New developments in liver disease

The liver disease session featured four highly regarded experts in the field who provided an outstanding overview.

They discussed what to do with a no responder to antiviral therapy for chronic hepatitis C. The current treatment that includes pegylated interferon with ribavirin leads to a sustained virologic response rate of close to 30%; thus a significant number of patients will not respond.

One of the options considered for these patients was long-term pegylated interferon to reduce inflammation and thereby reduce the progression toward cirrhosis, and also to prevent the complications of portal hypertension in those who already have cirrhosis.

But several prospective studies, including the HALT-C trial (Hepatitis C antiviral Long-term Treatment against Cirrhosis), showed that long-term interferon did not halt the progression of chronic HCV infection. The exciting aspect is that new antiviral is being developed and is currently in clinical trials. These antiviral include NS3/4A protease inhibitors, NS5B polymerase (RdRp) inhibitors, and NS5A inhibitors.

The next topic was chronic hepatitis B. They described which patients benefit from antiviral therapies, namely those with active disease defined as elevated ALT levels and/or inflammation on liver biopsy, with elevated HBV DNA levels (>20,000 IU/mL antigen-positive, and >2,000 IU/mL for the antigen-negative patients).

The benefits of therapy are to reduce progression, reduce hepatocellular carcinoma (HCC), and improve overall survival. The goal of therapy is to reduce inflammation, but unfortunately, it  is not to cure the disease. At this time there are excellent antiviral that can lead to viral suppression.

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease due to the obesity epidemic. Interestingly, the severity of NAFLD correlates with the severity of the metabolic syndrome, which is more commonly seen in obese patients.

Nonalcoholic steatohepatitis (NASH) is a more severe form of NAFLD, which may ultimately lead to complications such as cirrhosis and HCC. The treatment of NASH centers on diet and exercise. However, in a study that they led showed that vitamin E  improved the laboratory data and liver biopsy results in NASH. Therefore, lifestyle, medication, and vitamin E are the best treatments for NASH.

HCC is one of the fastest growing types of cancer in the United States and one of the leading causes of cancer-related deaths worldwide. Since HCV and HBV are the major etiologic agents that lead to HCC, surveillance of these patients has been shown to improve outcomes.

One of the most important aspects of HCC is that the diagnosis is determined by radiologic imaging using CT or MRI. An enhancing mass in the arterial phase followed by no enhancement (or washout) in the portal venous phase is diagnostic of HCC. Liver transplantation, surgical resection, and radio-frequency ablation are considered curative interventions, while transarterial chemoembolization and sorafenib improve overall survival but are considered palliative.