Liver biopsy in hepatitis C virus carriers with normal alanine aminotransferase levels

Abstract

We read with great interest and enthusiasm the American Association for the Study of Liver Diseases position paper on liver biopsy.1 In this article, the authors give clear and flexible recommendations on when and how to do (or not to do) liver biopsy in everyday clinical practice. However, we would like to raise some doubts about the approach suggested for hepatitis C virus (HCV) carriers with normal alanine aminotransferase levels (ALT). Rockey et al. stated that “assessment of liver histology may be particularly beneficial in patients with human immunodeficiency virus and HCV who have persistently normal ALT levels, because these patients may have significant fibrosis”. We believe that this approach is too restrictive, and that biopsy should be taken into consideration in all HCV carriers with normal ALT, regardless of human immunodeficiency virus (HIV) status. It is true that patients coinfected with HIV/HCV with normal ALT might suffer from more progressive fibrosis and more severe liver damage than carriers who are HIV-negative2; however, several studies have shown that the majority of HCV carriers with normal ALT have some degree of histological liver damage despite persistent biochemical normality,3 and that fewer than 20% of these people show normal liver (the true “healthy” HCV carriers).4 Although liver disease is usually minimal/mild and fibrosis is generally absent or minimal, the association of normal ALT with cirrhosis or with hepatocellular carcinoma has been reported,5, 6 even in the absence of HIV positivity. Thus, we believe that evaluation of liver fibrosis through biopsy might be very useful in this subset of patients with HCV, in particular when virologic or demographic features (e.g., unfavorable HCV types, advanced age, obesity, etc.) make it difficult to decide whether antiviral treatment should be offered.7 Laudio Puoti*, Lia Bellis*, Riccardo Guarisco*, * Department of Internal Medicine and Liver Unit, Marino General Hospital, Rome, Italy.