Patients with hepatitis C virus (HCV) and cirrhosis can develop high-risk gastroesophageal varices (GEV) after sustained virological response (SVR), according to a study published in The Japanese Society of Gastroenterology. Surveillance is especially recommended in those with GEV before antiviral treatment.

In this prospective multicenter study, researchers evaluated the benefit of SVR with direct-acting antivirals (DAAs) in compensated HCV-cirrhotic patients aged ≥18 years from November 2014 to October 2015 (N=247). Some patients had no varices at baseline (n=122), while 125 patients were classified according to the Baveno VI Consensus Workshop as low-risk (LR-GEV, n=72), high-risk GEV (HR-GEV, n=53).

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During the 6 months before DAA treatment, researchers collected baseline characteristics, including viral load, HCV genotype and subtype, liver function, abdominal ultrasound, liver stiffness measurement (LSM), and screening endoscopy. Te DAA regimen included sofosbuvir with simeprevir, ledipasvir, daclatasvir ± ribavirin as well as the combination of ritonavir-boosted paritaprevir with ombitasvir and dasabuvir. Follow-up with abdominal ultrasound surveillance for hepatocellular carcinoma was performed every 6 months; the decision of the best time to perform follow-up endoscopy was left to treating physicians.


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SVR was achieved in 93.1% of patients (n=230); lack of response was observed in 6.9% of patients (n=17), including 4.1% of patients without GEV (n=5), 8.3% of patients with LR-GEV (n=6), and in 11.3% of patients with HR-GEV (n=6). Compared with non-responders, patients achieving SVR had a lower proportion of baseline GEV (70.6% vs 49.1%) and HR-GEV (35.3% vs 19.6%). Among 33.1% of patients with baseline LR-GEV (n=50), 24% developed HR-GEV. In patients with LR-GEV or LSM ≥25 kPa at baseline, the cumulative probability of GEV progression was higher compared with those without varices (P =.013) or LSM <25 kPa (P =.007).

Limitations of this study include the unavailability of endoscopic follow-up in a significant proportion of patients. Overestimation of the GEV progression risk is possible in patients with milder liver disease. To minimize the subjective nature of the endoscopic evaluation, endoscopy was performed by experts blinded to clinical data in all cases. Further studies are needed to confirm the strength of these findings because the follow-up time was short and the number of patients included in the low-risk progression groups was limited.

The researchers concluded that HCV-infected cirrhotic patients can develop high-risk-GEV after SVR. “Baseline endoscopic findings and transient elastography allow risk stratification of varices progression after SVR, being endoscopic surveillance especially recommended in patients with varices or liver stiffness ≥25 kPa before antiviral treatment.  On the other hand, patients without GEV and liver stiffness <25 kPa before therapy or <20 kPa after SVR could avoid endoscopic surveillance due to the low risk of GEV progression. Applicability of Baveno and expanded-Baveno criteria increases, with good accuracy, despite the decrease of liver stiffness after viral eradication,” noted the researchers.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

References

Puigvehí M, Londoño MC, Torras X, et al. Impact of sustained virological response with DAAs on gastroesophageal varices and Baveno criteria in HCV–cirrhotic patients [published online September 6, 2019]. J Gastroenterol. doi: 10.1007/s00535-019-01619-0