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Hepatitis C is
reaching epidemic status in the U.S. and around the
world. Often, the disease goes undetected until serious
liver damage has been done, leaving no option other
than liver transplant. Early detection among persons
at risk is the key to saving lives.
In 2003, Victor Gonzalez
was bitten by a brown recluse spider. He spent three
days in an intensive care unit (ICU) fighting off the
poisonous spider’s venom. Mr. Gonzalez recovered,
but little did he know at the time that his health battle
was just beginning.
Mr. Gonzalez continued
to feel very weak, says his wife, Yasmin. One doctor
suspected leukemia because his white blood cell count
was low, but other tests ruled it out. Finally, after
a flurry of doctor visits and tests, the source of Mr.
Gonzalez’s symptoms was revealed. “A blood
test showed that at some point in Victor’s life,
he had the hepatitis C virus,” says Mrs. Gonzalez.
“The virus apparently came and did its damage,
but was no longer active.”
Mr. Gonzalez was not
a candidate for the standard drug treatment for hepatitis
C, a combination of interferon and ribavirin, because
his liver disease was too advanced. It had severely
damaged his liver. He was enrolled in The Liver Transplant
Program at University Hospital and became one of about
17,000 people in the United States waiting for a new
liver. As part of routine testing for the program, Mr.
Gonzalez had an ultrasound of the liver. It showed something
that looked like a lesion; a biopsy in December 2004
confirmed a lesion in the 6th segment of Mr.Gonzalez’s
liver, and it was malignant. He had liver cancer, a
complication of hepatitis C that often is not detected
until it is in an advanced stage.
Mr. Gonzalez had radiofrequency
ablation treatment, a procedure that uses heat to kill
tumor cells, in February 2005. Still, the 49-year-old
father of two needs a new, healthy liver. He no longer
works as an interior decorator. On some days Mr. Gonzalez
feels relatively good; on others, he is very weak and
his legs swell up so much it is painful to walk. He
also sometimes becomes depressed about his condition.
However, Mr. Gonzalez has strong support from his family
and a lion’s share of faith. “We try to
take things one day at a time,” says Mrs. Gonzalez.
“We are in good hands at University Hospital,
and we also believe that God allowed this to happen
for a reason.”
That reason might be
a nonprofit group that Mrs. Gonzalez is starting, The
Multicultural Liver Initiative. “There are many
organizations for people with cancer and their families,
but there’s not much out there to support people
with hepatitis and their families, especially minorities,”
says Mrs. Gonzalez. “In some cultures, having
hepatitis C is shameful, and there’s a belief
that if you ignore the virus, it will go away. People
are going untreated when there’s help available.”
Mrs. Gonzalez hopes the Initiative will help educate
people about hepatitis as well as provide money to cover
the cost of medicines for patients who are uninsured
or underinsured. The big dream, she says, is to raise
enough money to pay for a liver transplant for someone
in need. Meanwhile, her thoughts are constantly with
her husband. “Our family believes in miracles,”
she says. “Miracles still happen.”
Hepatitis
C: Often Silent, Often Deadly
Mysteries still happen,
too. Precisely how the spider bite impacted Mr. Gonzalez’s
health will probably never be known, says Dr.
Dorian Wilson, assistant professor of surgery at
New Jersey Medical School, a surgeon on University Hospital’s
liver transplant team and one of Mr. Gonzalez’s
physicians. “Generally speaking, when liver damage
is the result of a brown recluse spider bite, the onset
of liver disease is very rapid. I have seen two such
cases in my career, and transplants were needed both
times within days,” says the transplant surgeon.
Nonetheless, Dr. Wilson says the spider bite could “not
have been good” for his patient. And clearly,
the bite was an important turning point in the man’s
life.
“Until Victor was
bit by the spider, we considered him to be healthy.
His worst problem was acid reflux,” says Mrs.
Gonzalez. “Now he is fighting for his life. We
had not even heard of hepatitis C until he became sick.”
Unfortunately, multitudes
of other people are finding themselves similarly blindsided
by the insidious nature and destructiveness of hepatitis
C. The American Liver Foundation estimates that more
than 4 million people in the U.S. are or have been infected
with the hepatitis C virus, a mere fraction of the 280
million people worldwide believed to have the virus.
Alarmingly, only about 30 percent who have the virus
are aware that they do. The hepatitis C virus kills
between 10,000 and 12,000 Americans each year, but the
future holds even grimmer prospects. According to some
estimates, about 10 million Americans will have hepatitis
C within the next couple of decades;
“Hepatitis C is
at an epidemic level. It infects more people than HIV,
and there are less treatment options,” says Dr.
Andrew de la Torre, assistant professor of surgery
at New Jersey Medical School and a surgeon on the hospital’s
liver transplant team. Indeed, hepatitis C is by far
the leading indication for liver transplantation in
the United States, accounting for between 30% to 50%
of liver transplants, depending on the state where the
patient lives.
It may seem unbelievable
that so many people have such a serious health problem
and don’t know it, but the virus progresses very
slowly often over the course of decades. It does much
of its damage very “silently,” that is without
symptoms that can indicate to a person that something
may be wrong. “The hepatitis C virus can go undetected
for many years, quietly causing irreversible damage
to the liver,” says Dr. de la Torre. That damage
eventually takes the form of cirrhosis, in which healthy
liver cells are injured and scar tissue forms in their
place. Over time, cirrhosis can impair the liver’s
ability to perform some critical functions and reduce
the amount of blood that flows through the vital organ.
When a person with hepatitis
C does have symptoms, they are typically those caused
by a damaged liver. “A patient might have lingering
fatigue; jaundice, a yellowing of the whites of the
eyes and the skin; forgetfulness; fluid build-up, particularly
in the belly and around the ankles, or increased risk
of bleeding,” says Dr. de la Torre.
The hepatitis C virus,
discovered in 1989, is transmitted via blood, so anyone
who had a blood transfusion before 1992 or has used
intravenous drugs could be at risk. It’s possible
for an infected mother to pass along the virus to her
child at birth. As for whether hepatitis C can be transmitted
sexually, researchers still aren’t sure. If so,
it’s a rare occurrence, but people who’ve
had multiple partners are encouraged to be tested for
the virus. Certain groups of people have higher rates
of hepatitis C than the general population, such as
military veterans (especially those who served in Vietnam);
prisoners; hemophiliacs; the homeless; and people with
HIV.
Take
the Test
If there’s one
message that liver transplant surgeons Dr. de la Torre
and Dr. Wilson drive home, it’s that people who
are at risk for hepatitis C should talk to their doctor
about being tested for the virus as soon as possible.
“Don’t wait for the doctor to bring it up.
Physicians have at most about 15 minutes to spend with
the patient during a visit and have other pressing health
concerns to discuss, such as diabetes, heart disease,
and obesity,” says Dr. de la Torre.
Blood tests given as
part of a routine physical examination can miss up to
40% of patients with liver dysfunction resulting from
hepatitis C, which is why patients need to ask their
doctors to be tested for the virus. Blood tests can
determine how well the liver is functioning and whether
there is inflammation of or injury to the liver, but
there is even more specific testing for hepatitis C
available. Antibody tests can detect whether a person
has developed antibodies against the hepatitis C virus.
But that test alone doesn’t answer all the questions.
“Antibody positive doesn’t always mean someone
has an active hepatitis C infection,” says Dr.
de la Torre,” only that it was present at some
point in time.” It’s the HCV RNA blood test
that can detect whether there is an active hepatitis
C infection. While a qualitative HCV RNA test can determine
whether a person has active hepatitis C virus, a quantitative
HCV RNA test indicates how much virus is in the blood,
or the viral load; this is also important information
during and after treatment for hepatitis C. A liver
biopsy may also be taken. If a person test positive
for hepatitis C, the doctor will want to know what strain
of the virus is present. Most Americans with hepatitis
C have the HCV genotype 1 strain (there are six genotypes
or sub-groupings of the virus), which tends to have
a poorer response to treatment than other genotypes.
Treating
Hepatitis C
While there is no cure
for hepatitis C, the best treatment outcome is achieving
what’s known as sustained viralogic response or
being “clear” of the virus six months after
treatment ends. Currently, the standard treatment for
hepatitis C is a combination of two antiviral medications:
interferon, given by injection, and ribavirin, which
is taken by mouth. “It’s not always easy
for patients to tolerate the treatment, which can last
between six to 12 months,” says Dr. de la Torre.
“Interferon can cause fatigue, flu-like symptoms,
headache, and even depression. Ribavirin can result
in severe anemia, or a low red blood cell count. Although
it can be difficult, it’s important that patients
complete the full treatment.”
In addition to the medicine,
doctors recommend that hepatitis C patients get a lot
of rest and, also important, not drink alcohol. “By
itself, hepatitis C slowly causes damage to the liver,
but alcohol accelerates the progression of the virus
and thus, harm to the liver,” says Dr. de la Torre.
No doubt, the current
treatment for hepatitis C has helped eradicate the virus
from many people’s bodies. Country singer Naomi
Judd is perhaps among the most well-known of them; the
former nurse was at one point gravely ill, but after
treatment, has regained her health. Still, the treatment
results in a sustained response in only between 30%
and 40% of people with genotype 1. These low response
rates may also be related to patients having substantial
liver damage by the time there are diagnosed.
Researchers worldwide
are investigating new treatments and working to develop
a vaccine, as is available against hepatitis A and hepatitis
B. But those advances are years away. It wasn’t
until early 2005 that scientists were able to replicate
the hepatitis C virus in the laboratory for the first
time, a step forward, but with many more to follow.
Until those advances come, Dr. de la Torre has one suggestion
to those who believe they may be at risk for hepatitis
C: get tested.
For information about
other liver diseases, see the sidebar to this story,
“The Magnitude of Liver Disease”.
To
arrange for a consultation with University Hospitals
liver disease specialists, please call 973-972-7218.
To learn more about treatment options for liver diseases,
visit our liver
transplant website or listen
to Dr. Andrew de la Torre's recent appearance on HealthLink
Radio.
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