Your Liver Lets You Live

Your liver, located under your right rib cage, normally weighs about three pounds and is the body's second largest organ. (Your skin is the largest.) The liver is a complex organ that functions like a "chemical factory" processing many important body substances such as bile, digestive enzymes, clotting factors, cholesterol, and proteins. It is essential in the metabolism of fats, carbohydrates, proteins, and the various vitamins and minerals. It helps control the level of blood sugar and fats. It cleanses the blood and detoxifies drugs and potentially harmful chemicals such as alcohol. The liver is a storehouse for blood, vitamins and minerals, and glycogen - the stored form of sugar - the body's major fuel. The liver has an amazing ability to regenerate and replenish itself, but when disease strikes, this amazing factory can shut down and serious health problems occur. One such disease is hepatitis C.

What Is Hepatitis C?

Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). Hepatitis C is one of five (A, B, C, D, and E) viruses that are able to infect the liver. A virus is a very small organism, invisible to all but the strongest microscopes. Unlike other living organisms, a virus cannot reproduce itself. It needs to take over the reproductive mechanism of other cells within the body, like liver cells. Once a virus has invaded a cell, it reproduces quickly, eventually bursting the cell and scattering new virus particles into the bloodstream. These new viruses can then search out and invade more liver cells, repeating the process over and over. So, unchecked, a virus could rapidly spread throughout your body.

Fortunately, your body's immune system has a very efficient type of "radar tracking" mechanism which allows identification and destruction of virus particles - before they can spread. Every time you get a virus, like a cold or flu, there is a fierce battle being waged between the rapid formation of new virus particles and your immune system's ability to destroy them. Your immune system is pretty smart. It usually wins the battle and the infection is cured. But, the hepatitis C virus is even smarter. It has a type of "radar jamming" system which makes it near invisible to your immune system. So, in the case of hepatitis C, the virus usually wins. The infection is not cured and becomes chronic, or permanent, in three cases out of four. In these patients, the hepatitis C virus can be found in the blood stream, but it's favorite hideout is the liver. Still, you can have this infection in your liver and feel fine for many years. Over time, however, as the body repeatedly attempts to destroy the virus in the liver, inflammation of the liver occurs. This liver inflammation is called hepatitis. Once is has become chronic, the condition is called chronic hepatitis C.

Chronic hepatitis C is quickly becoming a serious public health problem in the United States. If your doctor has told you that you have this illness, you are not alone. The U.S. Center for Disease Control (CDC) estimates that at least 4.5 million Americans are now infected with this virus and over 170,000 new cases are added each year. More than 4 times as many people are infected with Hepatitis C tnan HIV-AIDS. There are approximately 170 million Hepatitis cases worldwide where it is the most prevalent of all the forms of hepatitis.

HCV first surfaced in the 1970's as a mysterious post-transfusion virus dubbed "non-A non-B hepatitis" since research did determine that it was neither the virus that causes hepatitis A nor hepatitis B. The virus was finally isolated and named "hepatitis C" in 1989. Since then scientists have been scrambling to find out how many people have it, how it is transmitted, and how to treat it. An antibody test to screen and protect the blood supply was developed in 1990.

What Are the Symptoms of HCV?

That's the problem. There are none, at least not in the beginning. HCV uses guerrilla tactics. Typically, it slips into your bloodstream without provoking any noticeable illness and can lurk there for decades. Of course, late in the course of the illness symptoms may occur. These often include loss of appetite, fatigue, nausea, vague stomach pain, and jaundice ( a yellowing of the skin and whites of the eyes ).

How Serious Is It?

HCV is a potential time bomb with a fuse of unknown length. Many infected persons remain healthy indefinitely; but, as mentioned above, 75% will develop a chronic infection that they are unable to clear. This can lead to cirrhosis (scarring) of the liver and 20% of infected patients develop life-threatening liver failure 15 to 20 years after their initial infection. At 30 years the risk of liver cancer increases.

Who Gets Hepatitis C?

A blood-borne virus is spread primarily by exposure to human blood. HCV is most often transmitted by blood transfusions and IV drug user's contaminated needles, but the source of many infections is unknown.

You are at risk for HCV if you:

* ever injected drugs or shared needles
* ever shared an apparatus to snort cocaine
* have a job that exposes you to human blood
* are a hemodialysis patient
* received a blood transfusion before 1990
You may be at risk if you:

* have had unprotected sex with multiple partners
* live with a person who has hepatitis C
* have had a tattoo or body piercing

How Can HCV Be Prevented?

People who have HCV should remain aware that their blood, and possibly other body fluids, are potentially contagious for the rest of their life. Care should be taken to avoid blood exposure to others by sharing toothbrushes, razors, needles, etc. In addition, infected individuals can never donate blood and should inform their medical and dental care providers so that proper precautions can be followed.

How About Sex

HCV has been transmitted between sex partners and among household members; however, the degree of this risk is unknown. Studies of HCV and sexual transmission offer conflicting results. A 1991 study from Stanford University showed no evidence of HCV in the urine, semen, or vaginal secretions of infected individuals with HCV. But similar studies have shown evidence of HCV in 5-27% of sexual partners.

Researchers seem to agree that if it is transmitted sexually, it isn't very efficient. The risks of catching HCV from an infected partner are estimated at less than 1% per year of exposure. Each couple will have to decide what is best for them, but currently the CDC does not advise changing sexual habits or using condoms in long-term monogamous relationships. As always, all people with multiple sexual partners should use condoms to reduce the risk of acquiring or transmitting HCV as well as other sexually transmitted diseases.

Is There A Vaccine for HCV?

Not yet. While there are vaccines for other forms of hepatitis such as hepatitis A and hepatitis B, there currently is no effective vaccine for this disease. Much research is being done, however, since HCV is a multibillion-dollar business worldwide. HCV patients should be vaccinated against hepatitis A and B. Infection with either could speed the damage done by C.

How Is HCV Diagnosed?

Usually by accident. Since most cases have no symptoms, HCV is usually discovered during a routine liver blood test Taken before donating blood, an insurance physical, or just a checkup in your doctor's office. Once your doctor notes a elevation in your liver enzymes he will usually request additional blood tests to confirm the abnormality and to determine the cause. A hepatitis profile if often requested which test for hepatitis A, B, and C. If the test is positive for HCV then additional blood tests are done to confirm active infection plus the amount of virus present. Often a needle biopsy of the liver is recommended to determine if the infection is damaging the liver.

How Is HCV Treated?

Alcohol use in any form must be stopped. Studies are clear the Hepatitis C patients who regularly ingest alcohol have more active hepatitis and are much more likely to progress to liver failure. In addition drug treatment of HCV does not seem to work in alcohol users. Think of the virus as a fire in your liver and alcohol as gasoline - don't mix them!!!!

Being overweight also appears to increase the amount of damage the virus does to the liver. Apparently fat deposited in the liver increases scarring caused by inflammation from the virus. Progressive scar tissue formation then leads to cirrhosis. A weight loss program, if necessary, and staying within 10 % of your ideal body weight is suggested

Currently the most effective drug therapy involves the use of two medications "Interferon and Ribavirin" given in combination for a 48 week period. Interferon is naturally produced in our bodies to fight viruses. It is a synthetic reproduction of the naturally produced interferon. There are two types of interferon currently available. Interferon-alpha 2a or 2b is the compound that has been extensively used and tested to this point. Though the dose varies, patients with Chronic Hepatitis C usually receive 3 million units 3 times per week. The duration of therapy is usually 48 weeks. Ribavirin is an antiviral medication taken by mouth, 5 to 6 pills per day. Used for many years to treat viral pneumonia in children this drug has no effect on its own against Hepatitis C. When given with interferon however it significantly enhances viral clearance.

A newer formulation of interferon just released on the market is called Pegylated Interferon. This drug was formulated in response to the rapid breakdown, fall in blood levels, and subsequent loss of antiviral effect seen with interferon given 3 times per week. By attaching a molecule called P.E.G to Interferon-alpha 2a or 2b researchers where able to slow its breakdown by the body so more consistent drug levels where achieved with the need to only give the drug once per week. Above and beyond the convenience of once a week injection, the peg formulations had greater viral clearance rates. It is expected with time that this newer formulation will replace entirely the older interferon-alpha 2a/2b.

Side effects of these medications are common and may preclude treatment in some patients. Interferon often makes patients feel as if they had a lingering case of the flu with fever, chills, headache, tiredness, loss of appetite, joint pain and muscle aches. These side effects may get better as the body gets used to the extra interferon. Tylenol or Advil plus rest are helpful.

Note: Patients with liver disease and/or who regular use alcohol should never take more than 4 regular-strength Tylenol per day and should not take Tylenol on a daily basis due to risk of liver failure. Tylenol taken with the above precautions, however, is safe.

Other more serious side effects may occur and frequent blood tests are mandatory during treatment. These help your doctor to assess your response to treatment and to check for possible side effects. Depression can occur or be aggravated by the use of interferon. Be sure to tell your doctor if you have suffered from depression in the past or develop symptoms while on therapy. Ribavirin seems to be better tolerated but can cause anemia or low blood counts and is damaging to the fetus if taken during pregnancy. Cardiac patients and some women of child bearing age may not be candidates for this drug and your doctor will help you decide if Ribavirin use is right for you.

The Role of Genotyping

Prior to initiating treatment a blood test will be needed to determine your genotype. Genotype is the genetic make-up of the virus. The virus can mutate or change its genetic makeup. By varying its structure, it has evolved into six known genotypes. Determining the genotype helps the doctor determine the duration of therapy and projected response. Genotypes 1a and 1b are the most common in the U.S., accounting for more than 75 percent of all infections. For these genotypes, the hardest to treat, the recommended length of treatment is 48 weeks. For those with genotype 1, the Sustained Virologic Response, (SVR), for combination therapy with Interferon/Ribavirin is 33%. The response rate is now 50% with Pegylated interferon/Ribavirin (preliminary data). Genotype 2 and 3 are present in approximately 20 percent of patients. These genotypes are easier to treat and respond to a recommended treatment period of 24 weeks, with an anticipated SVR of 60% with combined Interferon/Ribavirin and experts predict possible 90 to 100% SVR with combined Pegylated Interferon/Ribavirin though data still very preliminary and incomplete.

Future Developments

Despite increases in the number of new cases being diagnosed, new infections have actually decreased by more than 80% since the virus was identified. Unfortunately, even with recent advances in treatment, after a year of therapy between 40 and 60% of patients do not have a sustained response rate. These patients, despite improvement in their blood test, are unable to clear the virus completely. It does appear, however, that even patients who are not "cured" may benefit from therapy with a decrease in the amount of liver inflammation and possibly a decrease in their risk of liver cancer down the road. Clearly, treatment with these powerful drugs is not the answer for all patients. Patients with normal or minimal elevation of their liver test and favorable liver appearance on biopsy may be advised not to take treatment. Close follow-up is then undertaken awaiting further treatment developments. Future treatments in development such as ribozyme, helicase and protease inhibitors will be aimed at directly blocking viral replication rather than boosting immune response, like Interferon. In theory, as these drugs inhibit viral replication, the adverse side effects will be less. It is likely that the most effective therapy will employ the multi-drug type regimes like those currently used in HIV viral treatment.

Role of Liver Transplant

In severe cases if the liver is damaged beyond repair even with viral eradication, liver transplant is an option. In fact, HCV has now become the most common reason to perform liver transplant in the United States.

More Information About Hepatitis C