The Patient Bomb: Sustained Viral Response after Hepatitis C in Cirrhosis

The paper by Pereira Guedes et al. [1], analyzing data from a real-world Portuguese cohort with advanced liver disease, provides us with some interesting ideas, with translation into our clinical and real practice. The study, albeit retrospective, has evaluated data from 237 patients in a tertiary university hospital; 99% completed treatment, and the sustained viral response (SVR) was 98%, similar to the best trial results [2]. Almost two-thirds of the patients were cirrhotics, one-third having intense fibrosis. Patients have been included in the first years of medical therapy with direct antiviral agents (DAA) in Portugal [3]. The overall mortality rate in this study was 19/1,000 person-years, and the liver-related mortality rate was 9.5/1,000 person-years. The hepatic decompensation incidence rate was 25/1,000 person-years, and the hepatocellular carcinoma (HCC) incidence rate was 11.6/1,000. SVR is associated with a low risk of, but does not prevent, evolution to HCC disease progression, especially in the presence of other causes of liver injury [4]. It is recommended that these patients be kept under close surveillance [5]. There are two main messages: even with cirrhosis, it is possible to eliminate individually the virus, sustained some years after the end of therapy. There is no recurrence of HCV as is the case for HBV. Albeit, cirrhosis is a disease for life. We can talk about real “cure” for patients without cirrhosis but not for patients with intense fibrosis or cirrhosis. It is different to cure the virus only (cirrhosis) and to cure both the virus and the disease (if no cirrhosis). Some authors call for a need of simplification, saying that it is not necessarily the best evaluation of liver fibrosis. The two best methods for grading fibrosis are liver biopsy and elastography (Fibroscan®). We know the utility and the accuracy of some scores like AST to Platelet Ratio Index (APRI) and others like FIB-4, but they are not as good as elastography. If we live in a setting in which we have access to Fibroscan®, as is the case of the majority of Western Medicine, for example in Portugal. Liver cirrhosis is an oncogenic disorder, one of the most oncogenic situations that we know in medicine, with a 10–40% risk of evolution to HCC at 10 years. In the paper by Pereira Guedes et al. [1], elastography, liver biopsy and clinical evaluation was used before therapy. After DAA treatment, there is a reduction of the value of elastography. Specially in patients with values close to 12.5 kPa, after therapy, it will be less than 12.5 kPa, with a value of “no cirrhosis” – a false negative...