Hep C Discussion Forum

It's worth revisiting this, as it is possibly the most controversial topic in HCV workup and treatment. It's not helped by the lack of consensus between Hepatologists and between countries.

Chronic HCV causes liver inflammation that leads to liver fibrosis. Many factors affect this process including age of infection, chronological age, sex, coexistence of other liver disease, alcohol consumption, obesity etc. What is certain is that , over time, most patients have liver damage. Various surveys have tried to give an estimate of how quickly this develops e.g. 15% of patients will develop cirrhosis (F4) within 20 years of infection. Another survey found that all patients with chronic HCV developed cirrhosis by age 60. Such surveys only give a very rough estimate, and there is wide individual variation.

The question remains: should a newly diagnosed case of HCV have an assessment of liver damage before treatment is contemplated, and how is this best done? This is where the lack of consensus is most obvious. A case can be made for young patients (<40 yo) who have had HCV for less than 15 years- these patients are unlikely to have severe liver damage (in the absence of other liver diseases), so may not need assessment. In my opinion, all other patients need assessment, regardless of Genotype, Viral Load or LFT's. This is a serious disease and we need all the information we can get!

If liver assessment is required, how do we do this? This is where there is wide variation from country to country. Liver biopsy remains the gold standard- this is the only assessment Drug Companies will accept for the trials of new drugs. Fibroscan (Transient Elasticity) is widely used in Canada, Europe and Australia. It is only available in a few centres in the US. In Australia, Fibroscan results are accepted for most drug trials. Fibrotest (Fibrosure in the US) seems to be used in the US in some centres. It has been discarded as unreliable in Australia. Liver Imaging ( usually by U/S) is used in some centres- it is unreliable, and there are many papers confirming this. Other Biochemical and Physical formulae have been proposed- none are considered useful. There is a continuing search for a fibrosis blood marker.

My opinion is that all patients should have a liver biopsy. There is considerable patient resistance to this. I cannot understand how patients can be brave enough to embark on triple therapy, but be terrified by the prospect of a small needle in the liver. There are now numerous posts by Forum Members who have had biopsies- please read them, and see the benefits of the results. If you have had a biopsy more than 5 years ago, you need another one. Patients can progress from F3 to F4 in less than 5 years.