Docstoc

Hepatitis C Caring Ambassadors Program

Document Sample
Hepatitis C Caring Ambassadors Program Powered By Docstoc
					          Hepatitis C Caring
            Ambassadors
              Program



People Helping People
            Hepatitis C Caring Ambassadors Program
    The Role of
Liver Biopsy in HCV




           Hepatitis C Caring Ambassadors Program
Liver Biopsy

                   You
               want to
                     do
             WHAT?

        Hepatitis C Caring Ambassadors Program
              Liver Biopsy in HCV
               The Gold Standard for
    Assessment of Disease Status and Progression

 helps objectively helps provide a specific diagnosis
 aids in determining the severity of inflammation
 aids in determining the amount of scar tissue (fibrosis, cirrhosis)
 knowing the severity of liver disease aids development of
  treatment recommendations
 helps determine need to screen for liver cancer
 evaluate for other causes of chronic liver disease such as iron
  overload, fatty liver, and others


                                      Hepatitis C Caring Ambassadors Program
            Liver Biopsy: Pathologist’s View
               confirm clinical                                assess severity of
                  diagnosis                            inflammation & fibrosis - prognosis




                                           Role of
                                         Liver Biopsy

      assists in management                                                  assess need for
       if severe AEs (HCV)                                                     therapeutic
                                                                              intervention
                                         assess need to screen
                                             for hepatoma

Brunt EM. Hepatology. 2000;31:241-246.

                                                        Hepatitis C Caring Ambassadors Program
        HCV: The Unsuspected Diagnosis
       the records of 126 HCV patients were reviewed
       3/47 with suspected other diagnoses in addition to
        HCV were confirmed by biopsy
             hemochromatosis, HBV, NASH
       additional diagnoses found in another 3 patients
        (NASH)
       cirrhosis discriminant scores (ALT/AST ratio, platelet
        count, and INR) are poor indicators of the presence or
        severity of cirrhosis
             ~20% cirrhotics not suspected clinically

Saadeh A et al, Hepatology 2001; 33:196-200.

                                               Hepatitis C Caring Ambassadors Program
          Liver Biopsy Reporting
 Grade 0-4 indicates inflammation/necrosis

 Stage 0-4 indicates fibrosis/cirrhosis
    stage 0-1 has little chance of progressing rapidly and
     standard treatment is not immediately indicated
    repeat biopsy is recommended every 4-5 years to
     monitor for disease progression




                                 Hepatitis C Caring Ambassadors Program
     Inflammatory Grading of Liver Biopsies




      GRADE 0                      GRADE 1
                             <25% interface hepatitis
   no inflammation
                                                                        GRADE 4
                                                                    bridging necrosis




       GRADE 2                     GRADE 3
25-75% interface hepatitis   >75% interface hepatitis

                                            Hepatitis C Caring Ambassadors Program
            Fibrosis Staging of Liver Biopsies




    Stage 0                               Stage 1
   no fibrosis                         portal fibrosis




      Stage 2              Stage 3                           Stage 4
extraportal fibrosis   bridging fibrosis                    cirrhosis

                                           Hepatitis C Caring Ambassadors Program
                                          Normal Liver




Edward Klatt, MD, Department of Pathology, University of Utah: 1999.

                                                                 Hepatitis C Caring Ambassadors Program
                   Chronic Active Hepatitis

   Chronic active hepatitis of
    mild to moderate severity
    with portal and periportal
    inflammation. Trapping of
    periportal hepatocytes and
    inflammation extending
    beyond portal tract. Focal
    lobular inflammation is also
    evident. (H&E)




Greg Everson, MD. University of Colorado: 2005.


                                                  Hepatitis C Caring Ambassadors Program
                 Indications for Liver Biopsy

    Appropriate:
     fibrosis/cirrhosis status is unknown
     information is needed to make a decision about
      treatment
    Inappropriate:
     diagnosis of cirrhosis can be made without biopsy


Strader D, et al. AASLD Practice Guidelines. Hepatology 2004; 39(4):1147.


                                                                Hepatitis C Caring Ambassadors Program
       Limitations of Liver Biopsy
 sampling variation
 pain/discomfort
 low risk of major complications
 invasive
 patient compliance




                              Hepatitis C Caring Ambassadors Program
  Accuracy of Liver Biopsy Results

 accuracy is enhanced by:
    ultrasound guidance
    >2 cms tissue recovered
    >9 portal areas seen




                               Hepatitis C Caring Ambassadors Program
                      Sampling Error of Liver Biopsy
                                        Fibrosis area: 65%




Courtesy of M. Pinzani, Florence
                                   Fibrosis area: 15%
                                             Hepatitis C Caring Ambassadors Program
                 Liver Biopsy Complications
             pain                                                          .056-22%
             hemorrhage                                                    .03-.7%
             bile peritonitis                                              .03-.22%
             lung biopsy                                                   .001-.014%
             gallbladder biopsy                                            .034-.117%
             kidney biopsy                                                 .096-.029%
             hemothorax                                                    .18-.49%
              mortality                                                    .0088-.3%

Reddy and Jeffers. Schiff’s Diseases of the Liver, 8th ed, 1999


                                                                  Hepatitis C Caring Ambassadors Program
                   Liver Biopsy Risk vs. Benefit
        68,276 biopsies 1973-83 in Italy1
               only 6 deaths (3 with malignancy, 3 cirrhosis)
                      • approx. 1/10,000 overall
               all deaths due to hemoperitoneum


        405 outpatient biopsies from 1989-912
               13 (3.2%) pts. admitted, 5 for pain only, 2 received
                blood


1 Piccinino et al, J. of Hep, 1986;2:165
2 Janes and Lindor. Ann Int Med, 1993;118:96

                                                   Hepatitis C Caring Ambassadors Program
                  Liver Biopsy Risk vs. Benefit

       Ultrasound decreased hospitalization from 4% to 2%
        and was cost effective.1
       Ultrasound changed position of biopsy 15% of the
        time compared to blind biopsy.2
       Severe pain occurs in 20% of biopsies.3



1Younossi et al. Dig Dis Sci, Jan 1998
2 Riley et al, Am J Gastro 1999, 94:3320
3 Castera et al, J Hepatology, 1986;2:165

                                            Hepatitis C Caring Ambassadors Program
       Economics of Liver Biopsy vs.
        Interferon-Based Treatment
 liver biopsy: $1,500-$2,000
 interferon/ribavirin (ave. wholesale price)
    pegylated IFN ~$1100/mo (120ug/wk)
    ribavirin ~$1200/mo (1200mg/d)
    $17,000 to $36,000 for 24-48 weeks
 erythropoetin $547/wk
 GCSF $540/wk (300ug BIW or TIW)




                                Hepatitis C Caring Ambassadors Program
             Repeat Liver Biopsy

 Repeat every 3-5 years in any stage, even stage 0, if
  monitoring disease progression.

 Time interval between biopsies will be influenced by
  the presence of co-factors that predispose to
  accelerated disease progression.




                                Hepatitis C Caring Ambassadors Program
              Non-Invasive Tests
            to Assess Liver Fibrosis
 panels of serum biochemical markers of liver fibrosis
 report back an overall score and the probability of a
  range of fibrosis based upon the score
 two tests are currently available in the U.S.
    FIBROSpect™ (Prometheus Laboratories)
    Fibrosure™ (Laboratory Corporation of America)
 tests are not considered a replacement for liver biopsy
  at present, but as an alternative for those in whom
  biopsy is contraindicated or as an adjunct to biopsy
  decision-making


                                Hepatitis C Caring Ambassadors Program
              Non-Invasive Tests
            to Assess Liver Fibrosis
 the predictive values of these tests are dependent upon
  the definition of the endpoint, the cutoff values used,
  and the prevalence of significant fibrosis in the study
  population
 reported positive predictive values range from
  ~48% to 87%
 reported negative predictive values range from
  ~69% to 94%
 tests are best at distinguishing the extremes of the
  spectrum of fibrosis, but are less robust in the mid-
  ranges of fibrosis
                               Hepatitis C Caring Ambassadors Program

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:5/12/2013
language:Unknown
pages:22