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Changes in Viral Loads

Strange the way viral loads vary.  Its been 4 years since I had my viral load checked and it was at 7 million.  Had it checked last week and it was at 3 million. I wonder if my lifestyle change had anything to do with it?  I understand that viral load only is used to determine your chances for SRV. If this is true then I would have twice the chance of clearing today then I did four years ago.  60 years old  1b  liver condition unknown.

                                                         Ron
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Avatar universal
I agree with you that at times we do have to trust our doctors. My transplant surgeon told me 2 days after surgery that I should never trust anyone. I replied "except you, right?" and he replied "not me either, unless your under anesthesia". I think he was kidding me a bit but for the most part I have tried to follow his advice. I wish you well Sally. Mike
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Avatar universal
Thanks Mike. Sometimes I need to just trust my doctors and try not to overthink. I guess my job here is to be compliant and keep them informed.  At least for right now, I FEEL better than I have in months.  Ironic isn't it?  I am still waiting for a call so maybe I will take inventory of my food situation.  Steroids make me SO hungry.  lol
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Avatar universal
I really don't feel competent to comment on your situation Sally. This HCV stuff is complicated enough and when you add transplantation and immunosuppressive drugs into the equation the complexity increases exponentially. Perhaps the best advice I can give is to address your question to Hepatitis researcher (HR) and see if he has any ideas or insight. He seems extremely knowledgeable and may be able to help. I'm sorry but I don't feel that I can help you - it's just over my head Sally. Mike
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Avatar universal
Thank you for the response.
Female, 55 years, geno 1a
Diagnosis approx 1995 and treated with interferon monotherapy
Unsucessful and chose to ignore situation ?????
ESLD diagnosis 2000 - listed for transplant - could not treat
2003 - had to stop working, acites, fatigue, dehydration
2005 - Jan - transplanted
2005 - approx april began Peg/riba. Treated 70 weeks
UND first time in July 06 - tx inturrption due to anemia
restarted tx Aug but stopped again in Sep due to SOB
vl in July, aug UND (<615 bayer)
Vl 350 000 in sept
vl und oct and nov without tx
Due to anti fungal med used to treat my atypical pneumonia, the prograf was recuced as they enhanced their performance.

When anti fungals were d/c and I was feeling better, vl's began to show positive and increase with each test although the prograf levels were good (6-9)  I was also given a ton of predisone while treating the pneumonia.
  My doctor originally told me that if I were overly suppressed it would allow the virus to attack more aggressivly.  I really thought that was what was going on and expected a reduction in antirejection meds and to restart the Peg/riba.
   After the biospy however I am to beleive that the rise in enymes was  or is due to an rejection and they have therefore increased the prograf to 2mg bid and added medrol 20mg bid.  My last prograf level was 8. the enymes were alt316 and ast 250.  These numbers were normal or just slightly elevated not that long ago
   I have a call out to my nurse co ordinator so that I can ask some questions.  In the meantime I am doing as instructed on my phone message machine.  I will have to talk to her today as the medrol I have is slightly expired.
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Avatar universal
I don't think this subject is inappropriate - it's definitely HCV related. I don't fully understand your history. When you treated did you get tested frequently? You say that you stayed undetectable for 4 months after stopping treatment. I think that is unusual - at least in my personal experience and the experience of those people I know. I relapsed after my second TX within 3 weeks. I went from undetectable <5 IU/ml to 6.85 million IU/ml and the people I know who tested shortly after TX relapsed much sooner than 4 months. Did you test earlier than 4 months and show undetectable? Regarding your Prograf dose increase and the addition of solumedrol: Did you ever have any rejection problems before? Have you read your biopsy results? If you have the time and inclination tell me a little more history. If you are uncomfortable here, post over at the Hepatitis Community side and put my name in the title and I'll see it. I don't know if I'll be able to say anything of value but I will try. Mike
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87972 tn?1322661239
Hiya Mike;

Re: C7 above. I seem to remember from high-school Latin that the 5th declension nouns ending in -ex (such as index, etc.) would change to -ices when they become plural; therefore we get index, indices; vortex, vortices. Stay with me for a moment now; does the pluralized noun Heptimax change to Heptimices?.... (Said with a very wide grin.... ;-).
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Avatar universal
Those factors ARE used in predicting SVR. Please check out the url (link) that I posted in my earlier reply.
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Avatar universal
The guideline of high and low vl use to be 800,000. More recent studies use 400,000 when used as a "predictor" for SVR

http://tinyurl.com/36ubxu
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Avatar universal
Didn't realize that you had such a hellish journey to SVR, Mike. You have the strength of ten men to have gone through all that and still be here helping fellow travellers. You have my sincere respect.
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Avatar universal
A variation in your VL from 7 mil to 3 mil is pretty much meaningless. The viral load naturally undulates up and down over time, plus the test accuracy can easily account for a variation of this amount alone (according to Dr Schiffman's slide show). However, drinking alcohol has been shown to make VL's increase. So if someone were drinking and recently stopped, it's possible their VL really could go down.
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Avatar universal
That's very kind of you to say but honestly, I just did what anyone else who was as scared as I was would have done. We all do the same thing here - we do whatever it takes to stay alive and get well. I was one of the lucky ones - I got a liver and reached SVR. I do appreciate your kind words. Good luck to you. Mike
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Avatar universal
Strange.

I was always thought that viral load was a major factor when figuring the odds of SVR. With Geno type, your age, length of infection, age at infection, race, and gender.  Maybe these factors no longer come into play.

                                                Ron
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Avatar universal
I started treatment just a few weeks after surgery - TP June 17, 2000 and started TX July 27, 2000. I treated for one year with 800 mg ribavirin and Peg-Intron. I didn't clear. I waited 6 months and treated again for 53 weeks with the same drugs and same doses. This time I cleared late - I think at 9 months - and relapsed immediately. I started 5 weeks later with Pegasys and 1000 mg ribavirin daily and cleared by week 11 and treated for a total of 73 weeks, which made it June 2004. I was clear in April 2003, I think, so I have been serum undetectable for quite a while. Without boring you I had a major reduction in my anti rejection drug dose in late April 2006 (70% decrease over 6 weeks) and my enzymes started to soar. I was biopsied June 3, 2006 and a small amount of HCV was detected in my liver. I have tested monthly with Heptimax since June 2003 and have never had detectable HCV in my serum. In fact I had clear Heptimaxes a couple of weeks before and one week after my biopsy. That's my story HCA and I'm sticking with it.  Mike
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Avatar universal
HCA
These factors along with degree of disease progression do come into play,but as has been explained the fact that you have 3m now and 7m four years ago is not significant and 3m is not a 'low' viral load
You could re-test in a month and be a totally different figure .
All of these stats are of limited value to you as a patient.
Your chances are 50/50-you'll either clear or you won't.
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Avatar universal
You're correct in your statement that starting VL does factor into the likelihood of achieving an SVR. My only point in my last post was to clarify that VL's will naturally go up and down over time, and can very easily vary between 3 mil and 7 mil without any lifestyle changes or changes in liver histology. And as described by Schiffman, inaccuracies in the PCR test can also easily account for the variance observed in your VL's. So the lifestyle changes you mentioned may not be responsible for any apparent change in viral load (although a healthy lifestyle is always advised). Also, speaking for myself I've seen my VL go up substantially after engaging in a very healthy lifestyle with a near perfect diet and lots of exercise. I've also seen it decline significantly for no apparent reason.

You also stated "I understand that viral load only is used to determine your chances for SRV. If this is true then I would have twice the chance of clearing today then I did four years ago." Unfortunately it doesn't work that way. There is not a nice linear relationship between starting VL and odds of achieving SVR. Starting VL is only one of many factors predicting treatment outcome, and it cannot be simply and proportionally factored in when sizing up your odds of success. A low viral load is generally thought of as being <800,000 IU/ml, although I've seen varying accounts of what's considered low. A high VL is generally considered to be above this value (same disclaimer applies). And there is a pretty clear and measurable distinction bewteen the (average) SVR outcome of those who start with a high VL and those that start with a low VL (with low VL odds being better). On the other hand, although I don't have the statistics readily available, all other things being equal and accounting for the VL test variances previously mentioned, a difference between a starting VL of 3 mil and 7 mil when predicting SVR is probably quite small, or maybe even negligible.

Hopefully I'm not raining on your parade or taking away your "upbeat" outlook. But if you get another VL result back later and it's back up to 7 mil or higher, it should help put things in perspective.

Take care...

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Avatar universal
Upbeat.  I have been told that some hepatologist do not put as much emphasis on vl as others and that they can varie widely. They always tell me that however when mine is high, I think to somewhat console me.  Knowing that- I am still delighted when the numbers drop.

Mike simmon - What you described in this thread sounds very similar to what I am experiencing. I treated after transplant for 70 weeks.  I was a late responder (about week 70)and became ill.I stayed UND for about 4 months and then had a viral load of 6000, 7000, 9000 and then last week 374,000.  I had a biopsy last Wednesday and tonight when I came home there was a message on my answer machine. My nurse co-ordinator is telling me to increase the prograf and is starting medrol, somewhat explaining that my biopsy results indicated a rejection.
   I realize that this my not be the appropriate place to discuss post transplant issues so I was hoping that perhaps you could direct me to another forum.  The only people I have encountered that have had transplant are on this forum.
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Avatar universal
You might want to check out Mitchell Shiffman's slide presentation over at the Clinical Options site. According to Shifman, the difference between a 3 million and 7 million viral load can be accounted for solely by testing variances themselves. In fact, any change under a log has little or no meaning and your change is well under a log -- in fact closer to half a log. Assuming Shiffman's underlying study data is correct, this probably accounts for all the studies that show anything less than a two-log drop early on, significantly diminishes SVR. In fact, anything less than a two log drop might not only suggest a slow response, but indeed no response to the drugs.

As to having twice the chance of clearing with half the viral load, I don't think you could extrapolate like that even if the change in your viral load was greater than a log, bringing it down to 700,000 IU/ml or below. Certainly a better chance of SVR at that level, but  for how much better you would carefully have to take apart the study data and see if you can come up with something helpful.

All the best,

-- Jim
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Avatar universal
Thanks all
            I guess its just a **** shoot.

                                                       Ron
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Avatar universal
HCA
Did you clear pre or post transplant?
If you don't want to talk about it any more I understand.
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Avatar universal
Yes, I am a transplant recipient. No, I have been serum undetectable since 6/2004.
I agree that there is no magic number just ranges where response seems to be favorable or unfavorable. I couldn't find the article I was looking for but I did see at clinical care an article by Schiff in which he used >850,000 as a high VL. I seem to recall <400,00 as low but after that it's a blur. If Jim sees this he will likely have some recent numbers somewhere. Mike
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Avatar universal
HCA
My figure came from a study on the 'HIV and Hepatitis' site.
Couldn't locate the same article,but came up with another showing 600,000,so it's a draw.
Seriously though there isn't a universally recognided break point between high and low.
http://www.hivandhepatitis.com/hep_c/news/2005/ad/100705_a.html  There's the reference if you can be bothered to look at it.
Am I right you are transplant recipient?
Are you still positive for HVC?
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Avatar universal
Chit Chat not allowed on this forum!
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Avatar universal
I believe I read somewhere - probably at Clinicalcare - that the low VL is 400,000. I'll try to find it but I am thinking that 800,000 is too high according to recent studies. Mike
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Avatar universal
HCA
Current thinking is that 'low' viral load at commencement of treatment is <800,000 i.u
Viral load goes up and down all the time.
Once mine was 40,000 copies per ml. (different measurement system, but very 'low'.
Immediately started treatment to take advantage and didn't clear.
Your chances are not improved by the fact that your V.L has fluctuated down somewhat.It's a small plus but conversely you are four years older with four years more liver daamage and 60 is a dangerous age in this game.
To sum up the fluctuaction is not significcant.
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