Correspondence

Outcomes after Transfusion-Associated Hepatitis C

N Engl J Med 1995; 333:1224November 2, 1995

Article

To the Editor:

In their study of patients with chronic post-transfusion hepatitis C who were seen at a referral center, Tong et al. (June 1 issue)1 concluded that the disease was progressive and, in some patients, led to death from liver failure or hepatocellular carcinoma. These findings are in contrast to those of Seeff et al.,2 who reported no increase in mortality from transfusion-associated non-A, non-B hepatitis.2 In the retrospective study by Tong et al., any patient who had received a blood transfusion and in whom chronic hepatitis C developed was considered to have post-transfusion hepatitis C virus (HCV) infection. It was not possible to provide proof of HCV transmission through transfusion. It is possible that some patients classified as having post-transfusion hepatitis had sporadic hepatitis C infections.

The sporadic form of HCV infection is, epidemiologically, probably the more important one.3,4 In Europe more than 50 percent of all cases of hepatitis C–associated chronic liver disease are the result of community-acquired infection, and their clinical outcome is worse than that of transfusion-associated HCV infections.5 In view of this and the rather low risk of transfusion-associated hepatitis C,6 we think that some of the patients may not have acquired HCV through blood transfusion. Was there any difference in the clinical outcome between the 19 patients who recalled jaundice after transfusion and the other 112 patients?

G. Neumayr, M.D.
W. Vogel, M.D.
University of Innsbruck, A-6020 Innsbruck, Austria

6 References

1. 1

   Tong MJ, El-Farra NS, Reikes AR, Co RL. Clinical outcomes after transfusion-associated hepatitis C. N Engl J Med 1995;332:1463-1466
   Full Text | Web of Science | Medline

2. 2

   Seeff LB, Buskell-Bales Z, Wright EC, et al. Long-term mortality after transfusion-associated non-A, non-B hepatitis. N Engl J Med 1992;327:1906-1911
   Full Text | Web of Science | Medline

3. 3

   Alter MJ, Margolis HS, Krawczynski K, et al. The natural history of community-acquired hepatitis C in the United States. N Engl J Med 1992;327:1899-1905
   Full Text | Web of Science | Medline

4. 4

   Alter MJ, Sampliner RE. Hepatitis C: and miles to go before we sleep. N Engl J Med 1989;321:1538-1540
   Full Text | Web of Science | Medline

5. 5

   Neumayr G, Judmaier G, Stoffler G, Deitze O, Vogel W. Die Bedeutung der Infektionswege für die Hepatitis-C-Virus-assoziierte chronische Lebererkrankung. Z Gastroenterol 1994;32:338-341
   Web of Science | Medline

6. 6

   Dienstag JL, Alter HJ. Non-A, non-B hepatitis: evolving epidemiologic and clinical perspective. Semin Liver Dis 1986;6:67-81
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We attempted to eliminate all possible risk factors for acquiring HCV other than transfusion before enrolling patients in the study. Each of our patients recalled one episode of blood transfusion; those with more than one episode were not included. It is unlikely that other known risk factors were involved, and until other means of HCV transmission are identified, HCV infection in our patients is considered to be related to transfusion.

To elucidate the differences in clinical outcome between patients who recalled a bout of jaundice after transfusion and those who did not, we examined the frequency of the development of cirrhosis and the mortality rate attributed to liver disease. In the patients who recalled an episode of jaundice, the frequency of the development of cirrhosis was 73.7 percent (14 of 19 patients), as compared with 53.6 percent (60 of 112 patients) in those who did not (P<0.05). The mortality rate was 21.1 percent among those who recalled having jaundice, as compared with 13.4 percent among those who did not (P<0.05). The reasons for these differences are not clear but may involve a more exaggerated immune response to the initial and the subsequent chronic HCV infection. Other factors, such as the duration of the HCV infection, level of viremia, and genotype, may also be important.

It is not clear whether more serious liver disease develops in patients who acquire HCV “sporadically” as compared with those who are infected by the parenteral route. Recent studies have suggested that the chronic liver disease is more severe when HCV is acquired through transfusion and that in patients who acquire HCV sporadically, progression is slower.1-3 More precise identification of the time of HCV infection is obviously not possible in the sporadic cases, but the time may be one of the primary prognostic indicators of the severity of disease.

Myron J. Tong, Ph.D., M.D.
Neveen S. El-Farra, B.S.
Huntington Memorial Hospital, Pasadena, CA 91105

3 References

1. 1

   Alter MJ, Margolis HS, Krawczynski K, et al. The natural history of community-acquired hepatitis C in the United States. N Engl J Med 1992;327:1899-1905
   Full Text | Web of Science | Medline

2. 2

   Kiyosawa K, Sodeyama T, Tanaka E, et al. Interrelationship of blood transfusion, non-A, non-B hepatitis and hepatocellular carcinoma: analysis by detection of antibody to hepatitis C virus. Hepatology 1990;12:671-675
   CrossRef | Web of Science | Medline

3. 3

   Kao JH, Tsai SL, Chen PJ, et al. A clinicopathologic study of chronic non-A, non-B (type C) hepatitis in Taiwan: comparison between posttransfusion and sporadic patients. J Hepatol 1994;21:244-249
   CrossRef | Web of Science | Medline