How is that my
LFTs are so good when my viral load is seemly so high?
Few days ago I got a fax from a patient
of mine, whose blood chemical panels are all in normal ranges but his HCV
viral load was 3,470,000 iu/ml, which was a bit high. So he raised a few
questions that many of my patients have asked when they see their LFT’s
improve but their viral load fluctuate without improvement.
What is the relationship between
"viral load" and the liver damage?
How important is the viral count relative to its role in monitoring the
progression of the disease?
How to interpret clinical significance of viral count?
Patients often have these questions
while they read their blood tests results.
In order to answer these questions, we
first should know that HCV is a cytopathic and also an immunopathic virus.
Cytopathic means that the replication of the virus can directly cause
liver cell damage. Immunopathic means that HCV infection triggered
inadequate immune reactions that cause damage to the liver cells.
Clinically, we know that most liver cell damages were caused by
immunopathy. Cytopathy was not significant in chronic viral liver disease.
The relationship between the severity of
the liver cell damages and the viral count is weak at best. "It seems
that it is more important 'how' your body responds to the presence of the
hepatitis C virus in your liver than 'how much' virus is in your liver
that counts." (Howard Monsour, M.D., Viral Counts - Do We Need Them?
Hepatitis, Jul/Aug 2001, p. 22)
The body's constitutional make up, which
determines the immune response to the infection, has more influence than
the viral load in determining how much scar formation is caused under the
inflammation. Life style, such as alcohol drinking might also play a
greater role in promoting fibrosis than viral count.
The technique of viral load test is very
variable and the results are not reliable, depending on the specific lab
that performed the test. Different
labs and different times almost always produce different results.
Viral counts can also change within one
day and in a week, ranges varying several million copies per milliliter of
serum is common. I have one patient who tested one day with the result of
156,000 copies/ml and the next day, 5,000,000 copies/ml. These "ups
and downs" might not be caught at a single point of time. That is why
up to now, the FDA has still not approved viral count as a diagnostic
procedure and is only used for research purposes.
So, "Following viral counts to see
what's going on in the liver is of little use." (Howard Monsour,
M.D., same article as above) It might be
useful while doing research but not very useful in clinical practice.
There is poor correlation with ALT, AST levels and viral count. To really
determine the liver damage, a biopsy is still the best method, although it
is an invasive procedure. The clinical significance of viral load has only
been shown while doing IFN based treatments, low viral load (less than 2 million copies/ml) may
have better response rate to IFN based treatments.
So when the viral load elevated, it does
not mean the liver has taken more damage. We try to enhance the body's
immunity to control the viral load and at same time use herbs such as
olive leaf and its extract to lower the viral load. We have to admit that
anti-viral is the weak point of our herbal protocols. Because of this
weakness, some patients have started to experiment with "low dose IFN
injection every day plus herbal remedies" and they have been getting
very good results in normalizing their liver functions and also reducing
the viral load. Most of them
reduced to undetectable level. With low dose IFN combine with the herbal
protocol, they also experienced much less side effects.