0227 - Hepatitis C

Question 1

What type of virus is HCV?

Answer 1

RNA, single strand hepacivirus.

Question 2

How many million worldwide carriers of HCV?

Answer 2

170-200m.

Question 3

What is the prevalence and incidence of HCV in Australia?

Answer 3

226,700 infected

10,000 new notifications each year

Question 4

What are the dominant HCV genotypes in Australia

Answer 4

1 (52%)

3 (33%)

Question 5

How is HCV transmitted?

Answer 5

Blood-borne, and bodily fluids

75-85% transmission is IV drug users.

Question 6

What is the course of HCV?

Answer 6

Incubation 7 weeks (generally sublicinical)
20% progress to acute hepatitis, rarely fulminant
60-90% fail to clear virus (chronic infection).
Cleared virus tested by repeatedly normal LFTs and PCR negative

Question 7

How can chronic HCV be diagnosed?

Answer 7

Persistant elevation of ALT
However, may have continued viraemia and abnormal liver biopsy with normal ALT.
Look for presence of antibodies, and then PCR.

Question 8

What is the progression of HCV?

Answer 8

Chronic infection leads to chronic hepatitis.
Cirrhosis 20% at 20-30 years
HCC in 30% of cirrhotics at further 10 years
Cirrhosis may also decompensate

Question 9

What are the symptoms of HCV?

Answer 9

Often nothing or non-specific

Fatigue, nausea, arthralgia (joint pain), depression, anxiety, anorexia, wight loss, fever, muscle aches.

Question 10

What tests are used to investigate HCV?

Answer 10

LFT (ALT AST)
Imaging
HCV specific tests - HCV antibody, HCV RNA PCR, RIBA (recombinant immunoblot assay)

Question 11

In HCV, what does +Ab +PCR mean?

Answer 11

HCV - chronic or acute infection

Question 12

In HCV, what does +Ab -PCR mean?

Answer 12

Previous/cleared HCV infection (or chronic with undetectable RNA, or false positive)

Question 13

In HCV, what does -Ab -PCR mean?

Answer 13

No infection
Or immediately after infection, before viraemia
Or previous infection with clearance and seroreversion

Question 14

In HCV, what does -Ab +PCR mean?

Answer 14

Acute HCV (recent - no antibodies yet), or chronic HCV but unable to produce antibodies.

Question 15

Of what use is a liver biopsy in HCV?

Answer 15

Not mandatory but good to guide treatment (inflammation and fibrosis).
Fibroscan often used instead now, liver stiffness score.

Question 16

What are the key aspects of chronic HCV management?

Answer 16

Counselling - clinical course and outcomes/testing issues
Precautions about blood-borne viruses
Optimise course (BMI, alcohol)
Vitamins and diet
Plan therapy type and timing
Liver clinic support

Question 17

What is the threshold for alcohol use in HCV?

Answer 17

Ideally abstinent
>50g/day have more severe injury, more rapid disease progression, and higher frequency of cirrhosis and HCC.
Alcohol also decreases response to interferon therapy.

Question 18

What is the aim of HCV antiviral treatment?

Answer 18

to be PCR negative (undetectable RNA) 6 months after cessation of treatment.

Question 19

How do you treat chronic HCV?

Answer 19

Best option is triple therapy
Pegylated interferon + Ribavirin + Direct-Acting Antiviral (particularly type 1)
Genotype 2/3 without DAA

Question 20

How can you manage chronic HCC without antiviral therapy?

Answer 20

Optimise lifestyle/risk factors
Monitor liver bloods, AFP, 6 monthly ultrasound
Watch for cirrhosis, particularly in older men.