Other Hepatitis C online support groups I'm involved in
Education: Another Weapon Against Hepatitis C
Breaking the Hepatitis C Social Stigma
More people are currently living with Hepatitis C than any other chronic blood-borne infectious disease. Many patients still suffer with the associated stigma in many social circles. Discover two ways to reduce this unfortunate perception of a Hepatitis C diagnosis. Your efforts can help make the changes required.
by Nicole Cutler, L.Ac.
The MSN Encarta Dictionary defines stigma as “a sign of social unacceptability: the shame or disgrace attached to something regarded as socially unacceptable.” According to the US Department of Health and Human Services, “stigma is about disrespect.”
For some people, the stigma of living with Hepatitis C is more harmful than the virus itself. While medical research and treatment primarily target prevention and viral eradication, there is a lot more effort required to change public perception and attitudes toward Hepatitis C.
There are two parts to breaking a disease-related stigma: education and self-respect. By educating communities on Hepatitis C and learning to feel good about yourself (regardless of viral status), Hepatitis C can be removed from the category of socially unacceptable conditions.
Why?
The primary reasons for any condition to be stigmatized are the lack of compassion, fear and ignorance. Hepatitis C is a prime candidate for such an attitude for several reasons:
Fear of Transmission – Because Hepatitis C is an infectious disease without a definitive cure, people are afraid of getting it. Although not easily transmitted, people are nevertheless fearful and may shun those who have the disease. Fear and ignorance have cost those with Hepatitis C their jobs, friendships and marriages.
Fear of Illness – Some people do not like to be around people who are sick. Being uncomfortable around others who have an illness is how certain people protect themselves from their personal fears. This discomfort may cause them to socially reject people with diseases instead of risking exposure to suffering and/or death.
Judgment – Despite the many ways of acquiring Hepatitis C, misinformed people sometimes assume that everyone with Hepatitis C has a history of injection drug use. Even if this is a person’s mode of viral acquisition, our society lacks compassion and understanding about injection drug use. Those without personal exposure to injected drugs may judge people who have. Former injection drug users may feel haunted by their pasts and judge themselves.
Additionally, many active injection drug users carry shame about their addiction. Regardless of the situation, casting judgment on a person for their past addiction or viral status is devoid of compassion for their very personal situation.
Several of Hepatitis C stigma’s negative consequences include reduced self-esteem, diminished mental health, less access to medical care and fear of disclosing a positive status. Additionally, this attitude may contribute to hesitancy on the part of some medical providers to treat people infected with Hepatitis C.
In the January 2006 issue of Hepatitis magazine, the staff conducted an informal web poll about stigma and viral hepatitis.
On the plus side, 42 percent of poll participants felt they had not faced any stigma due to living with hepatitis. However, more than half of all respondents reported being treated differently due to their disease. Of those who participated in the poll, 20 percent felt they had experienced job discrimination due to having Hepatitis B or Hepatitis C, 13 percent reported hepatitis-related social stigma and 13 percent had been alienated from family and friends because of viral hepatitis.
Education
Any social stigma finds its roots in fear of the unknown. Many Americans have misconceptions about the way Hepatitis C is transmitted. Once diagnosed with the virus, most affected people diligently study how the disease is spread, and how they likely acquired it.
However, a person without firsthand experience with Hepatitis C may mistakenly assume it can be transmitted through sharing a glass of water or even from being coughed or sneezed on by an infected person.
Until all reaches of society learn the facts about this virus, inaccurate stereotypes fueled by fear will persist.
Educating yourself and others will break down the stigma associated with Hepatitis C.
Many communities have Hepatitis C task forces to promote community awareness. Getting involved with Hepatitis C informational training sessions targeting local schools, hospitals, drug treatment programs, government agencies and similar community organizations will fill replace fear with knowledge, helping to remove the negative perspectives about this disease.
In the words of Margaret Mead, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Self-Respect
If you have Hepatitis C, the first step in breaking the stigma is to start with your own attitude toward your illness. Some questions to ask in uncovering this include:
• Do you label yourself as a sick person?
• Do you expect to be shunned from co-workers, friends and family?
• Do you feel like you deserve to have Hepatitis C?
Honestly examining your own feelings of shame and working to shift those feelings into pride makes a tremendous difference when facing the world with any illness.
Living in the present and looking to the future are the best ways to leave negativity in the past. By learning how other people live with the disease, many people find help in discussing their feelings at Hepatitis C support groups.
In order to garner the respect from others, it is absolutely necessary to first develop respect for yourself. Additionally, feeling good is the single most important factor in living a long, healthy and rewarding life.
Compiled by the Hepatitis C Support Project, below are nine tips for developing a healthy attitude:
1. Make sure you know the truth. Get accurate information about Hepatitis C. Some people mistakenly believe Hepatitis C is an automatic death sentence. The truth is, the majority will die with Hepatitis C, not of Hepatitis C.
2. Don’t make things worse by imagining a future with pain, disability or loss. Improve your odds by visualizing your future the way you want it. Visualizing health, not illness, is a powerful tool for self-transformation.
3. Maintain perspective of the big picture. Focus your attention on something that brings peace, joy, laughter and meaning. Tell yourself that difficult moments will pass.
4. Watch your words. If you hear yourself talking negatively, substitute positive phrases. Say, “I will find a way to live with Hepatitis C” rather than “Hepatitis C is ruining my life.”
5. Practice gratitude. Make it a habit to find things for which you are grateful.
6. Learn what you can control and what you cannot. There are things you cannot control, such as the fact that you have Hepatitis C. However, there are things you can control, such as your attitude and what you say to yourself about having Hepatitis C.
7. Learn from the virus. Ask yourself what Hepatitis C can teach you about living.
8. Get support. Being with others who are dealing with the same issues can bring encouragement and hope.
9. Help others. When it comes to stepping outside of ourselves, probably nothing works as well as reaching out to others who are also struggling.
By cultivating self-respect through a positive attitude and through active participation in educating your community on Hepatitis C, you can take an active role in breaking the Hepatitis C stigma and helping those diagnosed with the disease to finally receive the compassion they deserve.
References:
Conrad, S., Garrett, LE, et al., Living with chronic hepatitis C means 'you just haven't got a normal life any more', Chronic Illness, June 2006.
www.encarta.msn.com, Stigma, Microsoft, 2007.
www.hcvadvocate.org, Hepatitis C and Drug Abuse, Janetta Astone-Twerell, PhD, Shiela M. Strauss, PhD, Corrine Munoz-Plaza, MPH, Hepatitis C Support Project, 2007.
www.hcvadvocate.org, Stigma and Hepatitis C, Lucinda K. Porter, RN, April 2006.
www.mentalhealth.samhsa.gov, Discrimination and Stigma, US Department of Health and Human Services, 2007.
www.thebody.com, Policy Facts: AIDS-Related Stigma, AIDS Action Council, 2007.
Hepatitis C (HCV for short) is a virus that lives in human blood. A virus is one of the smallest living things known to exist inside plants and animals.
HCV makes new hepatitis C viruses by infecting the liver and the blood, and after many years the liver can become so damaged by hepatitis C that it cannot perform many of the important jobs that it must do to keep us healthy.
You can only get hepatitis C by getting HCV infected blood from someone who has Hepatitis C, and ONLY if that infected blood gets into your body.
Many people have hepatitis C so you are not alone. It takes many years for hepatitis C to cause damage to the liver and to make someone sick.
There are many things that people can do to help fight Hepatitis C, and the best time is to start is early – before Hepatitis C has a chance to damage your liver.
One of the most important things you can do is to stop or cut down on drinking alcohol and smoking tobacco.
There are also medicines to get rid of Hepatitis C and they work for one half of the people who take them.
Talk with your doctor or nurse about ways to stay healthy and about medications that can get rid of Hepatitis C, and if they can help you.
HCV Facts
The government estimates that there are about 4-5 million Americans infected with hepatitis C.
However, some experts believe that the number of Americans infected with hepatitis C is closer to 5 to 6 million Americans.
About 8,000 to 10,000 Americans
die every year as the result of Hepatitis C.
It is expected that the number of people in the next 10 to 20 years who will die from hepatitis C will be 3 times more than now.
Hepatitis C is so common that it is the main reason that people need liver transplants.
Anyone with hepatitis C should try to stop drinking or cut down on drinking and smoking tobacco.
People with hepatitis C should be given shots to protect them from hepatitis A and hepatitis B.
What is the Liver?
The liver is the largest organ in your body. It is reddish-brown and is about the size of a football.
The really amazing thing about the liver is that if they took away half the liver – it would grow back in a few weeks.
The liver’s job is to run over 500 bodily functions to keep you healthy.
It is also a very important organ because it filters everything you eat and breathe – even things that get on your skin. The problem is that things such as alcohol, street drugs, cigarette smoke, toxic fumes, some herbs and even some regular medicines people buy without a doctor’s prescription can damage the liver.
The liver helps the body by taking certain foods and turning them into chemicals that give you energy and keep you healthy.
The liver also stores many important things such as vitamins. Sometimes you can take too many vitamins and this can damage the liver.
HEALTHY LIVER TIPS
Stay away from toxic fumes or liquids.
Stop drinking alcohol, smoking tobacco and taking street drugs. If you can’t stop, try to cut back – talk with a doctor, family or friends about getting some help to stop.
Talk to your doctor about vaccines to help protect the liver.
Tell your doctor about all medicines you are taking, even if it’s just an aspirin or Tylenol.
Eat a healthy and well-balanced diet.
Drink lots of water.
Stay away from raw or undercooked shellfish.
How Do You Give Or Get Hepatitis C?
Hepatitis C is spread by direct blood-to- blood contact.
This means that in order for someone to give hepatitis C to someone else they must get their blood into someone else’s bloodstream.
For this reason, it is difficult to get or give hepatitis C unless there is blood involved.
So if you have hepatitis C, make sure that your blood does not come into contact with anyone.
If you do not have hepatitis C, stay safe by making sure that you stay away from any blood from other people.
How Do You Give or Get Hepatitis C?
Getting Hepatitis C from Needles and Works
The most common way that people get hepatitis C is from sharing needles and anything else that is used to inject street drugs, hormones, steroids, vitamins or any other substance that is injected into the body.
Things used to inject drugs include needles, cookers (to mix drugs), cottons (to filter drugs), and tourniquets or ties. Even the water used to clean drug equipment can have Hepatitis C in it.
It is also important to wash your hands to help reduce the risk of getting Hepatitis C and other diseases.
Getting Hepatitis C from Sex
Getting hepatitis C by having sex is rare, but it could happen if someone has sex with a lot of different people, and engages in risky behavior.
Many experts believe that the risk of spreading hepatitis C is very low if people have sex with only one person over many years. But if the person with hepatitis C or the person you are having sex with is worried about catching hepatitis C then use condoms (rubbers) during sex.
People who have many sex partners or who have other sexual diseases should always use rubbers and take other precautions, such as covering any open cuts or wounds since these could pass Hepatitis C during sex.
Hepatitis C is also easier to spread while a woman is on her period. Remember to be safe if there is any blood during sex.
Getting Hepatitis C from Blood
Another way that many people got hepatitis C is from having a blood transfusion before 1992.
This can include having an operation that required someone to receive blood from another person or any other way where a blood product was used.
Other Ways to Get Hepatitis C
Some experts believe that you can get hepatitis C in other ways, such as by getting a body tattoo or piercing or sharing personal hygiene items (toothbrushes razor blades, nail clippers), but there has never been a proven case of this happening.
The Good News
The good news it that you can not get or give hepatitis C by sneezing, hugging, breast feeding, sharing eating utensils or drinking glasses. It is just not spread by this type of casual contact.
Safety Tips
Do not share needles or works (cottons, cookers, ties) used to inject drugs, hormones, steroids and vitamins. Do not even share the water. Wash hands before injecting.
Cover any open cuts or wounds.
Sexual transmission is low, but the use of condoms and barriers will help reduce the risk even more.
A mother can transmit hepatitis C to her baby during pregnancy or birth, but this doesn’t happen very often.
Do not share any straws to snort drugs, or pipes to smoke crack.
Make sure that in healthcare settings standard safety precautions are being carefully followed.
Do not share any personal hygiene items such as razors, toothbrushes, nail clippers or pierced earrings. Cover personal items and keep them separate from other people you live with.
Make sure tattoo and piercing equipment is sterile.
For a tattoo – make sure that a new needle and ink pot is used for each person.
For a piercing – make sure that a new needle is used and that the package that contains the needle is opened up in front of you.
What Are The Test For Hepatitis C
There are blood tests to find out if you have Hepatitis C.
The first test is to find out if you have ever been exposed to hepatitis C. This is called an antibody test.
This test only tells you if you have ever been infected. It does not tell you if you actually have the hepatitis C virus in your blood now.
There are other tests used to help find out what is going on in your liver and how sick or healthy you may be.
WHAT ARE THE TESTS FOR HEPATITIS C?
Antibody Test
When the hepatitis C virus enters your body, your immune system releases chemicals into your bloodstream to help fight off the hepatitis C virus.
These are called antibodies.
If you have hepatitis C antibodies it means that you have been infected with hepatitis C at one time, but it does not mean that you have active hepatitis C.
For some people (about 2 to 3 people out of 10) the body’s natural defenses can get rid of the virus, but for the other 7 to 8 people the body cannot kill off this virus.
Hepatitis C Viral
Hepatitis C Viral Load Test
There is a blood test that looks to see if it can find the virus in you. It is called a hepatitis C viral load test.
There are two reasons this test is done.
The first reason is to tell you whether you still have the virus in your body.
The other important reason for having a viral load test is for treatment.
It can help tell you the chances of getting rid of the hepatitis C virus from your body with HCV medicines and whether the medicines are working.
The really important thing to remember is that the amount of hepatitis C virus you have in your body does not mean how sick you are.
For example, having a lot of virus (high viral load) does not mean that you will get sicker more quickly.
For this reason it is not a very good test to monitor or tell you how much the hepatitis C virus is damaging your body.
ALT Levels
One of the most common blood tests used is a blood test that measures a certain chemical in your blood called ALT.
This chemical is released by the liver into the blood when the liver is damaged or sick.
High levels of ALT can be caused by many things like alcohol, drugs, toxins, and viruses such as Hepatitis C.
Unfortunately, it is not a perfect test for people with HCV – most people with what we call “normal” ALT levels will have little damage, but some people can still have ongoing liver damage.
In the past, if people with HCV had normal ALT levels they were not treated with HCV medications, but now doctors will treat Hepatitis C if there are other signs that the liver is damaged.
If your ALT level is high it means that something is going on in the liver, but it could be caused by many things.
Different Kinds of Hepatitis C
Not everyone with hepatitis C has the same kind.
In fact, there are six different kinds of hepatitis C.
These different kinds of Hepatitis C are called genotypes and are numbered 1 to 6. The genotype test is a blood test.
Knowing which genotype you have is really important to your doctor because some genotypes are easier to treat with HCV medications.
For example, genotype 1 or 4 is a little harder to treat than genotypes 2 or 3.
Also, the kind of genotype you have will tell your doctor how much medicine to give you and how long you should take the medicine.
Just because you have a certain genotype does not mean that you will get less or more sick.
It is important to remember that most people with hepatitis C never develop symptoms – no matter which type they have.
Other Blood Tests
There are many blood tests that are used to see how well your liver is working.
These tests will look at many types of chemicals that the liver produces and releases into your bloodstream.
Liver Biopsy
A liver biopsy is the best way to find out if your liver is healthy or damaged. It is also the best way for your doctor to know whether you have other liver conditions.
During a liver biopsy, a needle is put into your liver and a small sample of liver tissue is taken.
Try not to worry too much because most people only have mild to moderate pain. If you are nervous about the test, ask you doctor for some medicine to help you relax. The liver biopsy is done while you are awake.
Sometimes an ultrasound is also performed to take a picture of the liver. This will help to decide where to put the needle for the biopsy.
Most people are really concerned about having a biopsy because of the pain.
The good news is that only about half of people who have biopsies done have some brief pain that may spread to the right shoulder.
However, a few people have to be hospitalized after the biopsy due to pain or from another organ being accidentally hit during the test, but this doesn’t happen very often.
After the biopsy is performed the patient will lay on the right side of the body and will be checked for several hours to make sure nothing serious happens.
Talk with your doctor or nurse about having a biopsy. They will advise you about what to do before and after the test.
After the biopsy is done the liver tissue will be sent to another medical person to look at under a microscope and issue a report on the health of the liver.
Scientists are studying other ways to get the same information that they now get from biopsies.
Some of these new blood tests measure certain blood chemicals.
These new tests can tell if the liver has no damage or there is a lot of damage to the liver, but unfortunately, they do not tell your doctor if you have moderate damage to the liver – for this reason blood tests can not replace the liver biopsy at this time.
Some people with hepatitis C have no symptoms but others can have many symptoms.
The most common symptom people with hepatitis C say they have is that they feel tired a lot (fatigue).
Other symptoms people with Hepatitis C report is feeling sick to their stomach, aches and pains in their muscles, joints, stomach, and liver.
Some people have fevers and may sweat in their sleep. Others say that they feel depressed or worried all the time.
Still others say that they can’t think or remember as well as they used to before getting hepatitis C. These types of symptoms can be very troubling and they should be reported to your doctor to make sure that they are from Hepatitis C and not from another illness or condition.
The good news is that for most people with these types of symptoms it may not mean that you are getting any sicker – it may just mean that your body is fighting
the Hepatitis C. But talk to your doctor about any of these symptoms you’re having to make sure they are not serious.
There are other symptoms that people can have if their liver is really damaged and scarred.
The term for this condition is called cirrhosis (sir-oh-sis).
When you develop cirrhosis the liver cannot perform many of its important functions. There will be many warning signs and symptoms that your doctor will need to know about.
For this reason it is important to have regular check-ups with your doctor to keep an eye on you more closely and treat you for some of the symptoms.
What Are The Symptoms?
COMPENSATED CIRRHOSIS
Means that the liver is really scarred but can still do many of its important functions to keep you healthy; people with compensated cirrhosis have few or no symptoms.
DECOMPENSATED CIRRHOSIS
Means that there is so much scarring that the liver can no longer do its job without help.
People who have this type of severe scarring can develop
many signs and symptoms such as bleeding from the blood vessels in the throat, retaining a large amount of fluid or liquid around the stomach, and even a type of brain disease that causes mental confusion.
What About Treatment?
First of all, not everyone with hepatitis C needs to be treated with HCV medicines.
But if you are thinking about being treated for Hepatitis C, there are many things to think about.
The decision to treat should be made by you and your doctor based on how hepatitis C is affecting you. You will need to know your viral load, genotype and how much your liver is damaged.
The good news is that there are medicines to treat hepatitis C that can get rid of the virus in about 50% (5 out of 10 people) of the people who have genotype 1. For people with genotypes 2 or 3, treatment works up to 80% of people.(8 out of 10).
However, treatment is not easy and the decision is a difficult one for most people. Talk to your doctor about the possible benefits as well as the treatment side effects you might get.
There are two medicines (called combination therapy) to treat Hepatitis C – interferon and ribavirin.
Today, the use of a longer acting (time-released) form of interferon – pegylated (peg-a-lated) – combined with ribavirin is now considered the best way to treat Hepatitis C.
There are two brands of interferon – Pegasys and Peg-Intron. These are used in combination with ribavirin.
Many people with Hepatitis C can lead normal lives and will die of something other than Hepatitis C.
However, some people with Hepatitis C will get very sick, but this usually takes many years (up to 40 years).
The damage caused by hepatitis C usually takes place in the liver.
When the Hepatitis C virus gets into the liver it can irritate it and cause it to become inflamed like a sore.
The inflammation can lead to the liver becoming scarred, and for a few people Hepatitis C can lead to a form of cancer of the liver.
There is a simple way to estimate how many people will get sick from Hepatitis C:
About 80 out of 100 people who get hepatitis C will
develop chronic (long term) infection.
About 20 people out of the 80 people who have chronic
hepatitis C will become very ill or sick. It usually takes
many years to make the liver really sick.
About 2-3 people out of the 80 people who have chronic
hepatitis C will get liver cancer.
The important point to remember is that hepatitis C takes a
long time to damage the liver and many people will never get sick from hepatitis C.
There are also many things that you can do to stay healthy such as eating a healthy diet, getting lots of exercise, cutting down or stopping drinking alcohol, joining a Hepatitis C support group, taking HCV medicines – and many other ways to stay healthy.
What About Herbs?
Some people with hepatitis C take herbs and vitamins.
There are some herbs and vitamins that some doctors consider “safe” and other herbs and vitamins that should not be taken because they can damage the liver.
Since herbs are like medicines it is very important that you talk with your doctor before taking any herbs or high doses of vitamins.
Some Tips about Herbs and Vitamins:
Some people think that since herbs are natural that they should take them – but just because an herb is natural does not mean that it is safe. There have been deaths of people reported from taking certain herbs.
Do not take more herbs or vitamins than you are instructed to take.
Get advice about herbs from experts – medical doctors and herbal doctors.
How Do I Stay Healthy?
There are many ways to stay healthy. Here’s our top ten list of things you can do to stay healthy:
1. See your doctor and nurse for regular check-ups. Make sure you tell them of any problems or symptoms you are having. Talk to them about medicines to treat Hepatitis C.
2. Eat a healthy and balanced diet with lots of vegetables and fruits, and try to stay away from too much sugar, salt and fatty food. Balance the amount of food you eat with regular exercise such as walking. Walking will help to make you feel less tired.
3. Stay away from or protect yourself from chemicals. Everything you breathe or absorb
through the skin must be filtered by the liver. Fumes from paint thinners, pesticides, and aerosol sprays can damage your liver and should be avoided.
4. Rest when you are tired. Try to find time during the day for a short nap or times you can unwind and relax.
5. Get the hepatitis A and hepatitis B vaccines if you have not already been exposed. You
won’t want to get another illness that might make your hepatitis C worse so ask your doctor or nurse if you need to be vaccinated.
6. Cut down or stop drinking alcohol. Alcohol can harm the liver so it is important that you try to stop drinking. If you can’t stop drinking, cut down on the amount of alcohol you drink and ask for help on ways to stop drinking alcohol.
7. Be careful when mixing alcohol, drugs or herbs or when using over-the-counter drugs such as Tylenol and ibuprofen.
8. Join a support group. People in a support group can help you with emotional problems and give you information about how best to take care of yourself.
9. Try to do things that help you cut down on stress and to keep a positive attitude, such as meditation and prayer.
10. Try not to worry too much. Learn as much as you can about hepatitis C so that you know what you are facing.
The Bottom Line
It is important that if you have ever been in a situation where you may have caught hepatitis C that you are tested.
If you have Hepatitis C there are many things that you can do to stay healthy. One of the most important things that you can do is to find out as much as you can about Hepatitis C and work with your medical team to make the best choices to keep you healthy.
There many more things that you can do to educate yourself.
The Hepatitis C Advocate Fact Sheet– www.hcvadvocate.org contain information about all of these things in much greater detail.
Sitting around with good friends, laughing and have fun.
Enjoying every day to its fullest...Carpe Diem...De Colores
I try to live my life as a Christian everyday. This is a lot harder then the life I use to live.
Helping others in need when ever I can.
Educating as many people as possible about about Hepatitis C Awareness.
This Silent Killer has taken to many loved ones from us already, and is going to continue to get worse in the years to come. Please Educate yourself about the Hepatitis C Virus.
The Dragon and Hepatitis C
A few years ago the "hepatitis C community" on many internet sites began referring to the disease as "the Dragon" Probably because they were very hard to kill (like eradicating Hep C viruses).
In many legends-from China to England, many brave warriors and Knights lost their lives in fights with Dragons. In most of the legends they were very destructive beasts as well. A good blast of their fiery breath could destroy a whole village.
I taught English for a few years to a group of five Vietnamese Zen monks at a small temple in West Houston. In exchange they taught me the fundamentals of Zen - simple methods to meditate, the control of breathing, the ultimate goal of becoming an Enlightened person, etc. and some of the important symbols they used. The most important being the Dragon! In their culture the Dragon represents the "life force" or the thing that motivates you to do the things you need to do to become a better person.
Many of us have heard a recovering alcoholic say that they were grateful, that the suffering the endured made them a better person.
I feel that way now about the "Dragon" of Hep C. I think longer and deeper and with much more compassion for those who still suffer than ever before.
So, like so many things that occur in our lives, what starts out seeming to be the very worst thing that could have happened turns out to be a thing that makes us richer, deeper more compassionate people in my case it was, "What, I have Hepatitis C"? There go my plans for all the stuff I was going to do the rest of my life. Blam, it was all over! Now, 7 years later, the bulk of my daily work is with people who are suffering with Hepatitis C and the work is the most rewarding I have ever had. I think the philosophers and religious thinkers were right: "You are never going to be happy unless you are helping someone else". Remember, in many cultures, the Dragon is the force that keeps us alive.....
Please list the names of loved ones that died with Hepatitis C (HCV). The names will be read at a candle light vigil held each year in Washington DC.
Participants light candles and read names in remembrance of all those that passed from this devastating disease.
If you have lost a loved one or a friend to the Hepatitis C Virus and would like to leave a message for them, please go to
http://march-on-dc.com:80/Memorial/CyberWall1.asp
Paul Newman, Johnny Depp, Jack Nicholson movies, a good western, action, mystery movie, comedies. Tombstone is one of my all time favorite. I'll be your Huckleberry.
Television
Mind of Mencia, 2 1/2 Men, Everybody Loves Raymond, National Geographic, A&E, History Channel, and TCM
Books
The Bible,
Dr. Melissa Palmer's Guide to Hepatitis & Liver Disease
Being Sick Well, Jeffery H.Boyd M.D.
Heroes
a href="http://photobucket.com" target="_blank">
My Mom and Dad for always being there for me when I was growing up.
People who survive this virus to face another day. People who are helping spread the word to the public about the virus.
My wife Carol, for always being there for me, and not killing me when I was going through the different treatments I've been on. She has been my Angel.
My Pastor.
Some of my new friends I've met on myspace.
To all the people that are working hard to help educating, and helping to spread the word about Hepatitis C Awareness.
People that will reach out to others, in their time of need
Welcome one and all. I've started this site for people looking for information about Hepatitis C Awareness. This page is for anyone wishing more to learn the A-Z of Hepatitis C Awareness, friendship or just plain old' understanding. Please make yourself at home. Feel free to ask questions and leave in my messages bar on the top left side of the page. For updated information please read my blogs on this page. When you open my blog site, please go to the left side of the page and click on Blog Archive [ Older Newer ] for more information. The Blgs go back until July, 2006
They call this virus "The Silent Killer." They're usually no physical symptoms till there's liver damage. This virus is our Generations Nightmare. Please read the below quiz and if you answer yes to any of the questions, please get tested. I felt great and went in for additional life insurance and found out I had Hepatitis C and Cirrhosis. I didn't fill sick at all, and I worked construction and was working 50-70 hour weeks. I know people who have seen their doctor and found out they already had liver cancer and going into liver failure already and only had months to live. I have lost a family member, and many of my old friends, and new ones I've met since I started this group to this virus.
Why the Hepatitis C Virus is called “The Silent Killer”
Hepatitis C is a type of virus that primarily attacks the liver. As the virus reproduces, it kills surrounding cells and triggers the body's immune system to fight back. This defense can lead to reactions, such as inflammation and/or fibrosis (scarring) of the liver. If left untreated, hepatitis C can result in liver damage, which can lead to serious conditions such as cirrhosis (in which healthy liver tissue is replaced by scar tissue) or liver cancer.
Most people who are infected with the hepatitis C virus go on to develop chronic hepatitis C. The infection becomes chronic (long-lasting) because the body's immune system is unable to fight it off.
You might think that such a condition would make you feel sicker and sicker over time. However, for many people, hepatitis C is an asymptomatic condition—which means they may not have symptoms for many years after they are infected. No one can tell you now whether or not you will have symptoms in the future.
Here's the tricky part: having no symptoms does not mean that hepatitis C is not attacking your liver. The virus can stay active in the body without producing recognizable symptoms. In fact, many people have no symptoms that they are aware of until significant liver damage has occurred. That's why it's so important to talk to your doctor about your treatment decision.
GET TESTED!!!
The Necessity of Seeing a Specialist for Hepatitis C
Even though you may be on a first name basis with your general practitioner, research from Germany proves that your chances for successfully eliminating the Hepatitis C virus are greater when treated by a hepatologist.
by Nicole Cutler, L.Ac.
Once diagnosed with Hepatitis C, a little research will eventually reveal that the current standard treatment is pegylated interferon with ribavirin. Despite the relatively low rate of success in eliminating the virus, many may mistakenly believe that it doesn’t matter who administers the treatment. However, new research demonstrates that it is well worth the effort to seek out a specialist for monitoring your therapy.
Successful Treatment
Known as sustained virological response (SVR), successful treatment for Hepatitis C is described as the inability to detect any of the virus in the blood six months after stopping therapy. Although it is currently the only viable option for Hepatitis C, estimates of those attaining SVR with pegylated interferon and ribavirin treatment vary widely.
Regardless of a study’s country of origin, large trials evaluating Hepatitis C treatment success have reported SVR rates ranging between 30 and 80 percent. However, close examination of people fighting Hepatitis C in the real world have led researchers to suspect that the type of doctor a patient seeks help from significantly impacts SVR likelihood.
German Study
In an attempt to realize the real world impact of the type of physician administering Hepatitis C treatment, researchers at the University of Dusseldorf conducted a landmark retrospective study. At their outpatient clinics, these German researchers analyzed the records of patients receiving at least one dose of interferon treatment for Hepatitis C over a span of seven years.
After analyzing over 300 people receiving Hepatitis C treatment for the first time, approximately two thirds consulted with an expert hepatologist on a regular basis while just over one third had their interferon treatment administered and supervised by a general practitioner. Even though the characteristics of infection were similar between those working with a hepatologist and those seeing a general practitioner, the outcomes of Hepatitis C treatment were significantly different between the two groups.
Right after interferon treatment, elimination of the Hepatitis C virus was more likely for those seeing a hepatologist:
· A viral load of zero was evident in 74 percent of those seeing a hepatologist.
· A viral load of zero was evident in 48 percent of those seeing a general practitioner.
At the six-month mark when SVR is measured, those seeing a hepatologist continued to have a definite advantage:
· SVR was attained by 66 percent of those seeing a hepatologist.
· SVR was attained by 34 percent of those seeing a general practitioner.
When broken down even more, those with genotypes 1 and 4 and those with advanced liver damage specifically benefited from expert care:
· For study participants infected with genotype 1 or 4, SVR was attained by 61 percent of those seeing a hepatologist.
· For study participants infected with genotype 1 or 4, SVR was attained by 27 percent of those seeing a general practitioner.
· For study participants with advanced liver damage, SVR was attained by 69 percent of those seeing a hepatologist.
· For study participants with advanced liver damage, SVR was attained by 25 percent of those seeing a general practitioner.
These results led the German authors to conclude “Patients with…genotypes 1 and 4 or with advanced liver damage benefit from HCV therapy supervision by a specialist, probably because of less frequent treatment interruptions or dose reductions.”
What Is An Expert?
A hepatologist is a physician who has obtained additional, specialized training in liver diseases. Initially, all hepatologists are trained in general internal medicine (adult medicine) or pediatrics (children’s medicine). Some pursue additional training in gastroenterology (which includes digestive disorders involving the esophagus, stomach, small and large intestines, pancreas, gallbladder and liver). However, to be a hepatologist, a fellowship focusing solely on the liver is typically mandated. Even though a hepatologist is the most qualified type of doctor to treat liver disease, there is currently no separate board certification examination in this highly specialized field.
The field of hepatology is a rapidly changing, emerging field. Even though the standard of care for Hepatitis C has been interferon-based treatment for many years, there are many factors involved in its administration. Hepatologists are up-to-date on the latest research and discoveries for treatment modifications, length of treatment, dosage adjustments, side effect management and all of the other details related to Hepatitis C treatment.
Although most people are comfortable with their general practitioner – and they may have been the physician who originally detected their infection – an expert may be more qualified to administer Hepatitis C treatment. Especially important for people who have genotypes 1 or 4, or who already have advanced liver disease, the chance of achieving SVR is much higher when an expert liver specialist manages treatment.
References:
http://depts.washington.edu, Sagir, A., et al., Therapy outcome in patients with chronic hepatitis C: role of therapy supervision by expert hepatologists, Journal of Viral Hepatitis, September 2007.
www.acponline.org, Hepatitis C, American College of Physicians, ACP Observer, April 2006.
The History of Hepatitis C
Hepatitis C is a form of hepatitis caused by an RNA (Ribo Nucleic Acid) virus, and accounts for most of the hepatitis cases previously referred to as non-A, non-B hepatitis.
The Hepatitis C Virus (HCV) was first identified in 1988 and a hepatitis C antibody test (anti-HCV) to identify individuals exposed to HCV became commercially available in 1990. In 1995 the hepatitis C virus was seen for the first time by using an electron microscope.
The hepatitis C virus has a high mutation rate. These ongoing changes in the virus make it difficult for the body's own immune system to fight it off, as by the time the immune system figures out the virus, it has changed to look different. For the same reason it is very difficult to develop a vaccine.
What are the chances of persons with HCV infection developing long term infection, chronic liver disease, cirrhosis, liver cancer, or dying as a result of hepatitis C?
Of every 100 persons infected with HCV about:
•55%-85% of persons may develop long-term infection
•70 persons may develop chronic liver disease
•5-20 persons may develop cirrhosis over a period of 20 to 30 years
•1%-5% of persons may die from the consequences of long term infection (liver cancer or cirrhosis)
Hepatitis C is a leading indication for liver transplants.
http://hivandhepatitis.com
HCV Symptoms and Progression
After exposure to HCV, there is an incubation period that usually lasts 2-26 weeks. The initial phase of HCV disease is called acute infection. Many people with acute HCV have no symptoms. Others may have a flu-like illness, nausea, fatigue, fever, headaches, loss of appetite, abdominal pain, and muscle or joint pain. Some develop jaundice (a yellowing of the skin and whites of the eyes). Acute HCV usually resolves after 2-12 weeks.
A majority of people infected with HCV do not clear the virus from their bodies, and become chronically infected. This percentage is typically estimated at 80%, but some experts believe it may be as low as 50% in certain people. Most people with chronic HCV do not have symptoms; others experience symptoms similar to those of acute HCV, but with more prolonged fatigue. In a majority of people, HCV progresses slowly, but in 10-25% of chronically infected people, HCV-related liver disease progresses over the course of 10-40 years.
Chronic HCV infection can lead to liver dam¬age, including the development of fibrous tissue in the liver (fibrosis), fat deposits in the liver (steatosis), and cirrhosis. In people with compen¬sated cirrhosis, the liver is heavily scarred but can still function relatively well.
In people with de¬compensated cirrhosis, the liver cannot function properly; these people may develop complications such as portal hypertension, bleeding varices (stretched and weakened blood vessels) in the esophagus and stomach, ascites (abdominal fluid accumulation), jaundice, pruritus (itching), brain damage (hepatic encephalopathy), and hepatic coma.
In the most severe cases, liver failure may occur and a liver transplant may be necessary. A type of liver cancer called primary hepatocel¬lular carcinoma develops in 3-5% of people with chronic hepatitis C. A number of different extra¬hepatic (outside the liver) conditions are associ¬ated with chronic HCV.
These include cryoglobu¬linemia, glomerulonephritis, lichen planus, por¬phyria cutanea tarda, Sjögren’s syndrome, sclero¬derma, fibromyalgia, arthritis, psoriasis, thyroid disease, blood cell deficiencies, and mental and psychological conditions. Most serious conditions are associated with late-stage HCV disease. Many people with HCV never experience any of these conditions.
Some Symptoms Of Hepatitis C Virus "The Silent Killer"
Although most people with chronic Hepatitis C do not exhibit symptoms of the "silent" epidemic, a significant number will experience its impact in organs other than their liver. Learn how to recognize these lesser-known conditions to help in the early detection and treatment of Hepatitis C.
by Nicole Cutler, L.Ac.
Many people infected with the Hepatitis C virus have no symptoms. Even if the person has been infected with Hepatitis C for a long time, no symptoms of the disease may present themselves until cirrhosis has developed. When symptoms are present, they can range from mild to severe. The most common symptom of chronic Hepatitis C is fatigue. Additional common symptoms of Hepatitis C include:
• Intermittent abdominal pain
• Reduced appetite and weight loss
• Nausea or vomiting
• Depression
• Jaundice – yellowing of the skin or whites of the eyes
• Low-grade fever
• Muscle aches
• Pale or grey colored stool
• Dark urine
• Generalized itching
• Ascites
• Bleeding varices – dilated veins in the esophagus
Extrahepatic Manifestations
People with Hepatitis C may exhibit symptoms and signs of infection that manifest in organs other than the liver. Known as extrahepatic manifestations, or immune-complex mediated diseases, these symptoms arise from the immune system's effort to fight off the infection. Chronic Hepatitis C infection leaves people vulnerable to the development of diseases involving the kidneys, the skin, eyes, joints, immune system and the nervous system. The occurrence of an extrahepatic manifestation does not correlate with the severity of the underlying liver disease. The following associated conditions are the most commonly seen as a result of liver disease:
1. Cryoglobulinemia – This condition is due to the presence of abnormal antibodies (called cryoglobulins) that come from Hepatitis C virus stimulation of lymphocytes (white blood cells). These antibodies can deposit in small blood vessels, thereby causing inflammation of the vessels (vasculitis) in tissues throughout the body. The skin, joints and kidneys (glomerulonephritis) are often targets of the vasculitis.
People with cryoglobulinemia can present a variety of symptoms, including weakness, joint pain or swelling (arthralgia or arthritis), and a raised, purple skin rash (palpable purpura) usually in the lower portion of the legs. As well, people may experience swelling of the legs and feet due to loss of protein in the urine from the kidney involvement and nerve pain (neuropathy). What is more, this vascular condition can spawn Raynaud's phenomenon, in which the fingers and toes turn color (white, then purple, then red) and become painful in cold temperatures.
2. B-cell non-Hodgkin's lymphoma – This cancer of the lymph tissue is associated with the chronic Hepatitis C virus. Its cause is believed to be excessive stimulation by the Hepatitis C virus of B-lymphocytes, resulting in the abnormal reproduction of the lymphocytes. Most individuals with Hepatitis C virus-associated non-Hodgkin's lymphoma will require standard anti-cancer therapies.
3. Porphyria cutanea tarda (PCT) – PCT is a skin condition characterized by the overproduction of enzymes involved in the manufacturing of blood. People with PCT often have blisters and vesicles form on the back of the hands, forearms and neck, as well as the face. Lesions develop in areas exposed to the sun or have sustained minor trauma. Increased facial hair and pigmentation changes are also common. Major risk factors for the development of PCT include excessive iron exposure, heavy alcohol use, and the use of estrogens.
4. Lichen planus – A skin condition, Lichen planus appears as shiny, flat-topped bumps that often have an angular shape. This rash can occur anywhere on the skin, but often favors the inside of the wrists and ankles, the lower legs, back and neck. The mouth, genital region, hair and nails are affected in some individuals. Thick patches may occur, especially on the shins. About 20 percent of those affected with lichen planus of the skin experience minimal symptoms and need no treatment. However, in many cases the itching can be constant and intense.
5. Diabetes mellitus – An increasingly common metabolic disorder, diabetes mellitus is characterized by resistance to insulin, the hormone that regulates the amount of sugar in your blood. The accompaniment of Hepatitis C with diabetes is strongly associated with advanced liver fibrosis or cirrhosis. People with cirrhosis are believed to have decreased hepatic uptake of glucose, along with reduced hepatic clearance of insulin, leading to high levels of insulin and, therefore, insulin resistance syndrome.
Other conditions noted to be associated with Hepatitis C infection, include:
• Thyroid disease
• Kidney disease, especially Membranoproliferative Glomerulonephritis (MPGN)
• Vitiligo
• Arthritis
• Sjogren's syndrome
• Mooren's ulcer
• Neuropathy
While Hepatitis C is perceived as a virus attacking only the liver, clinical practice proves that its ramifications extend beyond solitary hepatic involvement. Perhaps due to the liver's involvement in nearly every aspect of health, Hepatitis C is a systemic problem.
The wide range of possible manifestations of this virus should signal increased public education for earlier diagnosis and treatment of Hepatitis C. Additionally, understanding the commonality between conditions associated with Hepatitis C can help a person suffering with multiple ailments recognize the likely origin of their extrahepatic manifestations.
References:
www.aocd.org, Lichen Planus, American Osteopathic College of Dermatology, 2006.
www.ccjm.org, Hepatitis C Infection: A Systemic Disease with extrahepatic manifestations, Aman Ali, MD, Nizar N Zein MD, Cleveland Clinic Journal of Medicine, November 2005.
www.hcvadvocate.org, Extrahepatic Manifestations of Chronic Hepatitis C, Roderick Remoroza, MD, Herbert Bonkovsky, MD, Hepatitis C Support Project, 2003.
www.idph.state.il.us, Health Beat: Hepatitis C, Illinois Department of Public Health, 2006.
www.medicinenet.com, What Conditions Outside the Liver are Associated with Hepatitis C?, Tse-Ling Fong, MD, MedicineNet, Inc, 2006.
In knowledge there is power over fear. You never have to be alone in your fight against the dragon again.
ALT Predicts Mortality & General Health
“Serum activity of alanine aminotransferase (ALT) as an indicator of health and disease”
Hepatology April 2008
W. Ray Kim 1 *, Steven L. Flamm 2, Adrian M. Di Bisceglie 3, Henry C. Bodenheimer, Jr. 4, On behalf of the Public Policy Committee of the American Association for the Study of Liver Disease
1Mayo Clinic College of Medicine, Rochester, MN
2Feinberg School of Medicine, Northwestern University, Chicago, IL
3Saint Louis University School of Medicine, St Louis, MO
4Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY
“ALT activity is predictive of future mortality in the general population…liver disease….risk for cardiovascular mortality……patients with high ALT among those with the metabolic syndrome may represent a subgroup with a propensity for systemic inflammation that may, in turn, increase the risk of atherosclerosis, leading to coronary artery or cerebrovascular disease abnormal……ALT activity is often ignored or minimized by practitioners as most patients are asymptomatic…..[in HCV] Significant fibrosis was found in 8% to 20% of patients with normal ALT levels compared to 60% of patients with elevated ALT activities……the sensitivity of ALT analysis can be improved with serial measurements and long-term follow-up.”
This document presents the official position of the American Association for the Study of Liver Diseases (AASLD) on the application of serum alanine aminotransferase (ALT) activity, based upon an analysis of the currently available scientific data. Its authorship was selected by the Public Policy Committee. The document is fully endorsed by the AASLD Governing Board.
“……These data highlight that ALT activity is predictive of future mortality in the general population. While mortality may be due to unrecognized liver disease, it may also be related to other risk factors for ALT elevation including obesity, serum cholesterol, and plasma glucose concentration, in addition to alcohol consumption, which are linked to non-liver health risks. The cardiovascular mortality risk associated with ALT activity described may in part be explained by the metabolic syndrome…..ALT may serve as a marker of a proinflammatory state that is associated with higher cardiovascular risk even among individuals with the metabolic syndrome [from] on a cohort of participants of a large health insurance program in Korea…..compared to those with ALT < 20 U/L, men with ALT >/=100 U/L had 59 times the risk of death from liver disease. In women, a similar trend was seen…..ALT activity correlated with the risk of cardiovascular mortality as well. Compared with those with ALT < 20 U/L, men with ALT >/=100 U/L had nearly 3 times the risk of death from cardiovascular causes…..
“….emerging data suggest that ALT has a role as a predictor of mortality independent of liver disease…. we found that ALT meets most of the accepted criteria for a screening test……an abnormal ALT result, as determined by a properly defined normal range, must trigger an appropriate clinical evaluation….. abnormal ALT activity is often ignored or minimized by practitioners as most patients are asymptomatic. Minor elevations are often construed to be clinically insignificant….. a Scandinavian study of 151 consecutive patients with mild to moderate elevations of serum aminotransferase levels for at least 6 months revealed that liver disease was common….If elevated ALT levels are confirmed and if they remain persistently elevated, additional work-up is indicated. ALT levels greater than 5 times the upper limit of the normal range suggest a potentially serious, active liver disease process and work-up should be initiated without waiting to confirm the persistence of abnormal ALT….. [in HCV] Significant fibrosis was found in 8% to 20% of patients with normal ALT levels compared to 60% of patients with elevated ALT activities. While ALT analysis alone may fail to detect a minority of persons infected with HCV, it is most effective in detecting those persons whose liver disease is more severe……the sensitivity of ALT analysis can be improved with serial measurements and long-term follow-up.
ALT represents an excellent screening test to detect significant NAFLD……Non-alcoholic Fatty Liver Disease (NAFLD).
is probably the most common cause of abnormal ALT values among US adults and may affect up to 3% of the US population. risk factors for NAFLD include obesity, diabetes and hyperlipidemia……Elevated ALT may be a component of the metabolic syndrome, the hallmark of which is insulin resistance, manifested by hyperglycemia, hyperlipidemia, abdominal obesity and hypertension……patients with high ALT among those with the metabolic syndrome may represent a subgroup with a propensity for systemic inflammation that may, in turn, increase the risk of atherosclerosis, leading to coronary artery or cerebrovascular disease……Twenty-eight percent of patients with mild fibrosis and 68% of patients with advanced fibrosis had raised ALT activity…..”
Physicians caring for patients with liver disease, predominantly hepatologists and gastroenterologists, have long been aware that measurements of liver enzyme activities (serum aminotransferases, including ALT [alanine aminotransferase] and AST [asparate amniotransferase]) are critical in the diagnosis and assessment of liver disease. These enzymes were formerly referred to as SGPT and SGOT, respectively. The serum ALT activity (hereafter termed ALT) has been regarded as a reliable and sensitive marker of liver disease. ALT may also be a good indicator of overall health, particularly in the context of obesity, the metabolic syndrome, and presence of cardiovascular disease, as many patients affected by these conditions also are at risk of having non-alcoholic fatty liver disease.
Despite all these considerations, abnormal ALT activity is often ignored or minimized by practitioners as most patients are asymptomatic. Minor elevations are often construed to be clinically insignificant, in part because of lack of a longitudinal perspective about the impact of abnormal ALT on long-term outcome such as end-stage liver disease or premature mortality. This document summarizes the position of the American Association for the Study of Liver Disease regarding ALT and includes review of its physiology, its distribution in health and disease, and its role as a screening and diagnostic test and clinical tool. Specifically, the significance of ALT measurements for determining general health, liver health and liver disease is addressed. The purpose of this document is to reinforce that the significance and etiology of a persistently elevated ALT must be evaluated regardless of the degree of elevation and to examine ALT as a population screening tool for early detection of liver disease.
Physiology of ALT
Alanine aminotransferase (ALT) is an enzyme that catalyzes the transfer of amino groups to form the hepatic metabolite oxaloacetate.[1] It is composed of 496 amino acids, which are encoded by a gene located in the long arm of chromosome 8.[2][3] ALT is found abundantly in the cytosol of the hepatocyte. ALT activity in the liver is about 3000 times that of serum activity. Thus, in the case of hepatocellular injury or death, release of ALT from damaged liver cells increases measured ALT activity in the serum. Although it is generally thought to be specific to the liver, it is also found in the kidney, and, in much smaller quantities, in heart and skeletal muscle cells.
ALT released in the blood is catabolized in the liver with a resulting plasma half life of 47 ± 10 hours, which is considerably longer than that of AST (17 ± 5 hours).[1] ALT activity varies day to day, by 10% to 30%. Within a given day, there is a significant diurnal variation, with ALT activities being up to 45% higher in the afternoon than in the early morning.[4][5]
In acute hepatocellular injury, serum AST levels usually rise immediately, reaching a higher level than ALT initially, due to the higher activity of AST in hepatocytes and its release with liver injury. Within 24 to 48 hours, particularly if ongoing damage occurs, ALT will become higher than AST, because of its longer plasma half-life. In chronic hepatocellular injury, ALT is more commonly elevated than AST; however, as fibrosis progresses, ALT activities typically decline, and the ratio of AST to ALT gradually increases, so that by the time cirrhosis is present, AST is often higher than ALT.[6][7] One notable exception to the predominance of serum ALT activity in chronic liver disease is alcoholic liver disease where AST activity is generally higher than ALT levels.
Serum ALT as a Blood Test
ALT measurement affords a readily available, low-cost blood test that is utilized throughout the United States as a tool for detection of liver disease. ALT is a valuable screening test to detect otherwise inapparent liver disease, such as asymptomatic viral hepatitis and non-alcoholic fatty liver disease, both of which represent an epidemic that remains largely undiagnosed in the United States. Apart from liver disease, however, serum ALT activity may be affected by a number of factors not associated with hepatic necrosis. ALT levels differ with gender, with higher values in men than in women.[8] Additional factors that affect serum ALT levels include body mass index (BMI) and triglyceride levels, regardless of gender.[9-11] Total cholesterol levels and alcohol consumption among men have a positive correlation, whereas smoking, physical activity and age have a negative correlation with ALT levels.[11-13] Glucose levels, in women, have a positive correlation with ALT activities, whereas use of oral contraceptives tends to lower ALT values.
Some of these correlations (such as BMI) may be explained by ALT being higher in people with fatty liver disease. Similarly, patients with hyperlipidemia or hyperglycemia may also have fatty liver disease, as a part of the metabolic syndrome. In light of the increasing prevalence of obesity in Americans, the distribution of ALT in the apparently healthy population has changed such that some patients with non-alcoholic fatty liver disease may have ALTs in the normal range as determined by the mean ± 2 standard deviations.[9] In response, some physicians have advocated lowering the normal range.[8]
To the extent that there is a rough correlation between ALT and degree of hepatic inflammation in general, patients with high ALT levels tend to have more severe inflammation in the liver than those with normal ALT values. In contrast, the correlation between ALT and degree of hepatic fibrosis, the parameter that is most relevant to the prognosis of the patient, is not very strong, as exemplified by the common observation that a cirrhotic patient may have normal or only mildly elevated ALT.
ALT as an Indicator of Liver Disease
Since serum ALT levels rise in disease states that cause hepatocellular injury, serum ALT levels can effectively identify an ongoing liver disease process. The probability of clinically significant liver disease increases, particularly if the elevated ALT is associated with symptoms such as fatigue, anorexia or pruritus.
The utility of additional evaluation of a patient with asymptomatic elevation of ALT depends upon the findings of history and physical examination, the length of time that ALT has been elevated and the level of ALT elevation. Whereas one study suggested that the majority of asymptomatic people with elevated ALT do not have significant liver disease, a Scandinavian study of 151 consecutive patients with mild to moderate elevations of serum aminotransferase levels for at least 6 months revealed that liver disease was common.[14][15] Diagnoses included non-alcoholic steatohepatitis and hepatic steatosis (noted in 42%), chronic HCV (15%), alcoholic liver disease (8%) and autoimmune hepatitis, primary biliary cirrhosis and alpha1 antitrypsin deficiency in smaller numbers.
The level of ALT also guides the urgency and extent of further investigation. A serum ALT level less than 5 times the upper limit of the normal range should be rechecked before an extensive work-up is undertaken. If elevated ALT levels are confirmed and if they remain persistently elevated, additional work-up is indicated. ALT levels greater than 5 times the upper limit of the normal range suggest a potentially serious, active liver disease process and work-up should be initiated without waiting to confirm the persistence of abnormal ALT.
ALT levels greater than 15 times the normal range indicate severe acute liver cell injury and evaluation should be initiated immediately. The differential diagnosis for patients with severe acute liver injury (ALT levels >15 times the normal range) is relatively limited. Acute viral hepatitis (A-E), ischemic hepatitis or other vascular disorders such as acute venous outflow occlusion (Budd-Chiari), or toxin-mediated hepatitis should be considered. Acute autoimmune hepatitis, hepatic lymphoma or acute biliary occlusion may also present with highly elevated ALT activity. The diagnosis may be made upon historical grounds [ischemic episode, risk factors of acquisition of viral hepatitis, medication or hepatotoxin exposure (e.g., isoniazid) or overdose (e.g., acetaminophen)]. Blood testing (hepatitis and autoimmune serologies) may be helpful where applicable, whereas abdominal imaging may be helpful in other settings (e.g., venous outflow obstruction, biliary obstruction or abnormal lymphadenopathy).
Non-alcoholic Fatty Liver Disease (NAFLD).
NAFLD is probably the most common cause of abnormal ALT values among US adults and may affect up to 3% of the US population.[16][17] Risk factors for NAFLD include obesity, diabetes and hyperlipidemia.[18] Elevated ALT may be a component of the metabolic syndrome, the hallmark of which is insulin resistance, manifested by hyperglycemia, hyperlipidemia, abdominal obesity and hypertension. The role of NAFLD as an increasing threat to public health is highlighted by the well-publicized trend in the proportion of overweight or obese Americans.[19] Similarly, the prevalence of the metabolic syndrome is also increasing rapidly.[20] In these patients, testing for ALT will facilitate timely diagnosis of NAFLD before irreversible fibrosis of the liver is established. Elevated ALT activities may be the only clue to this entity since there are no definitive blood tests to confirm the diagnosis. Furthermore, patients with high ALT among those with the metabolic syndrome may represent a subgroup with a propensity for systemic inflammation that may, in turn, increase the risk of atherosclerosis, leading to coronary artery or cerebrovascular disease.[21]
Elevated ALT levels may correlate with the severity of NAFLD. In a study in which 233 morbidly obese women were examined, 60% had some degree of hepatic fibrosis, and the majority of these patients had an elevated ALT value. Twenty-eight percent of patients with mild fibrosis and 68% of patients with advanced fibrosis had raised ALT activity. ALT levels were elevated in only 17% of patients without fibrosis.[22] These observations are helpful in correlating elevated ALT with severity of liver damage. Therefore, ALT represents an excellent screening test to detect significant NAFLD.[23]
Alcoholic Liver Disease (ALD).
ALD remains the most common cause of liver-related morbidity and mortality in the United States.[24] In alcoholic liver injury, AST activity is characteristically elevated in comparison to ALT activity, although mild elevation of ALT level is common.[25] This is thought to be due to the longer half-life of mitochondrial AST released in response to alcohol and the coexistence of deficiency of pyridoxal-6-phosphate in alcoholics, which is a cofactor for the enzymatic activity of ALT.[26] History of alcohol use should be ascertained by accurate questioning such as with the CAGE questionnaire[27] or the MAST (Michigan alcoholism screening test)[28] in all patients with serum aminotransferase elevations. Random blood alcohol level is sometimes useful in distinguishing ALD from NAFLD. The histology of ALD may be indistinguishable from that of NAFLD.[29]
Hepatitis C Virus (HCV) Infection.
Chronic HCV infection is the most common chronic blood-borne infection in the United States, affecting approximately 2% of the population.[30][31] However, ALT levels fluctuate in HCV and values may occasionally fall into the normal range.[32] Since HCV infection is frequently asymptomatic, ALT elevations noted upon routine blood testing often stimulate the work-up whereby HCV infection is diagnosed. Sixty-nine percent of 248 asymptomatic blood donors who tested positive for HCV antibody had elevated ALT activity.[33] Sixty-eight percent of patients positive for HCV RNA had elevated ALT levels, compared with 17% of those without detectable RNA. Patients with severe liver damage on liver biopsy in this cohort had at least 1 elevated ALT determination. Twenty-nine percent of HCV-infected patients with initially normal ALT values, when followed, will develop persistently elevated ALT levels, and 57% will develop transient elevation in ALT activities within 5 years.[34] HCV patients with persistently normal ALT levels (at least 2 normal ALT values within 6 months) are more likely to be females[35] and tend to have lower necroinflammatory and fibrosis scores on liver biopsy when compared to similar patients with elevated ALT activities.[36][37] Significant fibrosis was found in 8% to 20% of patients with normal ALT levels compared to 60% of patients with elevated ALT activities. While ALT analysis alone may fail to detect a minority of persons infected with HCV, it is most effective in detecting those persons whose liver disease is more severe. Such a characteristic enhances the value of ALT as a screening tool for detection of clinically important liver disease. Moreover, the sensitivity of ALT analysis can be improved with serial measurements and long-term follow-up.
Hepatitis B Virus (HBV) Infection.
Chronic HBV infection, a common etiology of elevated ALT values worldwide, afflicts at least 1.3 million individuals in the United States.[38] Certain risk groups, such as individuals born in endemic countries, with a history of injection drug use, or on hemodialysis, may be identified in whom prevalence of HBV infection is particularly high in the United States.[39] Chronic HBV infection is also frequently asymptomatic and is sometimes discovered because of an elevated ALT level identified upon routine blood testing. Among HBV patients, the level of ALT is associated with progression of liver disease and development of morbidity. The cumulative risk of development of complications is highest in patients with ALT values at least 1 to 2 times above the upper limits of normal (ULN).[40] Among patients who are hepatitis B e antigen (HBeAg)-positive, ALT is also predictive of the likelihood of HBeAg seroconversion.[41] Thus, in HBV patients, ALT is useful not only in determining the presence of significant liver disease and need for treatment but also in gauging the future course in the natural history of the infection.
Drug-Induced Hepatotoxicity.
The use of many medications has been associated with elevated ALT levels.[42] Over-the-counter medications and herbal preparations are also implicated. If elevated ALT levels are confirmed, unnecessary medications should be discontinued, and ALT levels should be monitored. If ALT activity remains elevated, other etiologies should be sought. If the medication must be maintained for clinical benefit, ALT activity should be monitored. If ALT values continue to increase or are associated with development of symptoms or alteration of hepatic synthetic function, the offending medication must be discontinued.
Autoimmune and Cholestatic Liver Diseases.
Autoimmune hepatitis (AIH) may also be identified by recognition of mild to moderate elevations of ALT activity.[43] Patients may be asymptomatic or have nonspecific symptoms such as fatigue and arthralgias. Once the diagnosis is confirmed with serologic testing such as antinuclear antibody (ANA) and smooth muscle antibody (SMA) and a liver biopsy, immunosuppressive therapy may be considered. Aminotransferase activity plays an important role in determining treatment candidacy and also treatment response in those who undergo immunosuppressive treatment. Although AST activity has been traditionally used in these criteria, ALT activity is important in these management decisions. ALT levels may also be variably elevated in cholestatic hepatic processes such as primary biliary cirrhosis or primary sclerosing cholangitis.[44][45]
Metabolic Liver Diseases.
Mild elevations in ALT level may be noted in hereditary hemochromatosis, a relatively common genetic disorder of iron overload in people of Northern European descent.[46] Elevated iron saturation and serum ferritin levels are usually present. Homozygosity of
