Antiviral therapy impacts esophageal varices in HCV-induced cirrhosis

May 25, 2010, Wiley

Italian researchers have discovered that antiviral treatment and sustained virologic response (SVR) prevents esophageal varices in patients with compensated hepatitis C (HCV)-induced cirrhosis, indicating that endoscopic surveillance can be safely delayed or avoided in these patients. Full findings are published in the June issue of Hepatology, a journal of the American Association for the Study of Liver Diseases (AASLD).

According to the National Digestive Diseases Information Clearinghouse (NDDIC), an estimated 4.1 million Americans have antibody to HCV (anti-HCV), indicating ongoing or previous infection with the virus. Researchers estimate that at least 20% of patients with chronic HCV develop cirrhosis. Progression of cirrhosis leads to , which can result in esophageal varices (EV) and other complications.

EVs are abnormally enlarged veins in the esophagus that occur when portal hypertension obstructs normal to the liver, causing blood to back up into the esophageal vessels. Esophageal varices can rupture which can be life-threatening. The onset of EV marks a crucial turning point in the outcome of cirrhosis. The research team led by Savino Burno, M.D., set out to determine whether resulting in SVR could prevent this condition.

The study, spanning from January 1989 to December 1992, evaluated 218 patients less than 70 years of age with compensated Child-Pugh class A cirrhosis who presented at three referral centers in Milan and tested positive for serum anti-HCV. Only subjects who agreed to undergo upper endoscopy at the time of enrolment and who were found to be EV-free were included. All 218 subjects had regular follow up with surveillance ultrasound for hepatocellular (HCC) every six months and endoscopy every three years to identify de-novo varices.

The standard antiviral regimens of recombinant alpha IFN or combination with both IFN and ribavirin were administered, regardless HCV genotype, for at least six months and for an additional six-month period in patients who achieved a complete biochemical response. Combination therapy with IFN or pegylated IFN and ribavirin was administered in agreement with guidelines. SVR was defined as undetectable serum HCV-RNA (<50 iu/ml) six months after stopping therapy.

The primary endpoints were development of de-novo varies or HCC. Of the 218 patients, 149 (68%) received HCV therapy and 34 (23%) achieved SVR and no EVs. During the follow-up of median 11.4 years, de-novo EVs were detected equally among untreated and treated patients who did not achieve SVR. Sixty-seven patients, 7 of whom achieved SVR, developed HCC.

"Our study provides an accurate estimate of the 10-year cumulative incidence of EV in this population of patients," stated Dr. Bruno. "A major finding of our study, of great importance in clinical practice, is that the achievement of SVR abolishes the development of EV in the long-term. The reliability of our result is guaranteed by the ample length of observation among this group of patients. In routine clinical practice, serial surveillance by EGD can be safely delayed or avoided in SVR patients, sparing a significant amount of useless invasive and costly procedures."

The Milan study is the largest study with the longest follow-up to date that addresses the impact of SVR on the development of esophageal varices. In his editorial also published in Hepatology this month, Dr. Richard Sterling concurs, "If these results are confirmed, it may not be necessary to subject patients with HCV-induced cirrhosis to the expense and risks of repeated endoscopies." He further points out that the current study is the first to demonstrate a pharmacologic treatment to reduce (or in this case, eliminate) the development of varices. However, Dr. Sterling cautions, "Before we get too excited, we must remember that current treatment to achieve SVR in those with cirrhosis is difficult and there are often increased side effects, more cytopenias, and lower response rates than those without cirrhosis. Therefore, given the cost, both in dollars and resources, the increased side effects, and decreased response rates of HCV therapy, it remains to be determined if the "bang is worth the buck" in this select group of patients."

More information: "Sustained Virologic Response Prevents the Development of Esophageal Varices in Compensated, Child-Pugh Class A HCV-induced Cirrhosis: A twelve-year prospective follow-up study." Savino Bruno, Andrea Crosignani, Corinna Facciotto, Sonia Rossi, Luigi Roffi, Alessandro Redaelli, Roberto de Franchis, Piero Luigi Almasio, and Patrick Maisonneuve. Hepatology; Published Online: January 27, 2010 (DOI: 10.1002/hep.23528); Print Issue Date: June 2010.

Editorial: "Long Term Effects of Sustained Virologic Response on the Development of Esophageal Varices in Compensated Cirrhosis: Is the Bang Worth the Buck?" Richard K. Sterling, M.D. Hepatology; Published Online: February 19, 2010 (DOI 10.1002/hep.23601 ); Print Issue Date: June 2010.

Related Stories

Recommended for you

Past encounters with the flu shape vaccine response

February 20, 2018
New research on why the influenza vaccine was only modestly effective in recent years shows that immune history with the flu influences a person's response to the vaccine.

Building better tiny kidneys to test drugs and help people avoid dialysis

February 16, 2018
A free online kidney atlas built by USC researchers empowers stem cell scientists everywhere to generate more human-like tiny kidneys for testing new drugs and creating renal replacement therapies.

Study suggests expanded range for emerging tick-borne disease

February 16, 2018
Human cases of Borrelia miyamotoi, a tick-borne infection with some similarities to Lyme disease, were discovered in the eastern United States less than a decade ago. Now new research led by the Yale School of Public Health ...

Expanding Hepatitis C testing to all adults is cost-effective and improves outcomes

February 16, 2018
According to a new study, screening all adults for hepatitis C (HCV) is a cost-effective way to improve clinical outcomes of HCV and identify more infected people compared to current recommendations. Using a simulation model, ...

Flu shot only 36 percent effective, making bad year worse (Update)

February 15, 2018
The flu vaccine is doing a poor job protecting older Americans and others against the bug that's causing most illnesses.

IFN-mediated immunity to influenza A virus infection influenced by RIPK3 protein

February 15, 2018
Each year, influenza kills half a million people globally with the elderly and very young most often the victims. In fact, the Centers for Disease Control and Prevention reported 37 children have died in the United States ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.