1. Alfredo ALBERTI

2. How to predict outcome in hepatitis C patients Alfredo Alberti Department of Clinical and Experimental Medicine Venetian Institute of Molecular Medicine University of Padova ITALY Paris, January 22 nd 2007

3. Natural History of Hepatitis C Acute Hepatitis C Chronic Hepatitis 50 - 85 % Chronic Hepatitis 50 - 85 % Cirrhosis 20 - 30 % Decompensation 6 - 10 % Decompensation HCC 5 - 10 % HCC Death Death 10 - 30 years

4. ASSESSING PROGNOSIS IN HEPATITIS C Progression to cirrhosis and end stage liver disease in a minority of cases Often takes decades Not linear Difficult to predict in the individual case Cofactors may play a major role

5. CLINICAL IMPLICATIONS OF ASSESSING “SHORT” TERM PROGNOSIS (3-5 yrs) IN A PATIENT WITH HCV To treat or not to treat, or to postpone therapy waiting for new drugs, particularly for “borderline” or “difficult-to-treat” patients or with some contraindication How to monitor Life style counselling

6. Need to Define (A)(B) Actual stage of liver disease Spead of Disease Progression (Where it is)(How fast is going)  Fibrosis Stage + Fibrogenesis Rate Prognosis How to Predict Outcomes in Patients with Chronic HCV

7. STAGES IN CHRONIC HCV INFECTION THE EARLY “HISTOLOGICAL” STAGES No significant fibrosis (F0-F1) Intermediate fibrosis (F2) Severe fibrosis (F3) Histological cirrhosis (F4) THE LATE “CLINICALLY OVERT” STAGES Compensated cirrhosis without portal hypertension with portal hypertension Decompensated cirrhosis

8. Incidence of HCC in Chronic Hepatitis C According to Stage of Fibrosis 012345678910 0 20 30 40 50 60 70 years F4 F3 F2 F0-1 Cumulative incidence (%) (490 IFN untreated patients) Yoshida et al., Ann Intern Med 1999

9. How to Define Stage F0 LIVER BIOPSY F1 F2 F3 F4 F5 F6 METAVIRMETAVIR F1 F2 F3 F4 FIBROTEST APRI FIBROSCAN and many others ISHAKISHAK Compensated disease stage of liver fibrosis

10. Sequential Algorithm for Fibrosis Evaluation (SAFE-Biopsy) in Compensated Hepatitis C APR I No fibrosis (low NPV) Significant fibrosis (high PPV) Grey Zone FIBROTEST Significant fibrosis (high PPV) F0-F1 (low NPV) Liver biopsy not neededLiver biopsy Sebastiani et al J Hepatol 2006 45-70% reduction in biopsies with >95% diagnostic accuracy Biopsy and non-invasive markers agonists and not antagonists

11. PROGRESSION OF HEPATIC FIBROSIS IN CHRONIC HEPATITIS C (Poynard et al Lancet 1997;349:825-832) Years 1020 30 Rapid Medium Slow 4 3 2 1 Fibrosis Absent Influenced by Male sex Age Alcohol

12. CROSS-SECTIONAL vs LONGITUDINAL STUDIES CROSS-SECTIONAL mild disease Vs. advanced disease identified variables : causes or effects ? LONGITUDINAL STUDIES non progressors vs. progressors May underestimated “dynamic” variables

13. The Changing View on Major Cofactors Affecting Hepatitis C Outcomes Candidates in the early 90’ THE VIRUS HCV genotypes Viral Load HCV quasispecies Candidates in the late 90’ ENVERONMENTAL COFACTORS Alcohol Coinfections (HBV - HIV) candidates in the new Millenium THE HOST Age / gender Race / genetics Metabolic syndrome

14. HCV-RNA and GENOTYPE as PROGNOSTIC MARKERS % fibrosis progression 1-2 points > 2 points HCV-1 33% 11% HCV-2 37% 13% HCV-3 30% 15% < 800.000 IU 28% 14% > 800.000 IU 33% 11% 7-10 yr outcome in initially mild CHC (longitudinal study in 177 cases) Boccato et al JVH 2006, Boccato et al 2007

15. Increased Risk of Cirrhosis and ESLD in HIV-HCV Coinfected Patients Histologic Cirrhosis Decompensated Liver Disease 0.761.02.0710.83 Combined 0.611.06.1410 Combined Relative Risk (95% CI) Makris Soto Pol Benhamou Eyster Telfer Makris Lesens 175.32 Clin Infect Disease. Graham GS et al. The University of Chicago Press. 2001. 33. 562-569.

16. HBV coinfection as Cause of Progression of Chronic Hepatitis C Fong et al, Hepatology 1991 Pontisso et al, Gastroenterology 1993 Crespo et al, Am J Gastroenterol, 1994 Liaw et al, Hepatology 1995 Zarski et al, J Hepatol 1998 Sagnelli et al, Hepatology 2000 Benvegnù et al 2004 Progression to cirrhosis x 2.1 - 6.6 Progression to HCC x 5.6 - 136 Occult (anti-HBc positive) HBV coinfection may also play a role in carcinogenesis

17. 58 54 50 46 42 34 38 o o o Grades of fibrosis progression over 7-10 years of observation 0123 Fibrosis Progression in initially mild chronic hepatitis C correlates with age at diagnosis A g e at entry 30 o © Boccato et al 2006

18. - 0.0 - 0.5 - 1.0 - 1.5 - 2.0 - 2.5 Age at time of infection (years) Ishak unit / year Age at infection and Fibrosis progression rate in chronic HCV Wright et al Gut 2003

19. 200 180 160 140 100 120 60 80 40 o o o o Mean ALT during follow-up Grades of fibrosis progression over 7-10 years of observation 0123 Fibrosis Progression in initially mild chronic hepatitis C correlates with Mean ALT During Follow-up © Boccato et al 2006

20. Progression of Liver Fibrosis in HCV Carriers with Normal or Elevated ALT % with fibrosis progression % with progression to severe fibrosis years of follow-up (High ALT) (Normal ALT) p = 0.06 p = 0.01 Hui, 2003

21. LONG TERM FOLLOW-UP IN HCV CARRIERS WITH INITIALLY NORMAL ALT 185 HCV patients with normal ALT (3 x 2 month apart) Final results of 10-15 year follow-up (mean 11.3 yrs) ALT % last observation at inclusion cases cirrhosis HCC (UNL=50 IU/L) <20 IU/L 27% 0% 0% 21-30 IU/L 33% 5% 0% 31-50 IU/L 40% 10% 4% Boccato et al 2007

22. 50 100 200 ALT (IU/L)                           P.P. o 43 yrs + GRADE 2 STAGE 0 GRADE 8 STAGE 3 NORMAL Reactivation of Hepatitis C After 6 Years of Persistently Normal ALT

23. ALT Flare in HCV Carriers with Initially (  6 mo) Normal ALT Author N° cases FU (yrs) % ALT flare Puoti et al, 20028801.821.5 % Martinot-Peignoux et al, 2001243.521 % Tsuy et al, 20011203.623.3 % Persico et al, 2000374.123 % Hui et al, 2003406.327.5 % Boccato et al, 2004457.333 %

24. HEPATITIS RECRUDESCENCE IN A CARRIER OF HCV2 WITH PNALT FOLLOWED BY BIOCHEMICAL REACTIVATION Rumi et al J Viral Hepatitis 2002;9:71-74) 1st liver biopsy (1994) grading 4, staging 1 2nd liver biopsy (1999) grading 6, staging 5

25. Disease Progression in HCV Patients presenting with PNALT and having ALT reactivation Initial Biopsy Final Outcome F111 % F1F261 % F3-428 % F25 % F2-F3F366 % F429 % HCC 9 % F0 25% F156% F2-3 19% F0 Alberti et al 2007 7-10 yrs

26. RISK FACTORS FOR DISEASE PROGRESSION IN HCV CARRIERS WITH INITIALLY PNALT F2 in initial biopsy ALT >50% UNL BMI > 32 Alcohol ALT FLARES OR STABLE REACTIVATION

27. Variables associated with fibrosis progression in initially mild CHC HCV1 (87 cases) HCV2 (51 cases) HCV3 (39 cases) Viral Loadns Age at entry0.05 Ns ALT profile0.05 Histologic activity in 1° Bx 0.05 ns Liver steatosis0.05 ns BMI at entry0.05 ns (7-10 yr follow-up of 177 cases)

28. Steatosis in Mild Chronic Hepatitis C STEATOSIS46% 5-10%22% 11-30%11% > 30%13% PROGRESSION TO F3/F4 16% SteatosisProgression of fibrosis 4 yrs6 yrs < 5%1.8%5.6% 5-10%3.8%17.6% 11-30%6.7%30% > 30%18.1%33.2% 135 patients with F0/F1 (A1) in initial biopsy, untreated, rebiopsed after 62 ± 28 mo Fartoux et al, Hepatology 2003

29. The Metabolic Cofactors affecting Liver Fibrosis in Hepatitis C BMI Obesity Steatosis NASH Diabetes (type 2) Insulin Resistance

30. LIVER STEATOSIS AND FIBROSIS HCV type 1 with similar duration of infection (12 - 14 years) No steatosis Grade of steatosis p< 1-2 3-4 N° Patients 28 18 12 Fibrosis score 1.43±0.15 1.58 ± 0.47 2.63±0.33 0.001 Yearly rate 0.12±0.01 0.14 ± 0.01 0.23±0.03 0.0001 Adinolfi et al Hepatology 2001

31. INSULIN RESISTANCE CONTRIBUTES TO FIBROSIS PROGRESSION IN HEPATITIS C Hui et al Gastroenterology 2003

32. Insulin Resistance but not Liver Steatosis affects Fibrosis stage in HCV-3 patients Bugianesi et at Hepatology 2006

33. Fibrosis Progression and Gender/Aging Martino et al, Hepatology 2004 PREMENOPAUSAL  fibrosis vs POSTMENOPAUSAL  fibrosis Pregnancy  HRT yes  vs Nulliparous  HRT no 

34. Family History and Outcome of Chronic HCV Infection Family history of advanced liver disease (any ethiology) N° % cirrhosis Median Time to Cirrhosis F / year NO 94612.8%25 yrs0.125 p <0.001 YES 23730.8%11 yrs0.750 Data from 1186 patients with HCV infection

35. On Stage of Basic Research for Disease Determinants Send in the Clones Send in the Genes HCV-J SNVSVAHDASGKRVYYLTRDPTTPLARAAWETVRHTPVNSWLGNIIMYAPTLWARMILMTHFFSILLAQEQLEKALDCQIYGACYSIEPLDLPQIIERLHGLSAFSLHSY Pt 2 TMA+.D..............................A.............L.................................................Q............. Pt 4 TMA+.D..............................A...............................................................Q............. Pt 11 TMA+................................A...............................................................Q............. HCV-J SPGEINRVASCLRKLGVPPLRVWRHRARSVRAKLLSQGGRAATCGKYLFNWAVKTKLKLTPIPAASQLDLSGWFVAGYNGGDIYHSLSRARPRWFMLCLLLL Pt 2 TMA+.....................................................R........................S.................W..... Pt 4 TMA+................................R....................R.................N......S.................W..... Pt 11 TMA+.....................A.......................R.......R.................N......S.................W..... Sequencing of virus clones ( searching for BAD Viruses) Microarrays of host genes (searching for BAD Signatures) Past Present/Future

36. THE PATIENT WITH HCV-RELATED CIRRHOSIS

37. Niederau et al Hepatology 1998

38. Variables associated with disease worsening and HCC development in HCV related cirrhosis Older age Male gender ALT and AFP profile Platelet count Bilirubin level HBV coinfectionHBV coinfection Alcohol intakeAlcohol intake Liver SteatosisLiver Steatosis Tobacco smokingTobacco smoking

39. NEGATIVE PROGNOSTIC VARIABLES AFFECTING “NATURAL” AND “THERAPY-RELATED” OUTCOMES IN PATIENTS WITH HCV Natural courseResponse to therapy HCV Load HCV genotype Age Stage of disease Insulin resistance HIV-HBV Alcohol * * * * * * * * * * * no

40. CONCLUSIONS  Prognosis still difficult to define individually  Need to consider age, stage of fibrosis, disease activity and ALT profile  Major negative cofactors are alcohol, HIV, HBV, obesity and Insulin resistance  More to be learnt on host genetics