Children with chronic hepatitis C: What future?
Authors: Raffaele Iorio, Francesco Cirillo, Vito Terlizzi, Antonietta Giannattasio
Journal: Hepatology (2008)

We read with interest the study by Goodman et al. in which hepatic histological features of 121 treatment-naïve children with chronic hepatitis C (CHC) were investigated.1 The authors reported that inflammation was minimal in 42% of the patients, mild in 17%, moderate in 38%, and severe in only 3% of patients. As for fibrosis, five (4%) patients had bridging fibrosis and two (2%) cirrhosis, whereas the remaining had a stage of fibrosis between 0 and 2 according to Ishak. Although the sample of children with bridging fibrosis or cirrhosis included only seven patients, a significant correlation between inflammation and fibrosis was found. There was a weak correlation between duration of infection and inflammation that did not reach the statistical significance (P = 0.058). In addition, no significant correlation was found between duration of infection and fibrosis. Nevertheless, the authors concluded that the positive correlation of inflammation with duration of infection and fibrosis suggested that children with CHC will be at risk for progressive liver disease as they age and possibly acquire other comorbid risk factors. Furthermore, Goodman et al. compared their histological findings with large published pediatric series. A previous study of ours regarding the long-term outcome of disease in a large series of children with CHC2 was not considered. Our study not only confirmed that CHC in children is morphologically mild in most cases, but it also showed that fibrosis progression is relatively slow and cirrhosis extremely rare. During a 18-year period, no child had decompensated liver disease or required liver transplantation. In addition, no linear correlation between duration of disease and progression of fibrosis was found. Two of three children with moderate fibrosis (score 4) at the time of the first biopsy had a short duration of disease (2.1 and 2.5 years). On the other hand, the only patient with absence of fibrosis had a disease duration of 13.9 years. Therefore, the severity of liver disease did not seem to depend on the duration of hepatitis C virus (HCV) infection. As for the long-term outcome of CHC in adults, it has been reported that 5%-20% of adults developed cirrhosis over periods of 20-25 years, whereas the majority of patients had a favorable course.3, 4 In another study regarding adults infected as young military recruits, the frequency of cirrhosis after 50 years was only 6%.5 No linear correlation was found between duration and severity of disease.5 Furthermore, it seems that higher degrees of fibrosis were related with age at infection being more frequent in patients ≥65 years regardless the duration of infection.6 Finally, it has been shown that the majority of fibrosis progression occurred in patients aged 50 years or older.7 In conclusion, on the basis of the majority of studies concerning the long-term outcome of HCV infection in children1, 2 and adults,3-7 we think that the conclusive sentence of Goodman that chronically HCV-infected children will be at risk for end-stage liver disease as adults is not adequately supported by results observed so far. Raffaele Iorio*, Francesco Cirillo*, Vito Terlizzi*, Antonietta Giannattasio*, * Department of Pediatrics, University of Naples Federico II, Naples, Italy.