SNFGE SNFGE
 
Thématique :
- Foie
Originalité :
Réexamen
Solidité :
Très solide
Doit faire évoluer notre pratique :
Immédiatement
 
 
Nom du veilleur :
Professeur Dominique VALLA
Coup de coeur :
 
 
The Lancet
  2019/02  
 
  2019 Feb. pii: S0140-6736(18)32111-1.  
  doi: 10.1016/S0140-6736(18)32111-1.  
 
  Clinical outcomes in patients with chronic hepatitis C after direct-acting antiviral treatment: a prospective cohort study.  
 
  Carrat F, Fontaine H, Dorival C, Simony M, Diallo A, Hezode C, De Ledinghen V, Larrey D, Haour G, Bronowicki JP, Zoulim F, Asselah T, Marcellin P, Thabut D, Leroy V, Tran A, Habersetzer F, Samuel D, Guyader D, Chazouilleres O, Mathurin P, Metivier S, Alric L, Riachi G, Gournay J, Abergel A, Cales P, Ganne N, Loustaud-Ratti V, D'Alteroche L, Causse X, Geist C, Minello A, Rosa I, Gelu-Simeon M, Portal I, Raffi F, Bourliere M, Pol S; French ANRS CO22 Hepather cohort.  
  https://www.ncbi.nlm.nih.gov/pubmed/30765123  
 
 

Abstract

BACKGROUND:

Although direct-acting antivirals have been used extensively to treat patients with chronic hepatitis C virus (HCV) infection, their clinical effectiveness has not been well reported. We compared the incidence of death, hepatocellular carcinoma, and decompensated cirrhosis between patients treated with direct-acting antivirals and those untreated, in the French ANRS CO22 Hepather cohort.

METHODS:

We did a prospective study in adult patients with chronic HCV infection enrolled from 32 expert hepatology centres in France. We excluded patients with chronic hepatitis B, those with a history of decompensated cirrhosis, hepatocellular carcinoma, or liver transplantation, and patients who were treated with interferon-ribavirin with or without first-generation protease inhibitors. Co-primary study outcomes were incidence of all-cause mortality, hepatocellular carcinoma, and decompensated cirrhosis. The association between direct-acting antivirals and these outcomes was quantified using time-dependent Cox proportional hazards models. This study is registered with ClinicalTrials.gov, number NCT01953458.

FINDINGS:

Between Aug 6, 2012, and Dec 31, 2015, 10 166 patients were eligible for the study. 9895 (97%) patients had available follow-up information and were included in analyses. Median follow-up was 33·4 months (IQR 24·0-40·7). Treatment with direct-acting antivirals was initiated during follow-up in 7344 patients, and 2551 patients remained untreated at the final follow-up visit. During follow-up, 218 patients died (129 treated, 89 untreated), 258 reported hepatocellular carcinoma (187 treated, 71 untreated), and 106 had decompensated cirrhosis (74 treated, 32 untreated). Exposure to direct-acting antivirals was associated with increased risk for hepatocellular carcinoma (unadjusted hazard ratio [HR] 2·77, 95% CI 2·07-3·71) and decompensated cirrhosis (3·83, 2·29-6·42). After adjustment for variables (age, sex, body-mass index, geographical origin, infection route, fibrosis score, HCV treatment-naive, HCV genotype, alcohol consumption, diabetes, arterial hypertension, biological variables, and model for end-stage liver disease score in patients with cirrhosis), exposure to direct-acting antivirals was associated with a decrease in all-cause mortality (adjusted HR 0·48, 95% CI 0·33-0·70) and hepatocellular carcinoma (0·66, 0·46-0·93), and was not associated with decompensated cirrhosis (1·14, 0·57-2·27).

INTERPRETATION:

Treatment with direct-acting antivirals is associated with reduced risk for mortality and hepatocellular carcinoma and should be considered in all patients with chronic HCV infection.

 

 
Question posée
 
Les antiviraux directs améliorent-ils l’évolution de l’hépatite C vers les complications graves chez les malades sans décompensation jusque là?
 
Question posée
 
Oui, et c’est très net pour retarder le décès ou prévenir le carcinome hépatocellulaire chez les patients atteints de cirrhose. En revanche l’impact sur la décompensation n’est pas évident au stade de cirrhose. L’impact chez les patients indemnes de cirrhose n’est pas net non plus dans le cadre de cette étude limitant la période d’observation à 5 ans.
 
Commentaires

Une référence pour longtemps. Reste ouverte la question de l’impact – et donc de la gestion de l’inscription sur la liste d’attente de greffe – pour les malades avec cirrhose décompensée.

 
 
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