The Brazilian Journal of Infectious Diseases - Sociedade Brasileira ...

BJID 2007; 11 (October) 1 

ISSN 1413-8670 

Volume 11 • Supplement 1 • October 2007 

THE BRAZILIAN JOURNAL OF 

INFECTIOUS DISEASES 

An Official Publication of the Brazilian Society of Infectious Diseases 

EDITOR 

Anastácio Q. Sousa 

Consensus of the Brazilian Society of Infectious Diseases 

on the Management and Treatment of Hepatitis C 

PUBLISHED BY CONTEXTO 

October 2007 

Printed in Brazil 

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2 BJID 2007; 11 (October) 

THE BRAZILIAN SOCIETY OF INFECTIOUS DISEASES 

The Brazilian Society of Infectious Diseases is conducted for scientific purposes, for the advancement 

and promulgation of knowledge relevant to infectious diseases. 

OFFICERS 

2007-2008 

President 

João Silva de Mendonça 

Vice President 

Denise Vantil Marangoni 

First Secretary 

Juvêncio José D. Furtado 

Second Secretary 

Érico Antônio Gomes de Arruda 

First Treasurer 

Roberto Marcio da Costa Florim 

Second Treasurer 

Flávio de Queiroz Telles Filho 

Federal 

Federal 

Alagoas - Maria Raquel dos A.S. Guimarães 

Amazonas - Eucides Batista da Silva 

Bahia - Adriano Oliveira 

Ceará - Anastácio de Queiroz Sousa 

Distrito Federal - Dea Márcia da Silva M. Pereira 

Espírito Santo - Carlos Urbano Gonçalves Ferreira Jr. 

Goiás - Marcelo Cecílio Daher 

Maranhão - Graça Viana 

Mato Grosso do Sul - José Ivan de A. Aguiar 

Minas Gerais - Carlos Ernesto Ferreira Starling 

Pará - Helena Andrade Zeferino Brígido 

Paraíba - Luciana Holmes Simões 

Paraná - Alceu Fontana Pacheco Jr. 

Pernambuco - Martha Maria Romeiro F. Fonseca 

Piauí - Kelsen Dantas Eulálio 

Rio de Janeiro - J. Samuel Kierszembaum 

Rio Grande do Norte - Hênio Godeiro Lacerda 

Rio Grande do Sul - Luciano Goldani 

Rondônia - André Luis de Freitas Alves 

Santa Catarina - Silvia Cristina C. Flores 

São Paulo - Maria Luiza Moretti 

Sergipe - Márcia Maria Macedo Lima 

Tocantins - Hertz Ward de Oliveira 

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THE BRAZILIAN JOURNAL OF INFECTIOUS DISEASES 

An Official Publication of the Brazilian Society of Infectious Diseases 

EDITOR 

Anastácio Q. Sousa 

ASSOCIATE EDITORS 

Adauto Castelo (BR) 

André Villela Lomar (BR) 

Antônio C. Pignatari (BR) 

Carlos Brites Alves (BR) 

Hélio Sader (BR) 

João Silva de Mendonça (BR) 

Márcio Nucci (BR) 

Roberto Badaró (BR) 

Roberto Focaccia (BR) 

EDITORIAL BOARD 

Achilea L. Bittencourt (BR) 

Antônio Alci Barone (BR) 

Antônio Andrade (BR) 

Antônio Campos Neto (BR) 

Antônio Carlos Nicodemo (BR) 

Arnaldo Colombo (BR) 

Caio Mendes (BR) 

Celso Ramos Filho (BR) 

Cláudio Sérgio Pannuti (BR) 

Dirceu Grecco (BR) 

Edgard Marcelino de Carvalho (BR) 

Eduardo Netto (BR) 

Érico Antônio Gomes de Arruda (BR) 

Esper Georges Kallas (BR) 

Eurico de Arruda Neto (BR) 

Flávia Rossi (BR) 

Guido Levi (BR) 

Henry Masur (US) 

Jeffrey Shaw (BR) 

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Jorge Luiz Sampaio (BR) 

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Kleber Luz (BR) 

Marcelo Ferreira (BR) 

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Naftale Katz (BR) 

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Ricardo Diaz (BR) 

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Warren D. Johnson, Jr. (US) 

Zilton Andrade (BR) 

PRODUCTION STAFF 

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This supplement was supported by: 

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• Schering-Plough do Brasil 

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COVER: Liver cells infected with the hepatitis C virus. 

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THE 

BRAZILIAN 

JOURNAL 

OF INFECTIOUS 

DISEASES 

Volume 11 • Supplement 1 October 2007 


on the Management and Treatment of Hepatitis C ........... 1 

Brazilian Society of Infectious Diseases HCV Consensus Group 

Epidemiological Aspects of Hepatitis C in Brazil .............. 6 

Decio Diament 

Sexual Transmission of HCV ............................................. 8 

Kleber Dias do Prado 

Hepatitis C Virus Perinatal Transmission ......................... 10 

Umbeliana Barbosa de Oliveira 

Hepatitis C: Virological Aspects and Practical 

Implications .................................................................... 12 

Antonio Alci Barone 

Pathogenesis of Hepatitis C – HCV Consensus 2007 ...... 14 

Ana Tereza R. Viso 

Antifibrotic Therapy in Chronic Hepatitis C .................... 20 

Rinaldo Focaccia Siciliano and Antonio Alci Barone 

Laboratory Testing for Hepatitis C ..................................21 

Neiva Sellan Lopes Gonçales and Fernando Lopes Gonçales Junior 

Hepatitis C: Genotyping ................................................... 25 

Norma de Paula Cavalheiro 

Noninvasive Means of Diagnosing Liver Fibrosis in 

Hepatitis C ......................................................................28 

Eduardo Sellan Lopes Gonçales, Adriana Flávia Feltrim Angerami 

and Fernando Lopes Gonçales Junior 

Chronic Hepatitis C: Pathological Anatomy .....................32 

Evandro Sobroza de Mello and Venâncio Avancini Ferreira Alves 

Co-Infection with Hepatitis B Virus and Hepatitis C 

Virus ................................................................................ 37 

Heloísa Pedrosa Mitre and João Silva de Mendonça 

Co-Infection with Hepatitis C Virus and Human T Lymphocyte 

Virus .................................................................................40 

Carlos Brites Alves 

Basic Guidelines for the Treatment of HIV/HVC Co- 

Infection ......................................................................... 42 

Edgard De Bortholi 

Basic Aspects of the Treatment for Hepatitis C: Mechanisms 

of Action of Interferon Alpha and Ribavirin and the Bases of 

Individualization ..............................................................47 

Carlos Eduardo de Melo, Evaldo Stanislau Affonso de Araújo and 


Therapeutic Approach to Acute Hepatitis C ...................49 

Rodrigo Nogueira Angerami and Fernando Lopes Gonçales Júnior 

Treatment of Chronic Hepatitis C in Treatment-Naïve 

Patients ........................................................................... 53 

Marcelo Simão Ferreira 

Retreatment of Hepatitis C Patients Who Previously 

Experienced Treatment Failure ......................................... 58 

Fernando Lopes Gonçales Jr. 

Maintenance Treatment for the Modulation of Liver 

Fibrosis ........................................................................... 60 

Evaldo Stanislau Affonso de Araújo and Antonio Alci Barone 

Treatment of Patients Infected with Hepatitis C Virus and 

Presenting Extrahepatic Manifestations ..........................64 

Fátima Mitiko Tengan1 and Antonio Alci Barone 

Hepatitis C Treatment Before and After Liver 

Transplant..................................................................... 69 

Edson Abdala, Daniela Rosa Magalhães Gotardo, Patrícia Rodrigues 

Bonazzi and Telésforo Bacchella 

Adverse Event Management ...........................................74 

Aline Gonzalez Vigani 

Treatment Options in the Management of Thrombocytopenia 

in Patients Infected with HCV .......................................... 79 

André Cosme de Oliveira 

Therapeutic Perspectives for Hepatitis C......................... 81 

Evaldo Stanislau Affonso de Araújo, Antonio Alci Barone and Jean- 

Michel Pawlotsky 

Instructions for Authors 

Statement of Editorial Policy 

Checklist for Submitted Manuscripts 

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BJID on line 

The Brazilian Journal of Infectious Diseases (BJID) is 

now present in a new Web Site: www.bjid.com.br. The 

BJID is an official publication of The Brazilian Society 

of Infectious Diseases and it is a vehicle for original 

publications in this field. The BJID is published bimonthly 

by Contexto Publishing (Salvador/BA, Brazil) 

since 1997. The aim of this site is to familiarize visitors 

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a nearly future, we will include a service to check 

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each issue, the abstracts will be available to be 

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BJID 2007; 11 Supplement 1 (October) 1 


on the Management and Treatment of Hepatitis C 

Evaldo Stanislau Affonso de Araújo, João Silva Mendonça, Antonio Alci Barone, Fernando Lopes Gonçales Junior, Marcelo 

Simão Ferreira*, Roberto Focaccia, Jean-Michel Pawlotsky§* and Brazilian Society of Infectious Diseases HCV Consensus Group 

Each year, and every day, the results of clinical trials and basic research provide us with a great deal of new 

information regarding viral hepatitis. We on the Viral Hepatitis Committee of the Sociedade Brasileira de Infectologia 

(SBI, Brazilian Society of Infectious Diseases) have been working to standardize the major issues surrounding dayto-day 

practice in treating patients infected with the hepatitis B or C virus (HBV or HCV). We have decided to 

address, in alternate years, HBV, together with hepatitis delta (HDV), and HCV, in our annual ‘Consensus’ on 

clinical management. Last year, we published the first HBV Consensus (BJID, 2007 (11):2-6). This year, we submit 

our HCV Consensus, 

which primarily serves to 

update the 2002 and 2004 

SPI Consensuses. We 

distributed the principal 

topics among the Committee 

members, revised their 

work and compiled it into a 

Proceedings Supplement 

(to be published together 

with the BJID), which 

elucidates the highlights of 

the Consensus. A deeper 

review was written and 

referenced (it is our advice 

to the reader to read the 

Proceedings as well). A 

meeting was then held in 

Mogi das Cruzes in order 

to discuss, in a very practical 

and directed way, the 

issues most relevant to the 

Consensus, from public 

policies to the most complex 

therapeutic points. The 

results are summarized in a 

question/answer, topic/ 

statement format in this issue 

of the BJID. The main 

Figure 1. HCV Consensus Group. 

message of our statement was 

that we need to have the 

courage to act in favor of life. 

Many of us have adopted certain practices based on very new knowledge despite a lack of formal or official policies 

to support such practices. Some of us have been awaiting new compounds while patients are dying of chronic liver 

diseases. Unfortunately, the news from the battlefield is not so good. New compounds have been very disappointing 

(low potency, viral resistance, ineffective without interferon and various side effects, some serious). It is also difficult 

to incorporate new policies into everyday practice. However, strategies such as optimizing the use of pegylated 

interferon/ribavirin and encouraging treatment compliance, as well as finding new ways to monitor and slow liver 

disease progression, are effective and should be put into practice. Most importantly, the low-dose maintenance of 

pegylated interferon seems to be very promising, and the use of interferon alpha has saved lives. That is why we 

choose to expound upon what we believe to be the current standard of care and the gold standard for dealing with 

this hard to treat virus, as well as with the chronic complications of HCV infection. Our position will be re-evaluated 

over the next two years. Until then, we are confident that our guide will be of great value to the readers. Finally, we 

would like to thank Roche and Schering Plough for the educational grants provided to the SBI. However, we must 

stress that neither company attempted to influence any of the decisions made by our consensus group. 

The Brazilian Society of Infectious Diseases HCV Consensus Group 

Social and Collective Impact of the Decision-Making Process 

Serologic triage for hepatitis C virus (HCV): When and how? 

Diagnosis ‘campaigns’? Most vulnerable groups? 

It is recommended that detection ‘campaigns’ be carried 

out for more vulnerable groups 1 , individuals in certain 

#Brazilian Society Infectious Diseases HCV Consensus Group: Ana 

Tereza Rodrigues Viso, Aline Vigani, André Cosme Oliveira, Carlos 

Eduardo de Melo, Carlos Brites Alves, Décio Diament, Edson Abdala, 

Edgard De Bortholi, Evandro Sobroza de Mello, Eduardo Sellan 

Gonçalves, Fátima Mitiko Tengan, Heloísa Pedrosa Mitre*, Kleber 

Dias Prado, Neiva Sellan Gonçales, Norma de Paula Cavalheiro, Rinaldo 

Focaccia Siciliano, Rodrigo Nogueira Angerami*, Umbeliana Barbosa 

de Oliveira, Venâncio Avancini Ferreira Alves*. § Special guest. *Members 

who did not participate of the Consensus Meeting occurred in the Blue 

Tree Park Hotel, Mogi das Cruzes/SP, on August 25 th -26 th , 2007. 

occupations (health professionals, technicians whose work 

potentially puts them in contact with blood), institutionalized 

individuals (prisoners, under-age felons, etc.), and the family 

members of patients with hepatitis C, as well as those infected 

with HIV. We emphasize that such individuals should be clearly 

informed that the triage diagnosis should be confirmed by a 

method with more sensitivity and specificity, as well as that 

confirmation of the diagnosis will not necessary imply 

treatment of the infection. Age is a factor to be considered, 

1 

History of blood product transfusion, history of major surgery, unsafe 

parenteral exposure (reusable syringes, sharing of utensils during the 

use of licit or illicit injected substances, undergoing diagnostic or esthetic 

therapeutic procedures involving reusable or inadequately sterilized 

material, e.g., tattoo, acupuncture, piercing, manicure, dental 

treatment, etc.), and sharing of utensils during the use of inhaled drugs. 

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2 Consensus of Hepatitis C Carried Out by SBI 

BJID 2007; 11 Supplement 1 (October) 

since older people are more likely to have been exposed to the 

disease over the course of their lifetime. 

The infected health professional: are their activities restricted 

in any way? 

A priori, the activity of health professionals with 

hepatitis C should not be restricted. However, strict 

application and educational measures are recommended 

regarding the biosafety guidelines, and it should be noted 

that more data are needed before a definitive 

recommendation can be made. 

Is hepatitis C a sexually transmitted disease (STD)? 

Although hepatitis C is not conceptually an STD, sexual 

transmission is possible, albeit uncommon, and the risk of 

such transmission increases when the individual presents 

genital lesions or HIV positivity, as well as when the 

individual engages in risky sexual behavior. In such 

situations, the use of condoms is recommended. 

Heterosexual monogamous couples who present 

discrepant serologic results can use condoms of their own 

accord after being properly instructed. We would like to 

issue a warning regarding the risk of transmission in the 

household through the communal use of utensils 

contaminated with blood. 

Hepatitis C during pregnancy and childbirth: To get pregnant 

or not? Cesarean or vaginal delivery? Breastfeeding? 

Pregnancy is not contraindicated in women of 

childbearing age infected with HCV, although 

contraindications related to the period of treatment should 

be respected. Regarding the type of delivery, the decision 

should be made by an obstetrician. It should be noted, 

however, that a high viral load of HCV can be a relevant 

factor in this decision. Nevertheless, at the present, we 

cannot recommend a definitive course of action. 

Breastfeeding is allowed, although the nipple should be 

carefully prepared, and breastfeeding should be 

discontinued if fissures appear or bleeding occurs. Pregnant 

women coinfected with HCV and HIV present a clearly 

greater risk of perinatal HCV transmission and therefore 

constitute an exception to these permissions. 

Prevention 

Unapparent HCV transmission in society and in the health 

care environment: What should we recommend to Health 

Oversight Agencies? 

We recommend extremely rigorous inspection of health 

and esthetic institutes, as well as continuing education 

of the professionals who work in this area. We should 

also emphasize the need for ongoing education of health 

professionals at all levels of patient care – from basic care 

to highly complex treatments. 

Vaccines: Which and when? 

Susceptible individuals with hepatitis C should be 

vaccinated against hepatitis A and B. There is a real need to 

make vaccines against hepatitis A available in the public health 

care system. 

The Laboratory in the Era of Individualized Treatment 

Quantification of viral loads for all genotypes? 

Yes, it is recommended that the viral load of all patients be 

quantified. 

Which quantification method should be used? 

It is recommended that the method used be reproducible, 

be sensitive, and present ample linearity. 

‘Moments of decision’: At baseline (One measurement? 

When? Several measurements?), as well as at weeks 4, 12, and 

24; end-of-treatment response (ETR), sustained virologic 

response (SVR)...What else? 

Baseline viral load should be determined prior to but as 

close as possible to the initiation of the treatment. It can be 

determined only once provided that the test is performed 

under ideal technical conditions. At week 4, the same test will 

be qualitative in order to define the presence of rapid virologic 

response (RVR), defined as the detection of no viral RNA. At 

week 12, it should be quantitative, adopting the criteria of no 

early virologic response (EVR) (a drop in viral load ≤ 2log10), 

partial EVR (drop ≥ 2log10), and complete EVR (no viral RNA 

detected). At week 24, the test will be qualitative. If viral RNA 

is detected, the treatment instituted exclusively for virologic 

purposes will have to be interrupted. Determination of the 

ETR – emphasizing the differences in duration in different 

genotypes and patients – as well as of the SVR, must be 

qualitative. The SVR should be determined at 24 weeks after 

the end of the treatment. 

It should be noted that monitoring will be unnecessary 

during the treatment in the cases in which RVR occurred and 

adequate treatment compliance is maintained. 

‘Week 12’ SVR? 

Determination of the SVR at 12 weeks after the end of the 

treatment is not currently considered a useful or valid measure. 

Metabolic alterations: Homeostasis model assessment 

(HOMA) and glucose tolerance test: when to order, how to 

interpret 

Various studies indicate the role of hepatitis C as a factor 

implicated in the development of type 2 diabetes in patients at 

high risk (male gender, over 40 years of age, and overweight). 

In experimental models, HCV was found to induce insulin 

resistance, including increased production of tumor necrosis 

factor as one of the contributing factors. Insulin resistance is 

also associated with the development of steatosis and 

progression of liver fibrosis, principally in patients infected 

with HCV genotype 1. Therefore, there seems to be an 

association between insulin resistance and the characteristics 

associated with patients presenting a worse response to the 

hepatitis C treatment: cirrhosis, obesity, concomitant infection 

with HIV (taking antiretroviral drugs), etc. 

In summary: HCV promotes insulin resistance, which leads 

to steatosis, fibrosis, and resistance to treatment with 

interferon alpha (IFN-α). 

The HOMA mathematical model [(serum levels of fasting 

insulin vs. serum levels of fasting glucose)/22.5] has proven 

useful in the evaluation of sensitivity to insulin; however, it 

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BJID 2007; 11 Supplement 1 (October) Consensus of Hepatitis C Carried Out by SBI 

3 

has not been completely standardized for all clinical situations, 

which is why its routine use is not recommended, except in 

the situations that will be reviewed now (metabolic alterations) 

and in the Proceedings. 

Noninvasive monitoring of fibrosis 

Value of simplicity: Thrombocytopenia as a marker of liver 

cirrhosis 

Thrombocytopenia in an individual with hepatitis C 

indicates moderate to severe liver fibrosis. The sensitivity of 

this diagnostic marker of advanced fibrosis increases when it 

is used in combination with other biochemical tests, such as 

determination of the aspartate aminotransferase to platelet 

ratio index, calculated using the formula: aspartate 

aminotransferase/alanine aminotransferase ratio + platelets. 

When is it indicated? 

Noninvasive monitoring of liver fibrosis should be performed 

in cases of (i) contraindication or difficult access to liver biopsy, 

(ii) the need for such monitoring in order to hasten the performance 

of a new biopsy in patients at greater risk of progression 

(immunocompromised patients) or in individuals presenting 

stage F1 fibrosis, and (iii) in patients with liver cirrhosis under 

treatment for modulation of fibrosis (IFN maintenance). 

How to measure: Serum panels vs. Fibroscan 

Sensitivity and positive predictive value are increased by 

combining the methods. 

Liver biopsy is dead. . . Long live liver biopsy! 

Biopsy for all genotypes? And for all patients? 

Yes, except for clinical contraindications, the biopsy 

should be performed for all patients presenting detectable 

levels of HCV RNA. 

The central issue is the absolute need for the biopsy sample 

to be representative of the hepatic parenchyma, since 

inappropriate biopsies frequently result in understaging of 

the disease. It is highly recommended that a needle biopsy be 

performed (wedge biopsies produce subcapsular samples that 

cannot be used in the staging of fibrosis nor in the staging of 

inflammation); needles that produce very thin biopsies highly 

limit architectural staging and should not be used. Trucut 14- 

gauge needles or needles that produce samples of equivalent 

diameter, measuring at least 1.5 cm long and/or 10 represented 

portspaces, are recommended. If the biopsy is performed 

during a surgical procedure, it should be done at the outset of 

the procedure in order to avoid the artifacts that surgery can 

produce in the liver tissue. 

The biopsy report should include a staging system and 

scoring (METAVIR or SBP, preferably). It should be noted, 

however, that the pattern of inflammatory alterations (portal, 

interface, and lobular components) should be described in 

detail, since it has become increasingly important in predicting 

the evolution of the disease as well as in the differential 

diagnosis with other diseases. In addition, the principal role 

of biopsy is to rule out other liver diseases – steatohepatitis 

(alcoholic or nonalcoholic), for example, frequently co-exists 

with hepatitis C and is known to have a significant impact on 

the evolution of the disease. 

Value of the imaging and serum level methods in the diagnosis 

of liver fibrosis: who needs endoscopy? 

Prior to biopsy, patients with indirect evidence of portal 

hypertension (ultrasonographic signs, thrombocytopenia) 

should be submitted to endoscopy of the upper digestive tract 

for detection of esophageal varicose veins that would render a 

liver biopsy unnecessary in the diagnosis of liver cirrhosis. 

Clinical Management in Borderline Situations 

Portal hypertension in clinical practice: Clinical management 

of pretreatment thrombocytopenia 

There is no conclusive evidence on the management of 

pretreatment thrombocytopenia; however, some alternatives 

can be considered and are reviewed in the Proceedings. 

Liver transplant in clinical practice: post-transplant limitations. 

Fibrogenesis, treatment after transplant, rejection control and 

live donor 

Liver disease caused by HCV corresponds to almost half 

of the indications for liver transplant. Currently, in Brazil, the 

distribution of the organ follows a criterion of severity, using 

the model for end-stage liver disease (MELD). After the 

transplant, up to 80% of the patients experience histologic 

recurrence, and the pre-transplant viral load is one of the most 

significant risk factors. For this reason, pre-transplant 

treatment should always be considered, even in patients with 

decompensated cirrhosis, provided that the treatment is given 

in a specialized center and with an active transplant treatment 

team. Post-transplant treatment for chronic hepatitis is 

generally indicated when fibrosis is ≥ 2 or when periportal 

activity is ≥ 3. Although the duration of treatment should be 

at least 48 weeks, it should be individualized according to the 

virologic response profile. 

Treatment 

Nondrug and nonspecific HCV treatment: metabolic syndrome, 

nonalcoholic steatohepatitis, diabetes, obesity – evidence for 

the use of diet, hypolipidemic agents, and antidiabetic 

medication 

It is recommended that the conditions associated with 

worsening of liver fibrosis and lower SVR rate, such as obesity, 

type 2 diabetes, nonalcoholic steatohepatitis, steatosis, 

dyslipidemia, and metabolic syndrome, be brought under 

control before antiviral treatment is instituted. 

Patients with concomitant diseases; how to use IFN-α and 

specific measures for drug users and patients with mental 

disease. Socially marginalized individuals and prisoners. 

Individuals with kidney disease in pre- and post-kidney 

transplant phases. Individuals with auto-immune disease and 

extrahepatic manifestations 

At facilities where a multiprofessional approach is taken or at 

specialized centers, both of which allow appropriate monitoring 

and control of all clinical situations of the underlying disease, as 

well as of those potentiated or triggered by HCV treatment, it is 

recommended that HCV treatment be instituted first. It is 

noteworthy that, in the case of auto-immune manifestations 

(cryoglobulinemia and auto-immune hepatitis in particular), 

treatment for HCV should be given – observing the premises 

www.bjid.com.br

4 Consensus of Hepatitis C Carried Out by SBI 


above. Corticosteroids and other immunosuppressants can be 

used concomitantly when indicated. 

Ribavirin: Always a full dose? And how much (0.8 g, 1 g, 11 

mg/kg/day, 15 mg/kg/day)? 

Ribavirin should always be given in a full dose. The 

recommended dose is 15 mg/kg/day or 1 g for patients who 

weigh < 75 kg. The minimum dose to be considered in 

adjustments is 11 mg/kg/day. 

Common adverse effects: how to deal with anemia, neutropenia 

and thrombocytopenia before the treatment, during the 

treatment, and triggered by the treatment? What are the basal 

limits for patients with and without cirrhosis to be treated? 

How can the effects be reversed? 

The minimum criteria for treatment should be hemoglobin 

≥ 10 g/dL, neutrophils > 1500/mm 3 and platelets > 60,000/mm 3 . 

Patients presenting a drop in hemoglobin to < 10 g/dL or a 

drop ≥ 3.5 g/dL with clinical manifestations should be given 

Erythropoietin in a dose of 40,000 IU/week until the end of the 

treatment or until anemia is under control. Patients in whom 

neutrophils drop to < 750/mm 3 should receive filgrastim in a 

dose of 300 µg one to three times a week until neutropenia is 

under control. In patients presenting a drop in platelets to < 

25.000/mm 3 , the treatment should be discontinued. Adjustment 

regimens of the dose of IFN with intermediate values are 

presented in the Proceedings. 

When to treat: the patient, the doctor, the system ... 

The patient wants to be treated. How can we deal with this? 

There is no definite position on this situation. We 

emphasize the need to give clear and exhaustive information 

regarding the indications for treatment and the factors 

associated with the progression of the disease. 

Is early indication of treatment worthwhile? In which cases? 

Treatment can be considered for individuals with level 1 

structural lesion (F1 METAVIR), who present incomplete septa, 

A3 activity (METAVIR), who are under 60 years of age, and 

present co-factors associated with risk of progression (obesity, 

nonalcoholic steatohepatitis, etc.). 

Use of IFN and ribavirin 

The patient, the virus, and the medication: Relevant factors 

in predicting response before and during the treatment 

There has been no relevant alteration regarding the 

elements described. Please see the concepts listed below 

regarding individualization based on EVR. 

Is conventional treatment with IFN-α dead? If not, when 

should we use it? 

It is the understanding of the Brazilian Society of Infectious 

Diseases that treatment with conventional IFN-α is no longer 

justifiable and should not be performed. 

Dose of IFN, the ‘burden’ of the ‘weight’ 

The dose of pegylated IFN-α-2a (PEG-IFN-α-2a) should 

be 270 μg/week for patients weighing > 85 kg and presenting 

a high viral load (> 850,000 IU/mL). The dose of PEG-IFN-α-2b 

should be 1.5 μg/kg/week. 

Short, long, standard treatment ... Always individualize? 

In patients presenting a RVR, no comorbidities (severe 

steatosis or cirrhosis), and a low viral load (< 250,000 IU/ 

mL for genotype 1), the duration of the treatment can be 

reduced: to 12 weeks for genotypes 2 and 3; and to 24 

weeks for genotype 1. Patients with a high viral load and 

complete EVR should be treated for the standard duration, 

and patients presenting a slow response (no RVR, partial 

EVR and negative at week 24) should be treated for an 

additional 24 weeks. 

The fear of suspending treatment: How should we deal with 

that decision? 

We emphasize that, if the objective of the treatment is 

virologic, the absence of EVR and viral detection at week 24 

necessarily imply the interruption of the treatment. 

Maintenance treatment with IFN: When and how? Is 

‘watchful waiting’ still a valid concept? 

Maintenance treatment with PEG-IFN-α is considered for 

the following patients: those with structural lesion > F3 and/ 

or signs of portal hypertension (esophageal varicose veins, 

splenomegaly, dilated blood vessels, etc.) and/or platelet 

counts < 110,000/mm 3 who are categorized as Child-Pugh class 

A or B, with no history of severe or potentially uncontrollable 

decompensation; those without hepatocellular carcinoma; 

relapsers; and partial responders or nonresponders to the 

combination of PEG-IFN-α and ribavirin (or to IFN only when 

ribavirin is contraindicated) administered with adequated 

compliance and for a minimum of 12 weeks. Maintenance 

treatment with PEG-IFN-α should also be considered for 

patients for whom the full dose treatment is contraindicated. 

Child-Pugh class C patients on the transplant waiting list 

should be treated in specialized centers. Proposed regimen 2 : 

PEG-IFN-α-2b, 0.5-1.0 μg/kg/week subcutaneously (sc); PEG- 

IFN-α-2a, 90 μg/week (sc). Duration 2 : Minimum of 24 months, 

indefinite, or even until there is an antiviral treatment that is 

proven to be safe and efficient. Monitoring the occurrence of 

complications (hepatocellular carcinoma, gastrointestinal 

bleeding, encephalopathy, etc.) 

Monotherapy with ribavirin, although previously 

described, cannot be recommended at the moment, due to 

insufficient evidence. 

Impact of reduction in the dose of IFN and/or ribavirin at 

various moments of the treatment 

Every effort should be made to always maintain full 

treatment. 

Positive and negative predictive values in clinical practice: 

patients mono- and co-infected with HIV 

Positive predictivity data in the presence of RVR and 

negative predictivity data in the absence of EVR are equally 

2 

Dose schedule and duration were suggested based on preliminary data 

and should be re-evaluated taking into account the results of ongoing 

studies. 

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BJID 2007; 11 Supplement 1 (October) Consensus of Hepatitis C Carried Out by SBI 

5 

valid for HCV mono-infected patients and patients co-infected 

with HCV and HIV. 

Retreatment: When and how? 

Retreatment will always be considered when the previous 

treatment was considered suboptimal for the current concepts 

(poor compliance, insufficient doses, inappropriate interruptions, 

inadequate management of adverse events, uncontrolled 

comorbidities, etc.) and when there is recurrence. The treatment 

in true nonresponders to PEG-IFN and ribavirin presents such 

a low chance of success that it cannot be routinely 

recommended. 

Due to the fact that relapsers/nonresponders to initial 

treatment constitute a quite heterogeneous group, it is 

necessary to qualify and carefully select the patients that should 

be retreated. Various factors that might have influenced the 

nonresponse should be modified before the initiation of or even 

during the new therapeutic cycle. Currently, patients considered 

less likely to respond to retreatment are those who are true 

nonresponders, those who are of the Black race, those infected 

with genotype 1, those with high viral loads, those with 

advanced liver disease, and those who present intercurrent 

conditions (obesity, etc.) 

Patients previously treated with IFN as monotherapy or 

with the combination of IFN and ribavirin stand a greater chance 

of presenting an SVR than do nonresponders to the 

combination of PEG-IFN and ribavirin. Those who experienced 

recurrence during the treatment (breakthrough) or after the 

treatment fare better than do true nonresponders. Patients who 

are noncompliant with previous treatment, as well as those 

who required reduced doses of IFN or ribavirin due to cytopenia 

or other adverse effects, usually respond better to retreatment 

than do those who received full doses. Of course, the factors 

responsible for noncompliance should be eliminated, and 

reductions in medication doses should be properly approached. 

In nonresponders, it is recommended that erythropoietin and 

filgrastim be started sooner, and further dose reductions should 

be avoided at all costs. Users of drugs or alcohol who, due to 

their addiction, did not adequately comply with all the phases 

of the previous treatment, can more adequately respond to 

retreatment provided that these co-factors are nullified. This 

also applies to patients who did not receive adequate social 

or cultural support. Patients who suffer from obesity, insulin 

resistance, dyslipidemia, steatosis, anemia, or liver diseases 

(e.g., hemochromatosis) should be retreated, preferably 

after the proper diagnosis and treatment of these 

concomitant conditions. Doses of PEG-IFN should be the 

same as those used for treatment-naïve patients. We believe 

that, in retreatment regimens, the doses of ribavirin should 

be as high as possible. Due to the paucity of studies with 

large patient samples, we recommend that the duration of 

retreatment be 48 weeks for all genotypes. At the moment, 

there are no consolidated data in the literature to support 

using higher doses of PEG-IFN or ribavirin, using induction 

doses, or extending the treatment time to more than 48 

weeks in retreatment cases. Regarding the week 12 rule, 

there is strong evidence that patients who do not present 

negativity for HCV RNA by this time will have very little 

chance of presenting an SVR, and their treatment should be 

interrupted. 

IFN: Backbone of the current treatment. And the future? 

Perspectives and frustrations 

Preliminary results of developing therapies show that IFNα 

will still be the active principle of the treatment for many 

years. For this reason, we have adopted several of the practices 

that are presented here. 

Co-infections 

Antiretroviral therapy 2007 and HCV treatment: relevant 

interactions 

Although ribavirin can reduce the concentration of some 

antiretroviral nucleoside analog reverse transcriptase inhibitors 

(NARTIs), there seem to be no clinical consequences. 

The adverse effects of NARTIs have been associated with 

HCV co-infection, female gender, obesity and prolonged exposure 

to these drugs. The principal combinations with less hepatic 

repercussion among NARTIs are as follows: lamivudine + abacavir; 

lamivudine + zidovudine; lamivudine + abacavir + zidovudine, and 

emtricitabine + tenofovir. However, current studies indicate that 

ribavirin interferes with the effect of abacavir. Therefore, ribavirin 

should be used with caution in patients receiving the highly active 

antiretroviral therapy regimen and being treated for HCV. 

Greater toxicity is principally caused by concomitant use of 

didanosine and ribavirin. 

CD4 counts: Minimum limits for treatment and decision-making in 

patients with reconstituted immunity or immunocompetent patients 

Precise indication of therapy in HIV/HCV co-infected 

patients can be made in patients with CD4 counts > 350 cells/ 

mm 3 . In patients with CD4 counts between 200 and 350 cells/ 

. 

mm 3 , the decision to treat HCV infection should take into 

account other factors, such as the duration of HCV infection, 

the severity of the liver disease, the level of HIV suppression 

and classical predictors of treatment response to HCV, such as 

genotype and viral load. 

The SVR can be predicted when HCV RNA is undetectable 

in serum by week 4 of treatment. However, a < 2log10 IU/mL 

reduction in viral load by week 12 and/or viremia detected at 

week 24 predict a lack of virologic response, and discontinuation 

of the treatment is indicated. 

Ongoing studies are evaluating 72-week maintenance therapy 

in co-infected patients and week-24 nonresponders. This might 

be the truly appropriate treatment duration for HIV-positive 

patients, even with longer time and smaller fractionated doses. 

Is the immunocompetent HIV/HCV co-infected patient ‘monoinfected’? 

Yes, the evolution is quite similar. 

Multiple viral infections: Who should we treat first and how? 

Care should be given to the dominant virus between HBV 

and HCV. When treating the dominant virus, the other might 

become active. We need to quantify the HBV DNA in order to 

manage this situation. 

The HTLV apparently modulates the host immune 

response, a fact that should be considered and which is 

detailed in the Proceedings. 

There is no consensus regarding the correct course of 

action in multiple co-infections. 

www.bjid.com.br

6 BJID 2007; 11 Supplement 1 (October) 

Epidemiological Aspects of Hepatitis C in Brazil 

Decio Diament 

Emílio Ribas Institute of Infectious Diseases; São Paulo, SP, Brazil 

The true dimension of the epidemiological situation of 

chronic hepatitis C in Brazil remains unknown. According to 

data from the National Ministry of Health, 52,489 cases were 

diagnosed in the period from 1994 to 2005. However, the data 

regarding the final year of this series are incomplete. There is 

a trend toward an increase in the number of diagnosed cases 

during this period, since diagnostic techniques have become 

more widely available, both in public and private health care 

facilities (Figure 1). 

Figure 1. Number of diagnosed cases of hepatitis C reported 

by the National Ministry of Health, from 1994 to 2005, totaling 

52,489 cases. 

This distribution reflects the greater availability of 

resources as well as the highly populated areas in the 

southeastern and southern regions of the country. However, 

serological surveys carried out in the Central-west and 

Northeast, as well as in the Federal District, showed prevalence 

rates similar to those of a previous survey carried out in the 

city of São Paulo (Figure 3). 

Figure 3. Prevalence of hepatitis C in serological surveys in 

several regions of the country (Galizzi Filho J, personal 

communication, for the data of the surveys on the Centralwest, 

Federal District and Northeast; Focaccia R., personal 

communication, for the data on São Paulo). 

Most diagnosed cases occur in the Southeast, followed 

by the South, Central-west, Northeast and North (Figure 2). 

Figure 2. Distribution of cases by macroregion (National 

Ministry of Health). 

The Brazilian Journal of Infectious Diseases 2007;11 (5) Suppl. 1:6-7. 

© 2007 by The Brazilian Journal of Infectious Diseases and Contexto 

Publishing. All rights reserved. 

Data obtained in these serological surveys indicate 

prevalence rates from 0.28 to 2.61%. According to the 2000 

census taken by the Brazilian Institute of Geography and 

Statistics, Brazil has a population of approximately 170 million. 

It has been shown that, of those testing positive for infection 

with the hepatitis C virus (HCV), approximately 80% have the 

chronic form of hepatitis C. Based on these data, we can 

estimate that there are 400,000 to 3,800,000 cases of chronic 

hepatitis C in Brazil. Comparing these numbers with the data 

from the National Ministry of Health, we can conclude that 

there are a great number of undiagnosed cases of the disease. 

Since there has been a trend toward an increase in the number 

of diagnosed cases, there will be a significant increase in the 

demand for diagnosis and treatment of chronic hepatitis C in 

the future. 

Another interesting fact is that only 17,204 (33%) of the 

52,493 cases of chronic hepatitis reported to the Center for 

Epidemiological Surveillance of São Paulo, from 1998 to 2006, 

were confirmed as being hepatitis C. Another 10,690 cases 

(20%) were classified as inconclusive for hepatitis C, 2099 

(4%) were excluded, and 416 (0.79%) were cases of HBV/HCV 

co-infection. The remaining cases were confirmed as hepatitis 

B, HBV/HDV co-infection, or cases under investigation. 

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BJID 2007; 11 Supplement 1 (October) Hepatitis C in Brazil 

7 

Of the 17,204 confirmed cases, the principal form of 

contamination was parenteral (use of injected illicit drugs, as 

well as blood and blood product transfusions), followed by 

sexual transmission. Work-related accidents accounted for 

few of the cases (Figure 4). 

Figure 4. Distribution of cases of chronic hepatitis C by form 

of transmission in 17,204 individuals in the state of São Paulo, 

from 1998 to 2006 (Source: Center for Epidemiological 

Surveillance, São Paulo). 

Transmission was classified as unknown in 40% of the 

reported and confirmed cases, as can be seen in Figure 4. This 

suggests that the investigation of the form of transmission 

should be improved, and that items such as administration of 

medication using nondisposable syringes, acupuncture, 

tattoos, and piercings should be included in the 

epidemiological investigation. Another unusual fact is sexual 

transmission in 10% of the cases, well above the expected, 

which is less than 1%. 

Another aspect to be considered is the occurrence of 

hepatitis C in groups of differentiated risk, that is, unusual 

cases such as those described in Figure 4. The first group 

would be that of the manicurists, since it is supposed that the 

community use of instruments by these professionals would 

expose them to a higher risk of contamination. There is no 

evidence that this could happen, and a recent serological 

survey conducted in the city of São Paulo in beauty salons 

located at shopping malls in various neighborhoods did not 

demonstrate prevalence rates different from those of the 

population in general (Oliveira, ACDS – personal 

communication). 

Another group is that of the dentists. In Brazil, localized 

serological surveys with small samples of patients have 

shown a low prevalence rate, ranging from 0.4 to 0.7%. 

However, a study on the level of knowledge of these 

professionals about the disease has shown it is very low, 

demonstrating the need of greater emphasis on training and 

continuing education, aiming at making them capable of 

properly protecting themselves, as well as of preventing 

transmission to patients and perhaps even help the 

diagnosis, since several extrahepatic manifestations appear 

in the mouth cavity, such as oral liquen planus, erythema 

nodosum, etc. 

References 

1. Bellíssimo-Rodrigues W.T., Machado A.A., Bellíssimo-Rodrigues 

F., et al. Prevalence of hepatitis B and C among Brazilian dentists. 

Infect Control Hosp Epidemiol 2006;27:887-8. 

2. http://portal.saude.gov.br/portal/saude/ 

visualizar_texto.cfm?idtxt=25340. Acessado em 24/08/2007. 

3. http://www.cve.saude.sp.gov.br/htm/hepa_home.html. Acessado em 

24/08/2007. 

4. Leão J.C., Teo C.G., Porter S.R. HCV infection: aspects of 

epidemiology and transmission relevant to oral health care 

workers. Int J Oral Maxillofac Surg 2006;35(4):295-300. 

5. Takahama A.J., Tatsch F., Tannus G., Lopes M.A. Hepatitis C: 

incidence and knowledge among Brazilian dentists. Community 

Dent Health 2005;22(3):184-7. 

www.bjid.com.br


Sexual Transmission of HCV 

Kleber Dias do Prado 


Although there is evidence that sexual transmission of 

HCV occurs, this form of transmission is of secondary 

epidemiological importance when compared to percutaneous 

forms of transmission [1]. Among the evidence that supports 

the possibility of sexual transmission of HCV we can list the 

following: 

1- Case reports of acute hepatitis C with anti-HCV 

seroconversion in sexual partners of individuals infected by 

HCV, excluding mechanisms of nonsexual transmission and 

with high genomic homology among viral strains infecting 

sexual partners [2-4]. 

2- Detection of HCV RNA in semen, vaginal secretion and 

cervical secretion, despite low titles in most cases [5-8]. 

3- Data from the Centers for Disease Control and Prevention 

demonstrating that, from 1995 to 2000, 18% of the cases of 

acute HCV infection in the United States occurred in patients 

reporting sexual contact with an individual infected with HCV 

in the preceding 6 months or multiple sexual contacts as the 

only risk factors for acquiring the infection [1]. 

The risk of acquiring HCV through sexual contact differs 

among subgroups of individuals: We can distinguish two main 

risk subgroups: 

1. Individuals who have multiple sexual partners or who 

engage in sexual practices that might lead to mucosal trauma: 

sex professionals; men who have sex with men (MSM); and 

patients treated in clinics specializing in the treatment of 

sexually transmitted diseases (STDs). 

2. Stable monogamous heterosexual sexual partners of 

individuals chronically infected with HCV. 

In general, rates of anti-HCV incidence and prevalence are 

higher in the first subgroup. This may be due to differences in 

sexual practices among the groups, but also to nonsexual 

factors (sharing personal objects, tattoos, use of illicit drugs, 

etc.) [1]. Seroprevalence studies in the United States 

demonstrated median positive anti-HCV rates in 6% of women 

who were sex professionals, as well as in 4% of MSM, 4% of 

clients of STD clinics and 4% of participants in HIV 

surveillance studies. Studies conducted in other parts of the 

world have obtained similar results [9-15]. The following risk 

factors were identified: having had a high number of recent 

and lifetime sex partners; engaging in unsafe sexual practices; 

being infected with HIV; and having an STD. This indicates 

that sexual activity in general is a risk factor for HCV 




transmission [1]. 

However it is essential to mention that the results of some 

studies contradict these findings. Studying the prevalence 

and incidence of positivity for anti-HCV antibodies in a cohort 

of 1085 HIV-positive Canadian MSM, Alary et al. found values 

of 2.9% and 0.038/100 individuals/year, respectively, both 

significantly associated with the use of injection drugs. The 

authors considered sexual transmission of HCV to be rare in 

this group [16]. In a study conducted in Thailand, Taketa et al. 

assessed the prevalence of anti-HCV in injection drug users, 

sex professionals and individuals with STDs. The prevalence 

was 85%, 2% and 0%, respectively, with a very low or null 

transmission rate in the last two groups [17]. Marincovich et 

al. prospectively studied a group of 171 couples discordant 

for HIV and HCV. The index cases were 152 men and 19 women, 

whereas the spouses were 152 women and 19 men. Fortythree 

per cent had engaged in unprotected vaginal and/or 

anal sex, 15% always used a condom but reported incidents in 

which the condom broke or slipped off during sexual contact, 

and 22% had performed unprotected orogenital sex. There 

was only one case of HIV seroconversion and no cases of 

HCV seroconversion during the follow-up of 529 individuals/ 

year. There were 31 cases of pregnancy, 2 of them in women 

infected with HCV. This study suggests that the rate of HCV 

transmission is low or null among heterosexuals, even when 

the partner is infected with HIV [18]. 

For the second subgroup, the best studies are those 

excluding percutaneous factors of infection and evaluating 

genotypes and genomic sequence of viral strains in anti-HCV 

concordant couples. In those studies, the prevalence of HCV 

was estimated at 2.8-11% in the Asian Southeast, 0-6.3% in 

Northern Europe and 2.7% in the United States [1]. 

In one of the first studies to use genotyping and analysis 

of the sequence of nucleotides of the hypervariable E2 region, 

Zylberberg et al., studying 24 anti-HCV concordant couples, 

reduced to 3 couples the possible cases of sexual transmission 

of HCV. Nevertheless, nonsexual factors could not be ruled 

out and might have contributed to HCV transmission between 

couples [19]. In Iran, Hajiani et al. studied the HCV transmission 

rate for home contacts with no percutaneous risk factors. The 

rates found were 1.33% for the contacts and 1% for the controls 

(p>0.06). Only 2 of 59 spouses presented evidence of infection 

(3.39%). The authors conclude that intrafamily transmission 

is possible, although not common [20]. 

In a recent study, McMahon et al. determined that the 

transmission of HCV in 265 heterosexual couples using drugs 

in New York City was associated with the use of injection 

drugs by the couple, although not with the pattern of sexual 

activity [21]. Along the same lines, Boonyarad et al., studying 

160 spouses infected with chronic hepatitis C (106 women 

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BJID 2007; 11 Supplement 1 (October) Sexual Transmission of HCV 

9 

and 54 men, all monogamous, stable heterosexual couples), 

verified that only 3 individuals (1.88%) tested positive for 

anti-HCV antibodies and HCV RNA after a mean period of 23 

± 5 years of unprotected sexual exposure. Nevertheless, in 

those 3 individuals, genotyping and sequence analysis did 

not clearly identify the same viral strains that infected their 

respective partners. The authors concluded that sexual 

transmission of HCV is rare [22]. 

Finally, Vandelli et al. conducted a large prospective study 

in which 895 monogamous and stable heterosexual couples 

were evaluated for 10 years [23]. Among the spouses, the 

authors identified 3 cases of seroconversion, none of which 

were attributed to sexual contact with the partner: in one case, 

the genotypes were different; in the other two, there were 

discrepancies in the sequence and phylogenetic analysis). 

Therefore, the authors conclude that the rate of sexual 

transmission of HCV is very low or even null in these patients. 

Therefore, it seems unnecessary to recommend condom use 

in this population. These couples did not practice anal sex, 

neither sex during menstruation nor used condoms [23]. 

The risk of sexual transmission of HCV ranges from 0- 

0.6%/year for heterosexual couples in monogamous, stable 

relationships to 1%/year to individuals with several sex 

partners [1]. Therefore, the formal, systematic recommendation 

of condom use is only necessary for the latter group. Condom 

use is also justified in HCV-positive individuals presenting 

concomitant STDs, having sex during menstruation or 

engaging in sexual practices that can traumatize the mucosal 

surfaces (anal sex, fisting, etc.) In conclusion, the sharing of 

objects potentially contaminated with blood, such as razor 

blades, scissors, nail clippers, cuticle trimmers and tooth 

brushes, is not recommended [1]. 

References 

1. Terrault N.A. Sexual activity as a risk factor for hepatitis C. 

Hepatology 2002;36:S99-105. 

2. Halfon P., Riflet H., Renou C., et al. Molecular evidence of maleto-female 

sexual transmission of hepatitis C virus after vaginal 

and anal intercourse. J Clin Microbiol 2001;39:1204-6. 

3. Nakayama H., Sugai Y., Ikeya S., et al. Molecular investigation of 

interspousal transmission of hepatitis C virus in two Japanese 

patients Who acquired acute hepatitis C after 40 or 42 years of 

marriage. J Med Virol 2005;75(2):258-66. 

4. Lai K.W., Young K.C., Cheng P.N., et al. Interspousal transmission 

of hepatitis C virus: application of comparing the variability of 

HVR1 nucleotide region. Hepatogastroenterology 

2004;51(57):791-5. 

5. Leruez-Ville M., Kunstmann J.M., De Almeida M., et al. Detection 

of hepatitis C virus in the semen of infected men. Lancet 

2000;356:42-3. 

6. Manavi M., Watkins-Riedel T., Kucera E., et al. Evidence of 

hepatitis C virus in cervical smears. J Infect 1999;38:60-1. 

7. Pekler V.A., Robbins W.A., Nyamathi A., et al. Use of versant 

TMA and bDNA 3.0 assays to detect and quantify hepatitis C 

virus in semen. J Clin Lab Anal 2003;17(6):264-70. 

8. Bélec L., Legoff J., Si-Mohamed A., et al. Cell-associated, nonreplicating 

strand (+) hepatitis C virus-RNA shedding in 

cervicovaginal secretions from chronically HCV-infected 

women. J Clin Virol 2003;27(3):247-51. 

9. Van de Laar T.J., Van der Bij A.K., Prins M., et al. Increase in HCV 

incidence among men who have sex with men in Amsterdam 

most likely caused by sexual transmission. J Infect Dis 

2007;196(2):230-8. 

10. Danta M., Brown D., Bhagani S., et al. Recent epidemic of acute 

hepatitis C virus in HIV-positive men who have sex with 

men linked to high-risk sexual behaviours. AIDS 

2007;21(8):983-91. 

11. Götz H.M., Van Doornum G., Niesters H.G., et al. A cluster of acute 

hepatitis C virus infection among men who have sex with men: 

results from contact tracing and public health implications. 

AIDS 2005;19(9):969-74. 

12. D’Oliveira A. Jr., Voirin N., Allard R., et al. Prevalence and sexual 

risk of hepatitis C virus infection when human immunodeficiency 

virus was acquired through sexual intercourse among patients of 

the Lyon University Hospitals, France, 1992-2002. J Viral Hepat 

2005;12(3):330-2. 

13. De los Angeles Pando M., Biglione M.M., Toscano M.F., et al. 

Human immunodeficiency virus type 1 and other viral coinfections 

among young heterosexual men and women in 

Argentina. Am J Trop Med Hyg 2004;71(2):153-9. 

14. Marx M.A., Murugavel K.G., Tarwater P.M., et al. Association of 

hepatitis C virus infection with sexual exposure in southern 

India. Clin Infect Dis 2003;37(4):514-20. 

15. Russi J.C., Serra M., Viñoles J., et al. Sexual transmission of hepatitis 

B virus, hepatitis C virus, and human immunodeficiency virus 

type 1 infections among male transvestite commercial sex 

workers in Montevideo, Uruguay. Am J Trop Med Hyg 

2003;68(6):716-20. 

16. Alary M., Joly J.R., Vincelette J., et al. Lack of evidence of sexual 

transmission of hepatitis C virus in a prospective cohort study 

of men who have sex with men. Am J Public Health 

2005;95(3):502-5. 

17. Taketa K., Ikeda S., Suganuma M., et al. Differential 

seroprevalences of hepatitis C virus, hepatitis B virus and human 

immunodeficiency virus among intravenous drug users, 

commercial sex workers and patients with sexually transmitted 

diseases in Chiang Mai, Thailand. Hepatol Res 2003;27(1):6-12. 

18. Marincovich B., Castilla J., Del Romero J., et al. Absence of hepatitis 

C virus transmission in a prospective cohort of heterosexual 

serodiscordant couples. Sex Transm Infect 2003;79(2):160-2. 

19. Zylberberg H., Thiers V., Lagorce D., et al. Epidemiological and 

virological analysis of couples infected with hepatitis C virus. 

Gut 1999;45(1):112-6. 

20. Hajiani E., Masjedizadeh R., Hashemi J., et al. Hepatitis c virus 

transmission and its risk factors within families of patients 

infected with hepatitis C virus in southern Iran: Khuzestan. 

World J Gastroenterol 2006;12(43):7025-8. 

21. McMahon J.M., Pouget E.R., Tortu S. Individual and couple-level 

risk factors for hepatitis C infection among heterosexual drug 

users: a multilevel dyadic analysis. J Infect Dis 

2007;195(11):1556-9. 

22. Boonyarad V., Chutaputti A., Choeichareon S., et al. Interspousal 

transmission of hepatitis C in Thailand. J Gastroenterol 

2003;38(11):1053-9. 

23. Vandelli C., Renzo F., Romanò L., et al. Lack of evidence of sexual 

transmission of hepatitis C among monogamous couples: results 

of a 10-year prospective follow-up study. Am J Gastroenterol 

2004;99(5):855-9. 

www.bjid.com.br


Hepatitis C Virus Perinatal Transmission 

Umbeliana Barbosa de Oliveira 


The hepatitis C virus (HCV) is the most frequent cause of 

chronic hepatic disease. Its principal route of transmission is 

exposure to contaminated blood. Perinatal transmission is one 

of the less common modes of infection with HCV. 

Incidence 

Vertical transmission of HCV has been reported in 

numerous studies. However, the estimated rate of vertical 

transmission varies considerably due to several factors: 

• Study methodology; 

• Selection of maternal population; 

• Risks involved in the transmission, such as coinfection 

with HIV and high levels of HCV RNA. 

A review of the literature carried out in 1998 identified 976 

children from 28 studies with follow-up periods that were 

sufficiently long to estimate the transmission rate. In those 

studies, the vertical transmission rate was below 10% in cases 

involving HIV-negative mothers. The risk of vertical 

transmission increased significantly in cases involving HIVpositive 

mothers. It is believed that, in these cases, the mother 

tends to present higher levels of HCV viremia, increasing the 

risk of transmission. 

In a more recent review (published in 2001), the authors 

searched through studies published in the 1992-2000 period 

and identified 77 studies. They found clinical and demographic 

variables that influenced the transmission rate. They 

concluded that co-infection with HIV is the most significant 

factor associated with the risk of vertical HCV transmission. 

Findings regarding other possible risk factors, such as HCV 

genotype, type of delivery, and breastfeeding, have been 

inconclusive. 

Risk Factors 

As previously mentioned, the principal risk factor for vertical 

transmission of HCV is concomitant infection with HIV. 

Viremia Level 

Some studies have shown that viral load can be an 

important determinant factor for vertical transmission of HCV. 

It has been demonstrated that women with viral loads lower 

than 1 × 10 5 copies per mL have a lower risk of vertical 

transmission, whether co-infected with HIV or not. One study 

that compared viral loads among HCV RNA-positive mothers 

whose children were infected with HCV or not showed that, in 

cases of probable vertical transmission, the maternal viral load 

was ten times higher than in those cases in which transmission 

did not occur. 

However, there are also inconsistent data in two large 

studies that found no significant differences between the HCV 

RNA levels of the mothers who transmitted HCV and those of 

mothers who did not. 




Co-Infection with HIV 

Numerous studies have shown that the HCV vertical 

transmission rate is higher among HIV-positive women that 

among those who are HIV-negative (19% vs. 4%). This is in 

part explained by the fact that HIV-positive women present 

higher viral loads of HCV. 

One study showed that the average level of HCV RNA in 

women co-infected with HIV was ten times higher than in 

women mono-infected with HCV. This shows that the increase 

in the co-infection risk can be nullified after adjusting the risk 

for the viral load, and antiretroviral therapy for HIV can reduce 

the risk of HCV transmission. 

One study that compared HIV-positive women and HIVnegative 

women with similar viral loads of HCV showed that the 

risk of HCV transmission was similar in both groups. In that study, 

all HIV-positive women were receiving antiretroviral therapy. 

Another study showed that children infected with HIV 

are at a higher risk of being infected with HCV than are those 

who are HIV-negative (17.1% vs. 5.4%). The explanation for 

these data remains unclear. 

Genotype 

There is no evidence that HCV genotype influences 

vertical transmission. The data collected to date do not allow 

us to establish a relationship between HCV genotype and 

vertical transmission risk. 

Breastfeeding 

It is possible to detect HCV RNA in breast milk and 

colostrum. However, HCV transmission through breastfeeding 

has not been documented. A likely explanation would be that 

HCV is inactivated by the effect of gastric acidity and that the 

HCV RNA levels in breast milk are very low. 

Therefore, breastfeeding does not increase the risk that 

HCV will be transmitted from an infected mother to her child. 

The American College of Obstetricians and Gynecologists, as 

well as the American Academy of Pediatrics, allows 

breastfeeding by mothers who are infected with HCV. 

It is important to emphasize that breastfeeding is not 

recommended in case of nipple fissure, due to the 

possibility of bleeding. 

Type of Delivery 

The impact that the type of delivery has on perinatal 

transmission of HCV is completely unknown. Vaginal delivery 

has been associated with an increase in the transmission risk. 

In a study carried out by Lin et al. in 1994, 70 pregnant women 

were evaluated. The vertical transmission rate among children 

who were born by vaginal delivery was 32%, compared to 6% 

in cases of cesarean section. However, the high transmission 

rate in the Lin et al. study was associated with the fact that a 

large proportion of the women evaluated (76%) were coinfected 

with HIV and HCV. Therefore, cesarean section is 

associated with a decrease in the HCV transmission risk in co- 

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BJID 2007; 11 Supplement 1 (October) Hepatitis C Virus Perinatal Transmission 

11 

infected women. The higher risk of transmission in vaginal 

delivery might be associated with exposure of the newborn to 

HCV-contaminated blood during its passage through the 

vagina. However, the exposure to blood can sometimes be 

greater in cesarean section. 

Many studies are needed in order to estimate the risk of 

perinatal transmission of HCV. Currently, cesarean sections 

are not recommended for pregnant women infected with HCV. 

Other risk factors associated with delivery are rupture of the 

placental membrane six hours or more before delivery and 

invasive procedures such as internal monitoring of the fetus 

(Blood 2000; 96:2045). 

Clinical Manifestations 

Newborns infected with HCV are generally asymptomatic. 

In these cases, a significant proportion presents normal 

alanine aminotransferase (ALT) levels. 

One study monitored 104 children with vertical 

transmission upon birth for approximately 49 months (J Infect 

Dis 2000;181:419). Although HCV RNA levels were positive 

for HCV in 90% of these children, the clinical manifestations 

were rare. None of them presented hepatic insufficiency. The 

majority presented persistent or transitory increase in ALT 

levels. Levels of ALT were, in general, normal or slightly 

increased at birth, evolving to an increase in the fourth to 

sixth months of age, remaining high for two years, and declining 

significantly thereafter. 

In that study, 20 children were submitted to hepatic biopsy. 

In all cases, evidence of chronic hepatitis was found. The 

degree of inflammation varied from mild to moderate. In three 

cases some level of fibrosis was found. 

Other studies suggest that children infected with verticallytransmitted 

HCV are generally asymptomatic. However, such 

transmission is often accompanied by an increase in ALT 

levels during the first 6 to 12 months of life. 

One large study monitored 266 perinatally HCV-infected 

children for an average of 4.2 years. In that study, approximately 

20% of the children presented spontaneous clearance of HCV, 

and 80% evolved to chronic infection. 

Clearance of HCV is defined as a loss in the polymerase 

chain reaction positivity for HCV RNA in those children who 

maintained detectable HCV RNA in the first year of life. Most 

of those children were asymptomatic. 

Further studies involving long-term follow-up evaluation 

are needed in order to determine what proportion of children 

with chronic hepatitis C caused by vertical transmission will 

develop hepatic insufficiency and hepatocarcinoma. 

Diagnosis 

The initial diagnosis of infection with HCV in adults is 

made through anti-HCV antibody testing. However, this test 

presents limitations when used in children. 

This is primarily due to the passage of IgG from the mother 

to the child through the placental barrier. Therefore, the 

presence of anti-HCV in the serum of the child does not 

necessarily indicate HCV infection. Clearance of the anti-HCV 

passively acquired from the mother can take more than 12 

months, although it occurs within 12 months in 95% of the 

cases. 

Second, the presence of maternal anti-HCV does not 

necessarily mean that the mother is chronically infected with 

HCV. 

A diagnosis of vertical transmission is made by identifying 

HCV RNA in the mother and child. 

It is important to emphasize that the HCV RNA test can 

also present false-positive or false-negative results. A falsepositive 

result can occur as a result of contamination of positive 

samples. A false-negative result occurs due to a loss of RNA 

during sample storage or to an error in RNA extraction. 

A consensus from the National Institutes of Health 

recommends that children born to mothers testing positive 

for HCV should be submitted to the HCV RNA test on two 

occasions: between 2 and 6 months of life and after 15 

months of life (together with anti-HCV tests on the latter 

occasion). 

Conclusions 

The incidence of vertical transmission by HCV is 

approximately 2% to 5%. The risk is higher in the following 

situations: co-infection with HIV; and high maternal viral load 

of HCV. 

There are still no effective interventions to reduce the risk 

of HCV transmission from the mother to the child. As yet, 

HCV testing is not recommended for pregnant women. 

References 

1. Manzini P., Saracco G., Cerchier A., et al. Human 

immunodeficiency virus infection as risk factor for mother-tochild 

hepatitis C virus transmission; persistence of anti-hepatitis 

C virus in children is associated with the mother’s anti-hepatitis 

C virus immunoblotting pattern. Hepatology 1995;21:328. 

2. Thomas S.L., Newell M.L., Peckham C.S., et al. A review of 

hepatitis C virus (HCV) vertical transmission: risks of 

transmission to infants born to mothers with and without HCV 

viraemia or human immunodeficiency virus infection. Int J 

Epidemiol 1998;27:108. 

3. Yeung L.T., King S.M., Roberts E.A. Mother-to-infant transmission 

of hepatitis C virus. Hepatology 2001;34:223. 

4. Terrault N. Epidemiological evidence for perinatal transmission 

of hepatitis C virus. Viral Hepatitis Reviews 1998;4:245. 

5. Lin H.H., Kao J.H., Hsu H.Y., et al. Possible role of high-titer 

maternal viremia in perinatal transmission of hepatitis C virus. 

J Infect Dis 1994;169:638. 

6. Kumar R.M., Shahul S. Role of breast-feeding in transmission of 

hepatitis C virus to infants of HCV-infected mothers. J Hepatol 

1998;29:191. 

7. Azzari C., Resti M., Moriondo M., et al. Vertical transmission of 

HCV is related to maternal peripheral blood mononuclear cell 

infection. Blood 2000;96:2045. 

8. Tovo P.A., Pembrey L.J., Newell M.L. Persistence Rate and 

Progression of Vertically Acquired Hepatitis C Infection. J Infect 

Dis 2000;181:419. 

9. Vogt M., Lang T., Frosner G., et al. Prevalence and clinical outcome 

of hepatitis C infection in children who underwent cardiac surgery 

before the implementation of blood-donor screening. N Engl J 

Med 1999;341:866. 

10. Three broad modalities in the natural history of vertically acquired 

hepatitis C virus infection. Clin Infect Dis 2005;41:45. 

www.bjid.com.br


Hepatitis C: Virological Aspects and Practical Implications 


Laboratory of Hepatitis, LIM 47 DMIP-HC-FMUSP; São Paulo, SP, Brazil 

The hepatitis C virus (HCV) is a member of the Hepacivirus 

genus of the family Flaviviridae. 

Other important pathogens for humans, such as the 

dengue virus and the yellow fever virus, belong to this family, 

as do infectious agents in animals, such as the bovine viral 

diarrhea virus and the classical swine flu virus. 

The shape of HCV is spherical (50 nm in diameter), and it 

has an enveloped nucleocapsid and a single-stranded RNA 

genome of positive polarity. The HCV genome, with 

approximately 10,000 nucleotides, consists of a single long 

open reading frame (ORF) flanked by two noncoding regions 

(NCRs) at the initial 5’ end, at which the internal ribosome 

entry segment (IRES) is located, and at the 3’ end. Its 

translation yields a large polyprotein (with nearly 3000 amino 

acids) that is processed by viral and host cell proteases into 

structural proteins, including the core, envelope 1 (E1), E2, 

and p7 proteins, as well as the nonstructural proteins NS2, 

NS3, NS4, and NS5. Recently, an alternate reading frame that 

codifies an F protein with more than 160 amino acids has been 

identified. However, its expression in natural HCV infection 

has not been confirmed. 

Structural proteins are cleaved by enzymes of the 

parasitized cell. Envelope proteins are extensively glycosylated 

and are involved in the binding with receptors as well as in 

the entrance and fusion of the virus. The function of p7 protein 

remains unknown. Nonstructural proteins, initially NS2 and 

subsequently NS3, undergo self-cleavage and position 

themselves in transmembrane domains across the host cell 

membrane and into the cytosol or lumen (Figure 1). 

Unlike that of the hepatitis B virus (HBV), the HCV genome 

does not invade the infected cell nucleus. After the binding 

through receptors (CD81, a tetraspanin, and the low density 

lipoprotein receptor), the HCV genome acts directly as an 

mRNA in the cytoplasm, where the translation is initiated 

through the IRES in the 5’ NCR. The protein produced is 

subsequently processed by the cell enzymes and by the 

enzymes within the virus itself, yielding structural and 

nonstructural proteins. After synthesis and maturation, these 

nonstructural proteins and the RNA form replication complexes 

that combine with the membrane and catalyze the translation 

of intermediate negative strands of RNA, from which positivestrand 

progeny are generated. The genomic RNA and capsid 

proteins unite, forming the nucleocapsid, which is transported 

in cytoplasmic vesicles. While passing through the Golgi 

complex, these vesicles assemble with the other particles and 

undergo exocytosis and cell release (Figure 2). 

The study of the HCV genome, even in samples obtained 

from a single individual, reveals great heterogeneity among 

the HCV genotypes. Genotypes in which multiple mutants 




coexist have been designated quasispecies. The multiple 

mutations represent a rapid and very efficient mechanism for 

the virus to evade the immune response and persist in the 

host. The selection process and the process of adaptation 

to the host have led to the evolution to different HCV 

genotypes. The classification system most commonly used 

is that proposed by Simmonds et al. and is based on the 

similarity of the sequence of nucleotides using the following 

criteria: similarity lower than 72% characterizes a new 

genotype; similarity between 75 and 86% characterizes a 

new subgenotype. There are 6 genotypes, which are 

numbered from 1 to 6, with subgenotypes 1a, 1b, 1c, 2a, 2b, 

2c, 3a, 3b, 4a, 5a, and 6a. Although the criterion is based on 

molecular biology, this classification has practical, 

pathogenetic, epidemiological, and treatment-related 

implications. Therefore, subgenotype 1a is more prevalent 

in the USA, 1b in Japan, 3a in Scotland, and 4a in Egypt/ 

Zaire. In Brazil, genotype 1 is found in approximately 60% of 

the patients, followed by genotype 3, which is found in 20 to 

30%, and genotype 2, which is found in a lower percentage. 

Subgenotype 1b can cause severe forms of the infection 

and, similar to genotype 4, does not respond as well to 

treatment with IFN-α. Therefore, genotypes 1 and 4 should 

be treated for 48 weeks. 

The important advances in the knowledge of viral hepatitis 

B and C are a consequence of some facts that will be discussed 

herein. 

The Use of Chimpanzees as a Model for the Study of Viral 

Hepatitis 

Although chimpanzees are not natural hosts for these 

viruses, they reproduce the disease, thus allowing important 

discoveries: 

• Epidemiological studies: knowledge of these diseases 

as communicable; 

• Infectivity and titers of pools of HCV and HBV, 

obtained from the infected animals; 

• Infectivity of the molecular clones of HCV and 

importance of genetic elements specific to HCV; 

• Neutralization capacity of antibodies specific for HBV 

and HCV; 

• Protective immunity, tested through re-exposure to the 

viruses; 

• Mutants that escape to humoral and cellular immunity 

could be recognized. 

However, the use of nonhuman primates has advantages 

and disadvantages. 

Advantages 

The only animal susceptible to the acute and chronic forms 

of the disease; non-selected population; and sequential 

biopsies. 

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BJID 2007; 11 Supplement 1 (October) Virological Aspects of Hepatitis C 

13 

Figure 1. Organization of the HCV genome, polyprotein 

processing, and protein topology [1]. 

Figure 2. HCV cycle in the host cell [1]. 

Figure 3. Systems used in the HCV in vitro study [1]. 

Disadvantages 

Ethical considerations regarding the use of primates; cost 

and availability; rarity of vertical transmission; more benign 

disease presentation; and weaker, more limited immune 

response 

Use of Replicons 

In HCV, subgenomic RNA replicons are those in which the 

structural region has been replaced by the neomycin 

phosphotransferase gene, and the translation of the 

nonstructural proteins is regulated by the IRES of the 

encephalomyocarditis virus. Through this experimental 

approach, it became possible for the first time to effectively 

and efficiently replicate HCV in vitro in cultured Huh-7 human 

hepatoma cells. Interestingly, some simple amino acid 

substitutions can increase the replication efficiency by up to 

10,000 times in all of the nonstructural proteins. The replicon 

system allowed the clarification of important aspects of the 

virus life cycle, as well as simplifying the evaluation of new 

antiviral strategies. However, some aspects of the virus life 

cycle cannot be studied using this system. 

Efficient Cell Culture Systems for HCV 

A 32-year-old male patient of Asian origin presented a 

profile consistent with fulminant hepatitis. Using reverse 

transcriptase polymerase chain reaction, HCV RNA was 

detected in the serum during the acute phase and not during 

the remission phase. 

Using these samples, the complete HCV genome was 

recovered and cloned. This strain, designated JFH1, has 9678 

bp in the genome, with a single long ORF (nt 341-9439), and 

encodes 3033 amino acids The transfection of this sample 

into HUH-7.5.1 cultured cells allowed three independent 

groups of researchers to obtain HCV infecting particles, for 

tissue culture as well as for chimpanzee. These studies [2-4] 

were published, between June and July of 2005, in the following 

journals: Proceedings of the National Academy of Sciences, 

Nature Medicine, and Science. 

The infectious virions of HCV obtained in this way have 

been used to infect laboratory animals and naïve cells. Such 

infection can be monitored by the detection of the expression 

of the NS5A, through analysis of reporter genes, or by direct 

measurement of viral RNA (Figure 3). 

In conclusion, more recent findings regarding the 

virological aspects of HCV have greatly increased the 

possibility of thoroughly studying this agent and especially 

its relationship with the human host. Based on this approach, 

it will be possible to better understand how to combat the 

virus in chronically infected patients, thus preventing the 

progression of the disease and its consequences. 

References 

1. Tellinghuissen T.L., et al. Studying Hepatitis C virus: making the 

best of a bad virus. Journal of Virology 2007;81(17):8853-67. 

2. Barthenschlager B., et al. Efficient hepatitis C virus cell culture: 

what a difference the host cell makes. PNAS 2005;102(28):9739- 

40. 

3. Wakita T., et al. Production of infectious hepatitis C virus in 

tissue culture from a cloned viral genome. Nature medicine 

2005;11(7):791-6. 

4. Lindenbach B.D., et al. Complete replication of hepatitis C virus 

in cell culture. Science 2005;309:623-6. 

5. Kato T., et al. Sequence analysis of Hepatitis C virus isolated from 

a fulminant hepatitis patient. J Med Virol 2001;64:334-9. 

www.bjid.com.br


Pathogenesis of Hepatitis C – HCV Consensus 2007 

Ana Tereza R. Viso 


The chronic hepatitis C virus (HCV) infects approximately 

130 million people worldwide [1]. It is estimated that 

approximately 15% of HCV-infected individuals eliminate the 

virus spontaneously, that 25% develop a mild form of the 

disease, and that 60% develop the chronic progressive form 

[2]. The elimination or persistence of HCV infection depends 

on the balance between the effectiveness, specificity and 

rapidity of the innate and adaptive immune responses, as well 

as on the HCV replication rate [3]. Persistence of HCV can 

also be caused by infection at privileged (extrahepatic) sites, 

viral inhibition of antigen presentation, selective immune 

suppression, negative regulation of HCV gene expression, 

viral mutations, immune exhaustion of T cells and the 

incomplete differentiation of memory T cells [4,5]. 

Fibrosis is the principal complication of chronic hepatitis 

C, and it is estimated that 20% of patients develop cirrhosis 

over a period of 10, 20 or 30 years [2,6]. The progression of 

fibrosis increases morbidity and mortality in chronic hepatitis 

C [7], since it can lead to death due to complications caused 

by cirrhosis or hepatocarcinoma [2]. 

Various studies have associated the progression of fibrosis 

in hepatitis C with diverse factors such as: the kinetics and 

pathogenicity of HCV; host-HCV interaction; intrinsic host 

factors such as demographic profile, body mass index and 

diabetes mellitus; host exposure to external factors; and the 

form of HCV acquisition. 

Life Cycle and Pathogenicity of HCV 

Belonging to the Flaviviridae family, HCV is a small 

enveloped virus [8]. Its genome consists of one RNA molecule 

that is composed of two terminal regions, 5’- and 3’- 

untranslated regions, and between these there is a single open 

reading frame that encodes a polyprotein with approximately 

3000 amino acids. This polyprotein cleaves at the N-terminal 

side of three structural proteins, the nucleocapsid (core), 

envelope 1 (E1) and envelope 2 (E2), all of which are involved 

in the architectural organization of HCV. At the carboxylterminal 

side, the polyprotein cleaves to six nonstructural 

proteins, NS2, NS3, NS4 (NS4A and NS4B), NS5 (NS5A and 

NS5B) and NS6, which are responsible for the life cycle of the 

virus [9]. 

After entering a susceptible host, HCV invades, infects 

and replicates within the blood stream, repeating the process 

in various tissues, as well as in peripheral B and T lymphocytes, 

as it proceeds to the liver by tropism, passing through various 

tissues such as those of the pancreas, thyroid, adrenal glands, 




spleen and bone marrow [10-12]. Since HCV can also directly 

infect the lymphatic tissue, its stimulation can lead to the 

development of B-cell lymphomas [13]. It is known that the 

liver is the principal site of HCV replication, and various studies 

have shown that this virus infects approximately 10% of 

hepatic cells [5]. Infection with HCV at extrahepatic sites can 

promote the appearance of HCV variants [14,15], thereby 

decreasing the chance that the immune system will recognize 

the virus. 

To enter the host cell, HCV E2 and E1 proteins recognize 

and bond with the CD81 receptors present on the surface of 

hepatocytes and lymphocytes [16,17]. Circulating HCV 

particles are accompanied by low-density and very lowdensity 

lipoproteins, which prompts discussion in the 

literature regarding the possibility that low-density lipoprotein 

is also a viral receptor [15]. After the interaction of the virus 

envelope with the host cell membrane, HCV enters the cell 

through endocytosis. In the cytoplasm, the messenger RNA 

then undergoes translation, and polyproteins are processed; 

the HCV RNA then replicates, after which the new viral ‘RNA’s 

are packaged and transported to the surface of the host cell 

so that they can disseminate and complete a new cycle [18]. 

The HCV replication rate is high, approximately 1 × 10 12 virions 

per day; this, together with its high mutation rate, estimated at 

10 -3 nucleotide substitutions per year, leads to great 

heterogeneity in its presentations, which are known as 

quasispecies [8]. The selection of and host adaptation to HCV 

quasispecies have given rise to distinct genotypes [19] whose 

classification is based on the similarity of the sequence of 

nucleotides: similarity below 69% characterizes a new viral type; 

and similarity between 75 and 80% characterizes a subtype [20]. 

The progression of fibrosis in chronic hepatitis C has been 

associated with the diversity of HCV quasispecies [21]. The 

production of new viruses is counterbalanced by the 

destruction of infected cells through tissue apoptosis or 

degradation in peripheral blood, since the half-life of the virus 

in peripheral blood is approximately 2.7 hours [7]. Experimental 

studies have shown that NS3 and NS5 proteins induce 

apoptosis in infected hepatocytes [22]. 

In individuals infected with HCV, the persistence of the 

virus can be attributed the large inoculum and the high rate of 

viral replication, which allow the virus to evade the host 

immune response [4,23]. There is controversy over whether 

the sequence of nucleotides is directly associated with more 

intense hepatic lesions [6,24,25]. 

There is some evidence of direct cytopathic lesion caused 

by HCV, including HCV-induced histological lesions with scant 

inflammatory infiltrate [26-28], fulminant hepatitis C after 

chemotherapy in liver transplants [29] and HCV-related acute 

cholestatic syndrome after renal transplantation [30]. 

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BJID 2007; 11 Supplement 1 (October) Pathogenesis of Hepatitis C 

15 

Studies suggest that specific genotypes, such as genotype 

1, can be more cytopathic [31] or can induce more rapid 

progression of the disease than do other genotypes [32]. 

Genotype 1 has been shown to be the genotype most strongly 

associated with chronic HCV infection [33]. The risk of 

cirrhosis and hepatocarcinoma has been shown to be greater 

in individuals presenting genotype 1b than in those presenting 

genotypes 2 and 3 [34]. However, other authors have stated 

that HCV genotype and viral load do not influence the 

progression of the disease [2,6]. 

It is known that steatosis is a cofactor that influences the 

progression of fibrosis in chronic hepatitis C [35]. Various 

studies have directly associated steatosis with HCV genotype 

3 [36,37]. Therefore, genotype 3 is considered cytopathic 

[38,39]. Kumar et al. identified the reduction of steatosis as 

the only variable predictive of the virological response to the 

treatment of chronic hepatitis C in individuals infected with 

HCV genotype 3 [38]. 

Innate Immune Response to HCV 

The innate immune response to HCV is responsible for 

the activation of cytokines such as interferon (IFN) which 

activate antiviral proteins that inhibit the replication of the 

virus while the adaptive immune response to HCV neutralizes 

viral particles and destroys infected cells [40]. Studies of HCVinfected 

chimpanzees that eliminate the virus without the 

specific T-cell immune response suggest that, in some cases, 

the innate immune response might be sufficient to destroy 

the infection [41]. 

The RNA of HCV is recognized by the innate immune 

response through the Toll-like receptor which responds with 

the production of IFN-1α and IFN-1β [5,42]. IFN-1 stimulates 

the nitric oxide synthase enzyme that is expressed in 

hepatocytes and macrophages as the isoform inducible nitric 

oxide synthase [43]. Patients with HCV who are treated with 

IFN present higher levels of inducible nitric oxide synthase, 

which have been correlated with lower serum levels of alanine 

aminotransferase [44]. 

In addition, IFN-1 induces the production of various 

proteins such as protein kinase (PKR), 2’,5’-oligoadenylate 

synthetase (OAS) and the Mx protein [44]. These proteins are 

responsible for the expression of the genes that inhibit the 

replication of this virus within hepatocytes in an attempt to destroy 

the infection [7,40]. When IFN bonds with the IFN receptor on 

the surface of the infected cell, it activates the Janus kinase, 

which induces phosphorylation of cytoplasmic proteins known 

as signal transducers and activators of transcription (STATs), 

specifically STAT 1 and STAT 2. The STATs form a dimer that 

directs itself to the cell nucleus where it forms a complex with 

the p48 protein, which is a stimulation factor for IFN-stimulated 

gene factor 3. That complex bonds with the IFN-stimulated 

response element ISRE, which is an RNA-polymerase promoter 

complex, and there is a stimulus of the genes responsible for the 

production of antiviral response proteins and of major 

histocompatibility complex (MHC) proteins [44]. 

Some individuals present genetic alterations in the STATs 

or in the Janus kinase that would impede the formation of 

antiviral proteins [45]. 

Various viral proteins have shown a capacity to escape 

the effect of IFN, as evidenced by the high rate of resistance 

to treatment with IFN-α seen among individuals with hepatitis 

C [44,45]. 

There are various characteristics of HCV that allow it to 

evade the innate immune response: 

• The viral replication complex appears to be composed 

of a membrane that is highly resistant to in vitro 

proteases and nucleases, which protects HCV from 

detection by the innate immune response [40]. 

• The HCV core protein interacts with diverse cell factors, 

including the tumor necrosis factor (TNF) receptor, 

which decreases the cytolytic activity of T cells [46] 

• Core proteins impede the antiviral activity of IFN, as 

do NS3/4A and NS5A proteins [40]. 

• The NS3/4A proteins can impede the recognition of 

the Toll-like receptor [5]. 

• The NS5A and E2 proteins can bind to PKR, thereby 

blocking its activity [5]. 

• Multiple mutations in the IFN-sensitivity-determining 

region (ISDR) modify the NS5A region, which inhibits 

the phosphorylation of PKR, thereby impeding its 

antiviral activity [45]. 

• The E2 region of HCV contains a sequence of eight 

amino acids identical to those of PKR, and this 

sequence is more common in genotype 1 than in 

genotypes 2 and 3, which probably accounts for the 

fact that individuals infected with genotype 1 present 

greater resistance to treatment with IFN [44]. 

• Mutations in the ISDR sequence of NS5A suppress 

the antiviral action of OAS. 

• Levels of this protein are lower in nonresponders to 

treatment with IFN [44]. 

The liver cell populations that participate in the innate 

immune response are the natural killer (NK) cells, NK T cells, 

Kupffer cells and dendritic cells [5]. The NK cells respond 

minutes or hours after HCV infection by polarizing of the 

granules in the direction of the infected cells as well as by 

releasing perforins that fragment the nuclei of infected cells 

and induce apoptosis [47]. They inhibit viral replication with 

the production of IFN gamma (IFN-γ), which recruits intrahepatic 

inflammatory cells and stimulates the T-helper 1 (Th1) response 

[48], thereby inducing the necrosis or apoptosis of the HCVinfected 

cell [49]. Studies suggest that HCV inhibits receptor 

genes in the activation of NK cells, decreasing the activity of 

these cells by reducing their number and function in chronically 

infected individuals [40]. The NK cells also have the capacity 

to increase the functions of dendritic cells in the presence of 

hepatic cells, although that capacity is impaired in NK cells 

derived from patients with chronic hepatitis C, in which the 

production of interleukin (IL)-10 and transforming growth factor 

beta (TGF-β) can inhibit the activity of dendritic cells [50]. 

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16 Pathogenesis of Hepatitis C 


After HCV enters the host cell, the binding of the E2 

glycoprotein with the CD81 receptor of NK cells inhibits the 

function of the NK cells [7,51], which alters the immune 

response to HCV infection. The E2 glycoprotein also inhibits 

cytotoxicity and the production of IFNγ by NK cells [40]. 

Various studies have suggested that the failure of dendritic 

cells to recognize HCV contributes to the persistence of 

hepatitis C [50,52-54]. 

Humoral Immune Response to HCV 

After HCV infection, there is expression of the 

hypervariable NS1/E2 region on the surface of the virus, which 

stimulates B cells to produce high antibody titers of antibodies 

with the objective of destroying the permanence of the virus 

[44]. The appearance of anti-HCV antibodies is significantly 

delayed, and these antibodies can first be detected from 7 to 

31 weeks after infection [7]. The host applies selective pressure 

on HCV, and this stimulates high nucleotide variation, as well 

as the appearance of mutations in the envelope proteins, from 

which the virus selects genomic variants in an attempt to 

eliminate the site of immune response recognition [55]. The 

great quantity of HCV quasispecies formed allows the virus 

to evade the humoral immune response, and the effect of HCVneutralizing 

antibodies appears to be insufficient to control 

the infection [7], which therefore persists [15]. 

Similar to what occurs in auto-immune type 2 hepatitis, 

HCV can mimic the immune system, leading to viral escape or 

postinfection immunity [4,56]. Anti-HCV antibodies have been 

implicated in tissue damage due to the formation of 

immunocomplexes such as antinuclear antibodies [57], autoantibodies 

that act against cytochrome P450 and antibodies 

that act against the liver and kidney [4]. The deposition of 

immunocomplexes has been related to the appearance of 

extrahepatic manifestations, such as arthritis, 

cryoglobulinemia [58], vasculitis, glomerulonephritis, Sicca 

syndrome and itchiness, all of which cause considerable 

morbidity [57]. 

There is evidence that HCV infection can be resolved by 

the cell response with specific CD4+ and CD8+ T cells when 

there is no formation of antibodies against this virus [59,60], 

showing that the humoral immune response is not always 

involved in the response to HCV infection. 

Cell Response to HCV 

Since there is a weak humoral immune response to HCV, it 

is believed that the reactivity of cytotoxic T-lymphocytes 

(CTLs) or CD8+ T cells is fundamental to viral elimination 

[61,62], and that impairment of this reactivity is one of the 

factors responsible for the chronicity of the infection 

[7,63,64]. The CD8+ T cells can eliminate HCV from the liver 

through two mechanisms: inducement of apoptosis in 

infected hepatocytes; and suppression of replication by the 

production of IFN-γ [22,65]. The CTL response is less 

vigorous in chronically infected patients than in those 

presenting acute infection [4]. This can be the result of 

immunologic tolerance or exhaustion of the CD8+ T cell 

response to the high viral load that persists in individuals 

chronically infected with HCV [4]. 

In addition to CD8+ T cells, CD4+ T cells seem to be 

involved in the viral damage mediated by the increased 

expression of MHC class II molecules. Some studies have 

attributed the vigorous and long-lasting response of CD4+ T 

cells to the elimination of HCV in the acute form the infection 

[4,66]. However, the loss of the specific CD4+ T cell reactivity 

to HCV has been associated with the persistence of the virus 

and the progression of liver damage [67,68]. 

In acute HCV infection, the peak in serum levels of 

transaminases corresponds with the cell response, which 

suggests that the hepatic lesion is immune-mediated [5,64]. It 

is known that, after activation, T cells initiate clonal 

proliferation by secreting cytokines and other substances that 

can affect hepatic function in a variety of ways [69]. 

Various cytokines act as mediators in the inflammation 

caused by chronic hepatitis C and have been related to 

hepatocyte death, i.e. cholestasis and fibrosis, and 

paradoxically play a role in regeneration following hepatic 

injury [69,70]. It is argued that the imbalance between the 

production of Th1 and Th2 cytokines is related to the 

progression of chronic hepatitis C. The expression of Th1 

cytokines such as IL-2 and TNF-α has been shown to be 

related to the more aggressive presentation of hepatic disease, 

whereas the expression of Th2 cytokines such as IL-10 has 

been shown to be related to the milder presentation [71]. 

The production of TNF-α is one of the earliest events in 

hepatic injury and is the ‘trigger’ for the production of other 

cytokines [72], as well as being implicated in the inducement 

of hepatocyte apoptosis in viral hepatitis [73]. 

The levels of cytokines such as IFN-γ, TNF-α, IL-6 and 

IL-8 are elevated in individuals with chronic hepatitis C [74- 

82], and some authors have shown that this increase is 

proportional to the extent of the damage, histologically 

[26,76,83,84]. 

There is evidence that IL-4 can modulate the immune 

response in HCV-infected individuals [75], principally through 

the activity of Th2 cells. 

It has been shown that IL-10 can suppress proliferation in 

the Th1 and Th2 responses, as well as inducing anergy [85]. 

There is evidence that IL-10 levels increase in chronic hepatitis 

C [75]. Some studies report reduced inflammatory activity [86], 

and others report that administration of IL-10 to such patients 

causes fibrosis [87]. 

Various studies have shown that TGF-β is increased in 

chronic hepatitis C and is involved in the progression of 

fibrosis, which has been challenged by other authors [88,89]. 

It has been suggested that TGF-β and IL-10 act as 

immunosuppressive agents in the liver [90]. In addition, both 

have been shown to inhibit the immune response and regulate 

the activity of dendritic cells [91], which can establish a 

balance between the Th1 and Th2 responses in chronic 

diseases [92]. 

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17 

Host Factors Associated with the Persistence and 

Progression of Hepatitis C 

In HCV infection, the genetic constitution and immune 

‘status’ of the host are important factors in the persistence 

and progression of the virus [23,93], since they influence 

antigen recognition and presentation, as well as the type of 

Th response [94]. 

Some MHC class II alleles, such as DR5, have been 

associated with a lower incidence of cirrhosis in individuals 

chronically infected with HCV [94]. Rehermann et al. [95] 

identified CTLs restricted by histocompatibility leukocyte 

antigen A2 in 97% of chronic hepatitis C patients, compared 

with 2% of anti-HCV-negative controls. It is speculated that 

the MHC class II molecule presentation of antigens is deficient 

in HCV-infected cells, since some viral proteins inhibit the 

presentation of the antigen through IFN-induced negative 

immunoregulation [44]. 

Some pro-inflammatory cytokines appear to be associated 

with the viral infection response as well as with the expression 

of specific haplotypes [94], such as IL-10 haplotypes, which 

can be predictors of spontaneous elimination of HCV [96]. 

However, there is disagreement in the literature, since other 

authors did not find evidence for polymorphism in the studied 

genes being considered as a relevant factor in the elimination 

of HCV or in the response to treatment [97-99]. 

The influence of demographic data such as age, gender 

[6,34] and ‘race’ [100,101] in the progression of hepatitis C 

can be due to genetic variations existent among those. Some 

studies report that HCV positivity increases with age [34,101], 

thereby leading to a greater chance of progression of the 

disease [6,34]. The male gender is more prevalent in most 

studies on hepatitis C [6,101] and, in addition, it was associated 

with the progression of the disease to cirrhosis [6,34]. Some 

studies suggest that Afro-Americans, due to a greater 

propensity to chronicity, resistance to treatment (higher 

percentage of genotype 1) and development of 

hepatocarcinoma, present a worse evolution of hepatitis C 

than do Caucasian-Americans [100,102]. Analyzing 99 chronic 

HCV-infected individuals and 31 individuals who had 

spontaneously eliminated HCV, Sugimoto et al. [103] found 

evidence that the CD4+ T-cell response was less vigorous in 

Afro-Americans than in Caucasian-Americans, with a 

predominance of the Th2 response and maintenance of the 

infection. The evolution of hepatitis C in different ethnicities 

could be due to genetic factors, such as the presence of HLA 

class II alleles, which could define the spontaneous elimination 

of HCV [104]. 

There are various extrinsic host factors that are related to 

the progression of chronic hepatitis C: alcohol abuse; smoking 

[6,34,105-109]; the endovenous acquisition of HCV; and 

coinfection with other viruses such as HIV, HBV and human 

T-cell lymphotropic virus [6,110,111]. 

The prevalence of HCV infection is higher among 

individuals who consume alcohol [112,113]. Studies suggest 

that alcohol increases the ability of HCV to enter and persist 

within the organism [112]. Other studies argue that alcohol 

intake affects some components of the immune response 

[112] and can alter the inflammatory response of cytokines, 

thereby increasing viremia, which can be an important 

cofactor in the development of hepatocarcinoma [114]. In 

addition, alcohol intake in HCV-infected individuals 

increases hepatic steatosis and induces apoptosis 

[107,112,115]. 

Smoking, in addition to increasing inflammatory activity 

and hepatic fibroses [109], can induce direct injury to the 

liver, as well as causing indirect damage (toxic effect), and 

can have immunological effects (production of IL-1, IL-6 and 

TNF-a, which cause liver damage). 

References 

1. Alter M.J. Epidemiology of hepatitis C virus infection. World J 

Gastroenterol 2007;13(17):2436-41. 

2. EASL International Consensus Conference on Hepatitis C: Paris 

26-28, February 1999. Consensus Statement. J Hepatology 

1999;30:956-61. 

3. Brown P.M.J., Neuman M.G. Immunopathogenesis of hepatitis C 

viral infection: Th1/Th2 responses and the role of cytokines. 

Clin Biochemistry 2001;34:167-71. 

4. Cerny A., Chisari F.V. Pathogenesis of chronic hepatitis C: 

Immunological features of hepatic injury and viral persistence. 

Hepatology 1999;30:595-601. 

5. Dustin L.B., Rice C.M. Flying under the radar: the immunobiology 

of hepatitis C. Annu Rev Immunol 2007;25:71-99. 

6. Poynard T., et al. Natural history of liver fibrosis progression in 

patients with chronic hepatitis C. The OBSVIRC, METAVIR, 

CLINIVIR, and DOSVIRC groups. Lancet 1997;394:825-32. 

7. Pawlotsky J.M. Pathophysiology of hepatitis C infection and 

related liver disease. Trends Microbiol 2004;12(2):96-102. 

8. Major M.E., et al. Hepatology 1997;25:1527-38. 

9. McGarvey M.J., et al. Structure and molecular virology. In: 

Zuckerman AJ, Toma HC, editors. Viral hepatitis. 2 nd ed. London: 

Churchill Livingstone; 1998. p.253-70. 

10. Koziel M.J., et al. Intrahepatic cytotoxic T Lymphocytes specific 

for hepatitis C virus in persons with chronic hepatitis. J Immunol 

1992;149(10):3339-44. 

11. Gowans E.J. Distribution of markers of hepatitis C virus infection 

throughout the body. Semm Liver Dis 2000;20:85-102. 

12. MacDonald A.J., et al. CD4 T helper type 1 and regulatory T cells 

induced against the same epitopes on the core protein in hepatitis 

C virus-infected persons. J Infect Dis 2002;185:720-7. 

13. Ferri C., et al. Hepatitis C vírus infection and B-cell lymphomas. 

Eur J Can 1994;30:1591-2. 

14. Maggi F., et al. Differences in hepatitis C virus quasispecies 

composition between liver, peripheral blood mononuclear cells 

and plasma. J Gen Virol 1997;78(Pt 7):1521-5. 

15. Giannini C., Bréchot C. Hepatitis C virus biology. Cell Death and 

Differentiation 2003;(10):S27-38. 

16. Pileri P., et al. Binding of hepatitis C virus to CD81. Science 

1998;282:938-41. 

17. Polyak S.J. Hepatitis C virus-cell interactions and their role in 

pathogenesis. Clin Liver Dis 2003; 7:67-88. 

18. Lindenbach B.D., Rice C.M. Unravelling hepatitis C virus 

replication from genome to function. Nature 

2005;436(18):933-8. 

19. Simmonds P., et al. Classification of hepatitis C virus into six major 

genotypes and a series of subtypes by phylogenetic analysis of 

the NS-5 region. J General Virology 1993;74:2391-9. 

20. Simmonds P., et al. Consensus Proposals for a unified system of 

nomenclature of hepatitis C virus genotypes. Hepatology 

2005;42(4):963-73. 

www.bjid.com.br

18 Pathogenesis of Hepatitis C 


21. Wang X.H., et al. Progression of fibrosis during chronic hepatitis 

C is associated with rapid virus evolution. J Virol 

2007;81(12):6513-22. 

22. Herzer K., et al. Hepatitis viruses: live and let die. Liver Int 

2007;27(3):293-301. 

23. Gremion C., Cerny A. Hepatitis C virus and the immune system: a 

concise review. Rev Med Virol 2005;15(4):235-68. 

24. Haruna Y., et al. Detection of hepatitis C virus RNA in liver tissues by 

an in situ hybridization technique. J Hepatol 1993;18(1):96-100. 

25. Brillanti S., et al. Persistent hepatitis C viraemia without liver 

disease. Lancet 1993;341(8843):464-5. 

26. Miller R.H., Purcell R.H. Hepatitis C virus shares amino acid 

sequence similarity with pestiviruses and flaviviruses as well as 

members of two plant virus supergroups. Proc Natl Acad Sci 

USA 1990;87:2057-61. 

27. Gonzalez-Peralta R.P., et al. Optimization for the detection of 

hepatitis C virus antigens in the liver. J Hepatol 1994;20:143-47. 

28. Barone A.A., et al. Response in patients with chronic HCV hepatitis 

to treatment with interferon-alpha. Braz J Infect Dis 

1999;3(3):118-28. 

29. Naoumov N.V. Hepatitis C virus-specific CD4+ T cells: do they 

help or damage? Gastroenterology 1999;117:1012-4. 

30. Delladetsima J.K., et al. Cholestatic syndrome with bile duct damage 

and loss in renal transplant recipients with HCV infection. Liver 

2001;21(2):81-8. 

31. Dusheiko G., et al. Hepatitis C virus genotypes: an investigation 

of typo-specific differences in geographic origin and disease. 

Hepatology 1994;19:13-8. 

32. Kobayashi M., et al. The natural course of chronic hepatitis C: a 

comparison between patients with genotypes 1 and 2 hepatitis 

C viruses. Hepatology 1996;23(4):695-9. 

33. Amoroso P., et al. Correlation between virus genotype and chronicity 

rate in acute hepatitis C. J Hepatology 1998;28:936-44. 

34. Bellentani S., et al. Clinical course and risk factors of hepatitis C 

virus related liver disease in the general population: report from 

the Dionysos study. Gut 1999;44(6):874-80. 

35. Cholet et al. Factors associated with liver steatosis and fibrosis in 

chronic hepatitis C patients. Gastroenterol Clin Biol 

2004;28:272-8. 

36. Rubbia-Brandt L., et al. Steatosis affects chronic hepatitis C 

progression in a genotype specific way. Gut 2004;53(3):406-12. 

37. Sharma P., et al. Hepatic steatosis in hepatitis C virus genotype 3 

infection: does it correlate with body mass index, fibrosis, and 

HCV risk factors? Dig Dis Sci 2004;49(1):25-9. 

38. Kumar D., et al. Hepatitis C virus genotype 3 is cytopathic to 

hepatocytes: reversal of hepatic steatosis after sustained 

therapeutic response. Hepatology 2002;36:1466-72. 

39. Negro F. Mechanisms and significance of liver steatosis in hepatitis 

C virus infection. World J Gastroenterol 2006;12(42):6756-65. 

40. Thimme R., et al. A target on the move: innate and adaptive 

immune escape strategies of hepatitis C virus. Antiviral Res 

2006;69(3):129-41. 

41. Lloyd A.R., et al. Host and viral factors in the immunopathogenesis 

of primary hepatitis C virus infection. Immunol Cell Biol 

2007;85(1):24-32. 

42. Mizukoshi E., Rehermann B. Immune responses and immunity in 

hepatitis C virus infection. J Gastroenterol 2001;36(12):799-808. 

43. Samuel C.E. Antiviral actions of interferons. Clin Microbil Rev 

2001;14(4):778-809. 

44. Taylor D.R., et al. Hepatitis C virus and interferon resistance. 

Microbes and Infection 2000;2:1743-56. 

45. Tan S.-L., Katze M.G. How hepatitis C virus counteracts the 

interferon response: the jury is still out on NS5A. Virology 

2001;284:1-12. 

46. Chen C.M., et al. Direct interaction of hepatitis C virus core 

protein with the cellular lymphotoxin-beta receptor modulates 

the signal pathway of the lymphotoxin-beta receptor. J Virol 

1997;71(12):9417-26. 

47. Rehermann B., Chisari F.V. Cell mediated immune response to 

the hepatitis C virus. Curr Top Microbiol Immunol 

2000;242:299-325. 

48. Janeway C.A., et al. Imunobiologia: o sistema imune na saúde e na 

doença. Tradução Ana Cristina Arámburu da Silva, Cristina 

Bonorino, Denise Cantarelli Machado, Gaby Renard, Isabel 

Cristina Ribas Werlang, Moisés Evandro Bauer. 6ª ed. Porto 

Alegre: Artmed, 2007. Cap. 1, p.37-101: Imunidade Inata. 

49. Winnock M., et al. Liver-associated lymphocytes: role in tumor 

defense. Semin Liver Dis 1993;13:81-92. 

50. Jinushi M., et al. Negative regulation of NK cell activities by 

inhibitory receptor CD94/NKG2A leads to altered NK cell-induced 

modulation of dendritic cell functions in chronic hepatitis C virus 

infection. J Immunol 2004;15;173(10):6072-81. 

51. Crotta S., et al. Inhibition of natural killer cells through engagement 

of CD81 by the major hepatitis C virus envelope protein. J Exp 

Med 2002;195(1):35-41. 

52. Longman R.S., et al. Presence of functional dendritic cells in 

patients chronically infected with hepatitis C virus. Blood 

2004;103(3):1026-9. 

53. Bain C., et al. Impaired Assostimulatory function of dendritic cells 

in chronic hepatitis C infection. Gastroenterlol 

2001;120(2):512-24. 

54. Sarobe P., et al. Abnormal priming of CD4+ T cells by dendritic 

cells expressing hepatitis C virus core and E1 proteins. J Virol 

2002;76(10):5062-70. 

55. Botarelli P., et al. T-Lymphocyte response to hepatitis C virus in 

different clinical courses of infection. Gastroenterology 

1993;104:580-7. 

56. Cerny A., Chisari F.V. Hepatitis C and Autoimmune Hepatitis. 

Hepatology 2000;31(3):811-2. 

57. Cacoub P., et al (Multivirc Group). Extrahepatic manifestations 

of chronic hepatitis C. Arthritis Rheum 1999;42:2204-12. 

58. Agnello V. Mixed cryoglobulinemia and hepatitis C virus. Hosp 

Pract 1995;30(3):35-42. 

59. Takaki A., et al. Cellular immune responses persist and humoral 

responses decrease two decades after recovery from a singlesource 

outbreak of hepatitis C. Nat Med 2000; 6(5):578-82. 

60. Lechner et al. Analysis of successful immune responses in persons 

infected with hepatitis C virus. J Exp Med 2000;191(9):1499- 

1512. 

61. Missale G., et al. Different clinical behaviors of acute hepatitis C 

virus infection associated with different vigor of the anti-viral 

cell-mediated immune response. J Clin Invest 1996;98:706-14. 

62. Gruner N.H., et al. Association of hepatitis C virus-specific CD8+ 

T cells with viral clearance in acute hepatitis C. J Infect Dis 

2000;181(5):1528-36. 

63. Chisari F.V. Cytotoxic T cells and viral hepatitis. J Clin Invest 

1997;100(12):S19-S24. 

64. Thimme R., et al. Determinants of viral clearance and persistence 

during acute hepatitis C virus infection. J Exp Med 

2001;194(10):1395-406. 

65. Kanto T., Hayashi N. Immunopathogenesis of hepatitis C virus 

infection: multifaceted strategies subverting innate and adaptive 

immunity. Intern Med 2006;45(4):183-91. 

66. Wertheimer A.M., et al. Novel CD4+ and CD8+ T-cell determinants 

within the NS3 protein in subjects with spontaneously resolved 

HCV infection. Hepatology 2003;37(3):577-89. 

67. Carucci P., et al. Hepatitis C virus-specific T helper cell responses 

in recurrent hepatitis C after liver transplantation. J Hepatol 

1997;26(suppl):145. 

68. Gerlach J.T., et al. Recurrence of hepatitis C virus after loss of 

virus-specific CD4+ T-cell response in acute hepatitis C. 

Gastroenterology 1999;117:933-41. 

69. Kerr J.F.R., et al. The nature of piecemeal necrosis in chronic 

active hepatitis. Lancet 1979;20:827-8. 

70. Marcellin P., et al. Fibrosis and disease progression in hepatitis C. 

Hepatology 2002;36:S47-56. 

www.bjid.com.br


19 

71. Napoli J., et al. Progressive liver injury in chronic hepatitis 

C infection correlates with increased intrahepatic 

expression of Th1-associated cytokines. Hepatology 

1996;24:759-65. 

72. Tilg H., et al. How to modulate inflammatory cytokines in liver 

diseases. Liver Int 2006;26(9):1029-39. 

73. Ding W.X., Yin X.M. Dissection of the multiple mechanisms of 

TNF-alpha-induced apoptosis in liver injury. J Cell Mol Med 

2004;8(4):445-54. 

74. Tilg H., et al. Serun levels of cytokines in chronic liver diseases. 


75. Cacciarelli T.V., et al. Immunoregulatory cytokines in chronic 

hepatitis C virus infection: pre- and posttreatment with 

interferon alfa. Hepatology 1996;24:6-9. 

76. Malaguarnera M., et al. Serum interleukin 6 concentrations in 

chronic hepatitis C patients before and after interferon-alpha 

treatment. Int J Clin Pharmacol Ther 1997;35(9):385-8. 

77. Oyanagi Y., et al. Enhanced expression of interleukin-6 in chronic 

hepatitis C. Liver 1999;19(6):464-72. 

78. Biró L., et al. Changes in the acute phase complement component 

and IL-6 levels inpatients with chronic hepatitis C receiving 

interferon alfa-2b. Immunol Lett 2000;72:69-74. 

79. Polyak S.J., et al. Elevated levels of interleukin-8 in serum are 

associated with hepatitis C virus infection and resistance to 

interferon therapy. J Virol 2001;75(13):6209-11. 

80. Lapinski T.W. The levels of IL-1 beta, IL-4 and IL-6 in the serum 

and the liver tissue of chronic HCV-infected patients. Arch 

Immunol Ther Exp. (Warsz) 2001;49(4):311-6. 

81. Kasprzak et al. Expression of cytokines (TNF-α, IL-1 α, and IL- 

2) in chronic hepatitis C: comparative hybridocytochemical 

and immunocytochemical study in children and adult patients. J 

Histochemistry and Cytochemistry 2004;52(1):29-38. 

82. Kamal S.M., et al. Kinetics of Intrahepatic hepatitis C virus (HCV)- 

specific CD4+ T cell responser in HCV and Schistosoma mansoni 

coinfection: relation to progression of liver fibrosis. J Infect 

Dis 2004;189:1140-50. 

83. Shimoda K., et al. Interleukin-8 and hIRH (SDF1-alpha/PBSF) 

mRNA expression and histological activity index in patients 

with chronic hepatitis C. Hepatology 1998;28(1):108-15. 

84. Neuman M.G., et al. Kinetics of serum cytokines reflect changes 

in the severity of chronic hepatitis C presenting minimal fibrosis. 

J Viral Hepat 2002;9:134-40. 

85. Taylor A., et al. Mechanisms of immune suppression by interleukin- 

10 and transforming growth factor-beta: the role of T regulatory 

cells. Immunology 2006;117(4):433-42. 

86. Nelson D.R., et al. Long-term interleukin 10 therapy in chronic 

hepatitis C patients has a proviral and anti-inflammatory effect. 

Hepatology 2003;38(4):859-68. 

87. Nelson D.R., et al. Interleukin 10 treatment reduces fibrosis in 

patients with chronic hepatitis C: a pilot trial of inferferon 

nonresponders. Gastroenterology 2000;118:655-60. 

88. Roulot D., et al. Quantitative analysis of transforming 

growth factor beta 1 messenger RNAin the liver of 

patients with chronic hepatitis C. Absence of correlation 

between high levels and severity of disease. Hepatology 

1995;21:298-304. 

89. Nelson D.R., et al. Transforming growth factor-beta 1 in chronic 

hepatitis C. J Viral Hepat 1997;4(1):29-35. 

90. Knolle P.A., Gerken G. Local control of the immune response in 

the liver. Immunol Rev 2000;174:21-34. 

91. Racanelli V., Rehermann B. The liver as an immunological organ. 

Hepatology 2006;43:S54-62. 

92. Yazdanbakhsh M., et al. Allergy, parasites, and the hygiene 

hypothesis. Science 2002;296(5567):490-4. 

93. Chitturi S., George J. Predictors of liver-related complications in 

patients with chronic hepatitis C. Ann Med 2000;32:588-91. 

94. Thursz M.R., et al. Host factors in chronic viral hepatitis. Semin 

Liver Dis 1997;17:345-50. 

95. Rehermann B., et al. Quantitative analysis of the peripheral blood 

cytotoxic T lymphocyte response in patients with chronic 

hepatitis C virus infection. J Clin Invest 1996;98:1432-40. 

96. Mangia A., et al. IL-10 haplotypes as possible predictors of 

spontaneous clearance of HCV infection. Cytokine 

2004;25(3):103-9. 

97. Bozkaya H., et al. Circulating IL-2 and IL-10 in chronic active 

hepatitis C with respect to the response to IFN treatment. 

Infection 2000;28:309-13. 

98. Constantini P.K., et al. Interleukin-1, interleukin-10 and tumour 

necrosis factor-alpha gene polymorphisms in hepatitis C virus 

infection: an investigation of the relationships with spontaneous 

viral clearance and response to alpha-interferon therapy. Liver 

2002;22(5):404-12. 

99. Minton E.J., et al; Trent Hepatitis C Study Group. Clearance of 

hepatitis C virus is not associated with single nucleotide 

polymorphisms in the IL-1, -6, or -10 genes. Hum Immunol 

2005;66(2):127-32. 

100.Reddy K.R., et al. Racial differences in responses to therapy with 

interferon in chronic hepatitis C. Consensus Interferon Study 

Group. Hepatology 1999;30:787-93. 

101.Lepe R., et al. Ethnic differences in the presentation of chronic 

hepatitis C. J Viral Hepat 2006;13(2):116-20. 

102.El-Serag H.B. Epidemiology of hepatocellular carcinoma. Clin 

Liver Dis 2001;5:87-107. 

103.Sugimoto K., et al. Influence of ethnicity in the outcome of 

hepatitis C virus infection and cellular immune response. 

Hepatology 2003;37:590-9. 

104.Azocar J., et al. MHC class II genes in HCV viral clearance of 

hepatitis C infected Hispanic patients. Hum Immunol 

2003;64(1):99-102. 

105.Pessione F., et al. Cigarette smoking and hepatic lesions in patients 

with chronic hepatitis C. Hepatology 2001;34:121-5. 

106.Campollo R O. Hepatitis C virus infection and alcohol. Rev 

Gastroenterol Mex 2002;67 Suppl 2:S80-3. 

107.Vento S., Cainelli F. Does hepatitis C virus cause severe liver 

disease only in people who drink alcohol? Lancet Infectious Dis 

2002;2(5):303-9. 

108.Monto A., et al. Risks of a range of alcohol intake on hepatitis c- 

related fibrosis. Hepatology 2004;39:826-34. 

109.El-Zayadi A.R. Heavy smoking and liver. World J Gastroenterol 

2006;12(38):6098-101. 

110.Kishihara Y., et al. Human T lymphotropic virus type I infection 

influences hepatitis C virus clearance. J Infect Dis 

2001;184:1114-9. 

111.Einav S., Koziel M.J. Immunopathogenesis of hepatitis C virus in the 

immunosuppressed host. Transpl Infect Dis 2002;4(2):85-92. 

112.Campollo R.O. Hepatitis C virus infection and alcohol. Rev 

Gastroenterol Mex 2002;67(Suppl 2):S80-3. 

113.Sanchez Avila J.F. Hepatitis C and addictions. Rev Gastroenterol 

Mex 2002;67(Suppl2):S84-7. 

114.Schiff E. The alcoholic patient with hepatitis C virus infection. 

Am J Med 1999;107(6B):95S-9. 

115.Bhattacharya R., Shuhart M.C. Hepatitis C and alcohol: 

interactions, outcomes, and implications. J Clin Gastroenterol 

2003;36(3):242-52. 

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Antifibrotic Therapy in Chronic Hepatitis C 

Rinaldo Focaccia Siciliano and Antonio Alci Barone 


The most pronounced histological characteristics of 

chronic hepatitis C are hepatocellular necrosis, inflammatory 

infiltrate and fibrosis. Unlike the first two, which present 

fluctuations, the evolution of liver fibrosis progressively 

evolves toward pathological sequelae due to the chronic liver 

injury induced by hepatitis C virus (HCV). Fibrosis results 

from the accumulation of extracellular matrix components, 

which leads to distortion of the liver architecture, alterations 

in hepatic microcirculation, and cellular dysfunction. This 

pathological hepatic process develops slowly and 

progressively, producing clinical repercussions only in its final 

stage, liver cirrhosis, which can take decades. Therefore, 

determination of the degree of fibrosis through liver biopsy 

or progression rate is crucial to the understanding of the natural 

history of chronic hepatitis C. 

Some authors have identified host factors that are 

associated with the accelerated progression of liver fibrosis 

in HCV infection. The most important are being over 40 years 

of age at the time of HCV infection, being male, consuming 

excessive quantities of alcohol, and presenting conditions 

that lead to immunodeficiency, such as HIV infection or 

transplant. Other factors also seem to contribute to a more 

rapid progression toward fibrosis, such as liver steatosis, coinfection 

with hepatitis B virus (HBV), obesity, and diabetes 

mellitus. 

Recent advances in clinical studies and basic science have 

brought new perspectives to the development of therapies 

that can curb the progression of the fibrogenic process or 

even promote reversion of liver fibrosis. These advances 

occurred after the recognition of fibrogenic cell types in the 

liver, as well as of the principal sites of fibrosis formation and 

its reversibility potential. 

Fibrosis seems to result from an imbalance between the 

synthesis and degradation of the extracellular matrix, resulting 

in the accumulation of conjunctive tissue in the liver. This 

process is triggered and sustained by the chronic liver damage 

caused by HCV and leads to the disruption of the normal liver 

architecture, culminating in the development of cirrhosis/ 

hepatic insufficiency. Stellate cells are the principal source of 

extracellular matrix in the damaged liver tissue. In a normal 

liver, they are present in the Disse space and are the principal 

reservoirs of vitamin A. Chronic hepatic injury secondary to 

HCV, through the increase of free radicals and fibrogenic 

mediators, leads to the activation of stellate cells, as well as to 

their proliferation and differentiation into myofibroblasts, when 

they acquire contractile, pro-inflammatory and fibrogenic 

properties. Once activated, they migrate to the sites of injury 




with the objective of effecting repair by secreting a large 

quantity of extracellular matrix. Activated stellate cells also 

produce cytokines that perpetuate their activation status, as 

well as being stimulated by the apoptosis of damaged 

hepatocytes. The leukocytes attracted into the hepatic 

inflammatory process secondary to HCV infection also induce 

the production of collagen by stellate cells. These activated 

cells, in turn, have a pro-inflammatory effect that feeds a 

vicious cycle. 

Under physiological conditions, the excess extracellular 

matrix is degraded through regulation by metalloproteinases. 

Activated hepatic myofibroblasts, in addition to producing 

large quantities of Type I and Type III collagen, secrete tissue 

inhibitors of metalloproteinases, which block the 

collagenolytic activity. We have begun to comprehend various 

parts of this process of accumulation of extracellular matrix in 

the liver tissue, although there are still many gaps in our 

understanding. In addition to the efficient collagenolytic 

activity of the metalloproteinases, the degradation of the 

extracellular matrix in the liver can also occur through the 

activities of neutrophils, macrophages and stellate cells 

themselves; however, the importance and modulation of each 

have yet to be clarified. The activation of stellate cells, as well 

as their proliferation and fibrogenic activity, is regulated by 

various soluble growth factors, such as platelet-derived 

growth factor, transformation growth factor beta, and 

endothelin-1. 

Determining the mechanisms involved in the process of 

liver fibrosis has led to a new perspective on the development 

of antifibrotic drugs in animal models. However, there is still 

an obstacle to be transposed before positive laboratory results 

can be reproduced in humans. New lines of research attempt 

to attenuate the activation of stellate cells, inhibit some of 

their properties when activated, promote their apoptosis, or 

stimulate the degradation of the extracellular matrix. No specific 

antifibrotic therapies have been approved for use in humans; 

however, considerable effort has been made in laboratory 

studies in this promising area. 

In clinical practice, the treatment of hepatitis C with the 

combination of pegylated interferon alpha and ribavirin is the 

only pharmacological regimen currently available that can 

modify the natural evolution of liver fibrosis. This does not 

simply occur by suppressing the viremia (achieving a 

sustained virological response) but possibly by the antifibrotic 

role of pegylated interferon alpha. Recent clinical studies show 

remission of liver fibrosis or reduction of its progression rate 

in patients under treatment with therapeutic regimens 

containing interferon alpha or pegylated interferon. This effect 

is even more apparent among hepatitis C patients presenting 

a biochemical or virological response after therapy. Notably, 

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BJID 2007; 11 Supplement 1 (October) Antifibrotics and Chronic Hepatitis C 

21 

most of these studies are retrospective, and their principal 

objective was the evaluation of the virologic response to the 

treatment with interferon alpha. 

Although liver fibrosis is a dynamic process, its remission 

is slow and demands prolonged therapy and follow-up 

evaluation. Multicentric prospective comparative studies that 

evaluate the histological impact of maintenance treatment with 

pegylated interferon in low doses versus placebo in patients 

with hepatitis C who are nonresponsive to treatment are 

currently being carried out. Preliminary results of these 

studies are quite promising; reduction of fibrosis or clinical 

complications resulting from liver cirrhosis can be seen after 

approximately two years of therapy with pegylated 

interferon. The final results, with histological analysis, after 

long-term follow-up treatment and inclusion of a large 

number of patients, will consolidate an evaluation of safety, 

clinical and histological benefits, and cost-effectiveness ratio 

of the prolonged use of pegylated interferon in low doses in 

hepatitis C. 

The role of the physician in the positive modification of 

the natural history of hepatitis C-related liver fibrosis should 

not be restricted to the removal of HCV as a hepatic aggressive/ 

pro-inflammatory factor (achieving a sustained virologic 

response) or to the use of interferon as a potential antifibrotic 

agent. In daily practice, other strategies aimed at attenuating 

the progression of liver fibrosis are based on the effects on 

modifiable factors that can alter the natural history of HCV: 

drinking cessation; prevention and control of obesity; and 

prevention of HIV or HBV co-infection. 

Much progress has been achieved in basic science 

regarding the understanding of the biological mechanisms 

that lead to the development of liver fibrosis. However, clinical 

trials to validate new drugs or antifibrotic strategies are 

warranted. 

References 

1. Albanis E, Friedman S,L. Antifibrotic agents for liver disease. Am 

J Transplant 2006;6(1):12-9. 

2. Friedman S.L., Rockey D.C., Bissell D.M. Hepatic fibrosis 2006: 

report of the Third AASLD Single Topic Conference. 

Hepatology 2007;45(1):242-9. 

3. Bataller R., Brenner D.A. Liver fibrosis. J Clin Invest 

2005;115(2):209-18. 

4. Marcellin P., Asselah T., Boyer N. Fibrosis and disease progression 

in hepatitis C. Hepatology 2002;36(5 Suppl 1):S47-56. 

5. Friedman S.L., Bansal M.B. Reversal of hepatic fibrosis - fact or 

fantasy? Hepatology 2006;43(2 Suppl 1):S82-8. 

6. Everson G.T., Hoefs J.C., Seeff L.B., et al. Impact of disease severity 

on outcome of antiviral therapy for chronic hepatitis C: Lessons 

from the HALT-C trial. Hepatology 2006;44(6):1675-84. 

7. Kaiser P., Hass H., Lutze B., et al. Long-term low dose treatment 

with pegylated interferon alpha 2b leads to a significant reduction 

in fibrosis and inflammatory score in chronic hepatitis C 

nonresponder patients with fibrosis or cirrhosis. 57th Annual 

Meeting of the American Association for the Study of Liver 

Diseases. Massachusetts – USA 2006. 

8. Afdhal N., Freilich B., Levine R., et al. Colchicine versus peginterferon 

long-term (COPILOT) trial: interim analysis of clinical 

outcomes at year 2. Hepatology 2004;40:238A. 

www.bjid.com.br


Laboratory Testing for Hepatitis C 

Neiva Sellan Lopes Gonçales and Fernando Lopes Gonçales Junior 

Hepatitis Study Group – MI/FCM/UNICAMP; Campinas, SP, Brazil 

Serological Detection of Hepatitis C Virus 

Serological diagnosis of patients infected with the hepatitis 

C virus (HCV) can be performed using two categories of tests: 

indirect tests, which detect antibodies against HCV; and direct 

tests, which detect, quantify, or characterize components of 

the viral particle, such as HCV RNA testing and testing for 

detection of the HCV core antigen. 

Anti-HCV antibodies are usually detected using third- and 

fourth-generation immunoenzymatic assays – enzyme 

immunoassay (EIA)/enzyme-linked immunosorbent assay 

(ELISA) 3 and EIA/ELISA 4, respectively – which contain 

HCV core antigens and HCV nonstructural genes. The 

specificity of the EIA tests available on the market that detect 

anti-HCV was determined to be higher than 99%, whereas 

their sensitivity, which was more difficult to determine due to 

the lack of gold standard tests with high sensitivity, was 95- 

99% [1]. However, false-positive results for anti-HCV can 

occasionally occur, especially in populations with prevalence 

rates below 10% [2-4]. 

There are many reasons why laboratories do not routinely 

use a supplementary test based on immunoblot analysis, such 

as the recombinant immunoblot assay, to complement the 

diagnosis of HCV infection. In addition to the high cost of 

such a test, the lack of laboratory standards that can evaluate 

its performance and interpretation, in conjunction with its 

actual accuracy, is among the principal reasons. Furthermore, 

this type of test does not distinguish past from present 

infection, and its use is only indicated for confirmation of EIA 

results. 

In contrast, the use of nucleic acid testing (NAT) makes it 

possible to differentiate between viremic and nonviremic 

individuals by detection of HCV RNA, allowing the clinician a 

differentiated approach to anti-HCV-positive individuals. 

However, there can be situations in which HCV RNA is not 

detected (negative HCV RNA) and the individual has active 

infection with HCV. This can occur in individuals in whom 

anti-HCV antibody titers are high and RNA titers are low [5]. 

Therefore, HCV RNA might not be detectable in certain 

individuals in the acute phase of the disease. However, these 

findings are transient, and chronic infection can develop [6]. 

In addition, HCV RNA intermittent positivity has been 

observed in individuals chronically infected with HCV [6-8]. 

Negativity of HCV RNA results can indicate resolved infection. 

In 15 to 25% of those anti-HCV positive individuals who 

acquired the infection after 45 years of age, the infection 

resolves spontaneously. This percentage increases to 40-45% 

in those who acquired the HCV infection in childhood or 

young adulthood [9]. 

Different tests based on polymerase chain reaction (PCR) 

have been developed to directly detect the viral particle. One 

characteristic of real-time PCR is amplification coupled with 




detection, which allows the evaluation of the number of viral 

genomes at the onset of and throughout the reaction. 

Qualitative detection of HCV RNA by reverse transcriptase 

(RT)-PCR is generally accepted as the most sensitive and 

standardized test to date [10,11]. Nevertheless, there is variability 

among the results from different laboratories, as evidenced by 

the use of international panels of proficiency. The accuracy 

and reliability of the results are directly related to the laboratory 

procedures adopted in the performance of the tests [12]. The 

lack of preliminary care in sample collection, in conjunction 

with the time involved in preparing and separating the samples, 

can result in incorrect results. It is extremely important that all 

laboratory procedures comply with Good Laboratory Practice 

and strictly follow the protocols standardized by the 

manufacturers of the diagnostic kits and reagents. 

The gold standard consists of the careful use of NAT, 

standardized for detection of HCV RNA, together with EIAs 

(specificity in conjunction with sensitivity). 

An alternative to aid diagnosis is the use of the ratio 

between optical density and cut-off value (OD/COV) or the 

sample/cut-off ratio as an indicator of the true positivity of 

the test. Studies carried out in Brazil show that, in EIAs, 

reagents with OD/COV greater than 3 are repeatedly associated 

with 100% true-positive results (positive predictive value) and 

present approximately 92% positivity for HCV RNA by RT- 

PCR [13]. In terms of the population studied, the positive 

predictive value is increased when accompanied by risk 

factors, high levels of alanine aminotransferase (ALT), or liver 

disease. 

In immunocompetent patients, EIAs present excellent 

reproducibility; however, in hemodialyzed or 

immunocompromised patients, EIA sensitivity is significantly 

reduced [14]. 

In low-risk populations, such as blood donors, or in 

random population screening, i.e., in populations that do not 

present risk factors for the acquisition of HCV infection, 

negative EIA results are sufficient to rule out the presence of 

HCV. However, false-positive results can occur in these 

populations. In such cases, a qualitative study of HCV RNA 

should be performed to confirm the diagnosis. 

In high-risk populations, when there is clinical suspicion of 

HCV infection, positive EIA results confirm the exposure to 

HCV. A qualitative study of HCV RNA should be performed to 

distinguish individuals with chronic infection from those who 

have eliminated the HCV spontaneously. 

In patients with chronic hepatitis of unknown cause and 

negative anti-HCV EIA results, especially in 

immunocompromised patients [14], a qualitative study of HCV 

RNA should be performed. The presence of HCV RNA confirms 

the diagnosis, although a negative result does not rule out 

HCV infection. In such cases, it is recommended that a new 

HCV RNA study be performed six months after the first study. 

Detection of the HCV core antigen by EIA can be an alternative 

for early diagnosis of HCV infection. 

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BJID 2007; 11 Supplement 1 (October) Laboratory Testing for Hepatitis C 

23 

The HCV core antigen ELISA was developed to be used 

as a serological screening test to detect the HCV core antigen, 

especially during the immunological window period, when 

antibodies are not detected. This assay was found to have 

sensitivity close to that of NAT, with a mean difference in 

detection of one to two days [15]. 

Based on this assay, a new assay was developed to detect 

and quantify HCV core antigen. The modifications made to 

this new assay, such as the dissociation of immune complexes, 

which allows the detection of free antigens and core antigen 

antibodies, and the change in the signal amplification, through 

the modification of the conjugate, have increased the 

sensitivity of the test. Studies have demonstrated that this 

test can reduce the immunological window by 3.3 days in 

comparison with the previous test (i.e., the HCV core antigen 

ELISA). This increase in sensitivity has led to a significant 

(58-day) decrease in the size of the immunological window. 

The difference between this EIA and PCR was only 0.24 

days [16]. 

This test can be considered a viable alternative to 

detecting viremia directly when NAT cannot be used for 

reasons of cost, organization, emergency, or logistic difficulties. 

Tests that allow simultaneous or combined detection of HCV 

core antigen and antibody in a single assay are currently 

available on the market. These tests, known as HCV Ag/Ab 

combo assays, have high sensitivity and specificity, reducing 

the duration of the immunological window (during which 

antibodies are not detected) by up to 12 days [17]. Studies 

carried out using this assay showed sensitivity close to that 

of NAT, with a mean difference in detection of 1 to 2 days [18]. 

The use of NAT in the diagnosis of HCV infection makes it 

possible to distinguish viremic from nonviremic individuals 

through the detection of HCV RNA. 

Therefore, these tests can be considered a plausible future 

solution in the screening of blood donors, organ 

transplantation programs, and cases of occupational exposure, 

in which a rapid and low-cost diagnosis is necessary. 

In order to standardize the tests, the World Health 

Organization and the United States National Institute for 

Biological Standards and Controls have established a standard 

measure known as the international unit (IU). Assays for 

qualitative detection of HCV RNA are important tools because 

they are significantly more sensitive than are most quantitative 

tests. Qualitative assays are based on the principle of target 

amplification using either PCR or transcription-mediated 

amplification. The cut-off value of the lower limit of detection 

of HCV RNA of these commercial assays is 50 IU/mL and 6 IU/ 

mL, respectively [19]. The specificity of these essays exceeds 

99%. A positive test for HCV RNA confirms active replication 

of HCV. Clinical and laboratory follow-up with study of HCV 

RNS should be performed to confirm the absence of active 

replication of HCV. Once HCV infection is confirmed, 

performing further qualitative tests for HCV RNA in patients 

submitted to clinical follow-up evaluation but not receiving 

treatment has no diagnostic utility. 

The quantification of HCV RNA can be performed by 

target amplification using PCR or by signal amplification using 

branched DNA (bDNA). In these commercial assays, the cutoff 

value of the lower limit of quantification of HCV RNA 

ranges from 600 to 615 IU/mL, and the upper linear limit ranges 

from 850,000 to 7,700,000 IU/mL [20]. The standardization in 

IU does not represent the actual number of viral particles in 

the preparation. There are significant variations among 

commercial assays. The dynamics of each assay should be 

observed, and appropriate dilutions of the material being 

analyzed should be performed to ensure the accuracy of the 

quantification. 

The ideal assay for HCV RNA should have a lower 

detection limit of 5 to 50 IU/mL and a linearity curve of 6 to 7 

log 10 

. Traditional assays for detection of viral load, such as 

bDNA and Roche Monitor, present detection limits of 615 IU/ 

mL and 600 IU/mL respectively [21,22], which are inadequate 

to define end-of-treatment response or sustained virological 

response. Real-time PCR assays are a promising tool due to 

their sensitivity and broad range of linearity. Cobas Taqman 

48 HCV assay is a quantitative assay that has a detection limit 

of 10 to 100 IU/mL, which makes it well suited for use in followup 

treatment (at the initiation and at week 12) [23]. 

Acute Infection and Cutting/Piercing Accidents 

After exposure to HCV, anti-HCV antibodies can be 

detected by EIA in 50 to 70% of the patients at the onset of 

symptoms, this percentage increasing to approximately 90% 

after 3 months. Routinely, HCV RNA can be detected between 

post-exposure weeks 1 and 3, remaining at detectable levels 

when symptom onset occurs. From post-infection week 2 to 

post-infection week 8, levels of ALT rise, and this increase is 

accompanied by the appearance of hepatocytic lesions. 

Vertical Transmission 

An important question is that of exactly how mother-tochild 

transmission of the HCV infection is defined. In many 

children born to mothers with chronic hepatitis C, anti-HCV 

(IgG) is detectable in the blood. These antibodies are acquired 

through passive transplacental transfer. These passively 

acquired antibodies will remain detectable for the first 12 to 15 

months of life. Therefore, the criterion to identify mother-tochild 

transmission of HCV infection is the detection of anti- 

HCV and HCV RNA in the blood of the child after the age of 18 

months. 

Chronic Infection 

In patients with chronic hepatitis C, the diagnosis of 

chronicity is based on the detection of anti-HCV and HCV 

RNA in the blood, using techniques of high sensitivity, and is 

confirmed through liver biopsy. 

Loss of anti-HCV and isolated presence of HCV RNA are 

uncommon in immunocompetent patients with chronic 

hepatitis C. However, these findings can occur in 

hemodialyzed patients and in severely immunocompromised 

patients 

Follow-Up Treatment 

Some patients with detectable HCV RNA should be 

considered for treatment. Genotyping should be performed 

at the initiation of treatment in order to define treatment 

duration, since, according to treatment protocols, patients 

infected with genotype 2 or 3 should be treated for 24 

www.bjid.com.br

24 Laboratory Testing for Hepatitis C 


weeks, whereas those infected with genotype 1 should be 

treated for 48 weeks [24]. 

A considerable limitation in the evaluation of patients 

with chronic infection with HCV has been the lack of 

standardization of the tests for detection of HCV RNA. A 

significant difference has been observed in the assays used, 

both in terms of sensitivity (upper limit of detection) and in 

terms of dynamics. These differences are observed not only 

among the different assays but also among different 

laboratories performing a given assay. Therefore, it is 

important that, throughout the clinical follow-up of a patient 

receiving specific treatment, the same assays and, if 

possible, the same laboratory always be used [25-28]. 

Quantification of HCV RNA should be performed in 

the pretreatment sample and in the week-12 sample in 

order to evaluate the predictive value of the treatment 

response. 

Since the qualitative study of HCV RNA presents a 

lower limit of detection of 50 IU/mL, it should be used at 

week 4 of treatment, as a predictor of sustained virologic 

response (SVR), then again, to detect the SVR, at the 

end of treatment and at 6 months after the end of 

treatment. Therefore, presenting negative PCR results 

by week 4 of treatment has a high predictive value for 

achieving an SVR. 

References 

1. Alter M.J., Kuhnert W.L., Finelli L. Guidelines for Laboratory 

Testing and Result Reporting of antibody to hepatitis C Virus. 

MMWR 2003;52:1-15. 

2. Kleinman S., Alter H., Bush M., et al. Increased detection of hepatitis 

C virus (HCV) – infected blood donors by a multiple-antigen HCV 

enzyme immunoassay. Transfusion 1992;32:805-613. 

3. Conry-Cantilena C., VanRaden M., Gibble J., et al. Route of infection, 

viremia, and liver disease in blood donors found to have hepatitis 

C virus infection. N Engl J Med 1996;334:1691-6. 

4. Hyams K.C., Riddle J., Rubertone M., et al. Prevalence and 

incidence of hepatitis C virus infection in the US military: a 

seroepidemiologic survey of 21000 troops. Am J Epidemiol 

2001;153:764-70. 

5. Busch M.P., Kleinmam S.H., Jackson B., et al. Nucleic acid testing 

of blood donors for transfusion-transmitted infectious diseases: 

report of Interorganization Task Force on Nucleic Acid 

Amplification of Blood Donors. Transfusion 2000;40:143-59. 

6. Thomas D.L., Astemborski J., Rai R.M., et al. Natural history of 

hepatitis C virus infection: host, viral, and environmental 

factors. JAMA 2000;284:450-6. 

7. Alter M.J., Margolis H.S., Krawczynski K., et al. Natural history 

of community-acquired hepatitis C in the United States. N Engl 

J Med 1992;327:1899-905. 

8. Larghi A., Zuin M., Crosignani A., et al. Outcome of an out break 

of acute hepatitis C among healthy volunteers participating in 

pharmacokinetics studies. Hepatology 2002;36:993-1000. 

9. Alter H.J., Seef L.B. Recovery, persistence, and sequelae in hepatitis 

C virus infection: a perspective on long term outcome. Semin 

Liver Dis 2000;20:17-35. 

10. Pawlotsky J.M. Molecular diagnosis of viral hepatitis. 


11. Pawlotsky J.M. Use and interpretation of virological tests for 

hepatitis C. Hepatology 2002;36:S65-S73. 

12. Callendo A.M., Valsamakis A., Zhou Y., et al. Multilaboratory 

comparison of hepatitis C virus viral load assays. J Clin Microbiol 

2006;44:1726-32. 

13. Gonçales N.S.L., Costa F.F., Vassalo J., Gonçales Jr., F.L. Diagnosis 

of hepatitis C in Brazilian blood donors using a reverse 

transcriptase nested polymerase chain reaction: comparison 

with enzyme immunoassay and recombinant protein immunoblot 

assay. Rev Inst Med trop S Paulo 2000;42(5):263-7. 

14. Lakshmi V., Reddy A.K., Dakshinamurty K.V. Evaluation of 

commercially available third-generation anti-hepatitis C virus 

enzyme-linked immunosorbent assay in patients on 

haemodialysis. Indian J Med Microbiol 2007;25:140-2. 

15. Tanaka E.C., Ohue K., Aoyagi K., et al. Evaluation of a new 

enzyme immunoassay for hepatitis C virus (HCV) core antigen 

with clinical sensitivity approximating that of genomic 

amplification of HCV RNA. Hepatology 2000;32:388-93. 

16. Laperche S., Le Marrec N., Simon N., et al. A new HCV core 

antigen assay based on disassociation of immune complexes: an 

alternative to molecular biology in the diagnosis of early HCV 

infection. Transfusion 2003;43:958-62. 

17. Laperche S., Elghouzzi M.-H., More P., et al. Is an assay for 

simultaneous detection of hepatitis C virus core antigen and 

antibody a valuable alternative to nucleic acid testing? 

Transfusion 2005;45:1965-72. 

18. Laperche S., Le Marrec N., Girault A., et al.. Simultaneous detection 

of hepatitis C virus (HCV) core antigen and anti-HCV antibodies 

improves the early detection of HCV infection. J Clin Microbiol 

2005;43:3877-83. 

19. Desombere I., Van Vlierberghe H., Couvert S., et al. Comparison 

of qualitative (COBAS AMPLICOR HCV 2.0 versus VERSANT 

HCV RNA) and quantitative (COBAS AMPLICOR HCV monitor 

2.0 versus VERSANT HCV RNA 3.0) assays for hepatitis C 

virus (HCV) RNA detection and quantification: impact on 

diagnosis and treatment of HCV infections. J Clin Microbiol 

2005;43(6):2590-2. 

20. Elbeik T, Surtihadi J, Destree M et al. Multicenter evaluation of 

performance characteristics of the Bayer VERSANT HCV RNA 

3.0 assay (bDNA). J Clin Microbiol 2004;42:563-9. 

21. Veillon P., Payan C., Picchio G., et al. Comparative 

evaluation of the total hepatitis C virus core antigen, 

branched-DNA, and Amplicor Monitor assays in 

determining viremia for patients with chronic hepatitis C 

during interferon plus ribarin combination therapy. J Clin 

Microbiol 2003;41:3212-20. 

22. Nolte F.S., Fried M.W., Shiffman M.L., et al. Prospective 

multicenter clinical evaluation of AMPLICOR and COBAS 

AMPLICOR hepatitis C virus tests. J Clin Microbiol 

2001;39:4005-12. 

23. Konnick E.Q., Willians S., Ashwood E.R., et al. Evaluation of 

Cobas hepatitis C virus (HCV) Taqman anlyte –specific reagent 

assay nd comparison to the Cobas Amplicor HCV monitor v2.0 

and Versant HCV bDNA 3.0 assays. J Clin Microbiol 

2005;43:2133-40. 

24. Fried M.W., Shiffman M.L., Reddy C., et al. Peginterferon alfa-2a 

plus ribavirin for chronic hepatitis C virus infection. N Engl J 

Med 2002;347:975-92. 

25. Shiffman M.L., Ferreira-Gonzalez A., Reddy K.R., et al. 

Comparison of three commercially available assays for HCV 

RNA using the International Units standard: Implications for 

management of patients with chronic hepatitis C virus infection 

in clinical practice. Am J Gastroenterol 2003;98:1159-66. 

26. Podzorski R.P. Molecular testing in the diagnosis and management 

of hepatitis C virus infection. Arch Pathol Lab Med 

2002;126:285-90. 

27. Schirm J., van Loon A.M., Valentine-Thon E., et al. External 

quality assessment program for qualitative and quantitative 

detection of hepatitis C virus in diagnostic virology. J Clin 

Microbiol 2002;40:2973-80. 

28. Pawlotsky J.M. Diagnostic testing in hepatitis C virus infection: 

viral kinetics and genomics. Semin Liver Dis 2003;23:3-11. 

www.bjid.com.br


Hepatitis C: Genotyping 

Norma de Paula Cavalheiro 


The heterogeneity of the hepatitis C virus (HCV) genome 

was described at the beginning of the 1990s. Subsequently, 

genotyping tests were developed in order to delineate and 

differentiate these variants, leading to various classifications 

in different parts of the world. However, in 1994, in a consensus 

publication, criteria were established and a universal 

classification was consolidated, comprising the identification 

of 6 large groups or viral genotypes, in addition to over 70 

different subtypes distributed worldwide. It was established 

that genotypes differ from one another in 31% to 33%, as do 

the subtypes in 20% to 25%. 

The standardization in HCV classification was in 

accordance with the uniformity of data published in scientific 

and epidemiological studies on evolution and pathogenesis. 

Due to genomic peculiarities of different populations in the 

world, databases for centralization and collection of 

information on HCV circulating genomes were created, by 

region: the first in Japan by Prof. Masashi Mizokami et al. 

(http://s2as02.genes.nig.ac.jp/); the second in the European 

Union by Prof. Gilbert Deleage et al. (http://euhcvdb.fr/); and 

the third in the United States by Dr. Carla Kuiken et al. (http:/ 

/hcv.lanl.gov/ or http://hcv-db.org). The accessibility of these 

databases, which are consulted and updated by researchers 

worldwide, helps standardize terms for HCV viral genotypes 

and subtypes [1]. 

Prior to 1994, new variants were identified in Vietnam, 

Thailand, Burma and Indonesia. These viral genotypes were 

originally classified as genotypes 7, 8, 9, 10 and 11. These 

variants were reclassified in 2005; genotype 10a came to be 

denominated subtype 3k, and genotypes 7a, 7d, 7b, 7e/7c, 

11a, 9a, 9b, 9c, 8b and 8a became subtypes 6e, 6c, 6d, 6f, 6g, 

6h, 6i, 6j, 6k and 6l, respectively [1]. 

In Brazil, HCV genotype 1 is predominant, being identified 

in 70% of the infected population, followed by genotypes 3 

(in 25%) and 2 (in approximately 5%). In the southern region, 

the profile is differentiated, the prevalence of genotype 3 being 

comparable to that of genotype 1 [2,3]. 

The HCV viral genotype can be determined in a clinical 

sample in different forms, and the regions of HCV genome 

considered appropriate include the core, E1, NS4 and NS5 

regions, as well as the 5’UTR, as mentioned in innumerable 

studies [4,5]. 

The most direct method, considered the gold standard, is 

the sequencing of the HCV genome in a certain region, 

sufficiently divergent for different genotypes and subtypes 

to be distinguished [5]. 




In practice, there are two categories of assays for the 

diagnosis of HCV viral types: serotyping and genotyping [6,7]. 

The enzyme-linked immunosorbent assay, also known as 

the indirect method (serotyping), commercialized only for 

research, discriminates among the six HCV genotypes, and 

not the subtypes. It presents genotype-specific antibodies 

for different HCV genotypes (Serotype HCV 5’NC – Abbott- 

Murex) in the NS4 region of the genome. This test omits the 

determination of the quantity of circulating viral particles and 

presents lower sensitivity and specificity in the diagnosis of 

HCV genotypes, when compared with genotyping. Its 

performance is also limited in the evaluation of 

immunocompromised patients [3,7,8]. 

Genotyping (the direct method) analyzes the sequences 

of various regions of the genome in the differentiation of HCV 

genotypes and subtypes. Therefore, it depends on samples 

that present viral particles for analysis. These techniques are: 

sequencing, hybridization with genotype-specific probes, and 

real-time polymerase chain reaction (PCR) [5,7,9]. 

Reverse hybridization, distributed under the commercial 

name Line Probe Assay (LIPA - Versant HCV Genotype assay 

1.0/2.0; Innogenetics, Ghent, Belgium; distributed by Siemens 

Medical Solutions Diagnostics, Tarrytown, NY, USA), as 

described by Lieven Stuyver et al. in 1993, uses nitrocellulose 

tapes, on which oligonucleotide probes of region 5’NC, 

complementary to each specific HCV genotype/subtype, are 

immobilized. These tapes are hybridized under high stringency 

conditions, and the PCR product is marked with biotinylated 

primers in the amplification process. After hybridization, an 

avidin conjugate will bind to the biotinylated hybrid. The 

substrate will yield the formation of a colored product, which 

will be deposited on the tape and reveal the viral genotype 

present in the sample. Genotypes 1 through 6, as well as 

subtypes 1a, 1b, 1a/1b, 2a/2c, 2b, 3a-c, 4a-h, 5a, 6a and 10a, are 

discriminated. The results are evaluated through visual 

assessment. 

A new version of LIPA (version 2.0) adds probes of the 

core region of HCV and enables distinction of subtypes 1c of 

6 and subtypes 1a and 1b, which, in the former version, was 

not possible for all the samples analyzed, since region 5’NC is 

extremely conserved and may not present sufficient diversity 

for the distinction of these subtypes. The interpretation of 

results is also performed by assessing the nitrocellulose tapes 

with a scanner, and the images are analyzed using a computer 

program. The new version is in the registration phase for 

distribution in Brazil [7,10,11]. 

Direct sequencing is the most complete information on 

the variations of the sequences analyzed. In addition, it is an 

ideal and definitive method for the study of viral genetic 

variability. Moreover, the study of viral dynamics in the context 

www.bjid.com.br

26 Hepatitis C: Genotyping 


of quasispecies, during the natural history of the disease or 

as consequence of antiviral therapy, depends principally on 

the direct sequencing of certain regions of the HCV genome. 

Furthermore, it is considered the gold standard for determining 

HCV genotypes and subtypes [7]. 

The sequencing technique for HCV genotyping consists 

of PCR amplification of part of the viral genome, especially of 

the 5’NC, NS5B and core regions. These regions are 

sufficiently conserved for the development of reliable primers 

and, at the same time, present diversity for the discrimination 

of viral genotypes and subtypes. The PCR employed for 

sequencing comes from PCR-HCV qualitative or 

quantitative PCR HCV products, the volume of DNA and 

the high purity of the resulting tapes being essential for 

the success of the analyses. This second PCR is performed 

specifically to adjust or mark these products for reading in 

sequencers. The assessment of both tapes, positive and 

negative, is essential in order to resolve possible 

ambiguities during the evaluation of the sequencings [7]. 

The sequences provided by the equipment should be 

analyzed, and there are international databases available 

for consultation, for this purpose. These databases are also 

used for the centralization and collection of sequences 

worldwide. The database recommended for Brazil is the 

European site http://euhcvdb.fr/, probably because of the 

epidemiological pathway followed during the Brazilian 

colonization period. 

The genotyping test TRUGENE-SIEMENS HCV 5’NC 

Genotyping Kit (Siemens Medical Solutions Diagnostics, 

Tarrytown, NY, USA) offers software used in conjunction 

with the equipment, with a previously selected genomic 

library that analyzes the sequences of region 5’NC 

immediately after sequencing. In addition to the genotyping 

results, it presents the homology with patterns of HCV 

genotypes and subtypes based on region 5’NC. This 

methodology is only available to researchers [1,7,12]. 

The real time PCR-HCV method is a quantitative 

molecular diagnostic test that uses TaqMan technology. 

In this test, genotype-specific probes marked for HCV 

typing were employed in order to identify genotypes 1, 2 

and 3a. Another test, also based on TaqMan technology, 

can identify genotypes 1 to 4 and presents specific probes 

for subtypes 1a/b, 2a/b/c, 3a and 4b/c/d. Both 

methodologies are based on region 5’NC [9,13-16]. 

Commercially, but only for research, there is the Abbott 

Real-Time PCR HCV Assay (Abbott Diagnostics Europe, 

Wiesbaden, Germany) test, which also determines the viral 

genotype of the samples for HCV genotypes 1a, 1b, 2a, 2b, 3, 

4, 5 and 6. This methodology for the genotyping of HCV is 

associated with viral quantification, levels below 6053 IU/mL 

compromising the efficiency and sensitivity of the test [9]. 

The identification of genotypes is clinically important, and 

treatment protocols recommend that genotype information 

be obtained in order to delineate the duration and type of the 

medication to be used. The literature mentions that genotypes 

1 and 4 are considered more resistant than are genotypes 2 

and 3, and that the standard treatment consists of interferon 

combined with ribavirin. Another disadvantage of genotypes 

1 and 4 is that they present a worse prognosis of evolution of 

the disease. For treatment-naïve patients, infection with 

genotype 1, 4 or 5 should be treated for 12 months, compared 

with 6 months for infection with genotype 2 or 3. The 

Consensus Group recommends pegylated interferon 

combined with ribavirin for genotype 1. For re-treatment, 

pegylated interferon associated with ribavirin is 

recommended, regardless of the genotype, in the usual doses, 

respecting the duration recommended for genotype 1 for other 

genotypes. In cases of HIV/HCV co-infection, the response 

to antiviral therapy for HCV is not favorable: 14%-38% for 

genotype 1; and 43%-73% for genotypes 2 and 3 [1,7,17,18]. 

The advantages of genotyping methods include reliability 

and the opportunity to obtain important information on the 

molecular pathogenesis of HCV [7]. 

The impact of HCV heterogeneity and its different 

genotypes on the everyday clinical management of HCV 

chronic infection has not been completely established, nor 

has its role as an epidemiological marker been clarified. 

The sensitivity and specificity of serological and virological 

tests can also be influenced by the heterogeneity of HCV, 

which justifies constant evolution in the study of patients 

and differentiation techniques of HCV genotypes and 

subtypes [4]. 

References 

1. Simmonds P., Bukh J., Combet C., et al. Consensus proposals for 

a unified system of nomenclature of hepatitis C virus genotypes. 

Hepatology 2005;42:962-73. 

2. Campiotto S., Pinho J.R.R., Carrilho F.J., et al. Geographic 

distribution of hepatitis C virus genotypes in Brazil. Brazilian 

Journal of Medical and Biological Research 2005;38:41-9. 

3. Cavalheiro N.P., Barone A.A., Tengan F.M. HCV Serotypes in 

brazilian patients. Int J Infect Dis 2002;6:228-32. 

4. Pawlotsky J.-M. Diagnostic tests for hepatitis C. J Hepatol 

1999;31 Suppl. 1:71-9,. 

5. Laperche S., Lunel F., Izopet J., et al. Comparison of Hepatitis C 

Virus NS5b and 5_ Noncoding Gene Sequencing Methods in a 

Multicenter Study. Journal of Clinical Microbiology 2005:733-9. 

6. Pawlotsky J.-M., Prescott L., Simmonds P., et al. Serological 

determination of hepatitis C virus genotype: Comparison with 

a standardized genotyping assay. J Clin Microbiol 

1997;35:1734-9. 

7. Stéphane C., Pawlotsky J.-M. Hepatitis C virus: Virology, diagnosis 

and management of antiviral therapy. World J Gastroenterol 

2007;13(17):2461-6. 

8. Prescott L.E., Simmonds P. Serological genotyping using synthetic 

peptides derived from the NS4 region. In: LAU, JOHNSON 

YIU-NAM. Hepatitis C protocols: methods in molecular 

medicine. Totowa, Humana Press, cap.17, p.199-205, 1998. 

9. Raymond H.W., Carol Cimmins. Evaluation of the Abbott 

Molecular Diagnostics Real Time PCR Assay for HCV 

Quantitative Viral Load and HCV Genotyping. Poster S30, 

Clinical Virology Symposium, 2004. 

10. Nadarajah R., Khan Y., Miller S.A., Brooks G.F. Evolution of a 

new generation Line-Probe Assay that detects 5’untranslated 

and Core regions to genotype and subtype Hepatitis C Virus. Am 

J Clin Pathol 2007;128:300-4. 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Hepatitis C: Genotyping 

27 

11. Bouchardeau F., Cantaloube J.F., Chevaliez S., et al. Improvement 

of Hepatitis C Virus (HCV) Genotype Determination with the 

New Version of the INNO-LiPA HCV Assay. Journal of Clinical 

Microbiology 2007;45:1140-5. 

12. Nolte F.S., Green A.M., Fiebelkorn K.R., et al. Clinical evaluation 

of two methods for genotyping Hepatitis C virus based on 

analysis of the 5’noncoding region. Journal of Clinical 

Microbiology 2003;41:1558-64. 

13. Lindh M., Hannoun C. Genotyping of hepatitis C virus by Taqman 

real-time PCR. Journal of Clinical Virology 2005;34:108-14. 

14. Moghaddam A., Reinton N., Dalgard O. A rapid real-time PCR 

assay for determination virus genotypes 1, 2 and 3a. Journal of 

Viral Hepatitis 2006;13:222-9. 

15. Rolfe K.J., Alexander G.J.M., Tim G.W., et al. A real-time Taqman 

method for hepatitis C virus genotyping. Journal of Clinical 

Virology 2005;34:115-21. 

16. Mukaide M., Tanaka Y., Kakuda H., et al. New combination test 

for hepatitis C virus genotype and viral load determination 

using Amplicor GT HCV MONITOR test v2.0. World J 


17. Poynard T., Marcellin P., Lee S.S., et al. Randomized trial of interferon 

alfa 2b plus ribavirin for 48 weeks or for 24 weeks versus interferon 

alfa 2bplus placebo for 48 weeks for treatment of chronic infectious 

hepatitis C virus. Lancet 1998;352:1426-32. 

18. Tom Wong, Samuel S.L. Hepatitis C: a review for primary care 

physicians. CMAJ 2006;174(5):649-59. 

www.bjid.com.br


Noninvasive Means of Diagnosing Liver Fibrosis in Hepatitis C 

Eduardo Sellan Lopes Gonçales, Adriana Flávia Feltrim Angerami and Fernando Lopes Gonçales Junior 

Study Group on Hepatitis, Infectious Diseases Division, UNICAMP; Campinas,SP 

Liver biopsy is still considered the gold standard for 

staging fibrosis in chronic liver diseases. However, liver 

biopsy is an invasive procedure, and complications occur in 

0.6%-5% of patients [1,2]. In addition, to perform the procedure 

there is a need for additional resources such as 

ultrasonography. Therefore, as a rule, patients undergoing 

liver biopsy are hospitalized for at least 6 hours [3]. 

Recent studies involving patients with chronic hepatitis 

C showed that fragments of technically inadequate hepatic 

tissue frequently lead to the underestimation of the stage of 

liver fibrosis [4]. That rate of diagnostic error can vary from 

10%-30% depending on the study [5]. In addition, in 

developed countries, there is greater patient resistance to 

undergoing biopsy. 

In Brazil there is an additional factor, which is that patients 

are obligated to submit to liver biopsy for indication of 

treatment, except in clinically confirmed cases of hepatic 

cirrhosis according to the Ministry of Health guidelines. 

For all of these reasons, an increasing number of studies 

are being conducted in order to evaluate the effectiveness of 

noninvasive markers for staging liver fibrosis. The 

noninvasive methods used in the largest number of published 

studies are the calculation of two indices - the aspartate 

aminotransferase (AST) to platelet ratio index (APRI) and 

the FibroTest index - and the FibroScan test. 

The effectiveness of the various methods evaluated in 

various studies revealed quite heterogeneous results. The 

APRI method and the Forns index are unable to stage a large 

percentage of patients, and their accuracies do not exceed 

80-85%. Therefore, a considerable number of patients are 

required to undergo liver biopsy. Otherwise, approximately 

20% would be incorrectly diagnosed. The efficacy of those 

methods encounters difficulty regarding standardization and 

the definition of cut-off values for each degree of fibrosis. 

cut-off values are used. The absence of cirrhosis (Ishak stage 

0-4) is defined as values lower than 1, and cirrhosis (Ishak 

stage 5-6) is defined as values higher than 2 [6]. The formula 

for calculating the APRI test is as follows: 

APRI = AST(/LSN) × 100 / Platelets (10 9 /L) 

Table 1 shows the APRI values obtained. 

Table 1. The aspartate aminotransferase to platelet ratio index 

results obtained by Wai et al. 

Cut-Off PPV NPV 

No Fibrosis < 0.5 64% 90% 

Fibrosis > 1.5 91% 65% 

No Cirrhosis < 1.0 35% 100% 

Cirrhosis > 2.0 65% 95% 

PPV=positive predictive value; NPV=negative predictive value. 

Therefore, the aforementioned Wai et al. showed that the 

APRI has a high positive predictive value to identify patients 

with significant fibrosis and a high negative predictive value 

to rule out cirrhosis. That study also showed that it is possible 

to predict the presence or absence of significant fibrosis in 

51% of patients and to predict the presence or absence of 

cirrhosis in 81% of patients [6]. 

FibroTest 

FibroTest combines and analyzes the serum levels of five 

factors in patients with chronic hepatitis C. Those five factors 

are bilirubin, gamma-glutamyl transferase, apolipoprotein A1, 

alpha-2-macroglobulin and haptoglobin. The results obtained 

are evaluated through a formula which predicts and classifies 

them as F0-1, F2-3 and F4 [7]. 

APRI 

The APRI was developed by Wai et al. [6] and is calculated 

based on AST levels and platelet counts. According to the 

results obtained in that study, the lower and upper cut-off 

values for the definition of significant fibrosis and cirrhosis 

are determined. Through analysis of the results, the positive 

and negative predictive values for the presence or absence 

of significant fibrosis or cirrhosis are also determined. 

To evaluate significant fibrosis, the following cut-off 

values are used: lower than 0.5 (absence of significant fibrosis, 

Ishak stage 0-2); and higher than 1.5 (presence of significant 

fibrosis, Ishak stage 3-6)[6]. To evaluate cirrhosis, different 




FibroScan - A New Noninvasive Method 

The evaluation of the degree of liver fibrosis is of 

fundamental importance to the prognosis, follow-up and 

therapeutic decision-making for patients with chronic liver 

disease. Biopsy is an invasive method and occasionally 

(although rarely) results in complications. In addition, the 

biopsy results, from an anatomical-pathological point of view, 

are often evaluated subjectively [8,9]. Nevertheless, biopsy 

continues to be the gold standard by which fibrosis is staged 

and evaluated 

There are various studies on noninvasive options in the 

staging, evaluation and monitoring of liver fibrosis. FibroScan 

is a new method, still only available on a small scale, which 

presents better results in various studies with respect to 

differentiating between cirrhotic and noncirrhotic patients. It 

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BJID 2007; 11 Supplement 1 (October) Noninvasive Diagnosis of Fibrosis in Hepatitis C 

29 

Figure 1. Algorithm proposed by Sebastiani et al. (EASL) [14], in which the aspartate aminotransferase to platelet ratio index 

(APRI) method is used in conjunction with FibroTest. ALT=alanine aminotransferase; UDE=upper digestive tract endoscopy; 

US=ultrasound. 

Chronic hepatitis C with elevated ALT levels 

APRI 

F0-F1 

Unclassified 

F≥2 

FibroTest 

F0-F1 

F≥2 

Biopsy 

F0-F1 

Significant fibrosis (≥F2) 

is considered a quick and easy noninvasive procedure for 

diagnosing cirrhosis and has been presented as an alternative 

to liver biopsy in patients with a formal contraindication [8]. 

FibroScan measures hepatic elasticity through a transducer 

positioned intercostally on the skin over the right lobe of the 

liver. The transducer transmits low amplitude and low 

frequency vibration pulses to the hepatic tissue. This 

vibration pulses propagate an elastic wave whose velocity is 

directly related to the elasticity of the tissue. Results are 

given in kilopascals (kPa). 

Some studies have shown that body mass index and age 

of the patient, as well as the level of experience on the part of 

the health professional, can influence the FibroScan results 

of patients with chronic hepatitis C. The body mass index 

and steatosis can affect the evaluation of fibrosis, although 

some studies have shown that those factors are minimized 

if the test is repeated a fair number of times. Some studies 

recommend a total of five measurements to validate the 

results [10]. 

For the detection of fibrosis ≥ F2, FibroScan presents 

85.2% sensitivity, 90.7% specificity, 93.8% positive 

predictive value, 78.8% negative predictive value and 87.7% 

diagnostic power. For the detection of cirrhosis, the test 

presents 78.3% sensitivity, 98.2% specificity, 97.8% positive 

predictive value, 81.6% negative predictive value and 88.2% 

diagnostic power [11-13]. 

Despite the reasonable quantity of published studies, few 

have compared the methods in a randomized manner. There 

are two studies that propose algorithms for evaluation. The 

first study, published by the European Association for the 

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30 Noninvasive Diagnosis of Fibrosis in Hepatitis C 


Figure 2. Algorithm proposed by Castéra et al. [15], in which the FibroTest results are evaluated together with the FibroScan 

results. 

Detectable HCV 

RNA 

FibroScan/ 

FibroTest 

Concordance 

between the two 

methods 

No 

Yes 

Liver biopsy 

No liver biopsy 

Treatment or 

monitoring 

Fibrosis absent or 

minimal (

BJID 2007; 11 Supplement 1 (October) Noninvasive Diagnosis of Fibrosis in Hepatitis C 

31 

The study conducted by Castéra et al. proposes the 

combination of FibroScan and FibroTest as a screening 

method for significant fibrosis. When there was concordance 

between the methods, which occurred in 70%-80% of patients, 

the compatibility with the liver biopsy was 84% in diagnosing 

fibrosis ≥ F2, 95% in diagnosing fibrosis ≥ F3, and a 94% in 

diagnosing cirrhosis (F4). 

Therefore, much still needs to be studied in relation to 

the noninvasive methods for estimating the degree of 

fibrosis, which is why it is necessary to carry out randomized 

comparative studies involving different patient populations. 

Table 2. FibroScan results 

Variable Degree of fibrosis 

≥F2 ≥F3 F4 

Sensitivity 67% 73% 87% 

Specificity 89% 91% 91% 

PPV 95% 87% 77% 

NPV 48% 81% 95% 

PPV=positive predictive value; NPV=negative predictive value. 

to the fact that the majority of patients presented significant 

fibrosis. The principal limitation of these markers is the 

difficulty in obtaining confirmation for patients with F0-F1 

fibrosis. Therefore, an algorithm for the evaluation of fibrosis 

that attempts to define which patients are not required to 

undergo liver biopsy was developed. 

Another study conducted by Castéra et al. [15] compared 

the effectiveness of transitory hepatic elastography 

(FibroScan, Echosens, Paris, France) in relation to the APRI 

and FibroTest. It succeeded in showing that FibroScan has a 

great capacity to diagnose significant fibrosis (≥ F2). The 

results can be seen in Table 2. 

Therefore, it can be seen that FibroScan presents a high 

positive predictive value for patients with fibrosis ≥ F2 and 

an excellent negative predictive value for patients with hepatic 

cirrhosis. It is undoubtedly a good method for demonstrating 

significant fibrosis or for ruling out hepatic cirrhosis. 

References 

1. Perrault J., McGill D.B., Ott B.J., Taylor W.F. Liver biopsy: 

complications in 1000 inpatients. Gastroenterology 

1978;74:103-6. 

2. Gunneson T.J., Menon K.V., Wiesner R.H., et al. Ultrasoundassisted 

percutaneous liver biopsy perfomed by a physician 

assistant. Am J Gastroenterol 2002;97:1472-5. 

3. Wong J.B., Koff R.S. Watchful waiting with periodic liver biopsy 

versus immediate empirical therapy for histologically mild 

chronic hepatitis C. A cost-effectiveness analysis. Ann Intern 

Med 2000;133:665-75. 

4. Colloredo G., Guido M., Sonzogni A., Leandro G. Impact of liver 

biopsy size on histological evaluation of chronic viral hepatitis: 

the smaller the sample, the milder the disease. J Hepatol 

2003;39:239-44. 

5. Poniachik J., Bernstein D.E., Reddy K.R., et al. The role of 

laparoscopy in the diagnosis of cirrhosis. Gastrointest Endosc 

1996;43:568-71. 

6. Wai C.T., Greenson J.K., Fontana R.J., et al. A simple 

noninvasive índex can predict both significant fibrosis and 

cirrhosis in patients with chronic hepatitis C. Hepatology 

2003;38:518-26. 

7. Poynard T., McHutchison J., Manns M., et al. Biochemical 

surrogate markers of liver fibrosis and activity in a randomized 

trial of peginterferon alfa-2b and ribavirin. Hepatology 

2003;38:481-92. 

8. Transient elastography: a new surrogate marker of liver fibrosis 

influenced by major changes of transaminases. Journal of Viral 

Hepatitis 2007;14:360-9. 

9. Diagnosis of hepatic steatosis and fibrosis by transient 

elastography in asymptomatic healthy individuals: a 

prospective study of living related potencial liver donors. 

Journal of Gastroenterol 2007;42:382-8. 

10. Usefulneness of elastometry in evaluating the extents of liver 

fibrosis in hemophiliacs coinfected with hepatitis C and 

human immunodeficiency virus. Hepatology research 

2006;35:135-9. 

11. Features associated with success rate and performance of fibroscan 

measurements for the diagnosis of cirrhosis in HCV patients: a 

prospective study of 935 patients. Journal of Hepatology 

2007;46:628-34. 

12. Transient elastography: a valid alternative to biopsy in patients 

with chronic liver disease. Journal compilation 2006;24:513-8. 

13. Do not trivialize the Fibroscan examination, value its accuracy. 

Journal of Hepatology 2007;46. 

14. Sebastiani G., Vario A., Guido M., et al. Stepwise combination 

algorithms of non-invasive markers to diagnose significant 

fibrosis in chronic hepatitis C. Journal of Hepatology 

2006;44:686-93. 

15. Castéra L., Vergniol J., Foucher J., et al. Gastroenterology 

2005;128:343-50. 

www.bjid.com.br


Chronic Hepatitis C: Pathological Anatomy 

Evandro Sobroza de Mello and Venâncio Avancini Ferreira Alves 

Pathological Anatomy Division, Hospital das Clínicas of São Paulo; LIM-14: Hepatic Pathology, 

University of São Paulo School of Medicine; CICAP – Hospital Alemão Oswaldo Cruz; São Paulo, SP, Brazil 

In infections with the hepatitis C virus (HCV), there is a 

wide spectrum of histological alterations that can affect the 

liver, from acute hepatitis to mild reactive phenomena to more 

severe forms, including chronic hepatitis with varying degrees 

of inflammation/fibrosis, cirrhosis, and hepatocellular 

carcinoma. In cases of acute hepatitis C, biopsies are rare, 

pathologists focusing their attention on the chronic form of 

the disease. The histological diagnosis of chronic hepatitis 

through liver biopsy remains extremely important in the 

management of patients infected with HCV, since it is the 

cornerstone of the detection of liver disease caused by the 

virus as well as the determination of the intensity of this 

disease. It should therefore be added to the diagnosis of 

infection made using serologic methods. 

The basic parameter for the histological diagnosis of 

chronic hepatitis is the presence of portal inflammatory 

infiltrate, with predominance of lymphocytes, usually with 

variations in the number of plasmocytes and histiocytes. This 

inflammation is accompanied by periportal activity of varying 

degrees (also denominated interface activity or piecemeal 

necrosis), parenchymal activity (lobular) and fibrosis. 

There are various classification systems using in the 

scoring and staging of chronic hepatitis [4,9,11,13,18,21,34]. 

Many of those systems are of historical importance. According 

to directive no. 863, issued by the São Paulo State Secretary 

of Health on November 4, 2002, it is recommended that one of 

two chronic hepatitis classification systems be used: the 

Sociedade Brasileira de Patologia (SBP, Brazilian Society of 

Pathology) system [13] or the METAVIR system [1,4]. These 

two systems are in fact very similar, and they both take into 

account the previously mentioned basic aspects of chronic 

hepatitis: periportal activity, lobular activity, and fibrosis. In 

addition to these, the classification system proposed by Ishak 

in 1995 [18] has been widely used in international literature. 

The Ishak system is an update of the system proposed by the 

same author in 1981, which gained popularity and was 

commonly referred to as the Knodell system [21] (a designation 

that should no longer be used), has been widely used in 

international literature. Table 1 shows an approximate 

correspondence between these systems, both for fibrosis 

(architectural alteration) and for periportal/lobular activity. 




Protocol of Histological Evaluation for Liver Biopsies of 

Patients with Chronic viral Hepatitis 

This protocol can be applied to several etiologies of 

chronic hepatitis, including, in addition to HCV, HBV, autoimmune 

hepatitis and, less frequently, Wilson’s disease or 

some forms of drug-induced hepatitis. The protocol is based 

on the criteria of the SBP National Consensus of Chronic 

Hepatitis [13]. 

1) Sample type (needle biopsy, wedge biopsy, resected 

surgical sample, other): 

2) Sample size 

Number of portal spaces in the biopsy: _____ 

3) Histological variables: 

• Portal fibrosis: 

( ) 0 (absent) 

( ) 1 (discrete, without septum formation) 

( ) 2 (with portal-portal septa) 

( ) 3 (with portal-portal and portal-central septa, with 

formation of nodules – in ‘nodular transformation’) 

( ) 4 (cirrhosis) 

• Portal inflammation 


( ) 1 (discrete) 

( ) 2 (moderate) 

( ) 3 (pronounced) 

( ) 4 (very pronounced) 

• Periportal activity (interface activity) 


( ) 1 (presence of spillover only) 

( ) 2 (discrete piecemeal necrosis – occasional foci in 

some portal spaces) 

( ) 3 (moderate piecemeal necrosis – occasional foci in 

many portal spaces or innumerable foci in few portal 

spaces) 

( ) 4 (pronounced piecemeal necrosis - innumerable foci 

in many portal spaces) 

• Parenchymal activity 


( ) 1 (tumefaction, lymphocyte sinusoidal infiltrate and 

occasional foci of lytic hepatocytic necrosis) 

( ) 2 (innumerable foci of lytic hepatocytic necrosis) 

( ) 3 (occasional areas of confluent necrosis) 

( ) 4 (innumerable areas of confluent necrosis or areas 

of panacinar necrosis) 

• Histological evidence of association with other conditions: 

( ) level ______ siderosis 

( ) steatohepatitis markers 

( ) others:______ 

Nature and Size of the Liver Biopsy 

Surgical biopsies performed with forceps generate 

subcapsular samples and should be discouraged, since the 

portal spaces in this location are frequently large, and it is 

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BJID 2007; 11 Supplement 1 (October) Chronic Hepatitis C – Pathological Anatomy 

33 

Table 1. Approximate equivalence of the most widely used classification systems for the staging and scoring of chronic hepatitis 

difficult or impossible to correctly evaluate the presence of 

fibrosis. Even during the surgical procedure, therefore, liver 

biopsy should be performed with a needle. In addition, the 

biopsy should preferably be performed at the outset of the 

surgery in order to prevent alterations secondary to surgical 

manipulation. 

Data in the literature demonstrate that the size of the needle 

biopsy greatly influences the result of the analysis 

[8,10,15,33,35]. Samples measuring 3.0 cm or more in length, 

show hepatitis with mild activity, as a result, in only 50% of 

the cases; 1.5-cm long samples, in 60%; and those measuring 

1.0 cm or less, in almost 90% of the cases [8]. Other authors 

have also considered 1.5 cm as the minimum size for diagnosis 

in needle liver biopsy [35]. Thin needles have also provided 

inferior results [8,33]. Bedossa et al. [3] only achieved a 

precision plateau with 2.5-cm long biopsies. Therefore, 1.5- 

cm long biopsies should be considered the minimum 

necessary size and, ideally, they should measure 2.5 cm or 

more. Larger diameter needles, such as Tru-Cut needles, are 

also recommended. 

Steatosis 

Approximately 50% of the biopsy samples collected from 

patients with HCV present steatosis [17,40]. The evaluation 

of the presence of steatosis, its scoring, and the evaluation of 

the presence of associated steatohepatitis has gradually 

become more important [6,7,12,16,19,20,24,29-32,36,40]. 

The spectrum of steatosis, steatohepatitis and cirrhosis has 

been denominated nonalcoholic fatty liver disease (NAFLD). 

Although NAFLD is common in the population in general, 

concomitance between NAFLD and HCV is 2-3 times greater 

Architectural Alteration (Fibrosis)* 

SBP, 2000 METAVIR, 1994 Ishak, 1995 

0 0 0 

1 

2 

1 

2 

1 or 2 

3 

3 3 4 or 5 

4 4 6 

Parenchymal activity 

Inflammatory Activity** 

SBP, 2000 and Ishak, 1995 METAVIR, 1994 

Periportal activity 

A 

0 or 1 0 0 

0 or 1 

2 

1 or 2 

0–1 

1 

1 

2 2 2 

2 

3 

3–4 

0–2 

3 

2 

3 3–4 3 

4 0–4 3 

SBP= Sociedade Brasileira de Patologia (SBP, Brazilian Society of Pathology). *Maximum Ishak 

score, 6; maximum METAVIR score, 4; maximum SBP score, 4. **Corresponds to periportal and 

parenchymal activity, independently, for SBP and Ishak, and mixed periportal and lobular for METAVIR; 

in the METAVIR classification, the activity score reaches 3, whereas in Ishak and SBP it reaches 4. 

than what would be expected only at random [24]. In patients 

with chronic HCV infection, steatosis has been attributed to a 

series of factors usually associated with NAFLD, including 

high body mass index, insulin resistance and old age [16,26,31]. 

Evidence also indicates that steatosis contributes to the 

progression of fibrosis in a pattern similar to that seen in NAFLD 

[7,16,17,40]. 

It has been suggested that steatosis can also result from 

the viral cytopathic effect, especially in patients infected with 

genotype 3. In a series of patients with genotype 3 and steatosis, 

a sustained virological response led to regression of steatosis in 

91% of the cases, a much higher index than the 19% observed for 

those who did not present sustained virological response [6], 

making the cytopathic effect a more consistent cause of steatosis. 

Other authors have reported similar results [22,36]. 

In HCV-positive patients, it is currently essential to 

characterize steatosis and related injuries, especially the 

presence and quantification of perisinusoidal and centrilobular 

fibrosis, which characterizes steatohepatitis. The lesson we learn 

from steatosis is that, in HCV-infected patients, biopsy is an 

instrument for the detection of liver diseases, whether associated 

with the virus or not, and that we should be prepared for other 

(probably less common) liver diseases that might be present in 

a particular case. 

Histopathological Aspects of Post-Transplant HCV 

Recurrence 

Immediate post-transplant virological recurrence of HCV 

is universal, and the progression of the disease is more rapid 

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34 Chronic Hepatitis C – Pathological Anatomy 


than in non-transplanted patients [22A]. Long-term studies have 

shown that 70-90% of cases will present histological recurrence 

of the disease [20A,23A]. In most cases, hepatitis C 

histologically manifests in the same manner before the 

transplant: with portal and parenchymal inflammation, 

aggression of the interface with piecemeal necrosis, and fibrosis 

at portal spaces. Steatosis and ductal injury are also common 

findings. Earlier findings are often predominantly lobular, with 

inflammation and apoptotic bodies (acute hepatitis), and 

steatosis is occasionally the first histological manifestation 

[4A]. In a small proportion of cases, hepatitis C can result in a 

severe, rapidly progressive cholestatic pattern, which leads to 

loss of the graft [36A,41,42]. Due to the low tolerance of 

transplanted individuals to the treatment with interferon and 

ribavirin [24A,45], the evaluation of the biopsy is crucial for 

indication of treatment. Some anatomopathological aspects can 

be useful in predicting its evolution: histological recurrence in 

less than six months [46]; level of inflammatory activity [23A,44]; 

marked ballooning of hepatocytes; and cholestasis [43]. 

Histopathological Criteria for Possible Predictive Value of 

Worse Evolution 

In chronic hepatitis, the contribution of the 

histopathological analysis of the samples collected by liver 

biopsy is currently considered decisive for diagnosis, for 

staging of the architectural damage, and for determining the 

level of necroinflammatory activity, assuming a decisive role 

in indicating the therapy with antiviral agents. 

In our view, in addition to reports on that decision, as 

summarized in the METAVIR, Ishak, Scheuer, and Desmet 

classification systems, or, among us, the SBP/Brazilian Society 

of Hepatology consensus led by Gayotto, most recent 

evidence brings back the need of a detailed report of each of 

the principal forms of liver damage, and there have been 

studies that demonstrate a more rapid evolution of cases that 

present, among other predictive factors, more interface activity, 

confluent necrosis of hepatocytes, and steatosis [47,48]. 

A study involving 106 patients with initial biopsy 

presenting architectural staging 0 or 1 and re-biopsied after a 

mean interval of 7.8 years (minimum of 48 months) [48] revealed 

progression of architectural damage in 64 cases (60.4%), 

suggesting the need for therapeutic intervention, even in 

infected individuals not yet presenting significant alterations 

to the hepatic architecture. Among the predictive factors for 

progression of the injury, those authors highlight the level of 

necroinflammatory activity: 31.2% of the cases with moderate 

activity (A2) presented progression, which only occurred in 

2.3% of those without activity (A0) and the presence of 

steatosis (progression in 87.5% of the cases with > 30% cells 

with steatosis, in 80% of those with < 30% steatosis, and in 

only 48.6% without steatosis). 

Other authors also emphasize the presence and extent of 

steatosis as a risk factor for progression of injuries in chronic 

hepatitis C, either resulting from viral cytopathic effect, as 

proposed for genotype 3a [49], or associated with coexistent 

steatohepatitis, alcoholic [50] or nonalcoholic [47]. A recent 

meta-analysis including 3068 Italian patients infected with 

HCV and submitted to biopsy [51] confirmed that steatosis is 

independently associated with genotype 3, fibrosis, diabetes, 

inflammatory liver activity, drinking, body mass index, and 

older age. 

Important experience was brought to debate in the most 

recent European Hepatology Congress: analyzing predictive 

factors of damage progression in 563 cases of HCV with mean 

intervals between biopsies of 5.4 years [52], it was determined 

that, in contrast to generic approaches that suggested that 

liver damage progress in a relatively uniform, linear manner, the 

speed of progression varied considerably in each patient. These 

authors, selecting statistically significant variables, identified 

the risk of progression associated with various architectural 

alterations (Table 2).We find, therefore, that important current 

studies demonstrate the outstanding contribution of 

histopathological findings in the discrimination of differentiated 

progression risk in patients chronically infected with HCV. More 

than dividing patients in classes that deserve antiviral treatment 

or not, most recent evidence point to the need of reviewing the 

systems of histological scoring, and the pathologist should 

inform, in addition to the stage of architectural alteration, the 

level of each type of necroinflammatory damage in each acinar 

compartment of the liver. 

Table 2. Progression risks of architectural alterations 

Factor 

Relative Risk 

Age > 50 years 1.6 

Brindging necrosis 4.0 

Confluent necrosis 3.4 

Piecemeal necrosis 2.9 

Steatosis 

Moderate/Pronounced 3.8 

Discrete 2.1 

Perivenular fibrosis 2.6 

References 

1. The French METAVIR Cooperative Study Group. Intraobserver 

and interobserver variations in liver biopsy interpretation in 

patients with chronic hepatitis C. Hepatology 1994;20:15-20. 

2. Bain V.G., Bonacini M., Govindarajan S., et al. A multicentre study 

of the usefulness of liver biopsy in hepatitis C. J Viral Hepat 

2004;11:375-82. 

3. Bedossa P., Dargere D., Paradis V. Sampling variability of liver 

fibrosis in chronic hepatitis C. Hepatology 2003;38:1449-57. 

4. Bedossa P., Poynard T. An algorithm for the grading of activity in 

chronic hepatitis C. The METAVIR Cooperative Study Group. 

Hepatology 1996;24:289-93. 

4a.Baiocchi L., Tisone G., Palmieri G., et al. Hepatic steatosis: a 

specific sign of hepatitis C reinfection after liver transplantation. 

Liver Transpl Surg 1998;4:441-7. 

5. Berg T., Sarrazin C., Hinrichsen H., et al. Does noninvasive staging 

of fibrosis challenge liver biopsy as a gold standard in chronic 

hepatitis C? Hepatology 2004;39:1456-7; author reply 1457- 

1458. 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Chronic Hepatitis C – Pathological Anatomy 

35 

6. Castera L., Hezode C., Roudot-Thoraval F., et al. Effect of 

antiviral treatment on evolution of liver steatosis in 

patients with chronic hepatitis C: indirect evidence of a 

role of hepatitis C virus genotype 3 in steatosis. Gut 

2004;53:420-4. 

7. Cholet F., Nousbaum J.B., Richecoeur M., et al. Factors associated 

with liver steatosis and fibrosis in chronic hepatitis C patients. 

Gastroenterol Clin Biol 2004;28:272-8. 

8. Colloredo G., Guido M., Sonzogni A., Leandro G. Impact of liver 

biopsy size on histological evaluation of chronic viral hepatitis: 

the smaller the sample, the milder the disease. J Hepatol 

2003;39:239-44. 

9. De Groote J., Desmet V.J., Gedigk P., et al. A classification of 

chronic hepatitis. Lancet 1968;2:626-8. 

10. Demetris A.J., Ruppert K. Pathologist’s perspective on liver needle 

biopsy size? J Hepatol 2003;39:275-7. 

11. Desmet V.J., Gerber M., Hoofnagle J.H., et al. Classification of 

chronic hepatitis: diagnosis, grading and staging. Hepatology 

1994;19:1513-20. 

12. Fiore G., Fera G., Napoli N., et al. Liver steatosis and chronic 

hepatitis C: a spurious association? Eur J Gastroenterol Hepatol 

1996;8:125-9. 

13. Gayotto L.C.C., Alves V.A., Cerski C.T., et al. Visão Histórica e 

consenso nacional sobre a classificação das hepatites crônicas - 

projeto do clube de patologia hepática da Sociedade brasileira de 

Patologia aprovado pela Sociedade Brasileira de Hepatologia. 

GED 2000;19:137-40. 

14. Giannini E., Testa R. Noninvasive diagnosis of fibrosis: the truth 

is rarely pure and never simple. Hepatology 2003;38:1312-13; 

author reply 1313. 

15. Holund B., Poulsen H., Schlichting P. Reproducibility of liver 

biopsy diagnosis in relation to the size of the specimen. Scand J 

Gastroenterol 1980;15:329-35. 

16. Hu K.Q., Kyulo N.L., Esrailian E., et al. Overweight and obesity, 

hepatic steatosis, and progression of chronic hepatitis C: a 

retrospective study on a large cohort of patients in the United 

States. J Hepatol 2004;40:147-54. 

17. Hwang S.J., Luo J.C., Chu C.W., et al. Hepatic steatosis in chronic 

hepatitis C virus infection: prevalence and clinical correlation. 

J Gastroenterol Hepatol 2001;16:190-5. 

18. Ishak K., Baptista A., Bianchi L., et al. Histological grading and 

staging of chronic hepatitis. J Hepatol 1995;22:696-9. 

19. Ismail F.W., Hamid S.S. Hepatic steatosis and hepatitis C. J Pak 

Med Assoc 2004;54:108-9. 

20. Khokhar N., Mushtaq M., Mukhtar A.S., Ilahi F. Steatosis and 

chronic hepatitis C virus infection. J Pak Med Assoc 

2004;54:110-2. 

20a. Feray C., Gigou M., Samuel D., et al. The course of hepatitis C 

virus infection after liver transplantation. Hepatology 

1994;20:1137-43. 

21. Knodell R.G., Ishak K.G., Black W.C., et al. Formulation and 

application of a numerical scoring system for assessing 

histological activity in asymptomatic chronic active hepatitis. 


22. Kumar D., Farrell G.C., Fung C., George J. Hepatitis C virus 

genotype 3 is cytopathic to hepatocytes: Reversal of hepatic 

steatosis after sustained therapeutic response. Hepatology 

2002;36:1266-72. 

22a. Gane E. The natural history and outcome of liver transplantation 

in hepatitis C virus-infected recipients. Liver Transpl 

2003;9:S28-34. 

23. Lebensztejn D.M., Kaczmarski M., Sobaniec-Lotowska M., 

Barwijuk-Machala M. Blind liver biopsy in children-diagnostic 

significance and complications in authors’ own material. Med 

Sci Monit 2000;6:1155-8. 

23a. Gane E.J., Portmann B.C., Naoumov N.V., et al. Long-term 

outcome of hepatitis C infection after liver transplantation. N 

Engl J Med 1996;334:815-20. 

24. Lonardo A., Adinolfi L.E., Loria P., et al. Steatosis and hepatitis C 

virus: mechanisms and significance for hepatic and extrahepatic 

disease. Gastroenterology 2004;126:586-97. 

24a. Garcia-Retortillo M., Forns X. Prevention and treatment of 

hepatitis C virus recurrence after liver transplantation. J Hepatol 

2004;41:2-10. 

25. Lu L.G., Zeng M.D., Wan M.B., et al. Grading and staging of 

hepatic fibrosis, and its relationship with noninvasive diagnostic 

parameters. World J Gastroenterol 2003;9:2574-8. 

26. Monto A., Alonzo J., Watson J.J., et al. Steatosis in chronic 

hepatitis C: relative contributions of obesity, diabetes mellitus, 

and alcohol. Hepatology 2002;36:729-36. 

27. Myers R.P., Benhamou Y., Imbert-Bismut F., et al. Serum 

biochemical markers accurately predict liver fibrosis in HIV and 

hepatitis C virus co-infected patients. AIDS 2003;17:721-5. 

28. Myers R.P., Tainturier M.H., Ratziu V., et al. Prediction of liver 

histological lesions with biochemical markers in patients with 

chronic hepatitis B. J Hepatol 2003;39:222-30. 

29. Negro F. Hepatitis C virus and liver steatosis: when fat is not 

beautiful. J Hepatol 2004;40:533-5. 

30. Patton H.M., Patel K., Behling C., et al. The impact of steatosis 

on disease progression and early and sustained treatment response 

in chronic hepatitis C patients. J Hepatol 2004;40:484-90. 

31. Ramalho F. Hepatitis C virus infection and liver steatosis. Antiviral 

Res 2003;60:125-7. 

32. Rubbia-Brandt L., Fabris P., Paganin S., et al. Steatosis affects 

chronic hepatitis C progression in a genotype specific way. Gut 

2004;53:406-12. 

33. Scheuer P.J. Liver biopsy size matters in chronic hepatitis: bigger 

is better. Hepatology 2003;38:1356-8. 

34. Scheuer P.J. The nomenclature of chronic hepatitis: time for a 

change. J Hepatol 1995;22:112-4. 

35. Schlichting P., Holund B., Poulsen H. Liver biopsy in chronic 

aggressive hepatitis. Diagnostic reproducibility in relation to 

size of specimen. Scand J Gastroenterol 1983;18:27-32. 

36. Sharma P., Balan V., Hernandez J., Rosati M, Williams J, Rodriguez- 

Luna H, Schwartz J, Harrison Eet al. Hepatic steatosis in hepatitis 

C virus genotype 3 infection: does it correlate with body mass 

index, fibrosis, and HCV risk factors? Dig Dis Sci 2004;49:25-9. 

36a. Kaneko J., Sugawara Y., Akamatsu N., et al. Cholestatic hepatitis 

due to hepatitis C virus after a living donor liver transplantation. 

Hepatogastroenterology 2004;51:243-4. 

37. Terjung B., Lemnitzer I., Dumoulin F.L., et al. Bleeding 

complications after percutaneous liver biopsy. An analysis of 

risk factors. Digestion 2003;67:138-45. 

38. Wai C.T., Greenson J.K., Fontana R.J., et al. A simple noninvasive 

index can predict both significant fibrosis and cirrhosis in patients 

with chronic hepatitis C. Hepatology 2003;38:518-26. 

39. Wawrzynowicz-Syczewska M., Kruszewski T., Boron-Kaczmarska 

A. Complications of percutaneous liver biopsy. Rom J 

Gastroenterol 2002;11:105-7. 

40. Wyatt J., Baker H., Prasad P., et al. Steatosis and fibrosis in patients 

with chronic hepatitis C. J Clin Pathol 2004;57:402-6. 

41. Pessoa M.G., Bzowej N., Berenguer M., et al. Evolution of hepatitis 

C virus quasispecies in patients with severe cholestatic hepatitis 

after liver transplantation. Hepatology 1999;30:1513-20. 

42. Troppmann C., Rossaro L., Perez R.V., McVicar J.P. Early, rapidly 

progressive cholestatic hepatitis C reinfection and graft loss 

after adult living donor liver transplantation. Am J Transplant 

2003;3:239-40. 

43. Pelletier S.J., Iezzoni J.C., et al. Prediction of liver allograft 

fibrosis after transplantation for hepatitis C virus: 

persistent elevation of serum transaminase levels versus 

necroinflammatory activity. Liver Transpl 2000;6:44-53. 

44. Prieto M., Berenguer M., Rayon J.M., et al. High incidence 

of allograft cirrhosis in hepatitis C virus genotype 1b 

infection following transplantation: relationship with 

rejection episodes. Hepatology 1999;29:250-6. 

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36 Chronic Hepatitis C – Pathological Anatomy 


45. Samuel D., Bizollon T., Feray C., et al. Interferon-alpha 2b plus 

ribavirin in patients with chronic hepatitis C after liver 

transplantation: a randomized study. Gastroenterology 

2003;124:642-50. 

46. Testa G., Crippin J.S., Netto G.J., et al. Liver transplantation for 

hepatitis C: recurrence and disease progression in 300 patients. 

Liver Transpl 2000;6:553-61. 

47. Westin J., Nordlinder H., Lagging M., et al. Steatosis accelerates 

fibrosis development over time in hepatitis C vírus genotype 3 

infected patients. J Hepatol 2002;37:837-42. 

48. Boccato S., Pistis R., Noventa F., et al. Fibrosis Progression in initially 

mild chronic hepatitis C. J Viral Hepat 2006;13:297-302. 

49. Rubbia-Brandt L., Leandro G., Spahr L., et al. Liver steatosis in 

chronic hepatitis C: a morphological sign suggesting infection 

with HCV genotype 3. Histopathology 2001;39:119-24. 

50. Pessione F., Degos F., Marcellin P., et al. Effect of alcohol 

consumption on serum hepatitis C virus RNA and histological 

lesions in chronic hepatitis C. Hepatology 1998;27:1717-22. 

51. Leandro G., Mangia A., Hui J., et al. Relationship between steatosis, 

inflammation, and fibrosis in chronic hepatitis C: a meta-analysis 

of individual patient data. Gastroenterology 2006;130:1636-42. 

52. Silini E.M., Cavallero A., Dal Bello B., et al. Modelling liver fibrosis 

progression in chronic hepatitis C: A study of 563 patients with 

sequential liver biopsies. J. Hepatol 2006;44(S2):S36-81. 

www.bjid.com.br


Co-Infection with Hepatitis B Virus and Hepatitis C Virus 

Heloísa Pedrosa Mitre and João Silva de Mendonça 

Infectious Diseases Division of the Hospital for State Civil Servants; São Paulo, SP, Brazil 

The hepatitis B virus (HBV) and the hepatitis C virus (HCV) 

share common transmission pathways. Therefore, co-infection 

can be expected. The World Health Organization estimates 

that, worldwide, 170 million people are infected with HCV, and 

350 million people are infected with HBV. However, the number 

of individuals co-infected with both viruses is unknown. 

Although various studies have evaluated small numbers 

of co-infected individuals, the inclusion criteria, parameters 

assessed, and study designs are not uniform. In addition, 

ethnicity, local epidemiology, and viral genotypes are also 

diverse. Therefore, the conclusions of a specific study, in 

principle, should not be widespread. 

In cases of co-infection with HBV and HCV, the replication of 

either virus can be inhibited, just as either virus can be dominant 

or the dominance can alternate between the two. It is more common 

for HBV to appear to be suppressed by HCV. The chronologies 

of the two infections have an influence on which virus will be 

dominant. Molecular biology techniques (to determine levels of 

HCV RNA and HBV DNA) have facilitated the definition of the 

interaction between the two viruses. 

Co-infections can appear in various manners: 

a) Simultaneous acute infection with HBV and HCV: 

presupposes same source and transmission pathway. The 

number of studies is small, but indicates that the interaction 

between the two viruses is similar to that which occurs in 

chronic infections. There are descriptions of cases in which 

there is a delay in the identification of the Hepatitis B surface 

antigen (HBsAg), lower levels of alanine aminotransferase 

(ALT), and lower HBV antigenemia, which can be attributed 

to suppression of HBV activity by HCV. 

b) Superinfection by one virus, the other virus being 

chronically present: it should be suspected above all in 

individuals with risk factors, such as the use of illicit 

intravenous drugs, multi-transfused individuals, and those 

living in areas of high HBV prevalence. 

Superinfection by HCV: infection by HCV in a patient that 

is already infected with HBV. This is known in Asian countries, 

where the prevalence of HBV is high. 

The viral suppression of the HCV may occur, although the 

viral suppression of the HBV is more frequent, noted by lower 

levels of HBV DNA and lower DNA polymerase activity, as 

well as by the hepatic expression of HBsAg and hepatitis B 

core antigen (HBcAg), clearance of the hepatitis B e antigen 

(HBeAg) or even of the HBsAg. 

The HCV core antigen seems to affect the transcription of 

HBV and, as a result, its replication, which is reported to be 

more accentuated for the HCV genotype 1. 




After HBV clearance, HCV can persist, resulting in chronic 

hepatitis. In addition, there is the possibility of evolution to 

severe disease, with a risk of death. 

Superinfection by HBV: infection by HBV in an individual 

that is already chronically infected with HCV. The HCV RNA 

levels are lower, and, in a study conducted in Italy, HCV 

clearance was higher in co-infected individuals (71%) than in 

mono-infected individuals (14%). 

However, the HBV DNA levels can be lower than those of 

mono-infected individuals, indicating HCV interference. 

Therefore, one virus can induce the clearance of another. 

The evolution to severe forms of the disease, with 

fulminant hepatitis profiles, has also been described. 

c) Asymptomatic infection with HBV: there are reports of 

patients infected with HCV, with low levels of HBV DNA, 

reactive anti-HBc, however, non-reactive HBsAg, HBeAg, 

anti-HBe, and anti-HBs, configuring co-infection with HCV 

with asymptomatic HBV. 

These individuals evolve with high ALT levels and high 

histological activity. There are reports in which biopsies 

from such patients were evaluated, and cirrhosis was found 

in 33% of the cases, compared with 19% for patients 

presenting chronic mono-infections. 

The data suggest that the evolution of the disease is more 

severe in co-infected individuals. 

There are various potential outcomes: 

a) Clearance of both viruses: negative HBsAg and, 

eventually, appearance of anti-HBs. The anti-HCV remains 

reactive. However, both HBV DNA and HCV RNA become 

undetectable. This is the best evolution for both viruses. 

b) Fulminant hepatitis: several studies indicate that 

individuals co-infected with HBV and HCV have a higher 

risk of evolution to fulminant hepatitis. In a prospective 

study involving patients with acute hepatitis C, of those 

who died, 23% were chronically infected with HBV, whereas 

only 2.9% were infected with HBV (OR=10.2). 

In a study conducted in France, among 40 patients with 

fulminant or sub-fulminant hepatitis, 12.5% presented acute 

hepatitis B or C, and 7.5% presented superinfection with 

HCV. 

c) Chronic hepatitis: of all possible events, this is the one 

that occurs most frequently and presents treatment 

possibilities. Among the chronic cases of hepatitis, several 

immunological and molecular-biological profiles can be 

identified: 

Active HBV and HCV: detectable HBV DNA and HCV RNA 

in serum. This situation has higher possibility of evolution to 

cirrhosis and hepatic decompensation. In these cases, 

treatment may be considered, either with interferon (IFN) + 

ribavirin (RBV) or IFN + lamivudine (LMV). 

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38 HBV/HCV Co-Infection 


Inactive HBV and active HCV: with evolution to undetectable 

HBV DNA and detectable HCV RNA. If treatment is indicated, 

IFN + RBV is the treatment of choice. 

Active HBV and inactive HCV or previous infection with 

HCV: with reactive HBsAg and HBeAg, detectable HBV DNA 

and undetectable HCV RNA. 

If indicated, therapeutic options may be IFN or IFN + LMV. 

Cirrhosis: co-infected individuals have a higher risk of 

evolution to cirrhosis if compared with mono-infected 

individuals (44% and 21%, respectively) as well as a higher 

risk of chronic hepatitis decompensation. 

Hepatocellular carcinoma: evidence indicates that the 

possibility of evolution to hepatocellular carcinoma (HCC) is 

higher in co-infected individuals. A prospective study 

comprising 290 individuals with cirrhosis concluded that, in 

the univariate and multivariate analyses, co-infection with 

HBV and HCV is a predictive factor for the development of 

HCC. These conclusions were confirmed in subsequent 

studies, in which the incidence of HCC in individuals coinfected 

with HBV and HCV was 2 and 3.7 cases/100 

individuals/year, respectively. 

The cumulative risk of HCC development in 10 years was 

45% in co-infected individuals, 16% in individuals monoinfected 

with HBV, and 28% in individuals mono-infected with 

HCV. 

Treatment 

The treatment guidelines have been defined in monoinfected 

individuals, among others, by professional associations 

of liver researchers, such as the Asian-Pacific Association for 

the Study of the Liver, the European Association for the Study 

of the Liver, and the American Association for the Study of 

Liver Diseases. According to these guidelines, the choice of 

pegylated interferon over conventional interferon was defined 

in association with ribavirin in cases of chronic infection with 

HCV, and, in isolation, in cases of chronic infection with HBV, 

when the administration of antiviral drugs is also considered. 

On the other hand, the treatment of individuals co-infected 

with HBV and HCV is complex due to the interaction between 

both viruses, and between both viruses and the host 

immunologic system. Standards for these treatments are not 

yet available. However, the therapeutic regimen should be 

carefully chosen and should be based on serologic markers, 

viremia levels, histology, and, above all, definition of the 

dominant virus. 

Individuals with uncompensated cirrhosis should be 

referred to facilities specializing in liver transplantation. 

Interferon 

Since IFN is an immunomodulating drug, with antiviral 

and antiproliferative effect, it is effective against HBV and 

HCV. It is also the most widely studied therapeutic option. 

The first study in co-infected individuals, carried out in the 

1990s, suggests that higher doses (9 MU 3 times a week) are 

more effective for the clearance of HBV or HCV. 

If suppression of one of the viruses is achieved, there is 

the possibility of reactivation of the other, since the suppressor 

effect of the former has been removed. Pegylated IFN, which 

is more effective in mono-infected individuals, can have a 

similar effect in co-infected individuals. 

In the infection with HCV and asymptomatic HBV 

infection, the histological changes and activity are typically 

pronounced. The response to treatment is less favorable and 

respondents present recurrence (downregulation?). 

IFN + RBV: this is the regimen that performs best in 

individuals mono-infected with HCV. There have been various 

studies, involving small samples of co-infected individuals, 

reporting rates of sustained biochemical response and 

sustained virologic response (SVR) that are comparable to 

those of mono-infected individuals, especially if HCV is the 

dominant virus. 

Due to the viral interaction, it is extremely important that 

HBV activity is monitored. It is known that at least half of the 

patients present HBV reactivation at the beginning of the 

treatment, and that 45% will have ‘flare-ups’. Therefore, we 

should pay attention to HBV, even if HBV DNA is undetectable 

at the beginning of the treatment. Over the course of the 

disease, HBV DNA can become undetectable in 10% to 30% 

of the patients. 

IFN + LMV: small studies suggest that the addition of LMV 

is useful, above all in patients with active HBV. One such study 

described eight HBeAg-reactive patients, in whom HBV DNA 

and HCV RNA were detected, submitted to a 12-month course 

of IFN + LMV, followed by an additional six months of treatment 

with LMV. In approximately one-third of the patients, there was 

HBV and HBeAg clearance. In half of the patients, there was 

normalization of ALT, HCV clearance, and an SVR. 

It would be premature to venture an opinion on what is 

the most appropriate regimen, considering that further studies, 

involving larger patient samples, are still needed. 

Adefovir and entecavir: there have been no studies involving 

co-infected individuals. These might be good options in 

patients with dominant HBV. 

Liver transplantation: little experience with co-infected 

individuals. 

There are reports of higher survival compared with 

individuals mono-infected with HBV, with suggestion of the 

benefit of HCV suppression over HBV in immunosuppression 

after transplantation. 

In order to define the risks and benefits, it is necessary to 

await the results of further, larger studies. 

Triple Co-Infection 

a) HBV, HCV, and hepatitis D virus (HDV): only patients 

who are already infected with HBV can acquire HDV. The 

triple infection can occur in certain geographic areas where 

the prevalence of infection with HBV is high. 

The evolution to severe disease is described, the desired 

treatment being that that consists of high doses of IFN for a 

long period and, still, with poor responses. 

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BJID 2007; 11 Supplement 1 (October) HBV/HCV Co-Infection 

39 

There are few relevant studies in the literature, and all of 

those involved small study samples, which precludes the 

standardization of the procedure in these cases. There are 

reports of treatment of seven patients with achievement of 

sustained biochemical response in two patients, and 

worsening with side effects in two other patients. 

b) HBV, HCV, and HIV: in these cases, the complexity of 

the HBV/HCV interaction is added to the effect of the HIV on 

the host immunologic system. 

It is known that, in HCV/HIV and HBV/HIV co-infections, 

the evolution of the hepatic disease is faster and potentially 

more severe. In addition, after the introduction of the highdose 

anti-HIV therapy known as highly active antiretroviral 

therapy, the mortality rate for chronic liver diseases has 

increased. 

There are few studies on the treatment of individuals coinfected 

with HBV, HCV, and HIV. The rate at which an SVR is 

achieved has been reported to be 17% with the use of IFN, 

compared with 25% for IFN + RBV. 

It must be borne in mind that, due to the frequent use of 

LMV in the antiretroviral therapy for HIV, HBV resistance to 

LMV is high in co-infected individuals. 

In one small study, the effect against the dominant virus, 

HBV or HCV, did not lead to the reactivation of the other, 

except in one case involving a patient with a very low CD4 

lymphocyte count. 

Studies of new antiviral drugs that are more effective 

against HBV (tenofovir, entecavir, adefovir, etc.) in HBV/ 

HIV or HBV/HCV/HIV co-infected individuals might inform 

therapeutic decisions regarding the complex treatment of 

co-infections involving HBV. 

References 

1. Chakravarti A., et al. Characteristics of dual infection of hepatitis B 

and C viruses among patients with chronic liver disease: a study 

from tertiary care hospital. Trop Gastroenterol 2005;26:183-7. 

2. Crockett S.D., et al. Natural story and treatment of hepatitis B 

virus and hepatitis C virus coinfection. Ann Clin Microbiol 

Antimicrob 2005;4:1-12. 

3. French A.L., et al. Isolated hepatitis B core antibody is associated 

with HIV and ongoind but not resolved hepatitis C virus infection 

in a cohort of US women. JID 2007;195:1437-41. 

4. Liu Z., et al. Hepatitis B virus (HBV) and hepatitis C virus (HCV) 

dual infection. Int J Med Sci 2006;3:57-62. 

5. Sagnelli E., et al. Virologic and clinical expressions of reciprocal 

inhibitory effect of hepatitis B, C, and Delta viruses in patients 

with chronic hepatitis. Hepatology 2000;32:1106-10. 

6. Sagnelli E., et al. HBV superinfection in hepatitis C cirus chronic carriers, 

viral interaction, and clinical course. Hepatology 2002;36:1285-91. 

7. Sagnelli E., et al. Hepatitis C virus superinfection in hepatitis B 

virus chronic carriers: a reciprocal viral interaction and a variable 

clinical course. J Clin Virol 2006;35:317-20. 

8. Soriano V., et al. Treatment of chronic hepatitis B or C in HIVinfected 

patients with dual viral hepatitis. JID 2007;195:1181-3. 

9. Wang Y.M., et al. Suppression of hepatitis C virus by hepatitis B 

virus in coinfected patients at the National University Hospital 

of Singapore. J Gastroenterol 1999;34:481-5. 

www.bjid.com.br


Co-Infection with Hepatitis C Virus and Human T Lymphocyte Virus 

Carlos Brites Alves 

Federal University of Bahia, School of Medicine; Salvador, BA, Brazil 

Most individuals infected with human T lymphocyte virus 

(HTLV) type 1 or 2 will not develop the disease related to this 

virus, remaining asymptomatic for the rest of their lives. This 

fact has important implications for prospective counseling 

and evaluation of this population. Individuals infected with this 

virus, once identified, should be submitted to anamnesis and 

complete physical examination (in order to identify early 

manifestations of the disease and probable forms of acquiring 

the infection) and should be periodically evaluated every 6-12 

months. It is recommended that injection drug users be tested for 

other pathogens common to this population, such as the hepatitis 

B virus, the hepatitis C virus (HCV), HIV, etc. It is recommended 

that partners of sexually active individuals be tested for HTLV. 

Children of women infected with HTLV-1 should be tested. 

Follow-up evaluations should include the following 

periodic laboratory tests (every 6-12 months): complete blood 

workups with platelet counts; parasitological stool 

examination (testing for Strongyloides); urine and urine 

sediment test (urinary infection). Although the proviral load 

of HTLV-1 is still under evaluation and has yet to be validated, 

some studies recommend annual quantification. 

Special Situations 

• In asymptomatic cases that present evidence of HTLVrelated 

systemic disease, such as dermatological 

alterations, hyperreflexia, clone or Babinski sign: 

• Serum calcium level, immunophenotyping of T 

lymphocytes (CD3, CD4, CD8, histocompatibility 

leukocyte antigen-DR, CD38 and CD56); diffuse 

histiocytic lymphoma, creatine phosphokinase, folate 

and vitamin B12 levels; free thyroxine 4 and thyroid 

stimulating hormone; and study of somatosensitive 

evoked potentials. 

Healthy individuals infected with HTLV-1 should be 

counseled regarding the transmission mechanisms of the 

infection and be reassured that the probability of developing 

the disease in the future is low. If necessary, they should be 

referred for specialized psychological follow-up evaluation. 

Currently, there is no indication – based on scientific 

evidence – that any certain type of specific anti-HTLV-1 

pharmacological intervention plays a role in the prophylaxis 

of HTLV-related diseases. Therefore, there is no indication for 

the use of immunomodulatory, immunosuppressant or 

antiretroviral drugs in asymptomatic individuals infected with 

HTLV (National Ministry of Health, guide of clinical 

management of the HTLV-infected patient, 2004). 




HTLV/HCV Co-Infection 

Infection with HCV is frequently detected in HTLV-infected 

individuals and vice versa, as seen in other commonly 

transmitted pathogens. 

Co-infection with HTLV-2 and HCV in patients who are 

drug users has been reported, principally in cohorts in the 

northern hemisphere [1]. A study carried out in Paraná, Brazil 

revealed a strong association (OR=22.60; 95% CI: 10.35-49.35) 

between these two pathogens, probably reflecting shared 

transmission forms [2]. 

The prevalence of co-infection also seems to increase in 

individuals infected with HIV in Brazil. Segurado et al. [3] 

demonstrated that HCV infection was an independent risk 

factor for HTLV infection (adjusted OR=6.43, p=0.02). 

Interactions Between HCV and HTLV in Co-Infected 

Individuals: Potential Clinical Implications 

There are few studies on the effects of co-infection with HCV 

and HTLV. Hisada et al. [4] demonstrated that the co-infection 

with HTLV is associated with greater viral load of HCV. 

In a study conducted in Japan, HCV/HTLV-1 co-infected 

individuals were found to be at a higher risk of incidental liver 

disease (RR = 5.9), hepatocarcinoma and death (RR = 21.9), as 

well as for developing diabetes [5]. In addition, co-infected 

individuals have been shown to present a higher frequency 

of anergy to purified protein derivative, although with no 

statistical significance, suggesting a differentiated 

immunomodulatory effect in this population [6]. 

A recent study conducted in the state of Bahia, Brazil 

revealed a high prevalence of HTLV/HCV co-infection. 

Although it did not evaluate the clinical impact, it showed the 

relevance of this association. 

In practical terms, there is no established recommendation 

for the management of HCV/HTLV co-infection. Nevertheless, 

the analysis what evidence there is suggests that this 

association can result in significant modifications in the natural 

history of HCV, increasing the viral load of HCV, as well as 

increasing the morbidity and mortality associated with this 

infection. Therefore, the co-infected patient requires special 

attention regarding the clinical evolution of hepatitis C and 

the markers of the infection. 

In addition to monitoring the parameters related to HTLV 

infection, especially the neurologic alterations secondary to 

the infection, we should carefully evaluate the stage of the 

liver disease, and routinely evaluate the viral load of HCV. 

Attention should be given to potential alterations of glucose 

metabolism, since there seems to be an increased tendency 

toward these problems in the co-infected individual. For coinfected 

patients, routine evaluations of fasting glycemia, as 

well as glucose tolerance tests, could be necessary. 

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BJID 2007; 11 Supplement 1 (October) HCV/HTLV Co-Infection 

41 

References 

1. Zunt J.R., Tapia K., Thiede H., et al. HTLV-2 infection in injection 

drug users in King County, Washington, Scand J Infect Dis 

2006;38(8):654-63. 

2. Morimoto H.K., Caterino-De-Araujo A., Morimoto A.A., et al. 

Seroprevalence and risk factors for human T cell lymphotropic 

virus type 1 and 2 infection in human immunodeficiency virusinfected 

patients attending AIDS referral center health units in 

Londrina and other communities in Paraná, Brazil (AIDS Res 

Hum Retroviruses 2005;21(4):256-62. 

3. Segurado A.C., Braga P., Etzel A., Cardoso M.R. Hepatitis C virus 

coinfection in a cohort of HIV-infected individuals from Santos, 

Brazil: seroprevalence and associated factors. AIDS Patient Care 

STDS 2004;18(3):135-43. 

4. Hisada M., Chatterjee N., Zhang M., et al. Increased 

hepatitis C virus load among injection drug users infected 

with human immunodeficiency virus and human T 

lymphotropic virus type II. J Infect Dis 

2003;188(6):891-7. 

5. Boschi-Pinto C., Stuver S., Okayama A., et al. A follow-up 

study of morbidity and mortality associated with hepatitis 

C virus infection and its interaction with human T 

lymphotropic virus type I in Miyazaki, Japan. J Infect Dis 

2000;182(1):379-80. 

6. Hisada M., Shima T., Okayama A., et al. Suppression of skin 

reactivity to purified protein derivative by hepatitis C virus 

among HTLV-1 carriers in Japan.J Acquir Immune Defic Syndr 

Hum Retrovirol 1998;19(4):421-5. 

www.bjid.com.br


Basic Guidelines for the Treatment of HIV/HVC Co-Infection 

Edgard De Bortholi 


The treatment of HIV/HCV co-infection presents many 

questions that have not yet been answered or on which there 

is no consensus. Since it is a recently introduced issue, the 

guidelines in the literature are divergent on some points. The 

still fragmented knowledge and lack of long-term worldwide 

experience in the treatment of such co-infections has forced 

referral facilities to constantly update their approaches. 

Some guidelines for the management of the HIV/HCV coinfected 

patient have been proposed, and new 

recommendations are particularly necessary: 

• Management of patients with persistently normal 

aminotransferase levels. 

• Definition and quantification of liver fibrosis: when 

and how? 

• Predictors of the response to anti-HCV therapy in coinfected 

patients. 

• Therapeutic doses of pegylated interferon and ribavirin. 

• Treatment duration. 

• Treatment of nonresponsive and recidivist patients. 

• Treatment of acute infection in HIV-positive patients. 

• HIV/HCV/HBV co-infected patients. 

• Interaction between antiretroviral drugs and anti-HCV 

therapeutics. 

• Antiretroviral hepatotoxicity in co-infected patients. 

• Antiretroviral drugs and recommended doses in 

hepatic insufficiency. 

Management of Patients with Persistently Normal 

Aminotransferase 

Establishing the persistence of normal aminotransferase 

levels in HCV-infected patients is difficult, especially in coinfected 

patients. Fluctuations in the levels of aspartate 

aminotransferase and alanine aminotransferase are common 

in this group of patients due to several factors, among 

which are the use of drugs of hepatotoxic potential, alcohol 

abuse, and infection with other opportunistic agents. In 

contrast to mono-infected patients, who present 

persistently normal alanine aminotransferase levels (~25%), 

co-infected patients present levels of 7-9%. However, of 

such patients, 25-40% present advanced liver fibrosis, 

which leads to liver cirrhosis. 

The rapid evolution of fibrosis in co-infected patients, 

even in those with normal transaminase levels, indicates 

treatment, based on patient motivation, duration of the disease, 

fibrosis stage, and viral load of HCV. 




Definition and Quantification of Liver Fibrosis: When and 

How? 

Various studies have demonstrated the rapidity of liver 

fibrosis progression in HIV/HCV co-infected patients. Such 

patients, even those presenting little or no fibrosis, should 

undergo histological evaluation at least every two years. 

Unfortunately, since it is an invasive procedure, liver 

biopsy might present complications resulting from technical 

performance. Pathologist reports are often made difficult by 

the small size of the liver fragments obtained in the biopsy, 

which has repercussions for the indication of anti-HCV 

therapy. 

Despite the disadvantages of liver biopsy, it remains the 

principal technique for determining the severity of hepatic 

injury. 

Noninvasive procedures to assess the level of the liver 

fibrosis are currently divided into two categories: imaging 

techniques, such as elastometry (FibroScan); and the use of 

biochemical markers (Fibrotest, APRISHASTA, FIB-4, and 

Forn Index). These procedures are accurate at discriminating 

between the absence of fibrosis and advanced fibrosis but 

are not very precise at evaluating the intermediate stages of 

the fibrosis. They present good predictive value for advanced 

liver fibrosis and cirrhosis. 

Biochemical marker determination in co-infected patients 

is of little utility, given the inflammatory nature of the HIV 

disease and the fact that, in this population, hepatotoxic drugs 

are used. Such drugs interfere with the serum markers of 

fibrosis in various ways: atazanavir elevates bilirubin levels; 

non-nucleoside analog reverse transcriptase inhibitors affect 

gamma glutamyl-transferase levels; and some protease 

inhibitors elevate cholesterol levels. 

Due to technical difficulties, complications and the number 

of times that the degree of fibrosis must be determined, liver 

biopsy might soon be replaced by FibroScan for the evaluation 

of co-infected patients, at least in one of their follow-up visits. 

Predictors of the Response to Anti-HCV Therapy in Co- 

Infected Patients 

The current trend in the treatment of HCV infection is to 

individualize the approach. 

All HIV/HCV co-infected patients should undergo HCV 

genotyping before any therapeutic decision is made. 

Since the first attempts at treatment of HCV infection in 

HIV-positive patients, a small percentage of patients presenting 

a sustained virological response at the end of the treatment 

has been demonstrated, especially those with manifested 

immunosuppression with low CD4 counts. These patients 

present high viral loads of HCV, lower CD8 anti-HCV 

responses, greater frequency of liver steatosis caused by the 

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BJID 2007; 11 Supplement 1 (October) Treatment of HIV/HCV Co-Infection 

43 

use of alcohol and hepatotoxic drugs (resulting from a lower 

kinetic response to HCV treatment), a higher percentage of 

adverse effects, and worse treatment compliance. 

In order to achieve an early virological response, it is 

necessary to interfere with the natural and adaptive responses, 

which are reduced in co-infected patients, inducing a delay in 

viral clearance, which translates to a late virological response. 

High levels of HCV RNA in co-infected patients might also explain 

the low rate at which a sustained virological response is achieved. 

Approximately 30% of co-infected patients do not present 

a significant reduction in HCV viremia during the first month 

of treatment with pegylated interferon and ribavirin. 

The precise indication for treatment in HIV/HCV coinfected 

patients is CD4 counts greater than 350 cells/mm 3 . In 

patients with CD4 counts between 200 and 350 cells/mm 3 , the 

decision to treat the HCV infection should take other factors 

into account, such as the duration of the HCV infection, the 

severity of the liver disease, the degree of HIV suppression, 

and the classic predictors of the response to the HCV 

treatment (genotype and viral load). 

A sustained virological response can be predicted based 

on the HCV RNA serum negativity in week 4 of treatment. 

However, a reduction of less than 2 log IU/mL in the viral load 

of HCV in week 12 or the presence of detectable viremia in 

week 24 predicts the absence of a virological response, and 

the treatment should be discontinued. 

Ongoing studies focus on the maintenance of the treatment 

for 72 weeks in co-infected patients who are nonresponsive 

at week 24. Perhaps this, or even a longer time with smaller 

and fractionated doses, is the real treatment time for HIVpositive 

patients. 

Contraindications and Special Populations 

The patients with hepatic decompensation (ascites, 

digestive bleeding, hepatic encephalopathy, etc.) cannot be 

treated with interferon due to the high risk of developing 

serious complications. In these patients, the possibility of a 

liver transplant should be considered, even though this 

possibility is still remote because of the inherent difficulties 

of immunosuppression and HIV infection. 

However, the patients with compensated (Child-Pugh class 

A or B) cirrhosis can be treated since they are the ones that 

benefit most from the treatment. 

As to intravenous drug users and chronic alcoholics, the 

treatment should be postponed until the habits are controlled, 

and such patients should be referred to a detoxification 

program. 

Therapeutic Doses of Pegylated Interferon and Ribavirin 

To date, the efficacy of high doses of pegylated interferon 

in the treatment of HIV/HCV co-infected patients has not been 

confirmed, and we should therefore await the results of future 

investigations. 

Ribavirin induces errors in the viral replication cycle, and 

this effect is relevant, principally in HIV-positive patients, in whom 

the mediated immune response is impaired. Various authors have 

demonstrated that the dose of ribavirin is directly related to 

achieving a sustained virological response. High doses of this 

drug are fundamental to the maintenance of viral suppression, 

especially in the first weeks of the treatment. Therefore, the 

recommended dose for the treatment of HCV is 15 mg/kg/day 

(the minimal dose for adjustment is 11 mg/kg/dose). 

Treatment Duration 

The current consensuses recommend that the duration of 

treatment for HIV/HCV co-infected patients be 48 weeks 

regardless of the genotype. However, values of HCV RNA > 2 

log IU/mL at week 12 have a negative predictive value similar 

to that observed for mono-infected patients. Nevertheless, 

recent studies have questioned this simplistic view of the 

treatment time. When patients infected with genotype 2 or 3 

test negative for HCV RNA in week 4 and maintain their 

negativity until week 12, the treatment time is reduced to 24 

weeks. When patients infected with genotype 1 or 4 are in the 

same situation, the duration of treatment is extended to 48 weeks. 

For the patients who, despite positivity in week 4, present a 

drop in HCV RNA > 2 log IU/mL by week 12, the polymerase 

chain reaction (PCR) for qualitative HCV should be repeated in 

week 12. If the PCR is negative, and the genotype is 2 or 3, the 

treatment should continue to week 48. However, if the genotype 

is 1 or 4, the treatment should be maintained until week 72. 

If the qualitative PCR for HCV is still positive at week 24, 

or there is an HCV RNA reduction < 2 log IU/mL in week 12, 

the treatment should be discontinued, regardless of the 

genotype. 

Using erythropoietin and filgrastim has been a good 

strategy, even in co-infected patients, for the treatment of 

anemia and neutropenia, respectively. 

Treatment of Nonresponsive and Recidivist Patients 

At least to date, the HIV/HCV co-infected patients, in 

contrast with mono-infected patients, are not candidates for 

liver transplant, due to the disease progression and the 

absence of a therapeutic response. 

A growing number of co-infected patients who have 

already undergone treatment with standard interferon with or 

without ribavirin, especially those with progression of the 

fibrosis staging, can now be retreated with pegylated interferon 

and ribavirin. 

For the patients who have already used pegylated 

interferon and ribavirin and did not respond to the treatment 

or presented recurrence, there is currently no regimen for 

infection control. 

Despite the absence of a virological response in these 

patients, 35-43% of them present a reduction in the degree of 

liver fibrosis, demonstrating the antifibrotic effect of 

interferon. These data provide a rationale if the maintenance 

of interferon, even in small doses, for a prolonged time, has 

no effect on the progression of the fibrosis, even in the patients 

in whom HCV has not been eradicated. 

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44 Treatment of HIV/HCV Co-Infection 


New anti-HCV drugs are urgently needed, especially for this 

group of patients, who depend exclusively on clinical treatment. 

Treatment of Acute Infection in HIV-Positive Patients 

Outbreaks of acute HCV infection in homosexuals have 

been reported in some European cities. Despite the knowledge 

of the low transmissibility of HCV through sex, sexual practices 

that generate traumatic lesions and genital ulcerations have 

been associated with the infection. 

The natural history of HCV infection in HIV patients has 

demonstrated its evolution to chronicity. Therefore, early 

therapeutic intervention (in the acute phase of infection) is 

particularly indicated in these cases, although treatment should 

not be instituted earlier than 12 weeks after the exposure, due 

to the possibility of spontaneous viral clearance. However, a 

delay in starting treatment might result in a reduction of the 

therapeutic response. 

The treatment of acute HCV infection in HIV-positive 

patients seems to provide a pattern of lower virological 

response when compared to HIV-negative patients. However, 

the viral clearance pattern obtained in HIV-positive patients 

in the acute phase is greater than that seen in those presenting 

chronic infection. 

Acute infection in HIV-positive patients should be treated 

with pegylated interferon and ribavirin for 24 weeks. 

HIV/HCV/HBV Co-Infected Patients 

In HIV-positive patients living in developed countries, the 

prevalence of multiple viral hepatitis (HBV/VCV; VBV/VDV; VBV/ 

HCV/HDV) is lower than 3%. However, this is still higher than 

that seen in the general population. Patients presenting HBV/ 

HCV co-infection seem to present reciprocal inhibition of viral 

replication, with one of the viruses being predominant. However, 

this predominance might oscillate from one virus to the other. 

Nevertheless, in patients with severe immunosuppression, 

replication of all of the viruses might occur simultaneously. In 

HIV-positive patients with good immune status, the interference 

seems to favor HCV, to the detriment of HBV. 

The progression of the liver disease seems to be more 

accelerated in HIV-positive patients infected with both HBV 

and HCV. In addition, these individuals are more likely to 

develop hepatocarcinoma. 

Using interferon to treat chronic HDV in HIV-positive 

patients is rarely effective. 

There is no established consensus as to the approach to 

treating multiple viral hepatitis. Few studies have examined 

the efficacy and safety of the combination of pegylated 

interferon and ribavirin for treating multiple infections in HIVpositive 

patients. When possible, all of the viruses involved 

in the hepatitis should be treated. 

Interaction between Antiretroviral Medications and Anti- 

HCV Therapy 

The highly active antiretroviral therapy (HAART) regimen 

is associated with increased survival due to the fact that it 

controls HIV and slows the progression of the hepatic disease. 

The better prognosis that the HAART regimen confers on HIV/ 

HCV co-infected patients is probably due to deceleration of the 

progression of hepatic fibrosis. This has principally been 

demonstrated in HIV patients treated with protease inhibitors. 

Some studies have suggested the early introduction of 

antiretroviral therapy in HIV/HCV co-infected patients, 

considering the beginning of the HAART regimen in patients 

with CD4 counts > 350 cells/mm 3 , particularly in male patients 

and in those who acquired HCV at an advanced age, which 

would decrease the effects resulting from immune 

reconstitution and the slowing of the progression of HCVinduced 

hepatic disease. 

The principal complication in the treatment of HIV-infected 

patients is the interaction between ribavirin and some 

antiretroviral drugs. 

Ribavirin can decrease the concentrations of some 

nucleoside analog reverse transcriptase inhibitors (NRTIs), 

although there seem to be no clinical consequences. 

The adverse effects of the NRTIs have been associated 

with HCV co-infection, female gender, obesity, and prolonged 

exposure to these drugs. The principal NRTI combinations 

associated with lower impact on the liver are as follows: 

lamivudine+abacavir (3TC/ABC); 3TC+zidovudine (AZT); 

3TC+ABC+AZT; and emtricitabine + tenofovir. However, 

recent studies have indicated that ribavirin interferes with the 

effects of ABC, and, therefore, its use in the HAART regimen 

for HCV patients should be considered with caution. 

The greatest toxicity is that resulting from the concomitant 

use of didanosine and ribavirin, worsening with the addition 

of stavudine. These combinations increase the possibility of 

mitochondrial toxicity and are potentiated by the presence of 

HIV and HCV. In patients treated with these antiretroviral drugs 

combined with ribavirin, lactic acidosis, pancreatitis and 

hepatic decompensation have been reported. Therefore, it is 

recommended that replacements for these antiretroviral drugs 

be found for patients who will initiate the treatment for HCV. 

In addition, AZT should be replaced, when possible, due to 

frequent, severe anemia and neutropenia when AZT is 

administered together with ribavirin. 

It is important to emphasize that the antiretroviral drugs, 

as well as the drugs used in the treatment and prophylaxis of 

the various opportunistic infections, are metabolized by the 

liver and, therefore, many of these metabolites can increase 

the risk of hepatic lesion. 

The chart below shows the principal interactions between 

the drugs used, facilitating the choice of antiretroviral drugs 

in the clinical approach to co-infected patients. 

The combination of ritonavir and saquinavir has proven 

to be highly hepatotoxic, and its use is not currently 

recommended, especially in HIV/HCV co-infected patients 

with concomitant tuberculosis, in whom noncompliance with 

treatment and, principally, the elevation of transaminase levels 

result from the discontinuation of the treatment with 

antituberculosis drugs or the introduction of alternative 

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BJID 2007; 11 Supplement 1 (October) Treatment of HIV/HCV Co-Infection 

45 

Chart 1. Drug interactions 

Antiretroviral drugs Adverse effects Therapeutic alternative Interaction with anti-HCV therapy 

Zidovudine Anemia and neutropenia Stavudine Potentiates the probability of anemia 

caused by ribavirin 

Didanosine Hepatotoxicity Lamivudine or efavirenz Ribavirin inhibits the 

Mitochondrial toxicity 

phosphorylation of this drug 

Stavudine Hepatotoxicity Lamivudine or efavirenz Should not be combined with 

Mitochondrial toxicity 

didanosine due to potentiation of 

mitochondrial toxicity 

Nevirapine Hepatotoxicity Efavirenz Do not combine with didanosine and 

stavudine; potentiation of 

mitochondrial toxicity 

Ribavirin Hepatotoxicity Tolerated in low doses Increases the probability of 

HCV=hepatitis C virus. 

Chart 2. Antiretrovirals and recommended doses in liver failure 

when used in combination 

with other protease inhibitors 

Name Hepatic metabolism Recommendations 

intolerance to the antiretroviral 

therapy. 

NRTIs 

Abacavir Yes Mild (A*)=200 mg twice a day / moderate/severe=contraindicated 

Didanosine Yes Not recommended 

Emtricitabine No No need for dose adjustment -recommended 

Lamivudine No No need for dose adjustment -recommended 

Stavudine Unknown No need for dose adjustment -recommended 

Zalcitabine No No need for dose adjustment -recommended 

Zidovudine Yes No need for dose adjustment -recommended 

NtRTIs 

Tenofovir No No need for dose adjustment -recommended 

NNRTIs 

Delavirdine Yes Not recommended 

Efavirenz Yes Not recommended 

Nevirapine Yes Mild (A*)/moderate (B*)=No need for dose adjustment -recommended 

Severe (C*)=contraindicated 

Protease inhibitors 

Atazanavir Yes Mild (A*)=No need for dose adjustment - recommended 

Moderate (B*)=300 mg/day. Severe (C*)=contraindicated 

Fosamprenavir Yes Mild/moderate=700 mg 2xday 

Severe=contraindicated (because the dose cannot be reduced to 

lower than 700 mg) 

Indinavir Yes Mild/moderate=600 mg 3× day. Severe=not recommended 

Nelfinavir Yes Not recommended 

Ritonavir Yes Mild/moderate=No need for dose adjustment -recommended 

Severe=not recommended 

Saquinavir Yes Mild/ moderate=not recommended. Severe=contraindicated 

Boosters w/ ritonavir 

Atazanavir/ritonavir Yes 

Not recommended at some levels of hepatic insufficiency because 

it has not been adequately studied 

Fosamprenavir/ritonavir Yes Not recommended 

Lopinavir/ritonavir Yes Not recommended 

Saquinavir/ritonavir Yes 

Mild/moderate=Not recommended. Severe=contraindicated 

Tipranavir/ritonavir Yes 

Mild=No need for dose adjustment - recommended 

Moderate/severe=contraindicated 

Fusion inhibitors 

Enfuvirtide Unknown Not recommended 

*Child-Pugh class. NRTIs=nucleoside analog reverse transcriptase inhibitors; NtRTIs=nucleotide analog reverse transcriptase inhibitors; 

NNRTIs=non-nucleoside analog reverse transcriptase inhibitors. 

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46 Treatment of HIV/HCV Co-Infection 


regimens that are less efficient in the resolution of infection 

with Mycobacterium tuberculosis. 

The data currently available are insufficient to determine the 

nature of the interaction of atazanavir, tenofovir, fosamprenavir, 

and tipranavir with the therapeutic regimen in HCV infection. 

References 

1. Arends J.E., Boucher C.A.B., Hoepelman A.I.M. Hepatitis C virus 

and human imunodeficiency virus coinfected: where do we 

stand? Journal of Medicine 2005;63:156-63. 

2. Lai, et al. Antiretroviral medication considerations for individuals 

coinfected with HIV and hepatitis C virus. AIDS Patient Care 

and STDs 2006;20(10):678-92. 

3. Rockstroh J.K. Influence of viral hepatitis on HIV infection. 

Journal of Hepatology 2006;44:S25-S7. 

4. Sancho A.R., Soriano Vicente. Coinfección por el VIH y el virus de 

la hepatitis C. http//www.doyma. Acessado em 26/02/2007. 

5. Soriano V., et al. Care of patients coinfected with HIV and hepatitis 

C virus: 2007 updated recomendations from the HCV-HIV 

international panel. AIDS 2007,21:1073-89. 

6. Thomas L.D. Options for treatment of hepatitis C in HIV-infected 

persons. Journal of Hepatology 2006;44:S40-S3. 

www.bjid.com.br


Basic Aspects of the Treatment for Hepatitis C: Mechanisms of Action of Interferon Alpha and 

Ribavirin and the Bases of Individualization 

Carlos Eduardo de Melo, Evaldo Stanislau Affonso de Araújo and Antonio Alci Barone 

Laboratory of Hepatitis, LIM 47 DCMIP-HC-FMUSP; São Paulo, SP, Brazil 

Pharmacological Characteristics of Interferons and 

Ribavirin 

The treatment of patients with chronic hepatitis C has 

developed considerably in recent years. However, it is still 

based on the use of interferon alpha (IFN-α) as an antiviral 

and immunomodulatory agent against the hepatitis C virus 

(HCV). 

The IFNs are a family of proteins that are naturally 

produced by the cells of the immune system. The IFN-á protein 

presents antiviral, antiproliferative and immunomodulatory 

activity [1-3]. Its mechanism of biological action occurs 

through the activation of specific genes, influencing cell 

growth and division, as well as modulating some immune 

system activities. Therefore, IFNs have an indirect antiviral 

effect on HCV [2,4]. 

Commercially, IFN-α is produced by means of recombinant 

DNA techniques and is available in preparations of two distinct 

subtypes (IFN-α 2a or IFN-α 2b), which can be combined 

with other molecules, such as polyethylene glycolor, more 

recently, albumin [5,6]. The only difference between IFN-α 2a 

and IFN-α 2b is in the amino acid present at position 23 of the 

protein: IFN-α 2a has a lysine at that position, whereas IFN-α 

2b has an arginine [7]. 

After the binding with its specific receptor (IFNAR) on 

the surface of the target cells, IFN-α activates an intracellular 

signaling cascade, which takes the induction of IFN-stimulated 

genes (ISGs), establishing a non-virus-specific antiviral state 

inside the cell [3,7]. The principal signaling mechanism used 

by IFN-α is the so-called Janus kinase/signal transducers and 

activators of transcription (Jak/STAT) pathway [3]. Therefore, 

two cytoplasmatic proteins with the activity of tyrosine kinase 

associated with IFNAR, activated Jak1 and tyrosine kinase 2 

(Tyk2), are activated by the dimerization of the receptors. 

Activated Jak1 and Tyk2 perform the phosphorylation of 

STAT1 and STAT2, respectively. The phosphorylated STAT1 

and STAT2 bond with the protein p48 forming IFN-stimulated 

gene factor 3 (ISGF3), which translocates into the nucleus 

and bonds with IFN-stimulated regulatory element in the 

sequences which promote a variety of genes inducible by 

IFN-α including antiviral proteins such as 2’5’-oligoadenylate 

synthetase (2’5’OAS), protein kinase RNA, and Mx protein 

[1,3,7,8]. 

The absorption of IFN-α (2a or 2b) is high (above 80%) 

when administrated intramuscularly or subcutaneously. The 

concentration typically peaks at 3-12 h after administration [9]. 




The metabolism and elimination of IFN-α occurs principally 

via the kidneys, with a half-life of 3-8 h [9]. 

Pharmacological Characteristics of the Pegylated 

Interferons 

Pegylated IFNs (PEG-IFNs) are produced through the 

binding of an inert molecule of polyethylene glycol to the 

recombinant IFN-á, thus reducing the renal clearance, altering 

the metabolism and increasing the half-life of the IFN molecule, 

although maintaining all of its immunostimulatory 

characteristics [10,11]. 

The two PEG-IFNs currently available are produced with 

polyethylene glycol molecules of different complexities. PEG- 

IFN-α 2b consists of the binding of IFN-α 2b with a linear PEG 

chain, forming a 12-kDa molecule. PEG-IFN-α 2a is formed by 

the binding of two 20-kDa chains with IFN-α 2a, resulting in a 

complex 40-kDa molecule [6]. 

The differences in the chemical structure of the two PEG- 

IFN-α formulations are associated with significant 

differences in the pharmacological characteristics of the 

two drugs. The PEG-IFN-α 2b (12 kDa) is more rapidly 

absorbed (with an absorption half-life of 4.6 h), presents a 

wide volume of body distribution (approximately 0.99 L/ 

kg) and a mean elimination time of 40 h. However, PEG-IFNα 

2a (40 kDa) is absorbed more slowly (absorption half-life, 

50 h), its distribution is restricted to well-vascularized 

organs with good perfusion, such as the liver, and it remains 

detectable in the serum for one week (approximately 65 h 

elimination half-life) [6,12,13]. 

Pharmacological Characteristics of Ribavirin 

Ribavirin is a synthetic nucleoside which is structurally 

similar to guanosine [14,15]. Ribavirin enters into the 

eukaryotic cells rapidly and, after it undergoes intracellular 

phosphorylation, shows virustatic activity against a broad 

spectrum of DNA and RNA viruses [14,15]. 

The exact mechanism of the antiviral action of ribavirin 

has not yet been totally elucidated [1,16]. However, some 

studies suggest the following possible mechanisms: 

a) direct inhibition of HCV replication; 

b) inhibition of the enzyme inosine monophosphate 

dehydrogenase of the host; 

c) induction of mutagenesis in the viral RNA; 

d) immunomodulation by the induction of a T helper 1 

(Th1)-type immune response Ribavirin is rapidly 

absorbed (half-life of approximately 2 h) and widely 

distributed throughout the body after its oral 

administration; its metabolization occurs principally 

via the kidneys [16]. 

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48 Treatment for Hepatitis C: Basic Aspects 


Treatment with IFN-α has as a success-defining 

characteristic, progressively more extensive and vigorous 

immune stimulation. The more rapid the stimulation is, the 

greater are the chances of success. The study of mononuclear 

cells ex vivo and in vivo demonstrated that, 3-6 h after the 

administration of conventional IFN-α, 516 genes were 

upregulated, of which 88 with actions directly linked to immune 

functions [17]; the same phenomenon was observed for PEG- 

IFN, also differentiating responders from nonresponders using 

the intensity of expression in certain IFN-inducible genes 

(2’5’OAS, MX1, IRF-7 and TLR-7), greater in the responders 

and lesser in the Afro-Americans [18,19]. 

The final pathway of the phenomenon triggered in the cell 

nucleus is the activation of effector cells. An initial activation 

of the innate immunity (natural killer cells) is supposedly 

necessary for the early reduction of the viremia – the greater 

and the more rapid it is, the more closely it associates with 

achieving a sustained virological response (also differentiating 

rapid responders from slow responders). Progressively, as of 

week 4 of the treatment, the effective immune stimulation induced 

by IFN with the respective reduction of the viremia would enable 

the specific defense mechanisms (CD4+ and CD8+ cells) which, 

in turn, would be in charge of disposing of the residual infected 

cells (hepatocytes and extrahepatic cells) [20]. In fact, Pillai et 

al. clearly showed that the magnitude and diversity of the cellular 

response was associated with early and sustained virological 

responses [21], in contrast to other authors who only associated 

the Th1-type cellular response with the initial viremia [22]. At 

any rate, it is clear that patients presenting a rapid and vigorous 

initial response have greater chances of success. However, 

patients presenting a slower response need more long-term 

stimulation. Therein reside the bases for the individualization 

of treatment. It is equally clear that this initial virological 

response depends on the gene stimulus induced by IFN-α. 

Whether or not these phenomena imply differences associated 

with the different types of IFNs used in clinical practice has yet 

to be answered. However, initial evidence was provided by the 

analysis of the expression of mRNA of inducible IFN genes in 

two groups of patients exposed to the two existing types of 

PEG-IFN, suggesting that, despite lower plasma exposure, the 

patients who used PEG-IFN-α 2b expressed their genes more 

vigorously, emphasizing the relevance of the intracellular 

environment in the response to HCV treatment [23]. 

References 

1. Feld J.J., Hoofnagle J.H. Mechanism of action of interferon and 

ribavirin in treatment of hepatitis C. Nature 

2005;436(7053):967-72. 

2. Peters M. Actions of cytokines on the immune response and viral 

interactions: an overview. Hepatology 1996,23(4):909-16. 

3. Wohnsland A., Hofmann W.P., Sarrazin C. Viral determinants of 

resistance to treatment in patients with hepatitis C. Clin 

Microbiol Rev 2007,20(1):23-38. 

4. Souvignet C., Lejeune O., Trepo C. Interferon-based treatment of 

chronic hepatitis C. Biochimie 2007;89(6-7):894-8. 

5. Chemmanur A.T., Wu G.Y. Drug evaluation: Albuferon-alpha—an 

antiviral interferon-alpha/albumin fusion protein. Curr Opin 

Investig Drugs 2006;7(8):750-8. 

6. Foster G.R. Review article: pegylated interferons: chemical and clinical 

differences. Aliment Pharmacol Ther 2004;20(8):825-30. 

7. Pestka S. The human interferon alpha species and receptors. 

Biopolymers 2000;55(4):254-87. 

8. Pawlotsky J.-M. Mechanisms of antiviral treatment efficacy and 

failure in chronic hepatitis C. Antiviral Res 2003;59(1):1-11. 

9. USP DI® Volume I: Drug Information for the Health Care 

Professional [database on CD-ROM]. Version 5.1. Greenwood 

Village, Colo: Thomson Micromedex. 

10. Reddy K.R., Wright T.L., Pockros P.J., et al. Efficacy and safety 

of pegylated (40-kd) interferon alpha-2a compared with 

interferon alpha-2a in noncirrhotic patients with chronic 

hepatitis C. Hepatology 2001;33(2):433-8. 

11. Strader D.B., Wright T., Thomas D.L., et al. Diagnosis, 

management, and treatment of hepatitis C. Hepatology 

2004,39(4):1147-71. 

12. Bailon P., Palleroni A., Schaffer C.A., et al. Rational design of a 

potent, long-lasting form of interferon: a 40 kDa branched 

polyethylene glycol-conjugated interferon alpha-2a for the 

treatment of hepatitis C. Bioconjug Chem 2001;12(2):195-202. 

13. Glue P., Fang J.W., Rouzier-Panis R., et al. Pegylated interferonalpha2b: 

pharmacokinetics, pharmacodynamics, safety, and 

preliminary efficacy data. Hepatitis C Intervention Therapy 

Group. Clin Pharmacol Ther 2000;68(5):556-67. 

14. Graci J.D., Cameron C.E. Mechanisms of action of ribavirin against 

distinct viruses. Rev Med Virol 2006;16(1):37-48. 

15. Leyssen P., De Clercq E., Neyts J. Perspectives for the treatment 

of infections with Flaviviridae. Clin Microbiol Rev 

2000;13(1):67-82. 

16. Parker W.B. Metabolism and antiviral activity of ribavirin. Virus 

Res 2005;107(2):165-71. 

17. Ji X., Cheung R., Cooper S., et al. Interferon alfa regulated gene 

expression in patients initiating interferon treatment for chronic 

hepatitis C. Gastroenterology 2003;37:610-21. 

18. Taylor M.W., Tsukahara T., Brodsky L., et al. Changes in gene 

expression during pegylated interferon and ribavirin therapy of 

chronic hepatitis C virus distinguish responders from non 

responders to antiviral therapy. Journal of Virology 

2007;81(7):3391-3401. 

19. He X.-S., Ji X., Hale M.B., et al. Global transcriptional response to 

interferon is a determinant of HCV treatment outcome and is 

modified by race. Hepatology 2006;44:352-9. 

20. Tang K.H., Herrmann E., Cooksley H., et al. Relationship between 

early HCV kinetics and T-cell reactivity in chronic hepatitis C 

genotype 1 during peginterferon and ribavirin therapy. Journal 

of Hepatology 2005;43:776-82. 

21. Pillai V., Lee W.M., Thiele D.L., et al. Clinical responders to 

antiviral therapy of chronic HCV infection show elevated 

antiviral CD4+ and CD8+ T-cell responses. Journal of Viral 

Hepatitis 2007;14:318-29. 

22. Aberle J.H., Perstinger G., Weseslindtner L., et al. CD4+ T cell 

responses in patients with chronic hepatitis C undergoing 

peginterferon/ribavirin therapy correlate with faster, but not 

sustained, viral clearance. The Journal of Infectious Diseases 

2007;195:1315-9. 

23. Silva M., Poo J., Wagner F., et al. A randomized trial to compare 

the pharmacokinetic, pharmacodynamic, and antiviral effects 

of peginterferon alfa-2b and peginterferon alfa-2a in patients 

with chronic hepatitis C (COMPARE). Journal of Hepatology 

2006;45:204-13. 

www.bjid.com.br


Therapeutic Approach to Acute Hepatitis C 

Rodrigo Nogueira Angerami 1 and Fernando Lopes Gonçales Júnior 2 

1 

Epidemiological Surveillance Unit, Hospital Epidemiology Service, Hospital das Clínicas, State University at Campinas and Campinas 

Referral Center for STD/AIDS; 2 Study Group on Hepatitis, Infectious Diseases Division, Clinical Medicine Department, School of Medical 

Sciences, State University at Campinas; Campinas, Brazil 

It is estimated that 150 to 200 million individuals are currently 

infected with the hepatitis C virus (HCV) [1-3], and that, annually, 

there are 3 to 4 million new cases of infection worldwide [4]. In 

view of the impossibility of immunoprevention [5] - either through 

vaccines or the use of post-exposure immunoglobulin - and the 

risk of chronicity in individuals exposed to the disease, which is 

estimated to be between 50% and 85% [2,4,6-9,33], the definition 

of strategies aimed at early detection and treatment of infected 

individuals, preferably during the acute phase of the infection 

[2,4], has been widely discussed in recent years. 

In individuals presenting symptoms consistent with acute 

hepatitis C (AHC), it is known that the possibility of 

spontaneous viral clearance, among various factors, depends 

especially on a potent initial cellular immune response 

mediated by cytotoxic T lymphocytes - initially by HCVspecific 

CD8+ T lymphocytes and, subsequently, CD4+ T 

lymphocytes [10-12]. Other factors associated with a higher 

rate of sustained virological response (SVR) are the specific 

characteristics of the patients. Individuals who are Asian or 

Caucasian, female, young, and HIV-negative, as well as 

presenting a rapid drop in HCV RNA levels and presenting 

specific human leukocyte antigen class II alleles, together 

with the previously mentioned T cytotoxic response, also 

respond better to treatment [16,17,33]. Better responses are 

also found in cases of infections with shorter incubation 

period produced by smaller inoculates. In addition, in a 

prospective study conducted by Santantoni et al., a higher 

rate of spontaneous viral clearance was observed in patients 

infected with genotype 3 [7]. 

A diagnosis of acute infection with HCV remains a rare 

event in clinical practice. In 70-80% of infected patients, AHC 

is asymptomatic, and 75% are anicteric [4,8,13-15,33]. 

Individuals with AHC present elevated serum levels of alanine 

aminotransferase (ALT) and aspartate aminotransferase 

(AST), with or without a clinical profile of acute hepatitis, 

detection of (previously undetectable) HCV RNA and 

seroconversion for anti-HCV antibodies. It is estimated that 

infection with HCV accounts for only 20% of all diagnosed 

cases of acute hepatitis [13]. In the United States, there are 

40,000 cases of AHC annually [12], and only a small 

percentage of those are clinically diagnosed in this phase. 

Considering the high risk of developing chronic hepatitis 

C and the favorable evidence, in terms of therapeutic response, 

it is fundamental to improve our capacity to properly detect 

and treat cases of acute infection with HCV [12]. 

At-Risk Populations 

Currently, it is thought that, in 90% of cases of infection 

with HCV, it is possible to identify the associated risk factors 

[14]. 




In the last two decades, especially after serologic triage 

was adopted as obligatory for blood donors, and due to the 

increased accuracy of serologic tests, there has been a drastic 

reduction in the number of new infections with HCV through 

blood and blood products. This resulted in significant 

changes in the epidemiological pattern of the disease [2,16,18]. 

However, new infections still occur via parenteral route, and, 

less frequently, by sexual or vertical transmission. Currently, 

the principal groups at risk for infection with HCV are as 

follows: health professionals exposed through cut or 

puncture accidents involving sharp objects contaminated 

with infectious material; intravenous drug users; individuals 

engaging in sex with HCV-positive partners; patients on 

hemodialysis; and patients submitted to various invasive 

procedures [4,12,14,18-21]. 

In the United States, intravenous drug users account for 

68% of the new cases of HCV infection, compared with 18% for 

individuals engaging in sex with HCV-positive partners, 4% for 

health professionals exposed through cut or puncture accidents, 

1% for individuals infected through other routes, and 9% for 

those in whom the source of infection cannot be identified [22]. 

Currently, it is believed that the risk of vertical transmission is 

significantly potentialized in cases of HIV/HCV co-infection, in 

which the rate of such transmission can be as high as 17% [37]. 

Special attention has been given to the occupational risk 

of infection with HCV in health professionals, and the 

estimated risk of cut or puncture accidents with sharp objects 

contaminated with infectious materials ranges from 1% to 

2% [5,22]. 

Although risks, impacts and recommendations are still 

controversial, it is estimated that the risk of sexual transmission 

ranges from 0% to 3% [34,37], increasing especially in specific 

situations, such as co-infection with HIV or other sexually 

transmitted diseases, and between homosexual partners. 

It is also known that the risk of HCV infection is higher in 

individuals with chronic kidney disease under treatment with 

hemodialysis. It is believed that, among such individuals 

treated in the United States, the prevalence of anti-HCV 

reactivity ranges from 15% to 50% [37]. 

The definition of protocols for clinical and laboratory 

periodic follow-up evaluation in these segments at increased 

risk is fundamental in order to improve the detection of AHC. 

Laboratory Diagnosis 

The laboratory techniques most commonly used in the 

detection of anti-HCV antibodies are fundamentally based 

on third- and fourth-generation enzyme-linked 

immunosorbent assays. Such serologic tests have 

demonstrated great specificity (> 99%) and sensitivity (95%- 

99%) [38]. However, one of the possible limitations in the 

diagnosis of acute infection with HCV results from the 

possibility of late seroconversion, occurring at 4 to 10 weeks 

after exposure [23]. Regarding detection of anti-HCV 

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50 Therapeutic Approach to Acute Hepatitis C 


antibodies, we observe 50% to 70% positivity at symptom 

onset; in addition, from postinfection month 3 onward, 

antibodies are detected in 90% of the cases [38]. 

However, HCV RNA determination constitutes an 

important tool for early detection of acute infections, since 

HCV is detectable by 1 to 3 weeks after transmission [23,38]. 

Immediately after HCV RNA detection and concomitantly with 

the appearance of possible signs and symptoms - 2 to 8 weeks 

after infection - it is possible to observe increased ALT levels 

[38]. Detection of HCV RNA, in the absence of anti-HCV 

antibodies, strongly suggests acute infection, especially 

when subsequent anti-HCV seroconversion is observed. The 

use of transcription-mediated amplification (TMA), together 

with other available techniques, constitutes an additional 

strategy for early detection of acute HCV infection [23]. 

Therapeutic Approaches 

The high rate of chronicity observed after infection with 

HCV justifies the increasing interest in possible therapeutic 

approaches in cases of acute infection. 

Various approaches have been proposed in literature, all 

of which aim at preventing the progression to chronic disease. 

Nevertheless, to date, the ideal treatment regimen to be 

adopted in clinical practice has not been established 

[4,6,8,9,14,18,19,24]. Comparing results from different clinical 

trials is difficult for the following reasons: acute hepatitis C is 

frequently asymptomatic; different criteria are used in case 

definition; samples of patients are small and heterogeneous; 

there are no control groups; different types and doses of 

interferon (IFN) are used; there are different end points, and 

follow-up time varies enormously. Therefore, it is impossible 

to define an ideal therapeutic regimen. 

When we evaluate the data available in literature, we 

observe excellent results in patients treated in the acute phase 

of the infection, even under monotherapy [15,16]. The principal 

post-treatment outcome measure is the rate at which patients 

achieve an SVR, defined as the absence of HCV RNA detected 

in serum by qualitative polymerase chain reaction (PCR) at 24 

weeks after the end of the treatment [25,26]. Among patients 

treated in the acute phase of the infection, this rate ranges 

from 37% to 98% [2,4,8,18,20,24], which is higher than the 54%- 

56% observed among patients with chronic hepatitis C, even 

among those under combined therapy with pegylated IFN (PEG- 

IFN) and ribavirin (RBV) [25,26]. 

Various trials evaluate the efficacy of different regimens 

using conventional IFN alpha (IFN α) in the treatment of 

AHC. The best results to date were those reported by Jaeckel 

et al., whose treatment regimen consisted of monotherapy 

with IFN α-2b with inducement - 5 million IU/day, s.c., for 4 

weeks, followed by 5 million IU, 3 times a week, for 20 weeks 

[2]. In that study, the use of IFN, even without RBV, made it 

possible to obtain high SVR levels. However, the Jaeckel et 

al. study raises the following considerations: 68% of the 

patients included in the study were icteric and therefore 

presented a higher probability of having self-limited infection, 

which could, in part, explain the high SVR rate reported. As 

previously mentioned, symptomatic individuals can evolve 

to spontaneous viral clearance. In addition, Kamal et al. 

observed a higher SVR rate in treated symptomatic individuals 

when compared to those asymptomatic individuals treated 

with the same therapeutic regimen (96% and 76%, 

respectively) [8]. However, Santantonio et al. reported an 

SVR rate of 94% among individuals who did not present 

spontaneous viral clearance by week 12 after acute symptom 

onset, when treated with PEG-IFN α-2b, in monotherapy, for 

24 weeks [12]. Such finding corroborates other reports 

demonstrating that it is safe to adopt the expected conduct 

up to week 21 in order to await possible spontaneous viral 

clearance [15,16,20,28,36]. 

In view of these facts, it should be noted that, among 

individuals acutely infected with HCV, those who are 

asymptomatic, especially those who are anicteric and present 

normal ALT levels, are more likely to present spontaneous 

viral clearance [8,12,14,18,20] - typically between weeks 5 

and 12 [27,28]. This viral clearance can occur, in rare situations 

(in 10%-50% of cases), up to 24 weeks after symptom onset 

[8,9,12-15,17,18,21]. Various authors suggest that the treatment 

be initiated, at most, 12 to 16 weeks after symptom onset, 

avoiding unnecessary exposure to IFN in patients who can 

clear HCV spontaneously [4,10,12,18,33]. 

However, some authors suggest that, in cases of 

asymptomatic acute infection, treatment should be 

introduced at the time of diagnosis [12]. 

It should be noted, however, that lower SVR rates have 

been observed in cases of late treatment. These rates were 

initially described by Nomura et al. [18] who, using IFN α (6 

million IU, i.m., daily, for four weeks), reported an SVR in 87% 

of early treated individuals - 8 weeks after detection of 

symptoms - and in 40% of patients treated after AHC symptom 

onset. This study demonstrated that early introduction of 

treatment enabled a high SVR rate, even in short-term treatment 

regimen. More recently, in a study conducted by Kamal et al., 

the SVR rate in individuals treated after week 20 was 76.6%, 

whereas, in individuals who started therapy at weeks 8 and 10, 

the rates were, respectively, 95.3% and 93.2% [20]. 

Similarly to what was observed in the treatment of chronic 

hepatitis C [14,29,30], negative HCV RNA at treatment week 1 

was associated with a greater probability of achieving an 

SVR [31]. In the study carried out by Kamal et al., achieving 

a rapid virological response (RVR), defined as HCV RNA 

negativity or a ≥ 2 log 10 

drop in HCV RNA, by treatment week 

4, was found to have positive and negative predictive values 

of 88% and 98%, respectively, for achieving an SVR. In 

another study, involving individuals with AHC treated with 

IFN as monotherapy in daily doses for 4 weeks, HCV RNA 

negativity in the first week of treatment was found to have a 

positive predictive value of 87% for achieving an SVR [18]. 

The combination of PEG-IFN α and RBV is currently 

considered the first-line treatment regimen for patients with 

chronic hepatitis C, those infected with genotype 2 or 3 and 

treated thusly achieving an SVR at a rate of 82% [20]. However, 

the efficacy, safety, duration and appropriate timing of PEG-IFN 

treatment in cases of AHC have not yet been well established. 

A multicenter, prospective, randomized controlled study, 

using PEG-IFN α-2b and involving a 48-week post-treatment 

follow-up period, reported SVR rates of 95.3% and 93.2%, 

respectively, in groups of patients in which treatment was 

initiated at week 8 or week 12 after symptom onset [20]. Studies 

that compared treatment results obtained with conventional 

IFN to those obtained with PEG-IFN found similarly high 

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BJID 2007; 11 Supplement 1 (October) Therapeutic Approach to Acute Hepatitis C 

51 

efficacy in both formulations [4]. Kamal et al., comparing the 

efficacy of PEG-IFN α, with and without RBV, reported 85% 

and 80% SVR rates, respectively [20]. It should be highlighted, 

however, that no evidence justifies the routine use of the 

combination with RBV up to the present moment. 

In a multicenter study, patients with acute hepatitis C 

received PEG-IFN α-2b (in a dose of 1.0-1.5 μg/kg/week) 

initiated at the time of diagnosis and continued for 12 weeks; 

HCV RNA negativity was found in 87% at treatment week 4, 

in 91% at the end of the treatment (week 12), and in 73% at 24 

weeks after the end of the treatment [9]. In patients treated 

with higher doses of PEG-IFN (≥ 1.2 μg/kg/week for 12 weeks), 

the same authors reported an 84% SVR rate, comparable to 

that found for 24-week regimens [9]. In a prospective, 

uncontrolled study, De Rosa et al., using PEG-IFN α-2b (1.0- 

1.6 μg/kg/week, during 12 weeks) initiated immediately after 

diagnosis, reported an overall rate of 74%, although higher 

rates were reported when higher doses of PEG-IFN were used 

(82% when ≥ 1.33 μg/kg/week doses were used) [21]. 

Similar to what was observed in the treatment for chronic 

hepatitis C, compliance to treatment regimen has proven an 

important SVR predictive factor in the treatment of AHC. This 

was demonstrated in a multicenter study, in which a 71% overall 

response rate was found, compared with an 89% rate found in 

the population with expected compliance to treatment [32]. 

When SVR rates were evaluated in difficult-to-treat 

populations, two studies involving intravenous drug users 

reported SVR rates between 72% and 74% [9.21]. In both 

situations, regular follow-up and multidisciplinary approach 

were used in order to provide adequate compliance to the 

proposed treatment regimen. 

Kamal et al. reported that HCV genotype is also an element 

to be considered as an SVR predictive factor in patients with 

AHC. Therefore, similar to what was reported in cases of chronic 

hepatitis C, there were associations among genotypes, 

treatment time, and SVR rates, in patients with acute hepatitis 

C. Distinct SVR rates were found, according to the genotype 

involved: 63.8% for genotype 1; and 100% for genotypes 2 

and 3. However, when a prolonged (24-week) treatment regimen 

was adopted, an SVR rate of 88% was observed in patients 

infected with genotype 1, higher than the 38% and 60% reported 

for 8-week and 12-week regimens, respectively [8]. 

In addition to genotypes other than genotype 1, relevant 

positive predictive factors for achieving an SVR include lower 

viral load at the start of treatment, early initiation of treatment, 

and rapid negative HCV RNA after the initiation of treatment 

[8,18]. Calleri et al. reported that, in addition to achieving an 

RVR (by week 4 of treatment) and low pre-treatment viremia, 

PEG-IFN doses ≥ 1.2 mg/kg/week were positive predictive 

factors for achieving an SVR [9]. 

It is not currently possible to determine the best treatment 

regimen for AHC cases. Nor can we establish a minimum 

follow-up time to be adopted after the end of the treatment. 

Wiegand et al., in a prospective study using biochemical, 

ultrasound, and virological monitoring (HCV-PCR, TMA and 

RNA detection in peripheral mononuclear cells) of patients 

treated with IFN α, in monotherapy, did not report any 

evidence of viral recurrence or hepatocytic lesion during the 

period studied (mean, 135 weeks; range, 52-224 weeks) [10]. 

However, as suggested by Alberti et al. [16] in a meta-analysis 

and subsequently by other authors, the minimum clinical, 

biochemical, and virological follow-up time should not be 

less than 48 weeks. 

Conclusions 

High SVR rates have been reported in patients treated for 

acute hepatitis C. In view of this, various national and 

international consensuses have recommended the treatment 

of this infection [6,14,19,34,35]. However, there is no 

consensus regarding the proper timing of the initiation of 

treatment onset duration of treatment. The best treatment 

regimen to be used, as well as the length of the post-treatment 

follow-up period, is also debatable. 

Taking into account the fact that acute hepatitis C is 

generally asymptomatic, serologic triage and often HCV RNA 

testing are universally recommended strategies for correct 

diagnostic approach of intravenous drug users, patients 

infected with HIV, patients on hemodialysis, children of 

mothers with HCV, sexual partners of HCV-positive 

individuals, and health professionals having been exposed 

to HCV. These segments are currently considered the principal 

at-risk groups for acute infection with HCV and, therefore, 

potentially considered for treatment. 

Diagnostic laboratory tests should include anti-HCV 

antibody tests (detectable between post-infection weeks 4 and 

10), determination of serum levels of aminotransferases such 

as ALT (high between post-exposure weeks 2 and 5) and 

especially detection of HCV RNA (detectable by 1 week after 

infection). The performance of liver biopsy for the diagnosis 

of acute hepatitis C is restricted to situations in which the 

clinical profile is consistent, although anti-HCV seroconversion 

or recent HCV RNA detection are not characteristic. 

Individuals with acute hepatitis C are those who present 

increased ALT, accompanied or not by clinical profile 

consistent with acute hepatitis, with detection of (previously 

undetectable) HCV RNA and seroconversion for anti-HCV. 

Taking into account the possibility of spontaneous viral 

clearance of HCV, especially reported in symptomatic 

individuals with acute infection, it is recommended that, in 

symptomatic individuals, the treatment be initiated from week 

12 after symptom onset onward. 

In the case of asymptomatic patients with acute infection, 

treatment should be initiated at the time of diagnosis, since 

there is less probability of spontaneous viral clearance and 

due to the fact that late specific therapy is associated with a 

lower SVR rate. 

Both IFN formulations - conventional IFN and PEG-IFN - 

are considered efficacious options for the treatment of acute 

hepatitis C. However, there has been an increasing tendency 

toward using PEG-IFN as a first option, especially in 

individuals infected with genotype 1. The option of high 

doses of PEG-IFN should be especially considered in 

situations in which short-course treatment regimens are used 

or in cases of infection with genotype 1. When there is an 

option for using the conventional IFN treatment regimen, 

adopting a daily induction dose, followed by reduction of 

the number of doses, up to the end of the treatment, seems to 

be the most efficacious option. There is as yet no conclusive 

evidence that the combination of IFN and RBV is superior to 

monotherapy with IFN. 

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52 Therapeutic Approach to Acute Hepatitis C 


Therefore, as observed in studies of chronic hepatitis C 

with HCV genotype 1, prolonged treatment regimens are 

recommended in cases of acute hepatitis C with HCV genotype 

1, although 24-week treatments can also be considered. In acute 

infections with genotype 2 or 3, short-course treatments (e.g., 

12-week courses) can be feasible options. 

Prolonged (24-week) treatment or combined therapy with 

RBV can be considered for patients who do not present an 

early virological response in the first 4 weeks of treatment. 

Monotherapy regimens, with shorter duration and supervised 

administration of IFN, especially in groups of difficult-totreat 

patients, would be desirable. 

The ideal duration of post-treatment evaluation - clinical, 

biochemical (ALT levels) and virological (detection of HCV 

RNA) - has not yet been well established. However, durations 

of at least 48 weeks should be considered. 

References 

1. Alter M.J., Kruszon-Moran D., Nainan O.V. et al. The 

prevalence of hepatitis C virus infection in the United States, 

1988 through 1994. N Engl J Med 1999;341:556-62. 

2. Jaeckel E., Cornberg M., Wedemeyer H., et al. Treatment of 

acute hepatitis C with interferon alfa-2b. N Engl J Med 

2001;345:1452-7. 

3. Kamal S.M., Ismail A., Graham C.S., et al. Pegylated interferon 

alpha therapy in acute hepatitis C: relation to hepatitis C 

virus-specific T cell response kinetics. Hepatology 

2004;39:1721-31. 

4. Weigrand K., Stremmel W., Encke J. Treatment of hepatitis C 

virus infection. World Journal of Gastroenterology 

2007;13(13):1897-1905. 

5. Updated US Public Health Service guideline for the management 

of occupational exposures to HBV, HCV and HIV and 

recommendations for postexposure prophylaxis. MMWR 

2001;50: RR1. 

6. EASL International Consensus Conference on Hepatitis C, 

Consensus Statement, 1999. J Hepatol 1999;30:956-61. 

7. Santantonio T., Fasano M., Sinisi E., et al. Efficacy of a 24- 

week course of peg-interferon a-2b monotherapy in patients 

with acute hepatitis C after failure of spontaneous clearance. 

J Hepatol 2005;42:329-33. 

8. Kamal S.M., Moustafa K.N., Chen J., et al. Duration of 

peginterferon therapy in acute hepatitis C: a randomized 

trial. Hepatology 2006;43:923-31. 

9. Calleri G., Cariti G., Gaiottino F., et al. A short course of 

pegylated interferon-a in acute hepatitis C. Journal of Viral 

Hepatitis 2007;14:116-21. 

10. Wiegand J., Jäckel E., Cornberg M., et al. Long-term followup 

after successful interferon therapy of acute hepatitis C. 

Hepatology 2004;40:98-107. 

11. McKiernan S.M., Hagan R., Curry M., et al. Distinct MHC 

class I and II alleles are associated with hepatitis C viral 

clearance, originating from a single source. Hepatology 

2004;108-14. 

12. Santantonio T., Medda E., Ferrari C., et al. Risk factors and 

outcome among a large patient cohort with communityacquired 

acute hepatitis C in Italy. Clin Infect Dis 

2006;43:1154-9. 

13. Afdhal N.H. The natural history of hepatitis C. Seminars in 

Liver Diseases 2004;24,suppl. 2:3-8. 

14. Strader D.B., Wright T., Thomas D.L., Seeff L.B. AASLD 

Practice Guideline – Diagnosis, Management and Treatment 

of Hepatitis C. Hepatology 2004;39:1147-71. 

15. Heller T., Rehermann B. Acute hepatitis C: a multifaceted 

disease. Seminars in Liver Diseases 2005;25:7-17. 

16. Alberti A., Boccato S., Vario A., Benvegnù L. Therapy of 

acute hepatitis. Hepatology 2002;5:S195-S200. 

17. Micallef J.M., Kaldor J.M., Dore G.J. Spontaneous viral clearance 

following acute hepatitis C infection: a systematic review of 

longitudinal studies. Journal of Viral Hepatitis, 2006;13:34-41. 

18. Nomura H., Sou S., Tanimoto H., et al. Short-term interferonalfa 

therapy for acute hepatitis C: a randomized controlled 

trial. Hepatology 2004;39:1213-19. 

19. Consensus Statements on the Prevention and Management of 

Hepatitis B and Hepatitis C in the Asia-Pacific Region. Journal 

of Gastroenterology and Hepatology 2000;15:815-41. 

20. Kamal S.M., Fouly A.E., Kamel R.R., et al. Peginterferon alfa-2b 

therapy in acute hepatitis C: impact of onset of therapy on 

sustained virologic response. Gastroenterology 2006;130:632-8. 

21. De Rosa F.G., Bargiacchi O., Audagnotto S., et al. Twelveweek 

treatment of acute hepatitis C virus with pegylated 

interferon-a-2b in injection drug users. Clinical Infectious 

Diseases 2007;45:583-8. 

22. Alter M.J. Prevention of spread of hepatitis C. Hepatology 

2002;36:suppl.1:593-8. 

23. Mondelli M.U., Cerino A., Cividini A. Acute hepatitis C: 

diagnosis and management. J Hepatol 2005;42:S108-S14. 

24. Corey K.E., Ross A.S., Wurcel A., et al. Outcomes and treatment 

of acute hepatitis C virus infection in a United States population. 

Clinical Gastroenterology and Hepatology 2006;4:1278-82. 

25. Manns M.P., Mc Hutchison J.G., Gordon S.C., et al. 

Peginterferon alfa-2b plus ribavirin compared with interferon 

alfa-2b plus ribavirin for initial treatment of chronic hepatitis 

C: a randomized trial. Lancet 2001;358:958-65. 

26. Fried M.W., Shiffman M.L., Reddy K.R., et al. Peginterferon 

alfa-2a plus ribavirin for chronic hepatitis C virus infection. 

N Engl J Med 2002;347:975-82. 

27. Hofer H., Watkins-Riedel T., Janata O., et al. Spontaneous 

viral clearance in patients with acute hepatitis C can be 

predicted by repeated measurements of serum viral load. 


28. Gerlach J.T., Diepolder H.M., Zachoval R., et al. Acute 

hepatitis C: high rate of both spontaneous and treatmentinduced 

viral clearance. Gastroenterology 2003;125:80-8. 

29. Davis G.I., Wong J.B., McHutchinson J.G., et al. Early virologic 

response to treatment with peginterferon alfa-2b plus 

ribavirin in patients with chronic hepatitis C. Hepatology 

2003;38:645-52. 

30. Firenci P. Predicting the therapeutic response in patients with 

chronic hepatitis C: the role of viral kinetics studies. J 

Antimicrob Chemother 2004;53:15-8. 

31. Yamaji K., Hayashi J., Kawakami Y., et al. Hepatitis C viral 

RNA status at two weeks of therapy predicts the eventual 

response. J Clin Gastroenterol 1998;26:193-9. 

32. Wiegand J., Baggish P., Boecher W., et al. Early monotherapy with 

pegylated interferon alpha-2b for acute hepatitis infection: the 

HEP-NET acute-HCV II study. Hepatology 2006;43:250-6. 

33. Jaeckel E., Cornberg M., Waldemeyer H., et al. Acute hepatitis 

C: to treat or not to treat? Hepatology 2002;35:1538-40. 

34. Management of hepatitis C: 2002. NIH Consensus 

Development Conference, 2002. 

35. Angerami R.N., Stucchi R., Gonçales N.S.L., Gonçales Jr. F.L.G. 

Hepatite C aguda. II Consenso da Sociedade Paulista de 

Infectologia para Manuseio e Terapia da Hepatite C 2004:34-6. 

36. Zekry A., Patel K., Mc Hutchison J.G. Treatment of acute 

hepatitis C infection: more pieces of the puzzle. J Hepatol 

2005;42:293-6. 

37. Focaccia R., Galante V.C., Oliveira U.B. Hepatite C – 

Epidemiologia. In: Tratado de Hepatites Virais. Ed Roberto 

Focaccia, 2ª Edição, Editora Atheneu, 2007:211-16. 

38. Consenso da Sociedade Paulista de Infectologia para Manuseio 

e Terapia da Hepatite C, 2004. 

www.bjid.com.br


Treatment of Chronic Hepatitis C in Treatment-Naïve Patients 

Marcelo Simão Ferreira 

Federal University of Uberlândia School of Medicine; Uberlândia, MG, Brazil 

After the initial acute phase of infection, 50-85% of patients 

infected with the hepatitis C virus (HCV) develop the chronic 

form of the disease, which, in 20-30% of cases, will evolve to 

cirrhosis, liver failure or hepatocellular carcinoma, albeit after 

several decades. Once this infection has been established, it 

rarely resolves spontaneously. It is known that, during the 

chronic phase, the more severe forms of this viral infection 

can be induced by various cofactors: chronic alcoholism; coinfection 

with HIV or the hepatitis B virus; liver biopsy-proven 

steatosis (or steatohepatitis); and advanced age. The main 

objective for treating this disease is, therefore, to prevent the 

occurrence of late complications, by means of the eradication 

of HCV, which can be achieved in just over half of the cases 

treated with the currently available drugs. 

Treatment for Chronic Hepatitis C: Drugs and Treatment 

Response Patterns 

The currently recommended treatment for the chronic 

forms of hepatitis C is the combination of interferon alpha 

(IFN-α) and ribavirin. The former is a cytosine that is a 

component of the innate response of the human host. Various 

genes involved in the immune response are induced/stimulated 

by IFN-α, resulting in the activation of natural killer cells, 

maturation of dendritic cells, and proliferation of memory cells, 

as well as in the prevention of apoptosis of T cells. The 

hepatocellular injury seen in chronic hepatitis C is not due to 

the cytopathic effect of HCV. It is immunomediated by natural 

killer cells and CD8 T lymphocytes, which are activated by 

the action of IFN-α. 

Ribavirin is an oral nucleoside analog with antiviral effects 

against various pathogens (respiratory syncytial virus, 

arenavirus, etc.) Although its mechanism of action in HCV 

remains unclear, it seems that ribavirin causes the virus to 

mutate rapidly to forms that are more easily killed, as well as 

depleting intracellular adenosine triphosphate, which is 

essential for the synthesis of viral RNA. Immunomodulatory 

effects have been also attributed to this drug. 

The use of IFN-α was approved for hepatitis C treatment 

in 1991. At that time, the response to this immunotherapy was 

very low (< 20%). However, when the combination of ribavirin 

and IFN-α began to be used, the proportion of patients in 

whom a sustained virological response (SVR) was achieved 

grew to 40-45%. Even at that time, treatment responses were 

confirmed by detecting HCV RNA through molecular tests 

such as polymerase chain reaction (PCR). In this context, the 

infection is considered eradicated when there is an SVR, which 

is defined as the absence of serum HCV RNA in a sensitive 

test (qualitative PCR) at the end of treatment and at six months 




after the end of treatment. Patients who achieve an SVR almost 

always show a dramatic decrease in HCV RNA levels, defined 

as a ≥ 2 log 10 

drop or the absence of HCV RNA by 12 weeks 

after the initiation of treatment. This response is designated 

the early virological response (EVR) and has been widely used 

for treatment follow-up of patients infected with HCV 

genotype 1. The maintenance of the undetectable viral load 

status at the end of the treatment is designated the end-oftreatment 

response (ETR). A patient is considered recidivist 

when HCV RNA becomes undetectable during treatment but 

becomes positive again after the end of the treatment, whereas 

a patient is considered a nonresponder when HCV RNA levels 

remain stable or decrease < 2 log 10 

during treatment with the 

combined regimen. 

The most recent advance in the treatment of hepatitis C 

has been the development of long-acting, pegylated 

formulations of IFN-α (PEG-IFN-α), produced by the covalent 

addition of a polyethylene glycol molecule to the IFN-α 

molecule. This combination decreased absorption, reduced 

the clearance of the drug and increased its half-life. With this 

increased half-life, PEG-IFN-α can be administered in weekly 

doses. Two pegylated formulations have now been approved 

for the treatment of hepatitis C: PEG-IFN-α 2a (Pegasys- 

Roche), with a molecular weight of 40 kDa, and PEG-IFN-α 2b 

(PEG-INTRON; Schering-Plough), with a molecular weight of 

12 kDa. 

Table 1 shows the names and doses of the drugs that are 

currently used for the treatment of chronic hepatitis C. 

Viral Kinetics After the Beginning of Treatment 

The most important objective of chronic hepatitis C 

treatment is HCV eradication. The introduction of treatment 

leads to a biphasic drop in the viral population. The speed at 

which the quantity of HCV drops differs among the treated 

patients, and the drops can therefore be classified as rapid 

or slow. Patients in whom there are rapid drops at the 

beginning of treatment more often achieve an SVR. During 

this rapid response phase, which generally occurs within 

the first 48 h of HCV treatment, the viral load decreases 

rapidly, which reflects the IFN-α inhibition of replication and 

the degradation of the drug in the serum. The HCV RNA 

titers begin to decline 8 to 12 h after the administration of the 

first IFN-α dose, and the drop ranges from 0.5 to 1.5 log 10 

within the first 48 h. Thereafter, the rate of viral load reduction 

slows, reflecting the clearance of the virus in the infected 

cells. The complete elimination of viral particles requires 

combined treatment for several months. During this second 

phase, ribavirin seems to play a crucial role in HCV 

depuration. Negative HCV viral load during treatment is 

generally followed by alanine aminotransferase 

normalization and improvement in the necroinflammatory 

activity in liver biopsy. 

www.bjid.com.br

54 Chronic Hepatitis C in Treatment-Naïve Patients 


Table1. Drugs used for the treatment of chronic hepatitis C 

Drugs 

Conventional interferon 

Alpha 2a 

Alpha 2b 

Consensus 

Pegylated interferon 

Peginterferon α 2a (40 kDa) 

Peginterferon α 2b (12 kDa) 

Nucleoside analogs 

Ribavirin 

MU: million units; sc: subcutaneous. 

Recommended doses 

3 MU sc 3 × week 

3 MU sc 3 × week 

9 μg sc 3 × week 

180 μg SC / week 

1.5 μg/kg SC / week 

From 1,000 mg (≤ 75 kg) to 

1250 mg (> 75 kg), oral, daily 

Treatment Protocols 

For adults diagnosed with chronic hepatitis C and 

presenting detectable serum levels of HCV RNA, together 

with persistent elevation of aminotransferases, histological 

evidence of progressive hepatic disease, no severe 

comorbidities, and no contraindications, treatment is 

recommended. All patients should be initially submitted to 

viral load quantification (quantitative PCR), HCV genotype 

identification (genotypes 1 to 6) and liver biopsy for the 

evaluation of necroinflammatory activity (intensity) and 

fibrosis (staging). The two most common methods for 

histological evaluation are the METAVIR and Ishak scoring 

systems, in which fibrosis is scored as absent (F0), only portal 

(F1), portal with septum formation (F2), hepatic with portalcentral 

and portal-portal bridging (F3), or cirrhosis (F4). 

Treatment is recommended for patients who present a score 

of at least F2. 

It must be borne in mind that liver biopsy is an invasive, 

costly, and potentially fatal procedure. For patients presenting 

HCV genotype 1, this procedure is useful for therapeutic 

decisions when there is no evidence of advanced fibrosis 

detected by other methods (ultrasound, etc.) However, for 

those presenting genotype 2 or 3 and high treatment response 

rates, liver biopsy might be unnecessary and might not 

influence the therapeutic decision, especially for those 

individuals who present persistently high levels of 

aminotransferases. 

The combination of PEG-IFN-α and ribavirin is the 

treatment currently recommended for patients with chronic 

hepatitis C; its efficacy in achieving an SVR is greater than 

that of the conventional treatment with IFN-α in isolation or 

with the combination of IFN-α and ribavirin (56% vs. 16% vs. 

42%). As demonstrated in Table 1, subcutaneous PEG-IFN-a 

is administered weekly, and oral ribavirin is administered in 

two daily doses. The recommended dose of PEG-IFN-α 2a is 

180 μg per week and that of PEG-IFN-α 2b is 1.5 μg/kg per 

week. Treatment duration and ribavirin dosing vary according 

to HCV genotype. Patients presenting HCV genotype 1 must 

be treated with either 1,000-mg or 1,250-mg doses of ribavirin 

(body weight ≤ 75 kg or > 75 kg, respectively) for 48 weeks. 

Patients infected with HCV genotype 2 or 3 must receive 800 

mg of ribavirin daily for 24 weeks. In Brazil, ribavirin capsules 

contain 250 mg, and so it is not possible to administer the 

recommended 800-mg doses. Therefore, we believe it is 

prudent to prescribe 1000-mg doses for all patients infected 

with these genotypes. There is little information on the 

treatment against hepatitis C genotypes 4, 5, and 6 (which are 

rare in Brazil). It has been recommended that the 48-week 

treatment regimen be used in these cases. 

In the treatment for infection with HCV genotype 1, the 

possibility of achieving an SVR is based on the EVR, as 

previously defined. Negative results or a significant (≥ 2 log 10 

) 

drop in HCV viral load by week 12 of treatment is indicative of 

an SVR, which appears in 65% of the patients treated with 

PEG-IFN-α 2a and in 72% of those treated with PEG-IFN-α 2b. 

However, among those who have not achieved an EVR by 

week 12 using either formulation, only 3% achieve an SVR. 

Therefore, the EVR is a strong negative predictor of the SVR. 

All patients who continue to present positivity (based on 

viral loads) at week 12 should be re-assessed at week 24, at 

which point a qualitative PCR should be performed. If results 

are negative, treatment should be maintained up to week 48. If 

is the results are still positive, treatment should be 

discontinued. For HCV genotypes 2 and 3, it is not generally 

recommended that molecular tests be performed during the 

24-week treatment regimen. At the end of the combined 

treatment, regardless of the genotype, a qualitative PCR should 

be performed in order to evaluate the ETR. 

Chart 1 shows the algorithm for the follow-up of patients 

with chronic hepatitis C during the treatment with PEG-IFN-α 

and ribavirin. 

With the current treatment protocols, the rate at which an 

SVR is achieved ranges from 54% to 56% after the use of the 

combination of PEG-IFN-α (either formulation) and ribavirin, 

which is considerably higher than that seen with older 

conventional treatments (Chat 1). Among patients infected 

with HCV genotype 2 or 3, the rate at which an SVR is achieved 

ranges from 75% to 80%, compared with 40% to 61% among 

those infected with HCV genotype 1. Among patients with 

HCV genotype 1, the rate at which an SVR is achieved is lower 

in blacks (28%) than in Caucasians (52%). Other factors that 

influence treatment response, leading to lower cure rates, are 

high viral load levels (> 600,000 IU/mL), male gender, high 

body mass index, biopsy showing advanced fibrosis and high 

iron levels in the hepatic parenchyma. In patients infected 

with HCV genotype 2 or 3 and treated with a conventional 

regimen involving the combination of IFN-α (3 million units 3 

times a week) and ribavirin, the rate at which an SVR is achieved 

can be similar to that of those treated with pegylated 

formulations and ribavirin. Therefore, this regimen is still 

recommended in Brazil (directive 863/2002). For such patients, 

the use of this treatment regimen for six months is less costly 

and better tolerated. 

Patients with liver cirrhosis have lower chances to eliminate 

HCV by means of the current treatment than do noncirrhotic 

patients. This might be due to the fact that the former present 

more advanced age, greater alterations in hepatic 

microcirculation (which prevent the adequate interaction 

between IFN and infected cells), and lower treatment 

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BJID 2007; 11 Supplement 1 (October) Chronic Hepatitis C in Treatment-Naïve Patients 

55 

Chart 1. Chronic hepatitis treatment strategies 

Table 2. Drugs for the treatment of chronic hepatitis C 

Genotype PEG-IFN-α Ribavirin Duration Treatment evolution SVR 

(dose) (dose) (weeks) (%) 

1 α 2a: 180 μg/week 1.0 g (< 75 kg) 48 a) No response: ¯HCV RNA at week 12 40-61 

(4, 5, 6) α 2b: 1.5 μg/kg/week 1.25 g (> 75 kg) < 2 log 10 

IU/mL or HCV RNA ⊕ by week 24 

b) Rapid response: treat for 24 weeks if 

HCV RNA Θ by week 4 and low initial 

viral load (< 600,000 IU/mL) 

2, 3 Same as above 1.0 g 24 a) No response: uncommon 75-80 

b) Rapid response: treat for 12-16 weeks 

if HCV RNA Θ by week 4 

PEG-IFN=pegylated interferon; SVR=sustained virological response; HCV=hepatitis C virus. 

www.bjid.com.br

56 Chronic Hepatitis C in Treatment-Naïve Patients 


compliance rates. These patients should be treated carefully 

due to the risk of decompensation of the disease during 

treatment and the worsening of pre-existing hematological 

parameters (leukopenia and platelet reduction). Patients with 

compensated cirrhosis should be treated if they present the 

minimum criteria to receive these medications: 

a) Total bilirubin < 1.5 g/dL 

b) Albumin > 3.4 g/dL 

c) Platelets > 75,000/mm 3 

d) Hemoglobin > 13 g/dL; neutrophils > 1500/mm 3 

e) Creatinine < 1.5 mg/dL 

f) Absence of ascites, together with hepatic encephalopathy. 

In patients with advanced fibrosis and treated with the 

PEG-IFN-α/ribavirin combination, the rate at which an SVR is 

achieved ranges from 37% to 50%, being higher (70%-75%) in 

those presenting HCV genotype 2 or 3, as well as in those 

with low viral loads. Side effects, especially thrombocytopenia 

and neutropenia, are more common in these patients. At this 

stage of the disease, cirrhotic patients who achieved an SVR 

are not totally protected against the risk of developing 

hepatocellular carcinoma. Two recent studies have confirmed a 

limited reduction in the risk of hepatocellular carcinoma in 

patients who successfully responded to the combined 

regimen; however, some degree of risk remains due to the 

carcinogenic effect of hepatic fibrosis. In addition, the 

complications of advanced liver disease, in these cases, 

occur less frequently, mortality is lower, and there will 

obviously be no re-infection of the organ after the liver 

transplant. In order to prevent re-infection in transplanted 

patients, those who are on a liver transplant waiting list and 

present decompensated cirrhosis have been treated with 

IFN-α or PEG-IFN-α and ribavirin for periods ranging from 

three to fourteen months. In these individuals, the rate at 

which an SVR is achieved has been low (from 20% to 25%), 

and morbidity/mortality due to the treatment have been 

considerably high. Bacterial infections, severe cytopenias, 

and even mortality have been reported during treatment. 

However, in those patients who responded to treatment, with 

the elimination of HCV, there was improvement in liver 

function, fewer episodes of decompensation and lower 

mortality. Benefits seem to be higher, as expected, for patients 

infected with HCV genotype 2 or 3, who traditionally respond 

better to the treatment regimen. 

Not every patient whose HCV RNA levels become 

undetectable during treatment achieves an SVR. In 10% of 

the treated patients, this molecular marker reappears in the 

serum during treatment, whereas in 20% of the treated patients, 

it reappears after the end of treatment (recurrence); in this 

context, HCV RNA becomes detectable a few weeks after the 

interruption of treatment, and aminotransferase levels again 

increase. Recurrence is more common with short treatment or 

when there is a delay in achieving negative HCV RNA results. 

In those patients who responded to treatment and achieved 

an SVR, long-term follow-up evaluations have shown that 

HCV RNA results remain negative in more than 95% of these 

patients, confirming the cure and the improvement in 

histological parameters. 

Modifications During the Course of Treatment of Chronic 

Hepatitis C 

In patients infected with HCV genotype 1, a 72-week 

combined regimen (PEG-IFN-α + ribavirin) may be beneficial 

for slow responders, who fail to present negative HCV RNA 

results by week 4 or week 12 of treatment (EVR). In a randomized 

study, 326 patients still presented positive results for the virus 

at week 4 of treatment. These patients received the 

medications for either 48 or 72 weeks. The rate at which an 

SVR was achieved was significantly higher in the group 

receiving the longer-duration regimen (45% vs. 32%; p = 0.01). 

In another randomized study, patients who did not achieve an 

EVR were submitted to either 48 or 72 weeks of treatment. The 

results showed that 29% (31/106) of the patients in the 72- 

week group achieved an SVR, compared with only 17% (17/ 

100) of those in the 48-week group (p = 0.04). Therefore, 

selected patients who present slow initial response to antiviral 

medications can be treated for longer periods. 

However, the treatment duration can be shortened if 

patients develop a rapid virological response (RVR), defined 

as presenting a response by week 4 of treatment. Various 

studies have demonstrated that negative results in the 

qualitative PCR by week 4 of treatment have a positive 

predictive value for SVR. Studies involving patients infected 

with HCV genotype 2 or 3 who achieve an RVR with the use of 

PEG-IFN-α 2b and ribavirin have demonstrated that treatment 

can be discontinued at 12 to 16 weeks after the beginning of 

treatment, since these patients presented SVR rates that were 

similar to those seen in the control group, which was submitted 

to the 24-week regimen. Recurrences were especially more 

common among patients infected with HCV genotype 2 and 

in those with high viral loads before treatment. In a recent 

randomized study, 150 patients infected with HCV genotype 2 

were treated with PEG-IFN-α and ribavirin for either 16 or 24 

weeks. The comparison showed that both groups presented 

high SVR rates (94% and 95%, respectively), indicating that 

patients infected with HCV genotype 2 can be treated for a 

shorter period of time. In a similar study, involving patients 

infected with HCV genotype 1, good results were 

demonstrated using a 24-week course of treatment. Patients 

achieving an RVR and a low viral load (< 600,000 IU/mL), 

treated for this short period of time, presented a high cure rate 

(89%), confirming the hypothesis that, even in patients 

infected with the more difficult to treat genotypes, it is possible 

that treatment can be shortened if patients are adequately 

selected regarding short-term regimens. 

Although further studies are necessary to confirm the 

efficacy of less prolonged therapies for the treatment of 

chronic hepatitis C, these current studies have already 

indicated that it is possible to use this strategy for patients 

achieving an RVR, significantly improving treatment 

compliance and quality of life of the patients, as well as 

reducing the frequency of side effects and increasing the 

cost-effectiveness ratio. Table 2 summarizes the current 

recommendations for the treatment of chronic hepatitis C, 

showing the recommended medications and doses, together 

with treatment durations and responses. 

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BJID 2007; 11 Supplement 1 (October) Chronic Hepatitis C in Treatment-Naïve Patients 

57 

Contraindications to and Side Effects of Treatment 

Absolute contraindications to the PEG-IFN-α and ribavirin 

treatment include pregnancy, breastfeeding and 

hypersensitivity to either drug. Relative contraindications, 

due to potential side effects are as follows: decompensated 

liver disease (jaundice, ascites, hepatic encephalopathy, 

severe coagulopathy, etc.); neuropsychiatric, pulmonary, 

cerebrovascular or coronary diseases; severe autoimmune 

diseases; malignant neoplasms; convulsions; and history 

of solid organ transplants. Patients addicted to injection 

drugs, as well as chronic alcoholics, should be advised to 

abandon the habit (for at least six months) prior to the 

beginning of the antiviral therapy. Patients diagnosed with 

anemia, leukopenia and platelet reduction should be treated 

with care, and hematological parameters should be closely 

monitored throughout the treatment. 

Side effects of interferon and ribavirin affect practically 

all of the patients. Table 3 shows these side effects, which 

are organized by their frequency. 

The most common side effects are fatigue, myalgia, 

psychological alterations (depression, anxiety, insomnia, and 

irritability) and worsening of hematological parameters 

(anemia, platelet reduction, and leukopenia). Ribavirin 

induces hemolytic anemia, which frequently requires dose 

reduction. In addition, ribavirin is teratogenic, which requires 

strict contraceptive control during treatment. Only 1% to 

2% of patients will develop severe side effects, requiring the 

interruption of one or both medications. Recombinant 

erythropoietin (for anemia) and filgrastim (for neutropenia) 

should be routinely used for the control of treatment-induced 

cytopenias. Patients suffering from depression or mood 

disorders can use antidepressants or anxiolytics, with 

variable success. 

References 

1. Hoofnagle J.H., Seef L.B. Peginterferon and Ribavirin for chronic 

hepatitis C. New England Journal of Medicine 2006;355:2444- 

51. 

2. Strader D.B., Wright T., Thomas D.L., Seef L.B. Diagnosis, 

management and treatment of hepatitis C. Hepatology 

2004;4:1147-71. 

3. Iacobellis A., Siciliano M., Perri F., et al. Peginterferon alfa-2b 

and ribavirin in patients with hepatitis C virus and 

decompensated cirrhosis: a controlled study. Journal of 

Hepatology 2007;46:206-12. 

4. Bruno S., Stroffolini T., Colombo M., et al. Sustained virological 

response to Interferon a is associated with improved outcome in 

HCV-related cirrhosis: a retrospective study 2007;45:579-87. 

5. Schiff E.R. Emerging strategies for pegylated interferon 

combination therapy. Gastroenterology & Hepatology 

2007;4(1):517-21. 

6. Navasa M., Forns X. Antiviral therapy in HCV decompensated 

cirrhosis: to treat or not to treat? Journal of Hepatology 

2007;46:185-8. 

7. Everson G.T., Hoefs J.C., Seef L.B., et al. Impact of disease severity 

on outcome of antiviral therapy for chronic hepatitis C: lessons 

from the HALT-C trial. Hepatology 2006;44:1675-84. 

8. Tan J., Lok A.S.F. Update on viral hepatitis: 2006. Current Opinion 

in Gastroenterology 2007;263-7. 

Table 3. Side effects of interferon and ribavirin 

Side effects 

Interferon α (including PEG-IFN) 

Flu symptoms (greater with PEG-IFN-α 2a) 

Neutropenia 

Thrombocytopenia 

Depression, acute psychosis, 

suicide attempts 

Irritability 

Visual disorders 

Fatigue, myalgia 

Hypothyroidism/hyperthyroidism 

Headache 

Nausea, vomiting 

Itching 

Fever, weight loss 

Hearing loss 

Alopecia 

Pulmonary interstitial fibrosis 

Angina/myocardial infarction 

Bacterial infections (in cirrhotic patients) 

PEG-IFN=pegylated interferon. 

Ribavirin 

Hemolytic anemia 

Fatigue 

Pruritus 

Skin rash 

Sinusitis 

Fetal malformations 

Gout 

9. Hadzyiannis S.J., Sette H., Morgan T.R., et al. Peginterferon a 2a 

and Ribavirin combination therapy in chronic hepatitis C. Annals 

of Internal Medicine 2004;140:346-55. 

10. Pawlotsky J.-M. Current and future concepts in hepatitis C 

therapy. Seminars in Liver Disease 2005;25:72-83. 

11. Mangia A., Santoro R., Minerva N., et al. Peginterferon alfa 2b 

and Ribavirin for 12 vs 24 weeks in HCV genotype 2 or 3. The 

New England Journal of Medicine 2005;325:2609-17. 

12. Zenzem S., Buti M., Ferenci P., et al. Efficacy of 24 weeks treatment 

with chronic hepatitis C infected with genotype 1 and low 

pretreatment viremia. Journal of Hepatology 2006;44:97-103. 

13. Delgard O., Bjoro K., Hellum K.B., et al. Treatment with pegylated 

interferon and ribavirin in HCV infection with genotype 2 or 3 

for 14 weeks: a pilot stydy Hepatology 2004;40:1260-5. 

14. Manns M., Waldemeyer H., Cornberg M. Treating viral hepatitis C: 

efficacy, side effects and complications. Gut 2006;55:1350-9. 

15. Davis G.L. Monitoring of viral levels during therapy of hepatitis 

C. Hepatology 2002;36:5145-51. 

16. Manns M.P., McHutchison J.G., Gordon S.C., et al. Peginterferon 

alfa 2b plus ribavirin for initial treatment of chronic hepatitis 

C: a randomized trial. Lancet 2001;358:958-65. 

17. Hofmann W.P., Zeuzem S., Sarrazin C. Towards individualized 

antiviral therapy of patients infected with hepatitis C virus 

genotypes 2 and 3. Hepatology Reviews 2006;3:3-10. 

18. Abergel A., Hezode C., Leroy V., et al. Peginterferon alpha-2b 

plus ribavirin for treatment of chronic hepatitis C with severe 

fibrosis: a multicentre randomized controlled trial comparing 

two doses of peginterferon alpha 2b. Journal of Viral Hepatitis 

2006;13:811-20. 

19. Hung C.H., Lee C.M., Lu S.N., et al. Long term effect of interferon 

alpha 2b plus ribavirin therapy on incidence of hepatocellular 

carcinoma in patients with hepatitis C virus-related cirrhosis. 

Journal of Viral Hepatitis 2006;13:409-14. 

20. EASL International Consensus Conference on hepatitis C. Paris, 

26-27 February 1999. Consensus statement. Journal of 

Hepatology 1999;3151:3-8. 

www.bjid.com.br


Retreatment of Hepatitis C Patients Who Previously Experienced Treatment Failure 

Fernando Lopes Gonçales Jr. 

Department of Viral Hepatitis Studies, State University of Campinas (Unicamp); Campinas, SP, Brazil 

In its different formulations, interferon (IFN) alpha 

combined with ribavirin (RBV) is the best treatment alternative 

for patients infected with the hepatitis C virus (HCV) [1]. In 

such patients, the objective is to achieve an end-of-treatment 

virological response – negative serum HCV ribonucleic acid 

(RNA) – followed by a sustained virological response (SVR), 

which is defined as HCV RNA negativity for six months after 

the suspension of treatment. 

The treatment regimens for HCV infection have evolved 

from monotherapy with conventional IFN alpha to combined 

therapy with IFN and RBV and, more recently, to combined 

therapy with pegylated IFN (PEG-IFN alpha-2a or alpha-2b) 

and RBV [2,3]. It is known that approximately 60% of the 

patients infected with HCV genotype 1 and nearly 40% of 

those infected with genotype 3 do not achieve an SVR when 

treated with the conventional regimen of IFN and RBV [2-7]. 

The availability of PEG-IFNs has reduced the percentage of 

patients experiencing treatment failure. In large international 

trials involving treatment-naïve patients, regimens that include 

the combination of PEG-IFN and RBV have produced 

significantly higher rates of SVR than those observed with 

the use of the conventional combination of IFN and RBV (54- 

56% vs. 44-47%) [5-7]. 

Similar to what occurs in treatment-naïve patients, 

retreatment provides the patient with a new chance to achieve 

an SVR. Long-term studies have proven that the vast majority 

of the patients who achieve an SVR usually remain negative 

for HCV RNA for a long time [8]. 

The arguments in favor of retreating patients would be 

the possibility of eradicating HCV, reducing fibrosis, and 

decreasing the risk of evolving to hepatocarcinoma. With 

regard to the new antiviral agents, we do not know when they 

will be available or whether all patients will be able to wait 

several years to initiate retreatment. 

It is known that patients who experience relapse after 

treatment with conventional IFN, with or without RBV, respond 

better to retreatment with PEG-IFN alpha and RBV than do 

those presenting no response to treatment with conventional 

IFN (with or without RBV). Krawitt et al. observed an SVR rate 

of 55% in 66 relapsing patients who were retreated with PEG- 

IFN alpha-2b (100-150 µg/week) and RBV (1000 mg/day), 

compared with only 20% in 116 previous nonresponders 

treated with the same regimen [9]. An SVR was observed in 

53% of the relapsing patients infected with genotype 1, 

compared with 59% of the relapsing patients infected with 

genotypes 2 or 3. There were, therefore, no significant 

differences between these groups of patients. This was not 




observed in the previous nonresponders receiving retreatment. 

Of those, only 17% of the individuals infected with genotype 

1, in comparison with 57% of the individuals infected with 

genotypes 2 or 3, achieved an SVR. Therefore, genotype had 

an influence on SVR in the previous nonresponders who 

underwent retreatment. 

Studies conducted in Brazil and involving nonresponders 

to IFN/RBV demonstrated SVR rates resulting from retreatment 

with the PEG-IFN alpha-2a + RBV regimen [10], as well as with 

the PEG-IFN alpha-2b + RBV regimen [11], that were higher 

than those reported in international studies. Of the relapsers 

treated, 57% [10] and 62% [11] achieved an SVR. These SVR 

rates in relapsers are higher than, for example, the rates of 

41% and 59% obtained, respectively, in Canada (by Sherman 

et al.) and in France (by Moucari et al.) [12,13]. In analyzing 

the response in relapsers by genotype, the Brazilian 

researchers found that an SVR was achieved in 69-70% of 

those infected with genotype 3, compared with 43-44% of 

those infected with genotype 1 [10,11]. 

True nonresponders, that is, patients who never presented 

viral negativity during or at the end of the treatment, are the 

most difficult group to retreat. Some authors showed that, 

after previous treatment with conventional IFN, with or without 

RBV, relapsers have significantly higher SVR when retreated 

with PEG-IFN alpha-2b and RBV than do nonresponders to 

previous treatment (55% vs. 20%; p

BJID 2007; 11 Supplement 1 (October) Retreatment of Hepatitis C Patients 

59 

IFN alpha-2a in the first 12 weeks, achieved an SVR at a rate 

of 30-37%, which is practically twice as high as the SVR rate 

of 18% observed in those treated with normal doses of PEG- 

IFN alpha-2a [16]. 

Since nonresponders to initial treatment/relapsers 

constitute a very heterogeneous group, it is necessary to 

carefully qualify and select the patients who should be 

retreated. The various factors that might have been 

responsible for the lack of a response should be modified/ 

nullified prior to the initiation of or even during the new 

treatment cycle. Currently, the patients who are considered 

the least likely to respond to retreatment are the true 

nonresponders, as well as those who are black, infected 

with genotype 1, presenting a high viral load, having 

advanced liver disease, or presenting intercurrent diseases, 

such as obesity, HIV coinfection, and coinfection with 

hepatitis B virus. 

Those who were previously treated with IFN as 

monotherapy or with the combination of IFN and RBV are 

more likely to achieve an SVR than are the nonresponders 

to the combination of PEG-INF and RBV. Those who had 

relapses during (breakthrough) or after the previous 

treatment also fare better than do those who are true 

nonresponders. Patients who were noncompliant with the 

previous treatment or those who needed to undergo IFN or 

RBV dose reduction due to cytopenias or other adverse 

effects usually respond better to retreatment than do those 

who received full doses. It is clear that the factors 

responsible for noncompliance should be corrected. In 

addition, medication dose reductions should be adequately 

addressed. In nonresponders, erythropoietin and filgrastim 

should be used earlier and further dose reductions should 

be avoided at all costs. Drug and alcohol users who, due to 

their dependence, did not satisfactorily complete all phases 

of the previous treatment might respond better to 

retreatment if these cofactors are removed. This also applies 

to the patients who did not have adequate social or cultural 

support. Obese patients, insulin-resistant patients, 

dyslipidemic patients, patients with steatosis, and patients 

with liver diseases, such as hemochromatosis, should be 

retreated, preferably after the diagnosis and treatment of 

these accompanying conditions have been appropriately 

addressed. The doses of PEG-IFN should be the same as 

those used in treatment-naïve patients. We recommend that, 

in retreatment, the doses of RBV be as high as possible. 

Due to the paucity of studies of large population samples, 

the duration of retreatment should be 48 weeks for all 

genotypes. At the moment, there are no conclusive data in 

the literature to support the use of higher doses of PEG- 

IFN and RBV, the use of induction doses, or the extension 

of treatment duration to more than 48 weeks in such 

patients. With regard to the week-12 rule, there is strong 

evidence that patients who do not present HCV RNA 

negativity by that time are much less likely to achieve an SVR, 

and that their treatment should therefore be discontinued. 

References 

1. National Institutes of Health Consensus Development Conference 

Statement: Management of hepatitis C: 2002-June 10-12, 

2002. Hepatology 2002;36:S3-20. 

2. McHutchison J.G., Gordon S.C., Schiff E.R., et al. Interferon 

alfa-2b alone or in combination with ribavirin as initial 

treatment for chronic hepatitis C. N Engl J Med 

1998;339:1485-92. 

3. Poynard T., Marcellin P., Lee S.S., et al. Randomised trial of 

interferon alpha-2b plus ribavirin for 48 weeks or for 24 

weeks versus interferon alpha-2b plus placebo for 48 weeks 

for treatment of chronic infection with hepatitis C virus. 

Lancet 1998;352:1426-32. 

4. Poynard T., McHutchison J., Goodman Z., et al. Is an “a la 

carte” combination interferon alfa-2b plus ribavirin regimen 

possible for the first line treatment in patients with chronic 

hepatitis C? Hepatology 2000;31:211-8. 

5. Fried M.W., Shiffman M.L., Reddy K.R., et al. Peginterferon 

alfa-2a plus ribavirin for chronic hepatitis C virus infection. 

N Engl J Med. 2002;347:975-82. 

6. Manns M.P., McHutchison J.G., Gordon S.C., et al. 

Peginterferon alfa-2b plus ribavirin compared with interferon 

alfa-2b plus ribavirin for initial treatment of chronic hepatitis 

C: a randomised trial. Lancet 2001;358:958-65. 

7. Hadziyannis S.J., Sette H., Morgan T.R., et al. Peginterferonalpha2a 

and ribavirin combination therapy in chronic 

hepatitis C: a randomized study of treatment duration and 

ribavirin dose. Ann Intern Med 2004;140:346-55. 

8. Marcellin P., Boyer N., Gervais A., et al. Long-term 

histologic improvement and loss of detectable intrahepatic 

HCVRNA in patients with chronic hepatitis C and sustained 

response to interferon-alpha therapy. Ann Int Med 

1997;127:875-81. 

9. Krawitt E.L., Ashikaga T., Gordon S.R., et al. Peginterferon 

alpha-2b and ribavirin for treatment-refractory chronic 

hepatitis C. J Hepatol 2005;43:243-9. 

10. Parise E., Cheinquer H., Crespo D., et al. Peginterferon alfa-2 

a (40 KD) (PEGASYS) plus ribavirin (COPEGUS) in 

retreatment of chronic hepatitis C patients, nonresponders 

and relapsers to previous conventional interferon plus 

ribavirin therapy. Braz J Infect Dis 2006;10:11-6. 

11. Gonçales F.L. Jr., Vigani A., Gonçales N., et al. Weight–based 

combination therapy with peginterferon alpha-2b and 

ribavirin for naïve, relapser and non-responder patients with 

chronic hepatitis C. Braz J Infect Dis 2006;10:311-6. 

12. Sherman M., Yoshida E.M., Deschenes M., et al. Peginterferon 

alfa-2a (40KD) plus ribavirin in chronic hepatitis C 

patients who failed previous interferon therapy. Gut 

2006;55:1631-8. 

13. Moucari R., Ripault M.P., Oules V., et al. High predictive value 

of early viral kinectics in retreatment with peginterferon and 

ribavirin of chronic hepatitis C patients non-responders to 

standard combination therapy. J Hepatol 2007;46:596-604. 

14. Shiffman M.L., Di Bisceglie A.M., Lindsay K.L., et al. 

Peginterferon alfa-2a and ribavirin in patients with chronic 

hepatitis C who have failed prior therapy. Gastroenterology 

2004;126:1015-23. 

15. Poynard T., Schiff E., Terg R., et al. Sustained virologic 

response (SVR) in the EPIC3 trial: week 12 virology predicts 

SVR in previous interferon/ribavirin treatment failures 

receiving Peg-Intron/Rebetol weight based dosing. J Hepatol 

2005;42 (Suppl. 2):40. 

16. Diago M. Peginterferon alfa-2a (40kd) (Pegasys®) and 

ribavirin (Copegus®) in patients infected with HCV 

genotype 1 who failed to respond to interferon and ribavirin: 

final results of the Spanish high-dose induction pilot trial. 

Presented at the 55 th AASLD; October 29-November 2, 

2004; Boston, MA. 

www.bjid.com.br


Maintenance Treatment for the Modulation of Liver Fibrosis 



In many cases, the evolution of chronic infection with the 

hepatitis C virus (HCV) is favorable. However, progression to 

liver fibrosis is a common phenomenon and can lead to liver 

cirrhosis. Phenomena associated with liver fibrosis have been 

previously reviewed and are more related to the host than to 

viral factors [1]. In brief, the onset of fibrosis is caused by the 

activation of stellate cells, which acquire the shape of 

myofibroblasts and become the source of collagen deposition, 

as well as of protein matrix formation. Activated stellate cells 

rapidly undergo apoptosis, after which the collagen matrix is 

degraded and removed by the activity of metalloproteinases. 

There is a complex balance between the procollagen and 

antifibrotic factors, although the mechanisms of fibrosis 

regression are not fully understood [2]. However, it appears 

that the tissue inhibitor of metalloproteinase-1 [3] and stellate 

cell apoptosis [4] are crucial to maintaining this balance. The 

mechanism through which HCV triggers fibrosis is little 

understood. Apparently, hepatocyte infection triggers a state 

of oxidative stress and induces inflammatory cell recruitment. 

These phenomena lead to the activation of stellate cells and 

collagen deposition. In addition, HCV proteins directly activate 

stellate cells [4]. 

Liver cirrhosis and the preceding transition stage are 

marked phenomena in the clinical evolution of patients and 

have been associated with morbidity/mortality due to chronic 

hepatitis C. A study involving a cohort of patients chronically 

infected with HCV, monitored from 1991 onward, with a mean 

infection period of 22 years, provided evidence that, five years 

after the diagnosis of cirrhosis (Ishak score ≥ 4), the survival 

rate was 80% [5]. This rate decreased to 19% after the first 

hepatic decompensation [5]. In the multivariate analysis, 

treatment with the combination of conventional or pegylated 

interferon alpha with ribavirin was found to be favorably 

associated with survival. In other words, the treatment was 

associated with the most important outcome: survival! In 

addition, subjects presenting a virological response, whether 

sustained or not, presented better evolution when compared 

to nonresponders. This fact suggests that even transitory 

negative viremia levels are a favorable phenomenon and may 

imply lower structural alterations and activity in the liver [5]. 

One relevant aspect of this study was that the interruption of 

alcohol consumption from the moment of diagnosis on 

prevented the previous ingestion from having an unfavorable 

influence on the disease progression. This fact reinforces the 

importance of alcohol abstinence for patients with hepatitis 

C. Poynard et al. [6] retrospectively analyzed data from 3,010 

patients treated with either conventional or pegylated 




interferon alpha, using various therapeutic regimens . The 

authors concluded that the treatment with pegylated interferon 

and ribavirin resulted in significant improvement in histology, 

inflammatory activity and structural alterations (fibrosis). 

There was improvement in the ‘fibrosis progression rate’, 

which is a valid concept, although reproducibility was 

jeopardized by the risks of sample variation. The least 

worsening of fibrosis was found in the optimized group 

receiving pegylated interferon and ribavirin (8%), and greatest 

degree of such worsening was found in the group receiving 

interferon for 24 weeks (23%) [6]. In general, fibrosis stabilized 

or improved even in those patients not achieving a sustained 

virological response (SVR). However, sample variations, a high 

percentage of patients with mild initial fibrosis (over 70% 

classified as F1), lack of paired biopsy results from all 

participants, lack of a control group, and principally, a relatively 

short follow-up period (20 months between biopsies, on 

average) were limitations of this analysis. Nevertheless, 

Poynard et al. [6] addressed the concept of cirrhosis 

‘reversion’, or as the authors designated it, the ‘reversible 

cirrhosis stage’. This group was composed of young patients, 

whose structural staging changed, regressing from F4. This 

phenomenon occurred in 75 (49%) of the 153 cirrhotic patients 

[6]. The authors postulated that this stage of fibrosis would 

still be ‘easily’ reversed. Some of the factors that were found 

to be associated with the regression of fibrosis after treatment 

are, obviously, the initial degree of fibrosis, minimal baseline 

activity, achieving an SVR, being less than 40 years of age, 

initial viral load lower than 3.5 million copies/mL, and (a new 

concept at that time) body mass index (BMI) < 27 kg/m 2 [6]. In 

another relevant meta-analysis, Cammà et al [7,8]. evaluated 

three randomized clinical studies comprising 1441 patients, 

paired biopsies being available for 1013 (70.3%). Similarly to 

Poynard et al. [6], these authors demonstrated improvement 

in hepatic fibrosis in the patients treated with pegylated 

interferon alpha-2a, when compared to those treated with 

conventional interferon, who achieved an SVR or even 

experienced recurrence. However, there was no improvement 

among nonresponders. The authors also found that a BMI 

higher than 30 kg/m 2 was associated with the worsening of 

hepatic fibrosis. However, in a more representative sample – 

447 (44%) of 1013 cirrhotic patients – no ‘regression of 

cirrhosis’ was found. Only 33% of the cirrhotic patients 

presented improvement in fibrosis. However, the observation 

period between biopsies was also short. Finally, high alanine 

aminotransferase level was another factor that was associated 

with histological improvement. More recently, Di Marco et al. 

[9] prospectively evaluated cirrhotic patients with portal 

hypertension and no previous decompensation who received 

pegylated interferon alpha-2b (1.0 μg/kg/week) with or without 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Maintenance Treatment for Liver Fibrosis 

61 

ribavirin (0.8 g/day). Patients infected with genotype 2 or 3 

showed rapid response, with negative viral RNA results by 

week 4 of treatment, and achieved an SVR. However, only 10 

of the patients infected with genotype 1 or 4 achieved an 

SVR. Nevertheless, for this subgroup of patients, the 

predictability of early response by week 12, but not by week 

4, was also valid, and high baseline viral load was a negative 

predictive marker for SVR. The occurrence of cytopenias was 

high; however, stimulating factors were not used with these 

patients. If stimulating factors had been available, the SVR 

rate associated with treatment maintenance would have 

certainly been better. Treatment compliance is even more 

critical for this group of patients and was associated with 

SVR [9]. Finally, it was clear that SVR is associated with better 

evolution. Only 6% of the patients achieving an SVR 

deteriorated, compared with 38% of the nonresponders [9]. 

Bruno et al. [10] conducted a retrospective multicenter study 

comprising 920 patients with compensated cirrhosis who were 

treated with conventional interferon alpha (from 3 to 6 million 

IU/3 times a week) for a year. Similarly to the prospective 

study conducted by Di Marco et al. [9], the authors 

demonstrated benefits for those who achieved an SVR, with a 

reduction in the risk of decompensation, occurrence of 

hepatocellular carcinoma (HCC) and death. They also found 

that a platelet count of 109,000/mL is an independent predictor 

of decompensation of the liver disease [10]. This factor is 

extremely relevant for clinical practice and could be used as a 

cut-off point in order to define the use of more aggressive 

measures, or even those that still need to be validated. 

Specifically regarding HCC, Cammà et al. [7,8] in 2001, pointed 

out that the benefit of the reduction in the incidence of HCC, 

albeit modest, is also more relevant among those who achieve 

an SVR after being treated with interferon alpha. Other authors 

have also reproduced data regarding the effective and 

tolerable treatment [11], fewer complications, reduction or 

negative incidence of HCC among cirrhotic patients monoinfected 

with HCV who achieved an SVR after the treatment 

with interferon alpha [12-14], and even histological response 

of patients co-infected with HIV [12]. Finally, even patients 

with severe cirrhosis under individualized, ascending-dose 

regimens benefit from treatment and can achieve an SVR, albeit 

a modest one [15-17]. Despite the innumerable benefits of the 

treatment with interferon alpha, we must emphasize that 

surveillance regarding the incidence of HCC is highly 

recommended, even in cirrhotic patients who have achieved 

an SVR [10]. 

There is clear evidence of improvement in fibrosis (a 

quantitative decrease, as well as functional gains such as 

lower portal hypertension) [3], greater survival, potential 

decrease in the incidence of HCC and hepatic complications, 

and even ‘cirrhosis reversion’ [6], even for nonresponders [6] 

or for those who presented recurrence [5-8]. Therefore, we 

should ask why we do not treat even those patients with more 

severe cirrhosis [15-17], and why we do not use the treatment 

with interferon alpha for objectives other than the virological. 

In order to answer these questions, it is initially important 

that recent knowledge on viral kinetics and the concepts of 

treatment individualization – dose and duration –be 

considered in the therapeutic decision-making, and that the 

same concepts are not clearly validated for cirrhotic patients. 

Therefore, if our goal is to achieve an SVR, extending the 

treatment of nonresponders to at least 24 weeks of ‘ideal’ 

treatment is considered ‘futile’ [1]. However, is this true from 

a histological point of view, or from the perspective of the 

need to modulate the natural history of the disease? In order 

to answer these questions and in view of the previously 

described evidence, physicians began to consider the use of 

maintenance treatment with interferon alpha. However, for a 

conclusive analysis, a prospective evaluation would be ideal, 

since differences in methodologies would greatly affect the 

quality of the results [17]. Three principal studies (Table 1) 

have addressed this issue: the Hepatitis C Antiviral Long- 

Term Treatment against Cirrhosis (HALT-C) trial, conducted 

by the NIH; the Evaluation of Peg-Intron in Control of 

Hepatitis C Cirrhosis (EPIC)3 trial; and the Colchicine versus 

Peg-Interferon Long-Term (COPILOT) trial. Other, smaller, 

studies, such as the PROFIC-C trial, have also addressed this 

issue [18]. 

The COPILOT study evaluates patients with fibrosis 

classified as greater than Ishak 3 and previous nonresponders 

to interferon/ribavirin or pegylated interferon/ribavirin, 

comparing, in two branches, colchicine to pegylated interferon 

alpha-2b at 0.5 μg/kg/week. Preliminary analyses after a twoyear 

follow-up period revealed that the group using interferon 

presented significantly fewer hepatic complications, 

especially portal hypertension and upper gastrointestinal tract 

bleeding [6]. Alterations in HCV quantification were minimal. 

The EPIC3 trial has yet to produce preliminary results. 

However, the HALT-C study has provided a consistent amount 

of information. Nevertheless, data regarding the main objective 

of the study, fibrosis modulation, are still unavailable but 

should be presented at the upcoming congress of the American 

Association for the Study of Liver Diseases (AASLD; Afdhal, 

personal communication). Using the available results from 

HALT-C, Everson et al. [15], in 2006, emphasized the need to 

‘optimize’ the treatment of cirrhotic patients, for whom the 

SVR rate was lower, regardless of platelet counts or the need 

to reduce interferon doses – or even the influence of previous 

treatment response. Therefore, cirrhosis is a determining factor 

of a lower SVR rate. Among the therapy ‘optimization’ measures 

that are currently available, should we consider treatment prior 

to the establishment of cirrhosis? What would be the criteria? 

We still cannot answer that, but if we consider some preliminary 

results of new therapies, we can predict that interferon alpha 

will still be the backbone of hepatitis treatment for many years. 

Therefore, we should certainly attempt to gain a better 

understanding of the potential of these treatments and use 

them wisely. 

Among the minor studies, Erhardt et al. preliminarily 

showed that the maintenance of a 0.35-1.0 μg/kg/week dose 

www.bjid.com.br

62 Maintenance Treatment for Liver Fibrosis 


Table 1. Maintenance studies with pegylated interferon 

Study HALT-C COPILOT EPIC3 

Disease stage Ishak 4-6 Ishak 3-6 METAVIR 2-4 

CTP ≤ 6 CTP ≤ 7 CTP ≤ 6 

Patients (n) 1400 800 1700 (700 cirrhotic) 

Treatment arms Placebo, IFN-α, Peg-IFN-α-2a (90 μg) Peg-IFN-α-2b (0.5 μg) 

Colchicine (0.6 mg bid) Peg-IFN á-2b (0.5 μg) 

Duration 3.5 years 4 years 3-5 years 

HALT-C=Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (trial); COPILOT= Colchicine versus Peg-Interferon Long-Term 

(trial); EPIC3=Evaluation of Peg-Intron in Control of Hepatitis C Cirrhosis (trial) 3; CTP=Child-Turcotte-Pugh score; IFN=interferon; 

Peg=pegylated. 

of pegylated interferon alpha-2b significantly reduced, after 

48 weeks, the incidence of HCC and complications due to 

cirrhosis when compared to the control group. In a similar 

study, Kaiser et al. [19] demonstrated that, in the intervention 

group, the fibrosis score dropped from 3.58 to 2.59 after 18 

months of treatment, and to 2.36 by six months after the end 

of treatment. In the control group, the fibrosis score increased 

from 3.88 to 4.07 and to 4.79 by the same time points. Therefore, 

monotherapy with lower doses of pegylated interferon alpha- 

2b effectively reduced and modulated hepatic fibrosis. The 

mechanism for the improvement induced by interferon is 

unknown and is certainly multifactorial. The elimination of 

the triggering agent is undoubtedly crucial, but, since even 

patients who suffer recurrence get better, it is possible that 

interferon alpha has an intrinsic antifibrotic effect, as well as 

inhibiting the activation of stellate cells [4]. Other possible 

approaches that are positively associated with the 

improvement of hepatic fibrosis in nonresponders – or as a 

coadjuvant – are the use of renin-angiotensin inhibitors 

(inhibiting the activation of stellate cells) and the control of 

metabolic syndrome [4]. Other substances that are potentially 

active against hepatic fibrosis are interleukin-10 and the natural 

herb known as Sho-saiko-to [4]. The maintenance treatment 

with ribavirin is clearly a discarded alternative since there are 

no positive effects [20]. Finally, the use of controlled 

phlebotomies may be an alternative in selected cases. 

Excessive iron in the hepatocytes, increased by the effect of 

HCV, has been associated with greater tissue damage [20]. 

The field of antifibrogenesis is in full development and has 

been recently reviewed in an AASLD symposium [3]. 

Considering all the reviewed aspects, we should finally 

evaluate who would benefit from the maintenance treatment. 

These would be the patients with extensive fibrosis (F3/F4) or 

cirrhosis that does not respond to the optimal standard 

treatment. In view of the risk of disease progression and the 

onset of HCC, as well as the body of evidence available, simply 

monitoring the progression of the disease is not an acceptable 

approach, neither for the patient nor for the physician [20]. 

Therefore, what is the ideal dose and how long should we 

maintain the treatment with interferon? The period has yet to 

be defined, and it may be indefinite (or until the appearance of 

a definitely efficacious, safe therapy). Biopsy monitoring every 

two years in association with HCC and screening for 

www.bjid.com.br 

esophageal varices are acceptable standards, although 

normalization of alanine aminotransferase levels and HCV 

reduction will rarely be seen [20]. The advent of noninvasive 

methods of monitoring fibrosis [21,22] has transformed 

maintenance into an even more alternative strategy. Regarding 

the adopted dose, in ongoing and published studies, 

pegylated interferon alpha has been used in smaller-thanhabitual 

doses, once a week. Tolerance and safety have proven 

adequate. Doses from one-third to one-half of the standard 

size seem to be satisfactory for hepatic fibrosis modulation. 

However, definitive results, which are still unavailable, could 

alter this perception. 

In summary: 

1. Hepatic fibrosis is a potentially reversible 

phenomenon, which can even provide functional 

benefits. 

2. Even for cirrhotic patients, treatment with interferon 

alpha is possible, efficient and safe, although it is less 

efficacious if we consider the SVR. 

3. Treatment with pegylated interferon alpha, even when 

it is ineffective, is associated with greater survival, 

fewer complications and lower incidence of HCC. 

4. Interferon alpha has a modulatory effect on hepatic 

fibrosis. 

5. Maintenance treatment with reduced doses of 

pegylated interferon alpha proved to be effective in 

modulating hepatic fibrosis as well as in altering the 

natural history of the disease. 

6. Antifibrogenesis is a field that is still in development, 

and, in addition to interferon alpha, other measures 

can be adopted, such as control of metabolic syndrome 

and the use of renin-angiotensin inhibitors. 

Considering the reviewed aspects, together with the facts 

that the number of antiviral therapies currently in development 

is smaller than expected, and that none of those are yet 

clinically available, as well as the fact that they will still need 

to be combined with interferon alpha, I believe that the 

optimization of interferon alpha will continue to be crucial. A 

pharmaco-economic analysis must be certainly considered as 

a supporting tool in the collective decision-making. However, 

considering the physician-patient relationship, some 

reflections are pertinent and should be debated by the 

Hepatitis Committee of the Brazilian Society of Infectology.

BJID 2007; 11 Supplement 1 (October) Maintenance Treatment for Liver Fibrosis 

63 

Therefore, we propose the following: 

Individualization 

The dose and duration of treatment with the combination 

of pegylated interferon and ribavirin should be defined based 

on patient body weight and on the early response during 

therapy for patients with minimal lesions (F1) who nevertheless 

are at risk for progression: moderate peri-portal activity, from 

40 to 60 years of age and comorbidities (nonalcoholic 

steatohepatitis, HIV infection or metabolic syndrome). 

Maintenance Treatment 

Considering maintenance treatment with pegylated 

interferon alpha for patients with structural lesions greater 

than F3 or portal hypertension signs (esophageal varices, 

enlarged spleen, dilation of vessels) or platelet counts lower 

than 110,000/mm 3 , classified as Child-Pugh class A or B, no 

evidence of severe or potentially uncontrollable 

decompensation, with no HCC, no recurrence, partial 

responders or nonresponders to pegylated interferon alpha 

in association with ribavirin (or only to interferon when there 

are contraindications regarding ribavirin) whose compliance 

can be confirmed for at least 12 weeks. This treatment should 

also be considered for patients who present contraindications 

regarding the use of full doses. Child-Pugh class C patients 

could be treated in specialized centers when on a transplant 

waiting list. 

Proposed regimen*: subcutaneous pegylated 

interferon alpha-2b at 0.5-1.0 μg/kg/week; 

subcutaneous pegylated interferon alpha-2a at 90 μg/ 

week. 

Duration*: at least 24 months, indefinite, or until the 

appearance of a definitely efficacious, safe antiviral 

therapy. 

Follow-up evaluation: Monitoring the onset of 

complications (HCC, digestive tract hemorrhage, 

encephalopathy, etc.) 

*Dose schedule and duration were suggested based on preliminary data 

and should be reassessed depending on the results of ongoing studies. 

References 

1. Hoofnagle J.H., Seef L.B. Peginterferon and ribavirin for chronic 

hepatitis C. New England Journal of Medicine 

2006;355(23):2444-51. 

2. Arthur M.J.P.Reversibility of liver fibrosis and cirrhosis following 

treatment for hepatitis C.Gastroenterology 2002;122(5):1525- 

8. 

3. Friedman S.L., Rockey D.C., Bissel M. Hepatic fibrosis 2006: 

report of the third AASLD single topic conference. Hepatology 

2007;45:242-9. 

4. Bataller R., Brenner D.A. Liver fibrosis. The Journal of Clinical 

Investigation 2005;115:209-18. 

5. Lawson A., Hagan S., Rye K., et al. The natural history of hepatitis 

C with severe hepatic fibrosis. Journal of Hepatology 

2007;47:37-45. 

6. Poynard T., McHutchinson J., Manns M., et al. Impact of pegylated 

interferon alfa-2b and ribavirin on liver fibrosis in patients with 

chronic hepatitis C. Gastroenterology 2002;122:1303-13. 

7. Cammà C., Di Bona D., Schepis F., et al. Effect of peginterferon 

alfa-2a on liver histology in chronic hepatitis C: a meta-analysis 

of individual patient data. Hepatology 2004;39:333-42. 

8. Cammà C., Giunta M., Andreone P., Craxì A. Interferon and 

prevention of hepatocellular carcinoma in viral cirrhosis: an 

evidence-based approach. Journal of Hepatology 2001;34:593- 

602. 

9. Di Marco V., Almasio P.L., Ferraro D., et al. Peg-Interferon alone 

or combined with ribavirin in HCV cirrhosis with portal 

hypertension: a randomized controlled trial. Journal of 

Hepatology 2007 (in press). 

10. Bruno S., Stroffolini T., Colombo M., et al. Sustained Virological 

Response to interferon-á is associated with improved outcome 

in HCV-related cirrhosis: a retrospective study. Hepatology 

2007;45:579-87. 

11. Helbling B., Jochum W., Stamenic I., et al. HCV-Related advanced 

fibrosis/cirrhosis: randomization controlled trial of pegylated 

interferon á-2a and ribavirin. Journal of Viral Hepatitis 

2006;13:762-9. 

12. Sarmento-Castro R., Horta A., Vasconcelos O., et al. Impacto f 

peginterferon alpha-2b and ribavirin treatment on liver tissue 

in patients with HCV or HCV-HIV co-infection. Journal of 

Infection 2007;54:609-16. 

13. Veldt B.J., Saracco G., Boyer N., et al. Long term clinical outcome 

of chronic hepatitis C patients with sustained virological 

response to interferon monotherapy. Gut 2004;53:1504-8. 

14. Coverdale S.A., Khan M.H., Byth K., et al. Effects of interferon 

treatment response on liver complications of chronic hepatitis 

C: 9-year follow-up study. American Journal of 

Gastroenterology 2004. 

15. Everson T.G., Hoefs J.C., Seef L.B., et al. Impact of disease severity 

on outcome of antiviral therapy for chronic hepatitis C: lessons 

from the HALT-C Trial. Hepatology 2006;44:1675-84. 

16. Everson T.G., Trotter J., Forman L., et al. Treatment of advanced 

hepatitis C with low accelerating dosage regimen of antiviral 

therapy. Hepatology 2005;42:255-62. 

17. Everson G.T. Maintenance Interferon for chronic hepatitis C: 

more issues than answers? Hepatology 2000;32:436-8. 

18. Schuppan D., Krebs A., Bauer M., Hahn E.G. Hepatitis C and liver 

fibrosis. Cell Death and Differentiation 2003;10:S59-S67. 

19. Kaiser S., Hass H., Luize B., et al. Long term, low dose treatment 

with pegylated interferon alfa 2b leads to a significant reduction 

in fibrosis and inflammatory score in chronic hepatitis C 

nonresponder patients with fibrosis or cirrhosis.41 st EASL, 2006. 

20. Kelleher T.B., Afdhal N.H. Maintenance therapy for chronic 

hepatitis C. Current Gastroenterology Reports 2005;7:50-3. 

21. Afdhal N.H., Kowdley K.V., Llovet J.M. CCO Independent 

Conference Coverage of the 2007 Annual Meeting of EASL. 

Interim analisys: peginterferon alfa-2b maintenance therapy 

may reduce incidence of HCV-related HCC, Cirrhosis 

complications, 2007. 

22. Afdhal N.H., Nunes D. Evaluation of liver fibrosis: a concise review. 

American Journal of Gastroenterology 2004;1160-70. 

www.bjid.com.br


Treatment of Patients Infected with Hepatitis C Virus and Presenting Extrahepatic Manifestations 

Fátima Mitiko Tengan1 and Antonio Alci Barone 

University of São Paulo School of Medicine; São Paulo, SP, Brazil 

HCV and Mixed Cryoglobulinemia 

Antiviral treatment should be performed with the same 

medications (standard or pegylated interferon alpha (PEG- 

IFN-α, with or without ribavirin) and similar regimens, until 

additional controlled studies provide further information on 

the treatment of mixed cryoglobulinemia (MC) related to 

infection with the hepatitis C virus (HCV). 

Data regarding antiviral treatment of MC (Table 1) show 

that this therapeutic approach should be the first choice due 

to the antiproliferative and immunomodulatory effects of IFN 

and the usefulness of antiviral treatment, as demonstrated in 

most studies. In addition, the strict correlation between 

virological and clinical response, as well as the positive effect 

of inhibiting viral replication in the expanded B-cell clones, 

which is considered the pathogenic basis of MC, are reasons 

to make this choice. However, IFN-α can also trigger or worsen 

autoimmune diseases [6,7]. 

Renal insufficiency and neuropathies can occur or be 

worsened, and ulcer cicatrization may be prolonged. Therefore, 

treatment with IFN-α should be restricted to symptomatic 

patients, with or without renal involvement, after the careful 

evaluation of clinical and laboratory characteristics regarding 

autoimmunity during this period. 

In comparison with the antiviral treatment of chronic 

hepatitis C, the antiviral treatment of MC is more complex due 

to various reasons, such as the lack of standardized treatment 

protocols, the higher incidence of recurrence and the 

contraindications to antiviral treatment (old age, severe hepatic 

disease, acute nephritis and disseminated vasculitis). In 

addition, the interpretation of laboratory findings seems to be 

more complex than in chronic HCV infection. In fact, 

biochemical markers of MC response (cryocrit, rheumatoid 

factor or complement activity) can be more independent of 

the virological response than are alanine aminotransferase 

(ALT) levels. 

At the moment, antiviral treatment is suggested as the 

treatment of choice for this condition, even when there is no 

indication of hepatic pathology. Patients with apparently 

benign manifestations of the disease (palpable purpura, 

arthralgia and mild fatigue) should not be treated or can be 

symptomatically treated with nonsteroidal anti-inflammatory 

drugs. Special attention must be given to the treatment of 

patients with severe MC (with acute nephritis and 

disseminated vasculitis).For these cases, the data are 

insufficient to guarantee the safety of IFN administration, and 

we therefore strongly suggest a cautious approach. It is 

preferable to use an alternative therapeutic approach to all 

patients for whom antiviral treatment is contraindicated or 

not tolerated, as well as for those who did not respond to 

previous treatment. Possible alternatives include the use of 

corticosteroids, immunosuppressants, plasmapheresis and a 

hypo-antigenic, or low-antigen-content, diet [8]. 

Treatment should be individualized for each patient 

according to the severity of clinical symptoms, considering 

other factors involved (age, comorbidities, etc.) and for a 

limited period of time (weeks or months) until the remission of 

symptoms. Any therapeutic approach must be avoided for 

clinically asymptomatic patients. 

Table 1. Therapeutic regimens used for mixed cryoglobulinemia associated with hepatitis C virus infection 

Author Year Number 

Treatment 

Treatment duration 

End-of-treatment 

Sustained 

(months) response virological response 

Zuckerman [1] 2000 9 NR 3 M IU IFN 3×/week 6 78% NA 

+ RBV 

Mazzaro [2] 2003 27 NR or 3 M IU IFN 3×/week 12 85% NA 

Relapsers + RBV 

Alric [3] 2004 18 3 M IU IFN 3×/week ≥ 18 NA 70% 

or PEG-IFN + RBV 

Cacoub [4] 2005 9 1.5 μg/kg/week PEG-IFN ≥ 10 88% 

+ RBV 

Mazzaro [5] 2005 18 1.0 μg/kg/week PEG-IFN 12 89% 44% 

+ RBV 

CS: corticosteroid; NR: Nonresponders; IFN: interferon; PEG: pegylated; RBV: Ribavirin; NA: not available. 

The Brazilian Journal of Infectious Diseases 


2007;11 (5) Suppl. 1:64-68. © 2007 by The Brazilian Journal of Infectious Diseases and Contexto 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Treating Extrahepatic Manifestations of Hepatitis C 

65 

Prior to the identification of HCV, corticosteroid therapy 

was the treatment of choice for MC, since corticosteroids, 

even in small doses, control most of the symptoms. However, 

corticosteroids can favor HCV replication, cause various side 

effects and not induce significant changes in the cryocrit or 

in the natural history of the disease. Cytostatic, 

immunosuppressive drugs (e.g., cyclophosphamide, 

chlorambucil and azathioprine) are mainly used, in combination 

with plasmapheresis, when there is no response to 

corticosteroids and during acute phases of MC (acute 

nephritis evolving to renal insufficiency and hyperviscosity 

syndrome). Various studies showed that rituximab (anti-CD20 

antibody, a specific B-cell surface antigen) is efficacious for 

most patients with MC, with the significant improvement or 

resolution of MC – particularly skin lesions – and regression 

of clonal expansion of B cells [9]. 

Plasmapheresis is indicated for the removal of circulating 

cryoglobulins and immunocomplexes. 

Due to its efficacy and fast action, plasmapheresis is 

especially recommended in the presence of acute 

manifestations (cryoglobulinemic nephritis, severe sensorymotor 

neuropathies, skin ulcers and hyperviscosity syndrome). 

Combined with cyclophosphamide, it has been shown to 

effectively reduce the rebound effect at the end of apheresis. 

The low-antigen-content diet has low macromolecule content 

with high antigenic properties, resulting in more efficient 

removal of cryoglobulins by the reticuloendothelial system. 

This diet can improve the minor manifestations of the disease 

(purpura, arthralgia and paresthesias) and is generally 

prescribed during the initial phase of the disease. 

HCV and Lymphoma 

The inclusion of antiviral treatment seems to be rational in 

therapeutic regimens for non-Hodgkin’s lymphomas (NHLs) 

and HCV infection. This approach is supported by recent 

studies on low-grade lymphomas [10], and, in particular, on 

marginal zone lymphomas [11,12]. 

Vallisa et al. [10] treated 13 patients diagnosed with 

concomitant low-grade NHL-B and HCV infection, 

characterized by an indolent evolution, with PEG-IFN and 

ribavirin. A hematologic response was seen in most patients 

(complete and partial response, 75%), and this was strongly 

associated with the clearance or reduction of HCV viral load 

in serum, after the treatment, which proved to be useful for 

treating this pathology. 

Hermine et al. [11] reported that patients with concomitant 

HCV infection and splenic lymphoma with villous lymphocytes 

presented complete remission after being treated with IFN. 

The inclusion of a control group with patients diagnosed with 

the same disease but presenting no HCV infection 

demonstrated that, unlike the patients with HCV infection, 

the HCV-negative patients did not respond to the treatment 

with IFN. Similarly, remission of polyclonal proliferation in 

response to the antiviral treatment proved to be clearly 

associated with virological response [13]. 

Although antiviral response seems to be an attractive tool 

for low-grade NHL and positive HCV, chemotherapy might be 

necessary for intermediate- or high-grade NHL, and the 

antiviral treatment can be maintained after chemotherapy [14]. 

The use of rituximab in NHL associated with HCV, alone or in 

combination (with antiviral treatment or with chemotherapy), 

seems very promising, especially for low-grade NHL [15-17]. 

Despite the limited number of described cases, it is reasonable 

to consider rituximab a safe and efficacious treatment for 

indolent B-cell lymphomas accompanied by HCV infection. 

HCV and the Presence of Autoantibodies 

From a clinical point of view, the major concern is 

represented by the use of IFN. It has been reported that the 

administration of IFN can have a negative effect on 

autoimmune hepatitis. Significant increases in ALT activity – 

even if transitory, corrected with corticosteroids and not 

associated with deterioration of liver function – have also 

been reported in HCV/anti-liver-kidney-microsomal type 1 

(anti-LKM1)-positive cases treated with IFN [18,19]. 

Initial treatment for CS is recommended when there are 

high antibody titers (≥ 1:320), high globulin titers, anti-LKM1 

antibodies, anti-human microsomal cytochrome P450 (CYP) 

IID6 257-279 antibodies and interface hepatitis with various 

plasmocytes. In the case of initial treatment with IFN, rigorous 

monitoring of ALT levels is suggested, especially in patients 

who are anti-LKM1-positive. 

HCV and Sjogren’s Syndrome 

In one study, 12 patients diagnosed with concomitant 

Sjögren’s syndrome and HVC infection were treated with IFN 

alone or with the combination of IFN and ribavirin [20]. Half of 

the patients presented improvement of the dry syndrome using 

the associated regimen, but none responded to IFN in 

isolation. Various patients presented adverse immunologic 

events during treatment. 

HCV and Arthritis 

Treatment decisions must be made case by case. Etiologic 

treatment with IFN-a and ribavirin is recommended when there 

is hepatic or systemic involvement, since it can occasionally 

induce or worsen autoimmune disturbances. The treatment 

leads to a significant improvement in HCV-related arthritis, 

even without a complete biochemical or virological response. 

Cryoglobulinemia-related arthritis generally responds to 

antiviral treatment. Considering there are few data available at 

the moment, the usually non-aggressive evolution of HCVrelated 

arthritis does not justify the use of antiviral medications 

as a standard treatment. 

HCV and Porphyria Cutanea Tarda 

Treatment with IFN-a seems to be less efficacious in 

patients with concomitant chronic HCV infection and 

porphyria cutanea tarda than in those with chronic HCV 

infection alone. [21]. The disease also responds to iron 

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66 Treating Extrahepatic Manifestations of Hepatitis C 


depletion by phlebotomy, which can be performed prior to 

antiviral treatment. However, porphyria can be triggered in 

genetically predisposed patients treated with the association 

of IFN-a and ribavirin, as a consequence of hemolysis 

induced by ribavirin, which causes an increase in serum iron 

levels [22]. 

HCV and Lichen Planus 

Doutre et al. [23] reported improvement in lesions of two 

patients treated with IFN-α. Other authors [24-28] also 

reported that lesions disappeared during treatment with IFNá 

for several months after the end of treatment. Protzer et al. 

[29] reported oral and cutaneous lichen planus (LP) 

exacerbations during the treatment with IFN-α. Treatment was 

discontinued because local measures did not improve the 

lesions. 

It is generally recommended that stricter control measures 

be taken when patients with previous manifestations of LP 

receive IFN. There are no detailed reports on the effect of the 

combination of IFN and ribavirin in patients with concomitant 

LP and HCV infection. 

HCV and Thyroid 

The treatment with IFN-α may trigger the formation of 

autoantibodies in patients with HCV and exacerbate thyroid 

dysfunction in patients with pre-existing antibodies [30-33]. 

Changes are generally detected after three months of treatment 

and disappear when treatment is discontinued [34]. 

In severe cases, treatment must be discontinued, 

particularly in patients with hypothyroidism. Alternatively, in 

patients previously receiving thyroid medications, it can be 

useful to increase the dose during the antiviral treatment [35]. 

Low antibody titers are not an indication for treatment 

discontinuation. The possibility of good treatment control 

generally allows the continuity of antiviral treatment. Prior to 

treatment, levels of thyroid hormones, including thyroidstimulating 

hormone (TSH), as well as anti-thrombopoietin 

antibodies, must be monitored. In addition, it is opportune to 

perform regular TSH monitoring during treatment. When there 

are altered values, the decision of continuing or discontinuing 

the treatment must be made case by case. 

HCV and Type 2 Diabetes Mellitus 

Considering that hyperglycemia was considered an 

independent risk factor for the ‘nonresponse’ to antiviral 

treatment of chronic hepatitis C [36], and that abnormal glucose 

levels can be associated with host-related factors, such as 

age, gender, alcohol use, ethnicity, obesity and resistance to 

insulin, it is recommended that glucose levels in blood be 

controlled (by means of medications or changes in lifestyle), 

prior to the administration of antiviral treatment. 

HCV and Nephropathies 

The treatment options for HCV and nephropathies are 

essentially the same as those described for MC [37-40]. 

However, during the acute phase of kidney disease (when 

renal insufficiency and systemic manifestations are present), 

it is recommended that antiviral treatment be avoided or 

discontinued. In this case, measures aimed at reducing the 

inflammatory activity of renal lesions (corticosteroid therapy), 

removing circulating cryoglobulins (plasmapheresis) and 

reducing the formation of new antibodies (cyclophosphamide 

administration) are used [41-45]. Under these conditions, 

favorable outcomes have been achieved with mycophenolate 

mofetil and, more recently, with anti-CD20 antibody (rituximab). 

Regarding the use of ribavirin, lower proteinuria and improved 

kidney function have been reported in patients treated with 

IFN + ribavirin [1, 46,47]. It must be highlighted that ribavirin 

clearance is reduced in patients with renal insufficiency, and 

that dialysis does not eliminate the medication. Therefore, the 

use of this antiviral drug in standard doses is not 

recommended for patients who present with creatinine 

clearance < 50 mL/min. 

HCV and Neuropathies 

Treatment with IFN-a is not efficacious and can worsen 

peripheral neuropathy in patients with chronic hepatitis C 

and MC [48]. A detailed review of available studies on patients 

with both HCV infection and peripheral neuropathy was 

inconclusive. There were patients who responded to 

corticosteroids, endovenous immunoglobulin or 

plasmapheresis combined with antiviral treatment [49]. 

HCV and Resistance to Insulin 

When treating patients with HCV infection, the physician 

has the challenge of differentiating patients with good 

prognoses from those with poor prognoses, especially 

regarding the intervention measures available. At the moment, 

the available data allow us to infer that the treatment of insulin 

resistance (reducing hyperinsulinemia) and of those factors 

that surely contribute to the onset and maintenance of 

steatosis can increase the rate at which a sustained virological 

response is achieved in patients with HCV infection who were 

treated with the combination of PEG-IFN and ribavirin. 

Comments 

Decisions regarding the treatment of the abovementioned 

pathologies must be taken on a case-by-case basis, since the 

pathogeneses of most of these clinical manifestations are 

unknown. Cumulative knowledge on each of the pathologies 

must be considered regarding the immunomodulatory effect 

of IFN-α, which is the standard treatment for HCV infection. 

One option would be the use of an immunosuppressive agent 

in conjunction with interferon when there are autoimmune 

phenomena. 

References 

1. Zuckerman E., Keren D., Slobodin G., et al. Treatment of 

refractory, symptomatic, hepatitis C virus related mixed 

cryoglobulinemia with ribavirin and interferon-alpha. J 

Rheumatol 2000; 27: 2172-8. 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Treating Extrahepatic Manifestations of Hepatitis C 

67 

2. Mazzaro C., Zorat F., Comar C., et al. Interferon plus ribavirin in 

patients with hepatitis C virus positive mixed cryoglobulinemia 

resistant to interferon. J Rheumatol 2003;30:1775-81. 

3. Alric L., Plaisier E., Thebault S., et al. Influence of antiviral 

therapy in hepatitis C virus-associated cryoglobulinemic MPGN. 

Am J Kidney Dis 2004;43:617-23. 

4. Cacoub P., Saadoun D., Limal N., et al. PEGylated interferon alfa- 

2b and ribavirin treatment in patients with hepatitis C virusrelated 

systemic vasculitis. Arthritis Rheum 2005;52:911-5. 

5. Mazzaro C., Zorat F., Caizzi M., et al. Treatment with peginterferon 

alfa-2b and ribavirin of hepatitis C virus-associated 

mixed cryoglobulinemia: a pilot study. J Hepatol 

2005;42:632-8. 

6. Cid M.C., Hernandez-Rodriguez J., Robert J., et al. Interferonalpha 

may exacerbate cryoglobulinemia-related ischemic 

manifestations: an adverse effect potentially related to its antiangiogenic 

activity. Arthritis Rheum 1999;42:1051-5. 

7. Suzuki H., Takei T., Tsuji H., Nishikawa T. Membranoproliferative 

glomerulonephritis and demyelinating neuropathy caused by 

type II mixed cryoglobulinemia associated with HCV infection. 

Intern Med 2000;39:397-400. 

8. Ferri C., Giuggioli D., Cazzato M., et al. HCV-related 

cryoglobulinemic vasculitis: an update on its etiopathogenesis 

and therapeutic strategies. Clin Exp Rheumatol 2003;21:S78- 

S84. 

9. Zaja F., De Vita S., Mazzaro C., et al. Efficacy and safety of 

rituximab in type II mixed cryoglobulinemia. Blood 

2003;101:3827-34. 

10. Vallisa D., Bernuzzi P., Arcaini L., et al. Role of anti-hepatitis C 

virus (HCV) treatment in HCV-related, low-grade, B-cell, non- 

Hodgkin’s lymphoma: a multicenter Italian experience. J Clin 

Oncol 2005;23:468-73. 

11. Hermine O., Lefrere F., Bronowicki J.P., et al. Regression of splenic 

lymphoma with villous lymphocytes after treatment of hepatitis 


12. Kelaidi C., Rollot F., Park S., et al. Response to antiviral treatment 

in hepatitis C virus-associated marginal zone lymphomas. 

Leukemia 2004;18:1711-6. 

13. Zuckerman E., Zuckerman T., Sahar D., Streichman S. Attias 

therapy on t(14;18) translocation and immunoglobulin gene 

rearrangement in patients with chronic hepatitis C virus 

infection. Blood 2001;97:1555-9. 

14. Gisbert J.P., Garcia-Buey L., Pajares J.M., Moreno-Otero R. 

Systematic review: regression of lymphoproliferative disorders 

after treatment for hepatitis C infection. Aliment Pharmacol 

Ther 2005;21:653-62. 

15. Hainsworth J.D., Litchy S., Burris H.A., et al. Rituximab as firstline 

and maintenance therapy for patients with indolent non- 

Hodgkin’s lymphoma. J Clin Oncol 2002;20:4261-7. 

16. Somer B.G., Tsai D.E., Downs L., et al. Improvement in Sjogren’s 

syndrome following therapy with rituximab for marginal zone 

lymphoma. Arthritis Rheum 2003;49:394-8. 

17. Ramos-Casals M., Lopez-Guillermo A., Brito-Zeron P., et al. 

Treatment of B-cell lymphoma with rituximab in two patients 

with Sjogren’s syndrome associated with hepatitis C virus 

infection. Lupus 2004;13:969-71. 

18. Muratori L., Lenzi M., Cataleta M., et al. Interferon therapy in 

liver/kidney microsomal antibody type 1-positive patients with 

chronic hepatitis C. J Hepatol 1994;21:199-203. 

19. Garcia-Buey L., Garcia-Monzon C., Rodriguez S., et al. Latent 

autoimmune hepatitis triggered during interferon therapy in 

patients with chronic hepatitis C. Gastroenterology 

1995;108:1770-7. 

20. Doffoel-Hantz V., Loustaud-Ratti V., Ramos-Casals M., et al. 

Evolution of Sjogren syndrome associated with hepatitis C virus 

when chronic hepatitis C is treated by interferon or the 

association of interferon and ribavirin. Rev Med Interne 

2005;26:88-94. 

21. Fernandez I., Castellano G., Salamanca R.D., et al. Porphyria 

cutanea tarda as a predictor of poor response to interferon alfa 

therapy in chronic hepatitis C. Scand J Gastroenterol 

2003;38(3):314-9. 

22. Jessner W., Der-Petrossian M., Christiansen L., et al. Porphyria 

cutanea tarda during interferon/ribavirin therapy for chronic 


23. Doutre M.S., Beylot C., Couzigou P., et al. Lichen planus and virus 

C hepatitis: disappearance of the lichen under interferon alfa 

therapy. Dermatology 1992;184:229. 

24. Boccia S., Gamberini S., Dalla Libera M., et al. Lichen planus and 

interferon therapy for hepatitis C. Gastroenterology 

1993;105:1921-2. 

25. Barreca T., Corsini G., Franceschini R., et al. Lichen planus induced 

by interferon- alpha-2a therapy for chronic active hepatitis 

C.Eur. J. Gastroenterol. Hepatol 1995;7:367-8. 

26. Nagao Y., Sata M., Ide T., et al. Development and exacerbation of 

oral lichen planus during and after interferon therapy for 

hepatitis C. Eur J Clin Invest 1996;26:1171-4. 

27. Schlesinger T.E., Camisa C., Gay J.D., Bergfeld W.F. Oral erosive 

lichen planus with epidermolytic hyperkeratosis during 

interferon alfa-2b therapy for chronic hepatitis C virus infection. 

J Am Acad Dermatol 1997;36:1023-5. 

28. Dalekos G.N., Christodoulou D., Kistis K.G., et al. A prospective 

evaluation of dermatological side-effects during alpha-interferon 

therapy for chronic viral hepatitis. Eur J Gastroenterol Hepatol 

1998;10:933-9. 

29. Protzer U., Ochsendorf F.R., Leopolder-Ochsendorf A., 

Holtermuller K.H. Exacerbation of lichen planus during 

interferon alfa-2a therapy for chronic active hepatitis C. 


30. Di Bisceglie A.M., Martin P., Kassianides C., et al. Recombinant 

interferon alfa therapy for chronic hepatitis C. A randomized, 

double-blind, placebo-controlled trial. N Engl J Med 

1989;321(22):1506-10. 

31. Lisker-Melman M., Bisceglie A.D., Usala S., et al. Development 

of thyroid disease during therapy of chronic viral hepatitis with 

interferon alfa. Gastroenterology 1992;102(6):2155-60. 

32. Marazuela M., Garcia-Buey L., Gonzalez-Fernandez B., et al. 

Thyroid autoimmune disorders in patients with chronic hepatitis 

C before and during interferon-alpha therapy. Clin Endocrinol 

(Oxf) 1996;44(6):635-42. 

33. Deutsch M., Dourakis S., Manesis E., et al. Thyroid abnormalities 

in chronic viral hepatitis and their relationship to interferon 

alfa therapy. Hepatology 1997;26(1):206-10. 

34. Mazziotti G., Sorvillo F., Stornaiuolo G., et al. Temporal 

relationship between the appearance of thyroid autoantibodies 

and development of destructive thyroiditis in patients undergoing 

treatment with two different type-1 interferons for HCV-related 

chronic hepatitis: a prospective study. J Endocrinol Invest 

2002;25(7):624-30. 

35. Willson R.A. Extrahepatic manifestations of chronic viral 

hepatitis. Am J Gastroenterol 1997;92(1):3-17. 

36. Lecoub A., Hernandez C., Simó R., et al. Glucose abnormalities are 

na independent risk factor for nonresponse to antiviral treatment 

in chronic hepatitis C. Am J Gastroentreol 2007;102:1-7. 

37. Johnson R.J., Gretch D.R., Yamabe H., et al. Membranoproliferative 

glomerulonephritis associated with hepatitis C virus infection. 

N Engl J Med 1993;328:465-70. 

38. Diego J.M., Roth D. Treatment of hepatitis C infection in patients 

with renale disease. Curr Opin Nephrol Hypert 1988;7:557. 

39. Misiani R., Bellavita P., Baio P., et al. Successful treatment ofHCVassociated 

cryoglobulinaemic glomerulonephritis with a 

combination of interferon-alpha and ribavirin. Nephrol Dial 

Transplant 1999;14:1558-60. 

40. Mazzaro C., Panarello G., Carniello S., et al. Interferon versus steroids 

in patients with hepatitis C virus-associated cryoglobulinaemic 

glomerulonephritis. Dig Liver Dis 2000;32:708-15. 

www.bjid.com.br

68 Treating Extrahepatic Manifestations of Hepatitis C 


41. Dammacco F., Sansonno D., Han J.H., et al. Natural interferonalpha 

versus its combination with 6-methyl-prednisolone in 

the therapy of type II mixed cryoglobulinemia: a long-term, 

randomized, controlled study. Blood 1994;84:3336-43. 

42. D’Amico G. Renal involvement in hepatitis C infection: 

cryoglobulinemic glomerulonephritis. Kidney Int 

1998;54:650-71. 

43. Bombardieri S., Ferri C., Paleologo G., et al. Prolonged plasma 

exchange in the treatment of renal involvement in essential 

mixed cryoglobulinemia. Int J Artif Organs 1983;6(Suppl. 

1):47-50. 

44. Ferri C., Moriconi L., Gremignai G., et al. Treatment of the renal 

involvement in mixed cryoglobulinemia with prolonged plasma 

exchange. Nephron 1986;43:246-53. 

45. Madore F., Lazarus J.M., Brady H.R. Therapeutic plasma exchange 

in renal diseases. J Am Soc Nephrol 1996;7:367-86. 

46. Jefferson J.A., Johnson R.J. Treatment of hepatitis C-associated 

glomerular disease. Semin Nephrol 2000;20:286-92. 

47. Reed M.J., Alexander G.J., Thiru S., Smith K.G. Hepatitis C- 

associated glomerulonephritis—a novel therapeutic approach. 

Nephrol Dial Transplant 2001;16:869-71. 

48. Scelsa S.N., Herskovitz S., Reichler B. Treatment of 

mononeuropathy multiplex in hepatitis C virus and 

cryoglobulinemia. Muscle Nerve 1998;21(11):1526-9. 

49. Ramos-Casals M., Trejo O., Garcia-Carrasco M., Font J. 

Therapeutic management of extrahepatic manifestations in 

patients with chronic hepatitis C virus infection. Rheumatology 

[Oxford) 2003;42(7):818-28. 

www.bjid.com.br


Hepatitis C Treatment Before and After Liver Transplant 

Edson Abdala 1,2 , Daniela Rosa Magalhães Gotardo 1 , Patrícia Rodrigues Bonazzi 1,2 and Telésforo Bacchella 1 

1 

Liver Transplant Section, Department of Gastroenterology, University of São Paulo School of Medicine; 2 Department of Infectious and 

Parasitic Diseases, University of São Paulo School of Medicine; São Paulo, SP, Brazil 

Advanced hepatic disease, either in the form of cirrhosis 

or hepatocellular carcinoma, caused by infection with the 

hepatitis C virus (HCV), is currently the main indication for 

liver transplant worldwide [1,2]. Hepatitis C also appears as 

an etiologic factor for terminal hepatic disease. However, 

although this procedure is defined as a standard therapy in 

both situations, recurrence of HCV infection is universally 

recognized. The potential for HCV infection to evolve in a 

more aggressive manner is greater among transplant patients 

than among immunocompetent individuals, and the reestablishment 

of hepatic cirrhosis in these patients can occur 

within five to ten years after the transplant. The progression 

to cirrhosis also occurs at a more accelerated pace in these 

patients, with decompensation rates higher than 40% a year 

after diagnosis [3]. 

Despite the risk of recurrence, cirrhosis caused by HCV 

has long represented a disease with good post-transplant 

evolution potential and low recurrence rates. In the mid 1990s, 

there was an increase in the rate of recurrence, which impairs 

the function of the graft and reduces the survival of the patient. 

Studies to determine the risk factors began to be carried out, 

and the adoption of certain measures has enabled better 

outcomes [4]. 

Natural History of Hepatitis C After Transplant 

Early recurrence of the HCV infection after the transplant, 

defined as the detection of HCV RNA in the serum or graft, is 

a practically universal event, observed in more than 95% of 

the cases. Hepatic disease recurrence is represented by a wide 

range of histopathological aspects, and the differential 

diagnosis with acute cellular rejection can delay its detection. 

In these cases, there is overlapping of histopathological 

standards, as well as immunopathogenic phenomena in 

common [5,6]. 

In the recurrence context, acute hepatitis generally occurs 

between one and six months after the liver transplant, at a 

frequency of approximately 70%. Its histopathological 

findings are characterized by hepatocyte edema, large-droplet 

steatosis, moderate lobular inflammation, and acidophilic 

corpuscles. Although spontaneous resolution of acute 

hepatitis C occurs in up to 15% of immunocompetent 

individuals, it is rarely observed in the transplant context [3,4]. 

Severe progressive cholestatic hepatitis can occur early, 

between one and three months after the transplant. This kind 

of recurrence is rarer, occurring only in 10% of the cases. Its 

severe evolution pattern is characterized by high levels of 




serum bilirubin (over 6 mg/dL), high serum levels of HCV RNA, 

central ballooning in the liver biopsy, low inflammatory 

infiltrate, and cholangiolar proliferation, without associated 

ductopenia, suggesting that HCV has a direct cytopathic effect. 

These patients evolve to rapid graft loss, and death occurs 

even before a new transplant attempt can be made [4]. 

In most cases, however, the hepatitis C recurrence is 

diagnosed as chronic hepatitis, with a more accelerated 

progression of fibrosis than that observed in the 

immunocompetent population, resulting in cirrhosis in 8% to 

30% of patients within five years. Cirrhosis is also more 

aggressive in these patients, with a 65% cumulative risk of 

complications within three years. The histopathological 

findings found in the graft are similar to those found in the 

native liver of an individual with hepatitis C and include mixed 

portal infiltrate with lymphoid aggregates, periportal 

inflammation, varied lobular inflammation, and steatosis. These 

findings can be detected in 70% to 90% of patients one year 

after the transplant [7]. 

In all of these cases, however, the real recurrence rate can 

only be estimated through routine serial biopsies, considering 

that 20% to 30% of patients do not evolve to increased 

aminotransferase levels, and that such an increase lacks 

specificity, potentially resulting from other events, such as 

rejection, ischemia or opportunistic infections [8]. In the Liver 

Transplant Sector of the Hospital das Clínicas da Faculdade 

de Medicina da Universidade de São Paulo (HCFMUSP, 

University of São Paulo School of Medicine Hospital das 

Clínicas), protocol biopsies are carried out every six months in 

the first year after the transplant, every year between the second 

and forth year after the transplant, and every three years after 

the sixth year of the transplant. An evaluation of 43 patients 

demonstrated histological recurrence caused by chronic 

hepatitis in 80% of cases in an average period of 9.9 months [9]. 

Risk Factors for the Severity of Post-Transplant HCV 

Recurrence of Hepatitis C 

The factors that determine the evolution of hepatitis C in 

patients submitted to liver transplant can be variables related 

to the donor and receptor, viral factors, and events associated 

with the transplant, resulting in greater severity of the disease 

and higher rates of graft loss. The factors that are more 

consistently associated with the severity of the disease are: 

advanced age of donors, treatment for acute cellular rejection 

involving pulse therapy with corticosteroids or administration 

of OKT3, and infection with the cytomegalovirus [3,5,7,10]. A 

better understanding of the factors that contribute to the 

progression of the disease may indicate the potentially 

modifiable mechanisms of its evolution. 

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70 Liver Transplant and Hepatitis C Treatment 


Donor and Receptor Factors 

The use of older liver donors is a factor that negatively 

affects the fibrosis progression rate. Recent studies show a 

tendency toward a ten-year increase in the age of donors in the 

last decade. This measure, although applied to compensate for 

the low availability of organs, has been shown to have a direct 

influence on the degree of fibrosis in recurrent hepatitis C. 

Recent studies have shown that the ten-year difference in donor 

age (40 versus 50 years) has been associated with greater fibrosis 

progression (from 0.6 to 2.1 units a year) and with a decrease in 

the interval of appearance of cirrhosis (of up to eight years). 

Donor age seems to influence graft survival only in HCVpositive 

patients. However, there is little chance that this will 

change, since very few transplant programs are able to pair 

younger donors with HCV-positive receptors [11,12]. 

The involvement of immunogenetic factors is also 

considered, with studies that observed the association 

between HLA-B14 and HLA-DRB104 as beneficial to hepatitis 

C evolution, and the mismatch between the donor/receptor 

HLA-DRB1 with an increased recurrence risk [13,14]. 

Other donor factors that require further investigation 

include the use of live donors, hepatic iron content, and hepatic 

steatosis [15,16]. 

Viral Factors 

Some studies have associated high viral load before or 

soon after the transplant with the severity of post-transplant 

HCV recurrence. An analysis involving 284 North-American 

and Spanish patients showed that the pre-transplant viral load 

is an independent factor in the progression of fibrosis. In 

another study carried out in the United States, the five-year 

survival of patients submitted to transplant for HCV was found 

to be lower in patients with viral loads higher than one million 

mEq/mL [7]. 

The importance of the HCV genotype in the progression 

of the disease remains controversial. Although most of the 

studies conducted in the United States failed to show this 

association, a large collaborative European study showed a 

higher rate of progression and severity in transplant patients 

infected with HCV genotype 1b. One hypothesis is that, in 

the liver transplant context, the host immune response to HCV 

is stronger for the 1b genotype than for other genotypes, and 

that the tissue lesion is associated with this response [17]. 

Factors Associated with the Transplant 

The treatment of acute rejection episodes with the use of 

corticosteroid pulse therapy or anti-lymphocyte preparations 

has been associated with greater severity of hepatitis C 

recurrence. However, for such patients, the use of 

immunosuppressive regimens is recommended, which is 

sufficient to prevent moderate or severe rejection, as is the 

subsequent use of corticosteroid pulse therapy or OKT3 

administration, but not to the point of exacerbating the 

hepatitis C progression or causing other long-term 

complications [5]. 

Considering that one of the hypotheses put forth to explain 

the more severe HCV recurrence observed in recent years is 

the increased potency of immunosuppressive agents, several 

studies have been carried out to minimize or even abandon 

the use of the immunosuppressive regimen. These studies 

have shown diverging results. However, there were differences 

among the studies in terms of the initial immunosuppressive 

doses and the dose reduction rates. In some studies, the 

prolonged use of maintenance corticosteroid therapy was 

associated with lesser severity of the hepatic disease 

recurrence. In this case, the method of reducing the dose was 

important, and gradual reductions have been associated with 

less aggressive forms of hepatitis C [18,19]. 

The use of azathioprine or mycophenolate mofetil has not 

been shown to have any consistent effect on HCV recurrence. 

Although cyclosporine has been shown to have antiviral 

properties in vitro, it has not shown to have any advantage 

over tacrolimus in clinical practice [20,21]. The long-term use 

of sirolimus can provide some benefit, since it has antifibrotic 

and potential antiviral effects, although such studies are still 

preliminary and do not support its preferential use in this 

group of patients. The use of new drugs, such as sirolimus 

and the interleukin 2 receptor antagonist, requires controlled 

and prospective studies. Therefore, the general 

immunosuppression status seems to be one of the possible 

determinant events in the course of recurrent hepatitis C 

[20,22,23]. 

Another factor that is associated with the transplant and 

negatively influences the post-transplant evolution of hepatitis 

C is the presence of infection with the cytomegalovirus, which 

leads to the worsening of fibrosis [24]. 

Pre- and Post-Transplant Approach to Treating HCV-Positive 

Patients 

Antiviral therapy is the main strategy used in treating HCVpositive 

patients. However, the ideal moment at which to 

intervene remains unknown. The authors of most studies have 

initiated the treatment for HCV recurrence when there is 

histological evidence of the disease. Alternative treatments 

include the use of antiviral therapy before or soon after the 

transplant, when there is still no clinical evidence of recurrent 

disease. This is known as pre-emptive therapy. Antiviral 

therapy is generally less efficient and less well tolerated in the 

transplant patient than in the immunocompetent patient. 

Treatment of Patients with Cirrhosis Who are on the 

Transplant Waiting List 

Viral clearance in the patient with cirrhosis, in addition to 

providing better expectations for the transplant (increased 

graft survival), can even interrupt the progression of fibrosis 

in these patients, and, in some cases, preclude the need for 

the liver transplant. 

Studies have proven that, although the side effect rates 

are high, the rate at which a sustained virological response is 

achieved in patients with compensated cirrhosis treated with 

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BJID 2007; 11 Supplement 1 (October) Liver Transplant and Hepatitis C Treatment 

71 

progressively higher doses of conventional interferon and 

ribavirin is approximately 22%, and can be even higher in those 

infected with genotype 2 or 3. When submitted to transplant, 

such patients do not present recurrence of the disease, 

confirming the validity of this therapeutic strategy [25]. 

In one study, carried out by Forns et al., 30 transplant 

waiting list patients of different functional classes were 

submitted to antiviral treatment. In that study, the efficacy of 

the treatment was evaluated on the basis of the virological 

response throughout the treatment period, as well as on the 

rate at which a sustained virological response was achieved. 

The simple reduction in the HCV viral load before the 

transplant was sufficient to avoid recurrence after the 

transplant (efficacy of approximately 66%). In addition, none 

of the patients achieving a sustained virological response 

experienced disease recurrence [26]. 

Most of the studies involving this population of patients 

have evaluated the efficacy of conventional interferon. Overall, 

they concluded that the treatment is recommended for patients 

with Child-Turcotte-Pugh class A or B cirrhosis and a model 

for end-stage liver disease (MELD) score lower than 18, or 

even in patients with decompensated cirrhosis. However, in 

the last case, following the treatment protocol in a center with 

support and possibility of immediate transplant [26]. 

In a recent study of data collected in the HCFMUSP Liver 

Transplant Sector, 37 transplant waiting list patients with HCVinduced 

cirrhosis were submitted to antiviral treatment. This 

population was composed of 46% women and 54% men, with 

a mean age of over 50 years. The predominant genotypes 

were 1 and 3. There was history of ascites and hepatic 

encephalopathy in 43.2% and 8.1% of the patients infected 

with genotypes 1 and 3, respectively. History of varicose 

digestive hemorrhage two months before the treatment was 

present in 5.4% of patients, and a history of spontaneous 

bacterial peritonitis was common (in 8.1%). Pegylated 

interferon was used in only five patients (all infected with 

genotype 1), and conventional interferon was used in the 

remaining patients. Both were used in combination with 

ribavirin. The mean duration of treatment was 7.9 months. 

The most common side effect associated with the treatment 

discontinuation was neutropenia (in 37.7%). Of the 37 patients, 

14 (37.8%) presented viral load reduction of at least 2 log. In 

that study, the presence of compensated or decompensated 

cirrhosis did not affect the treatment response [27]. 

Recent studies describe the treatment with pegylated 

interferon and ribavirin in patients with decompensated 

cirrhosis. Although they present a considerable virological 

response, the frequency of severe complications necessarily 

leads to the need to always analyze the risk/benefit ratio before 

the decision to initiate treatment is made, also considering the 

feasibility of an emergency transplant [28,29]. 

Pre-Emptive Therapy 

Antiviral therapy before the establishment of histologically 

confirmed disease presents theoretical advantages, 

considering that, immediately after the transplant, the HCV 

viral load and the degree of hepatic fibrosis tend to be lower. 

This could provide a better response to the treatment, similar 

to what occurs in nontransplant patients. However, this is a 

moment at which the immunosuppression is still high, interfering 

with the antiviral response, and the antiviral regimen tolerability 

is too low in view of all of the other post-transplant clinical 

complications, such as infections and cytopenias. In addition, 

the immunomodulatory effect of interferon can increase the 

risk of acute cellular rejection, which is higher in this phase of 

the transplant process. Another criticism of pre-emptive 

treatment is that it does not distinguish patients who will actually 

evolve to a more significant recurrence of the disease and for 

whom treatment is indicated, from those who might have no 

need of antiviral therapy after the transplant [30,31]. 

Controlled studies have shown that treatment with the 

combination of conventional interferon and ribavirin has an 

advantage over monotherapy with interferon. There was a 

delay in the appearance of recurrence in those patients, who 

presented viral load reduction and better histological profiles. 

Studies involving the use of pegylated interferon and ribavirin 

have also demonstrated histological improvement, although 

their results are generally disappointing, with sustained 

virological response rates of 7-13% with the use of isolated 

interferon, 16-33% with interferon and ribavirin, and 9% with 

isolated pegylated interferon [32]. 

This strategy is not applicable to all patients. Those with 

better MELD scores before the transplant seem to be the best 

candidates. The need to reduce the dose or even discontinue 

the treatment is common, typically caused by cytopenias and 

concomitant renal dysfunction, with secondary anemia, which 

makes the use of ribavirin particularly difficult [33]. 

Post-Transplant Treatment 

In general, most patients submitted to transplant for 

cirrhosis caused by HCV are treated after the transplant, when 

recurrence is already an established event. Unfortunately, most 

studies that support this treatment strategy have been 

uncontrolled, preventing the determination of the treatment 

risks, acute/chronic rejection rates, and even the evaluation 

of the therapeutic efficacy. 

This is a population that, in principle, presents the worst 

prognostic factors of evolution and treatment response, since 

it comprises older patients who are infected with genotype 1, 

have high viral loads and present more extensive fibrosis, as 

well as more often having a history of previous treatment. 

These characteristics are also associated with the fact that 

transplant patients present comorbidities that frequently 

prevent the use of full-dose therapies [34]. 

In this group of patients, protocol biopsies are an essential 

means of assessing the degree of hepatic fibrosis and should 

be carried out whenever clinically indicated (by an increase in 

aminotransferase levels) or at least on an annual basis, with 

the specific purpose of detecting and monitoring HCV 

recurrence [35]. 

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72 Liver Transplant and Hepatitis C Treatment 


The results of this group are no less disappointing, with a 

sustained virological response rate of 12.5% with isolated 

interferon, 21% with interferon and ribavirin, and 9% with 

isolated pegylated interferon. In uncontrolled studies the 

combined use of pegylated interferon and ribavirin proved 

to be the best strategy, with responses between 30% and 

45% [2,36-38]. 

The optimal duration of antiviral therapy remains 

undefined. Although most recent studies established 

treatment periods of 48 to 52 weeks, the validity of 

prolonging treatment in patients who achieved virological 

response by the end of the standard treatment period is still 

in question [39-41]. 

The advantages of therapy that begins within 6 to 24 

months after the transplant, compared with pre-emptive 

therapy, is that these patients require less 

immunosuppression, present better clinical status, and are 

at lower risk of acute or chronic rejection [7]. 

The occurrence of acute or chronic rejection has not 

been a limiting factor to the treatment, although there are 

some reports on this subject [42]. 

The use of ribavirin as isolated therapy or as maintenance 

after the combined use with interferon has no subside in the 

literature [43]. 

Use of Adjuvant Therapy 

In this group of patients, one of the central issues is the 

high rate of side effects from antiviral drugs, especially 

cytopenia, which often requires dose reduction or even 

discontinuation of the treatment. The risk/benefit ratio of the 

use of erythropoietin or granulocyte colony-stimulating factor 

has not been well established. However, its use has facilitated 

the maintenance of antiviral treatment and the use of optimal 

doses of ribavirin and interferon [44]. Efforts have been made 

to investigate the use of ribavirin substitutes that do not cause 

hemolysis, such as viramidine, although controlled studies 

are still needed in order to determine the best strategy in 

relation to the adverse effects of the therapy [5]. 

Second Transplants in Cases of Hepatitis C Recurrence 

Although a second transplant is always an option in 

patients presenting hepatitis C recurrence, this strategy is 

historically associated with disappointing results. Receptor 

age, total bilirubin, high prothrombin time, older donor age, 

admission to the intensive care unit, high creatinine level, 

and high MELD score are predictive factors of short survival 

after a new transplant. Second transplants remain 

controversial and require comprehensive discussions in view 

of the low availability of organs and the use of MELD score 

as an organ allocation criterion, which implies that second 

transplants will be given to recurrent patients presenting 

more severe clinical profiles. In general, a second transplant 

is recommended if one of the variables related to recurrence, 

and thus the natural history of HCV recurrence, can be altered 

[45-47]. 

References 

1. Gane E. The natural history and outcome of liver transplantation 

in hepatitis C virus-infected recipients. Liver Transplant 2003;9 

(suppl3):S28-S34. 

2. Teixeira R., Menezes E.G., Schiano T.D. Therapeutic management 

of recurrent hepatitis C after liver transplantation. Liver Int 

2007;27:302-12. 

3. Samuel D., Forns X., Berenguer M., et al. Report of the 

monothematic EASL conference on liver transplantation for 

viral hepatitis. J Hepatol 2006;45:127-43. 

4. Rodriguez-Luna H., Douglas D.D. Natural history of hepatitis C 

following Liver Transplant 2004;17:363-71. 

5. Wiesner R.H., Sorrell M., Villamil F., et al. Liver Transplantation 

Society Expert Panel. Report of the first international liver 

transplantation expert panel consensus conference on liver 

transplantation and hepatitis C. Liver Transplant 2003;9 

(suppl3):S1-S9. 

6. Guido M., Fagiuoli S., Tessari G., et al. Histology predicts 

cirrhotic evolution of post transplant hepatitis C. Gut 

2002;50:697-700. 

7. Terrault N.A., Berenguer M. Treating hepatitis C infection in liver 

transplant recipients. Liver Transplant 2006;12:1192-204. 

8. Charlton M. Liver biopsy, viral kinetics and the impact of viremia 

on severity of hepatitis C virus recurrence. Liver Transplant 

2003;9 (Suppl. 3):S58-S62. 

9. Campos S.V., Bonazzi P.R., Abdala E., et al. Chronic hepatitis C 

recurrence after liver transplantation. Liver Transplant 2007;13 

(suppl.1):S213-S14. 

10. Cameron A.M., Ghobrial R.M., Hiatt J.R., et al. Effect of nonviral 

factors on hepatitis C recurrence after liver transplantation. 

Ann Surg 2006;244:563-71. 

11. Berenguer M., Prieto M., San Juan F., et al. Contribution of 

donor age to the recent decrease in patient survival among 

HCV-infected liver transplant recipients. Hepatology 

2002;36:202-10. 

12. Machicao V., Bonatti H., Krishna M., et al. Donor age affects 

fibrosis progression and graft survival after liver transplantation 

for hepatitis C. Transplantation 2004;77:84-92. 

13. Langrehr J.M., Puhl G., Bahra M., et al. Influence of donor/recipient 

HLA-matching on outcome and recurrence of hepatitis C after 

liver transplantation. Liver Transplant 2006;12:644-51. 

14. Belli L.S., Burra P., Poli F., et al. HLA-DRB1 donor-recipient 

mismatch affects the outcome of hepatitis C disease 

recurrence after liver transplantation. Gastroenterology 

2006;130:695-702. 

15. Imber C.J., St.Peter S.D., Handa A., Friend P. Hepatic steatosis 

and its relationship to transplantation. Liver Transplant 

2002;8:415-23. 

16. Guo L., Orrego M., Rodriguez-Luna H., et al. Living donor liver 

transplantation for hepatitis C-related cirrhosis: no difference in 

histological recurrence when compared to deceased donor liver 

transplantation recipients. Liver Transplant 2006;12: 560-5. 

17. Féray C., Caccamo L., Alexander G.J.M., et al. European 

Collaborative Study on factors influencing outcome after liver 

transplantation for hepatitis C. Gastroenterology 

1999;117:619-25. 

18. McCaughan G.W., Zekry A. Impact of immunosuppression on 

immunopathogenesis of liver damage in hepatitis C virus-infected 

recipients following liver transplantation. Liver Transplant 

2003;9 (suppl3):S21-S7. 

19. Lladó L., Xiol X., Figueras J., et al. Immunosuppression without 

steroids in liver transplantation is safe and reduces infection 

and metabolic complication: results from a prospective 

multicenter randomized study. J Hepatol 2006;44:710-6. 

20. Berenguer M., Aguilera V., Prieto M., et al. Effect of calcineurin 

inhibitors on survival and histologic disease severity in HCVinfected 

liver transplant recipients. Liver Transplant 

2006;12:762-7. 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Liver Transplant and Hepatitis C Treatment 

73 

21. Hilgard P., Kahraman A., Lehmann N., et al. Cyclosporine versus 

tacrolimus in patients with hepatitis C infection after liver 

transplantation: effects on virus replication and recurrent 

hepatitis. World J Gastroenterol 2006;7:697-702. 

22. Jain A., Kashyap R., Demetris A.J., et al. A prospective randomized 

trial of mycophenolate mofetil in liver transplant recipients 

with hepatitis C. Liver Transplant 2002;8:40-6. 

23. Tisone G., Orlando G., Cardillo A., et al. Complete weaning off 

immunosuppression in HCV liver transplant recipients is feasible 

and favourably impacts on the progression of disease recurrence. 

Journal of Hepatology 2006;44:702-9. 

24. Chopra K.B., Demetris A.J., Blakolmer K., et al. Progression of 

liver fibrosis in patients with chronic hepatitis C after orthotopic 

liver transplantation. Transplantation 2003;76:1487-91. 

25. Crippin J.S., McCashland T., Terrault N., et al. A pilot study of the 

tolerability and efficacy of antiviral therapy in hepatitis C virusinfected 

patients awaiting liver transplantation. Liver Transplant 

2002;8:350-5. 

26. Forns X., Garcia-Retortillo M., Serrano T., et al. Antiviral therapy 

of patients with decompensated cirrhosis to prevent recurrence 

of hepatitis C after liver transplantation. J of Hepatol 

2003;39:905-15. 

27. Oliveira P.R.D., Freitas A.C., Tengan F.M., et al. Hepatitis C antiviral 

therapy in cirrhotic patients. J Clin Virol 2006;38(suppl):S135-S6. 

28. Horoldt B., Haydon G., O’Donnell K., et al. Results of combination 

treatment with pegylated interferon and ribavirin in cirrhotic 

patients with hepatitis C infection. Liver Int 2006;26:650-9. 

29. Iacobellis A., Siciliano M., Perri F., et al. Peginterferon alfa-2b 

and ribavirin in patients with hepatitis C virus and decompensated 

cirrhosis: a controlled study. J Hepatol 2007;46:206-12. 

30. Shiffman M.L., Vargas H.E., Everson G.T. Controversies in the 

management of hepatitis C virus infection after liver 

transplantation. Liver Transplant 2003;9(suppl3):S1129-S44. 

31. Kuo A., Terrault N.A. Management of hepatitis C in liver 

transplant recipients. Am J Transplant 2006;6:449-58. 

32. Szabo G., Katz E., Bonkowsky H.L. Management of recurrent 

hepatitis C after liver transplantation: a concise review. American 

J Gastroenterol 2000;95:2164-70. 

33. Davis G.L. New approaches and therapeutic modalities for the 

prevention and treatment of recurrent HCV after liver 

transplantation. Liver Transplant 2003;9(suppl3):S114-S19. 

34. Berenguer M., Palau A., Fernandez A., et al. Efficacy, predictors 

of response and potential risks associated with antiviral therapy 

in liver transplant recipients with recurrent hepatitis C. Liver 

Transplant 2006;12:516-19. 

35. Sebagh M., Rifai K., Féray C., et al. All liver recipients benefit 

from the protocol 10-year liver biopsies. Hepatology 

2003;37:1293-301. 

36. Wang C.S., Ko H.H., Yoshida E.M., et al. Interferon-based 

combination anti-viral therapy for hepatitis C virus after liver 

transplantation: a review and quantitative analysis. Am J 

Transplant 2006;6:1586-99. 

37. Murkherjee S., Lyden E. Impact of pegylated interferon alpha-2b 

and ribavirin on hepatic fibrosis in liver transplant patients 

with recurrent hepatitis C: an open-label series. Liver Int 

2006;26:539-5. 

38. Heydtmann M., Freshwater D., Dudley T., et al. Pegylated 

interferon alpha-2b for patients with HCV recurrence and graft 

fibrosis following liver transplantation. Am J Transplant 

2006;6:825-33. 

39. Lavezzo B., Franchello A., Smedile A., et al. Treatment of recurrent 

hepatitis C in liver transplants: efficacy of a six versus a twelve 

month course of interferon alfa-2b with ribavirin. J Hepatol 

2002;37:247-52. 

40. Rodriguez-Luna H., Khatib A., Sharma P., et al. Treatment of 

recurrent hepatitis C infection after liver transplantation 

with combination of pegylated interferon alpha-2b and 

ribavirin: an open-label series. Transplantation 

2004:77:190-4. 

41. Bizzolon T., Ahmed S.N.S., Radenne S., et al. Long term histological 

improvement and clearance of intrahepatic hepatitis C virus 

RNA following sustained response to interferon-ribavirin 

combination therapy in liver transplanted patients with hepatitis 

C recurrence. Gut 2003;52:283-7. 

42. Khalili M., Vardanian A.J., Hamerski C.M., et al. Management of 

hepatitis C-infected liver transplant recipients at large North 

American centres: changes in recent years. Clin Transplant 

2006;20:1-9. 

43. Schiano T.D., Martin P. Management of HCV infection and liver 

transplantation. Int J Med Sci 2006;3:79-83. 

44. Gotardo D.R.M., Abdala E., Bonazzi P.R., et al. Safety of recurrent 

hepatitis C treatment after liver transplantation with use of 

adjuvants. Liver Transplant 2007;13(suppl 1):S152. 

45. McCashland T.M. Retransplantation for recurrent hepatitis C: 

positive aspects. Liver Transplant 2003;9(suppl 3.):S67-S72. 

46. Wall W.J., Khakhar A. Retransplantation for recurrent hepatitis C: 

the argument against. Liver Transplant 2003;9(suppl 3):S73-S8. 

47. Ercolani G., Grazi G.L., Ravaioli M., et al. Histological recurrent 

hepatitis C after liver transplantation: outcome and role of 

retransplantation. Liver Transplant 2006;12:1104-11. 

www.bjid.com.br


Adverse Event Management 

Aline Gonzalez Vigani 

Department of Viral Hepatitis Studies, State University of Campinas (Unicamp); Campinas, SP, Brazil 

The treatment of hepatitis C involves combining 

conventional interferon (IFN) or pegylated IFN (PEG-IFN) with 

ribavirin (RBV). These therapeutic regimens are associated 

with numerous adverse events, among which constitutional 

and neuropsychiatric symptoms, as well as hematological 

abnormalities, stand out [1,2]. The adverse events observed 

with the use of PEG-IFN or conventional IFN are similar, and 

the frequencies of those events are shown in Table 1 [3-5]. 

Adverse events resulting from the treatment of hepatitis C 

can jeopardize the quality of life of patients and their response 

to treatment. The control of those events involves medicinal 

and non-medicinal interventions. The latter include a 

reduction in the dosage of IFN or RBV and discontinuation of 

the treatment. 

A temporary or permanent reduction in the dosage of PEG- 

IFN, conventional IFN or RBV as a result of an adverse event 

is necessary in approximately 30% of patients. In 10% of 

patients it is necessary to discontinue the treatment [4]. 

Hematological abnormalities (neutropenia, anemia and 

thrombocytopenia) and depression are the most common 

causes of dose reduction. 

The maintenance of the dosages of medications used in 

the treatment of hepatitis C and of the recommended course 

of treatment are important for the effectiveness of the therapy, 

as shown in Figure 1 [6]. Dose reduction is associated with 

lowering the rate at which a sustained viral response (SVR) is 

achieved. Early identification and strategies for controlling 

adverse events are important in the prevention of moderate 

and severe complications. These practices also attenuate the 

deleterious effects on the quality of life of patients and maximize 

the effectiveness of treatment for hepatitis C. 

Constitutional Symptoms 

Constitutional symptoms such as fatigue, headache and 

myalgia are the most common adverse events in patients 

Figure 1. Effect of dose reduction of pegylated interferon 

(PEG-IFN) and ribavirin (RBV) in relation to the sustained 

viral response (SVR) rate. 

Table 1. Adverse events associated with using the pegylated 

interferon-ribavirin combination in the treatment of hepatitis C 

Adverse event 

Approximate 

incidence (%) 

Reaction at the site of injection 36-58 

Fatigue 50-64 

Headache 50-62 

Myalgia 42-56 

Fever 43-56 

Chills 24-48 

Alopeica 28-36 

Artralgia 27-35 

Irritability 24-35 

Depression 21-34 

Anorexia 14-32 

Dermatitis 16-21 

Anemia 12-22 

Neutropenia 17-20 

Thrombocytopenia 3-6 




treated with the combination of IFN and RBV (Table 1). 

Practically all patients manifest at least one such event during 

the administration of the initial doses of IFN. These symptoms 

typically disappear or become less intense after the first month 

of treatment. Paracetamol, acetaminophen and ibuprofen taken 

immediately before the injection of IFN alleviate the symptoms. 

Adequate hydration, together with light to moderate exercise, 

can help minimize these side effects. 

Hematological Effects 

In approximately 25% of patients, it is necessary at least 

to reduce the dosage of IFN or RBV due to abnormalities in 

laboratory test results [4]. Conventional IFN and PEG-IFN 

have both been associated with the suppression of 

hematopoiesis. In addition, hemolytic anemia occurs in all 

patients treated with RBV, although the intensity of that anemia 

is variable. 

Anemia 

Anemia resulting from the treatment of hepatitis C is a 

multifactorial side effect. Those factors increase the 

destruction of red blood cells and reduce their production. 

The increased destruction of red blood cells occurs due to 

hemolysis triggered by RBV, and the reduction in red blood 

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BJID 2007; 11 Supplement 1 (October) Adverse Event Management 

75 

cell production occurs due to IFN-induced suppression of 

bone marrow erythroid precursors [7,8]. 

The RBV penetrates erythrocytes, in which 

monophosphate, diphosphate and triphosphate are 

phosphorylated. Those pharmacologically active forms are 

incapable of passing through the erythrocyte membrane, and 

so remain intracellularly retained at a concentration 60 times 

greater than that of plasma [7,8]. The accumulated 

phosphorylated derivates are slowly eliminated from the 

erythrocytes, which have a half-life of 40 days. In contrast, 

the elimination of RBV from plasma is rapid, since it has a halflife 

of 24 hours. 

The mechanisms by which IFN can exacerbate RBVinduced 

anemia include suppression of hematopoiesis in bone 

marrow and an increase in the destruction of erythroid 

precursor cells [9]. 

Anemia starts and develops almost immediately after 

the initiation of therapy, becoming more intense after 4 to 6 

weeks of treatment. The average decrease in the level of 

hemoglobin (Hb) is 2.5 to 3.0 g/dL, but more intense degrees 

of hemolysis can occur. Anemia associated with combined 

therapy can exacerbate other side effects resulting from 

the treatment of hepatitis C such as dyspnea, fatigue, 

dizziness and headache. 

Non-pharmacological control of the treatment of anemia 

involves dose reduction or permanent discontinuation of RBV 

[9]. In patients without heart disease, a reduction in the dosage 

of ribavirin when the levels of Hb fall below 10 g/dL is 

recommended, and discontinuation is recommended when Hb 

levels are under 8.5 g/dL (Table 2) [10]. Those 

recommendations are more restricted to patients with stable 

heart disease. In rare cases, when the level of Hb is lower than 

8.5 g/dL, a transfusion of packed red blood cells, in 

conjunction with discontinuation of the treatment for hepatitis 

C, might be necessary. 

Between 9 and 22% of patients receiving combined 

treatment for hepatitis C require an RBV dose reduction due 

to anemia [3,4]. 

However, the strategy of RBV dose reduction has been 

associated with a modest increase in the level of Hb (˜1 g/dL) 

at 4-8 weeks after the reduction, as well as with a decrease in 

the rate at which an SVR is achieved (Figure 1) [6,11]. 

Hematopoietic growth factors such as alpha erythropoietin 

can be an alternative in relation to RBV dose reduction for the 

treatment of anemia arising during the treatment of hepatitis C. 

Alpha erythropoietin is a synthetic glycoprotein that has a 

mechanism of action similar to that of endogenous erythropoietin, 

which is a hormone produced by the renal peritubular capillaries 

that stimulates erythropoiesis in bone marrow. 

Studies indicate that therapy with erythropoietin at the 

dosage of 40,000 IU once a week elevates the level of Hb after 

one week of use and thus permits the maintenance of RBV 

dosage in patients that become anemic during combined 

therapy for hepatitis C [12,13]. In the study conducted by 

Afdhal et al., the initial dose of RBV was maintained in 88% of 

the patients who received erythropoietin during treatment for 

hepatitis C, and Hb levels increased (from 10.6 ± 0.9 to 13.2 ± 

1.2 g/dL) in those same patients [13]. The initial dose of RBV 

was maintained in 66% of the patients who received a placebo. 

The cost of alpha erythropoietin is high, but it is a therapeutic 

option for patients who develop an Hb level < 10 g/dL during 

treatment of hepatitis C [14]. 

Neutropenia 

A decrease in neutrophil counts to below normal values 

occurs in the majority of patients receiving conventional IFN 

or PEG-IFN and results from the suppression of bone marrow 

caused by those medications [15]. Neutropenia (neutrophil 

count

76 Adverse Event Management 


Table 2. Dose modifications for adverse events resulting from therapy with interferon and ribavirin according to manufacturer 

recommendations 

Hematological parameters PEG-IFN-α 2b PEG-IFN-α 2a IFN RBV 

Hemoglobin a

BJID 2007; 11 Supplement 1 (October) Adverse Event Management 

77 

bone marrow suppression. A drop in platelet counts during 

combined treatment for hepatitis C is common, but IFN dose 

reduction or discontinuation of treatment as a result of that 

drop is uncommon [2,3]. Thrombocytopenia requiring IFN 

dose reduction is more common in patients treated with PEG- 

IFN and RBV than in those treated with conventional IFN and 

RBV, with frequency rates of 4% and 1%, respectively [18]. 

Recommendations for the discontinuation of PEG-IFN or 

conventional IFN as a result of thrombocytopenia are shown 

in Table 2. Platelet counts generally return to pretreatment 

levels by 4 weeks after the discontinuation of treatment [2]. 

There are ongoing studies that aim to evaluate the effectiveness 

and safety of growth factors that stimulate the production 

and maturation of megakaryocytes in thrombocytopenic 

patients undergoing treatment for hepatitis C. 

Rare cases of autoimmune thrombocytopenic purpura have 

been described during the treatment for hepatitis C, and the 

presence of that disorder should be investigated in rare cases 

involving an intense decrease in platelet counts. 

Neuropsychiatric Symptoms 

Approximately 20% to 30% of patients report depressive 

symptoms during treatment for hepatitis C [19]. The control of 

depression in patients who are candidates to receive treatment 

for hepatitis C is shown in Figure 2 [20]. In the pretreatment 

phase, it is important to establish the psychiatric status of the 

patient, which involves determining whether there is a history 

of depression, assessing the mood state and identifying abuse 

of illegal substances. Patients who abuse drugs or who have a 

complex psychiatric history involving disorders such as 

schizophrenia and bipolar disorder or who are receiving 

psychiatric treatment should be jointly accompanied by a 

psychiatrist during treatment for hepatitis C. Patients with 

current or previous depression should be evaluated before the 

initiation of treatment for hepatitis C, preferably through the 

use of scales that infer the intensity of depression. In patients 

with moderate depression, antidepressant medication can be 

given 4 weeks before the initiation of treatment for hepatitis C. 

Antidepressants belonging to a class of selective 

serotonin reuptake inhibitors (SSRIs) constitute the treatment 

of choice for IFN-associated depression [19]. Such 

antidepressants are safe and well-tolerated in patients with 

hepatic disease. In addition, the treatment success rate in 

patients with depression during treatment for hepatitis C is 

near 90% [18]. Fluoxetine, sertraline, citalopram, paroxetine 

and other SSRIs can have a slightly sedative effect, and the 

choice of SSRI to be used should be based on that effect and 

on the predominant symptomatology of the patient [21]. In 

patients with fatigue or cognitive slowness, fluoxetine or 

sertraline can be preferred over paroxetine, which tends to be 

less stimulating. In case of suicidal ideation or attempted 

suicide, the treatment of hepatitis C should be immediately 

suspended [22]. The dose of antidepressant medication started 

during treatment of hepatitis C should be slowly reduced over 

a 6 to 12 month period after the end of the treatment. 

Thyroid Disease 

Approximately 1-6% of individuals treated with IFN 

develop thyroid abnormalities [23]. In all patients, an 

evaluation of thyroid function is recommended. Levels of 

thyroid-stimulating hormone should be determined before the 

initiation of treatment for hepatitis C, every 12 weeks during 

treatment and once after the end of the treatment. Individuals 

who develop hypothyroidism while undergoing treatment 

should receive hormonal replacement therapy. 

Pulmonary Side Effects 

Dry cough, which can occur during treatment, has been 

associated with the use of RBV. In most cases the cough is 

tolerable, but occasionally it is necessary to discontinue the 

use of RBV. Cases in which cough becomes productive or is 

accompanied by abnormal pulmonary auscultation findings 

or fever, pneumonia should be investigated. Interstitial 

pneumonia can be severe, but it is normally reversible with 

the discontinuation of therapy [19]. 

Retinopathy 

The use of IFN can trigger or aggravate prior retinopathy. 

Subconjunctival hemorrhage and retinal hemorrhage have 

been reported during treatment with IFN [19]. Patients with 

risk factors for retinopathy such as systemic arterial 

hypertension and diabetes mellitus should undergo 

ophthalmological examination before and during therapy under 

the supervision of an ophthalmologist. Treatment should be 

discontinued in individuals who present either retinal lesions 

during treatment or the worsening of a prior lesion. 

References 

1. Maddrey W.C. Safety of combination interferon alfa-2b/ribavirin 

therapy in chronic hepatitis C-relapsed and treatment-naive 

patients. Semin Liver Dis 1999;19 Suppl 1:67-75. 

2. Fried M.W. Side effects of therapy of hepatitis C and their 

management. Hepatology 2002;36(5 Suppl 1):S237-44. 

3. Manns M.P., McHutchison J.G., Gordon S.C., et al. Peginterferon 

alfa-2b plus ribavirin compared with interferon alfa-2b plus 

ribavirin for initial treatment of chronic hepatitis C: a 

randomised trial. Lancet 2001;22:958-65. 

4. Fried M.W., Hadziyannis S.J. Treatment of chronic hepatitis C 

infection with peginterferons plus ribavirin. Semin Liver Dis 

2004;24 Suppl 2:47-54. 

5. Hadziyannis S.J., Sette H. Jr., Morgan T.R., et al. Peginterferonalpha2a 

and ribavirin combination therapy in chronic hepatitis 

C: a randomized study of treatment duration and ribavirin dose. 

Ann Intern Med 2004;2;140(5):346-55. 

6. Shiffman M.L., Di Bisceglie A.M., Lindsay K.L., et al. Hepatitis C 

Antiviral Long-Term Treatment Against Cirrhosis Trial Group. 

Peginterferon alfa-2a and ribavirin in patients with chronic 

hepatitis C who have failed prior treatment. Gastroenterology 

2004;126(4):1015-23. 

7. Bodenheimer H.C. Jr., Lindsay K.L., Davis G.L., et al. Tolerance 

and efficacy of oral ribavirin treatment of chronic hepatitis C: 

a multicenter trial. Hepatology 1997;26(2):473-7. 

8. De Franceschi L., Fattovich G., Turrini F., et al. Hemolytic anemia 

induced by ribavirin therapy in patients with chronic hepatitis 

C virus infection: role of membrane oxidative damage. 

Hepatology 2000;31(4):997-1004. 

www.bjid.com.br

78 Adverse Event Management 


9. Kowdley K.V. Hematologic side effects of interferon and ribavirin 

therapy. J Clin Gastroenterol 2005;39(1 Suppl):S3-8. 

10. Afdhal N.H. Role of epoetin alfa in maintaining ribavirin dose. 

Gastroenterol Clin North Am 2004;33(1 Suppl):S25-35. 

11. Sulkowski M.S., Wasserman R., Brooks L., et al. Changes in 

haemoglobin during interferon alpha-2b plus ribavirin 

combination therapy for chronic hepatitis C virus infection. J 

Viral Hepat 2004;11(3):243-50. 

12. Dieterich D.T., Wasserman R., Brau N., et al. Once-weekly epoetin 

alfa improves anemia and facilitates maintenance of ribavirin 

dosing in hepatitis C virus-infected patients receiving ribavirin 

plus interferon alfa. Am J Gastroenterol 2003;98(11):2491-9. 

13. Afdhal N.H., Dieterich D.T., Pockros P.J., et al. Epoetin alfa 

maintains ribavirin dose in HCV-infected patients: a prospective, 

double-blind, randomized controlled study. Gastroenterology 

2004;126(5):1302-11. 

14. Devine E.B., Kowdley K.V., Veenstra D.L., Sullivan S.D. 

Management strategies for ribavirin-induced hemolytic anemia 

in the treatment of hepatitis C: clinical and economic 

implications. Value Health 2001;4(5):376-84. 

15. Collantes R.S., Younossi Z.M. The use of growth factors to manage 

the hematologic side effects of PEG-interferon alfa and ribavirin. 

J Clin Gastroenterol 2005;39(1 Suppl):S9-13. 

16. Sulkowski M.S. Management of the hematologic complications 

of hepatitis C therapy. Clin Liver Dis 2005;9(4):601-16. 

17. Soza A., Everhart J.E., Ghany M.G., et al. Neutropenia during 

combination therapy of interferon alfa and ribavirin for chronic 


18. Aspinall R.J., Pockros P.J. The management of side-effects during 

therapy for hepatitis C. Aliment Pharmacol Ther 

2004;20(9):917-29. 

19. Russo M.W., Fried M.W. Side effects of therapy for chronic hepatitis 

C. Gastroenterology 2003;124(6):1711-9. 

20. Raison C.L., Demetrashvili M., Capuron L., Miller A.H. 

Neuropsychiatric adverse effects of interferon-alpha: 

recognition and management. CNS Drugs 2005;19(2):105-23. 

21. Edwards J.G., Anderson I. Systematic review and guide to selection 

of selective serotonin reuptake inhibitors. Drugs 

1999;57(4):507-33. 

22. Janssen H.L., Brouwer J.T., van der Mast R.C., Schalm S.W. Suicide 

associated with alfa-interferon therapy for chronic viral 

hepatitis. J Hepatol 1994;21(2):241-3. 

23. Huang M.J., Tsai S.L., Huang B.Y., et al. Prevalence and significance 

of thyroid autoantibodies in patients with chronic hepatitis C 

virus infection: a prospective controlled study. Clin Endocrinol 

(Oxf) 1999;50(4):503-9. 

www.bjid.com.br


Treatment Options in the Management of Thrombocytopenia in Patients Infected with HCV 

André Cosme de Oliveira 

Liver Transplant Section of the Clinical Hospital of University of São Paulo School of Medicine (HC-FMUSP); São Paulo, SP, Brazil 

Thrombocytopenia (platelet count < 80,000/mm 3 ) in 

patients with chronic hepatitis has been associated with two 

factors: the first is hypersplenism resulting from splenomegaly 

in portal hypertension [1]. The spleen continuously 

sequesters one-third of circulating platelets, so that 

splenomegaly increases the fraction of platelets trapped in 

the splenic sinusoids, especially when resulting from passive 

congestion or an increase in venous portal pressure [1]. 

Hypersplenism seems to be the most common cause of 

thrombocytopenia associated with liver cirrhosis and portal 

hypertension. 

The second mechanism is related to the decreased 

production of thrombopoietin, a hormone produced by 

hepatocytes, which regulates the development of the 

megakaryocyte. In cirrhosis, due to the reduction in the mass 

of functioning hepatocytes, there can be a reduction of 

thrombopoiesis in the bone marrow, leading to 

thrombocytopenia in the peripheral blood [1]. 

In some situations, patients who are otherwise eligible for 

HCV treatment with interferon and ribavirin cannot be so 

treated because their platelets counts are low, which 

jeopardizes the treatment [2,3]. 

Nevertheless, hepatitis C patients treated with interferon and 

ribavirin also present a drop in the platelet count as a side 

effect [2,3]. 

There is as yet no treatment consensus in the literature for 

the management of these patients. We therefore present some 

related studies that address the management of these patients, 

in the pre-treatment and intra-treatment phases. 

Patients receiving interferon alpha or peginterferon alpha 

can present a 30-50% reduction in the baseline platelet count, 

and a dose reduction is necessary in approximately 4% of the 

patients [2,3]. We should consider possible reduction of the 

dose when platelet counts drop to < 50,000/mm 3 , and 

discontinuation of treatment when < 25,000/mm 3 . 

When using peginterferon alpha-2, the weekly dose can 

be reduced from 180 μg to 135 μg, or even to 90 μg. While 

using peginterferon alpha-2b, the weekly dose can be reduced 

from 1.5 μg/kg to 1.0 μg/kg, or even to 0.5 μg/kg [2,3]. 

Human recombinant interleukin (IL)-11 (oprelvekin, 

Neumega ® ; Wyeth Laboratories, Collegeville, PA, USA) can 

be used as a way to stimulate the increase in the number of 

platelets at a dose of 5 μg/kg/day, subcutaneously, initially 

for 7 days. If necessary, maintenance can consist of 1 to 3 

doses per week during HCV drug therapy, similarly to what is 

recommended for filgrastim (granulocyte colony-stimulating 

factor) [4]. 




Administration of IL-11 has multiple effects on the 

hematopoietic system, specifically promoting the proliferation 

and maturation of megakaryocytes and inducement of 

neutrophilia and thrombocytosis [5]. 

In patients with cirrhosis, its use should be restricted to 

those with Child-Pugh class A or B cirrhosis [5]. 

In a study conducted by Ghalib et al. [6], none of the 

patients presented increased platelet counts until day 4 of 

daily use of the medication, and the maximal therapeutic 

response was observed near day 13 (Figure 1). At 6 to 8 days 

after the initiation of treatment, 89% of the patients presented 

duplication of the initial number of platelets, and 78% of the 

patients presented platelet counts > 80,000/mm 3 . 

Another treatment option for thrombocytopenia in these 

patients is splenic embolization. 

Figure 1. Ratio between platelet counts and duration of 

treatment with interleukin-11. 

Splenic embolization should preferably be performed with 

injection of polyvinyl alcohol particles between 355 and 500 

µm (Trufill PVA Embolization Particles; Cordis Corp., Johnson 

& Johnson Co., Miami Lakes, FL, USA) into the splenic artery 

and should not exceed an embolization volume of 30% of the 

initial spleen volume [7]. 

The most severe complications after embolization can be 

ascites, thrombosis of the splenic vein or portal vein, 

spontaneous bacterial peritonitis, and splenic abscess. 

Abdominal pain and fever are typically present postembolization 

[8]. 

Splenic embolization presented 50% of complication in 

embolizations < 30% of splenic volume, whereas, in 

embolizations > 30%, 100% of the patients presented 

complications [9]. 

Abdominal computed tomography scans can be performed 

2 to 3 weeks after embolization for assessment of effectiveness 

of the procedure and to identify complications [10]. 

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80 Thrombocytopenia in Patients Infected with HCV 


All patients should be previously vaccinated against 

pneumococci before embolization. In addition, antibiotic 

therapy should be initiated and maintained during 

hospitalization of the patient. We suggest the use of cefotaxime 

and ampicillin in these cases [11]. The combined treatment 

with interferon and ribavirin should not be initiated or reinitiated 

until 8 weeks after splenic embolization [12]. 

The use of human recombinant interleukin-11 (IL-11) 

(oprelvekin) and splenic embolization are both feasible 

treatments for these patients, taking into account the 

characteristics of the individual health care facilities at which 

the follow-up treatment is administered. 

References 

1. Moreno A., Bárcena R., Blázquez J., et al. Thrombocytopenia can 

be found in patients with chronic hepatitis related to hepatitis C 

virus (HCV). Both hypersplenism and decreased liver production 

of thrombopoietin (TPO) have been hypothesized as 

mechanisms responsible for thrombocytopenia. Hospital Ramón 

y Cajal, Madrid, Spain. 

2. Manns M.P., et al. Peginterferon alfa-2b plus ribavirin compared 

with interferon alfa-2b plus ribavirin for initial treatment of chronic 

hepatitis C: a randomised trial. Lancet 2001;358:958-65. 

3. Fried M.W. Peginterferon alfa-2a plus ribavirin for chronic hepatitis 


4. Hennepin County Medical Center. Management of HCV and 

treatment side effects. April 10, 2005. 

5. Lawitz E., Hepburn M., Casey T. A Pilot Study of Interleukin- 

11 in Subjects with Chronic Hepatitis C and Advanced Liver 

Disease Nonresponsive to Antiviral Therapy. 

Gastroenterology Service; Infectious Diseases Service; 

Pathology Department; Brooke Army Medical Center, San 

Antonio, Texas. 

6. Ghalib R., Levine C., Hassan M., et al. Recombinant Human 

Interleukin-11 Improves Thrombocytopenia in Patients With 

Cirrhosis. Hepatology 2003:1165-71. 

7. Zhu K., Meng X., Li Z., et al. Partial splenic embolization using 

polyvinyl alcohol particles for hypersplenism in cirrhosis: A 

prospective randomized study. Eur J Radiol 2007;24. 

8. Lee C.M., Leung T.K., Wang H.J., et al. Evaluation of the effect 

of partial splenic embolization on platelet values for liver 

cirrhosis patients with thrombocytopenia. World J 


9. Hayashi H., Beppu T., Masuda T., et al. Predictive factors for 

platelet increase after partial splenic embolization in liver 

cirrhosis patients. J Gastroenterol Hepatol 2007;7. 

10. Lee C.M., Leung T.K., Wang H.J., et al. Evaluation of the effect 

of partial splenic embolization on platelet values for liver 

cirrhosis patients with thrombocytopenia. World J 


11. Foruny J.R., Blázquez J., Moreno A., et al. Safe use of pegylated 

interferon/ribavirin in hepatitis C virus cirrhotic patients with 

hypersplenism after partial splenic embolization. Eur J 

Gastroenterol Hepatol 2005;17(11):1157-64. 

12. Pålsson B., Verbaan H. Partial splenic embolization as pretreatment 

for antiviral therapy in hepatitis C virus infection. Eur J 

Gastroenterol Hepatol 2005;17(11):1153-5. 

www.bjid.com.br


Therapeutic Perspectives for Hepatitis C 

OVERVIEW 



NEW THERAPIES FOR HEPATITIS C 

Jean-Michel Pawlotsky 

French National Reference Center for Viral Hepatitis B, C and Delta; Department of Virology, 

and INSERM U841, Hôpital Henri Mondor, Université Paris 12, Créteil, France 

Overview 

Hepatitis C virus (HCV) is represented by a single open 

reading frame of single-stranded RNA comprising 

approximately 3000 AA, positioned between 3’ and 5’ 

noncoding extremities. Transcription from the 5’ end results 

in a compound polyprotein, generated by structural proteins 

in the amino-terminal region extremity and by nonstructural 

proteins in the opposing terminal region. Post-transcription 

cleavage by viral and host cell proteases generates 10 

individual HCV proteins [1]. The HCV cDNA clone was first 

described in 1989. Subsequently, counter to the expectations 

of an enormous breakthrough, there was a hiatus in the growth 

of knowledge regarding the molecular virology of this virus. 

Only in 1997 was the first functioning and complete HCV cDNA 

clone described and used in animal models (chimpanzees) for 

preliminary analyses of the viral expression using 

biotechnological tools. A milestone in the study of viral 

molecular biology was the description, in 1999, of a viral culture 

model in tumor cells (Huh 7) using a HCV 1b subgenomic 

replicon. Based on this model, despite strict limitations, other 

viral fragments were used in order to evaluate the dynamics 

of viral replication in different settings and with exposure to 

antiviral agents. Nevertheless, the inability to obtain a complete 

HCV sequence remains an obstacle to be overcome [1]. 

One characteristic of HCV is that is has minimal cytopathic 

effects, with immunomediated hepatotropic injury. However, 

it is also found in extrahepatic sites, where it has a short halflife 

(approximately 3 hours) and high serum turnover [2]. 

Standard treatment involves the administration of pegylated 

interferon alpha together with ribavirin. This treatment regimen 

has had modest success, a little over 50% [3], reaching 71% in 

cases of dose optimization and full compliance [4]. However, 

it could be much less, if we consider real life data, as well as 

characteristics of the host (race, comorbidities, immune state), 

of the liver disease (level of fibrosis and steatosis), of the 

medication (dose, interferon type) and of the virus itself. In 

addition, it is well known that genotype 1 has a lower response 

rate, and certain viral proteins can subvert the stimulus induced 

by interferon and ribavirin [3]. Viral kinetics, the evaluation of 

the decay pattern of the viremia – in terms of intensity and 




speed – after the initiation of the therapy, has proven to be a 

useful tool in the management of patients. It demonstrates 

the interaction among virus, drug, and host, in a relatively 

simple way: intense, rapid decay indicates a favorable case; 

insignificant, slow decay indicates cases that are unfavorable, 

moderate or intermediate. Such kinetic patterns allow 

patients to be characterized as rapid responders, slow 

responders, or nonresponders. This approach allows the 

treatment to be individualized, with ideal doses per weight 

and shorter, standard, or extended duration. In addition, it 

allows early prediction of treatment response. Therefore, 

individualized therapy constitutes the best therapeutic tool 

at the moment [5]. 

Of course, for the sake of effectiveness, safety, and 

tolerability, the current therapy is insufficient to confront the 

present hepatitis C epidemic. Therefore, from a therapy with 

poorly understood mechanisms of action that function 

through essentially indirect means [6], we have evolved to 

the specifically targeted antiviral therapy for hepatitis C [7], 

that is, the search for compounds that have a direct effect on 

the HCV life cycle. However, the preliminary results of current 

clinical studies have demonstrated worrisome aspects 

regarding safety, tolerability, and efficacy for some of these 

compounds [7], which is why we believe that treatment with 

interferon alpha will continue to lead the field for many years 

to come, and studies involving combinations of new 

compounds including interferon and, occasionally, ribavirin 

are already underway. A good example of this fact are the 

preliminary results of the PROVE-1 study recently presented 

in Barcelona [8], in which the group that used the combination 

of pegylated interferon alpha-2a 180 μg + ribavirin 1-1.2 g + 

telaprevir 750 mg every 8 hours, in an intention-to-treat 

analysis, showed a markedly greater response than that 

observed for the control group (receiving pegylated interferon 

+ ribavirin), despite the fact that the subjects were infected 

with genotype 1. At week 4, 79% presented viremia < 10 IU/ 

mL. At week 12, 70% presented viremia < 10 IU/mL, whereas 

39% presented viremia ≥ 10 IU/mL, emphasizing the loss of 

cases and the intention-to-treat analysis. Nevertheless, the 

incidence of rash, gastrointestinal effects, and anemia was 

significantly higher in the telaprevir group. 

The new therapeutic options are divided into ‘smallmolecule’ 

(protease and viral polymerase inhibitors and 

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82 Therapeutic Perspectives for Hepatitis C 


protein inhibitors of the host – glucosidase) [9] – data 

summarized in Table 1 – and drugs whose targets are still 

indirect. In this second group, there are several that are 

currently in Phase I trials, specifically the Toll-like receptor 

agonists 7 and 9 (ANA 245 – Isatoribine – ANA 975 and 

Actilon) [10] whose mechanism of immune stimulation is 

broader than that induced by interferon alpha. The modulation 

of the inflammation and apoptosis by caspase inhibition is 

also under evaluation, and preliminary results demonstrate 

that aspartate aminotransferase normalizes in the patients who 

received it during trials ranging from Phase II to IDN-6556 

[11]. There are other forms of interferon in phase I and II trials: 

albuferon (interferon alpha-2b fused to albumin, with more 

favorable posology regimen and similar efficacy to that of 

pegylated interferon); omega interferon; gamma interferon; 

interferon for oral use; and oral interferon inducers 

(resiquimod and imiquimod). In addition, there are nucleoside 

analogs similar to ribavirin (viramidine, now known as 

taribavirin) in Phase III, inosine monophosphate 

dehydrogenase inhibitors– VX98-497 (merimepodib) in Phase 

II for previous nonresponders [12], mycophenolate mofetil, 

also in Phase II for nonresponders, broad spectrum antiviral 

agents in Phase II (amantadine and rimantadine) and other 

immunomodulators in Phases I to III (histamine, thymosin 

alpha-1, IL-10 and IL-12). Finally, therapeutic vaccines are 

being studied in pre-clinical phases (E1/E2) I or II (E1, NS3- 

NS4-NS5-core, IC41) [10]. 

After a brief review of developing drugs, we should bear 

in mind the problems and disappointments already 

encountered regarding the resistance developed in vitro or in 

vivo, in addition to the already mentioned weaknesses related 

to posology tolerance and complexity. Posology regimens, as 

already described for HIV, can be facilitated by the association 

with the protease inhibitor ritonavir, acting as a potent 

inhibitor of the enzyme system function of cytochrome P450, 

which would enable, in preliminary analyses, simplified 

posology regimens for some of the small molecules [13]. 

Regarding other problems, further review will bring up some 

relevant issues, in addition to the already evident necessary 

maintenance of interferon, and even ribavirin, in future 

therapeutic regimens. 

New Therapies for Hepatitis C 

The current standard of care for patients with chronic 

hepatitis C is the combination of pegylated interferon (IFN) 

alpha and ribavirin. This treatment is effective in 

approximately 80% of patients with hepatitis C virus (HCV) 

genotype 2 or 3 infection, but less than 50% of those with 

HCV genotype 1 [14]. Many new HCV drugs are at the 

preclinical developmental stage and several are in clinical 

development. Novel HCV therapies currently in development 

schematically belong to four categories: novel IFNs, 

alternatives to ribavirin, immune therapies, and specific and 

nonspecific inhibitors of the HCV lifecycle. 

Novel Therapies for Hepatitis C 

Novel IFNs 

New IFN alpha molecules are currently being developed. 

They are expected to yield more potent antiviral effects, and 

eventually more potent immunomodulatory effects, with 

improved pharmacokinetic and pharmacodynamic properties 

and, if possible, better tolerance. The potential interest in nonalpha 

IFNs is also being studied. 

Albumin-linked IFN alpha 

Albumin-linked IFN alpha (Albuferon ® , Human Genome 

Sciences and Novartis) is an IFN alpha-2b molecule attached 

to a human albumin moiety which has a prolonged half-life 

that allows dosing at intervals of 2 to 4 weeks. Albumin-linked 

IFN alpha is able to induce an antiviral response in previous 

nonresponders to pegylated IFN and ribavirin combination. 

Results presented at the 42 nd Annual Meeting of the European 

Association for the Study of the Liver (EASL) have shown no 

significant difference in the rates of sustained virological 

response between patients receiving pegylated IFN alpha-2a 

and ribavirin or various doses of albumin-linked IFN alpha 

administered every two or four weeks with ribavirin. 

Consensus IFN alpha 

IFN alphacon-1 (Infergen, Amgen and InterMune- 

Yamanouchi) is a synthetic recombinant “consensus” IFN 

(cIFN) created by scanning the sequences of several natural 

alpha IFNs and assigning the most frequently observed amino 

acid in each corresponding position to the recombinant 

molecule [15]. There is no clear evidence that cIFN is superior 

to other alpha IFNs when both are given in equivalent doses 

in terms of sustained virological response. 

Other alpha IFNs in development 

Multiferon (Viragen) is a highly purified, multi-subtype 

natural human IFN alpha derived from human leukocytes 

which has already been approved for use in HCV therapy in 

several countries. Medusa ® (Flamel Technologies) is a selfassembled 

poly-aminoacid nanoparticles system that can be 

used as a protein carrier for the development of novel longacting 

native protein drugs. Medusa IFN alpha-2a and Medusa 

IFN beta are currently in early clinical development. Various 

types of orally administered IFNs alpha are also currently 

being developed. Whether similar efficacy as with 

subcutaneous administration can be achieved is under study. 

Non-type I IFNs 

IFN omega, like IFN alpha or beta, is a type 1 IFN. It shares 

70% homology with IFN alpha and binds to the same receptor. 

A stable, glycosylated form of IFN omega has been developed 

(Intarcia) and has been administered to patients with chronic 

hepatitis C in phase I and II trials. The results of a phase II trial 

presented at the 42 nd EASL Annual Meeting have shown 

sustained virological response rates (HCV RNA below 50 

international units (IU)/mL at week 12 post-therapy) of 36% in 

www.bjid.com.br

BJID 2007; 11 Supplement 1 (October) Therapeutic Perspectives for Hepatitis C 

83 

Table 1. Developing drugs that have a direct effect on HCV (adapted from [7,10]) 

Site of action 

Compound 

Commercial 

name 

Development 

phase 

Posology 

Comments 

Input inhibitors Anti HCV Immunoglobulin Civacir Phase II 200-400 mg/kg Poor preliminary results 

(HCIg) 

Monoclonal antibodies — Phase I — Transitory reduction of 

(HCV-AB 68, HCV AB 65) 

viremia 

HCV-RNA Antisense oligonucleotides — Phase II Interrupted 

transcription ISIS 14803 

inhibitors AVI-4065 — Phase I Current 

RNA that catalyzes the Heptazyme Phase I — Interrupted 

cleavage of the target RNA 

(Ribozymes) 

IRES small-molecule VGX-410C Phase I — Current 

inhibitors 

Small Interfering RNA TT033 Pre-clinical — Parenteral use 

(siRNA) or short hairpin 

RNA (shRNA) 

Post-transcription Serum proteinase inhibitors BILN 2061 — — Interrupted 

processing to NS3-4A ACH-806/Gs-9132 

inhibitors VX-950 Phase II VO 450-750 mg PROVE –Telaprevir + 

(telaprevir) every 8 h RBV+PEG-IFN: 88% 

with RNA < 10 IU in 12 

without vs. 52% PEG+RBV 

Resistance 

Rash 

SCH 503034 Phase II VO 200-400 mg SCH+PEG-IFN-α-2b + 

(boceprevir) every 8 h RBV current 

ACH-806 — — Interrupted 

and GS-9132 

ITMN 191 Phase I — — 

ACH 1095 To initiate — — 

HCV replication Polymerase inhibitors NS5B Nucleoside NM283 VO Potent, but GI effects 

inhibitors (RdRp) analogs/ (Valopicitabine) 

Nucleotides –An.Nucleos. 

Phase II 

R1626 – VO Marked reduction 

An.Nucl. 1.5-4.5g PEG-IFN-RBV 

Phase II BID combination under study 

Anemia 

MK-0608 

Pre-clinical 

Non-nucleoside HCV-796 — Marked reduction 

inhibitors Phase II with PEG-IFN without resistance 

XTL 2125 Phase I 

R7128 Phase I 

Cyclophilin B inhibitors DEBIO-025 Phase I — Reduction of viremia 

NIM 811 Phase I 

NS5A inhibitors A 689 Pre-clinical — — 

A-831 Pre-clinical — — 

Helicase inhibitors QU633 — — — 

recombinant human antibodies 

Viral assembly Glucosidase inhibitor UT-231B Phase II future — Poor results 

and release (Iminosugar) MX-3253 Phase II — PEG-IFN/RBV 

(celgosivir) 

combination 

www.bjid.com.br



the IFN omega-ribavirin combination arm versus 6% in patients 

treated with IFN omega alone. The manufacturer plans to 

develop an implantable infusion pump that will release a steady 

amount of IFN omega for approximately four weeks. 

In spite of in vitro results that would support a potentiating 

effect of IFN gamma on IFN alpha [16], the proof of concept 

that IFN gamma could have a utility in the treatment of chronic 

hepatitis C still remains to be made. 

IFN lambda-1 (interleukin 29 or IL-29) is a member of a 

novel family of cytokines that are distantly related to the IL- 

10 family and type 1 IFNs. IFN lambda-1 exhibits dose- and 

time-dependent inhibition of HCV replication in various 

models, independent of types 1 and 2 IFN receptors and 

induced pathways [17]. A pegylated form of IFN lambda will 

soon enter clinical evaluation. 

Alternatives to Ribavirin 

Alternatives to ribavirin are needed that would have the same 

effects as ribavirin on infection in combination with pegylated 

IFN or other IFN molecules without its hemolytic properties. 

However, the challenge for discovering such molecules is 

hampered by the fact the antiviral mechanisms of ribavirin remain 

poorly understood. Taribavirin (Valeant Pharmaceuticals) is an 

amidine prodrug of ribavirin converted into ribavirin by adenosine 

deaminases, which are primarily present in hepatocytes. 

Taribavirin is thus preferentially taken up in the liver where it 

serves for ribavirin delivery to the major site of HCV replication, 

whereas it is not transported efficiently into red blood cells [18]. 

In two recent phase III trials in combination with pegylated IFN 

alpha 2a and 2b, respectively, taribavirin at a flat dose of 600 mg 

twice a day failed to achieve similar efficacy as weight-based 

dosed ribavirin in patients with chronic hepatitis C of various 

genotypes. The incidence of hemolytic anemia was however 

significantly lower with taribavirin. New trials with higher doses 

of taribavirin have been planned. 

Immune Therapies 

Various nonspecific immunomodulatory agents, including 

thymosin alpha-1 (Thymalphasin, SciClone), IL-10 or histamine 

(Maxym Pharmaceuticals) have been administered to patients 

with chronic hepatitis C, with little success. 

Vaccines can induce CD4+ and CD8+ T-cell responses to 

HCV. Preclinical and early human studies indicate that 

therapeutic vaccines using different forms of recombinant HCV 

proteins together with various adjuvants could upregulate 

both cellular and humoral immune responses in patients with 

chronic hepatitis C [19]. However, there is currently no 

evidence that therapeutic vaccines alone can result in changes 

in HCV RNA levels. It remains to be determined whether 

therapeutic vaccines could be useful in combination with 

potent antiviral molecules. 

Inhibitors of the HCV Life Cycle 

Every step of the HCV lifecycle constitutes a potential target 

for specific or nonspecific antiviral molecules. Many drugs are 

at the preclinical developmental stage and several are in clinical 

development, but initial trials using some of these inhibitors 

alone have raised concerns about their tolerability and the 

development of viral resistance. A number of specifically targeted 

therapies are now also being tested in combination with 

pegylated IFN alpha with or without ribavirin. 

Inhibitors of the early steps of the HCV life cycle 

Inhibition of HCV entry can be based on the use of specific 

antibodies that neutralize infectious particles and prevent their 

attachment to the receptor molecules. These include polyclonal 

hepatitis C immune globulins, that have been administered to 

prevent HCV infection in HCV-infected liver transplant recipients 

with little success [20], and anti-HCV monoclonal antibodies 

with high-affinity HCV neutralizing properties that reduce viral 

replication by 0.3 to 1.0 log [21,22]. Small molecule entry 

inhibitors can theoretically belong to two groups of drugs: 

molecules that specifically fix onto the HCV surface structures 

and neutralize the virus, or molecules that compete with 

infectious viral particles at the receptor level. Unfortunately, 

our understanding of HCV entry mechanisms remains 

rudimentary, hampering the development of such molecules 

inhibitors. Fusion could also become an interesting target for 

novel therapies when its mechanisms are better understood. 

HCV RNA translation inhibitors 

Several nucleic acid-based strategies have been tested, 

including antisense oligodeoxynucleotides, 

phosphorodiamidate morpholino oligomers (PMO), or 

ribozymes. All of them have been shown to potently inhibit 

HCV translation in vitro, but have been disappointing in vivo 

[23,24]. RNA interference initiated by small interfering RNAs 

(siRNA) or short hairpin RNAs (shRNA) is very specific and 

offers a potential to be used as antiviral against HCV. However, 

because of their size and chemical composition, siRNAs and 

shRNAs currently are not orally bioavailable and require 

parenteral administration. Alternative strategies currently 

target the three-dimensional functional internal ribosome entry 

site (IRES) complexed with ribosomal subunits and viral and 

cellular proteins with small molecule inhibitors. 

Inhibitors of HCV post-translational processing 

Highly selective, potent peptidomimetic inhibitors of HCV 

NS3/4A proteinase have been designed. VX-950 or telaprevir 

(Vertex Pharmaceuticals) and SCH 503034 or boceprevir 

(Schering-Plough Corporation) have now advanced to phase 

II clinical trials. Patients who received 750 mg of telaprevir 

alone every 8 hours experienced a median 4.4-log reduction in 

HCV RNA levels [25]. The drug is well tolerated over shortterm 

administration. However, viral breakthroughs occur 

during the second week of telaprevir administration in patients 

with low exposure to the drug. They are due to selection of 

telaprevir-resistant variants. Combination with pegylated IFN 

alpha with or without ribavirin could theoretically at least partly 

prevent telaprevir resistance. This hypothesis is currently 

www.bjid.com.br


85 

under study in two phase II trials. Boceprevir appears to have 

less potent antiviral properties than telaprevir in vivo at the 

doses used to date [26]. In combination, the antiviral effect of 

boceprevir appears to be additive to that of pegylated IFN 

alpha-2b [26]. A phase II clinical trial is ongoing in combination 

with pegylated IFN alpha and ribavirin, where high doses of 

boceprevir are administered to treatment-naïve patients. 

Other approaches have been developed to inhibit the NS3/ 

4A serine proteinase function. ACH-806/GS-9132 (Achillion 

Pharmaceuticals and Gilead Sciences) inhibits binding of 

NS4A to the NS3 proteinase, therefore inhibiting polyprotein 

processing by preventing the formation of the active 

proteinase complex. ACH-806/GS-9132 has potent in vitro 

activity against HCV genotype 1 and administration of 300 

mg twice daily for 5 days resulted in an average change in 

HCV RNA level from baseline of -0.9 log [27]. The development 

of this drug has been halted because of nephrotoxicity [27]. 

Inhibitors of HCV replication 

Inhibitors of the RNA-dependent RNA polymerase (RdRp) 

belong to two categories: nucleoside/nucleotide inhibitors, 

that target the catalytic site of the enzyme, and non-nucleoside 

inhibitors that target allosteric sites of the RdRp. Three RdRp 

inhibitors have been administered to patients in clinical trials, 

including two nucleoside and one non-nucleoside inhibitor. 

Two have been withdrawn due to toxicity. R1626 (Roche 

Products) induces a dose-dependent HCV RNA level reduction 

[28]. At very high doses, HCV RNA level decrease reaches 

more than 3 logs, but side-effects are frequent. R1626 in 

combination with pegylated IFN alpha and ribavirin has 

recently progressed into phase II of clinical development. Other 

drugs have entered phase I clinical development. 

The HCV RdRp has been reported to bind cyclophilin B, a 

cellular peptidyl-prolyl cis-trans isomerase that apparently 

regulates HCV replication through modulation of the RNA 

binding capacity of RdRp. Synthetic, non-immunosuppressive 

cyclophylin B inhibitors have been developed and are being 

tested in patients with chronic HCV infection [29]. Side-effect 

were however frequent and led to treatment withdrawal in 

several cases [16]. Another cyclophilin B inhibitor, NIM 811 

(Novartis) is currently being tested in a phase I trial [30,31]. 

Inhibitors of virus assembly and release 

Iminosugars have been suggested to be able to cross 

cellular membranes and concentrate in the endoplasmic 

reticulum where they could competitively inhibit envelope 

proteins glycosylation and interfere with viral assembly [32]. 

MX-3253 or celgosivir (Migenix) has a modest antiviral effect 

on HCV in monotherapy. It is currently administered in 

combination with pegylated IFN alpha and ribavirin in a phase 

II clinical trial. 

Questions and Issues with New Therapies 

Among the many new avenues being explored, orally 

administered antiviral drugs that specifically inhibit a step of 

the HCV lifecycle have come under the spotlight. However, 

although encouraging results have been published, serious 

issues have been raised as to the antiviral potency of these 

drugs, their tolerability, and the crucial problem of viral 

resistance. 

Antiviral Potency 

Antivirals usually enter development as soon as they show 

some degree of antiviral efficacy in one of the existing in vitro 

models. However, in vitro antiviral activity does not always 

translate into antiviral efficacy in vivo. There are several 

examples of drugs that were highly potent in vitro but failed 

when administered to patients. Unfortunately, studies with 

“negative” results are rarely published, even though they 

could teach us a lot. There are several possible reasons for 

these in vitro/in vivo discrepancies, including the use of 

poorly relevant preclinical models, misinterpretation of 

preclinical data, poor pharmacokinetics, poor delivery of a 

potentially potent drug to its target site, or the fact that the 

target is not physically accessible in infected cells in vivo. 

Tolerability 

Small-molecule viral inhibitors have been under close 

scrutiny for potential toxicity. The clinical development of 

BILN 2061 (Boehringer-Ingelheim, Ingelheim, Germany), a 

potent HCV NS3 serine protease inhibitor and the first drug of 

this type to be administered to infected patients, has been 

suspended because of myocardial toxicity in animals [33,34]. 

The development of an enormous number of potentially active 

HCV drug candidates was stopped before they were given to 

patients, owing to concerns raised by preclinical toxicity 

studies in vitro and in animal models. The clinical development 

of several drugs has been stopped because of their side-effect 

profile, including valopicitabine (digestive side-effects), HCV- 

796 (ALT elevations) and ACH-806 (nephrotoxicity). Other 

drugs are still being developed in spite of serious side-effects. 

R1626 has been shown to induce a dose-dependent reduction 

of blood cell counts and hemoglobin levels after two weeks of 

administration at high doses [28], and the outcome of these 

effects is unknown if therapy is prolonged or if ribavirin is 

used in combination. Apparent safety during short-term 

administration does not guarantee that no serious adverse 

effects will occur when the drug is given for several weeks or 

months. Reesink et al. observed no serious adverse events 

during 14 days of telaprevir administration [25]. However, a 

recent commercial press release from Vertex Pharmaceuticals 

(December 13, 2006) states that, in the PROVE 1 study, a phase 

2b twelve-week clinical trial of the triple combination of 

pegylated IFN alpha, ribavirin and telaprevir in treatment-naive 

patients, 3% of the patients discontinued telaprevir because 

of rash (rash was the most common reason for treatment 

discontinuation). Drug-drug interactions may also be a 

problem when HCV inhibitors are used in combination with 

pegylated IFN, with or without ribavirin. In addition, although 

synergy or additive efficacy may be expected, antagonism 

www.bjid.com.br



can also occur. Here again, in vitro studies may give clues as 

to likely adverse effects but they cannot replace in vivo 

studies. 

Resistance 

A surprising finding has been the frequency and early 

timing of the emergence of resistance with all classes of anti- 

HCV drugs. These results suggest that resistant variants are 

preexisting, fit, and ready to be selected by any specific HCV 

inhibitor. These findings disqualify HCV inhibitor 

monotherapy and raise major ethical issues as to whether 

naive or nonresponder patients should now be included in 

trials of these drugs in monotherapy, as there is a risk that 

they will be disqualified from future trials and therapies with 

drug combinations. 

Conclusion 

At this point, it is clear that specific HCV inhibitors should 

not be used alone. Combination therapy with oral antiviral 

drugs will require company portfolios to contain more than 

one such drug. And appropriate preclinical drug-drug 

interaction studies will have to be performed before clinical 

trials are initiated. This may take several years. In the 

meantime, new strategies are needed to improve the results 

of current HCV therapy. The “conservative“ approach aimed 

at optimizing pegylated interferon-ribavirin therapy should 

not be neglected. Preliminary results have shown that 

increasing the dose and/or the number of injections of 

pegylated IFN increases the response rate, and this is being 

further explored in ongoing trials. Likewise, increasing the 

dose of ribavirin has been shown to significantly improve 

the cure rate, and the adverse effects of ribavirin can now be 

partly controlled by using erythropoietin. Other trials are 

addressing the best way of tailoring the duration of treatment 

to the early virologic response (i.e. the HCV RNA decline at 

week 4 or even week 2). Another option is to enhance 

pegylated IFN-ribavirin efficacy by adding antiviral drugs 

with an additive or synergistic antiviral effect. Such 

combinations have the advantage of theoretically preventing 

the onset of resistance to the inhibitor, through the antiviral 

effect of IFN alpha. This may indeed happen in good IFN 

responders, although it is unclear whether IFN inhibition 

will be sufficient to avoid the emergence of resistance. In 

addition, patients with little or no response to IFN will in 

effect be receiving inhibitor monotherapy. Preliminary data 

are encouraging and ongoing trials will show how well double 

and triple combinations are tolerated, and whether the 

responses persist. 

References 

1. Tellinghusein T.L., Evans M.J., Hahn T., et al. Studying Hepatitis 

C Virus: making the best of a bad virus. Journal of Virology 

2007;81(17):8853-67. 

2. Lindenbach B.D., Rice C.M. Unravelling hepatitis C virus 

replication from genome to function. Nature 

2005;436(18):933-7. 

3. Wohnsland A., Hofmann W.P., Sarrazin C. Viral determinants of 

resistance to treatment in patients with hepatitis C. Clinical 

Microbiologogy Reviews 2007;20(1):23-38. 

4. Pawlotsky J.-M. Mechanisms of antiviral treatment efficacy 

and failure in chronic hepatitis C. Antiviral Research 

2003;59:1-11. 

5. Marcellin P., et al. Which patients with genotype 1 chronic 

hepatitis C can benefit from prolonged treatment with the 

‘accordion’ regimen? J Hepatology 2007 (in press). 

6. Goodbourn S., Didcock L., Randall R.E. Interferons: cell signalling, 

immune modulation, antiviral responses and virus 

countermeasures. Journal of General Virology 

2000;(81):2341-64. 

7. Pawlotsky J.-M., Chevaliez S., McHutchison J.G. The hepatitis C 

virus life cycle as a target for new antiviral therapies. 


8. McHutchinson J.G., et al. EASL 2007 Late Breaker 786. 

9. Harrison S.A. Small Molecule and novel treatments for chronic 

hepatitis C virus infection. American Journal of Gastroenterology 

2007;102:1-7. 

10. McHutchinson J.G., Bartenschlager R., Patel K., Pawlotsky J.-M. 

The face of future hepatitis C antiviral drug development: recent 

biological and virologic advances and their translation to drug 

development and clinical practice. Journal of Hepatology 

2006;44:411-21. 

11. Walters L., Nelson M. New therapeutic options for hepatitis C. 

Current Opinion on Infectious Diseases 2006;19:615-22. 

12. Marcellin P., Horsmans Y., Nevens F., et al. Phase 2 study of the 

combination of merimepodib with peginterferon-a2b, and 

ribavirin in nonresponders to previous therapy for chronic 

hepatitis C. J Hepatology 2007 (in press). 

13. Kempf D.J., Chen H.-J., Yeung J.T., et al. Pharmacokinetic 

boosting of VX-950, an inhibitor of HCV protease, by co-dosing 

with ritonavir. Journal of Hepatology 2006;44(2):S4. 

14. NIH Consensus Statement on Management of Hepatitis C: 2002. 

NIH Consens State Sci Statements 2002;19:1-46. 

15. Keeffe E.B., Hollinger F.B. Therapy of hepatitis C: consensus 

interferon trials. Consensus Interferon Study Group. Hepatology 

1997;26:101S-7S. 

16. Larkin J., Jin L., Farmen M., et al. Synergistic antiviral activity of 

human interferon combinations in the hepatitis C virus replicon 

system. J Interferon Cytokine Res 2003;23:247-57. 

17. Marcello T., Grakoui A., Barba-Spaeth G., et al. Interferons alpha 

and lambda inhibit hepatitis C virus replication with distinct 

signal transduction and gene regulation kinetics. 


18. Wu J.Z., Lin C.C., Hong Z. Ribavirin, viramidine and adenosinedeaminase-catalysed 

drug activation: implication for nucleoside 

prodrug design. J Antimicrob Chemother 2003;52:543-6. 

19. Leroux-Roels G., Batens A.H., Desombere I., et al. Immunogenicity 

and tolerability of intradermal administration of an HCV E1- 

based vaccine candidate in healthy volunteers and patients with 

resolved or ongoing chronic HCV infection. Hum Vaccin 

2005;1:61-5. 

20. Davis G.L., Nelson D.R., Terrault N., et al. A randomized, openlabel 

study to evaluate the safety and pharmacokinetics of human 

hepatitis C immune globulin (Civacir) in liver transplant 

recipients. Liver Transpl 2005;11:941-9. 

21. Schiano T.D., Charlton M., Younossi Z., et al. Monoclonal antibody 

HCV-AbXTL68 in patients undergoing liver transplantation 

for HCV: results of a phase 2 randomized study. Liver Transpl 

2006;12:1381-9. 

22. Galun E., Terrault N.A., Eren R., et al. Clinical evaluation (Phase 

I) of a human monoclonal antibody against hepatitis C virus: 

safety and antiviral activity. J Hepatol 2007;46:37-44. 

23. McHutchison J.G., Patel K., Pockros P., et al. A phase I trial of an 

antisense inhibitor of hepatitis C virus (ISIS 14803), administered 

to chronic hepatitis C patients. J Hepatol 2006;44:88-96. 

www.bjid.com.br


87 

24. Soler M., McHutchison J.G., Kwoh T.J., et al. Virological effects 

of ISIS 14803, an antisense oligonucleotide inhibitor of 

hepatitis C virus (HCV) internal ribosome entry site (IRES), 

on HCV IRES in chronic hepatitis C patients and 

examination of the potential role of primary and secondary 

HCV resistance in the outcome of treatment. Antivir Ther 

2004;9:953-68. 

25. Reesink H.W., Zeuzem S., Weegink C.J., et al. Rapid decline of 

viral RNA in hepatitis C patients treated with VX-950: a phase 

Ib, placebo-controlled, randomized study. Gastroenterology 

2006;131:997-1002. 

26. Sarrazin C., Rouzier R., Wagner F., et al. SCH 503034, a novel 

hepatitis C virus protease inhibitor, plus pegylated interferon 

á-2b for genotype 1 non-responders. Gastroenterology 

2007;in press. 

27. Pottage J.C., Lawitz E., Mazur D., et al. Short-term antiviral 

activity and safety of ACH-806 (GS-9132), an NS4A 

antagonist, in HCV genotype 1 infected individuals. J 

Hepatol 2007;in press. 

28. Roberts S., Cooksley G., Dore G., et al. Results of a phase 1b, 

multiple dose study of R1626, a novel nucleoside analogue 

targeting HCV polymerase in chronic HCV genotype 1 patients. 

Hepatology 2006;44 (suppl. 1):692A. 

29. Flisiak R., Orban A., Kierkus J., et al. The cyclophilin inhibitor 

DEBIO-025 has a potent dual anti-HIV and anti-HCV activity 

in treatment-naïve HIV/HCV co-infected subjects. Hepatology 

2006;44 (suppl. 1):609A. 

30. Ma S., Boerner J.E., Tiong Yip C., et al. NIM811, a cyclophilin 

inhibitor, exhibits potent in vitro activity against hepatitis C 

virus alone or in combination with alpha interferon. Antimicrob 

Agents Chemother 2006;50:2976-82. 

31. Goto K., Watashi K., Murata T., et al. Evaluation of the antihepatitis 

C virus effects of cyclophilin inhibitors, cyclosporin 

A, and NIM811. Biochem Biophys Res Commun 

2006;343:879-84. 

32. Durantel D., Carrouee-Durantel S., Branza-Nichita N., et al. Effects 

of interferon, ribavirin, and iminosugar derivatives on cells 

persistently infected with noncytopathic bovine viral diarrhea 

virus. Antimicrob Agents Chemother 2004;48:497-504. 

33. Hinrichsen H., Benhamou Y., Wedemeyer H., et al. Short-term 

antiviral efficacy of BILN 2061, a hepatitis C virus serine 

protease inhibitor, in hepatitis C genotype 1 patients. 


34. Reiser M., Hinrichsen H., Benhamou Y., et al. Antiviral efficacy of 

NS3-serine protease inhibitor BILN-2061 in patients with chronic 

genotype 2 and 3 hepatitis C. Hepatology 2005;41:832-5. 

www.bjid.com.br


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2. Submit four copies of your manuscript (original plus three copies and a disk of the manuscript - Word 

Perfect/Word for Windows), each with a complete set of original illustrations. 

3. The entire manuscript (including tables and references) must be typed double-spaced and printed on standardsized 

paper. The left and right margins must be at least 3 cm. 

4. The entire manuscript must be typed in a font size of at least 12 points. 

5. Please number pages beginning with the title page (title page is page 1). 

6. The order of appearance of material in all manuscripts should be as follows: title page, abstract, text, 

acknowledgements, references, tables, legends for figures, figures. 

7. The title page must include a title of not more than three printed lines (250 letters and spaces), authors (no 

titles or degrees), institutional affiliations, a running headline of not more than 40 letters and spaces, a name and 

complete address to which correspondence and reprint requests should be sent, and footnotes indicating sources 

of financial support and changes of address. 

8. Abstract (maximum 250 words) must be on a separate page before the introduction. Do not submit an 

abstract with correspondence. 

9. Acknowledgements of persons who assisted the authors should be included on the page preceding the 

references. 

10. References must begin on a separate page. 

11. References must be cited on (not above) the line of text and in brackets instead of parentheses, e.g., [7,8]. 

12. References must be numbered in the order in which they appear in the text. References not cited in the text 

cannot appear in the reference section. References that are only or are first cited in a table or figure are numbered 

according to where the table or figure is cited in the text. For instance, if a table is placed after reference 8, a new 

reference cited in table 1 would be reference 9. 

13. Reference citations must follow the format established by the "Uniform Requirements for Manuscripts 

Submitted to Biomedical Journals" (see examples in Instructions to Authors). 

14. If you reference your own unpublished work (i.e., an "in press" article) in the manuscript that you are 

submitting, you must enclose three copies of the "in press" article and an acceptance letter from the journal. 

15. If you cite unpublished data that are not your own, you must provide a letter of permission from the author 

of that publication. 

16. Please provide four glossy or laser-produced prints of each figure that you are submitting. Label all figures 

clearly with first author's name and figure number (place typed label on the back of the figure). 

17. Provide a figure legend for each figure. Figure legends must be on a separate page at the end of the 

manuscript. 

Please refer to Instructions to Authors for further information regarding the section to be submitted 

the manuscript, title page, abstract, references, tables and figures, and style. 

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