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Direct-acting antivirals have substantially modified the profile of patients with cirrhosis who require hospitalization in Spain
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Hospital Admissions, Deaths With HCV Cirrhosis Plunge After DAAs Arrive
EASL 2020, Digital International Liver Congress, August 27-29, 2020.
Mark Mascolini
HCV-related cirrhosis accounted for a steeply falling proportion of cirrhosis admissions to a large hospital liver unit in Spain after direct-acting antivirals (DAAs) arrived in 2015 [1]. HCV cirrhosis also explained a steadily dwindling proportion of intensive care unit (ICU) admissions and deaths after DAAs began seeing wide use for HCV infection.
Researchers in the University of Barcelona Liver Unit note that liver cirrhosis accounts for most admissions to such units. And in regions with high HCV prevalence, HCV causes most cirrhosis cases that need in-hospital care. These investigators undertook this analysis of cirrhosis admissions to their unit to chart changes in those cases from the pre-DAA period (2011-2014) to the DAA era (2015-2019).
The Barcelona liver unit includes 40 standard hospital beds, 8 ICU beds, and 4 semi-ICU beds. The analysis included all admissions due to cirrhosis-excluding admissions for acute hepatitis, liver transplantation, or a diagnosis other than liver cirrhosis. This process yielded 10,414 admissions of 6272 patients.
The proportion of hospital liver units admissions attributed to HCV cirrhosis remained stable in the pre-DAA era (47.0% in 2011 to 49.9% in 2014). Starting in 2015, the fraction of admissions due to HCV cirrhosis fell significantly from 43.8% to 27.1% (P < 0.001). HCV cirrhosis accounted for 3885 inpatient days per year (44.9%) in 2011-2014, and those numbers dropped to 1909 inpatient days per year (22%) in 2019. As HCV cirrhosis admissions dwindled, those due to metabolic fatty liver disease jumped 5-fold and those caused by autoimmune hepatitis rose 4-fold.
The proportion of HCV cirrhosis inpatients with active HCV infection fell throughout the study period, from 93.8% in 2011 to 66.0% in 2015. The researchers then charted a steep stepdown in proportion of active infection in 2016, to 48.3%, and that proportion continued to fall to 40.1% in 2019 (P < 0.001 for drop from 2015 to 2019). Numbers of ICU admissions and deaths due to HCV cirrhosis hit highs of 106 and 43 in 2012, then fell to 73 and 31 in 2015, down to 50 ICU admissions and 21 deaths in 2019.
Most demographic and clinical factors in people admitted with HCV cirrhosis did not change from 2011 through 2019. Median age stayed stable over that span (66 in 2011 and 64 and 2019), as did proportion of patients with hepatocellular carcinoma (50% in 2011 and 52% in 2019) and proportion with alcohol abuse (16% in 2011 and 21% in 2019). But the proportion of male HCV cirrhosis patients did appear to rise in recent years, from 59% in 2011 to 73% in 2018 and 71% in 2019.
Slope analysis with a binomial regression model let the researchers project where the downward trend in HCV cirrhosis admissions during 2015-2019 could end up in 2025, if prevailing forces continue. The Barcelona team estimated that HCV cirrhosis would account for only 2.3% of cirrhosis admissions to their liver unit in 2025. On the basis of this analysis, they predict that HCV cirrhosis "will be a marginal cause of hospital admissions in liver units in Spain."
The researchers conclude that DAA therapy ushered in not only a waning rate of cirrhosis admissions due to HCV in their liver unit, but also a significant reduction in hospital morbidity and mortality caused by HCV-related cirrhosis.
Reference
1. Rodriguez-Tajes S, Pocurull A, Castillo JA, et al. Direct-acting antivirals have substantially modified the profile of patients with cirrhosis who require hospitalization in Spain. EASL 2020, Digital International Liver Congress, August 27-29, 2020. Abstract THU384.
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