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Going from Fibrosis grade 2/4 to 2/3
I've been puzzled about something I forgot to ask the Gastroenterologist and Hepatologist. I was once Grade 2/4 Fibrosis, and now am Grade 2/3. How is it possible to go from worse to better without clearing the virus. I know I sound naive, but it's a question that's been gnawing at me. Anyone?
Magnum
Magnum
I think 4C summed it up nicely (and am going to be curious to hear how well her bx score correlates with the fibroscan). My experience has been similar with progressive bx's showing improvement which I'm deeply suspicious of since regardless of clean-living there's just too much evidence pointing the other way. The benefits of tx, and I know you've done more than your share, remain in question, but overall the evidence seems to suggest the time served did us relapsers some good.
The key study here used to be Poynard'02
Abstract Impact of pegylated interferon alfa-2b and ribavirin on liver fibrosis in patients with chronic hepatitis C.
Gastroenterology. 2002 May;122(5):1303-13.
PMID: 11984517 [PubMed - indexed for MEDLINE]
which boldly concluded:
"PEG-interferon and ribavirin combination significantly reduces the rate of fibrosis progression in patients with hepatitis C."
as evident from the number of published comments on that paper, this assertion kicked-up a bit of a s*storm in hepato-land and I was curious if anything had changed over the last 4 years. Looks like cautious optimism is justified, at least for kids:
Reversal of liver cirrhosis: a desirable clinical outcome and its pathogenic background.
J Pediatr Gastroenterol Nutr. 2007 Apr;44(4):401-6. Review.
PMID: 17414134 [PubMed - indexed for MEDLINE]
and transplant recipients:
Histological benefit of retreatment by pegylated interferon alfa-2b and ribavirin in patients with recurrent hepatitis C virus infection posttransplantation.
Am J Transplant. 2007 Feb;7(2):448-53. Epub 2006 Dec 6.
PMID: 17173661 [PubMed - indexed for MEDLINE]
for whom it was observed that:
"More interesting is that fibrosis score was improved in 65% of treated patients despite failure of HCV eradication."
A recent comment by Friedman tries to separate fact from spin:
Reversibility of hepatic fibrosis and cirrhosis--is it all hype?
Nat Clin Pract Gastroenterol Hepatol. 2007 May;4(5):236-7.
PMID: 17476207 [PubMed - indexed for MEDLINE]
"Now that the idea that hepatic fibrosis is reversible is taking root, many clinicians are beginning to ask why, if fibrosis is reversible, is there so little progress in the clinical setting, and will patients ever really benefit from antifibrotic therapies? Underlying such questions is a subtle cynicism that the reversibility of fibrosis and cirrhosis has been overhyped—yet another example of the medical media 'spin machine' giving false hope to desperate patients. The situation has been fueled by the actions of ambitious institutional press relations officers. One such example is the worldwide media focus on the use of sulfasalazine to treat hepatic fibrosis, with claims that half of all liver deaths could be avoided1 even though the drug's reported efficacy was based on a single study in rodents.
So what is the truth, and how do we maintain perspective? First of all, progress has been tremendous. The mere idea that fibrosis can regress when the initial disease is controlled or cured is exciting, given the decades of dogma that suggested scar formation was a unidirectional pathway. Ample evidence that fibrosis regresses with control of hepatitis B, hepatitis C, or other chronic liver diseases2 attests to the tremendous regenerative power of the liver, and the rapid progress made in the development of targeted antiviral and disease-specific treatments. "
Personally, I still think caution is the best strategy which would mean:
- get your bx slides read by at least a couple of pathologists
- get fibrotest and fibroscan tests to supplement the bx and confirm all are in agreement
The key study here used to be Poynard'02
Abstract Impact of pegylated interferon alfa-2b and ribavirin on liver fibrosis in patients with chronic hepatitis C.
Gastroenterology. 2002 May;122(5):1303-13.
PMID: 11984517 [PubMed - indexed for MEDLINE]
which boldly concluded:
"PEG-interferon and ribavirin combination significantly reduces the rate of fibrosis progression in patients with hepatitis C."
as evident from the number of published comments on that paper, this assertion kicked-up a bit of a s*storm in hepato-land and I was curious if anything had changed over the last 4 years. Looks like cautious optimism is justified, at least for kids:
Reversal of liver cirrhosis: a desirable clinical outcome and its pathogenic background.
J Pediatr Gastroenterol Nutr. 2007 Apr;44(4):401-6. Review.
PMID: 17414134 [PubMed - indexed for MEDLINE]
and transplant recipients:
Histological benefit of retreatment by pegylated interferon alfa-2b and ribavirin in patients with recurrent hepatitis C virus infection posttransplantation.
Am J Transplant. 2007 Feb;7(2):448-53. Epub 2006 Dec 6.
PMID: 17173661 [PubMed - indexed for MEDLINE]
for whom it was observed that:
"More interesting is that fibrosis score was improved in 65% of treated patients despite failure of HCV eradication."
A recent comment by Friedman tries to separate fact from spin:
Reversibility of hepatic fibrosis and cirrhosis--is it all hype?
Nat Clin Pract Gastroenterol Hepatol. 2007 May;4(5):236-7.
PMID: 17476207 [PubMed - indexed for MEDLINE]
"Now that the idea that hepatic fibrosis is reversible is taking root, many clinicians are beginning to ask why, if fibrosis is reversible, is there so little progress in the clinical setting, and will patients ever really benefit from antifibrotic therapies? Underlying such questions is a subtle cynicism that the reversibility of fibrosis and cirrhosis has been overhyped—yet another example of the medical media 'spin machine' giving false hope to desperate patients. The situation has been fueled by the actions of ambitious institutional press relations officers. One such example is the worldwide media focus on the use of sulfasalazine to treat hepatic fibrosis, with claims that half of all liver deaths could be avoided1 even though the drug's reported efficacy was based on a single study in rodents.
So what is the truth, and how do we maintain perspective? First of all, progress has been tremendous. The mere idea that fibrosis can regress when the initial disease is controlled or cured is exciting, given the decades of dogma that suggested scar formation was a unidirectional pathway. Ample evidence that fibrosis regresses with control of hepatitis B, hepatitis C, or other chronic liver diseases2 attests to the tremendous regenerative power of the liver, and the rapid progress made in the development of targeted antiviral and disease-specific treatments. "
Personally, I still think caution is the best strategy which would mean:
- get your bx slides read by at least a couple of pathologists
- get fibrotest and fibroscan tests to supplement the bx and confirm all are in agreement
I got my grades and stages mixed up, it was late....if you go on Dr. Cecil's site, and a few others, you'll see of patients who were able to take their stages down a notches, with a few people a few notches, ..but it seems like all things hep c related, everyone can have a different experience....
CS: Grade is generally reversable
Stage generally is NOT reversable, but INF can and does reverse fibrosis in some.
CS
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Since you didn't mention HCV status, not sure if we disagree, but according to the liver specialists I've consulted with, stage generally is reversible with successful treatment, and that even includes some with stage 4 damage, which used to be considered non-reversal. Stage also may be reversal with INF, but unsuccessful treatment, but not sure how durable that is. I've seen "Grade" reverse in my own case (from 4 to 2(or1) ) without treatment.
-- Jim
Stage generally is NOT reversable, but INF can and does reverse fibrosis in some.
CS
-------------------------------------------------------------------------------------------------------
Since you didn't mention HCV status, not sure if we disagree, but according to the liver specialists I've consulted with, stage generally is reversible with successful treatment, and that even includes some with stage 4 damage, which used to be considered non-reversal. Stage also may be reversal with INF, but unsuccessful treatment, but not sure how durable that is. I've seen "Grade" reverse in my own case (from 4 to 2(or1) ) without treatment.
-- Jim
Magnum: was once Grade 2/4 Fibrosis, and now am Grade 2/3.
-------------------------------
First, want to say I'm very sorry treatment did not work out and all the best with the future. Your meeting with Gish must have been very reassuring though, and the latest results from the Telaprevir trials should be encouraging.
It's difficult to say what the above notations mean. Fibrosis is stated in "stages", not "grades" while activity is stated in "grades".
The way you noted the numbers it seems you might have meant that you were using the Metavir system (4 stages and 4 grades) and that you were stage 2, grade 4 and are now stage 2, grade 3? However, this is simply a guess. If correct, it shows no change in liver damage.
If you haven't already, my suggestion is to get your own copies of the pathology reports and/or ask your doctor: what is (was) your stage and grade and what scroring system was used, such as 'Metavir'.
All the best,
-- Jim
-------------------------------
First, want to say I'm very sorry treatment did not work out and all the best with the future. Your meeting with Gish must have been very reassuring though, and the latest results from the Telaprevir trials should be encouraging.
It's difficult to say what the above notations mean. Fibrosis is stated in "stages", not "grades" while activity is stated in "grades".
The way you noted the numbers it seems you might have meant that you were using the Metavir system (4 stages and 4 grades) and that you were stage 2, grade 4 and are now stage 2, grade 3? However, this is simply a guess. If correct, it shows no change in liver damage.
If you haven't already, my suggestion is to get your own copies of the pathology reports and/or ask your doctor: what is (was) your stage and grade and what scroring system was used, such as 'Metavir'.
All the best,
-- Jim
Forseegood pretty much nailed it.
Unless you have been on Interferon sampling error would explain the reduction in stage.
Grade is generally reversable
Stage generally is NOT reversable, but INF can and does reverse fibrosis in some.
CS
Unless you have been on Interferon sampling error would explain the reduction in stage.
Grade is generally reversable
Stage generally is NOT reversable, but INF can and does reverse fibrosis in some.
CS
Not that I'm any expert on this, and perhaps I should leave this to someone else to answer, but if your gaging this from a biopsy scores, it's been said in studies that biopsies can be off by one to even two grades at times...
Some of this is because at times, different docs will read the same slides differently..... Also, the liver is not necessarily uniform in it's damage, or lack of it...
When I was taking my fibroscan with HR, (and he scans a lot of the liver, I understand that in other places, fibroscan techs do not scan this much of the liver, but don't quote me)
He told me that much of my liver was a low 1, a high 1, and also that some of it was a low 2, in terms of the way biopsies stage fibrosis damage...using that a biopsy staging rubric...so if I were to go get a biopsy now, perhaps I would be graded a 1, or a 2, depending on where they poked....
A biopsy will lance only a fairly small portion of one's liver, obviously, no one is going to get needles all over the liver taking samples...
so maybe either one of these scenarios played out with you? and your first biopsy was off? just speculating of course, I sure don't know what happened....
Some of this is because at times, different docs will read the same slides differently..... Also, the liver is not necessarily uniform in it's damage, or lack of it...
When I was taking my fibroscan with HR, (and he scans a lot of the liver, I understand that in other places, fibroscan techs do not scan this much of the liver, but don't quote me)
He told me that much of my liver was a low 1, a high 1, and also that some of it was a low 2, in terms of the way biopsies stage fibrosis damage...using that a biopsy staging rubric...so if I were to go get a biopsy now, perhaps I would be graded a 1, or a 2, depending on where they poked....
A biopsy will lance only a fairly small portion of one's liver, obviously, no one is going to get needles all over the liver taking samples...
so maybe either one of these scenarios played out with you? and your first biopsy was off? just speculating of course, I sure don't know what happened....
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