Real-world experience with the all-oral, interferon-free regimen of ombitasvir/paritaprevir/ritonavir and dasabuvir for the treatment of chronic hepatitis C virus infection in the German Hepatitis C Registry.

Real-world studies are relevant to complement clinical trials on novel antiviral therapies against chronic hepatitis C; however, clinical practice data are currently limited. This study investigated effectiveness and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r)±dasabuvir (DSV)±ribavirin (RBV) for treatment of HCV genotype (GT) 1 and GT4 infection in a large real-world cohort. The German Hepatitis C Registry is an observational cohort study prospectively collecting clinical practice data on direct-acting antiviral therapies. Patients with GT1/4 infection treated with OBV/PTV/r±DSV±RBV were analysed. Effectiveness was assessed by sustained virologic response in 558 patients who reached post-treatment week 12 (SVR12). Safety is reported in 1017 patients who initiated treatment. Of the patients, 892 (88%) had GT1 and 125 (12%) had GT4 infection. Prior treatment experience and cirrhosis were reported in 598 (59%) and 228 (22%) patients, respectively. Overall, SVR12 (mITT) was 96% (486/505) in GT1- and 100% (53/53) in GT4 patients. SVR12 rates were high across subgroups including patients with cirrhosis (95%, 123/129), patients with moderate to severe renal impairment (100%, 34/34), and subgroups excluded from registrational trials like patients ≥70 years (96%, 64/67) and failures to prior protease inhibitor treatment (96%, 46/48). Adverse events (AEs) and serious AEs were reported in 52% (525/1017) and 2% (21/1017) of patients, respectively, and led to treatment discontinuation in 1.5% (15/1017) of patients. OBV/PTV/r±DSV±RBV was effective and generally well tolerated for treatment of HCV infection in clinical practice.

Impact of ribavirin priming on viral kinetics and treatment response in chronic hepatitis C genotype 1 infection.

Ribavirin amplifies the interferon-alpha (IFN) signalling cascade. As ribavirin needs 4 weeks to reach steady state, ribavirin priming may optimize hepatic IFN sensitivity before starting a pegylated (PEG)-IFN/ribavirin combination therapy. This study investigated potential benefits of ribavirin priming prior to PEG-IFN2a/ribavirin combination therapy on viral kinetics, on-treatment and sustained virological response (SVR) in chronic hepatitis C virus (HCV) genotype 1 infection. Sixty-eight treatment naive patients were randomized 2:2:1 to ribavirin (ribavirin arm) or placebo (placebo arm) or PEG-IFN2a (PEG-IFN2a arm) for 6 weeks prior to 12 weeks of PEG-IFN2a/ribavirin combination therapy within a double-blind, placebo-controlled trial. Then, standard PEG-IFN2a/ribavirin combination therapy according to the German guidelines was continued under the responsibility of the investigators. Ribavirin was given according to body weight and PEG-IFN2a at a dose of 180 µg subcutaneously once/week. During ribavirin priming, HCV RNA showed a decline of -0.58 log10  IU/mL (P < 0.001) that was unrelated to the IL28B rs12979860 genotype (CC vs CT/TT, P = 0.244). Ribavirin priming did neither increase the PEG-IFN2a-induced first- or second-phase viral decline (P values >0.100) nor on-treatment response or SVR (HCV RNA undetectable at week 12 of combination therapy: ribavirin arm 56%, placebo arm 38%, PEG-IFN2a arm 50%; SVR: ribavirin arm 41%, placebo arm 54%, PEG-IFN2a arm 50%; P values >0.300). In conclusion, ribavirin monotherapy showed a significant antiviral activity that was not influenced by the IL28B genotype. Ribavirin priming prior to PEG-IFN2a/ribavirin combination therapy did neither increase the first- or second-phase viral decline nor on-treatment response or SVR.

Treatment of severe, nonfulminant acute hepatitis B with lamivudine vs placebo: a prospective randomized double-blinded multicentre trial.

Acute hepatitis B virus (aHBV) infection can lead to fulminant liver failure, which likely is prevented by early lamivudine therapy. Even nonfulminant but severe acute hepatitis B can lead to significant morbidity and impaired quality of life. Therefore, lamivudine was evaluated in patients with severe aHBV in a placebo-controlled trial. Patients with severe aHBV infection (ALT >10× ULN, bilirubin >85 µm, prothrombin time >50%) were prospectively treated with lamivudine 100 mg/day or with placebo within 8 days after the diagnosis. The primary end point was time to bilirubin <34.2 µm. Secondary end points were time to clear HBsAg and HBV-DNA, development of anti-HBs and normalization of ALT. Eighteen cases were randomized to lamivudine, 17 to placebo. 94% of patients were hospitalized. No individual progressed to hepatic failure; all but one patient achieved the primary end point. Due to smaller than expected patient numbers, all study end points did not become statistically significant between treatment arms. Median time end points [in days] were bilirubin <34.2 µm (26.5 vs 32), ALT normalization (35 vs 48) and HBsAg clearance (48 vs 67) referring to earlier recovery under lamivudine, in contrast to loss of HBV-DNA (62 vs 54) and development of anti-HBs (119 vs 109). In all but two patients (one in every group), HBsAg clearance was reached in the study. Adverse events occurred more frequently during lamivudine therapy, but did not reach statistical significance. Lamivudine may ameliorate severe aHBV infection, but limited patient numbers prevented definite conclusions.

Estimating the likelihood of sustained virological response in chronic hepatitis C therapy.

The likelihood of a sustained virological response (SVR) is the most important factor for physicians and patients in the decision to initiate and continue therapy for chronic hepatitis C (CHC) infection. This study identified predictive factors for SVR with peginterferon plus ribavirin (RBV) in patients with CHC treated under 'real-life' conditions. The study cohort consisted of patients from a large, retrospective German multicentre, observational study who had been treated with peginterferon alfa-2a plus RBV or peginterferon alfa-2b plus RBV between the years 2000 and 2007. To ensure comparability regarding peginterferon therapies, patients were analysed in pairs matched by several baseline variables. Univariate and multivariate logistic regression analyses were used to determine the effect of nonmatched baseline variables and treatment modality on SVR. Among 2378 patients (1189 matched pairs), SVR rates were 57.9% overall, 46.5% in HCV genotype 1/4-infected patients and 77.3% in genotype 2/3-infected patients. In multivariate logistic regression analysis, positive predictors of SVR were HCV genotype 2 infection, HCV genotype 3 infection, low baseline viral load and treatment with peginterferon alfa-2a. Negative predictors of SVR were higher age (≥40 years), elevated baseline gamma-glutamyl transpeptidase (GGT) and low baseline platelet count (<150,000/µL). Among patients treated with peginterferon plus RBV in routine clinical practice, genotype, baseline viral load, age, GGT level and platelet levels all predict the likelihood of treatment success. In patients matched by baseline characteristics, treatment with peginterferon alfa-2a may be a positive predictor of SVR when compared to peginterferon alfa-2b.

Efficacy and tolerability of peginterferon alfa-2a or alfa-2b plus ribavirin in the daily routine treatment of patients with chronic hepatitis C in Germany: the PRACTICE study.

In randomized clinical trials, treatment with peginterferon plus ribavirin (RBV) results in a sustained virological response (SVR) in around half of hepatitis C virus genotype 1-infected and 80% of genotype 2/3-infected individuals. This study aimed to evaluate efficacy and tolerability of peginterferon alfa-2a plus RBV compared with peginterferon alfa-2b plus RBV for the treatment of chronic hepatitis C in routine clinical practice. The intent-to-treat cohort consisted of 3414 patients treated with either peginterferon alfa-2a plus RBV (Group A) or peginterferon alfa-2b plus RBV (Group B) in 23 centres participating in the large, multicentre, observational PRACTICE study. Collected data included baseline characteristics, treatment regimen, RBV dose and outcome. Rates of early virological response, end of treatment response and SVR were 76.6%, 75.7% and 52.9% in Group A, and 70.2%, 65.6% and 50.5% in Group B, respectively. In patients matched by baseline parameters, 59.9% of patients in Group A and 55.9% in Group B achieved an SVR (P < or = 0.051). In genotype 1-infected patients matched by baseline parameters and cumulative RBV dose, SVR rates were 49.6% and 43.7% for Group A and Group B, respectively (P < or = 0.047); when matched by baseline parameters and RBV starting dose, SVR rates were 49.9% and 44.6%, respectively (P = 0.068). Overall, 21.8% of group A and 29.6% of group B patients discontinued treatment (P < or = 0.0001). The efficacy and tolerability of peginterferon plus RBV in this large cohort of patients treated in routine daily practice was similar to that in randomized clinical trials. In matched pairs analyses, more patients achieved an SVR with peginterferon alfa-2a compared with peginterferon alfa-2b.

Interferon-alpha improves glucose tolerance in diabetic and non-diabetic patients with HCV-induced liver disease.

This pilot study was initiated to evaluate factors controlling glucose tolerance in patients with hepatitis C virus-induced liver disease before and after therapy with recombinant interferon-alpha (r-INF-alpha). Fifteen patients with histologically and serologically proven hepatitis C infection underwent oral and frequently sampled intravenous glucose tolerance tests (FSIGTT) before and after four months of therapy (6 x 106 U r-INF-alpha, subcutaneously, three times a week). Glucose, insulin and C-peptide data from FSIGTT were analysed using the minimal modeling technique to determine insulin sensitivity, glucose effectiveness and first and second phase insulin secretion. According to the WHO criteria 13 patients, had normal glucose tolerance; diabetes mellitus was diagnosed in 2 patients. In the morning following the last r-INF-alpha injection four months later, insulin sensitivity improved significantly in hepatitis C virus-infected patients with normal glucose tolerance (2.17 +/- 0.37 vs. 6.18 +/- 0.94 10(-4) min(-1) per microU/ml, p < 0.001) and with diabetes mellitus (0.86 to 2.61; 0.46 to 1.06 10(-4) min(-1) per microU/ml). This effect was independent of the extent of fibrosis, virus load before treatment and therapy response. First phase insulin secretion increased in non-diabetic (139.2 +/- 17.1 vs. 200.0 +/- 32.7, p < 0.05) and diabetic patients with HCV infection (55.24 to 118.5; 84.23 to 261.1). Moreover, free fatty acid concentrations in all HCV-infected patients were significantly reduced (0.48 +/- 0.01 vs 0.21 +/- 0.03 mmol/l, p < 0.01). Therapy with recombinant interferon-alpha is associated with an amelioration of glucose tolerance in non-diabetic and diabetic HCV-infected patients.

Hepatitis B virus superinfection in a patient with chronic hepatitis C receiving alpha-interferon treatment.

We report on a patient with chronic hepatitis C who developed acute hepatitis B during interferon alpha treatment. However, our patient promptly eliminated HBsAg and had a sustained complete response to interferon, even 6 months after the end of treatment. Acute hepatitis B superinfection in patients with chronic hepatitis C is a rarely observed event. The natural course of these patients is unknown. In our case it may be speculated that alpha-interferon treatment contributed to the prompt elimination of HBsAg from the serum.

Impaired health-related quality of life in patients with chronic hepatitis C and persistently normal aminotransferase levels.

A significant impact of hepatitis C virus (HCV) infection on health-related quality of life (HRQOL) has been previously described. However, comprehensive data on the quality of life in patients with chronic hepatitis C and persistently normal aminotransferase levels (PNAL) are currently not available. One hundred fifteen patients with chronic hepatitis C (45 with persistently normal aminotransferases and 70 with elevated aminotransferases) and 50 healthy subjects were enrolled. Emotional and psychological states were assessed by Profile of Mood States (POMS) scale and HRQOL was assessed by the 'Everyday Life' questionnaire (EDLQ), a validated questionnaire related to the SF-36 Health Survey. An impairment in HRQOL was observed in patients with chronic hepatitis C showing PNAL compared with healthy subjects with significant differences for the factor scores depression and anger in the POMS scale as well as for the items body, relationship to partner, self-confidence and zest of life in the EDLQ. No differences in any questionnaire were observed between patients with chronic hepatitis C showing PNAL or elevated aminotransferase levels except of a worse mean level for factor score anger in POMS scale in patients with persistently normal aminotransferases. No association of quality of life with severity of liver disease was found. Impairment of HRQOL by chronic infection with HCV is similar in patients with PNAL and those with elevated aminotransferase levels.

[Hepatic hydrothorax]. / Der hepatische Hydrothorax.

Hepatic hydrothorax is a rare complication of portal hypertension secondary to liver cirrhosis affecting approximately 5-10% of cirrhotic patients with ascites. Hepatic hydrothorax results from an accumulation of fluid migrating through a diaphragmatic defect from the abdominal cavity into the pleural cavities. The effusion of hepatic hydrothorax is typically transudative whereas the effusion of spontaneous bacterial empyema (SBEM) is exudative. The clinical management of hepatic hydrothorax is equivalent to that of ascites. Patients with persistent hepatic hydrothorax despite fluid and sodium restriction as well as the use of maximally tolerable doses of diuretics and repeated thoracentesis are considered to have refractory hepatic hydrothorax. SBEM is a frequent underlying condition. SBEM occurs in up to 13% of patients with hepatic hydrothorax and should be treated by antibiotic therapy. Refractory hydrothorax is observed in 10% of patients with hepatic hydrothorax. These patients should be considered for transjugular intrahepatic portal systemic shunt (TIPS) placement which is the most effective option for refractory hepatic hydrothorax with response rates ranging up to 80% in most studies. Suitable patients with hepatic hydrothorax should be considered as candidates for liver transplantation. TIPS may help to bridge the time to liver transplantation.

Noninvasive assessment of liver steatosis, fibrosis and inflammation in chronic hepatitis C virus infection.

BACKGROUND: Duplex-Doppler ultrasound is a noninvasive method for the assessment of hepatic hemodynamics beyond conventional gray-scale imaging. The clinical value of the method for the grading and staging of chronic hepatitis C virus (HCV) infection and the prediction of hepatic steatosis still has to be determined. This study aimed to compare Duplex-Doppler and ultrasound with the histologic staging and the estimation of hepatic steatosis in chronic HCV infection. PATIENTS AND METHODS: One hundred and nineteen consecutive patients with chronic HCV infection underwent both liver biopsy and ultrasound with Duplex-Doppler. Maximum portal venous blood flow velocity, portal venous flow undulation, hepatic venous flow pattern and spleen size were assessed and compared with histologic findings. Histologic grading and staging was performed according to the modified HAI and hepatic steatosis was estimated. RESULTS: Doppler ultrasound was unable to discriminate between different degrees of fibrosis. Sensitivity/specificity of portal venous flow and undulations for the diagnosis of hepatic cirrhosis was 74.5%/53% and 76.5%/100%. The PPV and NPV of reduced undulations was 100% and 96.2%. Mono- or biphasic hepatic venous flow indicated advanced hepatic steatosis (sensitivity 88.2%, specificity 74.5%, PPV 36.6%, NPV 97.5%). Spleen size was significantly enlarged both in patients with cirrhosis and steatosis. CONCLUSIONS: Although Duplex-Doppler of the portal and hepatic veins is not a substitute for histologic grading and staging, portal vein undulations can predict liver cirrhosis with considerable accuracy. Moreover, triphasic patterns of hepatic venous flow virtually exclude significant fatty liver disease. Additional studies should perform intraindividual follow-up investigations to further define the role of Duplex-Doppler ultrasound in chronic HCV infection.

Sonographic characterisation of hepatocellular carcinoma at time of diagnosis.

BACKGROUND: Hepatocellular carcinoma (HCC) is a malignant liver tumour with a high prevalence world-wide. For screening procedures conventional transabdominal B-mode ultrasound and AFP determination are commonly used. We investigated 100 consecutive patients with histologically proven hepatocellular carcinoma in order to evaluate sonographic characteristics in unselected patients and to compare native and contrast-enhanced ultrasonographic techniques. PATIENTS AND METHODS: We investigated 100 consecutive patients with hepatocellular carcinoma at time of diagnosis with respect to echogenicity, patterns of vascularity, and portal/hepatic vein thrombosis. In addition to B-mode and native power Doppler sonography, contrast-enhanced power Doppler sonography with SHU 508A was used in 65 patients. RESULTS: The ultrasound appearance with conventional B-mode of hepatocellular carcinoma was hypoechoic in 48 % of the cases, isoechoic in 9 %, hyperechoic in 19 %, and in 25 % a mixture between hyper- and hypoechoic appearance was found compared to the surrounding liver tissue. Contrast-enhanced power Doppler sonography with SHU 508A changed the pattern of tumour vascularity in 27 % of patients into hypervascular, mainly in small lesions. DISCUSSION: At the time of diagnosis, the most commonly observed finding in hepatocellular carcinoma is that they appear hypervascular, independent of their size. The use of ultrasound contrast media should be considered to achieve characterisation of liver nodules in cirrhotic livers because they can improve the evaluation of tumour vascularity. Hypovascular HCC are found in about 10 % even after the administration of a contrast agent.

Detection of residual hepatitis C virus RNA by transcription-mediated amplification in patients with complete virologic response according to polymerase chain reaction-based assays.

A considerable proportion of patients with chronic hepatitis C who achieve a virologic end-of-treatment response relapse after discontinuation of therapy. It is conceivable that polymerase chain reaction (PCR)-based assays with a lower detection limit of 100 to 1, 000 hepatitic C virus (HCV) RNA copies/mL are still too insensitive to detect residual viremia. End-of-treatment serum samples of 47 patients with a virologic relapse according to results of qualitative PCR assays (Amplicor HCV; Roche Molecular Systems, Mannheim, Germany) were tested by transcription-mediated amplification (TMA), an isothermal, autocatalytic target amplification method that has the potential to detect less than 50 HCV RNA copies/mL. Virologic sustained responders (n = 59) and nonresponders (n = 49) served as controls. In end-of-treatment serum samples of virologic sustained responders and nonresponders an almost complete concordance between PCR and TMA results was observed (98%). However, HCV RNA was detectable by TMA in end-of-treatment serum samples from 16 of 25 relapse patients (64%) who were HCV-RNA-negative according to Amplicor HCV version 1.0 (lower detection limit 1,000 copies/mL) and in 8 of 22 patients (36%) who were HCV-RNA-negative according to Amplicor HCV version 2.0 (lower detection limit 100 copies/mL). End-of-treatment alanine transaminase (ALT) levels of sustained virologic responders and TMA-negative relapsers were similar, whereas a trend toward higher ALT values was observed in TMA-positive relapsers compared with sustained virologic responders (P = 0.09). In conclusion, HCV RNA can be detected at the end of treatment by TMA in a considerable proportion of patients who were classified as virologic end-of-treatment responders with a subsequent virologic relapse according to PCR-based methods.

Randomized, double-blind, placebo-controlled trial of interferon alfa2a with and without amantadine as initial treatment for chronic hepatitis C.

Although the antiviral effects of amantadine sulphate (1-aminoadamantan sulphate) have not been characterized for the hepatitis C virus (HCV), previous pilot studies have suggested promising results in patients with chronic hepatitis C. The aim of the present study was to compare the efficacy, safety, and health-related quality of life (HRQOL) of interferon alfa (IFN-alpha) alone or in combination with oral amantadine for treatment of chronic hepatitis C. One hundred nineteen previously untreated patients with chronic hepatitis C were randomly allocated to treatment with IFN-alpha2a at a dose of 6 megaunits 3 times a week subcutaneously for 24 weeks, followed by 3 megaunits thrice weekly for an additional 24 weeks plus amantadine sulphate administered orally 100 mg twice a day for 48 weeks or the same IFN regimen plus a matched placebo. The primary endpoint was undectable serum HCV RNA (<1,000 copies/mL) at week 24 after treatment. At the end of treatment and the 24-week follow-up period serum HCV RNA was undetectable in 20 (34%) and 6 (10%) of the 59 patients treated with the combination IFN-alpha plus amantadine and in 20 (33%) and 13 (22%) of the 60 patients treated with IFN-alpha alone, respectively (P = n.s.). Discontinuation of therapy for adverse events was similar in both treatment groups. Although treatment with IFN-alpha worsened HRQOL, combination with amantadine showed a substantial trend to improve fatigue and vigor. In conclusion, combination therapy IFN-alpha plus amantadine is as effective as IFN-alpha monotherapy in previously untreated patients with chronic hepatitis C.

[Re-treatment with interferon-alpha in chronic hepatitis B and C virus infection]. / Interferon-alpha-Retherapie der chronischen Hepatitis-B- und -C-Virusinfektion.

The efficacy of interferon-alpha retreatment was assessed in patients with chronic hepatitis B or C, not responding to a first cycle of interferon or reactivating thereafter. 27 patients with chronic hepatitis B and 25 patients with chronic hepatitis C were investigated. After an interval of at least 6 months these patients received an interferon-alpha retreatment in a higher dosage schedule and with a different interferon-alpha subtype. In patients with chronic hepatitis B a loss of serum HBV-DNA was observed in 59% patients after interferon-alpha retreatment. HBeAg seroconversion occurred in 8 of these patients. In chronic hepatitis C 32% of the patients responded completely to the second cycle of interferon-alpha treatment with a normalization of ALT associated with a loss of serum HCV-RNA. A partial response with a marked reduction of ALT was seen in 4 patients. In chronic hepatitis B and C a complete or partial response to the retreatment was closely associated with the response status after the first cycle. Thus, interferon retreatment seems to be effective in patients with chronic hepatitis B or C, especially in the subgroup of patients exhibiting a partial or complete response after the first interferon treatment.

Indomethacin treatment in amphotericin B induced nephrogenic diabetes insipidus.

Nephrogenic diabetes insipidus (NDI) is a serious side effect of various drugs. Elevated renal prostaglandin E2 levels have been found in patients with lithium-induced NDI and have been implicated in the pathogenesis. We report the case of a patient who developed NDI following treatment with amphotericin B. Prostaglandin levels were elevated. Indomethacin had an antidiuretic effect and normalized prostaglandin levels.

Interferon-alpha retreatment in chronic hepatitis C.

For chronic hepatitis C virus (HCV) infection, interferon-alpha (IFN-alpha) treatment has recently been established. However, the complete responding rate is not higher than 20-25%. The aim of our study was to assess IFN-alpha retreatment in chronic hepatitis C. In summary, during a second cycle of IFN-alpha, 60% of the patients responded to the retreatment. Indeed, a sustained complete response, together with long-lasting normal alanine aminotransferase values and negative serum HCV-RNA, was observed in about 40% of the retreated patients. Future prospective and controlled trials must define the optimal retreatment strategy, as well as the response-predicting factors including HCV genotypes and quantitative HCV-RNA levels.

Risk factors for the transmission of hepatitis C.

BACKGROUND: Due to the availability of testing for antibodies to the hepatitis C virus (anti-HCV) and with the use of the polymerase chain reaction (RT-PCR) to detect HCV-RNA, more sensitive and specific measures can be applied to assess routes of HCV transmission. The aim of the present study was to investigate possible risk factors for transmission of HCV. METHODS: 160 consecutive patients with chronic hepatitis C (mean age 47.1 +/- 14.1 yr) attending a hepatology out-patient clinic were interviewed to identify transmission risk factors. Genotyping of HCV isolates was performed by direct sequencing of RT-PCR products in the 5'-noncoding and the NS-5 region. RESULTS: The risk factors of HCV infection were as follows: transfusion of blood or blood products 34.4%, intravenous drug abuse 20.6%, heterosexual contact 3.8%, occupational risk 1.9% and tattoo 0.6%. In 62/160 (38.7%) the route of transmission remained unknown. In one HCV-infected couple we analyzed the nucleotide sequences of the NS-5 region of the respective HCV isolates and found almost complete sequence homology (> 97%). The majority of patients with post-transfusional or unknown mode of transmission were infected with genotype HCV-1a and -1b, while in 6/10 patients with previous i.v. drug abuse, genotype HCV-3a was present. We found no evidence that the mode of disease acquisition influences the course of liver disease. CONCLUSION: The majority of patients with chronic hepatitis C have a classical parenteral transmission risk factor. In our study, no source of HCV acquisition was identified in 38.7% of patients. It may well be that the major factors in these "sporadic" HCV infections are variations on the known risk factors. However, since the proportion of these cases is rather high, further attention should be on alternative and as yet unclear transmission routes.

Long-term follow-up of patients with chronic hepatitis C after interferon-alpha treatment.

In this study, 72 patients with chronic hepatitis C virus (HCV) were followed prospectively for a mean period of 27 months after interferon treatment. Fifty-seven percent (20/35) of the patients with complete response, 18/20 with HCV-RNA-negative serum, had a sustained biochemical remission. Reactivation was seen in 43% of these patients after a mean follow-up of 7.3 months. A late relapse after more than 12 months of follow-up occurred in only 2/15 patients. Patients with a long-term complete response had significantly lower pretreatment serum HCV RNA levels than complete responders with relapse (106,239 vs. 345,649 mEq/ml, p = 0.0213). A delayed sustained biochemical remission was seen in 3/37 patients with partial or no response. Thus, long-term response is achieved in 32% of the patients treated with interferon, clearly associated with a suppression of serum HCV RNA. Patients with normal ALT values and undetectable levels of HCV RNA for more than 12 months of follow-up may usually be considered as sustained responders. Thus, for the first time, the pretreatment HCV RNA level in serum was identified as predictive of long-term response.