C-related Chronic Liver Disease Research Articles

Utility of P²MS Index in Predicting Esophageal Varices in Patients with Hepatitis C Associated Chronic Liver Disease in Pakistani Population

Background: Screening for esophageal varices (EVs) in patients with chronic liver disease is critical for identifying those needing primary prophylaxis against variceal bleeding. The gold standard for EV screening is endoscopy, an invasive and costly procedure often avoided by patients. This necessitates the need for non-invasive predictive tools for the presence of EVs and high-risk varices (HRVs). The P²MS index, a relatively new model, has shown promise in this regard. Objective: This study aimed to evaluate the effectiveness of the P²MS index, alongside APRI and FIB-4 scores, in predicting the presence of EVs and HRVs in patients with hepatitis C-related chronic liver disease. Methods: Conducted at the Sindh Institute of Urology and Transplantation's Hepato-Gastroenterology department, this cross-sectional study involved 375 participants aged 18-50 years, recently diagnosed with liver cirrhosis due to hepatitis C. Excluding those with varied medical backgrounds, the study used non-probability consecutive sampling. Diagnostic procedures included esophagogastroduodenoscopy (EGD) and complete blood count. P²MS index, APRI, and FIB-4 scores were calculated for each participant. Data analysis was performed using SPSS version 25.0, focusing on the Area Under the Receiver Operating Curve (AUROC) to assess diagnostic accuracy. Results: In our population, the P²MS index at a cutoff of <10.7 showed a specificity of 93.22% and sensitivity of 87.88% for predicting the presence of EVs, with a PPV and diagnostic accuracy exceeding 90%. For HRVs, a cutoff of <5.4 demonstrated an excellent NPV, alongside good sensitivity, specificity, and diagnostic accuracy. Compared to APRI and FIB-4, the P²MS index had the highest AUROC for predicting the presence of EVs (0.92, 95% CI 0.89-0.95, p<0.001). For HRVs, it was comparable to APRI (AUROC=0.88, 95% CI 0.85-0.92, p<0.01) and superior to FIB-4. Conclusion: The P²MS index is an effective non-invasive tool for screening EVs in patients with hepatitis C-related chronic liver disease, demonstrating high accuracy for predicting the presence of EVs. However, its efficacy in predicting HRVs is comparable to other non-invasive indices and warrants further validation.

S1198 Diagnostic Accuracy of Neutrophil to Lymphocytes Ratio to Determine Fibrosis Stage Using Shear Wave Elastography in Patients With Hepatitis C-Related Chronic Liver Disease

S1198 Diagnostic Accuracy of Neutrophil to Lymphocytes Ratio to Determine Fibrosis Stage Using Shear Wave Elastography in Patients With Hepatitis C-Related Chronic Liver Disease

Cardiac dysfunction as an early predictor of portal hypertension in chronic hepatitis C.

Background:Cirrhotic cardiomyopathy is characterized by a set of cardiovascular modifications observed in advanced chronic liver disease. The aim of this study was to investigate cardiovascular alterations in chronic liver disease with different stages of fibrosis and to correlate cardiac involvement with endoscopic complications of portal hypertension.Methods:Seventy patients with chronic hepatitis C-related chronic liver disease and 20 sex- and age-matched controls underwent clinical evaluation, hepatic transient elastography, and echocardiography. Forty-nine of the 70 patients underwent an esophagogastroduodenoscopy for screening of esophageal and gastric varices.Results:According to the value of liver stiffness (LS), patients were divided in 2 groups: non-cirrhotics (LS<12.5 kPa; n=30; median LS=8.1 kPa, 95% confidence interval [CI] 6.4-9.2 kPa) and cirrhotics (LS>12.5 kPa; n=40; median LS=19.4 kPa, 95%CI 17-22 kPa). Compared to non-cirrhotics, cirrhotics showed a significant dilatation of the left atrium (P=0.007 and P=0.003 for area and volume index, respectively). In patients with chronic liver disease, peak systolic wave velocity (S¢) measured by tissue Doppler imaging (TDI) was lower (P=0.004), but ejection fraction was not reduced. Left atrial volume, left ventricular mass index and TDI S¢-wave velocity, but not liver stiffness, correlated with endoscopic signs of portal hypertension.Conclusions:Left atrial enlargement and peak S¢-wave systolic velocities are echocardiographic markers of diastolic and systolic dysfunction in liver cirrhosis. Cardiac alterations closely correlate to endoscopic portal hypertension; further studies could elucidate the potential role of echocardiography in the early identification of cirrhotic patients at higher risk for endoscopic complications of portal hypertension.

A community based model for non-invasive detection, stratification and treatment of hepatitis C-related chronic liver disease in substance misusers: Exploring barriers to and attitudes towards testing and treatment

Background: Despite discovery of direct acting antiviral agents (DAA), a two–three fold increase in hepatitis C virus (HCV) detection and treatment is necessary to reduce the national HCV burden. Ninety percent of HCV positive individuals in England are people who inject drugs (PWID), a population with a history of poor engagement with health services. This study forms part of a wider evaluation of an integrated ‘one stop’ community-based hepatitis and addiction service in Brighton. Our primary aim was to assess feasibility of non-invasive detection, stratification and treatment of HCV-related chronic liver disease (CLD) in the community. Our secondary aim was to evaluate the service via qualitative interviews with patients and clinical staff, with a particular focus on exploring barriers and motivators to hepatitis C testing and treatment. Methods: A total of nine participants were recruited for the qualitative sub-study. Participants were either currently receiving, waiting to start or had completed HCV treatment. Semi-structured interviews were conducted, covering topics such as history of injecting drug use, motivations for starting treatment and perceptions of the community-based service. Interviews were audio-taped, transcribed verbatim and analysed using thematic content analysis. Results: This is a vulnerable group of patients with complex health, emotional and social needs. The interviews identified multiple interrelated barriers to HCV care at the individual-, provider and system-level. At the individual-level fear of treatment side effects, reluctance to confront the diagnosis and competing health and social issues emerged as key barriers. Overall, hospital services appeared ill-adapted to meet the needs of this vulnerable population; the bureaucratic, inflexible and impersonal hospital environment coalesced to create a mistrust of secondary care. Many of these constraints were minimised in the community-based setting. However, the interviews revealed distinct and contrasting attitudes among participants towards the community-based treatment service: although a number of participants preferred an integrated ‘one stop’ service, for some the stigma attached to the SMS acted as an important system-level barrier. Despite multiple barriers a number of facilitators to engaging in HCV care emerged from the interviews. Most notably, an awareness of the impact of untreated HCV on the liver, a trusting client-provider relationship and the desire to regain one’s health following addiction recovery. Conclusion: Preliminary findings from this qualitative study have important implications for interventions aimed at engaging this complex population in hepatitisCtesting and treatment. Future research should explore the impact of newer treatments on existing barriers to treatment uptake.

CLINICAL SIGNIFICANCE OF SERUM N-TERMINAL PRO C-TYPE NATRIURETIC PEPTIDE IN HEPATITIS C-RELATED CHRONIC LIVER DISEASES.

To evaluate the clinical utility of serum levels of N-terminal pro C-type natruretic pep-tide (NT-pro CNP) in patients with hepatitis C related chronic liver disease (CLD), in prospective to disease complications and progression. This study included 66 hepatitis C-related CLD patients with and without ascites and 15 healthy individuals (control group). Serum NT-pro CNP was measured by ELISA. A stepwise progressive increase in NT-pro CNP levels was recorded through controls, patients without ascites and patients with ascites (p< 0.05). In addition, patients with hematemesis or encephalopathy had more than its double values than those without (p<0.01). Moreover, a significant difference was observed in the marker levels among esophageal varcies stages 1, 2, 3 (H=13.679, p=0.001), with highest levels in grade 3. NT-pro CNP correlated positively with alpha fetoprotein (rs =0.455, p=0.008) with no significant correlation neither with MELD nor Child scores (p>0.05). ROC curve analysis revealed the overall performance of the marker in discriminating CLD patients collectively from controls, the optimum cut-off level was 85 ng/L (AUC= 0. 803, sensitivity 84.8%& specificity 53.3%). An increased level of NT-pro CNP is a promising non-invasive marker of hepatitis C related CLD complications and disease progression.

Thrombocytopenia in Patients with Chronic Liver Disease: What’s in a Name?

Thrombocytopenia is likely the most common haematological alteration that can be observed in patients affected by chronic liver disease [1]. In compensated cirrhosis, it is the most prevalent and incident peripheral blood cytopenia; in chronic hepatitis C patients, thrombocytopenia represents an obstacle to antiviral therapy in 6.5 % of patients who are otherwise good candidates for interferon treatment [2, 3]. Furthermore, besides being the hallmark of a possible increased risk of bleeding, thrombocytopenia has several diagnostic and prognostic meanings [4, 5]. This versatile use of platelet count and thrombocytopenia is supported by the multi-faceted etiology of decreased platelet count in chronic liver disease patients [1, 5]. Indeed, the platelet count is incorporated into numerous diagnostic algorithms aimed at non-invasively assessing the severity of chronic liver diseases and features of portal hypertension, can be used to pinpoint patients at higher risk of developing hepatocellular carcinoma in population studies, and is a predictor of death in cirrhotic patients with and without hepatocellular carcinoma [6–12]. The study by Hermos et al. [13] published in this issue of Digestive Diseases and Sciences describes the longitudinal course of platelet count in a large series of patients with non-hepatitis C-related chronic liver disease followed for a median of 3.3 years at the New England Veterans Administration Center, evaluating the occurrence of severe thrombocytopenia—defined as platelet count below 50 9 10/L—and significant bleeding, and the association between bleeding episodes and platelet counts. The relevance of this retrospective study lies in its ability to provide reliable data on the time-trend of platelet counts in a large cohort of chronic liver disease patients consistently followed over an adequate period of time, showing that severe thrombocytopenia occurs in a modest proportion of patients (13.4 %) and is expectedly more incident among patients with a baseline platelet count close to the threshold (i.e., 50 9 10/L). As compared to previous studies that assessed platelet count modifications over time, it has the merit of including patients with all forms of chronic liver disease while excluding patients with chronic hepatitis C virus infection where multiple causes of thrombocytopenia might have impaired interpretation of the results [14, 15]. The most important information contained in the study, however, is provided by the analyses of the association between platelet counts and bleeding episodes. Indeed, the current vision of the coagulopathy of chronic liver disease patients reflects the presence of a balanced coagulation asset despite altered blood coagulation tests, due to the lack of standardized tests able to adequately evaluate the derangement in both proand anti-coagulant factors [16]. Therefore, data regarding a possible association between platelet counts and bleeding might improve our knowledge on this topic. Overall, this study confirms that a decreased platelet count is a good indicator of the severity of chronic liver diseases, as patients with more compromised liver function and higher Model for End-stage Liver Disease (MELD) scores were prevalent in the group of patients with baseline severe thrombocytopenia. Bleeding as a primary cause of hospitalization occurred in 10.8 % of the patients, an incidence five times higher in patients with severe thrombocytopenia compared with patients with a platelet count above the lower limit of normal. Nevertheless, 98.1 % of the bleeding episodes reported in this study were gastrointestinal; unfortunately, no data were available regarding their relation to E. G. Giannini (&) Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, no.6, 16132 Genoa, Italy e-mail: egiannini@unige.it

Thrombocytopenia and Bleeding in Veterans with Non-hepatitis C-related Chronic Liver Disease

Thrombocytopenia in chronic liver disease (CLD) typically reflects disease severity and may indicate an increased risk for bleeding. To describe the longitudinal course of thrombocytopenia and risks for bleeding in veteran patients with non-hepatitis C-related CLD. We identified 2,349 patients with non-hepatitis C-related CLD from databases of the New England Veterans Healthcare System between 1999 and 2008. The cohort was stratified by baseline platelet counts of <50,000, 50-100,000, > 100,000-150,000, and >150,000/μl. Primary outcomes were the incidence and hazard rates for bleeding episodes requiring hospitalization and incident severe thrombocytopenia (<50,000/μl). Over a median follow-up of 3.3 years (IQR 1.2, 6.3), incident major bleeds, predominantly gastrointestinal, occurred in 254 patients (10.8 % of the cohort) and in 19.9 % of those with baseline platelets <50,000/μl. Incident severe thrombocytopenia occurred in 315 patients (13.4 % of cohort) and in 40.7 % of those with baseline platelet counts between 50,000 and 100,000/μl. Baseline platelet counts between 50,000 and 100,000/μl independently predicted bleeding [adjusted HR 2.89 (1.76, 4.73) p < 0.001] as did esophageal varices, hemoglobin ≤ 9.9 g %, and INR 1.4-2.0. Incident severe thrombocytopenia and minimum platelet counts <25,000/μl each associated with bleeding episodes, but the average of minimum platelet counts recorded for those who bled was 76,000/μl. Among veteran patients with non-hepatitis C-related CLD, baseline platelet counts of 50,000 to 100,000/μl increased subsequent risks for both incident severe thrombocytopenia and major bleeding events. Whereas associations between severe thrombocytopenia and bleeding most likely reflect CLD severity, liver-related coagulopathies, and co-morbid bleeding risks, interventions to enhance platelet production may be beneficial for such patients.

Alloantibodies and Drug-Induced Immune Hemolytic Anemia in Liver Transplantation

Red blood cell alloantibodies can cause severe delayed hemolysis, despite immunosuppression which they receive posttransplantation. A female patient with Hepatitis C-related chronic liver disease reported to our center for liver transplantation. During preoperative evaluation, she was found to have significant red blood cell alloantibodies which gave rise to problems during pre transfusion compatibility test. Stringent measures were taken by the transplant team to minimize blood loss during surgery. It was decided to have lower transfusion trigger for red cell transfusion, and blood conservation was done by intraoperative red cell salvage and use of antifibrinolytic agent. During immediate postoperative period, she developed drug-related immune hemolytic anemia. Presence of both warm autoantibodies and alloantibodies posed a big challenge for us to get cross-match compatible blood. She received 22 units of crossmatch compatible red cell transfusions during her hospital stay, which was uneventful. Hence, we reported this case.

Interstitial pulmonary changes in patients with hepatitis C-related chronic liver disease

Background and study aims Several extrahepatic manifestations (EHMs) have been reported in the natural history of hepatitis C virus (HCV) infection. Some studies had demonstrated a higher frequency of HCV in patients with idiopathic interstitial pulmonary fibrosis (IPF). The aim of this study is to investigate interstitial pulmonary changes via high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) in patients with HCV infection. Patients and methods Forty patients with HCV infection without diagnosis of any pulmonary diseases (group I) and 10 healthy persons (group II) were enrolled in the study. PFT and HRCT were performed in all cases. Results Findings of interstitial pulmonary involvement were detected in the HRCT of 19 out of 40 patients (47.5%). A decrease lower than 80% of the predicted value was detected in forced vital capacity (FVC) with restrictive pattern together with post-exercise hypoxia, in 21 (52.5%) patients. There was a significant difference between both groups in the findings of HRCT ( x 2 = 7.66, df = 1, p = 0.004) and PFTs ( x 2 = 9.05, df = 3, p = 0.002). According to the Child–Pugh classification, in group I, 15 patients were of class A, 16 were of class B and nine of class C, with no significant difference between classes as regards HRCT findings and PFT values. Six patients were positive for serum cryoglobulins. In these patients, all the parameters were not related to age. Conclusion Pulmonary interstitial changes are prevalent in HCV-infected patients, irrespective of the severity of their liver condition. It may also occur without respiratory symptoms.

A Simple Noninvasive Score Predicts Gastroesophageal Varices in Patients With Chronic Viral Hepatitis

Guidelines recommend upper endoscopic screening of cirrhotic patients for gastroesophageal varices. Cirrhosis is not always distinguishable from chronic hepatitis. To identify low-risk patients who can be spared upper endoscopy irrespective of a diagnosis of cirrhosis. We evaluated 13 nonendoscopic variables as predictors of esophagogastric varices in 254 patients with hepatitis B or hepatitis C-related chronic liver disease who underwent upper endoscopy. Any size varices occurred in 30.3% (77/254), and large varices in 12.2% of patients (31/254). Age >50 years [odds ratio (OR): 11.29; 95% confidence interval (CI): 2.33-54.67], platelet count <150,000/mmc (OR: 4.40; 95% CI: 1.85-10.45), albumin <3.6 g/dL (OR: 2.99; 95% CI: 1.31-6.79), and aspartate aminotransferase/alanine aminotransferase ratio >1 (OR: 2.83; 95% CI: 1.26-6.34) independently predicted varices by logistic regression. Using a score based on age >50 years, platelets <150,000/mmc, and aspartate aminotransferase/alanine aminotransferase ratio >1 (1 point/predictor), only 3.2% of patients with a score <2 had varices, all small. Patients with chronic viral hepatitis and a score <2 need not undergo upper endoscopy, as they are unlikely to have large varices. Because about 50% of our patients had this score, 50% of upper endoscopies may be safely avoided.

Chronic liver disease mortality in the United States, 1990-1998.

In 1998, chronic liver disease (CLD) was the tenth leading cause of death in the U.S. Alcohol and hepatitis C are thought to be important etiologies. However, traditional methods for calculating CLD mortality rates from death certificates may underestimate hepatitis C-related CLD mortality. We studied patterns of CLD deaths reported from 1990 through 1998, using an expanded definition that included death certificates where CLD, viral hepatitis, or CLD-related sequelae were reported as the underlying cause. We calculated overall age-specific and age-adjusted mortality rates, and according to demographic characteristics and recorded causes, and evaluated trends using linear regression modeling. CLD mortality declined 5% overall from 1990 through 1994 (12.1 to 11.6/100,000; P = 0.002), but remained unchanged from 1995 through 1998 (P = 0.366). Decreases were similar for all causes except hepatitis C, for which rates increased 220% from 1993 to 1998 (0.57 to 1.67/100,000). Rates declined in all racial-ethnic groups except American Indians and Alaska Natives (AI/AN), among whom rates were unchanged. Of 30,933 CLD deaths in 1998, 39% were coded as alcohol related, 15% as hepatitis C, 4% as hepatitis B, and 44% had no recorded cause. Age-adjusted rates were higher among males (47.6/100,000) than females (32.2/100,000) and among Hispanics (19.1/100,000) compared with non-Hispanics (10.8/100,000). Rates among AI/AN (28.7/100,000) were more than twice those of African Americans and whites (12.9/100,000 and 11.5/100,000, respectively). In conclusion, 1998 CLD deaths and the proportion attributable to viral hepatitis increased by 23% and 19%, respectively, compared with traditional methods. Mortality declines of the early 1990s were not sustained after 1994. Large disparities in CLD mortality remain, particularly among American Indians and Alaska Natives.

Influence of hepatitis B virus genotypes on the progression of chronic type B liver disease

To investigate the hepatitis B virus (HBV) genotype-related differences in the progression of liver disease, 585 patients with chronic HBV infection including 258 with histologically verified chronic liver disease (CLD) and 74 with hepatocellular carcinoma (HCC) were examined. The mean ages of both patients with advanced fibrosis (F3 or F4) and with HCC were significantly older in genotype B than in genotype C patients ( P = .018, P = .024, respectively). Both the hepatitis B e antigen (HBeAg) negativity rate at biopsy and the cumulative HBe seroconversion rate in patients with CLD were significantly higher in genotype B patients than genotype C patients ( P < .01, P = .022, respectively). Multivariate analysis revealed that genotype B, presence of precore mutation, high ALT levels, and severe histologic activity were independent factors for HBe seroconversion. Among all the biopsy-proven CLD patients, the ratio of patients with advanced fibrosis in genotype B was significantly lower than that in genotype C (4/30 vs. 74/224, respectively; P = .034). This difference was more remarkable in younger patients (≤45 years; 1/25 vs. 47/180, respectively; P = .020), and there was no difference in older patients (>45 years). The distribution of each genotype between CLD and HCC was very similar (B and C: 11.2% and 87.0% vs. 10.8% and 89.2%, respectively). In conclusion, our results suggest that, although the patients with genotype B experience earlier HBe seroconversion, slower progression of liver fibrosis, and slower development of HCC, the life-long risk of progression to advanced fibrosis and development of HCC may not differ among genotypes B- and C-related chronic liver disease. (H EPATOLOGY 2003;37:19-26.)

High Prevalence of Transfusion-Transmitted Virus Infection in Patients with Chronic Liver Diseases in an Endemic Area of Hepatitis B and C Virus

Objective: To determine the prevalence and clinical impact of transfusion-transmitted virus (TTV) DNA in patients with chronic liver diseases in the Southeast Anatolia region of Turkey where hepatitis B and C viral infections are endemic. Subjects and Methods: Patients diagnosed with chronic liver disease by clinical, biochemical and histologic means were enrolled in the study. Serum samples of 60 patients (19 males, 41 females) with chronic liver diseases, and of 45 healthy volunteer blood donors as a control group were collected. The chronic liver disease group consisted of 11 patients with hepatitis B, 44 with hepatitis C and 5 with chronic liver disease of unknown etiology. Presence of TTV DNA was investigated by the polymerase chain reaction. Using a scoring system histological grading of inflammation and staging of fibrosis were performed only in the chronic hepatitis C group. Results: TTV DNA was detected in 47 (78%) patients with chronic liver disease and 5 (11%) volunteers in the control group. The difference was statistically significant (p < 0.001). Ten of the 11 (91%) patients with hepatitis B, 32 of 44 (73%) of those with hepatitis C-related chronic liver disease, and 5 of 5 (100%) of the patients with cryptogenic liver disease were positive for TTV DNA. Conclusion: TTV is highly prevalent in patients with chronic liver diseases in Southeast Anatolia, Turkey but no pathogenic effect attributable to TTV infection was detected.

Beneficial influence of an indigenous low-iron diet on serum indicators of iron status in patients with chronic liver disease.

The main Fe storage organ in the body is the liver. In patients with chronic liver disease, secondary Fe overload is common. Phlebotomy, often used in the West to reduce Fe overload to improve the efficacy of interferon therapy, is not socially acceptable in India. We assessed the efficacy of a low-Fe diet in reducing serum Fe levels. Nineteen patients with hepatitis B- and C-related chronic liver disease, ten with normal (< 25 mumol/l) baseline serum Fe levels (group A) and nine with high (> 25 mumol/l) serum Fe levels (group B) were included. All the subjects were advised to eat a low-Fe diet. The daily Fe intake was reduced approximately 50% by consumption of the rice-based diet. Haemoglobin, serum Fe, transferrin saturation index (TSI), ferritin and alanine transaminase (EC 2.6.1.2) levels were studied at 1 and 4 months. Dietary Fe intake and body weight were closely monitored. All patients complied with the dietary regimen and at 4 months significant (P < 0.001) reductions from baseline were seen in serum Fe (20 (SD 3) v. 12 (SD 4) mumol/l group A; 30 (SD 3) v. 19 (SD 7) mumol/l group B) and TSI (38 (SD 8) v. 23 (SD 9)% group A; 53 (SD 15) v. 34 (SD 13)%, group B) in both the groups, albeit earlier in group B subjects. Serum ferritin levels, however, reduced only in group A (112 (SD 62) v. 43 (SD 25) ng/ml, P < 0.05) and not in group B. Non-significant reductions in haemoglobin levels were seen in both groups. Alanine transaminase levels reduced significantly (P < 0.05) in both the groups (95 (SD 49) v. 44 (SD 25) IU/l, group A; 82 (SD 16) v. 51 (SD 14) IU/l group B). Thus, a low-Fe diet results in significant reductions in serum Fe and TSI levels, irrespective of baseline Fe levels. This diet should be evaluated to improve the efficacy of interferon therapy in patients with hepatitis B- and C-related chronic liver disease.

Cryoglobulinemia associated with hepatitis C-related chronic liver disease in Japan

Cryoglobulinemia associated with hepatitis C-related chronic liver disease in Japan

Hepatitis C-related chronic liver disease among asymptomatic blood donors in the North West of England

In the first 19 months of screening, the North Western Regional Transfusion Centre (RTC) tested 224,000 consecutive blood donors for antibody to hepatitis C virus (anti-HCV) by second generation enzyme immunoassay (EIA). Of these, 366 repeatedly reactive samples were referred for confirmatory testing at Manchester Public Health Laboratory (PHL). There, the initial EIA was repeated, together with two further EIAs. All the referred samples were subjected to a confirmatory line immunoblot (RIBA-II). Reverse transcription followed by the polymerase chain reaction (RT-PCR), in order to detect viral RNA, was performed on selected samples. Among the donors, 61 accepted offers for medical review and were assessed for risk factors, clinical findings and results of standard liver function tests. Of these donors, 53 proceeded to liver biopsy. The overall prevalence of confirmed positive donors was 0.04%. Main risk factors identified included intravenous drug abuse in 31 (51%) donors and prior blood transfusion in 12 (20%) but a risk factor was not apparent in 11 (18%). Viraemia, detected by RT-PCR, could be predicted with a high degree of accuracy by means of the readily available and simpler screening and confirmatory tests (EIA and RIBA-II). Established chronic hepatitis was demonstrated in 90% of the liver biopsies. A trend towards worsening histological findings accompanied increasing concentrations of serum transaminase. Even so, many donors with normal transaminase values had abnormal biopsies including those showing chronic active hepatitis (CAH). These findings indicate that a substantial proportion of previously unrecognised asymptomatic persons with established chronic liver disease exists among North Western blood donors.(ABSTRACT TRUNCATED AT 250 WORDS)