Iron Reduction by Phlebotomy Reduces alpha Fetoprotein in Patients with Advanced Chronic Hepatitis C: A Long Term Follow-Up Study

Abstract

Purpose: Phlebotomy with iron depletion is known to lower transaminases in patients with chronic hepatitis C (CHC). We present the results of long term (up to 9 years) maintenance phlebotomy program in patients with advanced CHC, high AFP and proven cirrhosis or bridging fibrosis. Methods: All 18 patients with CHC failed therapy with PEG-interferon/ ribavirin. Liver biopsy showed cirrhosis in 13 patients and bridging fibrosis in 2 patients. 9 patients were African American. None of the patients demonstrated HFE mutations. Patients underwent phlebotomy with 300 ml to 500 ml removed every two weeks, with the intent to reduce ferritin while maintaining hemoglobin above 11.5. Liver enzymes, ferritin, hemoglobin, AFP and platelets were recorded; we rounded to the nearest time interval with respect to the six-biochemical parameters. The (n) in table 1, for 3 months and 1 year is < 18 because not all patients had labs done at those time points. Signs and symptoms for clinical decompensation were assessed.Table: Average lab values at different time intervals pre and post phlebotomyTable: Clinical characterestics of patients with CryptococcosisResults: Average ALT, AST and AFP at 3 months, year 1, year 3, and year 5 were all significantly lower than baseline (P < 0.01 for all except AST at 5 years, P= 0.025) (Table 1). There was no significant difference seen in platelet count or hemoglobin. AFP dropped in all patients. Pre-phlebotomy AFP was >40 in 7 patients, none of these patients developed hepatoma over an average of 39 months. No patients developed: encephalopathy, refractory ascites, variceal bleeding or hepatoma. Conclusion: In patients with CHC, high ferritin and high AFP, a maintenance phlebotomy program can lower AFP as well as transaminases, and maintain the low AFP long term, without inducing anemia. Despite a very high AFP at the start of the phlebotomy regimen, none of the patients developed a focal mass or clinical evidence of hepatoma or clinical decompensation. Maintenance phlebotomy and sustained iron depletion needs to be evaluated further as a strategy in patients with CHC cirrhosis who have failed anti-viral therapy.