Management of decompensated patients
Dennis Freshwater
pp 1-3
The prognosis of cirrhosis is highly variable, since it is influenced by a number of factors, including aetiology, presence of complications, and comorbid diseases. The ten-year survival rate in patients with cirrhosis from autoimmune hepatitis who are treated with steroids or immunosuppressive agents is similar to survival rates of treated patients with autoimmune hepatitis who do not have cirrhosis. Abstinence from alcohol substantially improves survival in alcoholic cirrhosis, but in patients with alcoholic cirrhosis who continue drinking, mortality over 60 months is 58–85%. This compares with a mortality of 7.3% over 50 months in hepatitis C cirrhosis, and of 29% over 60 months in hepatitis B cirrhosis. The prognosis of patients with decompensated cirrhosis is much worse.
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Comment: Overcoming resistance?
Alastair Miller
pp 3-3
Safe and effective vaccination against hepatitis B virus (HBV) has been available since the mid-1980s, and in 1992 the World Health Organization declared that universal vaccination should be in place by 1997. Nearly 20 years later, the UK remains one of six northern European countries that eschews a policy of universal childhood vaccination and, instead, recommends a targeted approach delivering vaccine to individuals and groups perceived as being at high risk of acquiring HBV infection. Tom Fletcher and Nick Beeching explore the ethical, economic and clinical arguments around universal vaccination. They make the point that it is unlikely to become a reality in the UK unless the cost of vaccine delivery is further reduced.
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When is it appropriate to amplify therapy in chronic hepatitis B?
Phillip M Harrison
pp 4-5
European Association for the Study of the Liver (EASL) guidelines recommend monotherapy with either entecavir or tenofovir as first-line nucleoside/ nucleotide analogue therapy in chronic hepatitis B (CHB). Before the guidelines were introduced, many patients with CHB were commenced on antiviral therapy using earlier drugs. It is recognised that a high proportion of these patients develop viral drug resistance, leading to reactivation of viral replication and recrudescence of liver injury. Such individuals require modification of antiviral therapy.
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Universal vaccination against hepatitis B – cost versus ethics
Tom Fletcher and Nick Beeching
pp 6-7
Hepatitis B virus (HBV) is a global public health problem, even though vaccines have been available for almost 30 years. Worldwide, it is estimated that over 450 million people are chronically infected, and that 500,000 to 1.2 million people die from HBV-related illness each year. HBV is a carcinogen, causing 50% of all liver cancers. The UK is considered to be of low prevalence (estimated at 0.3%) and the Department of Health estimates that around 180,000 people are infected with chronic hepatitis B (CHB). CHB is not seen as a priority, and misses out on the publicity and financial support given to other preventable diseases, despite estimates that its treatment costs the NHS £26–375 million each year.
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The Hepatitis C Trust: disease prevention and awareness
Charles Gore
pp 8-8
According to the WHO, there are 130–170 million people living with hepatitis C globally and 3–4 million new infections every year. In the UK, it is estimated that 250,000–500,000 people are infected, of whom considerably more than half have no idea that they have this virus. Despite government action plans in all four countries of the UK, awareness remains dangerously low, leaving all those still undiagnosed at risk of developing potentially fatal liver disease as well as unwittingly infecting others.
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Hepatitis C and IL-28B polymorphisms
Paul Flanagan and Paul Richardson
pp 9-11
Hepatitis C virus (HCV) is a leading cause of end-stage liver disease and hepatocellular carcinoma. Spontaneous clearance of the virus only occurs in 30% of cases, and around 170 million people worldwide have chronic infection. The current standard of care is combination pegylated interferon-alfa (pegIFN-a) and ribavirin (RBV), but only around 42–52% of genotype 1 (G1) patients will achieve sustained virological response (SVR). Numerous studies have identified both viral and host characteristics that have an impact on treatment response rates. Viral genotypes, baseline viral titres and, more recently, on-treatment viral kinetics, have all been found to influence SVR.
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