Duke University School of Medicine, Durham, North Carolina, USA.
Treatment of hepatitis C virus (HCV)-infected patients with cirrhosis remains challenging. Biopsy to stage liver fibrosis remains the standard for identifying cirrhosis, although the noninvasive technique of transient elastography is promising in this regard. Cirrhosis is categorized as compensated or decompensated, with the latter characterized by ascites, hepatic hydrothorax, bleeding varices, hepatic encephalopathy, and hepatorenal syndrome. In the interferon alfa treatment era, patients with compensated cirrhosis have been candidates for interferon alfa-based treatment, whereas those with decompensated cirrhosis have been treated with caution and only at a tertiary care or transplant center. New interferon alfa-free regimens offer safer treatment alternatives to patients with cirrhosis. Response to interferon alfa-based therapy alone and in combination with the first-generation HCV protease inhibitors boceprevir or telaprevir for the treatment of HCV genotype 1 infection has been poorer in patients with cirrhosis than in those without. With regimens that include newer direct-acting antivirals, response rates are tremendously improved for patients with cirrhosis but still slightly lower than those for patients without cirrhosis. As new regimens enter use outside of clinical trials, optimizing efficacy for patients with cirrhosis will be an important goal. Patients with cirrhosis must be taught to practice liver wellness following HCV cure, to lower the risk of progression of their liver disease. Risk of hepatocellular carcinoma also persists in patients with cirrhosis even if cure of HCV infection is achieved. The risk of these complications is dramatically reduced with cure of HCV infection through antiviral treatment. This article summarizes a presentation by Andrew J. Muir, MD, MHS, at the IAS-USA continuing education program held in Atlanta, Georgia, in September 2013.