Hepatology

=**Hepatitis/Liver Care**=

**Liver Function Tests**:
Please note that large studies have shown that ALT is a good marker of hepatic inflammation. Cut-offs that predict long-term **death** from liver disease include: Please see presentation by Dr. Hargrave on .toc
 * Men ALT >30
 * Women ALT >20

**2. Hepatitis C**

 * See this simplified Guideline for GT 1 patients [[file:Hep C guidance HCH.pdf]]
 * Who to test: CDC now recommends ALL pts between ages of 45-65 should be tested for HCV. Additional risk based screening includes:
 * h/o IVDU
 * Transfusions before 1987
 * hx of incarceration
 * hx of homelessness
 * MSM
 * Hx of living in Egypt, Pakistan or China
 * What to order:
 * Genotype (GT) most important,
 * LFT'S
 * CBC (platelets below 150 suggests cirrhosis)
 * HIV
 * Hep C RNA (doesn't correlate with disease, but lower viral loads may be easier to treat)
 * 25 hydroxyvitamin D (Vit D is hydroxylated in liver)
 * PT/INR
 * NKBC
 * Counseling and Choric Disease Management:
 * Smoking increases fibrosis.
 * Obesity/fatty liver worsen fibrosis and makes treatment less effective. attempt to lose weight if needed
 * Alcohol cessation is strongly advised. Pts should be clean and sober for 6 mos
 * Depression and pain should be in good control
 * For Interferon Based Regimens (Only GT 3 right now):
 * Pts should be in stable living situation, and staying in the area for at least the next year.
 * If there is a significant psychiatric history, they should already be followed by psychiatry prior to referral. If they have attempted suicide within the last 10 yrs, they are not a treatment candidate.
 * Who/when to refer: Calculate an [|APRI score] This helps predict fibrosis and cirrhosis is patient a score of > 1 is at risk for cirrhosis.
 * Genotype 1,2,3,4,5,6: Medi-cal is paying for treatment if APRI score > 1.5 or if there is other evidence of fibrosis/cirrhosis. Feel free to refer at any stage for discussion of treatment.
 * Other Tests:
 * Vitamin D levels: Vitamin D is hydroxylated by the liver, so most pts w/ significant liver dz are Vitamin D deficient: and it appears that deficiency worsens fibrosis and decreases response rate: supplementation in a small study actually increased cure rate.
 * Test of Cure:
 * Patients are now considered "a cure" if their viral load is undetectable 3 months after completing treatment = 12 week SVR (= Sustained Viral Response). There is close to 99% chance of "permanent" SVR if negative at 3 mos. Traditionally we checked SVR at 6 mos or 12 mos, now we think 3 mos is sufficient. Maybe can check again in 6 mos to be really really sure.
 * Treatments:
 * Currently we are using non-IFN based regimens for most patients, except for GT 3 patients. Treatment is usually for 12 weeks.
 * Ledipasvir-Sofosbuvir (Harvoni), approved for GT 1, provides a 1 daily pill for 8 - 24 weeks with 95-100% cure rates. Please discuss/refer to GI clinic to decide on best treatment regimens for patients.
 * Pharmacy:
 * Dolphin Pharmacy, Oakland: 510-900-3131
 * Walgreens Specialty Pharmacy: 888-347-3416
 * Other Resources:
 * University of Washington has a non-industry sponsored website and training curriculum free online. Probably the best source of evidence based information.

3. Statin Use

 * Statin Use in liver disease is FINE - actually some statins have been shown to have some anti-hep c virus activity.

**4. Cirrhosis**

 * Diagnosis: **LOW PLATELETS** -- 5 fold relative risk of cirrhosis with platelets <150. If platelets <120, overwhelmingly likely pt is cirrhosis. Low albumin also suggestive. AST>ALT usually implies at least stage 2 fibrosis.
 * Abd sono or CT can make dx if varices seen (gastric, esophageal or splenic) but echotexture (in our system) in NOT diagnostic, hard to differentiate between fatty liver and cirrhosis sometimes.
 * **HCC Surveillance**: **ALL cirrhotics need q 6 months HCC (Hepato-cellular Carcinoma) surveillance:** AASLD recommends q 6 mos sonograms, if there is suspicion of HCC, triphasic or quad phasic CT(contrast) or MRI. AFP testing is optional: primarily it is the rate of change of AFP that is helpful: if there is a steady significant increase (like doubling), this is suspicious for HCC. Keep in mind that perhaps 40% of HCC's do not produce AFP, so a low/normal AFP means nothing. Also, many pts with active liver disease may produce high levels of AFP without HCC. Pts with platelets under 100k have a 20% risk of developing HCC in 5 yrs!
 * All cirrhotics need at least 1 EGD to screen for esophageal varices.

**5. Fatty Liver Disease: NAFLD/NASH**

 * Bottom Line: Treatment = Vitamin E 800 iu/day has small beneficial affects, but cure is weight loss, exercise, high-fructose corn syrup thought to worsen NASH.

6. Transplant:
> []
 * No need to refer to GI clinic, but fine to do so. Ok to contact CPMC directly at [] or UCSF
 * Consider making a Public Health Nurse referral to assist with connecting the patient through financial counseling, disability, and follow-up.