hispresent,weight-basedribavirinshouldbeadded.
I,A
Daclatasvir plussofosbuvirNS5ARAStestingisrecommendedforgenotype3-infected,treatment-experiencedpatientswithoutcirrhosisbeingconsideredfor12weeksofdaclatasvir plussofosbuvir.IfY93Hispresent,weight-basedribavirinshouldbeadded.
I,B
NS5ARAStestingisrecommendedforgenotype3-infected,treatment-naivepatientswithcirrhosisbeingconsideredfor24weeksofdaclatasvir plussofosbuvir.IfY93Hispresent,treatmentshouldincludeweight-basedribavirin,oradifferentrecommendedtherapyused.
I,B
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ImportanttoAssessSeverityofLiverDisease
• Liverbiopsy:veryinfrequentlydonesince2014
• Fibroscan:transientelastography
• Fibrotest/Fibrosure:biochemical
• MRelastography• Determiningfibrosislevelisimportantasitmayaffectdurationoftreatmentand
determinestheneedforHCCscreeningpost-cureMR = magnetic resonance; HCC = hepatocellular carcinoma.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ImportanceofAssessingFibrosisinHepatitisCTreatment
• Determinesurgencyoftherapyforsomepayors• Selectspatientsinneedofadditionalscreeningwithcirrhosis
– Varices– Hepatocellularcarcinoma
• Allowsforselectionofpropertreatmentplananddurationoftherapy• Maybeusedbymanypayorsasawaytorestrictaccesstotherapyortoprioritizetherapy
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
StandardLabTestsSuggestingCirrhosis
• AST:ALTratio>1
• Elevatedtotalbilirubin >2mg/dL
• INR>1.5
• Plateletcount<125,000/μL
Note: If the AST:ALT ratio > 2, then alcohol-related liver injury is likely!
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
•Clinical Calculators•CTP Calculator•APRI Calculator•BMI Calculator•CrCl Calculator•FIB-4 Calculator•Glasgow Coma Scale•GFR Calculator•MELD Calculator•SAAG Calculator•Substance Use Screening Tools•AUDIT-C Questionnaire•CAGE Questionnaire
https://www.hepatitisc.uw.edu/page/clinical-calculators
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Howdoyouassessfibrosisseverityinyourpractice?
• A.Transientelastography (Fibroscan)• B.Serumbiomarkers- fibrotest/fibrosure• C.MRelastography• D.Liverbiopsy• E.Donotroutinelyassessfibrosis
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
LiverStiffnessMeasurement(LSM)RangesinChronicLiverDisease
METAVIRScore
F0– F1 F2 F3 F4
Liver Fibrosis
Mild Moderate Severe Cirrhosis
LSM 2.5– 7.0kPa à MildorabsentfibrosisislikelyLSM>12.5kPa à Cirrhosisislikely
2.5 7.0 9.5 12.5 12.5 kPa
Castera L, et al. J Hepatol. 2008;48(5):835-847
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Fibroscan results
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
InvasiveandNoninvasiveFibrosisTestsLiverBiopsy SerumMarkers TransientElastography MRE
Methodology Directobservation Measuresdirectandindirectserummarkers*offibrosis
Liverstiffnessbydetectionofultrasound-propagatedshearwaves
LiverstiffnessbyMRIofvibration-propagatedshearwaves
Accuracyfordetectingcirrhosis High Moderate(APRI)tohigh(FibroSURETM,ELF)
High High
Accuracyfordetectingintermediatefibrosis
High Low(APRI)tomoderate(FibroSURETM,ELF)
Moderatetohigh High
Riskofcomplications Riskofpain/bleeding Minimal Minimal Minimal
Contraindications Coagulopathy Minimal Obesity;narrowribspaces Claustrophobia;otherMRIcontraindications
Limitations SamplingerrorObservervariation
False-positiveswithhemolysis,inflammation,Gilbert’ssyndrome
False-positiveswithinflammation,congestion
False-positiveswithinflammation,congestion
Longitudinalmonitoring Unsuitable Indicesmaychangewithdiseaseprogression/therapy
Liverstiffnesschangeswithdiseaseprogression/therapy
Liverstiffnesschangeswithdiseaseprogression/therapy
Cost Highestper-testcost Lowper-testcost Highinitialequipmentcost Veryhighinitialequipmentcost
NguyenD,TalwalkarJA.Hepatology.2011;53:2107-2110.
*Serumteststhatincorporatemarkersoffibrogenesis aregenerallymoreaccurate.APRI=AST-to-plateletratioindex;AST=aspartateaminotransferase;ELF=enhancedliverfibrosis;MRE=magneticresonanceelastography,MRI=magneticresonanceimaging.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
IndirectSerumTestsforFibrosisTest TestComponents Sensitivity
(%)*Specificity
(%)*PPV(%)*
NPV(%)*
CirrhosisDiscrimination
FibrosisDiscrimination
AST/ALTratio1 AST,ALT 53 100 100 81 + –
APRI2 AST/plateletcount 77 72 70 79 + +/– (moderate)
FIBROSpect II®3,4 HA,TIMP-1,a2-macroglobulin 72 74 61 82 + +
FibroSURETM5,6
•FibroTesta2-macroglobulin,haptoglobin,ApoA1,GGT,totalbilirubin,ALT 84 95 76 91 + +
HepaScore®7 Age,gender,bilirubin,GGT,HA,g2-macroglobulin 77 70 71 77 + +
ELF8 HA,N-terminalpropeptide oftypeIIIcollagen,TIMP-1 86 62 80 70 + +
1.Sheth SG,etal.AmJGastroenterol.1998;93:44-48;2.LinZHetal.Hepatology.2011;53:726-736;3.ZamanA,etal.AmJMed.2007;120:280.e9-e14;4.www.prometheuslabs.com/Resources/Fibrospect/Fibrospect_II_Product_Detail.pdf;5.Poynard T,etal.CompHepatol.2004;3:8;6.www.labcorp.com/.EdosPortlet/TestMenuLibrary?libName=File+Library&compName=L1080;7.Guéchot J,etal.Clin Chim Acta.2010;411:86-91;8.Guéchot J,etal.Clin Chem LabMed.2012;50:693-699.
ALT=alanineaminotransferase;ApoA1=apolipoprotein A1;GGT=gamma-glutamyl transpeptidase;HA=hyaluronicacid;NPV=negativepredictivevalue;PPV=positivepredictivevalue;TIMP-1=tissueinhibitorofmetalloproteinase.*Sensitivity,specificity,PPV,andNPVvaluesareforsignificantfibrosis,withtheexceptionofAST/ALTratio,wherethevaluesareforcirrhosis.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
DetectionofCirrhosis:TransientElastography versusFibroTest &AST-PlateletRatioIndex(APRI)
TransientElastography
FibroTest(FibroSURE) APRI
Cut-off value ≥ 12.5kPa ≥ 0.75 ≥ 1.0
AUROC(95%CI) 0.92(0.86-0.98) 0.78 (0.66-0.89) 0.73 (0.58-0.88)
Sensitivity(%) 76.9 61.5 77
Specificity(%) 86.4 73.8 72.8
PositivePredictiveValue(%) 41.7 22.9 26.3
NegativePredictiveValue(%) 96.7 93.8 96.2
Correctlyclassified(%) 85.3 72.4 68.1
Castera,HIVMed.2014;15:30-39.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ChoosingaRegimen2018
• Youmaynothaveachoice:thechoicemaybemadebythepayors• Decidingfactors
– SVRrates– all>95%,similaramongexistingregimens– Durationoftherapy– 8-12weeksnaïve,longerforcirrhosispatientsandnon-responders– Impairedrenalfunction(GFR,30ml/min);Protease/NS5ainhibitorsmaybeusedsafely– Genotype alsoguidesthechoiceofregimen
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Case(cont’d)• Hegetstransientelastography
– 15.4kPa (stage4fibrosis/cirrhosis)– GetsanEGD- novarices– Child’sAcompensatedcirrhosis
• Treatmentisinitiated– SVRachievedwith12weeksoftreatment– Repeatfibroscan postcureis11.0(stage3fibsosis)
• Whatelsedoyouneedtodoforhim?– Cancersurveillance
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
ScreeningEGDandfollowup
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/variceal-hemorrhage/
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
CirrhosisandHCCScreening
• CirrhosisisthemostimportantriskfactorfordevelopingHCCinpatientswithchronichepatitis Cinfection.
• Lesscommonly,HCCwilloccurinpatientswhohaveadvancedfibrosisbutwithout cirrhosis.
• TheAASLDpracticeguidelinesrecommendsurveillanceforHCCusingabdominal ultrasoundevery6 months forallHCV-infectedpatientswhohavecirrhosis(oradvancedfibrosis).
• SomeexpertsstillrecommendusingAFPinadditiontoultrasound,butitisstronglyrecommendednottouseAFPasthesolescreeningtool.
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
HCCScreening
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
PersistentElevationInALTPostCureofHCV
• ElevatedALTinpatientswithSVR:– 2-8%ofpatientstreatedwithPEGINF– 1%ofpatientstreatedwithoralanti-viraltherapy
• Whatcausesthis?– NAFLD,didtheygainweight?– Anotherco-existentliverdisease– Alcoholconsumption,isASTelevated?– ?re-infection,alwaysneedtoconsiderthis
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
KeyMessages–Needtoassessfibrosisstagepriortotreatmentinitiation–NeedforcontinuedHCCscreeningpostcurewithadvancedfibrosis(stage3and4).
– Indicationsforbaselineresistancetestingwelllaidout.– ScreeningforandmonitoringforHBVreactivationduringDAARx– ElevatedALTpostcure- ?NASH,?alcohol/meds?Re-infection–CounselingonreinfectionpostCureremainsimportant.–Visithcvguidelines.org OFTEN
ACTHIV 2018: A State-of-the-Science Conference for Frontline Health Professionals
Thanksforyourattention