Epidemiology of chronic hepatitis and cirrhosis in Turkey

Transcription

1 Epidemiology of chronic hepatitis and cirrhosis in Turkey Prof. Dr. Cihan Yurdaydın University of Ankara Medical School Gastroenterology Dpt. VIRAL HEPATITIS PREVENTION BOARD MEETING, ISTANBUL, NOV 12-13, 2009

2 Projection of Lifetime Outcomes in HCV Infection 100 acute HCV infections 20% recovery 20 patients 80% persistent infections 80 patients 30% stable, chronic, nonprogressive 40% variable progression 30% severe progressive hepatitis 24 patients 32 patients 24 patients Antiviral therapy 56 patients End-stage disease, HCC, liver transplantation, death Adapted from Alter HF, Seeff LB. Semin Liver Dis. 2000;20: Treatment failure (50%) 28 patients Sustained response (50%) 28 patients

3 Characteristic phases of CHB infection Immune tolerance Immune clearance Immune control Immune escape HBeAg+ve HBeAg ve < > < > HBV-DNA ALT HBeAg +ve chronic hepatitis Inactive (carrier) state HBeAg ve/+ve active chronic hepatitis

4 Who should be considered for treatment? Immune tolerance Immune clearance Immune control Immune escape HBeAg+ve HBeAg ve < > < > HBV-DNA ALT treat treat HBeAg +ve chronic hepatitis Inactive (carrier) state HBeAg ve/+ve active chronic hepatitis

5 ETIOLOGY OF HEPATOCELLULAR CARCINOMA IN TURKEY (Uzunalimoğlu et al, Dig Dis Sci 2001) Alcohol (6.6%) Cryptogenic (16.3%) HCV+Alcohol (3.1%) HBV/HDV (48%) HCV (16.7%) HBV+HCV (3.5%) HBV+Alcohol (6.2%)

6 FULMINANT HEPATITIS IN TURKEY 5.2% 3% 5.2% 6.7% 5.2% 19.3% 39.3% 39.3% 20.7% Viral Drug Cryptogenic Wilson Toxic (Am.ph.) Pregnancy Misc.

7 FULMINANT HEPATITIS IN TURKEY VIRAL ETIOLOGY 4/53 (7,5%) 47/53 (88.9%) HBV HAV HCV HEV

8 Table 1: Etiology of hepatocellular carcinoma in Turkey according to geographical region Uzunalimoğlu et al, Dig Dis Sci 2001 Region Etiology Hepatitis B Hepatitis C Alcohol West Turkey 18/54(33.3%) 20/54(37%) 17/54(31.5%) Central Turkey 53/85(62.4%)* 21/85(24.7%) ## 7/85(8.3%) South & 45/68(66.2%)* 7/68(10.3%) # 9/68(13.2%) Southeast Turkey (Hepatitis B prevalence: * p<0.001 vs. the prevalence in West Turkey. Hepatitis C prevalence: # p<0.001and ## p<0.05 vs. the prevalence in West Turkey; p<0.05 vs.the prevalence in Central Turkey. Alcohol: p<0.05 and p<0.001 vs. the prevalence in West Turkey)

9 Chronic Viral Hepatitis in the WEST: Change in etiology by years % % % % HBV HCV HDV HBV+HCV HDV+HCV Toplam (n) Ökten A. İstanbul Tıp Fak. GEH BD.

10 Liver Cirrhosis in the WEST: Change in etiology by years Etiology % % % Viral Cryptogenic Alcohol Others Ökten A. İstanbul Tıp Fak. GEH BD.

11 Liver Cirrhosis in the WEST: Change in viral etiology by years Etiology % % % HBV HCV HDV HBV+HCV TOTAL Ökten A. İstanbul Tıp Fak. GEH BD.

12 Viral Etiology of Liver Cirrhosis in the EAST (n: 505) 80 Bayan K, et al, Hepatogastroenterology % 17% 8% 2.5% HBV HCV Alcohol Misc. HBV HCV Alcohol Misc.

13 Prevalence of delta hepatitis according to geographic region in patients with chronic hepatitis B in Turkey Degertekin et al, Liver Int 2008 Region Total n Delta (+) N (%) West Turkey (4.82%) 1 Central Turkey (12.1%) 2, 3 East Turkey (23.5%) Southeast Turkey (27.1%) 1 p< vs. Central, East and Southeast Turkey; 2 p<0.05 vs East Turkey and 3 p= vs.southeast Turkey

14 Prevalence of delta hepatitis according to geographic region in patients with cirrhosis due to HBV in Turkey Degertekin et al, Liver Int 2008 Region Total N Delta (+) N (%) West Turkey (20.0%) 1, 2 East Turkey (27.8%) 2 Southeast Turkey (46.3%) 1 p<0.01 vs. East Turkey and 2 p<0.001 vs. Southeast Turkey

15 Change in delta hepatitis prevalence among patients with chronic hepatitis B in different regions of Turkey Degertekin et al, Liver Int 2008 Disease < 1995 >1995 Group n (%) n (%) p value Central Turkey CHB 106/365 (29.0%) 20/166 (12.1%) <0.001 Southeast Turkey CHB 58/154 (37.7%) 78/288 (27.1%) <0.001 Western Turkey LC 70/183 (38.3%) 113/564 (20.0%) <0.001 Southeast Turkey LC 73/110 (66.4%) 83/179 (46.4%) <0.001 (CHB: chronic hepatitis B, LC: liver cirrhosis)

16 An estimation of the potential burden of chronic hepatitis B in terms of mortality and morbidity in Turkey using mathematical modelling Toy M et al, AASLD 2009

17 Methods Establishing the patient cohort: Age-specific HBsAg prevalence obtained through extensive analysis of the Turkish hepatitis B literature- compared with populations statistics (Turkish Statistics-Institute) Analysis of the databases of the gastroenterology departments of the University of Ankara and a state hospital in Ankara (Türkiye Yüksek İhtisas Hastanesi) specific for age, HBV DNA level, HBeAg status und ALT: 1453 patients - 24,5 % with active hepatitis Comparison with an international patient cohort with regard to age, HBeAg status and cirrhosis-diagnosis (Hadziyannis et al, NEJM 2003)

18 Age-group specific distribution of CHB in Turkey by HBeAg and stage of liver disease Age Group Population HBsAg (%) HBsAg (+) HBeAg (+) HBeAg (-) Active CHB Cirrhosis (Years) HBeAg (+) HBeAg (-) eag(+) eag (-) % % % % % % % Total % Total CAH CAH with cirrh

19 Mathematic Model Markov Simulation Spontaneous viral recovery CBH e+ CBH e HCC 35 Cirrhosis Dekom. Cirrh Liver Tx Death 3.1

20 Markov Modell- II Morbidity and mortality calculated seperately for children and adults Analysis constructed taking into account age, HBeAg Status und presence or absence of cirrhosis: Natural history Under Lamivudine (high resistence profile drug) Under Lamivudine + Adefovir Rescue Therapie) Under Entecavir (low resistence profile drug)

21 Reults of a 20 year projection: Natural history of CHB in Turkey CHB Stage at entry n Cirrhosis Decompensated HCC Liver Tx Death (%) cirrhosis (%) (%) (%) (%) Total (46) (9) (10) (4) (22) Chronic hepatitis No cirrhosis (33) (6) (8) (4) (15) HBeAg (+) (15) (3) (3) 6.062(2) (8) HBeAg (-) (46) (9) (13) 8.614(2) (31) Cirrhosis (100) (26) (23) 4.399(4) (77) HBeAg (+) (100) 5.798(31) 1.870(10) 379(2) (76) HBeAg (-) (100) (24) (26) 1.825(2) (77)

22 Liver-specific death rate in the CHB patient cohort 50% Patients without cirrhosis Ölüm (%) 40% 30% 20% 10% 0% 46% Yıllar D.S. Y.D.R.İ. Kombine Kurtarma D.D.R.İ. 80%

23 Liver-specific death rate in the CHB patient cohort Patients with cirrhosis Ölüm (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 40% Yıllar D.S. Y.D.R.İ. Kombine Kurtarma D.D.R.İ. 62%

24 SUMMARY HBsAg Prevalence in Turkey: 4,29 % Westturkey: 3,54 % Centralturkey: 4,55 % Eastturkey: 6,88 % Number of HBsAg Positives: x 4,29 % = If 10 % were to have active chronic hepatitis = patients Patienten under Therapy: * *SGK According to net sold pill tablets in Turkey 02/ / 2009

25 Construction method of the patient cohort Literature, population data, HBsAg prevelance AUMS/TYİH patient cohort (n=1323) Age, ALT, HBVDNA, eag CHB(%) and Cirrhosis (%) (n=330) Age specific HBsAg prevelance (%) Prevalence of cirrh. and non-cirrh. CHB Literature, Cirrhosis Rate Abbreviations: AUMS, Ankara University Medical School; TYIH: Turkey Yüksek İhtisas Hospital

26 IMPORTANT NOTICE EASL Monothematic Conference on Delta Hepatitis will be held in Istanbul in 2010, Sep 24-26

27 Greetings from ISTANBUL