Question
Is liver biopsy indicated for all HCV-infected patients before initiating therapy, regardless of genotype?
|
|
Response from Rowen K. Zetterman, MD, FACG
Dean, Professor of Medicine, Creighton University School of Medicine, Omaha, Nebraska |
Hepatitis C virus (HCV) has multiple genotypes of which genotype 1 is the most common in the United States. Cirrhosis does not develop in all patients infected with HCV. Elevated serum aminotransferase levels do not reliably predict the presence or absence of either fibrosis or progressive disease. This prompted a recommendation for pretreatment percutaneous liver biopsy in patients with genotype 1 HCV infection to establish prognostic information (presence of necroinflammatory disease and fibrosis that indicate progressive disease), and to delay treatment in those lacking such evidence because these patients were assumed to be at lower risk for cirrhosis. The American Association for the Study of Liver Diseases (AASLD) practice guideline, published in 2004, indicates that liver biopsy should be considered "when the results will influence whether treatment is recommended."
Genotype 1 HCV infection has a sustained treatment response to pegylated interferon and ribavirin of approximately 40%. Treatment response can be further reduced by concomitant fatty liver; cirrhosis; older patient age at treatment; or lifestyle activities, such as excessive alcohol consumption. In patients with genotype 2 or 3, the sustained viral response to pegylated interferon and ribavirin is 80% or greater. New combination therapies under development will improve the response to treatment of patients with HCV infection, including genotype 1.
As these new therapies improve the treatment response of all genotypes, the need for a liver biopsy to select those who should be treated will diminish.
Currently, I suggest that a liver biopsy be considered for patients with genotype 1 HCV infection if clinical parameters suggest that the liver disease might be a consequence of disease other than HCV, if there is an additional reversible component to identify that could improve response to therapy (e.g. alcoholism or fatty liver due to obesity), or if patients need further proof that they have liver disease that is likely to progress to cirrhosis. In patients with genotypes 2 and 3, treatment without biopsy is suggested.