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Cirrhosis in HCV Patients may be Underdiagnosed

Cirrhosis was found to be underdiagnosed among patients with hepatitis C virus infection enrolled in the Chronic Hepatitis Cohort Study, according to new study data.

“Progression of chronic hepatitis C to cirrhosis occurs over a period of several years,” the researchers wrote. “The identification of patients with cirrhosis may have significant implications pertaining to the management of [chronic hepatitis C] and health resource utilization.”

Researchers, including Stuart C. Gordon, MD, division of gastroenterology and hepatology, Henry Ford Health System, Detroit, Michigan, analyzed data of 9,783 patients with HCV enrolled in the Chronic Hepatitis Cohort Study (CHeCS). The CHeCS is comprised of a large, geographically and racially diverse cohort of patients “receiving routine care at four large U.S. health-care systems,” according to the research. Data of all the patients was extracted from the electronic health record database who received health services at the health care facilities between 2006 and 2010.

“We sought to estimate the prevalence of cirrhosis among [chronic hepatitis C] patients in the CHeCS based on an expanded set of parameters that included [Fibrosis-4 scores] as well as liver biopsy results and the presence of diagnosis or procedure codes for cirrhosis and various manifestations of hepatic decompensation,” the researchers wrote.

Overall, 28.5% of all patients were diagnosed with cirrhosis by at least one of the methods used by the researchers (n = 2,788). Liver biopsy identified cirrhosis in 6.8% of patients (n = 661) compared with 22% diagnosed by FIB-4 scores (n = 2,194), 5.7% diagnosed by diagnosis/procedure codes for cirrhosis (n = 557) and 4.9% diagnosed through hepatic decompensation (n = 482). Cirrhosis was indicated by all methods in 2.3% of patients (n = 221).

“[The] use of all four parameters … suggests a fourfold higher prevalence of cirrhosis than is indicated by biopsy alone,” the researchers wrote.

Among the patients with biopsy-confirmed cirrhosis, 54% had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for cirrhosis (n = 356).

Multivariate logistic analysis showed older age, male gender, Asian race, Hispanic ethnicity, genotype 3 infection, HIV coinfection, diabetes, history of antiviral therapy and history of alcohol abuse to be independent variables associated with an increased odds of developing cirrhosis (P < .05 for all). Patients with private health insurance coverage, of black race and HCV genotype 2 were associated with a decreased odds of developing cirrhosis, according to the research.

“Only a minority of HCV patients had their diagnosis of cirrhosis established by liver biopsy, which is being performed less commonly because of the availability of validated biomarkers and less invasive tests,” Gordon told Healio.com/Hepatology. “Half of those patients with biopsy proven cirrhosis never had an associated ICD-9 code for cirrhosis in their charts, suggesting that using coding data in large cohorts may underestimate the prevalence of HCV related cirrhosis in the US.” 

The researchers concluded: “A high proportion of patients with biopsy-confirmed cirrhosis are not assigned ICD-9 codes for cirrhosis. Consequently, ICD-9 codes may not be reliable as the sole indicator of the prevalence of cirrhosis in cohort studies. … These findings suggest that cirrhosis in [chronic hepatitis C] patients may be significantly underdocumented and underdiagnosed.” – by Melinda Stevens

Disclosures: Gordon reports receiving grant and researcher support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Intercept Pharmaceuticals, Merck and Vertex Pharmaceuticals. He also serves as a consultant for AbbVie, Amgen, Bristol-Myers Squibb, CVS Caremark, Gilead Science, Merck and Novartis, as well as serves on the data monitoring board for Tibotec/Janssen Pharmaceuticals.