Reports of successful antiviral therapy for chronic hepatitis B virus (HBV) infection appeared three decades ago,1 and during the past decade, progress has accelerated dramatically. Along with progress, however, has come complexity. So much more is known now than at the dawn of the antiviral era about the protean clinical expressions of HBV infection that determining whom, when, and how to treat has become progressively more challenging.
Virologic and Epidemiologic Factors and Natural History
HBV, a DNA virus transmitted percutaneously, sexually, and perinatally, affects 1.25 million persons in the United States and 350 to 400 million persons worldwide. HBV infection accounts annually for 4000 to 5500 deaths . . .
http://content.nejm.org/cgi/content/full/359/14/1486
Hepatitis B Virus Infection
Management of Cirrhosis and Ascites
Cirrhosis, most frequently caused by hepatitis C or alcoholism, was the 12th leading cause of death in the United States in 2000, accounting for more than 25,000 deaths.1 Ascites is the most common complication of cirrhosis and is associated with a poor quality of life, increased risks of infections and renal failure, and a poor long-term outcome.2,3 In recent years, important advances have been made in the management of cirrhosis and ascites.
Pathophysiology of Ascites
The chief factor contributing to ascites is splanchnic vasodilatation.4 Increased hepatic resistance to portal flow due to cirrhosis causes the gradual development of portal hypertension, collateral-vein formation, and . . .
http://content.nejm.org/cgi/reprint/350/16/1646.pdf
Prolonged Therapy of Advanced Chronic Hepatitis C with Low-Dose Peginterferon
ABSTRACT
Background In patients with chronic hepatitis C who do not have a response to antiviral treatment, the disease may progress to cirrhosis, liver failure, hepatocellular carcinoma, and death. Whether long-term antiviral therapy can prevent progressive liver disease in such patients remains uncertain.
Methods We conducted a randomized, controlled trial of peginterferon alfa-2a at a dosage of 90 µg per week for 3.5 years, as compared with no treatment, in 1050 patients with chronic hepatitis C and advanced fibrosis who had not had a response to previous therapy with peginterferon and ribavirin. The patients, who were stratified according to stage of fibrosis (622 with noncirrhotic fibrosis and 428 with cirrhosis), were seen at 3-month intervals and underwent liver biopsy at 1.5 and 3.5 years after randomization. The primary end point was progression of liver disease, as indicated by death, hepatocellular carcinoma, hepatic decompensation, or, for those with bridging fibrosis at baseline, an increase in the Ishak fibrosis score of 2 or more points.
Results We randomly assigned the patients to receive peginterferon (517 patients) or no therapy (533 patients) for 3.5 years. The level of serum aminotransferases, the level of serum hepatitis C virus RNA, and histologic necroinflammatory scores all decreased significantly (P<0.001) p="0.90)." p="0.07)."
http://content.nejm.org/cgi/content/full/359/23/2429
