Quality of Life of Patients With Chronic Hepatitis C Virus Infection

Chronic Hepatitis C Virus Infection Causes a Significant Reduction in Quality of Life in the Absence of Cirrhosis. Foster GR, Goldin RD, Thomas HC. Hepatology 1998;27:209–12. Summary: Foster et al. used the short form 36 (SF-36) symptomatology questionnaire to assess the quality of life of adult patients with chronic hepatitis C virus (HCV) infection, with no clinical or biopsy evidence of cirrhosis. A control population of patients with chronic hepatitis B virus (HBV) infection (hepatitis B e antigen positive) without cirrhosis were also studied. The authors found that patients with chronic HBV infection showed a reduction in the SF-36 scores that assessed mental functions, but they had no decrease in the scores that measured physical symptoms. By contrast, patients with chronic HCV infection had significant reductions in all areas of health-related quality of life assessed with the SF-36. Thus, chronic HCV infection reduced patients' physical functioning, social functioning, mental health, and general health perception; produced limitations in physical and emotional roles; and resulted in poor scores on the energy and fatigue subscale. Most of the scores for physical incapacity were significantly reduced compared with those for patients with chronic HBV. In patients with HCV infection, there was no correlation between the reduction in quality of life with either the degree of liver inflammation or the mode of acquisition of HCV infection. The authors concluded that the presence of HCV per se appeared to cause physical symptoms that significantly reduced the quality of life of infected patients. Comment: The World Health Organization estimates that approximately 3% of the world's population may be infected with HCV (Vox Sang 1998;74(Suppl):143–6). Infection with HCV may be asymptomatic, but it is associated with development of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (Dig Dis Sci 1996;41(Suppl):75S–80S;Vaccine 1999;17:1730–3). In industrialised countries, HCV infection accounts for approximately 40% of cases of end-stage cirrhosis and 30% of liver transplantations (J Hepatol 1999;30:956–61). A number of recent studies have demonstrated significant impairment in the quality of life of adults with chronic HCV infection (Clin Ther 1994;16:334–43;Clin Transplant 1997;11:406–11;Hepatology 1999;29:264–70). Most of these studies, however, have focused either on patients with advanced HCV liver disease (Clin Transplant 1997;11:406–11) or have compared patients with healthy control subjects (Clin Ther 1994;16:334–43;Hepatology 1999;29:264–70). It may therefore be argued that the reduction in quality of life may simply be attributed either to severe liver disease or to the knowledge of a severe illness. Foster et al. attempted to address these issues by studying patients with HCV with varying severity of liver involvement and by making comparisons with patients who had chronic HBV infection. They clearly demonstrated that the reduction in quality of life of patients with HCV is not necessarily dependent on the severity of liver inflammation and that adults with chronic HCV infection have a worse quality of life than those with chronic HBV infection. In one of the earlier studies that examined quality of life in chronic HCV infection, Davis et al. (Clin Ther 1994;16:334–43) used the Sickness Impact Profile to evaluate the impact of disease and treatment with interferon-α on health-related quality of life. Before treatment, patients with chronic HCV scored significantly worse than a control group from the general population. The highest degree of impairment was in the categories of work, sleep and rest, and recreation and pastime. After treatment, patients who received interferon had significant improvement in work, sleep and rest, and recreation and pastime scores. Bonkovsky and Wooley (Hepatology 1999;29:264–70) recently studied the health-related quality of life of 642 patients with HCV infection and compensated chronic liver disease, by using the SF-36 questionnaire. They found that, compared with healthy control subjects, patients with chronic HCV had poorer quality of life on all eight scales of the SF-36 (P < 0.001 for all). Patients who had a sustained viral response to interferon therapy exhibited marked improvements in quality of life compared with nonresponders. In 1997, Singh et al. (Clin Transplant 1997;11:406–11) studied the quality of life of patients with end-stage liver diseases. They compared those with HCV with those who had other causes for liver disease. The authors showed that total mood disturbance (P = 0.038), tension and anxiety (P = 0.047), confusion and bewilderment (P = 0.035), and depression and dejection (P = 0.035), as assessed by the Profile of Mood States scale, were significantly higher in patients with HCV than in other patients. Patients with HCV were also significantly more depressed, as assessed by the Beck Inventory scores (P = 0.014). After orthotopic liver transplantation, patients with recurrence of HCV infection have been shown to have a significant reduction in their quality of life compared with patients without HCV recurrence (Transpl Int 1998;11(Suppl):S475–9). Dickson et al. (Clin Transplant 1997;11:282–5) also demonstrated that patients who undergo transplantation for HBV and are treated with hepatitis B immunoglobulin prophylaxis attain a higher quality of life than patients who undergo transplantation for HCV. In a more recent study, Singh et al. (Transplantation 1999;67:69–72) examined the quality of life, psychologic distress, depression, adaptive coping, and functional status in 59 liver transplant recipients before transplantation and at 6 and 12 months after transplantation. They compared patients with recurrent HCV hepatitis with all other patients. At 12 months, the patients with recurrent HCV had a significantly lower quality of life (P = 0.003), greater depression (P = 0.045), higher psychologic distress (P = 0.05), and lower physical functioning (P = 0.008) than all other patients. Studies examining the quality of life of children with chronic HCV infection have not been undertaken, probably because appropriate validated tools are not available. Iorio et al. (Pediatr Infect Dis J 1997;16:984–90) used a modified version of the Sickness Impact Profile to investigate the impact of interferon therapy on health-related quality of life in 94 children with chronic viral hepatitis, including 28 with HCV infection. They found that the mean total scores of the children before interferon therapy were comparable with those found in the general adult population. Health-related quality of life deteriorated during the first month of interferon therapy but improved to baseline scores within the subsequent 3 months. In this study, no comparison was made between patients with HCV infection and those with HBV infection. The fascinating observation put forth by Foster et al. raises a fundamental question. Why do adults with chronic HCV infection have a poorer quality of life than those with chronic HBV infection? The answer to this question is uncertain. Although their study was not controlled for factors such as viral load or cytokine levels, the authors speculated that the mechanism for the significant impairment in quality of life of patients with HCV infection may involve the release of cytokines or infection of leukocytes. Foster et al. suggest that, in view of the significant impairment in the quality of life of patients with chronic HCV infection, even in the absence of significant liver inflammation, the term “asymptomatic infection” should be used with care in these patients. In an editorial accompanying the article of Foster et al., Owen (Hepatology 1998;27:292–3) suggested that using the severity of liver inflammation to determine which patient with chronic HCV infection is a priority for antiviral treatment may not be adequate, because the degree of liver inflammation is a poor marker for detecting patients whose quality of life has been adversely affected by HCV. Most of the available evidence links chronic HCV infection with significant impairment in quality of life. Interferon therapy may lead to marked improvements in the quality of life of responders (Hepatology 1999;29:264–70;Clin Ther 1994;16:334–43;Gastroenterol Hepatol 1998;21:161–8). Assessment of health-related quality of life should form an important part of the evaluation of patients with chronic HCV infection. Validated tools for measuring quality of life in children are needed for the appropriate psychologic and emotional support to be offered to the whole family.