Hepatitis C

Aka: Hepatitis C

1. See Also
   1. Viral Hepatitis
   2. Bloodborne Pathogen Exposure
2. Epidemiology
   1. Prevalence
      1. U.S. Population: 1.8% (4 to 6.5 million)
      2. World Prevalence estimated at >150 million
      3. Intravenous Drug Abuse: 97% (some communities)
      4. Four fold higher Prevalence than Hepatitis C
   2. Incubation 7-8 weeks
      1. HCV RNA found in blood within 3 weeks post-exposure
   3. Transmission by Blood Products and blood exposure
      1. Intravenous Drug Abuse (43% of cases)
      2. Intravenous Immunoglobulin
      3. Transfusion
         1. Accounts for 85% transfusion associated hepatitis
         2. Risk from transfusion low after July 1992
            1. Now <1 case per 100,000 units transfused
      4. Tattoo needles
      5. Organ transplant
      6. Vertical transmission from mother to child
         1. Delivery method does not alter transmission rate
         2. Average rate: 6%
         3. HIV coinfection: 17%
      7. Needle stick injury (4-10% rate of infectivity)
         1. Seroconversion in 2200 healthcare workers per year
      8. No apparent parenteral risk factor in 40% of cases
   4. Transmission by other body fluid is less common
      1. Transmission to simple household contacts is rare
      2. No association with Lactation
      3. Sexual transmission is much less common
         1. Prevalence 1.5% in longterm partners
         2. Higher risk behaviors that raise transmission
            1. Multiple partners
            2. Early sex
            3. Non-Condom use
            4. Sex with associated trauma
            5. Comorbid Sexually Transmitted Disease
3. Pathophysiology
   1. Similar to Flavivirus with RNA genome
   2. Similar viruses
      1. Yellow Fever virus
      2. DengueVirus
4. Signs and Symptoms
   1. Acute infection
      1. See Viral Hepatitis
      2. Jaundice is uncommon in acute infection
      3. Constitutional symptoms in up to 35%
         1. Malaise
         2. Weakness
         3. Anorexia
         4. Minor Fatigue
         5. Right upper quadrant abdominal ache
         6. Nausea
         7. Arthralgias
   2. Chronic disease
      1. Most patients are asymptomatic
      2. Observe for signs of Cirrhosis
5. Differential Diagnosis
   1. Acute Hepatitis Causes
6. History: Screening Questionairre (indications)
   1. Screen all patients born between 1945 and 1965 for Hepatitic C
   2. Other screening indications
      1. Use of injectable street drugs
      2. Received blood Clotting Factor concentrate before 1987
      3. Received Blood Transfusion or transplant before 1993
      4. Received blood from donor later found with HCV
      5. Received Hemodialysis
      6. Symptoms or signs of liver disease
      7. Mother with HCV at the time of delivery
7. Labs
   1. See Hepatitis C Serology
   2. Diagnosis
      1. Screening: EIA for Anti-HCVAntibody
         1. Consider false negative if immunocompromised
      2. Confirmation of positive EIA: RT-PCR for HCV RNA
         1. Start with qualitative PCR (more sensitive)
         2. Positive EIA with negative PCR suggests resolved
         3. Repeat in 1-2 months if negative
      3. Viral Genotype
         1. HCV Genotypes 2 and 3 have better prognosis than 1
   3. Assessment of liver disease
      1. Liver Function Tests
         1. Serum Albumin
         2. ProTime (PT) with INR
         3. Partial Thromboplastin Time (PTT)
      2. Liver Transaminase (Indicate hepatocellular necrosis)
         1. Serum AST
         2. Serum ALT
            1. Increases by 2-21 weeks from onset (mean 7 weeks)
            2. Normal in up to one third of patients
      3. Comorbid Infections
         1. Human Immunodeficiency Virus Test (HIV Test)
         2. Anti-HAV (Hepatitis A Virus Antibody)
         3. Hepatitis B Surface Antigen (HBsAg)
      4. Other tests
         1. Renal Function Tests
            1. Serum Creatinine
            2. Blood Urea Nitrogen (BUN)
         2. Serum Iron (for Hemochromatosis)
8. Management: General
   1. See Prevention of Liver Disease Progression
   2. Avoid Alcohol
      1. Alcohol and Hepatitis C work synergistically
      2. Alcohol decreases response to interferon therapy
   3. Avoid Hepatotoxins
   4. Avoid iron supplements
   5. Maintain a Low Fat Diet
   6. Vaccination (decreases Hepatitis C progression risk)
      1. Hepatitis A Vaccine
      2. Hepatitis B Vaccine
   7. Prevent transmission
      1. Do not share razors or toothbrushes
      2. Cover skin lesions
      3. Do not donate Blood Products
      4. Use protection for intercourse
9. Management: Antiviral Agents
   1. See Hepatic C Treatment with Interferon and Ribavirin
10. Management: Liver Transplantation
    1. Hepatitis C is most common cause of liver transplant
    2. Post-transplant survival similar to other liver failure
       1. One year survival post-transplant: 84%
       2. Five year survival post-transplant: 68%
       3. Ten year survival post-transplant: 60%
    3. Predictors of poorer outcome
       1. Female liver donor
       2. Recipient over age 52 years
       3. Preoperative Serum Creatinine >1 mg/dl
       4. More urgent UNOS status
       5. Increased Serum AST and Serum ALT levels
    4. References
       1. Ghobrial (2001) Ann Surg 234:384-94
11. Complications
    1. Cirrhosis (20% in 20 years)
       1. Individualized risk can be calculated (see below)
    2. Decompensated Cirrhosis
       1. Five Years: 18%
       2. Ten Years: 29%
    3. Hepatocellular Carcinoma
       1. Annual risk: 2-4% if Cirrhosis present
       2. Five Years: 7%
       3. Ten Years: 14%
    4. Other associated conditions
       1. Diabetes Mellitus
       2. Sjogren's Syndrome
       3. Lymphoma
       4. Glomerulonephritis
       5. Dermatologic conditions
          1. Porphyria cutanea tarda
          2. Lichen Planus
          3. Cutaneous necrotizing Vasculitis
12. Course
    1. Chronic Hepatitis: 85% (full recovery in 15%)
    2. Survival
       1. Five Years: 91%
       2. Ten Years: 79%
    3. Risk Factors for Progression to fibrosis and Cirrhosis
       1. Age over 40 years at time of infection
       2. Duration of infection
          1. Median duration of infection to Cirrhosis: 30 years
          2. In up to one third, Cirrhosis delayed for >50 years
       3. Male gender
       4. Excessive Alcohol intake
          1. Marked risk at >50 grams/day
          2. Moderate risk
             1. Men: >40 grams/day
             2. Women: >20 grams/day (2 beers, 1 pint wine)
13. Resources
    1. Probablility of Cirrhosis in Patients with Hepatitis C
       1. http://www.aafp.org/afp/20031101/poc.html
14. References
    1. Gross (1998) Mayo Clin Proc 73(4):355-60
    2. Morton (1998) Ann Emerg Med 31:381-90
    3. Heathcote (2000) N Engl J Med 343:1673-80
    4. Ward (2004) Am Fam Physician 69(6):1429-40