Spontaneous Clearance of Chronic Hepatitis C

[jmjm530]

I was surprised when I came across these two studies recently. That's because the studies talk about spontaneous clearance in *chronic* cases, not acute cases where  the concept is more familiar.

Keep in mind they are only two studies and while interesting on a number of levels, I don't think it prudent for anyone to use them to guide any treatment decision as the per cent of those with spontaneous clearance is simply too small to factor into the decision as I see it.

That said, it may explain a number of things including the occasional person who claims they were "cured" by this or that without SOC. If these studies are correct, it may turn out that they would have been cured anyway, just by a small statistical chance.


http://tinyurl.com/2hddnu
http://www.journals.uchicago.edu/CID/journal/issues/v42n7/38040/38040.html

[trebor45]

two months ago my liver panel came back with 486 ALT, 263 AST, had a ultrasound a month ago, it showed liver was normal, just got results back from liver panel i had done last week, ALT 35, AST 13, has anybody ever heard of such a thing? I have had hepc over 35 yrs now, i take lots of vitas, and herbs, including selenium, and milk thistle, also had 2 treatments with interferon, and ribaviran, partial respondent, that was 15, and 12 yrs ago

[ladybug52]

Wow! I'm so proud of you for your selfless time, energy and dedication in fighting Hep c. You turned a challenge into a calling, and I'm sure many have benefited from your exposure to this disease. Educating the medical community takes more than knowledge, it takes courage to come forward and speak from the heart. You're much braver than I am, and you have a big heart to offer support counseling. Thank you for battling the bias that hep c brings, keep up the good work and check in now and then to say hi..
Hugs,
Bug

[Whrose]

yes. i had hepc! G3, F1G2 with bx, hi viral load>20 mill.  length of infection over 20yrs from needle stick exposure probably during my time spent working at a trauma center. aymptomatic the whole time, infection found on pre employment testing lab upon new job application. tx with pegintron 96mcg/week and riba 1000mg/day divided for 6 months,  rvr 4wks to SVR. tough tx with epogen for 4 months. btw my children and husband of 30 yrs have no virus :) which was a better gift then getting that SVR!  many may ask "why treat with this histology". it is an individual decision for sure but after 30 yrs in critcal care units i decided to give my liver the best gift to cruise into the golden years with and that was viral free. from my long experience in critical care practice i admit i am pro treatment- many reasons here based on my life and work experiences.  but after being in the hepc community for a few years i have matured to a healthy respect for individual rationals not to treat with present SOC.
   i must admit i have seldom seen such an educated community and because of this i was a well informed patient and had my personal ideas of treatment in which to partner with my treating gastroenterologist. i shared the same fear and confusion at the beginning of my journey with disappointment in the medical community and the lack of information i needed to make my best choices and will be always grateful for the educational forums and internet which brought  me through it all.  i have since dedicated my time to educating myself, hospital medicals with my personal experiences, support counseling at my hospital for hcv, and advocate for liver health.  amazing but true many community hospitals have no clue of the challenges of hcv infection.  my primary had no idea what genotype meant!  i found my self sharing my experience with my peers in order to awaken them to our needs and community.  it is now one of my passions and i must say i have not yet been able to satiate my curiosity in hepc pathology. my hope is the hope of us all *cure and prevention*,and plan to spend my lifetime supporting those dreams.
   (((bug))) thanks for asking. if i remember right you are SVR  too! i have seen your posts many times and congratulate you on your strengths and wonderful heart of support you give to all. your inital experience with your doc while sad can only be understood in that hcv was not well understood in those days and treatment very limited. a sad fact but then again...look how far we've come! not good enough- yet, but getting better all the time. hope you are feeling better. in regards to your question of low antibodies seeming to confirm you were not fighting disease can not be accurately assessed, but i think that the levels alone would not reflect the level of your particular immune response or active infection.  antibody production is not the initial immune reponse to viral infection and come later as the adaptive (humoral) immune response is stimulated by epitope presentation. really all it can tell you is you have been exposed and you have produced antibodies which indicates immune response. unfortunately this arm of the immune system is unsuccessful to beat the disease because of the mutifactorial causes of immune disregulation and genetic variabilty characteristics seen with  hcv. research has shown it is the initial cellular response that is responsible for viral clearance and both ribavirin and interferon promote the Th1 response. we all have the ability to mount the good defense on a cellular level but it seems our particular genetic traits may infer advantage in this regard.
   although this diagnosis was devasting to me i believe that God brought to me to it and He will bring me through it. all for a reason and i am proud to be in this community. i have met so many amazing warriors and will fight for our dignity and battle all stigmas and ignorance that surround us. unfortunately i don't have the time to devote on forums as in past since returning to a busy life after treatment but on my visits i think this forum is great and does so much good.
    hugs

[ladybug52]

Very well stated. I think you're right. Where are you in your journey? Do you have hep c and have you treated.
I believed in 92 that I had spontaneously cleared the virus based on what the drs. told me. I had antibodies but when they "tested" my antibody level it was 'very low'. Based on that and my lack of symptoms the dr's thought I was one of the lucky ones. Well, now that I know more, (and hopefully those dr's do also) I know that lack of symptoms does not mean clearance. I wish I knew what test I was given when I was told that I had a very low antibody level. It makes no sense now. If my antibody titer was low, it would seem to confirm that I wasn't fighting the disease. Right?? The dr was actually treating hep c patients but they were a lot sicker than I was. Hope he treated them more aggressively than he treated me, but I don't think the SOC nowadays existed then. He biopsied patients with signs of liver damage, didn't feel as if I qualified for a biopsy. I was frightened initially, but kind of grateful to find out I had nothing to worry about:) Those were the good old days...
Bug

[ladybug52]

What an idiot I am! Here's the url:http://www.akidjustlikeme.com/id92.htm
As I said you have to go half way down the page to see the PET scan, featuring my brain activity on the right side of the page....
Thanks for helping me finish that thought:)
Hugs,
Bug

[meki]

Where ladybug??? Where? The pic... (what chicken... What road?) Hey --- where's the pic?

LOL!

Meki

[Whrose]

i have been following this discussion for quite some time and have spent many hours cruising literature on the immune response in hcv, mechanisms how hcv disarms the immune system, and the immune environment in the liver. sallies article on replicative homeostasis is one of my favorite but IMO does not quite explain the immune response in acute and chronic infection and perhaps focuses more on replication viral characteristics.
   like all here i am quite interested in factors of spontaneous clearnace vs viral persistance.  i get the impression that many here pursuing methods to keep their immune system healthy by expensive vitamins/herbs suplements in hopes of perserving histolgy thus damage from the virus are placing importance on the viral load and liver enzyme levels as a measure of success. while i agree that many of those supplements do benefit liver metabolic function and cellular homeostasis; i do not agree that they are the reason for progression or lack of fibrotic damage to the liver during chronic infection. i get the impression that some believe that such measures to boost the immune sytem may also factor to their decreased viral loads. how is that achieved? what arm of the immune system are they strengthening, cellular or adaptive? in hcv cell damage directly correlates with the hosts immune response. hcv replication ( known to produce up to 1 trillion virons a day) do not kill the hepatocyte but the cellular Th1 immune response to the virus presence in the hepatocyte does. this is why in acute infection we see high levels of liver enzymes.
    from my understanding chronic infection shifts the immune response from a TH1 response (which btw has been the primary response found in individuals who spontaneously clear hcv) to a TH2 response.  the cytokines stimulated from the cells in each response are antagonistic and are responsible for regulating not only immunity but  inflammation and hematopoiesis. in theory if the cellular immune response dominated in the course of chronic infection the cytokines expressed in this response (pro inflammatory) could contribute to more cellular death and increased fibrosis. because of the shift to a TH2 response viral replication may surge or ebb without signficant liver damage as the cytokines expressed in this response are anti inflammatory. while measuring viral loads are the cornerstone to assess response to therapy i can not find evidence that the fluctuating viral levels have anything to do with histolgy or can be markers in the level of inflammation and fibrosis caused by viral infection.
     since my odessey in the world of hcv i have read of many peoples experiences with treatment. i have yet found any research that defines viral levels and also liver enzyme levels as definitive markers of progression of fibrosis. so why i ask myself do many with chronic infection believe that by these measurements they can accurately assess their response to "holistic, vitamin, natural, etc" measures as evidence that these measures are successful to prevent fibrotic progression? i often hear of many using products that claim to boost their immune system. again i can find no specific evidence of cellular aspects in the immune system that these products promote.  the hard truth is that the best definitive way to prevent liver damage in hcv is by viral eradication and not decrease in viral loads or liver enzyme levels. the only purpose of the multitude of supplements ($) is to promote cellular function but this can not prevent the fibrotic changes in chronic infection which is immune related, influenced by viral immune disregulation, and genetically influenced.
     several researchers have developed vaccines to boost the Th1 cellular immune response in theory that this will adjunct viral clearance (by shifting the body back to a TH1 response) but have yet to find success or significant decrease in viremia or viral remission. again i wonder at the expense that many with hcv take preferring these methods in lieu of the SOC that may eliminate the virus. i do understand the many reasons of why SOC is not appropiate and not successful but certainly is the best medicine available for us living with chronic infection who want to eliminate the risks of liver damage,progression to cirrhosis, and HCC not to mention the extra hepatic effects from hcv.
      don't get me wrong. i love my antioxidants and vitamins and i do believe they promote cellular function and homeostasis but to suggest they prevent fibrosis and give one more time to delay treatment is far fetched and an illusion in view of hcv immunopathology.  and although many with chronic disease may never progress to cirrhosis and thus delay treatment how confident can they be to live a full life without disease progression and liver damage.  so far medicine is unable to accurately predict specifically what category one may be in with chronic infection although there is research that is studying genetic factors in hcv clearance and pathology the information is not available to the chronic sufferer. i lean towards prevention of damage caused by viremia, restoration of immune balance accomplished by eliminating infection, and liver homeostasis by viral eradication.  the only way to accomplish this while not easy is by treatment known to eliminate the virus.  to delay SOC if able to medically tolerate tx in lieu of 'supplements' are bypassing a great chance to be viral clear.  my opinion.
my best regards to all and may we all find the cure word in our journey!

[ladybug52]

Good to see your name appear. It was Kit07 who had the MRI done. ADHD is usually diagnosed by symptoms, here's a website with more info:
http://psychcentral.com/lib/2006/diagnosing-adhdadd-in-adults/
I attended a continuing ed course on ADHD and they showed a PET scan of a "normal" brain, and a brain of someone with ADHD. The PET scan shows the high area of radioactivity which is associated with brain activity. The PET scan was really cool to look at because it showed all the activity going on in the brain by these bright neon like colors. You'd think that the ADHD person would have had a rainbow of colors exploding on the PET scan....but it was the "normal" brain with all the colors. The ADHD brain had far less activity, and  the theory at that workshop was that the ADHD person has to work harder to stimulate brain activity. There's a lot more info about ADHD and MRI's but I think the importan thing to remember is that ADHD is usually dxed by childhood behaviors, not something aquired with hep C.
Here's a picture of a brain without ADHD on the left, and my brain on the right....it's about 1/2 way down the page:)
Hugs,
Bug

[meki]

There's Myown - was begining to wonder about you.

Hmmm... Spontaneous and early response sound kind of similiar in mechanism. I'll have to think about this.

Meki

[Myown]

It IS all about money,you're right its too bad though.

Post tx -  I could be better, thats for sure. I am having horrible hot flashes as of recent and also I have to go to a Neurologist. I had a brain MRI and it showed a change in the white matter pointing to possible small blood vessel disease.

There doesn't seem to be many people who have hep c who have had brain MRI's so going to a neurologist who is not used to seeing the brain of someone who had hep is the concern I expressed, and my concern was understood.

Interesting though, I'm wondering if some of these post sx people experience are brain related from the hep and not from the meds. Also I wonder if those with hep C who were dx ADHD are misdiagnosed as far as ADHD and are experiencing the effects the virus has on the brain. I don't know if doctors use MRI's as part of the exam to dx ADHD.  As you know the virus can cross the blood brain barrier and my concern is if I have cryo (test was never done correctly) maybe cryo caused the inflammation of the blood vessels or whatever the problem is and because being the Peggasys molecule is too large to cross the blood brain barrier, maybe would be the reason the blood vessels get inflamed. I believe its an autoimmune attack that causes the vessel problem but at this point I am dizzy from reading all this stuff so I may be getting things mixed up.

You would think that because these doctors know the virus crosses over the BBB, that they would include an MRI as part of the examination. But ..... a member had posted an article that said the contrast used with MRI's can cause a problem for those chronic liver and also those with kidney problems, so it would be important to discuss this with their doctor before getting an MRI, if someone is thinking of doing so.

So from what I was told the Neurologist keeps an eye on the problem, whatever that means. I guess he'll let me know if he sees a mini stroke on the horizon. That sounds like fun. Thought this stuff would be over when I completed tx, but its not. Well we know that HIV can effect the brain so it really doesn't surprise me that Hep c can also cause similiar problems. I'm just not happy about the pleading I had to do with several doctors to get an MRI and now it winds up I was right - there is a problem. It's unbelieveable, none of us are medical people yet most of us dx ourselves as far as hep C and now again I found another problem without the help of a doctor.

Well anyway hopefully the Neurologist will say its not that bad. My mood and attitiude is up and down and that bothers me. I don't like feeling this way, but this too shall pass hopefully soon too. I had to remind my husband about an hour ago that he said "Till death do us part." LOL

Gotta run. Good talking to you. If you have an thoughts on the subject, I'd like to hear them.

Thanks.
Ps. I think I remember Cuteus was going to a neurologist. Do you know if she had an MRI of the brain? It would probably be hard for you to remember, but just in case.... I would be curious to see what hers read. I know someone else on forum mentioned brain MRI showed something similiar to mine and now I can't remember who, but anyhow take care.

[niceguy2007]

i also took a rabies shot on tx so i wonder what difference that cudve made.  it resulted in digestive convulsions and panic attacks all night long andi cudnt complete the rabies course.  

[Myown]

I take MT and I know its good for the liver. It does seem to lower enzymes and supposedly helps the immune system. As far as MT making the liver "stronger," I'm wasn't aware of that, but my liver was stage O - and if I remember correctly, yours was also,,,so we do have 'strong' livers and yet didn't spontaneously clear. My liver enzymes at highest were high 30's and touching 40's, so my enzymes were never the problem. But anyhow I try to looked at both sides Conventional and Alternative and felt that at this time Conventional medicine was the route to take.

As far as waiting to tx, I didn't want to wait after giving it thought. I was concerned that my immune system would be in constant overdrive trying to rid the virus from my body.  If I did tx I figured injecting interferon would only put it in overdrive for 6 months, but now my feeling is that because the virus mutates and the body does not recognize it as an invader,,,,maybe the immune system comes out of overdrive and settles down. But on the other hand, the longer the virus is in our body maybe this gives it chance to enter other areas that it may not have had time to do if it was eradicated early on. Who knows? The doctors certainly don't.

[jmjm530]

Yes, you think they would be studying the h*ll out of these cases for common links and possible future non-toxic cures. But where is the $$$ in a "non-toxic" (non-pharmacological) cure for HCV? Doubt you will see much money spent here.

Good to see you stop by. How are you doing post tx?

-- Jim

[niceguy2007]

here is one possible scenario

you start taking milk thistle, but viral load does not decrease.  however, your enzymes get better.  you take milk thistle regularly.  milk thistle could make your liver gradually stronger, so that all of a sudden, after two or more years of milk thistle, your liver suddenly kills the virus by itself, even though you didn't see the viral load decreasing earlier.

[Myown]

Hi Jim,

Several doctors that I consulted mentioned spontaneous clearance for acute cases, but never chronic. I had heard chronic HCV clearance a couple of times on forum by members who knew of someone that cleared, but never had read of a study and was surprised in fact when I first read this post. I did and still do believe it is possible but I really wonder how much more research there will be. I wish I knew the results of some other labs (of those mentioned in study) and if their test results were the similiar to each other - that's IF they were even tested for the labs that I am curious about. I have found that some tests are only done if I request it.

For instance my progesterone was one of the tests that was not in reference range (low). I had this test prior to dx. As I'm sure you know - progesterone supports the immune system. My zinc range was low and again zinc is needed for a strong immune system. As far as vitamin defiency I know it's not my diet because I take good care of myself. IMO its the body being depleted as it tries to fight off the virus.


I would take a guess and say that if these people who were chronic and cleared, they not only had the low VL in common but also had other common links(such as NORMAL levels of zinc etc) but who knows if this will ever be looked into anytime in the near future. If their body had the ability to fight off the virus on its own as in these cases mentioned,IMO it's only logical to test the levels of nutrients in the body that obviously helped the bodies defences. But then that would be opening the door to alternative medicine and not too many conventional doctors will jump on that bandwagon.

Hope all is well with you.
Take care.

[SonicBandaid]

Hi jmjm530,
I have been away, sorry not to reply to your post earlier.
There has been a suggestion for some time that HCV genotypes and viral levels are in some way related, with HCV genotype 1(s), for example TENDING to be associated with higher levels that genotype 2 or 3.  As everyone knows (and have known for sometime) viral genotype is a critical determinant of whether or not someone will respond to interferon (and other therapies); Sallie wrote one of the early papers on this many years ago: "Genotypic analysis of hepatitis C virus in American patients; Hepatology, 20, 1405-11. 1994.  The importance of genotype has been confirmed in dozens of subsequent papers.  

With regard to viral load, As Sallie points out, it can't be the absolute levels of virus by itself that determines the effectiveness of therapy; treatment of patients with acute HCV, where viral load may be 50-1000 x the viral load during chronic infection, is MUCH more effective than treatment given during the chronic phase.  

Sallie is saying, I think, that the mechanism(s) that maintain genotype and are responsible for generating viral load are one in the same.  Now, viral load will fluctutate, because of the homeostatic mechnism he postulates but this has nothing to do with changing genotype (he certainly hasn't suggested that would or could occur).

As for "error catastrophe" due to ribavirin, this theory has been highly suspect for a while now, not in the least because ribavirin is ineffective when used as a sole agent.
Take care,
Sonic

[tallblonde1]

Thank you SO much for your thoughts on this.  I'm really going to give this some serious consideration.  It seems that the potential upside far outweighs any possible risks.  The "pulse" approach is very interesting, too. And makes a heck of a lot of sense.  As I think about a gameplan, I may indeed contact that particular doctor, as well.

I'll let you know what, if anything, comes of this.

Thank you again, Jim.  I really appreciate it.

Have a great weekend!

Susan

[jmjm530]

The other thing I would discuss -- esp with Dr. A. -- is would he recommend strictly one injection of Peg (and which Peg but I'm thinking Peg Intron) or would he combine the Peg with ribavirin. If the latter, would he pre-dose for let's say a month, since I doubt you would get your serum riba levels up very much in only a weeks time.

[jmjm530]

If in theory you did go ahead with SIA, I would imagine that you would want to time start of treatment with a *recent* viral load test. By very recent I mean within two weeks or however much time it takes from drawing the blood to getting the results. That would mean two things. First, having the injection(s) on hand prior to the viral load testing; and second, be prepared to do a series of weekly or monthly viral load tests pre-treatment if the first test isn't low enough to whatever you and your doctor pre-determine an acceptable level, which in your case might be under 500 IU/ml, but just speculating here.

I mentioned Dr. L.B. in the preceeding post because of his work with "pulse" therapy. Pulse therapy is different from SIA but akin in philosophy, being using a minimal amount of drugs to kill the virus. How pulse therapy works is that you take your first injection plus riba and then test viral load weekly. As soon as you're non-detectible, you stop injections. That's the end of "pulse" number 1. Then you continue weekly viral load tests. Assuming the virus comes back (last time I heard the virus always came back after pulse 1 in the few subjects he treated) then you start the cycle again with peg and riba and weekly vl tests until non-detectible again. Once non-detectible, you have finished pulse 2. In theory these pulses are continued until the patient stays non-detectible. The idea behind it is that each pulse trains the immune system a little more to take over on its own. Last time I checked -- over a year ago -- he had treated under a dozen patients with this treatment but no SVRs although he did get someone viral negative for four months. Things may have changed since then. Again, his protocol is different from the SIA approach that myself and Dr. A. mentioned but I suppose you could look at SIA as a single pulse. In any event, Dr. L.B. is big on out of the box and frequent testing and might have some worthwhile thoughts on SIA. I've also been thinking about it since the last post and asked myself if I would do it if in your shoes. Answer is I don't know but I would probably speak to as many of the several doctors already discussed to get more feedback. Often these fellows are not as hard to get in touch with -- phone and/or email -- as people think, even if you're not a patient, especially if you present yourself as knowledgeable and have an interesting case for them to consider.

All the best,

-- Jim

[tallblonde1]

Good to see you, too.

Probiotics can boost the immune system, which is obviously a good thing for people in our shoes.  I used to just rely on eating yogurt daily, but decided to add the probiotic supplement.  

After nearly four years of this, I think I've become a bit of a supplement junkie!  My protocol list keeps getting longer and longer.  Too bad health insurance doesn't cover this self-treatment approach.

So where are you at in the treat/not treat dilemma?  

Susan  

[Forseegood]

just my big ego, ha ha! and I have a bad habit of just scanning posts...no I understand, my vl was 182,000, but never over 200k, which ain't bad I guess...she is welcome to get HR;s info from me, Ina has her number, and mine...TB you might want to get a fibroscan if you haven't biopsied in awhile, infinitely more fun then a biopsy....! course, youre call...be well..

[jmjm530]

You also might want to try and email or get this fellow on the phone. He works in the same group as Dr. J. in NYC and my understanding is that he's done some work with unorthodox treatment approaches such as what was called "pulse" therapy because I would think most cookie cutter doctors would just shake their head at this approach.  But I do think he might find your case interesting and might have some ideas although just be careful with ANY of these doctors as in the end it's your liver and with them it may just be a novel idea or experiment.
http://www.cornellphysicians.com/gvl2002/

-- Jim

[jmjm530]

I suppose there's a potential downside in everything but see more of an upside if you can limit treatment to four weeks or less, and you couldn't do better than Dr. A. to oversee your situation if he takes you under his wing, as long as you both agree beforehand to limit the treatment as human nature can get us carried away once we begin something.  If it were me, I'd want viral load tests weekly at a minimum with a sensitivity of at least 5 IU/ml like Quest's "Heptimax", and ideally might want a 24-hour as well as a 48-hour VL as well. Of course, if you only decide on one injection, a lot of this becomes academic as it either will work or not.

You might also want to consult with a researcher who used to post here under "hepatitisresearcher" or "HR" as we call him. He's not a hepatologist as I understand it, and has done more work with hep "b" than "c" --  but still might have some thoughts regarding this type of approach. He's also big into nutritional supplements, etc. "Forseegood" has his email and can put you in touch. Bottom line is that you will be going into somewhat uncharted territory but I just can't see too many long-lasting negative effects from one or two shots, and if it works, hey that would be really nice.

Thanks for posting your supplement list again.

All the best,

-- Jim

[tallblonde1]

Jim,

You've really given me a lot to think about.  In fact, I spent a great deal of time tonight talking about the SIA (love that!) with my hubby.  The whole thing scares him, but that's because he's been in a state of denial about this situation ever since I was diagnosed nearly four years ago.  The good thing is, Dr. C is known for unconventional approaches and I'll bet I could easily get him to sign onto this, after a quick phone consult with Dr. A.

Foreseegood,

I'll be eager to see what path you decide to take: Vertex or otherwise.  I would like to contact HR, but I no longer have any of Ina's contact information after a recent computer crash.  And she doesn't have my e-mail address either because it's new.  

How about this....my new email address is: ***@****.  Ina can help you figure this out.  If you're able to send me HR's contact info, I'd be very grateful.  Also, please tell Ina that I said hi.  I've been very busy lately with a relatively new job, but I continue to keep her in my prayers.

Best wishes to both you and Jim.  It's nice to reconnect with old friends.

Susan