Hepatitis C: Information and hepatitis C doctors

Leading Medicine Guide Editors
Author
Leading Medicine Guide Editors
Hepatitis C is a viral infection of the liver. The pathogen is the hepatitis C virus. The prevalence of the hepatitis C virus is estimated at 0.5-5% (5-50 per 1000 inhabitants), depending on the European country. The symptoms of hepatitis C are very inconspicuous and most patients do not notice the infection at all. Here you will find further information and selected hepatitis C doctors and centers.
ICD codes for this diseases: B17.1

Recommended specialists

Article overview

Many millions of people in Europe suffer from chronic liver disease. Liver cirrhosis is a (scarring) change in the liver. It is one of the four most common causes of disease-related death in adults between the ages of 30 and 50.

In addition to alcohol, the main causes of chronic liver disease are hepatitis B and C caused by viruses. Hepatitis is an inflammation of the liver.

In Europe, several thousand new hepatitis B and C infections are expected every year. The hepatitis C virus infection rate is estimated at 0.5-5% (5-50 per 1,000 inhabitants), depending on the country.

Background: The liver

The liver is the largest internal organ in the human body, weighing around 1500g. It is located in the right upper abdomen and is surrounded by a connective tissue capsule. The liver is the body's central metabolic organ.

One of its tasks is to break down toxins before they enter the large bloodstream. The liver produces important proteins that are necessary for blood clotting and defense against infection, for example.

Also important is the production of bile, which is directed into the duodenum via a special duct system. The bile is used to dispose of breakdown substances from red blood cells and enables the digestion of fat. Various toxins are also excreted from the body with the bile.

Die Lage der Leber im menschlichen Körper
The location of the liver in the human body © nerthuz | AdobeStock

The liver itself does not contain any nerve fibers that could transmit pain. However, tension in the connective tissue capsule can lead to pain. This can be the case, for example, if the liver swells or scars due to inflammatory processes.

Definition: What is viral hepatitis C?

Hepatitis C is a viral infection of the liver. The pathogen is the hepatitis C virus. The virus multiplies in the liver and is released into the blood by the liver cells.

In around 60-80% of patients, the body's own defense system is unable to successfully combat the virus. Hepatitis C then takes a chronic course.

In the other 20-40% of patients, hepatitis C heals within six months of infection without treatment.

Mechanism of the disease in hepatitis C

In a chronic infection, new liver cells are constantly infected by the hepatitis viruses. As a sign of inflammation, white blood cells migrate into the liver tissue. They ensure that infected and dead liver cells are destroyed and cleared away. As a rule, they are not able to eliminate the virus itself.

The dead liver cells can later be replaced by connective tissue (= scar tissue). If the liver is altered by connective tissue, this is referred to as liver fibrosis in the early stages and later as liver cirrhosis.

The body can no longer convert cirrhotic scar tissue into liver tissue. As a result, the liver becomes increasingly scarred and gradually loses its capacity.

Infection with hepatitis C

Infection with the hepatitis C virus usually occurs via direct or indirect blood contact (parenteral transmission).

Before 1990, infection with the hepatitis C virus through the transmission of blood and coagulation products was not uncommon. Nowadays, hepatitis C-positive blood donors can be identified using modern testing methods. The residual risk of hepatitis C infection through a blood transfusion is now minimal.

The virus can also be transmitted via contaminated syringes, e.g. when using drugs. Other risk factors for infection with the hepatitis C virus are tattoos or piercings. Transmission via

  • open wounds,
  • razor blades or
  • toothbrushes

is also possible.

Sexual transmission of the virus is possible. However, the risk for sexual partners of infected patients is considered to be low. The risk of transmission depends on sexual behavior.

Transmission of the virus via intact skin or saliva has not yet been described. An infection via dishes, glasses or cutlery is therefore not to be feared as long as there is no contamination with blood.

Consequential damage of hepatitis C

Cirrhosis of the liver

Chronic hepatitis leads to the development of liver cirrhosis in around 30% of patients in the following years. The risk of developing liver cirrhosis depends, among other things

  • the age of the patient at the time of infection and
  • the duration of the disease

duration of the disease. The disease often progresses more rapidly with an infection at an older age (over 40 years)

Darstellung von Leberzirrhose
Illustration of a severely cirrhotic liver © SciePro | AdobeStock

Risk factors for the development of liver cirrhosis are

  • additional chronic liver diseases, for example with other liver viruses (e.g. an additional infection with the hepatitis B virus) or
  • substances that damage the liver in other ways. This primarily includes alcohol.

Changes to the blood circulation

Cirrhosis of the liver occurs when a large part of the liver tissue has been replaced by connective tissue. This destroys the normal structure of the liver tissue. This leads to changes in the blood circulation. This in turn can lead to high blood pressure in the portal vein (vein between the intestine and liver).

A backlog of blood can cause dilated veins (varices) to form in the oesophagus and stomach. If these vessels burst, this can lead to severe gastrointestinal bleeding. The risk of bleeding is increased by the fact that the blood's ability to clot is restricted. This is caused by reduced protein synthesis in the liver and a reduction in the number of blood platelets (thrombocytes).

The high blood pressure in front of the liver can also lead to the retention of body fluid in the abdominal cavity(ascites).

Further damage

In the presence of liver cirrhosis, the liver can no longer break down some of the toxins that enter the blood from the gastrointestinal tract. They therefore enter the body's circulation. Here they can lead to increased tiredness and poor concentration(hepatic encephalopathy, encephalon = brain).

A cirrhotic liver leads to reduced protein production. This also results in a lack of production of substances that are needed for the body's defenses. For the person affected, this means an increased susceptibility to infection.

Severe liver disease is often indicated by a yellow discoloration of the eyes and skin(icterus). This is caused by a build-up of bile. This is often associated with itching. At the same time, the urine may turn dark in color.

Gelbsucht bei Leberschaden
Liver damage is often manifested by yellowing of the eyes © Creative Cat Studio | AdobeStock

After a long course, the risk of developing liver cancer(hepatocellular carcinoma) also increases. In most patients, hepatocellular carcinoma develops on the basis of liver cirrhosis. Regular ultrasound and blood tests are therefore advisable.

In some cases, hepatitis C takes such a severe course that a liver transplant may be necessary.

A histological examination provides more precise information about

For this purpose, tissue must be removed from the liver (liver biopsy). Indirect procedures, such as elastography, can also provide a good estimate of the extent of liver fibrosis.

Hepatitis C and pregnancy

The risk of transmission of the hepatitis C virus from mother to child during pregnancy is considered to be low.

Transmission usually only takes place during birth. However, the probability of the newborn being infected with the hepatitis C virus is less than 5%. The probability of transmission is higher in patients who are also infected with the AIDS virus(HIV).

Whether a hepatitis C infection can be transmitted through breastfeeding is still controversial. However, most pediatricians do not generally advise HCV-infected mothers not to breastfeed.

Symptoms of hepatitis C

The symptoms of hepatitis C are very inconspicuous, most patients do not notice the infection at all.

Some patients

  • experience increased tiredness,
  • feel exhausted and reduced performance or
  • have right-sided upper abdominal pain.

The development of jaundice is rather rare.

Diagnosis of hepatitis C

Blood tests as part of hepatitis C diagnostics

The hepatitis C virus can be detected in the blood

  • directly via its genetic information (RNA) or
  • indirectly via the antibodies produced by the patient's white blood cells.

can be detected.

Positive RNA detection indicates an active disease. Detected antibodies against the hepatitis C virus (anti-HCV) can, however

  • indicate both a healed hepatitis C infection
  • as well as an ongoing, chronic infection.

chronic infection. In patients who have already been cured, antibodies can therefore be detected for a long time, but not HCV RNA.

The basis for the diagnosis of hepatitis C is the detection of hepatitis C antibodies (anti-HCV). A patient is therefore anti-HCV-positive if they have hepatitis C virus antibodies in their blood.

In this case, the virus should be detected directly, e.g. using a so-called PCR (polymerase chain reaction). This is a particularly sensitive test for detecting hepatitis C viruses in the blood.

If antiviral therapy is being considered, it is also useful to determine the amount of virus in the blood (viral load) and the genotype of the hepatitis C virus.

The liver values provide information about the inflammatory activity of the hepatitis with certain limitations. However, normal liver values do not mean that chronic hepatitis C can be ruled out. The liver values are also determined to monitor the course of treatment.

Patients with chronic hepatitis C have an increased risk of developing liver cancer. Therefore, the tumor marker of hepatocellular carcinoma should be determined in the blood at regular intervals (6 to 12 months). The alpha-fetoprotein serves as a tumor marker. An ultrasound examination of the liver should be carried out at similar intervals.

Liver biopsy (liver puncture) and hepatitis C

A liver puncture is useful for estimating

  • the proportion of connective tissue fibers,
  • the inflammatory activity and
  • the degree of fatty degeneration in the liver.

During a liver puncture, a small piece of tissue is removed under local anesthesia. In the laboratory, it is examined histologically under a microscope.

A complete histological assessment shows the inflammatory activity (grading) and the fibrosis stage (staging) separately.

"Healthy" hepatitis C virus carriers are defined as

  • Viruses detectable in the blood,
  • normal liver values and
  • normal liver tissue sample

However, they are very rare.

In the majority of patients, signs of chronic hepatitis can be detected in the liver tissue even with normal liver values.

Treatment of hepatitis C

Drug therapy

Treatment with interferon alfa can be used to halt the progression of the disease. If possible, this should be carried out in combination with ribavirin.

Ribavirin is a substance that inhibits hepatitis C viruses via a mechanism that is not yet fully understood. It only works in combination with interferon alfa and is taken as a tablet or capsule. Ribavirin alone is not effective against hepatitis C viruses.

Interferon alpha is an endogenous protein that is produced by white blood cells, among other things. Production increases in particular when the body has to defend itself against infectious agents.

The interferon alfa used to treat viral hepatitis is produced biotechnologically. Interferon alfa must be injected into the subcutaneous fatty tissue.

An important factor in assessing the effectiveness of a drug is the response rate. The response rate is the number of patients in whom no more viruses are detectable in the blood during therapy.

The effect is optimized when interferon alfa is coupled to polyethylene glycol (PEG) (pegylated interferons alfa, PEG interferons alfa). The interferons modified in this way remain active in the body for longer and therefore only need to be injected once a week.

The polyethylene glycol surrounds the interferon alfa like a "protective shield" against premature degradation. The sites that are important for the effect of the interferon are therefore not blocked. This means that a constant level of effectiveness can be maintained and viral replication can be constantly suppressed over a longer period of time.

Clinical studies show a doubling of the response rate with PEG interferons alfa compared to therapy with standard interferons. Response rates can be further increased by combining PEG interferons alfa with ribavirin. This combination is also superior to the combination of standard interferons with ribavirin in terms of tolerability.

Dosages

The standard doses of interferons alfa are as follows:

  • Interferon alfa-2a: 3-6 million units three times a week
  • Interferon alfa-2b: 3-5 million units three times a week
  • PEG interferon alfa-2a: 180 µg once a week
  • PEG interferon alfa-2b: 1.0-1.5 µg/kg body weight once a week

The ribavirin dose should also be adjusted by your doctor, taking into account

  • your blood count and
  • your current body weight and
  • the HCV genotype

be determined individually. It is between 800 and 1200 mg daily, divided into two doses in the morning and evening. An even higher dose may be considered for particularly severe patients.

Implementation and duration of treatment

The main aim of treatment is to ensure that the hepatitis C virus is no longer detectable, even with sensitive methods. The response rate of therapy with (PEG) interferons alfa and ribavirin is initially 60-90%.

If patients initially respond to a drug, this does not necessarily mean that treatment is successful. In some patients, the virus recurs during treatment or after discontinuation of the medication.

The overall treatment success rate of (PEG) interferon alfa and ribavirin therapy is therefore 50-60%.

It is particularly important to take the medication regularly. If severe side effects occur during (PEG) interferon alfa/ribavirin therapy, these can be treated with medication if necessary. The side effects also include depression.

The side effects of (PEG) interferon-alfa/ribavirin therapy disappear quickly after the end of therapy. The concomitant therapy can therefore be discontinued quickly.

Particularly good treatment successes can be achieved if treatment is started as early as possible. Chronicity of acute hepatitis C can be prevented by 24 weeks of monotherapy with (PEG) interferon alfa.

Treatment is more successful in younger patients with a short course of disease than in older patients. Patients who have already reached the stage of liver cirrhosis no longer respond as well. Last but not least, the duration of interferon therapy has a major influence on the success of treatment for chronic hepatitis C.

The German guidelines for the treatment of chronic hepatitis C (2004) recommend 24 weeks of therapy for patients with HCV genotype 2 or 3. For patients with HCV genotype 1 or 4, the duration of therapy should be 48 weeks.

Furthermore, a lower ribavirin dose can be used for patients with genotype 2 or 3 than for genotypes 1 or 4. Current study results indicate the possibility of improved, individualized therapy.

The recommended duration of therapy can vary between 12 and 72 weeks, depending on the

  • the HCV genotype,
  • the viral load before the start of therapy and
  • the virological response at week 4 of treatment.

Prognosis for the chance of recovery

It is possible to assess the chance of permanent virus elimination after just four and twelve weeks. The initial drop in viral load in the blood is used for this purpose. Patients with a 99% drop in viral load in the first twelve weeks of treatment have a very good chance of being cured.

New studies have shown that treatment with interferon alfa

  • the proportion of connective tissue fibers in the liver decreases and
  • the incidence of liver cancer is reduced.

This also applies to patients in whom the virus had not disappeared during treatment.

Deutsche Leberhilfe e.V. believes that treatment with (PEG-)interferon alfa and, if necessary, ribavirin makes sense for all patients. The prerequisite is that there are no additional illnesses or other circumstances that would prohibit such therapy.

The decision on the dose and duration of therapy should be reviewed individually by the attending physician.

Side effects of therapy with (PEG-)interferon alfa and ribavirin

Side effects often occur at the beginning of treatment with (PEG-)interferon alfa. They usually decrease significantly over the course of treatment.

The most common side effects are flu-like symptoms such as

  • fever,
  • headaches, joint and muscle pain,
  • tiredness,
  • loss of appetite and
  • weight loss.
Grippe und Müdigkeit
Tiredness and a general feeling of illness are possible side effects of hepatitis C therapy © Justlight | AdobeStock

    Occasionally there are also

    • Disorders of thyroid function,
    • particularly dry skin
    • Temporary hair loss
    • Mood changes and even depression

    Also important are changes in blood count, which mainly affect the white blood cells.

    Patients should speak to their doctor regularly during treatment and report all side effects in detail. Many side effects can be prevented by

    • dose adjustments or
    • or by the (temporary) prescription of additional medication.

    favorable influence. Before therapy is completely discontinued due to intolerance or side effects, all options should first be exhausted.

    Allergic symptoms can be triggered by both (PEG-)interferon alfa and ribavirin. Temporaryanemia is known to be a common side effect of ribavirin. Regular blood count checks are therefore essential.

    It cannot be ruled out that the risk of fetal malformations is increased by ribavirin. Patients receiving therapy with ribavirin must therefore use a safe form of contraception during therapy and for up to six months after the end of therapy.

    Women who are already pregnant before starting therapy cannot be treated.

    What must be observed during treatment with (PEG-)interferon alfa and ribavirin?

    During therapy with (PEG-)interferon alfa, regular checks of the liver

    • liver values (GPT, GOT),
    • the blood count and
    • thyroid values

    should be carried out. After four and twelve weeks of therapy, the viral load (HCV RNA) in the blood should also be measured.

    The results are used to decide whether the therapy can be successful and how long it should be continued.

    Are there alternative treatment options?

    The (PEG) interferon alfa therapy described above is currently the only way to eliminate the virus from the body.

    In addition, successes with so-called alternative substances are repeatedly described. However, there are no controlled studies in which the effectiveness of these drugs and methods has been investigated. Therefore, all information in this regard is based on experience reports.

    Substances that are used to treat liver diseases include, for example

    • Milk thistle extracts (silibinin),
    • Phyllanthus amarus, a remedy used in Ayurvedic medicine,
    • solanine or
    • the Äbrotanum tea.

    Glycyrrhizin, which is mainly used in South East Asia, is also said to have a positive effect on chronic liver diseases. However, its effectiveness against hepatitis viruses has not been proven.

    Herbal preparations can also have side effects or interact with other medications.

    Patients should inform their general practitioner or specialist about any additional preparations they are taking. This will enable their doctor to comment on tolerability and possible risks.

    Future treatment options for hepatitis C

    Various therapeutic approaches are currently being clinically tested, including

    • other long-acting interferons (e.g. albinterferon)
    • Inhibitors of HCV-specific enzymes that are responsible for viral replication (protease and polymerase inhibitors). Based on initial clinical studies, these substances are considered particularly promising
    • immunomodulators (e.g. so-called toll-like receptor (TLR) agonists)
    • therapeutic vaccines, i.e. vaccines. They are intended to help the body's own immune system to eliminate the hepatitis C virus or at least slow down the course of the disease.

    These new substances will only be approved once comprehensive data from clinical studies on their

    • efficacy,
    • tolerability and
    • safety

    are available. Outside of clinical trials, further drugs against hepatitis C will not be generally available before 2011 in the best case scenario.

    Is it possible to be vaccinated against hepatitis C?

    Vaccination is only possible against hepatitis A and B, but not against hepatitis C. A vaccine against hepatitis C will probably not be available in the foreseeable future either.

    If you have not previously had hepatitis A or B, you should be vaccinated against these two viruses if necessary. Be sure to discuss this with your doctor. Acute co-infection with the hepatitis A or hepatitis B virus in patients with chronic hepatitis C can be particularly severe.

    What do I need to consider in my diet?

    As long as liver function is not impaired, there is no need to follow a special diet for chronic hepatitis C.

    If liver function is impaired, a reduction in protein (meat and dairy products) and salt intake may be necessary. Your doctor should discuss this with you, possibly together with a nutrition specialist. It is important that you avoid alcohol.

    Whatsapp Facebook Instagram YouTube E-Mail Print