Hepatology For The Nonhepatologist

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1 Hepatology For The Nonhepatologist Andrew Aronsohn, MD Associate Professor of Medicine University of Chicago Chicago, Illinois Learning Objectives After attending this presentation, learners will be able to: Describe progression of fibrosis in patients infected with chronic hepatitis C Assess various methods to determine stage of fibrosis Slide 2 of 35 ARS Question #1 A 43 year old male present to your clinic with a new diagnosis of HCV. His first question to you is how bad is is?. Your best answer would be based on: 1. Degree of inflammation of the liver such as ALT 2. Mechanism of transmission 3. HCV Genotype 4. Viral Load 5. Fibrosis of the liver Slide 3 of 35

2 Staging HCV Fibrosis is the key to understanding disease progression Up to 40% of patients with chronic HCV will have normal ALT,AST Viral load does not predict severity of disease Progression is variable over time Various factors will effect progression HIV coinfection Alcohol use Immune suppression Genetics (host and virus) Slide 5 of 35 Too Soon for a Coffee Break? Slide 6 of 35 Modi et al Hepatology 2010 Slide 7 of 35 Carrieri et al J Hep 2017

3 Chronic HCV Leading to Cirrhosis and Hepatocellular Cancer Slide 8 of 35 Wouldn t It Be Great. Years Disease Severity Slide 9 of 35 Importance of Staging Lots of variation in disease severity (fibrosis) Progression is variable Patients with advanced fibrosis / cirrhosis Urgency to treat Highest risk of mortality / morbidity Require life long follow up post SVR Patients with early stages of disease May get denial from insurance So how bad is my HCV?? Slide 10 of 35

4 Diagnosing Cirrhosis Slide 11 of 35 What About Everyone Else? Some patients have obvious features of cirrhosis Many patients without cirrhosis or well compensated cirrhosis all look the same (normal) How to distinguish? Slide 12 of 35 Staging of Fibrosis Slide 13 of 35

5 Liver Biopsy Pro Gold standard Dx other diseases Info about portal HTN Sampling Error Con Invasive Expense Sampling error Need Pathologist with experience Slide 14 of 35 Deciphering Pathology Words Slide 15 of 35 Complications of Liver Biopsy Slide 16 of 35 Rocky et al Hepatology 2008

6 Sampling Error Slide 17 of 35 Indirect Markers of Fibrosis Use common labs Helpful, especially when combined with other information Useful to determine: cirrhosis or no cirrhosis APRI AST / Platelet FIB-4 Age, AST, ALT, Platelet Slide 18 of 35 APRI Slide 19 of 35

7 Direct Markers of Fibrosis Specialized labs Send out Measurement of specific markers of inflammation, fibrosis in blood Examples Fibrosure Fibrotest Fibrospect Hepascore Slide 20 of 35 Fibrosure: Example Slide 21 of 35 Transient Elastography Slide 22 of 35

8 Transient Elastography Slide 23 of 35 Magnetic Resonance Elastogaphy / MRE Highly reproducible Strongest correlation with biopsy Inexpensive Accurate in obesity Allows for measurement of fatty liver Slide 24 of 35 The Natural History of Cirrhosis in HCV Decompensation: Variceal hemorrhage Ascites Encephalopathy Jaundice Slide 25 of 35 D Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:

9 ARS Question #2 You are seeing a 56 year old with HCV related cirrhosis in clinic. Which of the following would predict the highest 3 month mortality? 1. History of nonbleeding varices on EGD 2. Childs A Classification 3. HCV that relapsed after DAA therapy 4. MELD score of HIV coinfection Slide 26 of 35 Decompensation and Mortality Stage Definition 1-year mortality 1 Compensated without varices 2 Compensated with varices 3% 3 Decompensated with ascites without variceal hemorrhage 4 Decompensated with/out ascites with variceal hemorrhage Median Survival 1% >12 years 20% ~2 years 57% Slide 27 of 36 D Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44: Prognosticating Decompensated Cirrhosis Slide 28 of 35

10 Slide 29 of 35 Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124:91-6. MELD Slide 30 of 35 MELD and Survival Slide 31 of 35

11 Treatment Response and Clinical Outcomes Slide 32 of 35 Clinical Outcomes with SVR Slide 33 of 35 Heathcote EJ, et al. Ann Intern Med Criteria for Referral Decompensation Ascites Encephalopathy Variceal Bleed MELD >15 Liver Cancer / Liver Mass Slide 34 of 35

12 Take Home Fibrosis progression is variable Many noninvasive tests exist to determine degree of fibrosis Serologic markers Elastography In patients with cirrhosis, predicted mortality is determined by: Degree of decompensation MELD Childs classification Slide 35 of 35 Question-and-Answer Remember to raise your hand and wait until you have the microphone before you ask your question we are recording! Slide 35 of 35

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