Published online Mar 21, 2018. doi: 10.3748/wjg.v24.i11.1269
Peer-review started: December 5, 2017
First decision: December 14, 2017
Revised: January 27, 2018
Accepted: March 3, 2018
Article in press: March 3, 2018
Published online: March 21, 2018
It is known that the hepatic steatosis prevalence in hepatitis C patients who have achieved a sustained virological response with interferon is approximately 50%. However, the prevalence of fatty liver in hepatitis C patients who have achieved a sustained virological response with direct-acting antivirals has not previously been studied. Knowledge of this is important in order to direct appropriate long-term follow up for patients.
Post-sustained virological response (SVR), hepatitis C patients, many of whom have normal liver enzymes, are too often being discharged from their hepatologists’ care with no further plans for follow up. The current European and United States guidelines only recommend long-term follow up in patients with elevated enzymes. In addition, many hepatitis C patients who have achieved an SVR are excluded from nonalcoholic fatty liver disease (NAFLD) clinical trials. We think it is important to determine the prevalence of NAFLD post-SVR and assess the severity of liver disease in these patients. Determining these things can provide a basis for future research aimed at determining the long-term natural history of the disease in these patients, and may prompt changes in both liver society guidelines for follow up and in clinical trial exclusion criteria.
The main objective, to determine the prevalence of fatty liver in hepatitis C patients who have achieved a sustained virological response with direct-acting antivirals, was achieved. This knowledge provides a basis for future research aimed at determining the long-term natural history of the disease in these patients.
In this study we used transient elastography with controlled attenuation parameter to measure steatosis and fibrosis in hepatitis C patients post-SVR. This was the first study to measure both fibrosis and steatosis in hepatitis C patients using the FibroScan technology.
Our findings have added knowledge previously unknown in this field that may help to guide the need for long-term monitoring of hepatitis C patients post-SVR, with a particular focus on the possible occurrence of NAFLD in these patients, whether or not there are elevated liver enzymes. The most important future research will be to carry out long-term follow up on hepatitis C patients post-SVR to determine the prevalence of fatty liver over time.
This is the first prospective study to assess the prevalence of fatty liver in hepatitis C patients who have achieved a sustained virological response with direct-acting antivirals. The study’s findings that fatty liver is present in 47.5% of these patients and that some steatotic patients have clinically significant fibrosis despite normal liver enzymes should raise awareness of the high post-SVR prevalence of fatty liver and the importance of post-SVR assessment of steatosis and fibrosis and long-term follow up with these patients. The study’s findings raise concern that the recommendations found in the current U.S. and European guidelines for follow up of patients post-SVR could result in a lack of adequate long-term monitoring of these patients. In particular, the very high prevalence of fatty liver (47.5%) with continuing clinically significant fibrosis in the steatotic patients despite normal liver enzymes should be of concern to clinicians. Therefore, we recommend post-SVR assessment of steatosis and fibrosis in those with abnormal BMI or other risk factors typical of NAFLD. In patients found to have hepatic steatosis long-term follow up is clearly warranted.
Our study’s assessment of steatosis and fibrosis in hepatitis C patients at almost a year post-SVR has shown that long-term monitoring of these patients to assess the possibility of fatty liver and fibrosis is important. With this study, we have provided a foundation upon which lengthier and larger studies should expand, using regularly scheduled transient elastography with controlled attenuation parameter assessments in order to determine whether this high level of steatosis is still present multiple years post-SVR and the clinical ramifications for patients.