The burden of cirrhosis, hepatic decompensation, and hepatocellular carcinoma has risen dramatically during the past decade among patients with chronic hepatitis C virus infection, Dr. Fasiha Kanwal and her colleagues reported in the April issue of Gastroenterology.
In a large retrospective cohort study of more than 300,000 patients at Department of Veterans Affairs medical centers across the country, the prevalence of cirrhosis and hepatic decompensation doubled – and that of hepatocellular carcinoma increased 19-fold – between 1996 and 2006.
"Thus, 1 of 5 patients with HCV had cirrhosis and 1 of 100 patients with HCV had hepatocellular carcinoma in the 2006 calendar year," said Dr. Kanwal of the John Cochran division of the St. Louis VA Medical Center, and her associates.
This increase was significantly greater than that predicted by several mathematical models, they noted.
The investigators examined the burden of HCV illness directly, quantifying changes in the prevalence of cirrhosis and assessing trends in its related complications, because indirect data had suggested that it was increasing. "Our data are the first to provide direct and contemporary estimates of the time trends in the burden of cirrhosis from the largest assembled group of HCV patients anywhere in the world," the researchers said.
"Measuring the burden in HCV is important ... to understand changes in the pattern of care delivery, provide a critical insight into the magnitude of the problem, and guide both clinicians and the health care system to develop strategies [for] providing timely and effective care to this highly vulnerable group of patients," they said.
They analyzed data from the VA’s HCV database, which included HCV patients who sought treatment at any of 128 VA medical centers in 1996-2006. There were 17,261 patients in the database in 1996, a total that increased to 106,242 in 2006.
Overall, the number of patients with HCV who had cirrhosis rose from 2,061 to 23,294 during the study period, the number with hepatic decompensation rose from 1,012 to 13,724, and the number with hepatocellular carcinoma rose from 17 to 1,619.
The prevalence of cirrhosis doubled from 9% to 18.5% during that time, and still continues to rise. The prevalence of hepatic decompensation rose in parallel, with a twofold increase (from 5% to 11%).
The prevalence of hepatocellular carcinoma also rose, but the upward slope became particularly steep from 2003 onward. Prevalence grew 19-fold (from 0.07% to 1.3%) during the study period overall. This pattern suggests that "there might be a greater epidemic of hepatocellular carcinoma [coming] than we were expecting,’ Dr. Kanwal and her colleagues said.
Mortality of cirrhosis patients also increased over time, with a greater proportion of patients dying in recent years than in the 1990s.
The aging of the cohort explains part of these increases, but all of them persisted even after the data were adjusted to account for aging. It is not yet known what other factors play a role in these trends.
"The morbidity and mortality associated with cirrhosis and hepatocellular carcinoma may be greatly reduced if potentially life-saving interventions – such as liver transplantation and, for HCC, local ablation and surgical resection – are applied in a timely manner," they noted.
However, recent data from other studies demonstrate that patients with cirrhosis rarely receive high-quality health care, and their own previous research found that "the quality of health care given to patients with HCV infection falls far short of that recommended by practice guidelines."
In this study, only 16% of the cohort had ever received a prescription for interferon.
"Given the significant increase in the number of patients with cirrhosis, and given the data suggesting marked gaps in the quality of care, the health care system may need to rechannel its efforts in patients with HCV to provide timely and effective care to the patients with cirrhosis," the investigators said.
The research was supported in part by grants from the Department of Veterans Affairs. The authors had nothing to disclose.