July 26, 2002

Does Hepatitis C Virus (HCV) Infection Cause Severe Liver Disease Only in People Who Drink Alcohol?

Lancet Infectious Diseases published in May 2002 an interesting article on the relationship of alcohol and hepatitis C by Professors Vento and Cainelli, Department of Pathology, University of Verona, Verona, Italy. The article focuses on the primary role of alcohol in HCV disease progression, cirrhosis and hepatitis C-related cancer.

Hepatitis C virus (HCV) is thought to infect about 170 million people worldwide, and is often portrayed in the media as a silent killer, implying that cirrhosis and hepatocellular carcinoma are the certain and final outcomes of infection.
This results in considerable fear and anxiety among people diagnosed with hepatitis C, who assume the worse and demand immediate treatment. People must be provided with a balanced perspective of their disease, which includes probabilities not only of gloomy outcomes, but also of absent progression to cirrhosis, long-term survival, and even spontaneous clearance of HCV.
Indeed the results of numerous population-based surveys clearly indicate that chronic HCV infection is highly prevalent in elderly people who, in most instances, do not proceed to end-stage liver disease.

As only a minority of HCV-infected people progress to cirrhosis, future research efforts should focus on the search for markers that will help to predict outcome in any person who unexpectedly receives a diagnosis of chronic HCV infection; however, the most important factor in affecting outcome has emerged already: alcohol.
Indeed, in hepatitis C virus-infected individuals who do progress to cirrhosis and hepatocellular carcinoma, alcohol plays a fundamental part, through mechanisms that result in increased viral replication, enhanced viral complexity, increased liver cell death, suppression of immune responses, and iron overload.
The importance of even low amounts of alcohol can not be overlooked, as the hepatotoxic dose of alcohol in the general population can be as low as 20-30 g daily in women and 40g in men, and 20g of alcohol daily can cause hepatic steatosis, which in itself constitutes a risk factor for alcohol-induced liver injury and is often present in HCV-infected individuals.
Although it is difficult to ascertain the amount of alcohol consumed by a patient, since many individuals who consume alcohol either deny doing so or underestimate the amount they drink, it is possible to get more reliable estimates by asking for single type of drinks rather than alcohol use in general. The histological examination of tissue obtained through a liver biopsy can also be of some help in revealing the role of alcohol in HCV disease progression even in people who deny drinking.

Alcohol consumption is a hard habit to stop, as it has been found that less than 50% of patients who regularly consume alcohol stop drinking after being diagnosed with chronic hepatitis C.
Clinical attention must be redirected: high-impact, continuous public-health campaigns should be designed and interventions made available, since ethanol intake is very high both in developed countries and in poorly-developed areas of the world, and alcohol is still the main cause of symptomatic liver cirrhosis.

In conclusion, sustained efforts must be made to persuade doctors and patients infected with HCV of the importance of abstaining from alcohol if risk of progression towards cirrhosis and hepatocellular carcinoma is to be reduced.
Vento, S. and Cainelli, F. (May 2002).

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