与 HCV 感染根除相关的肝性脑病发生率降低和更高的缓解几率。
Reduced Incidence of Hepatic Encephalopathy and Higher Odds of Resolution Associated With Eradication of HCV Infection.
机构信息
Division of Gastroenterology and Hepatology, University of Michigan Health System; Division of Gastroenterology, Ann Arbor Veterans Administration, Ann Arbor, Michigan.
Division of Gastroenterology and Hepatology, University of Michigan Health System.
出版信息
Clin Gastroenterol Hepatol. 2020 May;18(5):1197-1206.e7. doi: 10.1016/j.cgh.2019.09.033. Epub 2019 Oct 4.
BACKGROUND & AIMS: It is unclear whether a sustained virologic response (SVR) to direct-acting antiviral (DAA) therapy reduces the risk of incident hepatic encephalopathy (HE) in patients with hepatitis C virus (HCV) infection or whether it leads to resolution of pre-existent HE.
METHODS
We identified 71,457 patients who initiated antiviral treatments in the Veterans Affairs Healthcare System from January 1, 1999 through December 31, 2015; 35,871 patients (58%) received only interferon, 4535 patients (7.2%) received DAAs plus interferon, and 21,948 patients (35%) received DAA-only regimens. We collected data from patients through October 31, 2018, for an average of 6.6 years. We evaluated the association between SVR and the development of incident HE or the resolution of pre-existent HE (defined by cessation of pharmacotherapy) as well as the risk of hospitalization with HE after adjusting for potential confounders.
RESULTS
Compared to no SVR, SVR after DAA therapy was associated with a significantly lower risk of developing HE (0.28 vs 1.39 per 100 person-years; adjusted hazard ratio [AHR] 0.41; 95% CI, 0.32-0.51). This association persisted among patients with co-morbid alcohol use disorder and diabetes as well as patients with cirrhosis (AHR, 0.36; 95% CI, 0.31-0.43) and model for end-stage liver disease (MELD) scores of 9 or more (AHR, 0.36; 95% CI, 0.30-0.44). SVR was also associated with reduced risk of hospitalization with HE (AHR, 0.59; 95% CI, 0.43-0.81). Among 2396 patients who were receiving pharmacotherapy for HE at the time of antiviral treatment, SVR was associated with a significantly increased likelihood of HE resolution for those with MELD scores below 9 (AHR, 2.26; 95% CI, 1.74-2.93) but not those with MELD scores of 9 or more.
CONCLUSIONS
In a retrospective study of veterans, we found DAA eradication of HCV infection to be associated with a 59% reduction in risk of development of HE and a > 2-fold increased likelihood of resolution of pre-existing HE in all subgroups except patients with MELD scores of 9 or more.
背景与目的
尚不清楚直接作用抗病毒（DAA）治疗的持续病毒学应答（SVR）是否降低丙型肝炎病毒（HCV）感染患者发生肝性脑病（HE）的风险，或者是否导致先前存在的 HE 得到缓解。
方法
我们在退伍军人事务部医疗保健系统中确定了 71457 名于 1999 年 1 月 1 日至 2015 年 12 月 31 日期间开始抗病毒治疗的患者；其中 35871 名患者（58%）仅接受干扰素治疗，4535 名患者（7.2%）接受 DAA 联合干扰素治疗，21948 名患者（35%）接受 DAA 单药治疗方案。我们通过 2018 年 10 月 31 日的数据收集，平均随访 6.6 年。我们评估了 SVR 与新发生 HE 或先前存在的 HE （通过停止药物治疗定义）之间的关联，以及在调整潜在混杂因素后与 HE 住院风险的关系。
结果
与无 SVR 相比，DAA 治疗后的 SVR 与发生 HE 的风险显著降低相关（每 100 人年 0.28 比 1.39；调整后的危险比 [AHR] 0.41；95%CI，0.32-0.51）。在患有合并酒精使用障碍和糖尿病以及患有肝硬化（AHR，0.36；95%CI，0.31-0.43）和模型终末期肝病评分（MELD）为 9 分或更高（AHR，0.36；95%CI，0.30-0.44）的患者中，这种关联仍然存在。SVR 也与 HE 住院风险降低相关（AHR，0.59；95%CI，0.43-0.81）。在 2396 名在抗病毒治疗时正在接受 HE 药物治疗的患者中，对于 MELD 评分低于 9 的患者，SVR 与 HE 缓解的可能性显著增加（AHR，2.26；95%CI，1.74-2.93），但 MELD 评分 9 分或更高的患者则没有。
结论
在一项退伍军人的回顾性研究中，我们发现 DAA 根除 HCV 感染与 HE 发展风险降低 59%相关，并且除 MELD 评分 9 分或更高的患者外，所有亚组中先前存在的 HE 缓解的可能性增加>2 倍。
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