The
Brazilian
Journal
of
INFECTIOUS
DISEASES
w w w . e l s e v i e r . c o m / l o c a t e / b j i d
Original
article
Association
between
age
at
diagnosis
and
degree
of
liver
injury
in
hepatitis
C
Ana
Cláudia
de
Oliveira
a,b,∗,
Ana
Clara
Bortotti
b,
Nathália
Neves
Nunes
b,
Ibrahin
A.H.
El
Bacha
a,
Edison
Roberto
Parise
aaDisciplineofGastroenterology,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
bDepartmentofMedicine,UniversidadeFederaldeSãoCarlos(UFSCar),SãoCarlos,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received16January2014
Accepted25April2014
Availableonline4June2014
Keywords:
ChronichepatitisC
Ageatdiagnosis
Hepaticfibrosis
a
b
s
t
r
a
c
t
Introduction:Apopulation-basedsurveyconductedinBraziliancapitalcitiesfoundthatonly
16%ofthepopulationhadeverbeentestedforhepatitisC.Thesedatasuggestthatmuchof
theBrazilianpopulationwithHCVinfectionremainsundiagnosed.Thedistributionofage
rangesatdiagnosisanditsassociationwiththedegreeofhepatitisCarestillunknownin
Brazilianpatients.
Materialandmethods: PatientswithHCVinfection,diagnosedbyHCVRNA(Amplicor-HCV,
Roche),wereincludedinthestudy.PatientswithHBVorHIVcoinfection,autoimmune
diseases, oralcoholintake>20g/daywereexcluded.HCVgenotypingwasperformedby
sequenceanalysis,andviralloadbyquantitativeRT-PCR(Amplicor,Roche).TheMETAVIR
classificationwasusedtoassessstructuralliverinjury.TheChi-square(2)testandstudent’s
t-testwereusedforbetween-groupcomparisons.Spearman’srankcorrelationcoefficient
wereusedforanalysingthecorrelationbetweenparameters.
Results:Atotalof525chartswerereviewed.Ofthepatientsincluded,49.5%weremale,only
10%ofthepatientswereagedlessthan30years;peakprevalenceofHCVinfectionoccurred
inthe51-to-60yearsagerange.Genotype1accountedfor65.4%ofthecases.Information
onHCVsubtypewasobtainedin227patients;105hadsubtype1aand122had1b.According
tothedegreeofstructuralliverinjury,8.3%hadF0,23.4%F1,19.8%F2,11.9%F3,and36.5%
F4.Ageatdiagnosisofhepatitiscorrelatedsignificantlywithfibrosis(rs=0.307,p<0.001).
Thedegreeoffibrosisincreasedwithadvancingage.Onlyageatdiagnosisandfastingblood
glucosewereindependentlyassociatedwithdiseasestage.Thosepatientswithsubtype1a
hadhigherprevalenceofF2–F4thanthosewithsubtype1b.
Conclusion: InBrazil,diagnosisofhepatitisCismorecommonlyestablishedinolderpatients
(age45–60years)withmoreadvanceddisease.ReassessmentofstrategiesforhepatitisC
diagnosisinthecountryisrequired.
©2014ElsevierEditoraLtda.Allrightsreserved.
∗ Correspondingauthorat:DepartmentofMedicine,UniversidadeFederaldeSãoCarlos,WashingtonLuiz,Hw235Km310SPSãoCarlos,
SP,Brazil.
E-mailaddresses:anaol@terra.com.br,anaol@ufscar.br(A.C.deOliveira).
http://dx.doi.org/10.1016/j.bjid.2014.04.003
Introduction
Accordingtoofficialestimatesoftheprevalenceofhepatitis
C inBraziland demographic datafrom the Brazilian
Insti-tuteofGeographyandStatistics(IBGE),1,2 approximately2.5
millionpeopleinthecountry wouldhavebeen positivefor
anti-hepatitis C virus (anti-HCV) antibodies. A
population-basedsurvey conductedinmajorstate capitalsfoundthat
only16%ofthe populationhad everbeentested forHCV.3
Justover60,000patientswithhepatitisChavereceived
antivi-ral treatment in the country over the last 6 years.4 These
datashow that a large portion ofthe Brazilianpopulation
infected with HCV remains undiagnosed. The high
preva-lenceofadvancedhepatitisCinthecountryappearstoreflect
thelack ofan aggressivepolicyfordiagnosingthis serious
condition, which is compounded by its oligosymptomatic
course.HepatitisCisthesecond leadingcause ofcirrhosis
inBrazilandtheleadingcauseofhepatocellularcarcinoma,
and,consequently, the mostcommon cause ofliver
trans-plantationinthecountry.5–7However,noconsistentdataare
availableontheassociationbetweenagerangeatdiagnosis
anddiseaseprogression.Therefore,thepresentstudysought
toassessthedemographicprofileofpatientswithconfirmed
HCVinfectionpresentingfortheirfirstvisitatatertiary
refer-ralcenter,andascertainwhethercorrelationsexistbetween
this variable and clinical and histological severity of the
illness.
Material
and
methods
We reviewed the charts of all adults (age>15 years) seen
consecutivelybetweenJanuary2009andJune2013atthe
out-patient Gastroenterology Clinicof Universidade Federalde
São Paulo(UNIFESP), atertiary referral service forpatients
withHCV-relatedliverdisease.Theinclusioncriterionwasa
confirmedHCV infection.AfterdiagnosisofHCV exposure,
usually by detection of anti-HCV antibodies by
second-generation and, later inthe study period, third-generation
enzyme-linked immunosorbent assay (ELISA) (Abbott IMX,
AbbottLaboratories,USA),diagnosiswasconfirmedby
detec-tionofHCVRNAinperipheralbloodthroughthepolymerase
chainreaction(PCR)(Amplicor-HCV,RocheDiagnostics).HCV
genotypingwaslatercarriedoutbysequenceanalysisofthe
5′noncodingregion,andviralloadwasmeasuredby
quanti-tativeRT-PCR(Amplicor,Roche).
Foranalysisoftheassociationbetweenageatdiagnosis
anddegreeofliverinjury,genderdistribution,and
distribu-tionofviralgenotypes,weexcludedpatientswithhepatitis
BvirusorHIVcoinfection,autoimmunediseases,oralcohol
intake>20g/day(regardlessofgender).Allpatientshad
under-gone percutaneous liver biopsy, exceptthose with clinical
manifestationsorultrasoundand/orendoscopyfindings
con-sistentwithcirrhosis.Theresultingbiopsy specimenswere
embeddedin paraffin and stained with hematoxylin/eosin
(H&E),reticulin,andMasson’strichromeforhistological
exam-ination.Onhistopathologicalanalysis,structuralliverinjury
wasassessedandgradedinaccordancewiththehistological
METAVIRclassification.8
10
13
29 30
18
0 10 20 30 40
>30yo 31-40yo 41-50yo 51-60yo >60yo
%
pa
ti
e
nt
s
Age range
Fig.1–Distributionofageathepatitisdiagnosisbypatient agerange.
Statisticalanalysis:Resultswereexpressedasmeansand
standarddeviations.TheChi-square(2)testorstudent’st
-testwasusedforbetween-groupcomparisonsasappropriate.
Spearman’s rank was used totest for correlation between
parameters.Thesignificancelevelwassetat5%(p<0.05).
Results
Initialassessmentincluded thechartsof525patientswith
HCV infection, ofwhom 49.5% were male and 50.5% were
female.Only10%ofthesepatientswereaged<30yearsat
diag-nosis;peakprevalenceoccurredbetweentheagesof51and60
years(Fig.1).
In61patientswithconfirmedviralinfection,liverinjury
couldnotbestagedduetotheirrefusaltoundergobiopsy,loss
tofollow-up,orthepresenceofexclusioncriterianot
identi-fiedatthetimeofenrollment.Theremaining464patientshad
agenderdistributionsimilartothatoftheinitialsampleand
ameanageof48.9±12.4years(range,15–78years).Regarding
genotype,65.4%hadgenotype1HCV,29%hadgenotype3,7%
had genotype2,and4%hadothergenotypes.Furthermore,
HCVsubtypewasdeterminedin227patientswithgenotype1:
105hadsubtype1aand122hadsubtype1b.Regardingthe
dis-tributionofdegreesofstructuralliverinjury,8.3%ofpatients
hadnofibrosis(F0),23.4%weregradedasF1,19.8%asF2,11.9%
asF3,and36.5%ascirrhotic(F4).
Ageatdiagnosisofhepatitiscorrelatedsignificantlywith
the degreeofstructuralliverinjury(rs=0.307,p<0.001).As
showninFig.2,degreeoffibrosisincreasedwithadvancing
age.Thepercentageofpatientswithcirrhosisalsoincreased
progressively with increasing age range at diagnosis;
con-versely,the percentageofpatientswithmild orno fibrosis
decreasedprogressivelywithadvancingage.Thepresenceof
advanced fibrosisdidnotcorrelatewithgender, bodymass
index,genotype,viralload,orepidemiologyofinfection.
Thegenderdistributionwasreversedamongpatients
diag-nosedafterage45years.Amongpatientsyoungerthanthis
cutoff,menaccountedfor60%ofalldiagnosedcases,whereas
afterthisage,womenwerethemajority,accountingfor55%
ofcasesonaverage(Fig.3).However,therewerenosignificant
genderdifferencesinthedegreeoffibrosis(2=2.221,p=0.695)
orthedistributionofviralgenotypes(2=1.185,p=0.757)in
<30 yo 100%
90% 80%
70% 60%
50% 40%
30% 20%
10%
0%
22.7 13.6
24.0
13.2
5.1 43.4
50.6
1.2 31-45 yo 46-60 yo
F4 F3 F2 F1 F0
>60 yo
Fig.2–Distributionofdegreeofstructuralliverinjuryby patientage.
<30 years 80%
60%
40%
20%
0% 44%
56%
37% 63%
57%
43%
52% 48%
30-45 years
Female Male
46-60 years >60 years
Fig.3–Distributionofgenderaccordingtopatients’age.
Therewerenosignificantdifferencesingender,age,body
massindex,orthepresenceofdiabetesmellitusamong
differ-entgenotype1HCVsubtypes.However,whenpatientswere
stratifiedbydiseasestage,despitenodifferencesinthe
pres-enceofadvancedfibrosis(F3,F4),patientswithsubtype1ahad
astatisticallyhigherprevalenceofsubstantialfibrosis(F2–F4)
thanpatientswithsubtype1b.Ahistoryofbloodtransfusion
wasmoreprevalentamongpatientswithsubtype1b(Table1).
Discussion
Althoughrestrictedtotheadultpopulation,thesedatashow
thatdiagnosisofhepatitisCinBrazilincreasesinprevalence
from the fourth decade of life and that nearly half of all
patients in whom the condition isdetected are diagnosed
betweentheagesof46and 60years,withpeakprevalence
atage 50–60years.These data essentiallyreproduce those
reportedbyFoccaciaetal.,9whoconducteda
seroepidemio-logicpopulation-basedsurveyofanti-HCVantibodypositivity
inthecityofSãoPauloandfoundthatthemostsignificant
prevalencewas foundafterage 30 years,withpeak
preva-lenceat50–60years.Thesefindingswerealsoconsistentwith
the distribution ofcasesreported to theBrazilian Ministry
ofHealthNotifiableDiseasesInformationSystem(Sistemade
Informac¸ãodeAgravosdeNotificac¸ão,Sinan).10
Anotherremarkablefindingofthisstudywastheimpactof
ageatdiagnosisonthedegreeofliverinjury,withagrowing
prevalenceofadvancedfibrosisand aprogressivereduction
inthenumberofmildcaseswithadvancingage.On
analy-sisoffactors associatedwithdisease progression,onlyage
andthe presenceofdiabetesmellituscorrelated withmore
advanceddiseaseinoursample.Theimportanceofageinthe
naturalhistoryofchronichepatitisChasbeendemonstrated
in a variety ofstudies conducted in Brazil and elsewhere.
Patientsinfectedatanolderageorthosewithalonger
dis-easecoursepresentwithmoreadvancedstages.11–14 Several
investigationshavedemonstratedrapiddiseaseprogression
amongpatientsinfectedatolderages,particularlyinstudies
ofpatientsenrolledwithearly-stagefibrosis (F0,F1),where
progressiontoadvancedfibrosiswasmorecommonamong
patientsolderthan40–50years.15,16
Themostsignificant conclusionone candraw from the
data presented herein is that, in addition to diagnosing
only a minute portion of those persons who are actually
infected withHCVinBrazil,the majority ofthesepatients
are beingdiagnosedatadvancedstagesofhepatitisC.The
lackofearlydiagnosisofhepatitisC(i.e.,duringthe
asymp-tomatic stage) hinders its curative treatment and has a
major impacton health expenditures. Indeed,the costsof
treatingthecomplicationsofcirrhosisandperformingliver
transplantation far exceedthoseoftherapyaimedat
erad-icating the virus. Several studies have demonstrated the
cost-effectivenessofbroaderprogramsforHCVdetectionand
diagnosisbasedonpatientageratherthantestingofhigh-risk
groupsalone.17,18ThesestudiesledtheU.S.Centersfor
Dis-easeControlandPreventiontorecognizeaneedforexpansion
oftheestablishedHCVriskgroupstoincludetheso-called
“baby boomer” generation, i.e., persons born in the years
1945–1965.19
Table1–Clinical,demographic,andhistologicalfeaturesofpatientswithhepatitisCgenotype1,stratifiedbyHCV
subtype.
Genotype1a(n=105) Genotype1b(n=122) p
Age(SD) 45.9(11.4) 48.7(13.1) 0.092
Females(%) 50.5% 50.8% 0.92
BMI>25 59% 65% 0.466
Diseasestage
F0–F2vs.F3–F4 49%vs.51% 57%vs.43% 0.321
F0–F1vs.F2–F4 25%vs.75% 44%vs.56% 0.007
Historyoftransfusion(%) 31.4% 47.5% 0.002
On the other hand, the finding that patients are being
diagnosed at more advanced stages of the disease is a
causeforconcern,asthesepatients areknown torespond
relatively poorly to antiviral therapy, whether with
inter-feronalfa/pegylatedinterferonandribavirinorwithprotease
inhibitor-based triple therapy; furthermore, these patients
experiencemoreadverseeffectsduringtreatment.20–23
In the present study, we were unable to identify any
changesinthemodeofdiseasetransmissionovertime.Blood
transfusionwasthe leadingknownpotentialsourceof
dis-easetransmission,followedbyintravenousdruguse.Blood
transfusionhadoccurred,onaverage,32.4±9.7yearsbefore
diagnosis(median,33years).Thisprobablyexplainstheage
differenceingenderdistribution. Therewasanincrease in
theprevalenceofwomenbeingdiagnosedwithHCVasage
advanced,butgenderwasnotsignificantlyassociatedwiththe
degreeoffibrosis.Thebestexplanationforthisfindingappears
tobeslowerprogressionofliverdiseaseinwomen,14,24which
iscorroboratedbytheprolongedclinicalcourseseeninthese
patients.Indeed,mostofthesepatientsstillhadblood
trans-fusionasthemostimportantfactorfordiseasetransmission.
Anotherinterestingfindinginthisstudywasprovidedby
HCVsubtype analysis.Some investigationshave suggested
thatsubtype1bwouldbeassociatedwithmoremarked
dis-easeprogressionandagreatertrendtowarddevelopmentof
hepatocellularcarcinomathansubtype1a.25–27Otherauthors,
however,maintainthatthesenegativefindingsareonly
asso-ciatedwiththemoreadvancedageofpatientswithsubtype
1b,whoarebelievedtobephylogeneticallyolderthanthose
withsubtype1a.25–27Althoughpatientswithsubtype1binour
caseserieshadagreatermeanageandweremorelikelyto
havecontractedHCVthroughbloodtransfusion(which
rein-forcesthenotionofphylogenetic precedence),wefoundno
significantdifferencesinthedegreeoffibrosiswhenpatients
werestratifiedusingadvancedfibrosis(gradeF3/F4)asa
cut-off.Conversely,whengradeF2(substantialfibrosis)wasused
asthecutoffforpatientstratification,wefoundagreater
fre-quencyofsubstantialfibrosisamongpatientswithsubtype1a
thanamongthosewithsubtype1b.Therewerenosignificant
differencesingender,age,bodymassindexorthepresence
ofdiabetesamongthesubtypes,whichsuggeststhat
higher-gradefibrosis was exclusivelyattributable toHCV subtype.
Asthis wasaretrospectivestudyandsubtypeanalysiswas
limitedtopatientswithgenotype1HCV,wecannotconfirm
thesefindings.However,amorein-depthinvestigationofthe
relationshipbetweengenotype1subtypesandprogressionof
hepatitisCinBrazilianpatientsiscertainlywarranted.
Thisstudyclearlyshowsthatmethodsfordiagnosing
hep-atitisCinfection mustimprove inBrazil.Ifwe continueto
diagnosepatientsaftertheageof50years,wewillbe
select-ingforcasesthataremorelikelytodevelopcomplications,
lesslikelytorespondtoantiviraltherapy,andmorelikelyto
developcirrhosisandhepatocellularcarcinomaandrequire
livertransplantation.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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