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Patients infected with HCV usually have a long period of mild disease of 15–25 years. After this period, a substantial number of patients develop liver-associated morbidity and mortality, including clinical complications of liver cirrhosis such as ascites, variceal haemorrhage, hepatic encephalopathy, hepatocellular carcinoma (HCC) or liver-related death. This natural course of disease has been best described in young and mostly healthy women who were infected by a contaminated anti-D immunoglobulin preparation in East Germany in 1978/1979. Less than 2% of women with chronic HCV infection developed liver cirrhosis or HCC in the first 25 years of infection, while this number increased substantially to approximately 15% in the 35-year follow-up.1 ,2 These data were discussed controversially, since this initially mild course was partially attributed to the cohort of young, female patients with few comorbidities. A recent evaluation of a cohort of intravenous drug users (IVDU) who were followed since the 1970s, however, found a similarly slow progression of HCV-associated liver disease in this ‘real-world’ cohort. Indeed, this study analysed autopsies from 61 chronically infected subjects who had died mostly due to drug-related reasons. None of the 18 subjects who had died <15 years after HCV exposure had F3 or F4 METAVIR fibrosis stage, while 6 of 17 …
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