icon-folder.gif   Conference Reports for NATAP  
  American Association for the Study of Liver Diseases 2003 Conference
Boston, MA
Oct 24-28, 2003
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Hepatitis C in Elderly Goes Undetected and Is More Severe
  Reported by Jules Levin
Dominique Thabut and colleagues from Groupe Hospitalier Pitie-Salpetriere, Paris, France reported on the problem of hepatitis C in folks over 65 years of age. And the study highlights the general inattention paid by general practice physicians and citizens regarding hepatitis C. Individuals do not know that perhaps they should be tested for HCV and doctors often are not testing individuals. This is not very different from HIV, where very often women and older folks are not tested for HIV because their doctors don’t feel they are in a risk group and because the individuals are not aware they should be tested.
According to this study many older individuals over 65 yrs of age may not be getting tested for hepatitis C antibody until they present with more advanced hepatitis disease. As you can see from the results of this study individuals over 65 often did not get diagnosed with HCV until showing up at their doctor with severe complications such as internal bleeding or liver cancer. Therefore, these individuals could not benefit from care and monitoring and education about the harm of drinking alcohol. Because older folks are likely to have had HCV for more years than younger folks, this study found individuals over 65 were much more likely to present themselves with advanced fibrosis. This study found that despite older folks having more advanced disease they had similar ALT levels as younger individuals. This highlights what experts know, that liver enzymes (ALT) do not necessarily accurately reflect the stage of disease of hepatitits. Up to 50% of individuals with HCV can have normal ALT and more advanced liver disease. This study also found that individuals over 65 years respond well to HCV therapy. Results are reported below. This raises a question: should all individuals be tested for hepatitis C antibody? Perhaps.
There is little data is available on hepatitis C in elderly patients. The purpose of this study is to make a comparison of patients 65 years or older (GE65) with those less than 65 (LT65) in terms of the demographic and clinical features of hepatitis C, the severity of hepatic injury, the efficacy and safety of antiviral therapy and the usefulness of biochemical markers [FibroTest-ActiTest (AT-FT)].
Two groups of patients were analyzed: group 1, a prospective group including all HCV patients from our institution (n=4,182); and group 2, all consecutive patients who had had FT-AT performed in France between September 2002 and May 2003 (n=8,540).
A total of 2,410 GE65 were included, 881 from group 1 and 1,529 from group 2. In group 1, the duration of infection and age at infection were higher in GE65 than in LT65 (26 vs 20 and 50 vs 24 years, respectively, p< 0.001).
Infection with Genotype 1 and history of transfusion were more frequent in GE65 than in LT65 (78% vs 57% and 51% vs 29%, respectively, p<0.001).
Fibrosis stage at liver biopsy was higher in GE65 than in LT65, regardless of the duration of infection.
Among the 2,169 patients who underwent liver biopsy, bridging fibrosis (F2 and F3/F4) was more frequent in GE65 than in LT65 (76% vs 46%, respectively, p<0.001).
In multivariate analysis, factors associated with more advanced fibrosis (F2/F3/F4) were age at biopsy and age at infection, meaning that older individuals were not receiving adequate care or even being tested or diagnosed.
The initial manifestation of HCV infection was most often a complication (jaundice, bleeding, ascites, liver cancer) in GE65 as compared to LT65 (14% vs 4%, p<0.001).
In multivariate analysis, 3 factors were associated with complications:
(1) age at diagnosis
(2) alcohol consumption >50g/day
(3) coinfection with HIV.
A total of 170 (19%) GE65 had received interferon and/or ribavirin (patients > 80 years, n=4); treatment was well tolerated (interruption of treatment: 20%; decrease of dose: 7%).
In 20 GE65 treated by PEG Interferon-Ribavirin, a sustained virologic response was obtained in 45% of cases.
In group 2, the prevalence of F2/F3/F4 estimated by FT was 73% in GE65 (1,121 of 1,529) vs 35% in LT65 (2,419 of 7,011; Armitage trend p<0.001).
The prevalence of moderate or severe necrosis (AT) was also higher, 39% vs 14%, respectively (p<0.001). Cirrhosis was detected in 70% (94/148) of patients older than 80 yrs, 36% of patients between 65-80 and 14% of LT65 (p<0.001).
Despite the dramatic increase in fibrosis and necrosis prevalences in GE65, the prevalence of elevated ALT (greater than 50 IU/L) was similar between GE65 (53%) and LT65 (52%). Among patients with F2/F3/F4, non-elevated ALT was observed in 41% of patients older than 80 years, 39% of those between 65-80 and 31% in LT65 (p<0.001); despite non-elevated ALT Cirrhosis was present in 36%, 30% and 27%, respectively (p=0.03).
In patients 65 years or older, chronic hepatitis C is more severe and presents with lower ALT levels than in younger patients. Treatment is effective and well tolerated. Biochemical markers such as FibroTest-ActiTest seem particularly useful as a non-invasive alternative to liver biopsy in this population.