SVR, sustained suppression or elimination?

[spectda]

I guess that is the million dollar question. I was reading another thread where someone mentioned that it was about suppression of the virus rather then it's elimination.

It seems like there would be evidence that our immune system was actively suppressing the virus after we stopped taking the treatment drugs. I suppose the immune system response might be undetectable though.

also found it interesting that someone mentioned in another thread that their relatives virus may have come back after svr because of using immunosuppressant drugs to combat another illness. I would expect that would mean that we would be advised to avoid immunosuppressant drugs after svr and that there would be evidence at this point that those drugs could risk long term svr.

[Aaron57]

J Med Virol. 2010 Sep;82(9):1554-9.

Diagnosis of occult hepatitis C without the need for a liver biopsy.
Castillo I, Bartolomé J, Quiroga JA, Barril G, Carreño V.

Foundation for the Study of Viral Hepatitis, 28015 Madrid, Spain.

Abstract
The diagnosis of occult hepatitis C virus (HCV) infection is based on the presence of HCV-RNA in the liver. This study aimed to evaluate the use of combining non-invasive assays to diagnose occult HCV. A total of 122 patients with occult HCV (HCV-RNA in the liver without detectable anti-HCV and serum HCV-RNA) and 45 patients with cryptogenic chronic hepatitis (without HCV-RNA in the liver and negative for anti-HCV and serum HCV-RNA) were included. HCV-RNA was tested in peripheral blood mononuclear cells (PBMCs) and in 2 ml of ultracentrifuged serum. Anti-core HCV was examined by a non-commercial enzyme-linked immunosorbent assay. All controls were negative for the three HCV markers studied. Among patients with occult HCV, 36% were anti-core HCV positive, 57% had serum HCV-RNA after ultracentrifugation, and 61% had HCV-RNA in PBMCs. Combining the results of the assays, 91% of the patients were positive for at least one marker. Intrahepatic HCV-RNA load was significantly higher in patients who were positive simultaneously for the three HCV markers than in patients who were negative for all markers (P = 0.006) and than in those with one or two HCV markers (P = 0.039). Replication of HCV in liver was detected more frequently in patients with three (93%, P = 0.002), two (82%, P = 0.001), and one HCV marker (73%, P = 0.011) than in those without markers (27%). In conclusion, testing for all these markers allows diagnosis of occult HCV without the need for a liver biopsy and these assays may help to elucidate the clinical significance of occult HCV infection.

PMID: 20648609 [PubMed - in process]


I guess it's a matter or perception .

What factors define "cure" ? Suppression or total eradication , big toes excluded ......

The point being , if 1a and very lucky to achieve SVR , what is the course of action, or, non action after Tx ?

If Tx is finished and after 6 months & still SVR , do you just say ... ok , i'll never ever check this again yahoo ! ! Or do regular check up's ?

Why would a person check later in life after  having SVR'd if they are "cured" ?

As we all know, this virus and how it acts or reacts ,,,  at the end of the day , nobody  really does know .... do they ....

[eureka254]

I do equate SVR to cure, but that being said, it is an interesting if academic question regarding suppression v. elimination.

Perhaps an inappropriate analogy, but my mind keeps going back to chicken pox -- most of us clear chicken pox, end of story... but there are those who develop shingles later in life when the virus 'reactivates' in a 'perfect storm' situation.  But millions of people have chicken pox and never have shingles, right?

Perhaps the same is true of hcv and SVR... millions of people never relapse after clearing infection, but some do if their bodies are harbors of 'perfect storms'?  Science still can't explain why some sustain SVR while others relapse... so it shouldn't be a foregone conclusion that once declared SVR that relapse is not possible.  SVR is durable, but not absolute, imho.  Medical terminology being "Sustained Viral Response" implies to me the virus is still present -- otherwise, it wouldn't be called 'response.'

My thinking is that SVR is suppression of viral activity and therefore elimination of the disease, but it may not correlate to 100% elimination of the virus in all cells.

[Bali05]

that`s great , thank you  :-)

[desrt]

Sorry, I had to rush back to work. I knew I should have taken the time to pst the link.

http://www.ncbi.nlm.nih.gov/pubmed/20648609

[spectda]

Although our immune system suppresses invasion all the time, part of the diagnosis of certain diseases besides the obvious symptoms and distress of the patient is based in part on immune system response, wbc count, specifically which white blood cells, platelet levels, rbc levels.

I actually wasn't thinking of occult infection when I started the thread. I was thinking that perhaps in the same manner that combos of drugs suppress (not eliminate) hiv and hep b, that hcv tx teaches our immune system to suppress the continual attempt of the virus to replicate.

Perhaps that is what is meant by occult infection, but I thought it meant there may be hcv remnants in our body tissue, but that it is not replicating or trying to replicate.

[Trinity4]

Well, I should have known when it involves any type of test you will be in the forefront. :)

[Bali05]

the concept of "occult HCV infection " is new to me and I will further investigate it
before I come to any conclusions.
For example I was just reading a medical paper
from a few years back that looked at occult infection and found that even with
HCV RNA negative in serum an occult infection sometimes existed in the liver
They took liver tissue and found HCV still replicating but called it a mild form
of the disease.What this means , I have no clue  . In some individuals enzymes were still elevated even with HCV RNA negative in serum and no other burden on the liver present but occult infection.
Why do I want to know ?
Because I am investing a great deal into this disease and I am interested in EVERY
aspect. Even if for the time being  there is nothing you I do about an occult
infection it is my personal preference to know everything I can about it.

So if desrt or anybody else is aware of any accurate bloodtests regarding the
matter I would love to take a look at it.

Cheers
b

[miserableandreadytoquit]

Well I can't wait to be svr.  It will be a while, since i am only shot 14 tonight, but I know that once I am "cured" sitting on my back porch with a glass of good wine in my hand and enjoying the scenery will mean a whole lot more to me than it ever did in the past.~:0)

[RobertBeWell]

Ahh, nuts. So much for proofreading. This:

"Personally, I believe we will never be completely rid of ACTIVE virus (keyword ACTIVE), "

Should have been:

"Personally, I believe we will never be completely rid of INACTIVE virus (keyword INACTIVE), "

Kinda spoiled my whole point of view there.

[RobertBeWell]

"Even if occult exits what the hell can anyone do about it anyway?  SVR is durable and if your liver is not under siege any longer and possibly regenerating isn't that the most important thing?"

That's exactly my thought. Nothing can be done anyhow, so why sweat it.

Personally, I believe we will never be completely rid of ACTIVE virus (keyword ACTIVE), as study after study has found viral RNA in SVR patients even > 5+ years post SVR.

But if the net effect is nothing, then who cares? Personally, when I SVR I'll worry about it no more. The damage stops, and that's all I care about.

Oh, and to address an earlier comment about not being able to detect the immune system surpressing things - your immune system surpresses thousands of invaders every day, Hep C or not. That's the job of the immune system.

The way you detect that is the absence of widespread systemic infection and the mortality that follows :-) If your immune system was severely compromised, you could find that a paper cut resulted in your untimely demise.

Robert

[Trinity4]

Bali, why would it matter?  Even if occult exits what the hell can anyone do about it anyway?  SVR is durable and if your liver is not under siege any longer and possibly regenerating isn't that the most important thing?

What does a person say?  Oh Hi, my name is Bali and I'm SVR but I have occult Hepc
virus and go into this big long explanation that really has no significance in the big scheme of things?

[Bali05]

It matters to me.
Never heard of any high accuracy blood test for "occult HCV infection".
How do you know this and what are the test names ?

[Trinity4]

Deb, that's for sure about sharing the good, bad and in between.  You never kicked me to the curb and that speaks volumes.

Trin

[spectda]

I agree Deb-
I don't want to know if it's in my big toe either. If I svr, and I am not getting sicker any longer that's what is important to me. And if it is eating at my brain what can I do anyway, I don't think they have figured out how to do a brain transplant at this point. I just found the whole subject interesting.  

If it was going to pick up residence somewhere I would prefer something disposable like a toe rather then a liver.  

[nygirl7]

Dave it's cool, Trin and I will share - we're friends so it means sharing the good and the bad and all in between.

Either way you have to realize even if the concept of occult is actually true - so what if there are a few of them floating about in your big toe.......as long as the damage is halted and your liver can even get better who cares. (Although I really dont believe it is true).

I wouldn't want to know if it's in there or not as long as I test UND I am fine and happy with that completely. (But I had such a hard time getting to UND and then post EOT getting back a false positive I am sure I would be one to get this positive result - since it makes no difference but would probably drive me crazy, I wouldn't take that test for all of the world).

[Bali05]

"There is now a series of blood tests you can do that will predict with a high degree of accuracy whether or not you carry occult virus "

What is the name of these tests ?

[desrt]

Multiple studies have shown that 85-90% of people who become serum undetectible, whether with IFN or clearing it on their own, will still show a recognizable form of the virus either in their liver, their spinal fluid, or their lymph system. There is now a series of blood tests you can do that will predict with a high degree of accuracy whether or not you carry occult virus and you can skip the spinal biopsy. If it matters to you.
Personally, serum UND works for me.

[Anne1717]

I've gone to my happy place and threw up a little in my mouth

[Andiamo1]

At my last visit to Mt  Sinai, lat June, I asked this same question.  The opinion at Mt Sinai is that in most cases, the virus is eliminated.  In some people, the virus does persist at an undetectable level.  When SVR people take heavy immune system suppressants, a small number will relapse.  In very rare cases, SVR people do relapse with no identifiable cause.  This from Dr Ds assistant.

[spectda]

"Hey, if I wore a bikini, I’m sure it’d evoke strong emotion in you as well, Dave…"
hahaha

[Bill1954]

Hey, if I wore a bikini, I’m sure it’d evoke strong emotion in you as well, Dave…

[spectda]

Your point is well taken. If damage ceases or reverses and the virus is undetectable then it enough for me. I certainly won't spend my remaining years being concerned about it if I svr.

Still makes one wonder about the few that have reported that possibly immunosuppressant drugs reactivated the virus,

- Dave

[spectda]

I choose deb as the best answer because I want to be cured if I svr regardless of what the real truth is, and mostly because Deb looks really good in a Bikini.

Of course at the time Trin had not commented, so well just have to call if a tie for best answer. This is the first time I have chosen best answer I think, it just evoked so much emotion (the bikini I mean)

Seriously though, I guess this question has been running through this forum and the drs and scientists minds for a while.

- Dave

[Trinity4]

I believe SVR to mean cured as well.  Even if a few of those weakened, powerless occult rascals are running around in the body there are so many studies to support liver damage is halted unless of course a person is drinking excessively or pounding  the OTC pain medication or pain pills with acetaphetamine or ibuprofen.  This is a primarily a disease associated with the liver and no more liver damage is good enough for me, especially when the damage is late stage before the SVR.

Trinity