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The liver lies just inferior to the diaphragm, the largest and most
complex organs in the body. A  single liver cell can carry on more than 500 separate metabolic activities. The right lobe of the liver is larger than its left lobe and has three main parts. - - Each liver lobe is divided into thousands of microscopic lobules, which are the functional units of the liver.  - - -  A lobule consists of several plates of liver cells.   


- - - With so many of us now testing HEP C positive, liver function tests, biopsies, ultrasounds and Interferon are words that are continually cropping up.  - - Trying to sift through all the available information can be very difficult, especially when you can hear such conflicting views; liver biopsy's are excruciatingly painful - -no, they don't hurt a bit, Interferon was great, my viral load is undetectable now - God it was terrible, vomited constantly and still it did nothing.

- - - -What is apparent however, is that drug users don't always get the medical attention they need.  - - Getting overlooked, sent away, ignored, or superficially treated is unfortunately not unusual.  BUT, while your peers activate and agitate for better health care for all drug users, there is something you can do. ------------   You know the saying,

"Knowledge is power?"

Learning a bit about how your liver works, what it needs to function well and understanding what your results actually mean to you, allows you to be a bit more forearmed when treatment decisions come your way. First, we thought  we should start with deciphering the liver function test.
It is usually the first test you will have when information about your liver is required. It is helpful to understand these results and by comparing them over time you may be able to find out whether lifestyle changes are benefiting (or not) your liver.


The role of the liver is to keep the body's complex internal chemistry in balance. It takes raw nutrients from our digestive system (in the form of carbohydrates, so they can be stored and sent to different parts of our body in the right form and quantity.

- - - - - The liver regulates the level of sugars in our blood and manufactures bile (which breaks down fats in our stomach). It also helps remove toxins, drugs and hormones from our bloodstream.

This brief explanation does the liver little justice - -it actually carries out over 1,500 complex biochemical functions.  - - - Perhaps it is because the liver is so important, that up to a certain point, like a lizard's tail, it can rejuvenate itself.


A liver function test (LFT) is a blood test that gives an indication of whether the liver is functioning properly. The test is also very useful to see if there is active damage in the liver (hepatitis) or sluggish bile flow (cholestasis). Liver function tests measure the amount of particular chemicals in the blood.  - - -This gives a gauge of possible damage to liver cells- damage that can be caused by many things including HCV. So a more correct term for a liver test would actually be   a liver dysfunction test.

It's important to remember that diagnosis of liver disease depends on a combination of patient history, physical examination, laboratory testing, biopsy and sometimes     imaging studies such as ultrasound scans.
Diagnosis of hepatitis C usually also involves antibody tests      or PCR tests.

- - People reading this should keep in mind that abnormalities within liver tests don't necessarily point to specific diseases. Only a physician who knows all the aspects of a specific case can reliably make a diagnosis.

- - - - -So what are the substances measured in an LFT blood test and what is so important about them? - - - -

Total protein Is simply a combined measure of the concentrations of proteins in the blood. This information can provide clues to several diagnostic possibilities. There are two major types of protein: albumin and globulin.

Albumin
Provides a gauge of nutritional status. Can be reduced due to liver damage and kidney disease. Because albumin is made in the liver, levels tend to drop with cirrhosis.

Globulin
Describes the specific level of globulin's - which include antibodies. This measure can be raised when liver cells are damaged due to autoimmune liver damage or to long standing liver disease of many types, particularly when cirrhosis exists.

Bilirubin
Is a by-product of the yellowish pigment responsible for jaundice. - - -  Bilirubin levels can be raised due to Diseases, as well as conditions, other than liver, for example ---Gallstones.   In cases of long term liver illness (chronic hepatitis), the level usually stays within the normal range until significant liver damage has occurred and cirrhosis is present. - - - -- ---------- In cases of short term liver illness (acute hepatitis), elevated Bilirubin levels indicate the severity of the acute illness.

GGT
Is an enzyme produced in bile ducts that may be raised due to bile duct illness. The GGT test is extremely sensitive and may be elevated due to any type of liver disease or by different drugs, including alcohol, even when liver disease is minimal. GGT levels sometimes rise even in the case of a normally functioning liver.

Alk phos
Refers to Alkaline Phosphatase, a family of enzymes produced in the bile ducts, intestine, kidneys, placenta and bones. These levels may rise when a disease of the bile ducts or bone disorder occurs.

ALT
Is an enzyme produced in hepatocytes (the major type of liver cells) . ALT level in the blood is increased when hepatocytes are damaged or die- all types of hepatitis (viral, alcoholic, drug induced ) cause hepatocyte damage. Levels of ALT may equate to the degree of cell damage but this is not always the case, particularly with hepatitis C. An estimate of cell damage can only be made by liver biopsy.

AST
- - -  -Is similar to ALT above, but less specific for liver disease because it is also produced in body muscle cells. It does tend to be higher than ALT in cases of alcohol related liver disease. (Hep C Review August 98)
There are an estimated 200, 000 to 400, 000 Hepatitis C positive people in Britain and a possible global infection rate of 170, 000, 000 people. (Mainliners 98)

Platelets are the smallest of all blood cells and are involved in promoting clotting of the blood.- normally a process of healing. In cases of chronic liver disease where cirrhosis exists, the platelet count can be lowered- although this can occur due to many conditions other than liver disease.

Adult range or normal range-

-------  This figure allows you to compare your various LFT readings with what is considered to be normal ( these figures will vary slightly for each laboratory). As shown in our sample LFT result, David Browns ALT reading of 108 would be over twice the pathology labs upper normal range of 45.

Reference: Black Poppy October 2004
                 Understanding Human Anatomy and Physiology; Solomon and Philips  1987


Acute Hepatitis C is almost
indistinguishable from acute
Hepatitis B infection. 

- - - -  Patients with acute
acute Hepatitis Care are
frequently asymtomatic
 ....  
(meaning they have no 
symptoms), even  when
liver tests are abnormal.

Soon after contracting the
infection many people have
a flu-like illness with fatigue fever, muscular aches and
pains, nausea and vomiting.

About 10% of patients become jaundiced (their skin turns yellow).  - -- Generally these symptoms resolve and the patient has no symptoms of liver disease for many years. Symptoms may occur from two weeks to six months after exposure but usually within two months.


The symptoms of chronic infection range from no symptoms at all, to gradually progressive fatigue and lack of energy, to complete debility. The effects of the virus vary widely between individuals.

The symptoms of cirrhosis include progressive fatigue, jaundice (yellow skin), icterus (yellow eyes), dark urine (the color of cola), abdominal swelling, muscle wasting, itching, disorientation and confusion, loss of appetite, - - - - - and easy bruisability.

In an informal survey of hepatitis C symptoms, Scott Warren polled 50 people on the HEPV-L list and compiled the following results:

FATIGUE, WEAKNESS, TIREDNESS - 72%
JOINT, MUSCLE PAINS - 52%
MEMORY LOSS, MENTAL CONFUSION - 50%
SKIN PROBLEMS-DRY\ITCHY\RASHES\SPOTS - 44%
DEPRESSION, ANXIETY,
IRRITABILITY- 44%
INDIGESTION
, NAUSEA, VOMITING, GAS - 34%
SLEEP DISTURBANCES - 32%
PAIN OR DISCOMFORT IN ABDOMEN - 32%
CHILLS, SWEATING, HOT \ COLD FLASHES - 26%
EYE OR EYESIGHT PROBLEMS - 24%
SENSITIVITY TO HEAT OR COLD - 22%
NO SYMPTOMS - 20%
VERTIGO, DIZZINESS, COORDINATION - 18%
FLU LIKE SYMPTOMS - 18%
HEADACHES - 18%
URINARY PROBLEMS, ODOR, COLORATION - 16%
FEVER - 16%
SLOW HEALING AND RECOVERY - 14%
SUSCEPTIBILITY TO ILLNESS \ FLU - 14%
WEIGHT GAIN, WATER RETENTION - 10%
MENSTRUAL PROBLEMS - 10%
APPETITE \ WEIGHT LOSS - 8%
SWELLING OF STOMACH, LEGS OR FEET - 8%
ORAL, OR MOUTH SORES \ PROBLEMS - 8%
EXCESSIVE BLEEDING - 4% 


The main symptom of most people with hepatitis C is chronic fatigue, ranging from simply getting tired easily to extreme, debilitating fatigue.


Many hepatitis C patients find that they are no longer interested in sex.  --- This tends to be especially true for those undergoing interferon treatment. This is not necessarily directly related to the hepatitis, but is most likely due to the stress, discomfort and exhaustion caused by the struggle with a chronic illness.


Even though the liver itself contains no nerve endings, and does not feel pain, many people with HCV experience a pain on the upper right side of their body, just beneath the ribs.  - - This is thought by some to be "referred pain" from the swelling of the liver capsule due to the disease process. This pain may also be referred to the right shoulder or to the back between the shoulder blades.


Red palms can occur in any chronic liver disease and are not specifically caused by the virus. The cause for the redness is unknown, but it's speculated that it may involve upset hormone metabolism or micro-circulatory changes.


A few of the more popular nausea aids are chewing candied ginger, putting a (small) drop of peppermint oil on the end of your tongue, eating small frequent meals, dry crackers and weak tea, and popsicles.


This is the mental fuzziness and forgetfulness that some people experience. It's not the same as encephalopathy, and seems to occur in all stages of the illness.  - - -Some people have found taking CoEnzyme Q10, also known as CoQ10, to be helpful (2 30mg capsules per day).  - -  - Another list member recommends taking Gingko Biloba.


Some hepatitis patients complain of blurring vision, and dry eyes. This can be especially true while undergoing interferon treatment.


There are two products (mouthwash and toothpaste) by the name of Biotene®, which are designed to help with the problem of a dry mouth and gum problems as a result of medication use. Several list members have reported great relief by using these products.


Some people have found that wearing "Sea Bands" helps with their dizziness. --- - - - - Sea Bands are elastic bands that can be bought, usually in sporting goods stores, which press against pressure points in the wrist. - They were designed for use in seasickness.


The build-up of bilirubin in the skin may cause itching. Itching can be treated with antihistamines, or cholestyramine (which binds bile in the intestines). Actigall and Questran are two drugs reported to help with this problem.

Reference:  Heroin Times October 04/hepc3.html 


Information from the American Liver Foundation,
1425 Pompton Avenue Cedar Grove, NJ 07009
1-800-GO LIVER (465-4837)


Hepatitis C (HCV) is a virus that infects the liver.
Up to 85% of people exposed to this virus develop chronic liver disease. In general, chronic HCV appears to be a slowly progressive disease that may gradually advance over 10-40 years.
While not as yet totally defined, many factors influence the rate of disease progression. Diet may play an important role in this process, as all foods and beverages that we ingest must pass through the liver to be metabolized.

- - -General guidelines for individuals infected with HCV include maintaining a healthy lifestyle, eating a well-balanced, low-fat diet, and avoiding alcohol. - A diet high in complex carbohydrates may be helpful in providing calories and maintaining weight.  - - Since HCV infection may lead to loss of appetite, those individuals whose appetite is diminished may find frequent, small meals more easily tolerated.  Adequate rest and moderate exercise can also contribute to a feeling of well-being.


Alcohol is a potent toxin to the liver. Excessive intake can lead to cirrhosis and its complications, including liver cancer.  - - - - - - - -  Heavy drinkers are not the only individuals at risk for liver diseases, as damage can occur in even some moderate "social drinkers."

The hepatitis C virus has frequently been isolated from patients with alcoholic liver disease. In fact, these patients have been found to have a higher incidence of severe liver damage, cirrhosis, and a decreased life span, when compared to individuals without the virus. It is suggested that the combination of alcohol and HCV accelerates the progression of liver disease.

The consensus statement concerning management of HCV released in March, 1997 from the National Institutes of Health further warned about the dangers of excessive alcohol use, and advised limitation of alcohol to no more than one drink per day.
Therefore, patients with HCV would be unwise to drink alcohol in excess, and total avoidance of all alcohol intake is recommended.


You are a greater risk if you drink. - - - - -think about it before you have the next one.  It can make all the difference in the world- - - would you prefer to continue to drink even if it may stop you from acquiring Hepatitis C.


The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal.  ----The average American diet contains about 10-20 mg of iron per day.
About 10% of this iron is absorbed, in keeping with the body's need for 1 to 2 mg. of iron per day.  - - -  Patients with chronic HCV sometimes have an increase in the iron concentration in the liver.

Excess iron can be very damaging to the liver. - - - Studies suggest that high iron levels reduce the response rate of patients with HCV to interferon.

- - -Thus, patients with chronic HCV whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplements. In addition, these patients should restrict their intake of iron-rich foods, such as red meats, liver, and iron-fortified cereals, and should avoid cooking with iron-coated cookware and utensils.


- - -Overweight individuals are often found to have abnormalities related to the liver, ranging from fatty deposits in the liver (steatosis) to fatty deposits accom-panied by inflammation (steatohepatitis). In overweight patients with a fatty liver who subsequently lose weight, liver related abnormalities improve. Therefore, patients with chronic HCV are advised to maintain normal weight.

For those who are overweight, it is crucial to start a prudent exercise routine and a low fat, well balanced, weight reducing diet. Diabetic patients should follow a sugar restricted diet. - - A low cholesterol diet should be followed in those with hypertriglyceridemia. It is essential that patients consult with    their physician before beginning any diet or exercise program. 


Adequate protein intake is important to build and maintain muscle mass and to assist in healing and repair.  - - - Protein intake must be adjusted to one's body weight and medical condition.  - -  Approximately 1.0 to 1.5 gm. of protein per kilogram of body weight is recommended in the diet each day for regeneration of liver cells in non-cirrhotic patients.
In a small but significant number of individuals with cirrhosis, a complication known as encephalopathy, or impaired mental status, may occur.  - - Affected individuals may show signs of disorientation and confusion. The exact cause(s) of encephalopathy is not fully understood.

While some experts do not believe there is a link between dietary protein and encephalopathy, others believe in substantially reducing or even eliminating animal protein and - - - adhering to a vegetarian diet, in order to help improve mental status.  Patients who are at risk for encephalopathy may be advised to eat - - - no more than .6 - .8 gm. of animal source protein per kilogram of body weight per day.  - -  (Animal source proteins are meat, fish, eggs, poultry, and dairy products. Each provides 7 gm. of actual protein per ounce of food.)

There is no limit on vegetable protein consumption. - - - Maintaining adequate protein intake and body weight should be considered a priority if vegetarian protein substitutes are not utilized . The table below gives recommended grams of animal source protein intake per pound of body weight.  (Note: The chart is intended to provide guidelines for patients with hepatitis C.  - - - -   For specific recommendations, consult your physician.)

Weight Recommended average protein intake for regeneration of liver cells in non-cirrhotic patients. Maximum recommended protein intake for patients at risk for encephalopathy.

100 lbs. 45-68 gm. (6 -9 oz. meat or equivalent) 27 gm.
130 lbs. 59-87 gm. (8 - 12 oz. meat or equiv.) 35 gm.
150 lbs. 68-103 gm. (9.7-14 oz. meat or equiv.) 40 gm.
170 lbs. 77-116 gm. (11 -16 oz. meat or equiv.) 46 gm.
200 lbs. 91-136 gm. (13 -19 oz. meat or equiv.) 54 gm     


Advanced scarring of the liver (cirrhosis) may lead to an abnormal accumulation of fluid in the abdomen, referred to as ascites.  - - - Patients with HCV who have ascites must be on sodium (salt) restricted diets.

Every gram of sodium consumed results in the accumulation of 200 ml. of fluid. The lower the salt content of the diet, the better this excessive fluid accumulation is controlled.

Sodium intake should be restricted to 1,000 mg. a day or less. - -This requires careful shopping and reading all food labels. It is often surprising to discover which foods are high in sodium. For example, one ounce of corn flakes contains 350 mg. of sodium; one ounce of grated parmesan cheese, 528 mg. of sodium; one cup of chicken noodle soup, 1,108 mg. of sodium; and one teaspoon of table salt, 2,325 mg. of sodium.

Avoid fast food restaurants, because most fast foods are high in sodium. Meats, especially red meats, are high in sodium, so meat consumption may need to be reduced and vegetarian alternatives considered.

Patients with chronic HCV without ascites are advised not to overindulge in salt intake, although their restrictions need not be as severe.


- - - -   Like foods and beverages, medications also pass through the liver to be metabolized.  - -  Individuals with chronic liver disease should be careful about taking medications, even those sold over-the-counter. Read package labeling carefully before taking medications, and discuss any questions you may have with your physician and/or pharmacist.

Author:  Melissa Palmer, MD



What are the treatment options for Hepatitis C ?

Alpha interferons either alone or in combination with the anti-viral ribavirin are currently the only drugs scientifically shown to result in sustained response.  Natural interferons are produced in the body when invaded with a virus.  Interferon stimulates the immune system to attack the invading virus and any infected liver cells. Fevers, chills, nausea, and general malaise are caused by the interferon your body releases.  Interferon treat-ment has two goals: 1)  clearing the Hepatitis C virus from your system and/or   2) causing some remission of liver disease.

The National Institute of Health Consensus Development Conference recommends that treatment should be limited to those patients with progressive liver disease as evidenced by fibrosis moderate to severe inflammation and necrosis by liver biopsy.
Individuals with less severe degrees of histology should be managed on an individual basis.

Duration of treatment varies.  For combination therapy in patients with genotype 2 or 3, a 24-week treatment is redommended.  For combination therapy in HCV genotype 1, a 48  week treatment is recommended.  Non-responders can be identified by assessing the ALT level and qualitative PCR at 6 months of treatment with interferon.  Patients with detection of HCV by PCA RNA are non-responders and treatment should be discontin-ued.  Response rates vary according to some different factors.  Genotypes 1a and 1b have a lower overall response rate than types 2a, 2b,3a, and 3b.  Early detection of HCV infection can raise the response.  A high viral load (greater than 1mU/ml of blood serum)
can negatively affect the response rate.  A high viral load (greater than 1mU/ml of blood serum) can negatively affect the response rate. - The presence of advanced liver disease can lower predicted response.  None of these predictors of response should be used to deny treatment. 

Contraindications for Interferon Treatment:

Patients who are active alcohol users,  patients with clinically decompensated cirrhosis, patients with autoimmune hepatitis, patients with sarcoidosis, patients with uncontrolled diabetes, uncontrolled high blood pressure, or uncontrolled heart disease.  Patients with very bad depression, especially if uncontrolled are not canditates for treatment.  

Uncommon Side Effects of Interferon Treatment Are:

Autoimmune, especially Thyroid Disease, severe Bacterial Infections; Seizures; Tinnitus; Depression; Retinopathy, and Hearing Loss

Side effects of ribavirin can include:

 Anemia. fatigue and irritability, itching, skin rash, nasal stuffiness, sinusitis and cough, angina pectorisand some rare cases of myocardial infarction and stroke. 

It is recommended that all HCV patients be vaccinated for Hepatitis A and in some situations Hepatitis B.  Co-infections with Hepatitis B and C can be devastating and a dual infection with Hepatitis A and C can be deadly.

If left untreated/uncured, how might Hepatitis C affect the body?

It can permanently damage the liver by replacing the normal liver with scar tissue.  When this is severe, it is called cirrhosis.  In some cases, Hepatitis C can cause liver cancer; although the liver has to become scarred first.

Treatment Information  

The Food and Drug Administration has approved three antiviral therapies for treatment of chronic Hepatitis C in persons 18 years or older. alpha interferon, pegylated interferon and alpha or pegylated interferon in combination with ribavirin. All are given for up to 52  weeks.

The main goal of therapy is to eliminate the Hepatitis C virus.  Undetectable virus at the end of treatment is called the end of treatment response (ETR).  Therapy is con-sidered successful if the virus remains undectable six months after treatment ends. This is called sustained virologic response (SVR). 

While antiviral therapy is available, it is not recommended for all chronically infected individuals.  Because of advances in the field of antiviral therapy for chronic Hepatitis, standards of practice may change over time.  Those with Hepatitis C should consult  with a health care provider who is experienced in treating vital hepatitis. 

Patient Assistance Programs 

Information on Pegasys and the Pegassist program:   
1-800-285-4484      or         1-877-734-2797

Information on Peg-Intron. Commitment To Care And Be In Charge programs:
1-800-656-9485
http://www.beincharge.com


Think twice before you share syringes.  - -  I know how difficult it is if you are in need of a fix.  You can think of nothing else but shooting up.  Stop!  - - - - - -The agonizing pain you will suffer if you contract a disease will be much worse.  If you need syringes - before you share one - give us a call and let us see what we can do for you.  Prepare ahead - don't share your syringes.   Think about giving it all up and trying methadone.  It saved my life --- it can yours, too.

Edited and Compiled by: Deborah Shrira, RPH,CMA             --   4 November 2005  Phone   (Metro Atlanta Area)  770-428-8769      Open 24/7  Hours Daily for you .                                                    

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