The development of decompensated cirrhosis and the composite outcome of death, liver transplant, decompensated cirrhosis, or hepatocellular carcinoma (HCC) was independently associated with post-anti-viral therapy liver stiffness greater than 20 kPa in patients with hepatitis C virus (HCV) infection. Pre-treatment liver stiffness was not associated with any outcome indicating that measuring stiffness post-treatment should be considered, according to the data published in Alimentary Pharmacology & Therapeutics.
Investigators conducted the study to assess the associations with liver stiffness pre- and post-treatment with several adverse outcomes in a retrospective cohort of US veterans. According to investigators, fibroscan-derived liver stiffness decreases after treatment, which may affect the associations and interpretation of liver stiffness.
Veterans who initiated treatment and had at least one liver stiffness assessment before (n=492) or after (n=877) treatment were identified. Cox-proportional hazards regressions were used to determine the associations between pre- and post-treatment stiffness and the development of decompensated cirrhosis, HCC, death, or liver transplant. The analysis was adjusted for age, race/ethnicity, history of cirrhosis, body mass index, diabetes, FIB-4 score, Charlson comorbidity index, alcohol use disorder, Model for end-stage liver disease score, and sustained virological response status.
During a mean follow-up of 27.3 months in the post-treatment group, 21 patients (2.4%) developed decompensated cirrhosis, 26 patients (2.4%) developed HCC, and 57 patients (6.5%) died or underwent liver transplant. When compared to patients with post-treatment liver stiffness of 12.5 kPa or less, patients with post-treatment stiffness of greater than 20 kPa had higher rates of developing decompensated cirrhosis (adjusted HR [aHR], 3.85; 95% CI, 1.29-11.50) and the composite outcome of death, liver transplant, decompensated cirrhosis, or HCC (aHR, 1.95; 95% CI, 1.07-3.56). No significant associations were found between pre-treatment stiffness and any outcome.
This was the first study looking at associations between pre- and post-treatment stiffness and adverse outcomes. Several limitations were noted including that data was acquired retrospectively and derived from a male, military veteran population. The findings will require validation in other patient populations. Direct comparisons for each patient were difficult as a minority of patients underwent both pre- and post-treatment liver stiffness measurements.
In future studies, investigators recommend obtaining both measurements. The statistical power of some analyses was likely limited because there were few outcomes particularly in the pre-treatment liver stiffness category of 12.5 kPa or less. The mean follow-up time in the post-treatment and pre-treatment cohorts was 27.3 months and 34.6 months, respectively. Investigators point out that “future longitudinal studies with longer follow-up time will need to be done to evaluate whether our associations persist further out from time of post-treatment liver stiffness.”
Investigators were able to conclude that in this patient population, post-treatment liver stiffness of greater than 20 kPa was independently associated with the development of decompensated cirrhosis, HCC, or death after adjustment for readily available predictors. Investigators believe that the lack of associations with pre-treatment stiffness “may suggest that post-treatment liver stiffness is a more important predictor of long-term outcomes.” They further recommend that HCV patients treated with anti-viral therapies may benefit from a post-treatment liver stiffness measurement as this could identify those at risk for long-term adverse outcomes.
Vutien P, Kim NJ, Moon AM, et al. Fibroscan liver stiffness after anti-viral treatment for hepatitis C is independently associated with adverse outcomes. Published online September 20, 2020. Aliment Pharmacol Ther. doi: https://doi.org/10.1111/apt.16092