A 74-year-old man with end-stage renal disease who is receiving hemodialysis is found to have elevated liver transaminase levels. He has had no fever or jaundice. The patient does not drink alcohol and has received a complete vaccine series for hepatitis B. Vital signs are normal. BMI is 24 kg/m2. Physical examination shows anicteric sclerae and no hepatosplenomegaly. Laboratory results are positive for hepatitis C virus RNA. Six months previously, he tested negative for hepatitis C. Without treatment, which of the following is the most likely outcome in this patient?
This patient has a new infection with hepatitis C virus (HCV), presenting with elevated hepatic aminotransferases and confirmed on HCV RNA assay. The risk of HCV infection is elevated in patients on hemodialysis due to their frequent exposure to blood products, and these individuals are regularly screened for HCV.
Immediately after exposure to HCV, some patients develop jaundice, abdominal pain, and elevated aminotransferases (ie, acute hepatitis C), whereas others remain asymptomatic. Although some patients clear the virus spontaneously within 6 months of initial infection, the majority (50%-80%) remain persistently viremic and develop chronic HCV unless they receive treatment with antiviral medication (Choice E). Viral persistence is even more likely in elderly or immunosuppressed individuals (eg, end-stage renal disease, HIV infection).
Most patients with chronic HCV exhibit nonspecific disease manifestations, including fatigue, abdominal pain, and elevations in aminotransferases. Approximately 20% of chronic HCV infections lead to cirrhosis, which takes decades (25-30 years) to develop. Of those with HCV-related cirrhosis, a small minority develop life-threatening hepatic decompensation (eg, esophageal variceal bleeding, ascites) or hepatocellular carcinoma (Choices B and C). Given this patient's age and comorbidities, he is unlikely to survive long enough to develop cirrhosis or carcinoma.
(Choice A) Acute HCV can cause acute (eg, fulminant) liver failure, a life-threatening condition characterized by encephalopathy and impaired hepatic synthetic function (eg, prolonged prothrombin time). However, this is a rare manifestation and is much less common than chronic HCV.
Educational objective:
The most common outcome of hepatitis C infection without antiviral treatment is lifelong persistent infection (ie, chronic hepatitis C). Of those with chronic hepatitis C, approximately 20% develop cirrhosis, and only a minority experiences complications (eg, ascites, variceal bleeding, hepatocellular carcinoma).