Diagnosi e management non invasivo dell epatite cronica da HCV

Transcription

1 Diagnosi e management non invasivo dell epatite cronica da HCV Giovanni Squadrito Clinical and Molecular Hepatology University of Messina gsquadrito@unime.it

2 Outline Diagnosis of HCV Non invasive tools for the management of CHC treatment (before and after) Identification of patients at risk of complications

3 Diagnosis of acute and chronic HCV EASL HCV Guidelines. J Hepatol 2016

4 Diagnosis of CHC Wilkins T et al Am Fam Phys 2015; Esteban JI J Med Virol 2013

5 Concordance of SVR 4, 12, 24 weeks post treatment in the era of new DAAs: a coincise review SVR measured at week 12 has been shown to be highly concordant with SVR 24 for CHC patients treated with Peg-IFN-Ribavirin. 2 studies and 4 abstracts were found that performed concordance analyses using positive and negative predictive vaules in CHC patients treated with DAAs. Overall SVR 4 and SVR 12 were highly concordant with SVR with PPV and NPV of >97 an > 94% respectively. SVR 12 is a reliable assessment of HCV eradication and could be used instead of SVR 24. Burgess SV. Ann Hepatol 2016

6 Genotipi di HCV e HCV RNA

7 RESIST HCV: Flow-chart 5,592 patients started DAA therapy between 1th March 2015 and 10 February patients (2.6%) started a sub-optimal regimen (SVR 61%) 5,448 patients (97.4%) started an optimal DAA regimen 3,128 patients (57.4%) evaluable for SVR at 12 February 2017 I Cacciola et al AISF 2017

8 SVR12 according to genotypes and disease stage (ITT analysis) I Cacciola et al AISF 2017

9 HCV and progression of liver disease

10 Severity of liver disease evaluation Unfortunately, the medical history and physical examination do not provide a sufficient basis for detecting advanced fibrosis. Classic signs jaundice, ascites, splenomegaly, and encephalopathy are absent in early cirrhosis. Similarly, patients with cirrhosis may have normal results of liver chemical profiles. Angulo P et al Gastroenterology 2015, Ekstedt M, Hepatology 2015, Veldt BJ et al Ann Intern Med 2007; Fontana RJ et al Hepatology 2008, Lackner C et al J Hepatol 2017; de Bruyn G, Graviss EA BMC Med Inform Decis Mak 2001; Udell JA et al JAMA 2012.

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12 BIOPSIA EPATICA: RISULTATI CONCORDANTI E DISCORDANTI N : 3 osservatori (blinded) e 234 campioni esaminati % Concordant/Discordant 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% F0 F1 F2 F3 F4 Central Metavir Biopsy Score Discordant Concordant

13 NON-INVASIVE METHODS OF HEPATIC FIBROSIS ASSESSMENT

14 Currently available serum biomarkers for non-invasive evaluation of liver fibrosis

15 FibroScan Examination Explored volume TE: 1/500 of the liver total mass Liver biopsy: 1/50000 of the liver total mass Probe Probe

16 Noninvasive Assessment of Liver Fibrosis

17 Non invasive Risk Stratification for HCV

18 Diagnostic performance of serum biomarkers for significant fibrosis (F>2) and cirrhosis (F4) in CHC

19 Diagnostic performance of TE for significant fibrosis (F>2) and cirrhosis (F4) in CHC

20 Hepatology 2009

21 Fibrosis algorithms Boursier J et al Hepatology 2011

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25 All-cause mortality (%) All-cause mortality p<0.001 No SVR SVR Time (years) No. at risk No SVR SVR SVR is associated with a reduction in allcause mortality Liver-related mortality or Liver transplantation (%) Liver-related mortality or liver transplantation p<0.001 No SVR SVR Time (years) No. at risk No SVR SVR Van der Meer JAMA 2012;308:

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27 Transient Elastography Performance is Poor in Patients with an SVR TE (KPa) kpa (1) 5 0 F 1 (n=1) F 2 (n=6) F 3 (n=10) F 4 (n=11) METAVIR D Ambrosio R, et al. J Hepatol 2013;69:

28 Reduction in Most of Serum Biomarkers After the Achievement of an SVR D Ambrosio R and Degasperi E, et al. PloS One 2016

29 Probability of occurrence and progression of esophageal varices (EV) according to SVR in 404 patients with HCV cirrhosis F0 F1/F2/F3 F1 F2/F3 Patients with occurrence of EV (%) No SVR SVR Patients with progressiom of EV (%) No SVR SVR Log rank p < Log rank p = Di Marco V et al Gastroenterology 2016; Jul;151(1): e2. doi:

30 Identification of patients with cacld who can safely avoid screening endoscopy (new) Patients with a liver stiffness <20 kpa and with a platelet count >150,000 have a very low risk of having varices requiring treatment, and can avoid screening endoscopy (1b;A). These patients can be followed up by yearly repetition of TE and platelet count (5;D). If liver stiffness increases or platelet count declines, these patients should undergo screening esophagogastroduodenoscopy (5;D).

31 Validating the Baveno VI recommendations for screening varices Summary of studies evaluating performance of Baveno VI criteria for screening endoscopy (OGD) in patients with compensated advanced chronic liver disease. Journal of Hepatology 2017 vol. 66 j

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36 GRAZIE Clinical and Molecular Hepatology, University Hospital of Messina