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Li Vecchi M, La Spada E, Li Vecchi V, Montalto G. Hepatitis C Virus Infection in Hemodialyzed Patients. Int J Artif Organs 2018; 30:100-7. [PMID: 17377904 DOI: 10.1177/039139880703000204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In spite of our present improved knowledge of the epidemiology and pathways of contamination of the hepatitis C virus (HCV), infection still remains a public health problem. One category of patients who have suffered greatly from the consequences of HCV infection is certainly that of hemodialysis patients. In the past, in fact, their need for transfusions exposed these patients to infection and, as a result, subjects on dialysis for over 15 years are today paying the price for those inevitable transfusions, as the virus and its pathways of contagion were unknown then. However, still today, albeit at a much lower prevalence, even subjects with a shorter dialysis age present a higher prevalence of anti-HCV than the general population, suggesting that other factors of contamination than the classical ones contribute to keeping this prevalence high. Its clinical course is generally asymptomatic and the biological and virological progression of the disease is quite particular and apparently benign. The mortality rate of infected patients is higher than in non-infected subjects and this is not only due to the liver disease itself but also to cardiovascular disorders. Even anti-viral therapy, after its first timid steps, is now routinely used in patients with a certain degree of liver damage and kidney transplant candidates. The appropriate use of pegylated interferons is expected to improve the percentage of eradication and limit side effects, in parallel with what has been observed in non-dialysis patients. Ribavirin, however, is at present contraindicated due to its toxic effects on red blood cells as hemoglobin content could be dangerously reduced in these patients.
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Affiliation(s)
- M Li Vecchi
- Department of Nephrology, University of Palermo, Palermo, Italy
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Peltekian KM, Bain VG, Lee SS, Sherman M, Cooper CL, Yoshida EM, Marotta PJ, Krajden M, Balshaw R, Deschênes M. Is pre-treatment liver biopsy necessary for all hepatitis C genotypes? Ann Hepatol 2011. [DOI: 10.1016/s1665-2681(19)31537-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
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Chen EQ, He LL, Wang LC, Lei BJ, Bai L, Liu C, Lei XZ, Tang H. Change of liver histology in chronic hepatitis B patients with alanine aminotransferase less than two-time up limits of normal. Shijie Huaren Xiaohua Zazhi 2008; 16:2476-2481. [DOI: 10.11569/wcjd.v16.i22.2476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the change of hepatic histology in patients with chronic hepatitis B virus (HBV) infection whose alanine aminotransferase (ALT) level is lower than two-time up limit of normal (ULN) and discuss the factors affecting the change of liver histology.
METHODS: According to ALT ≤ 0.5 × ULN, 0.5 × ULN < ALT ≤ 1 × ULN and 1 × ULN < ALT < 2 × ULN, 170 patients were divided into group Ⅰ (n = 39), group Ⅱ (n = 87) and group Ⅲ (n = 44). We retrospectively analyzed whether the change of liver histology was related to ALT level, HbeAg status, HBV DNA duplication and the age of patients.
RESULTS: The rates of grade 2 or 2+ inflammation in group Ⅰ, Ⅱ and Ⅲ were 43.6%, 56.4% and 65.9%, respectively, and the rates of stage 2 or 2+ fibrosis were 38.4%, 48.3% and 61.3%, respectively. There were 5.1%, 8.1% and 18.2% patients with liver cirrhosis (stage 4) in the three groups. The activity of liver inflammation and degree of fibrosis were related to ALT level (F= 4.162, 3.992; both P < 0.05) and the age of patients (F = 32.831, 20.084; both P < 0.05), while the degree of liver fibrosis was related with HbeAg positive rate (χ2 = 7.839, P < 0.05).
CONCLUSION: Of the patients with chronic HBV infection, 55.9% have grade 2 or 2+ inflammation even if ALT level is less than 2 × ULN. Thus for the patient with a long medical history, especially those over 40 years old, conventional liver biopsy should be performed, which may help us decide whether to start antiviral therapy.
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Ranalli TV, Dell'isola S, Gomes VV, Ialungo AM, Starnini G, Roselli P, Ghittoni G, Caturelli E. Liver schistosomiasis: an unexpected finding in hepatitis B virus-related chronic hepatitis. Int J Infect Dis 2008; 12:e67-70. [PMID: 18691925 DOI: 10.1016/j.ijid.2008.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Revised: 03/19/2008] [Accepted: 04/23/2008] [Indexed: 01/22/2023] Open
Abstract
CASE REPORT We report the unusual case of an African patient who underwent a liver biopsy for a chronic HBV-related hepatitis, whose histological sample also unexpectedly revealed elements diagnostic for schistosomiasis. The patient was only mildly symptomatic for the Schistosoma infestation; stool examination confirmed the presence of parasitic eggs. Hepatitis B virus (HBV)-schistosomiasis co-infection is particularly rare in Western countries. Only the identification of some pathological elements atypical for HBV infection by means of step sections in the liver biopsy sample allowed us to disclose the unsuspected diagnosis. CONCLUSIONS Since migratory flows have increased, the number of foreign people being referred to our hospitals has increased. Patients coming from areas endemic for infectious diseases that are absent in Western countries must be carefully evaluated, taking into account possible unexpected co-infections, including in the setting of pathological studies of liver biopsies.
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Affiliation(s)
- Teresa V Ranalli
- Unità Operativa di Anatomia Patologica, Ospedale Belcolle, strada Sammartinese, 01100 Viterbo, Italy
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Abstract
OBJECTIVES To define the incidence of fibrosis progression among hepatitis C virus (HCV)/HIV-co-infected adults, to assess whether HCV or HIV treatment alters the risk of progression, and to determine the utility of liver biopsy to predict future disease. DESIGN This prospective cohort evaluated 184 HIV/HCV-co-infected individuals who had at least two liver biopsies (median interval 2.9 years). METHODS Biopsies were scored according to the Ishak modified histological activity index scoring system by a single pathologist blind to biopsy sequence. Significant fibrosis progression was defined as an increase of at least two Ishak fibrosis units between the first and second liver biopsy. Logistic regression analysis was used to assess determinants of fibrosis progression. RESULTS A total of 174 non-cirrhotic patients were eligible; the majority were African-American men undergoing HIV treatment. On initial biopsy, no or minimal fibrosis was identified in 136 patients (77%). Significant fibrosis progression occurred in 41 patients (24%). Measures of HIV disease and its treatment before and after initial biopsy were not significantly different in progressors and non-progressors. Fibrosis progression was not associated with HCV treatment, which was received by 37 patients (21%) but only three sustained HCV-RNA suppression. In adjusted analysis, only an elevated serum aspartate aminotransferase level between biopsies was associated with progression (odd ratio 3.4, 95% confidence interval 1.4-7.9). CONCLUSION Over a 3-year interval, significant fibrosis progression can occur in co-infected individuals even if minimal disease was detected on initial biopsy. In this context, factors other than treatment for HIV or HCV modify the risk of fibrosis progression.
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Giannini EG, Zaman A, Ceppa P, Mastracci L, Risso D, Testa R. A simple approach to noninvasively identifying significant fibrosis in chronic hepatitis C patients in clinical practice. J Clin Gastroenterol 2006; 40:521-7. [PMID: 16825935 DOI: 10.1097/00004836-200607000-00011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identification of the presence of significant fibrosis is an important part of the diagnostic work-up of patients with chronic hepatitis C (CHC). AIM To evaluate the performance of the aspartate to alanine aminotransferase ratio (AST/ALT ratio) and platelet count in reducing the number of liver biopsies and diagnosing the presence/absence of significant fibrosis in a large cohort of patients with CHC seen at 2 tertiary referral centers. METHODS Liver biopsies of 409 patients with CHC were evaluated. Staging was carried out by means of the Ishak and METAVIR scores in the Italian and US series, respectively. Prevalence of significant fibrosis was 43%. Receiver operating characteristic curves were used to identify AST/ALT ratio and platelet count cutoffs with the highest accuracy for the diagnosis of significant fibrosis. These cutoffs were used to devise a diagnostic algorithm for reducing the number of liver biopsies and diagnosing/ruling out significant fibrosis. RESULTS AST/ALT ratios increased and platelet counts decreased as liver fibrosis worsened. Both AST/ALT ratio (c-index=0.747) and platelet count (c-index=0.733) had high accuracy for the diagnosis of significant fibrosis. The use of AST/ALT ratio and platelet count cutoffs in a diagnostic algorithm would have avoided liver biopsy in 68.9% of the patients and would have correctly identified the absence/presence of significant fibrosis in 80.5% of these cases. CONCLUSIONS In clinical practice, the use of simple, reproducible, and inexpensive parameters such as the AST/ALT ratio and platelet count can reduce the need for liver biopsy in a substantial proportion of patients with CHC.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.
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Romagnuolo J, Andrews CN, Bain VG, Bonacini M, Cotler SJ, Ma M, Sherman M. Simple clinical variables predict liver histology in hepatitis C: prospective validation of a clinical prediction model. Scand J Gastroenterol 2005; 40:1365-71. [PMID: 16334447 DOI: 10.1080/00365520500287400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A recent single-center multivariate analysis of hepatitis C (HCV) patients showed that having any two criteria: 1) ferritin > or =200 microg/l and 2) spider nevi and/or albumin < or = 35 g/l predicted grade 2 or greater histological inflammation; the presence of any two of the following criteria: spider nevi, platelets < or =150 x 109/l, palpable splenomegaly and/or albumin < or =35 g/l predicted stage 2 or greater histological fibrosis. Absence of predictors also predicted a lack of inflammation and fibrosis. Our aim was prospectively to validate this clinical prediction model using an independent multicenter sample. MATERIAL AND METHODS Eighty-one patients with previously untreated active chronic HCV underwent physical examination, laboratory investigation, and liver biopsy. Biopsies were read, in blinded fashion, by a single pathologist, using a modified Hytiroglou (1995) scale. The clinical scoring system was correlated with histology; likelihood ratios (LRs), Fisher's exact p-values, and receiver operating characteristics (ROCs) were calculated. RESULTS Data recording was complete in 77 and 38 patients regarding fibrotic stage and inflammatory grade, respectively. For fibrosis, 3/3 patients with any three criteria (LR 17, positive predictive value (PPV) 100%), 4/5 patients with any two criteria (LR 5.1), and 15/47 with no criteria (LR 0.6, negative predictive value (NPV) 68%) had stage 2 or greater fibrosis on biopsy (p=0.01). For inflammation, 5/5 patients with both criteria (LR 15, PPV 100%), and 8/19 patients with no criteria (LR 0.5, NPV 58%) had moderate-severe inflammation on liver biopsy (p=0.036). When missing variables were assumed to be normal, recalculated LRs were almost identical. An alanine aminotransferase (ALAT) level <60 U/l may increase the NPVs. CONCLUSIONS This independent multicenter data set has validated our published model which uses simple clinical variables accurately and significantly to predict hepatic fibrosis and inflammation in HCV patients.
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Affiliation(s)
- Joseph Romagnuolo
- Digestive Disease Center, University of South Carolina, 96 Jonathon Lucas Street, PO Box 250 327, Charleston, SC 29425, USA.
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Almasio PL, Niero M, Angioli D, Ascione A, Gullini S, Minoli G, Oprandi NC, Pinzello GB, Verme G, Andriulli A. Experts' opinions on the role of liver biopsy in HCV infection: a Delphi survey by the Italian Association of Hospital Gastroenterologists (A.I.G.O.). J Hepatol 2005; 43:381-7. [PMID: 16006002 DOI: 10.1016/j.jhep.2005.02.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Revised: 02/09/2005] [Accepted: 02/10/2005] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Liver biopsy represents the gold standard to establish a diagnosis in all liver patients, but its current position in chronic viral hepatitis is questioned. We aimed to create a consensus on best practice of use of liver biopsy in the management of chronic HCV infection. METHODS We applied the Delphi method to 12 clinical scenarios of chronic HCV infection, to assess the extent of agreement (consensus measurement) and to resolve disagreement (consensus development) on the appropriateness of liver biopsy. RESULTS Among 108 chosen hepatologists, 61 (56.5%) accepted to participate to the first-round survey. In four patients the majority of experts (from 61.4 to 86.2%) agreed not to perform liver biopsy; in two cases an equivalent opinion was found, and in the remaining six scenarios the majority of experts would have recommended a biopsy. No expert recommended liver biopsy in all cases, while most agreed for an histological evaluation of 4 to 8 cases. At the second round, 36 experts (59%) submitted ballots. Fifty-four out of 431 (12.6%) original judgments were changed with equal distribution among different scenarios. CONCLUSIONS Our survey showed a great divergence of management of similar patients and should provide a stimulus for an evidence-based evaluation of liver histology in chronic HCV infection.
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Affiliation(s)
- Piero Luigi Almasio
- Division of Gastroenterology, University of Palermo, A.O.U.P. Piazza delle Cliniche, 2, 90127, Palermo, Italy.
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Iacobellis A, Mangia A, Leandro G, Clemente R, Festa V, Attino V, Ricciardi R, Giacobbe A, Facciorusso D, Andriulli A. External validation of biochemical indices for noninvasive evaluation of liver fibrosis in HCV chronic hepatitis. Am J Gastroenterol 2005; 100:868-73. [PMID: 15784034 DOI: 10.1111/j.1572-0241.2005.40881.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Angelo Iacobellis
- Division of Gastroenterology, Hospital Casa Sollievo della Sofferenza, IRCCS, San Giovanni Rotondo, Italy
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Andriulli A, Persico M, Iacobellis A, Maio G, Di Salvo D, Spadaccini A, Bacca D, Leandro G, Ventrella F, Mangia A. Treatment of patients with HCV infection with or without liver biopsy. J Viral Hepat 2004; 11:536-42. [PMID: 15500554 DOI: 10.1111/j.1365-2893.2004.00519.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Expert consensus recommends liver biopsy before therapy for chronic hepatitis C. A cost effectiveness analysis suggested that the best strategy in the management of patients was to treat without biopsy. We compared therapy in patients who did, or did not undergo biopsy. Hepatitis C virus (HCV)-positive patients (78) who did not agree to (n = 57) or with contraindications to liver biopsy (n = 21) (group A) were matched for age, sex and genotype with those who consented (group B). Before therapy (interferon/ribavirin for 12 months), a clinical diagnosis of chronic hepatitis, on the basis of standard biochemical and ultrasonographic parameters. The two groups showed similar baseline characteristics. A noninvasive, diagnosis of chronic hepatitis was made in 75.6% of group A, and in 83.3% of group B (P = 0.26). Concordance between clinical and histological diagnosis in group B amounted to 91%. End-of-therapy virological response was 52.6% in group A, and 57.7% in group B (P = 0.63). Sustained virological response was 41.0% [95% confidence interval (CI) 30.1-51.9] and 43.6% (95% CI 32.6-54.6) in the two groups (P = 0.87). Predictors of sustained response were noninvasive diagnosis of chronic hepatitis (P = 0.006), lack of portal hypertension (P = 0.037), platelets >10(5)/mm3 (P = 0.007), prothrombin >70% (P = 0.02), and genotype 2 or 3 (P < 0.0001). At multivariate analysis, genotype (P < 0.0001) and platelets (P = 0.004) maintained their predictive power. In most patients with HCV infection, virological clearance after therapy can be achieved irrespective of whatever a liver biopsy might show.
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Affiliation(s)
- A Andriulli
- Division of Gastroenterology, Hospital Casa Sollievo della Sofferenza, IRCCS, San Giovanni Rotondo, Italy.
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Andriulli A, Annese V, Facciorusso D, Giacobbe A. First do no harm: power, oppression, and violence of liver biopsy. Gastroenterology 2003; 125:272-3; author reply 273-4. [PMID: 12870494 DOI: 10.1016/s0016-5085(03)00815-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Abstract
The report of the 1997 National Institutes of Health Consensus Development Conference on hepatitis C endorsed pretreatment liver biopsy. We revisit the following questions: Does liver histology help determine the urgency of, and predict the likelihood of response to, antiviral therapy, and can surrogate markers supplant histological assessment? Because the rate of progression of chronic hepatitis C is influenced by baseline histological grade/stage, patients can be stratified into those with moderate to severe hepatitis, who merit imminent therapy, and those with mild hepatitis, in whom therapy can be postponed until more effective/tolerable treatments become available. Less advanced baseline histology has been shown to be an independent predictor of responsiveness to antiviral therapy. Although the predictive value of biopsy is insufficient to withhold therapy from patients with advanced fibrosis, baseline biopsy helps gauge expectations for the outcome of therapy. Reports have been published recently suggesting that laboratory markers can predict distinctions between low-grade fibrosis and therapy-indicating septal fibrosis/cirrhosis. These indices, however, are insufficiently reliable to predict histological distinctions in populations with varying prevalences of fibrosis/cirrhosis or to provide anything more than broad qualitative distinctions, far short of the potential information in a liver biopsy. For most patients, the value of pretreatment liver biopsy outweighs its risks, provides information about the urgency of treatment, and should be retained. Studies to identify noninvasive laboratory markers of histological activity and stage, especially genetic predictors of accelerated disease progression, command a high priority.
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Affiliation(s)
- Jules L Dienstag
- Gastrointestinal Unit (Medical Services), Massachusetts General Hospital, Boston, MA 02114, USA.
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Abstract
The report of the 1997 National Institutes of Health Consensus Development Conference on hepatitis C endorsed pretreatment liver biopsy. We revisit the following questions: Does liver histology help determine the urgency of, and predict the likelihood of response to, antiviral therapy, and can surrogate markers supplant histological assessment? Because the rate of progression of chronic hepatitis C is influenced by baseline histological grade/stage, patients can be stratified into those with moderate to severe hepatitis, who merit imminent therapy, and those with mild hepatitis, in whom therapy can be postponed until more effective/tolerable treatments become available. Less advanced baseline histology has been shown to be an independent predictor of responsiveness to antiviral therapy. Although the predictive value of biopsy is insufficient to withhold therapy from patients with advanced fibrosis, baseline biopsy helps gauge expectations for the outcome of therapy. Reports have been published recently suggesting that laboratory markers can predict distinctions between low-grade fibrosis and therapy-indicating septal fibrosis/cirrhosis. These indices, however, are insufficiently reliable to predict histological distinctions in populations with varying prevalences of fibrosis/cirrhosis or to provide anything more than broad qualitative distinctions, far short of the potential information in a liver biopsy. For most patients, the value of pretreatment liver biopsy outweighs its risks, provides information about the urgency of treatment, and should be retained. Studies to identify noninvasive laboratory markers of histological activity and stage, especially genetic predictors of accelerated disease progression, command a high priority.
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Affiliation(s)
- Jules L Dienstag
- Gastrointestinal Unit (Medical Services), Massachusetts General Hospital, Boston, MA 02114, USA.
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Pradat P, Alberti A, Poynard T, Esteban JI, Weiland O, Marcellin P, Badalamenti S, Trépo C. Predictive value of ALT levels for histologic findings in chronic hepatitis C: a European collaborative study. Hepatology 2002; 36:973-7. [PMID: 12297846 DOI: 10.1053/jhep.2002.35530] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of this retrospective study was to determine the predictive value of alanine aminotransferase (ALT) levels for histologic findings in patients with chronic hepatitis C virus (HCV) infection. Data on 864 HCV RNA-positive patients were collected. ALT values were obtained at the time of biopsy (before treatment), and normal ALT values were defined as normal values obtained at serial evaluations during a 6-month period. Histologic results were scored using the METAVIR system. Among all patients, 99% of those with elevated ALT levels had a score of at least F1 (positive predictive value [PPV], 99%) and 88% had a score greater than A1F1. Among patients with persistently normal ALT values, 65% had a score of at least F1 (negative predictive value [NPV], 35%) and 26% had a score greater than A1F1. The receiver operating characteristics analysis indicates that the ALT threshold for the best compromise sensitivity-specificity was about 2.25 times the upper limit of normal (ULN). In conclusion, almost all HCV RNA-positive patients with elevated ALT levels have some degree of fibrosis. However, an important proportion of patients with persistently normal ALT levels also show some histologic signs of fibrosis; the degree of fibrosis is usually mild but is sometimes more marked, and in rare cases cirrhosis may be present. In this subset of patients, the indication of liver biopsy and the potential benefit of therapy need to be further evaluated. These results suggest the need to revisit the algorithm for liver biopsy practice.
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