Managing Asymptomatic HBV or HCV Carrier in Outpatients With Systemic Chemotherapy or Other Immunosuppressive Therapy

Background and Aims: Acute hepatic decompensation is often encountered in patients with stable hepatitis C (HCV) cirrhosis.The most common precipitating event is a systemic infection.Interferon-based antiviral therapies can also trigger decompensation.Although decompensation may be transient, it is associated with worsening of prognostic indices such as MELD and CTP score, and can lead to death.We hypothesize that the prognosis following decompensation may differ according to the nature of the precipitating event.The aim of this case-control study was to compare the liver-related outcomes (death and transplant) in HCV cirrhotic patients decompensating due to Interferon vs. those decompensating following infections.Methods: A retrospective review of patients with compensated HCV cirrhosis who were treated with Interferon was performed to identify those who developed decompensation while on treatment.They were matched by age and CTP class to cirrhotics not receiving interferon who decompensated due to systemic infections.Decompensation was defined according to the HALT-C criteria as the occurrence of one of the following: hepatic encephalopathy, ascites, portal hypertension related bleeding, hepatocellular carcinoma or CTP score >6.The following data were collected: age at decompensation, baseline MELD score, infection causing decompensation, liver related outcomes (death or liver transplantation) and time from decompensation to the outcome.Patients records were followed for at least 3 years until they died or required transplant.Results: On review, we identified 28 subjects (mean age 52, mean MELD 10, all CTP class A) who decompensated (ascites 11, 5 became CTP B, HE 5, Bleeding 5, HCC 2) while receiving interferon.These were agematched matched to 28 HCV cirrhotics (mean age 53, mean MELD 9, CTP score A) who decompensated secondary to infections (cellulitis 9, pneumonia 9, bacteremia 4, osteomyelitis 1, UTI 1, panniculitis 1, pericarditis 1, fever 1, cholecystitis 1).There was no difference in MELD scores before decompensation between groups.By Kaplan Meier survival analysis, over the first three years of followup, only 6% of patients who decompensated after infection died or were transplanted, all within the first six months.In contrast, decompensation following interferon was associated with higher rate of death or transplantation that began immediately and was significant by log-rank analysis at six months (14%), one (24%) and three years (39%)(p<0.0001).Conclusion:The cause of decompensation is an important determinant of outcome in HCV cirrhosis.Decompensation secondary to interferon treatment, although less common than decompensation triggered by infections, is associated with a worse prognosis.Patients with interferon-induced decompensation merit early evaluation for liver transplantation.