Pegylated Interferon and Ribavirin Causing Reversal of Cirrhosis in Hepatitis C Infection

Abstract

Purpose: Cirrhosis occurs in 20-40% of patients with hepatitis C infection and can cause further complications such as hepatocellular carcinoma and end stage liver disease. It is thought to be irreversible. We report two patients whose liver biopsy has shown reversal of cirrhosis with pegylated interferon and ribavarin combination therapy. Case Report: A 51 yr old male patient was diagnosed with hepatitis C infection with genotype 1b. His HCV RNA PCR at the time of diagnosis was 850000. His pretreatment liver biopsy showed moderate piecemeal necrosis, lobular activity (grade 2) and cirrhosis (stage 4). He received 12 months of treatment with pegylated interferon and ribavarin. He responded well to treatment and showed sustained viral response persistently for last 7 years with undetectable HCV RNA. Recent liver biopsy showed complete reversal of cirrhosis with stage no fibrosis (stage 0) and mild piecemeal necrosis (grade 1) A 62 yr old male who was diagnosed with hepatitis C infection with genotype 2b. His pretreatment liver with biopsy showed severe piecemeal necrosis, lobular activity with bridging necrosis (grade 3) and cirrhosis (stage 4). He was treated with pegylated interferon and ribavarin for total 18 months for hepatitis C infection with sustained viral response for 3 years. His post treatment liver biopsy showed regression of changes with mild piecemeal necrosis (grade 1) and Fibrosis (stage 4). Discussion: More recently reversal of cirrhosis has been demonstrated in various chronic liver conditions including autoimmune hepatitis, primary biliary cirrhosis, biliary obstruction, thalassemia, hemochromatosis, hepatitis B and in patients with hepatitis C virus related cirrhosis. Mallet et al followed treated hepatitis C related cirrhosis for more than 10 years and concluded that control of fibrosis/necroinflammatory activity of the liver disease is more important than viral clearance. They further demonstrated that the documented improvement in histology is associated with a reduction in cirrhosis-related complications and prolonged survival. We have demonstrated reversal of histology in a patient without complete eradication of virus (presented at previous ACG meeting). Conclusion: Traditionally treatment goals for hepatitis C infection were focused on viral eradication instead of histological outcomes. New focus should be histological improvement and regression of cirrhosis thus preventing end stage liver disease and hepatocelluar carcinoma. Newer treatment strategies are needed to target regression of cirrhosis.