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EASL 2015: Heavy Alcohol Use Is Strongest Predictor of Liver Damage and Death in French Hepatitis C Patients

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People with hepatitis C have a much greater risk of liver-related hospitalization or death if they have an alcohol use disorder or another serious comorbidity such as HIV infection, chronic kidney disease, or cancer, according to an analysis of everyone hospitalized in France between 2008 and 2012 presented at the European Association for the Study of the Liver (EASL) 50th International Liver Congress last week in Vienna. In the absence of these problems, however, people with hepatitis C did not have an increased risk of death compared to the general population.

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Previous research in smaller cohorts has shown that alcohol use greatly increases the risk of liver-related death in people with hepatitis C, but the French study is the largest study of the effects of alcohol on liver-related clinical disease and death ever reported.

Michaël Schwarzinger of the Translational Health Economics Network in Paris and colleagues designed the study to assess the contribution of various confounding factors to the prognosis of people with hepatitis C virus (HCV) infection. In particular, the study sought to determine the extent to which alcohol might contribute to the poor prognosis of hepatitis C -- and whether people without high levels of alcohol consumption also have a poor prognosis if infected with HCV.

The study could assess alcohol use only by physician report of an "alcohol use disorder," and the hospitals database does not contain any information about patients' average consumption level, the definition of alcohol misuse, or the duration of heavy drinking. The diagnosis of alcohol use disorder covers a spectrum of problematic drinking -- ranging from regular over-indulgence to severe physical dependence -- and is classified as mild, moderate, or severe. The appearance of "alcohol use disorder" on a medical record is therefore a red flag that someone has a history of heavy alcohol consumption, but provides no information that can be used to calculate less harmful levels of consumption or how many years of heavy drinking might negatively affect the prognosis of people with hepatitis C.

The study also looked at the contribution of serious comorbidities to the need for hospitalization for liver-related events. These included both liver disease complications such as cirrhosis, liver cancer, and end-stage liver disease, as well as unrelated conditions such as HIV/AIDS, chronic kidney disease, and metabolic syndrome.

During the period 2008-2012, a total of 28,953,755 people in France were admitted to hospital and 1,506,453 people died in while hospitalized. Chronic HCV infection was present in 112,146 (0.39%) of hospitalized patients, alcohol use disorders in 705,259 (2.44%), and both chronic hepatitis C and alcohol use disorders in 23,351 (i.e., 20.8% alcohol use disorders recorded among hepatitis C patients).

The analysis found that people with hepatitis C were 6 times more likely to have an alcohol use disorder than other hospitalized patients, and 2.4 times more likely to have at least 1 serious comorbidity.

Of all liver-related events in people with hepatitis C, 46% occurred in those with alcohol use disorders, approximately one-third in people with at least 1 serious comorbidity, and only 14% in people with hepatitis C who had neither an alcohol use disorder nor a comorbidity.

The study also found that people in the general population had a much worse prognosis than others if they had an alcohol use disorder. They were 3 times more likely to die while hospitalized than people who did not drink.

People who had stopped drinking or who had remained abstinent had a one-third reduction in the risk of death compared to people who drank any alcohol, while in the general population abstinence or withdrawal reduced the risk of death by one-quarter.

The poor prognosis of people with hepatitis C is largely explained by alcohol misuse and by severe comorbidities, Schwarzinger told a, EASL press conference. The findings call into question the cost-effectiveness of direct-acting antiviral treatment for hepatitis C for people without alcohol misuse disorders, he went on, because rates of progression and consequent medical costs averted by immediate treatment may be much lower than current models suggest.

"These results show that alcohol use disorders are a much more accurate indicator of mortality in chronic HCV infection, and highlight the need to encourage alcohol withdrawal and abstinence in all patients," said EASL Scientific Committee Member Tom Hemming Karlsen.

Schwarzinger said that the effect of alcohol abstinence and withdrawal should be investigated more closely in people with hepatitis C.  For example, the better prognosis of people with genotype 4 HCV may be a consequence of its epidemiology -- genotype 4 is prevalent in Muslim countries in North Africa and the Middle East where alcohol consumption is culturally unacceptable -- rather than any inherent feature of the genotype, Schwarzinger argued.

5/1/15

Reference

M Schwarzinger, S Thiébaut, V Mallet, and J Rehm. The confounding role of severe comorbidities and alcohol use disorders on prognosis in chronic hepatitis C virus infection: an analysis of the 2008-2012 French national hospital discharge database. 2015 International Liver Congress: 50th Annual Meeting of the European Association for the Study of the Liver (EASL). Vienna, April 22-26, 2015. Abstract G16.

Other Source

EASL. Alcohol use disorders are a stronger predictor of mortality than chronic hepatitis C virus infection in the general population. Press release. April 25, 2015.