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HCV infection should be managed in specialist centres
  1. G Dusheiko
  1. Royal Free and University College School of Medicine, London NW3 2QG, UK; G.Dusheiko{at}rfc.ucl.ac.uk

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Chronic hepatitis C virus (HCV) infection may cause slowly progressive chronic hepatitis, cirrhosis, advanced liver failure, and hepatocellular carcinoma.1 These varying outcomes of type C hepatitis pose a challenge and responsibility which requires firstly, that antiviral treatment is targeted as precisely as possible to those who have progressive disease, and secondly, that patients with advanced disease are managed by specialist centres with the capability of minimising the morbidity of the disease. Presently, most patients with community and hospital associated hepatitis C requiring treatment are referred to specialist liver centres.

The hepatologist has a pivotal role in the management of chronic hepatitis C. This includes the differential diagnosis, clinical management, and assessment of the stage of disease. Hepatology has become an increasingly specialised discipline and hepatologists are ideally placed to collate investigations and to ensure the appropriate management of coexisting liver disease. Specialist hepatologists also provide the continuity and follow up required for understanding the sometimes complex dynamic nature of the disease.

There is a unique requirement for the histopathological investigation of hepatitis C to inform and deliver the National Institute of Clinical Excellence (NICE) guidelines. Useful classifications for staging and grading of disease have been devised.2 There is a need for experienced clinical input to complement the interpretation of liver biopsies by histopathologists who should see sufficient numbers of patients with a full spectrum of disease.3 Liver biopsy moreover is an invasive technique and requires skilled and practised operators. If haemostasis is abnormal, transjugular biopsies may be required.

The hepatologist is required to ascertain the trajectory of the disease in chronically infected patients to make informed decisions regarding treatment. Alpha interferon and ribavirin are the current standard of care. NICE makes clear recommendations for the treatment of chronic disease, and the appropriate application of this treatment is an obvious example of specialist input to ensure that national guidelines are followed (wws.nice.org.uk). The optimal timing of treatment necessary to minimise unnecessary treatment for those who would not progress to severe chronic disease, but avoiding treatment failure through delay, is being established. Generally, hepatologists are engaged in applying antiviral therapy for this disease and in monitoring patients for response or complications during treatment. They are also well placed to assess indications and contraindications for antiviral therapy and the management of resistance, relapse, or non-response. Hepatologists take a specialist research and clinical interest in therapeutic trials for HCV infection and are at the forefront of emerging technologies.4,5

There is clearly a mandatory role for the hepatologist in the management of cirrhosis. This applies to the management of complications including the medical, endoscopic and portosystemic intrahepatic shunt management of variceal bleeding, and other complications of portal hypertension, including ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and the renal dysfunction associated with cirrhosis. Specialist transplant hepatologists together with pathologists, radiologists, and the surgeon provide the tools and full range of expertise for the seamless management of patients with decompensated cirrhosis. Appropriately timed referral for transplantation demands particular training and experience.

To date, hepatologists have played a pivotal role in the diagnosis and management of hepatocellular carcinoma (HCC). This includes aspects of surveillance for small HCC as well as the imaging and diagnosis of focal lesions. Hepatologists and interventional radiologists must be involved in decisions regarding the treatment of HCC, including liver biopsy, surgical resection, liver transplantation, or targeted treatment, which in some cases may be curative. The management of advanced HCC is aided by chemotherapy and specialist oncologists.

The hepatologist has also begun to play a unique role in coinfection clinics, assessing the clinical management of coinfection with human immunodeficiency virus (HIV) and HCV (or hepatitis B). Together with the retrovirologist, decisions must now be made regarding the prescription of complex multiple antiretroviral agents and their combination with other antiviral agents in this rapidly evolving field. Liver involvement in acquired immunodeficiency syndrome (AIDS) or antiretroviral therapy also requires the involvement of a hepatologist. A number of extrahepatic manifestations, including renal disease, mixed essential cryoglobulinaemia, and lymphoma are being encountered in association with hepatitis C, which may require assessment by the hepatologist and clinical interactions with appropriate specialists.

Hepatologists have overseen the generation of guidelines for the management of hepatitis C, including the NIH and EASL guidelines.6–8 Generally, the specialist with liver disease is likely to act as the “driver” in developing recommendations for implementing the requisite virological and other laboratory investigations, and for steering the migration of tests from the research laboratory to clinical practice. In this way a composite of clinical and laboratory results enable the development of suitable diagnostic algorithms. In turn, the NICE guidelines are driving the necessity for specialist hepatologists to deliver appropriate care. Hepatology services provide the necessary education, training, and accreditation of specialists likely to see patients with the disease, the application of clinical governance, as well as the definition of existing practice and refinement of NICE guidelines as the need arises. There is a developing argument for defining and developing the commissioning of hepatology services within the national framework of Strategic Health Authorities. Hepatology has been recognised as a subspecialty of gastroenterology by the JCHMT and the STA of the Royal College of Physicians. The arrangements for the commissioning of specialist liver services are still being examined at the time of writing. The most appropriate configuration for regional management of liver diseases including liver transplant services, hepatitis C services, paediatric hepatology, and the most efficient use of resources that will avoid duplication and reduce waiting times should be devised. The volumes of service required suggest that transplantation should continue to be supraregionally funded in a limited number of centres but that liver centres may need to be more numerous because of the volume of patients requiring antiviral therapy.

Hospital based care for hepatitis C increasingly encompasses a specialist juxtaposition of hepatologists, virologists, pathologists, radiologists, the nurse specialist, surgeon, and sometimes haematologists, and nephrologists, to manage both the hepatic and extrahepatic manifestations of hepatitis C. It is important not to ignore the contribution of public health specialists, epidemiologists, infectious disease specialists, virologists, transfusion specialists, oncologists, molecular biologists, and others in the multidisciplinary role of caring for patients with hepatitis C.9 There may be local needs which require consideration. Hepatitis C offers a unique opportunity for scientific and clinical collaborations. A multidisciplinary contribution is welcomed, and indeed the NHS does not have a surfeit of manpower. A strong case is made for the jurisdiction of specialist hepatology units to manage patients with hepatitis C however.

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