Journal of Gastroenterology and Hepatology

April 2005

RAKESH KUMAR*, SUDHEER KUMAR*, BARJESH CHANDER SHARMA*, JAGDEEP SINGH* AND SHIV K SARIN*

*Department of Gastroenterolgy, GB Pant Hospital, New Delhi, India

Background: Antiviral therapy has not been adequately evaluated in patients with hepatitis C virus (HCV)-related advanced liver disease due to apprehensions of adverse events and intolerance. The titrable dose of interferon (IFN)-alpha and ribavirin was evaluated in a flexible regimen in a pilot study.

Methods: Twenty-five patients with HCV-related advanced chronic liver disease received IFN-alpha 1-3 MIU daily with ribavirin 200-600 mg daily for 9 months-3 years. Careful assessment of safety, tolerability and efficacy was made.

Results: Improvement in Child-Pugh score (8.4 ± 1.2 to 7.4 ± 2.0; P = 0.010) and serum albumin (3.0 ± 0.5 g/dL to 3.6 ± 0.5 g/dL; P = 0.007) occurred at follow up after antiviral therapy (median dose and duration: IFN-alpha 1.5 MIU/day for 12 months and ribavirin 400 mg/day for 7.5 months) as compared to baseline. Ascites regressed in 53% of patients (11/21). Thirteen patients (52%) lost HCV-RNA on therapy and eight (32%) achieved sustained virological response (SVR). Death occurred in three patients (12%) while on therapy, in two due to infection. No patient died in the responder group compared to five deaths (29%) in the non-responder group. However, there was no difference in the cumulative probability of survival in the sustained virological responder versus non-responder (P = 0.09). Adverse events were common (92%), but permanent withdrawal was required in only five patients (20%).

Conclusions: Low and titrable dose IFN-alpha and ribavirin therapy in patients with HCV-related advanced chronic liver disease achieves improvement in hepatic synthetic function, Child-Pugh score and ascites. However, close monitoring for serious adverse events is warranted.

Cirrhosis due to hepatitis C virus (HCV) infection is a major health problem. In the USA, according to the National health and Nutrition examination survey (NHANES) of 1988-1994, 3.9 million Americans were infected with HCV and of this group, 2.7 million were estimated to have chronic infection. 1 Prospective studies have shown that 60-85% of HCV-infected persons develop chronic infection and 3-20% of these chronically infected patients will develop cirrhosis over a 20-year period. Over a 10-year period, 30% of these cirrhotic patients develop decompensation. 2

Interferon (IFN)-alpha and ribavirin is the standard combination therapy used for patients with chronic hepatitis C and compensated cirrhosis, but the trials exclude patients with advanced chronic liver disease, particularly decompensated disease. The patients with advanced liver disease constitute a difficult group to treat and their 5-year survival is 50%. 2 Presently, no alternative therapeutic option other than liver transplantation is available to these patients. However, post-transplant HCV recurrence and poor graft survival in those who are HCV viremic at the time of transplantation, is a matter of great concern. The 5-year survival has been reported to be 61% versus 76% in those with or without HCV infection at the time of transplantation. 3 The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplant database reported that patients with low-level pretransplant viremia (<1 x 106 viral copies/mL) had a significantly lower risk for mortality and allograft loss compared with patients with high viral loads. The 5-year cumulative patient survival is 84% and 57%, respectively, in the two groups with low and high level viremia (relative risk 4.3).

Therefore, a rational approach to improve the post-transplant graft and patient survival might be to reduce viremia or render them non-viremic by using antiviral drugs before undertaking transplantation. Combination therapy using ribavirin with pegylated interferon (PEG-IFN)-alpha or standard IFN-alpha, can achieve sustained virological response (SVR) between 45% and 56% in chronic hepatitis C. Even in cirrhotic patients, the SVR to combination with either IFN-alpha or PEG-IFN-alpha and ribavirin reaches 34-45%. 4,5 However, this combination antiviral therapy has not been offered to patients with advanced chronic liver disease due to concerns regarding its safety, especially the risks of bone marrow suppression and life-threatening complications and tolerability. 6 Hence, very limited data evaluating the benefits and risks of antiviral therapy in patients with hepatitis C related advanced liver disease are available. 6,7

We undertook a pilot study with a flexible and titrable dose regimen of combination antiviral therapy of IFN-alpha and ribavirin in patients with advanced chronic liver disease due to HCV infection to examine its efficacy, tolerability and safety.

From April 1996 to September 2002, we enrolled 25 patients in this open labeled pilot study involving hepatitis C-related advanced chronic liver disease at GB Pant Hospital, New Delhi. Advanced chronic liver disease was defined as: (i) Child-Pugh score >=7; and (ii) presence of one or more complications of liver disease, namely, ascites, history of variceal bleed, hepatic encephalopathy or spontaneous bacterial peritonitis. Patients with advanced chronic liver disease eligible for inclusion were those with (i) detectable HCV antibody by third-generation ELISA, and (ii) HCV-RNA detectable in serum by reverse transcription-polymerase chain reaction (RT-PCR). Patients were excluded if they had any of the following: (i) serum bilirubin >3 mg/dL; (ii) serum creatinine >1.5 mg/dL; (iii) thrombocytopenia (i.e. <70 000/mm3) or severe anemia (i.e. <8.0 g/dL); (iv) history of hepatic encephalopathy; (v) presence of spontaneous bacterial peritonitis or systemic infection; (vi) dual infection with hepatitis B virus (HBV) or human immunodeficiency virus (HIV); (vii) chronic and significant alcohol abuse (>20 g/day for >=5 years); (viii) significant comorbid condition, namely, severe cardiopulmonary or systemic disease; (ix) major psychiatric illness; (x) evidence of superimposed acute viral hepatitis E (HEV) or acute hepatitis A (HAV); (xi) concomitant hepatocellular carcinoma (HCC) or any other malignancy; or (xii) non-cirrhotic portal hypertension.

All patients were given standard IFN-alpha 1 MIU/day and ribavirin 200 mg/day. The dose of IFN-alpha and ribavirin were increased every 2-4 weeks by 0.5-1 MIU/day and 200 mg/day, respectively, if patients did not develop dose-limiting adverse events (given in a following section) or until the maximum daily dose of IFN-alpha 3 MIU/day and ribavirin 600 mg/day was achieved. In the occasional patient, if the patient was not able to tolerate IFN-alpha 1 MIU/day, it was given on alternate days.

Patients received antiviral treatment until 3 months after the initial loss of HCV-RNA or for a minimum period of 9 months, whichever was longer. In case of non-response, antiviral therapy continued for a maximum period of 3 years, if tolerated well.

Salt-free human albumin (20%), antibiotics and growth factor (granulocyte macrophage colony-stimulating factor; GM-CSF) were given as and when needed. Salt-free human albumin was supplemented if the serum albumin was <3 g/dL. The follow-up data of serum albumin were collected if patients had not received albumin infusion in the previous 2 weeks. The GM-CSF was used in a dose of 1-1.5 µg/kg bodyweight for leucopoenia <3000/mm3.

(1) If total leukocyte count (TLC) < 3000/mm3: dose reduction of IFN-alpha by 0.5-1 MIU/day was done and the TLC was repeated after 48 h. The GM-CSF was given as per the mentioned dose at 48 h if no improvement in TLC was seen.

(2) If TLC < 2000/mm3: IFN-alpha was stopped and GM-CSF was given immediately. The TLC was repeated after 24 h and further dose of GM-CSF was given if TLC < 3000/mm3.

The antiviral therapy was reintroduced only if TLC increased >3000/mm3 and the patient had no clinical features of apparent infection.

(3) If platelets <70 000/mm3: the therapy was discontinued and the platelet count repeated every 3 days and antiviral therapy was started only when the platelet count became >70 000/mm3.

(4) Ribavirin was withheld for 2 weeks if the hemoglobin dropped below 9 g/dL. It was introduced after 2 weeks if there was no further deterioration of hemoglobin level and the dose was gradually built up to maximum 600 mg/day. Only dose reduction of ribavirin was done if hemoglobin was <10 g/dL. The dosage was reduced by 200 mg/day every 1-2 weeks unless there was further deterioration requiring withdrawal of the drug during this period. During the period that the dose was being modified or withheld, patients were carefully monitored clinically and the hemoglobin was tested every week or on a per-need basis.

(5) Therapy was discontinued if patients developed spontaneous bacterial peritonitis, any serious infection, hepatic encephalopathy, or variceal hemorrhage.

(6) Ribavirin was also stopped if IFN-alpha was discontinued due to development of side-effects. However, the patients continued to receive IFN-alpha alone in case ribavirin was stopped for reasons aforementioned. Therefore none of the patients received ribavirin alone, while some of them received only IFN-alpha as antiviral therapy for varying periods of time.

All episodes of upper gastrointestinal tract bleeding were managed with supportive therapy, including transfusions of blood and plasma, infusion of somatostatin or octreotide, emergency ligation or balloon tamponade. Other complications of liver disease, such as hepatic encephalopathy and spontaneous bacterial peritonitis, were managed according to standard protocols.

Patients were followed through July 2003. At the onset of treatment, patients were admitted for 1-2 weeks to monitor side-effects and assess tolerance to therapy. Thereafter, they were followed up every 1-2 weeks for the first 8 weeks and subsequently at 4 weeks or on a per-need basis at the liver clinic. At each visit, careful clinical evaluation; biochemical tests including liver, renal function tests; and complete hemogram were done. The HCV-RNA was done using RT-PCR at baseline and then every 3 months until follow up or 6 months after the end of treatment. The planned follow-up period in the study protocol was 3 years.

Minor side-effects such as headache, fatigue, fever, nausea, vomiting and myalgia were managed symptomatically. Only major adverse events as described here were noted and dose modification or withdrawal of therapy was undertaken. They included (i) cytopenia (total leukocyte count <3000/mm3; platelet counts <70 000/mm3; hemoglobin <9 g/dL); (ii) evidence of hemolysis; (iii) systemic infection such as pneumonia, spontaneous bacterial peritonitis or tuberculosis; (iv) significant mucosal bleed or bleeding tendency, namely ecchymotic patches; and (v) worsening of liver function in the form of new-onset hepatic encephalopathy, hyperbilirubinemia (>3 mg/dL) or variceal bleed.

The deaths were recorded and every attempt was made to determine the cause of death in those cases when it occurred outside the hospital. Death was considered to be therapy-related if it occurred while the patient was on therapy or within a month of stopping therapy.

The principal end-point was SVR. Additional end-points included the permanent withdrawal from therapy, virological relapse and death.

The primary goals of treatment were to assess improvement in (i) clinical status and Child-Pugh score, and (ii) hepatic synthetic function. The secondary goal was virological response to antiviral therapy.

This protocol was approved by the Institutional Ethics Committee. All subjects signed an informed written consent for participation in the trial.

Quantitative data were expressed as mean ± SD or as medians (range). Non-parametric tests were used for comparing two groups of continuous variables. Kaplan-Meier method and the log-rank test were used to compare the survival probability in the virological responder versus non-responder. P was considered significant at <0.05. Statistical analyses were performed by using the SPSS 10.0 statistical software (SPSS and Microsoft, Chicago, IL, USA).

The baseline patient characteristics of 25 patients who received antiviral therapy are shown in Table 1. There were 20 men and five women with a mean age of 52 ± 13.6 years. All patients were anti-HCV- and HCV-RNA-positive before the onset of the treatment. Twenty-one patients (84%) had clinical ascites at inclusion and seven (28%) had a history of variceal bleed. When classified according to Child-Pugh score, 20 patients were in class B and five patients in class C. Liver biopsy was done in 13 patients (52%) at 2-11 weeks before starting antiviral therapy (median 7 weeks). Grade 4 fibrosis was seen in six patients (46%), grade 3 in six (46%) and grade 2 in one (8%), respectively. Baseline HCV-RNA quantitative assay could be done in 13 patients (52%) and it varied widely (268-6020 000 copies/mL), the median value being 87 471 copies/mL. Only two patients had HCV viral load >2 million copies/mL. The HCV genotype was available in 13 patients (52%). Eight patients (61.5%) had genotype 3, four (31%) had genotype 1 and one had mixed genotype 1 and 3 infection.

The median follow up in the study protocol was 22 months (range 3-37 months). However, the patients were followed up longer until a median duration of 10 months (range 0-55 months) after stopping antiviral therapy. The median duration of follow up after stopping antiviral therapy in sustained viral responder was 18 months (range 4-55 months) as compared to 9.4 months (range 0-36 months) in non-responders (P = 0.110).

The median dose of IFN-alpha administered to patients was 1.5 MIU/day (range 0.75-3.0 MIU/day) for a median duration of 12 months (range 1-36 months). The median dose of ribavirin received by patients was 400 mg/day (range 200-600 mg/day) for a median duration of 7.5 months (range 0.8-20 months). Only one patient could achieve the full-proposed dose of 3 MIU/day IFN-alpha and 600 mg/day of ribavirin. One patient had received IFN-alpha 1.5 MIU on alternate days for 36 months. Because the dosage of antiviral drugs varied in each patient over the treatment period due to modification or withdrawal of therapy, the average dosage of drugs was calculated after dividing the total dose received by the actual number of days on which these drugs were given.

During follow up, ascites improved in 11 of 21 patients (53%). It disappeared in five patients (24%) and became easily controllable on minimum dose of diuretics in six patients (28.6%).

Table 2 lists the biochemical response to antiviral therapy. The serum albumin level improved from 3.0 ± 0.5 g/dL to 3.6 ± 0.5 g/dL (P = 0.007) and the Child-Pugh score from 8.4 ± 1.2 to 7.4 ± 2.0 (P = 0.010) at the end of follow up as compared to baseline. When compared from baseline, serum albumin improved from 2.9 ± 0.5 g/dL to 3.6 ± 0.6 g/dL (P = 0.016) at follow up in the non-responders and from 3.3 ± 0.3 g/dL to 3.6 ± 0.5 g/dL (P = 0.234) in the responder group, respectively. Similarly in the non-responder group the Child-Pugh score improved from 8.5 ± 1.1 to 7.6 ± 2.3 (P = 0.040), and in the responder group from 8.4 ± 1.5 to 7.1 ± 1.5 (P = 0.123). However, when the virological responder was compared with the non-responder, there was no difference in improvement in serum albumin and Child-Pugh score from baseline to follow up (Table 3). The baseline characteristic of responder and non-responder was similar (Table 4). The reversal of Child-Pugh score was observed in 17 patients (68%). Eleven patients improved from Child-Pugh class B to class A and one patient from class C to class A. In the remainder of the five patients showing improvement in Child-Pugh score, four improved from B8 (n = 3) and B9 (n = 1) to B7, and one from class C10 to B8. Nine patients (36%) showed improvement of at least 2 or more in Child-Pugh score. In four patients (16%), no improvement in the Child-Pugh score was seen. In three patients (12%), there was worsening of the Child-Pugh score while in one patient the data were inadequate to calculate the score at follow up (Fig. 1). Serum alanine aminotransferase (ALT), serum bilirubin and prothrombin time index (PTI) did not improve significantly with antiviral therapy as compared to the baseline value.

The virological response by loss of HCV-RNA on treatment was seen in 13 patients (52%). The median time to loss of HCV-RNA was 12 months (range 3-23 months) after the start of antiviral therapy. Eight of these patients (32%) achieved SVR. In the five remaining patients two relapsed; one was lost to follow up and two patients are yet to be tested for SVR. These five patients were not considered to be virological responders in the study.

Patients experienced minor side-effects such as headache, fever, anorexia and fatigue. These were managed symptomatically. However, major side-effects as aforementioned, were recorded. One or more of these were seen on a single or multiple occasions in the majority of patients (92%) and required dose modification, temporary withdrawal or permanent withdrawal of therapy (Tables 5,6). Only one patient could be treated with a dose of 3 MIU/day and achieved SVR. All the other patients required reduction in the dose of IFN-alpha. The maximum ribavirin dose (i.e. 600 mg/day) could be achieved in only two patients.

Cytopenia was the major cause of dose modification or temporary discontinuation in therapy, observed in 21 patients (84%). Spontaneous bacterial peritonitis was the most common infectious complication observed in five patients (20%) followed by pneumonia in three patients (12%) and orbital cellulitis, pulmonary tuberculosis and skin infection in one patient each. Infectious complications were treated with discontinuation of antiviral therapy and antibiotics as per culture sensitivity pattern wherever applicable. After the control of infection, the antiviral therapy was again instituted. Antitubercular treatment was given along with antiviral therapy in one patient with close monitoring. This patient achieved SVR.

Pneumonia responded to antibacterial therapy with resolution of the pulmonary lesion in two patients. Of these one had developed pneumonia 8 months after viral clearance and 5 months after stopping antiviral therapy. He recovered fully and went home after approximately 1 month of hospitalization. After a month of discharge from hospital, he again suffered an episode of spontaneous bacterial peritonitis from which he recovered and is now stable. One female patient died of pneumonia despite prompt and vigorous antibiotic therapy because she presented late in a septicemic condition after initially being treated at a general hospital.

During the study period, hepatic encephalopathy developed in three patients (12%). Worsening of hepatic decompensation was seen in two patients (8%) requiring permanent withdrawal of antiviral therapy. These patients had received antiviral therapy for 1 month and 1.5 months, respectively.

Two patients (8%) were lost to follow up after 7 months and 12 months, respectively.

Five patients (20%) died during the follow-up period of 3-37 months. In the responder (SVR) group, none died compared to five patients (29%) in the non-responder group. No difference was observed in survival probability of patients who achieved SVR versus those who were non-responders or who did not achieve SVR (log-rank statistic 2.86; 1 d.f.; P = 0.09; Fig. 2). There was no difference in survival probability (log-rank statistic 1.87; 1 d.f.; P = 0.172) even with a longer duration of follow up outside the study protocol, between the responder and non-responder group.

Three of these patients (12%) died while on antiviral therapy. The deaths in two cases were related to uncontrolled systemic infection. One patient developed orbital cellulitis, the cause of which could not be ascertained, and the other developed florid pneumonia. The third patient died of liver-related causes (i.e. hepatic encephalopathy). The cause of death in the remaining two patients was hepatic encephalopathy and spontaneous bacterial peritonitis with renal failure and hyperkalemia, occuring at 11 and 3.5 months after stopping therapy, respectively. These two patients had worsening of hepatic decompensation following antiviral therapy, necessitating permanent withdrawal of antiviral treatment.

The results of this pilot study demonstrate the benefits of titrable dose of antiviral therapy in patients with advanced chronic liver disease due to HCV. Our study shows for the first time that these patients can be treated successfully with antiviral therapy, leading to improvement in the synthetic function and reversal of decompensation, indicated by improvement in ascites and Child-Pugh score. These improvements were seen irrespective of virological response to antiviral therapy.

There is a paucity of data regarding antiviral therapy in patients with advanced chronic liver disease due to HCV. In an earlier study by Everson et al., the virological response on treatment was 32% and SVR 17%. 7 The details of the study outcomes are not fully available. Crippin et al. treated 15 patients with advanced chronic liver disease. 6 They reported HCV loss on treatment in 33% of the patients. However, SVR was not documented in their study. The present study shows a treatment response rate of 52% and SVR of 32%. The relatively higher rate of virologic response in the present study as compared to the other studies could be due to a higher prevalence of the non-1 HCV genotype in India. This has been documented in several studies in the past. 8-10 It is well-known that patients infected with non-1 genotype respond better to antiviral therapy. 11-14 We also believe that patients with advanced liver disease with a relatively small liver volume may achieve equivalent virological response with a smaller dosage of IFN-alpha and ribavirin. An additional factor, which could have contributed to the success of therapy, could be prolonged duration (median duration: IFN-alpha for 12 months and ribavirin for 7.5 months) of antiviral treatment in these patients.

The antiviral therapy led to improvement in hepatic synthetic function, Child-Pugh score, ascites and reversal of clinical hepatic decompensation. This observation indicates fulfillment of the primary goal of antiviral therapy in these patients and marks slowing or prevention of clinical disease progression following antiviral therapy. This improvement was seen irrespective of the virological response and occurred in both responder and non-responder groups. This is important because it implies that the clinical status of the patients with HCV-related advanced chronic liver disease might improve even without virological response, which is otherwise considered an important surrogate marker and yardstick of success for patients with chronic HCV infection or compensated liver disease. Thus, antiviral therapy may potentially delay or even obviate the need for liver transplantation in some patients with advanced disease. Antifibrotic and histologic efficacy of an IFN-based regimen and anti-inflammatory effect of ribavirin may be responsible for these improvements. A retrospective study from four large multicenter trials of IFN-based treatment of chronic hepatitis C had shown reversal of cirrhosis in 49% and improvement in necrosis and inflammation in 34-73% of cases. 15

In the two earlier studies, adverse events caused a drop-out of 38% of the patients in one study, 7 while the second study was prematurely closed due to increased incidence of infectious complications. 6 However, in the present study the withdrawal due to adverse events was relatively low, and was observed in only five patients (20%). We attribute this to better tolerance to the low and flexible regimen. Death on treatment occurred in three patients (12%). Thus, eight patients (32%) could not receive full-duration antiviral therapy due to either death or major adverse events causing permanent withdrawal. In an earlier study of IFN-alpha in decompensated liver disease due to hepatitis B, Perillo et al. observed deaths in 19.2% of patients (5/26) during and in the immediate post-treatment period, which compares with a death rate of 12% in the present study group. 16 However, our study involved patients with severe liver disease as compared to the mentioned study. The total number of deaths during the follow up was five (20%) in the present study and 12 (46%) in the study by Perrillo et al. The survival probability was not different in virological responders versus non-responders in the present study despite clinical and biochemical improvement, but there was a trend towards significance (P = 0.09). This could be because of small sample size and limited power of the study. This needs to be confirmed as one of the primary outcome measures in a larger trial with adequate sample size.

Major adverse events were frequently noted. It did not, however, warrant permanent withdrawal of therapy in all cases. In a study by Crippin et al. adverse events occurred in 87% of patients (13/15) enrolled in that study compared to 92% of patients (23/25) in the present study; with thrombocytopenia being the commonest. 6 In the present study, leucopoenia (64%) and thrombocytopenia (60%) were equally common.

In the present study, infectious complications were seen in 10 patients (40%) on therapy and in two patients (10%) after stopping the antiviral drugs. In the study by Perrillo et al. the infection rate with low-dose IFN-alpha therapy was low, around 12%, as compared to 30-50% in other studies. The adverse events in these studies were dose dependent. 17,18 The high infection rate despite use of low-dose of antiviral therapy in the present study as compared to other studies could be because of inclusion of more advanced liver disease patients as compared to the aforementioned studies. The most common complication in the present study was spontaneous bacterial peritonitis. None of the previous studies in decompensated cirrhotic patients has shown such a high incidence of spontaneous bacterial peritonitis as in the present study. 6,17 This is possibly due to the presence of ascites in the majority of the present patients (85%) with advanced liver disease. These patients are relatively immunocompromised and hence more prone to infections. The infectious complications proved fatal in two patients (8%). The remainder of the patients were managed with antibiotics and required only temporary discontinuation of therapy.

None of the present patients had any major psychiatric manifestations such as depression, delirium or suicidal tendency.

However, in the present study the sample size was small and different patients had received varying durations of antiviral therapy. We need to assess the optimum duration of antiviral therapy in these patients, especially those who are non-responders, to achieve the desired clinical effects. Whether achievement of virological response in such patients with advanced disease has any long-term benefit or not also needs to be critically looked into. In patients with advanced chronic liver disease due to HCV, the virological response should not be considered as the surrogate marker and viral clearance may not necessarily be the end-point of the study.

In summary, we believe that combination antiviral therapy is beneficial for patients with advanced chronic liver disease due to HCV infection. The low-dose IFN-alpha and ribavirin introduced gradually can be tolerated by these patients despite the need for modification and temporary withdrawal during the treatment phase. This regimen achieved improvement in liver synthetic function, Child-Pugh status and ascites, fulfilling the primary goal of therapy (i.e. slowing of disease progression). Virological response is also very encouraging, with SVR rate of 32% despite use of low-dose antiviral drugs. Such low-dose antiviral therapy may help delay or even obviate the need for liver transplantation in these patients. Although side-effects are frequent, they can be managed with proper meticulous monitoring. However, this pilot study needs to be confirmed in a large randomized controlled trial before we can recommend such therapy outside study protocol.

1 Alter MJ, Kruszon-Moran D, Nainan OV et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N. Engl. J. Med. 1999; 341: 556-62.

2 Fattovich G, Giustina G, Degos F et al. Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients. Gastroenterology 1997; 112: 463-72.

3 Berenguer M, Prieto M, San Juan F et al. Contribution of donor age to the recent decrease in patient survival among HCV-infected liver transplant recipients. Hepatology 2002; 36: 202-10.

4 Manns MP, McHutchison JG, Gordon SC et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized controlled trial. Lancet 2001; 358: 958-65.

5 Fried MW, Schiffman ML, Reddy RK et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C infection. N. Engl. J. Med. 2002; 347: 975-82.

6 Crippin JS, McCashland T, Terrault N, Scheiner P, Charlton MR. A pilot study of the tolerability and efficacy of antiviral therapy in hepatitis C virus-infected patients awaiting liver transplantation. Liver Transpl. 2002; 8: 350-5.

7 Everson GT, Trouillot T, Trotter J et al. Treatment of decompensated cirrhotics with a low accelerating dose regimen (LADR) of interferon alfa-2b plus ribavirin: safety and efficacy. Hepatology 2000; 32: 308A (Abstract).

8 Chowdhury A, Santra A, Chaudhuri S et al. Hepatitis C virus infection in the general population: a community-based study in West Bengal India. Hepatology 2003; 37: 802-9.

9 Amarapurkar D, Dhorda M, Kirpalani A, Amarapurkar A, Kankonkar S. Prevalence of hepatitis C genotypes in Indian patients and their clinical significance. J. Assoc. Physicians India 2001; 49: 983-5.

10 Raghuraman S, Shaji RV, Sridharan G et al. Distribution of the different genotypes of HCV among patients attending a tertiary care hospital in south India. J. Clin. Virol. 2003; 26: 61-9.

11 Poynard T, Marcellin P, Lee S et al. Randomised trial of interferon alfa 2b plus ribavirin for 48 weeks or for 24 weeks versus interferon alfa 2b plus placebo for 48 weeks for treatment of chronic infection with hepatitis C virus. International Hepatitis Interventional Therapy Group (IHIT). Lancet 1998; 352: 1426-32.

12 Hoofnagle JH. Therapy of acute and chronic viral hepatitis. Adv. Intern. Med. 1994; 39: 241-75.

13 Davis GL, Lau JY. Factors predictive of a beneficial response to therapy of hepatitis C. Hepatology 1997; 26 (Suppl. 1): 122S-7S.

14 Chemello L, Cavalletta L, Bernardinello E, Guido M, Pontisso P, Alberti A. The effect of interferon alfa and ribavirin combination therapy in naïve patients with chronic hepatitis C. J. Hepatol. 1995; 23 (Suppl. 2): 8-12.

15 Poynard T, McHutchison J, Manns M et al. Impact of pegylated interferon alfa-2b and ribavirin on liver fibrosis with chronic hepatitis C. Gastroenterology 2002; 122: 1303-13.

16 Perrillo R, Tamburro C, Regenstein F et al. Low-dose, titrable interferon alfa in decompensated liver disease caused by chronic infection with hepatitis B virus. Gastroenterology 1995; 109: 908-16.

17 Kassiaiandes C, Di Bisceglie A, Hoofnagle J et al. Alfa interferon therapy in patients with decompensated chronic type B hepatitis. In: Zuckerman AJ, ed. Viral Hepatitis and Liver Diseases. New York: Liss, 1988; 840-3.

18 Hoofnagle HH, Di Bisceglie AM, Waggoner JG, Park Y. Interferon alfa for patients with clinically apparent cirrhosis due to chronic hepatitis B. Gastroenterology 1993; 104: 1116-21.