Snapshots from AASLD 2014, by Lucinda K. Porter, RN

December’s Snapshots typically features abstracts presented at the recent Liver Meeting. The research presented here was gathered from conference posters, presentations and abstracts. It represents part of the story and unless and until the studies reviewed here are published in peer-reviewed journals, the data and conclusions are considered preliminary.
Abstract #LB-29: Patients Meeting ‘Highest’ or ‘High’ Priority for HCV Treatment in the Chronic Hepatitis Cohort Study
  Authors: Fujie Xu, et al.
Results and Conclusion: The new AASLD/IDSA treatment guidelines prioritize treatment for hepatitis C virus (HCV) infection. For example, people with stage 3 or 4 fibrosis have the highest priority for HCV treatment; people with stage 2 are high priority. The goal of this research by a Centers for Disease Control and Prevention (CDC) team was to calculate how many people meet the criteria of ‘highest’ or ‘high’ priority for HCV treatment. Examining data from more than 10,000 people, at least two-thirds would meet the ‘highest’ or ‘high’ criteria for treatment according to the new treatment guidelines. However, treatment costs and other barriers hinder access to treatment. 

Editorial Comments:
This year’s liver meeting devoted an entire session to “Hepatitis C: Health Economics and Cost-Effectiveness.” The fact that there were multiple presentations on this subject underscores the frustration physicians experience because their attempts to treat their patients are hampered by state and private insurance plans.  

Abstract #1499: Most Patients with Hepatitis C Virus-Associated Lymphoma Present with Mild Liver Disease at Cancer Diagnosis: A Call to Revise Indications for HCV Treatment
  Authors: Harrys Torres and Parag Mahale
Results and Conclusion: It is widely known that HCV patients’ risk for hepatocellular carcinoma does not occur until liver disease has progressed to stage 3/4 fibrosis. Researchers from MD Anderson Cancer Center evaluated liver disease stages of patients with HCV-associated B-cell non-Hodgkin lymphoma (NHL). They found that most of the patients with HCV-NHL had mild liver disease at cancer diagnosis (33% had stage F-1; 36% had stage F-2). Only 8% of those with HCV-NHL had undetectable HCV.
Editorial Comments: These data offer compelling reasons for changing the AASLD/IDSA treatment guidelines. Although the risk of NHL is relatively low, waiting for patients to have cirrhosis before they are treated is far too late. It is like waiting for a diabetic patient to have peripheral neuropathy or vision loss before treating diabetes.
Abstract #174: Mortality and Progression to Decompensated Cirrhosis in Chronic Hepatitis C (CHC) Patients with Liver Biopsy Confirmed Fibrosis in the Chronic Hepatitis Cohort Study
  Authors: Anne Moorman, et al.
Results and Conclusion: CDC researchers examined data from 14,256 chronic HCV patients, from 2004-2011. Among those with higher fibrosis who were not treated, there was substantial progression to decompensated cirrhosis, hepatocellular carcinoma, and death. Patients who had received any HCV treatment had less disease progression.
Editorial Comments:
Over the years, we’ve seen many studies such as this one. The results are so apparent that one might even ask why anyone bothers to do this research. Despite the obvious nature of this, people are being denied HCV treatment. Research such as this reminds us of the critical need to treat everyone who wants to be treated.
Abstract #1498: Potential Impact on Mortality of HCV Eradication Post-Liver Transplant in the Era of Direct Anti-Viral Agents
  Authors:  Carmi Punzalan and Graham F. Barnard
Results and Conclusion: HCV recurs after liver transplantation. This study investigated the relationship between HCV recurrence and mortality post-transplantation. They found that treatment of HCV pre-or post liver transplant may slightly improve survival from 70% over 8 years to 87%.
Editorial Comments:
At the risk of sounding like a broken record, it seems to me that an even better way to reduce HCV-mortality is to treat patients long before they need a liver transplant. How about offering treatment to patients who have no or mild liver damage?
Abstract: Low Rates of Baby Boomer Screening for Hepatitis C in Initial Primary Care Visits at a Tertiary Care Center
  Authors: Bonnie Ewald, et al.
Results and Conclusion: In 2012, the CDC recommended HCV screening guidelines to include one-time HCV screening for people born between 1945 and 1965. This research examined the HCV screening practices of a large outpatient clinic from 2012-2103, and found only 12% were screened.
Editorial Comments:
Screening baby boomers and people with HCV risk factors is fundamental. We can’t cure people without first diagnosing them. Urge baby boomers you know to be tested.
Abstract #1522: Mutual Inhibition between Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)
  Authors: Ge Yu, et al.
Results and Conclusion: This study evaluated 1529 people in China who had HBV, HCV, or both: 1251 were HCV-positive, 164 HBV–positive, and 114 had both HBV/HCV.
The HBV/HCV co-infected patients had lower HBV DNA compared to patients with HBV monoinfection and lower HCV RNA compared to those with HCV monoinfection. Compared to the HBV-only group, the HBV/HCV co-infection group showed signs of more liver damage, measured by fibrosis and liver function tests. The HBV/HCV results were similar to the HCV-only group.
These results suggest that the interaction between HCV and HBV inhibit the replication of viruses in HBV/HCV co-infected patients. Lab tests of HBV/HCV co-infected patients were similar to patients with HCV but were worse when compared to HBV monoinfected patients.
Editorial Comments:
This interesting study leads me to ponder a few things. 1) We know that viral load does not matter in HCV, where it does in HBV. However, in this study, both HBV and HCV viral load was more likely to be lower in HBV/HCV co-infected patients, and they had more indication of liver damage compared to HBV patients. 2) Why wasn’t there more indication of liver damage in the HBV/HCV group compared to the HCV group? I hope to see more studies on this subject. 

Abstract #1792: Behavioral Risk Changes in Young People Who Inject Drugs Following Rapid HCV Testing
  Authors: Alice K. Asher, et al.
Results and Conclusion:
This study conducted in 2012, enrolled adult active drug injectors under 30 years old.  They offered rapid HCV-antibody testing and gathered information on a range of issues, including demographics,  medical history, and high-risk behaviors. Compared to those who received standard (not rapid) HCV testing in 2010 and 2011, rapid testing was associated with a decrease in high-risk behaviors and completion of HIV testing. Rapid anti-HCV testing provides the opportunity for immediate counseling.
Editorial Comments:
The high association between HCV and injection drug use in younger people is of great concern. This study shows the potential benefit of rapid HCV test results. Now if we could also have rapid HCV viral load testing.
Abstract #1458: Failure of Perinatal Hepatitis C Testing: Philadelphia, 2011 - 2013
  Authors: Danica Kunciom and Kendra Viner
Results and Conclusion:
Most of the HCV infection in children is the result of vertical transmission from mother to infant. There are guidelines that require testing of both hepatitis B virus positive pregnant mothers and their infants, but none that test for HCV. This study of 74,718 infants born in Philadelphia found that an insufficient number of infants are being tested for HCV after birth. HCV is largely asymptomatic for many years, especially in children. These researchers urged the expansion of testing practices to include HCV screening for pregnant women and confirmatory HCV testing for their infants.
Editorial Comments:
Prenatal HCV testing would be easy to do and cost-effective.