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DDW 2015: Cirrhosis and Decompensation Are Common Among People with Chronic Hepatitis C

More than one-quarter of Kaiser-Permanente chronic hepatitis C patients developed cirrhosis over 12 years and 40% of these experienced decompensation -- rates higher than expected, according to a presentation at the recent Digestive Disease Week 2015 meeting in Washington, DC. The study also found that cirrhosis and decompensation were associated with comorbid conditions, supporting the idea of hepatitis C as a systemic disease.

Over years or decades, chronic hepatitis C virus (HCV) infection can lead to serious liver disease including advanced fibrosis, cirrhosis, liver cancer, decompensated liver failure, and the need for liver transplantation. People with decompensation -- which occurs when the liver can no longer carry out its vital functions -- may develop ascites (abdominal fluid accumulation), bleeding varices (enlarged veins) in the esophagus or stomach due to portal hypertension, and hepatic encephalopathy (brain impairment).

Lisa Nyberg and colleagues analyzed outcomes among people with hepatitis C who received care through Kaiser Permanente Southern California -- a large, integrated health maintenance organization with approximately 3.5 million members -- between January 2002 and December 2013.

The projected public health burden of hepatitis C is based on old natural history studies that may not reflect the current patient population, the researchers noted as background. Hepatitis C is most common among Baby Boomers born during 1945-1965. Compared with earlier studies, the current cohort of people with hepatitis C is older and has a higher prevalence of obesity and other comorbid conditions that may affect the natural history of the disease. Patients today have access to much more effective and well-tolerated interferon-free therapy, but this was not available for most of the study period.

This retrospective analysis included 54,383 patients with a relevant diagnosis code or a positive HCV RNA lab test. Those who had liver cancer or had already had a liver transplant were excluded. Of these, 24,968 adults with HCV had been KP members for at least a year and met the inclusion criteria. About 60% were men, more than 40% were white, more than a quarter were Hispanic, and the mean age was approximately 53 years.

Results

• Among the 24,968 eligible hepatitis C patients, 19% were found to have prevalent or pre-existing cirrhosis, 23% developed incident or new cirrhosis during follow-up, and 58% were non-cirrhotic.
• Among people with pre-existing cirrhosis, 17% already had a decompensation diagnosis, 41% developed new decompensation, and 42% did not experience decompensation.
• Among 20,285 patients without cirrhosis, 28% received a new diagnosis of cirrhosis over the entire 12-year study period, with an annual rate of 5.63%.
• Among the people with new cirrhosis, 20% had decompensation when they were diagnosed with cirrhosis, 46% later developed decompensation, and 34% did not have decompensation.
• People who developed incident cirrhosis were significantly more likely than non-cirrhotics to have cardiovascular disease (17.5% vs 12.6%; crude hazard ratio [HR] 1.21) and diabetes (25.5% vs 19.5%; crude HR 1.18).
• Cirrhotic patients were also more likely to have HIV/AIDS, but this was not a significant difference (2.3% vs 1.9%; crude HR 1.14).
• Among 7680 hepatitis C patients with initially compensated cirrhosis, 40% developed incident decompensation over the 12-year study period, with an annual rate of 9.94%.
• Decompensation was significantly associated with cardiovascular disease, diabetes, chronic kidney disease, and obesity.
• Cirrhotic patients who developed decompensation were much more likely to require liver transplants (14.2%) than either compensated cirrhotics (0.03%) or people without cirrhosis (0.03%).
• Cirrhotic patients with decompensation had a 19.3% likelihood of developing hepatocellular carcinoma, compared to 3.1% for compensated cirrhotics and 0.1% for non-cirrhotics (annual rates of 3.31%, 0.47%, and 0.02%, respectively).
• People with decompensated cirrhosis were twice as likely to die as compensated cirrhotics (54.8% vs 20.6%), who in turn were more likely to die than patients without cirrhosis (7.8%).

"Selected comorbid conditions are seen [at] higher prevalence in patients with HCV and cirrhosis and are associated with an increased risk of decompensation," the researchers concluded, "support[ing] the idea of HCV as a systemic illness."

"Our study lends support for early diagnosis and treatment of chronic hepatitis C to reduce morbidity and mortality," they added. The findings also support "aggressive management of comorbid conditions."

7/16/15

Reference

LM Nyberg, X Li, K Chiang, et al. The Natural History of Chronic Hepatitis C. An Updated Look at the Rate of Progression to Cirrhosis and the Incidence of Decompensation in a Large U.S. Health Maintenance Organization. Digestive Disease Week 2015. Washington, DC, May 16-19, 2015. Abstract 809.