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Müller T, Wiese M, Berg T. Reply: To PMID 23929603. Hepatology 2014; 60:1449-50. [PMID: 24890461 DOI: 10.1002/hep.27237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 12/07/2022]
Affiliation(s)
- Tobias Müller
- Sektion Hepatologie, Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, AöR, Leipzig, Germany
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Puoti C, Bellis L, Costanza OM, Elmo MG. Liver disease progression in hepatitis C virus carriers with normal alanine aminotransferase levels. Hepatology 2014; 60:1448-9. [PMID: 24700090 DOI: 10.1002/hep.27052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 01/08/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Claudio Puoti
- Department of Internal Medicine and Liver Unit, Marino General Hospital, Rome, Italy
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Xu CJ, Zhang CP, Wang XH, Liu LJ, Zhou SS, Wang JH, He QJ, Wang YZ, Guo WS, Zhu WB, Jiang Y. An individualized strategy for treatment of hepatitis C virus carriers with normal aminotransferase levels: Analysis of 73 cases. Shijie Huaren Xiaohua Zazhi 2014; 22:2317-2322. [DOI: 10.11569/wcjd.v22.i16.2317] [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 evaluate the efficacy and safety of peginterferon alpha-2a (PEG-IFN α-2a) combined with ribavirin (RBV) in the treatment of chronic hepatitis C (CHC) patients with normal aminotransferase levels.
METHODS: Patients with CHC and at least three normal aminotransferase values over an 18-month period or increased aminotransferase were offered a treatment with PEG-IFN α-2a 180 μg/wk and ribavirin (800 mg/d for weight ≤ 65 kg; 1000 mg/d for weight > 65 and < 75 kg; 1200 mg/d for weight ≥ 75 kg). All patients were followed for 24 wk post treatment. Curative effects were evaluated at 4 and 12 wk during the treatment and 24 wk post treatment. The adverse effects were also recorded.
RESULTS: A total of 161 patients completed the therapy. The 73 patients with normal transaminase and the 88 patients with increased transaminase had similar baseline characteristics. Overall, the two groups showed similar rapid virologic response (RVR) rate (78.1% vs 75.0%, P > 0.05), complete early virologic response (cEVR) rate (93.2% vs 92.0%, P > 0.05) and sustained virologic response (SVR) rate (92.7% vs 91.9%, P > 0.05).
CONCLUSION: Combination therapy with PEG-IFN α-2a and RBV is safe and effective in CHC patients with persistently normal aminotransferase levels.
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Abdel-Rahman M, Saad Y, El-Raziky M, Zayed N, El-Akel W, Said M, El-Beshlawy M, Esmat G. Hepatitis C genotype 4 with normal transaminases: correlation with fibrosis and response to treatment, a cohort Egyptian study of 4277 patients. Clin Res Hepatol Gastroenterol 2013; 37:479-84. [PMID: 23540379 DOI: 10.1016/j.clinre.2013.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/29/2013] [Accepted: 02/14/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Chronic hepatitis C virus (HCV) patients with persistently normal transaminases represent a subgroup of patients with mild, slowly progressive disease, natural history, and optimal management of these patients needs to be investigated in Egypt. Our aim is to assess the severity of hepatic fibrosis and response to therapy in a cohort of Egyptian HCV patients with normal transaminases. PATIENTS AND METHODS Retrospective demographics, laboratory, histological features and treatment outcome of patients included in the national program for the control of viral hepatitis in Egypt since 2007 were collected. Combined pegylated IFN/ribavirin therapy was given for patients with fibrosis stage ≥ F1 and elevated transaminases while those with normal transaminase; therapy was initiated only in patients with fibrosis stage ≥ F2. RESULTS Normal ALT and AST were detected in 1308/4277 (30.6%) and 1662/4277 (38.9%) patients, respectively, while both enzymes were normal in 943 patients (22%). Multivariate regression analysis showed that lower AFP and higher platelets count (compared with elevated transaminases group) were significantly correlated with normal transaminases (P<0.01), however, HCV-RNA levels did not show such significance. The number of patients with HAI score ≥ A1 was significantly lower in normal than elevated transaminases (36.5% vs 40.9%, respectively, P<0.01) and patients with fibrosis ≥ F2 was significantly lower in normal than elevated transaminases (36.4%) and (43%), respectively (P<0.01). There was no significant correlation between baseline transaminases levels and response to treatment. CONCLUSION Normal transaminases are frequently encountered in chronic HCV Egyptian patients (22%). They show low AFP level, mild degree of activity and stage of fibrosis with no correlation with response to therapy.
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Affiliation(s)
- Mahasen Abdel-Rahman
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Calleja JL, García-Samaniego J, Ruiz-Antorán B, Trapero M, Morillas R, de la Revilla J, Erdozaín JC, Espinosa MD, Suárez D, Solá R, Romero-Gómez M, Baños F, Alvarez MA. Peginterferon alpha-2a and ribavirin in patients with hepatitis C virus genotype 1 infection with persistently normal alanine aminotransferase levels. J Gastroenterol Hepatol 2012; 27:1705-10. [PMID: 22742958 DOI: 10.1111/j.1440-1746.2012.07214.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM To evaluate the efficacy and safety of peginterferon α-2a plus ribavirin at standard doses in patients with hepatitis C virus (HVC) genotype 1 infection with persistently normal alanine aminotransferase (ALT) levels. METHODS Patients aged 18 to 65 years were included in this observational, prospective study if they had evidence of a HCV genotype 1 infection. The serum HCV RNA concentration was determined at baseline and week 12. A qualitative HCV RNA test was performed at baseline and at weeks 48 and 72. Liver function tests were performed at each study visit. The primary efficacy measure was the sustained virological response in the intention-to-treat population. Logistic regression analyses were also performed to explore predictors of virological response. RESULTS A sustained virological response was observed in 100 of the 175 patients (57%). An early virological response and end-of-treatment response were seen in 159 patients (91%) and 133 patients (76%), respectively. Thirty-seven of the 122 evaluable patients for this outcome (30%) showed a rapid virological response. A higher viral load was a significant predictor for a lack of rapid virological response and lack of sustained virological response. There were not any unexpected safety or tolerability findings. CONCLUSIONS Our study suggests that the efficacy of the combination of peginterferon α-2a and ribavirin in patients with HCV genotype 1 infection and normal ALT levels is at least similar to that reported in patients with elevated ALT levels.
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Affiliation(s)
- José-Luis Calleja
- Department of Gastroenterology and Hepatology, University Hospital Puerta de Hierro Mahadahonda Madrid, Spain.
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Matsuo J, Mizui M, Okita H, Katayama K, Aimitsu S, Sakata T, Obayashi M, Nakanishi T, Chayama K, Miyakawa Y, Yoshizawa H, Tanaka J. Follow up of the 987 blood donors found with hepatitis C virus infection over 9-18 years. Hepatol Res 2012; 42:637-47. [PMID: 22404331 DOI: 10.1111/j.1872-034x.2012.00966.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To follow up blood donors found with hepatitis C virus (HCV) infection, to improve the outcome by antiviral treatments. METHODS Between 1991 and 2001, 3377 of the 1 925 860 donors (0.18%) were found to have HCV infection at the Hiroshima Red Cross Blood Center in Japan. Of them, 987 were able to be followed regularly over 9-18 years until 2009, and received antiviral treatments as required. RESULTS At the start, chronic hepatitis was diagnosed in 541 (54.8%), cirrhosis in five (0.5%) and hepatocellular carcinoma (HCC) in one (0.1%), whereas the remaining 439 (44.5%) had persistently normal aminotransferase levels (PNAL). Hospital visits were terminated voluntarily in 24.3% within the first year, 46.8% by 10 years and 50.9% by 17 years. Liver disease improved in 178 (18.0%), remained stable in 606 (61.4%) and aggravated in 170 (17.2%). Of the 541 donors with chronic hepatitis, HCC developed in 28 (5.2%) and cirrhosis in 11 (2.0%), whereas HCV infection was cleared in 107 (19.8%) by antiviral treatments. In addition, HCV infection resolved in 54 of the 439 donors (12.3%) with PNAL after they had developed chronic hepatitis and received treatments. In donors with chronic hepatitis, the cumulative incidence of HCC was 4.1% at 10 years. By multivariate analysis, age and diagnosis of chronic hepatitis at the entry were found to be independent risk factors for the development of HCC. CONCLUSION Individuals with undiagnosed HCV infection need to be identified and receive medical care. They have to be motivated to merit from this health-care program.
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Affiliation(s)
- Junko Matsuo
- Department of Epidemiology, Infectious Disease Control and Prevention Department of Medicine and Molecular Sciences, Graduate School of Biomedical Sciences, Hiroshima University Hiroshima Red Cross Blood Center Hiroshima Red Cross Hospital National Hospital Organization Fukuyama Medical Center Onomichi General Hospital Miyoshi Chuo Hospital, Hiroshima Hiroshima University, Hiroshima Miyakawa Memorial Research Foundation, Tokyo, Japan
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Puoti C, Guarisco R, Spilabotti L, Bellis L, Mitidieri Costanza O, Dell' Unto O, Elmo MG. Should we treat HCV carriers with normal ALT levels? The '5Ws' dilemma. J Viral Hepat 2012; 19:229-35. [PMID: 22404720 DOI: 10.1111/j.1365-2893.2011.01485.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Approximately 30% of patients with chronic HCV infection have persistently normal ALT levels. Although formerly referred to as 'healthy' or 'asymptomatic' HCV carriers, and thus historically excluded from antiviral treatment, it has now become clear that the majority of these patients have some degree of histological liver damage that may be significant in up to 20% of cases and might progress towards a more severe degree of liver fibrosis. A significant proportion of patients experience periods of increased serum ALT associated with enhanced disease progression. However, controversies still exist in clinical practice regarding the definition of 'persistent' ALT normality, the virological and histological features of these subjects, the need for liver biopsy, the role of noninvasive tools for the assessment of liver fibrosis, the natural history and the usefulness of antiviral treatment. The advent of new therapeutic options (pegylated interferon plus ribavirin) has shifted treatment targets towards the eradication of underlying infection, with therapy decision based on age, severity of disease and likelihood of response rather than on aminotransferase levels. This review is aimed at approaching the main unresolved issues on this topic, trying to give evidence-based answers to the more frequently asked questions from patients and their physicians.
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Affiliation(s)
- C Puoti
- Department of Internal Medicine and Liver Unit, Marino Hospital, Rome, Italy.
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Kainuma M, Furusyo N, Azuma K, Kajiwara E, Takahashi K, Nomura H, Tanabe Y, Satoh T, Maruyama T, Nakamuta M, Kotoh K, Shimoda S, Hayashi J. Pegylated interferon α-2b plus ribavirin for Japanese chronic hepatitis C patients with normal alanine aminotransferase. Hepatol Res 2012; 42:33-41. [PMID: 22103907 DOI: 10.1111/j.1872-034x.2011.00907.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To investigate the efficacy and safety of a pegylated interferon (PEG-IFN) α-2b plus ribavirin (RBV) combination treatment for patients with chronic hepatitis C virus (HCV) infection who have persistently normal alanine aminotransferase (NALT). METHODS This multicenter study included 989 patients with HCV genotype 1 (114 with NALT and 875 with elevated ALT) who received weight-based doses of PEG-IFN α-2b plus RBV for 48 weeks. We compared the sustained viral response (SVR) rates of patients with NALT and elevated ALT who received at least 80% or more of the target dosage of PEG-IFN α-2b and 60% or more of the target RBV (minimum acceptable dosage). RESULTS No significant difference was found in the overall SVR rate between the NALT (42.1%) and elevated ALT groups (37.3%). No significant difference in the SVR rates was found between NALT (63.3%) and elevated ALT group (61.6%) patients who received minimum acceptable dosage. Multivariate analysis showed that age (<65 years old) and total cholesterol (≧220 mg/dL) were significantly independent positive factors associated with an SVR in the NALT group. Twenty-four weeks after treatment, an ALT increase above the normal range was observed for 34.0% (18 of 53) of the non-responsive group of NALT patients. CONCLUSIONS The efficacy and safety of PEG-IFN α-2b plus RBV combination therapy for patients with chronic HCV infection are similar for patients with NALT and those with elevated ALT levels. These results indicate that patients with NALT should be considered for treatment with PEG-IFN α-2b plus RBV.
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Affiliation(s)
- Mosaburo Kainuma
- Department of General Internal Medicine, Kyushu University HospitalDepartments of Medicine and Clinical Science Medicine and Bioregulatory Science Medicine and Biosystemic Science, Graduate School of Medical Science, Kyushu University Department of Medicine, Hamanomachi Hospital The Center for Liver Disease, Shin-Kokura Hospital Department of Medicine, Fukuoka City Hospital Department of Gastroenterology, Kyushu Medical Center, National Hospital Organization, Fukuoka Department of Internal Medicine, Nippon Steel Yawata Memorial Hospital Harunomachi Center for Liver Disease, National Hospital Organization Kokura Medical Center Harugaoka Department of Medicine, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
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Efficacy of pegylated interferon plus ribavirin combination therapy for hepatitis C patients with normal ALT levels: a matched case-control study. J Gastroenterol 2011; 46:1335-43. [PMID: 21858637 DOI: 10.1007/s00535-011-0455-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 07/16/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND The antiviral effect of pegylated interferon (Peg-IFN) plus ribavirin combination therapy in chronic hepatitis C (CHC) patients with normal alanine aminotransferase (ALT) levels (N-ALT) has been reported to be equivalent to that for patients with elevated ALT levels (E-ALT). However, the actual antiviral effect in N-ALT patients remains obscure because efficacy can be overestimated in patients with an advantageous background. METHODS In this study, 386 patients were extracted, for a matched case-control study, from 1320 CHC patients treated with Peg-IFN alpha-2b plus ribavirin combination therapy; 193 N-ALT patients [116 with hepatitis C virus genotype 1 (HCV-1), 77 with HCV genotype 2 (HCV-2)] were matched with 193 E-ALT patients by a propensity score method using the variables of age, sex, IFN treatment history, body mass index, and platelet counts. RESULTS On multivariate analysis for sustained virological response (SVR) in N-ALT patients, younger age, low HCV RNA level at baseline, and HCV-2 were significant factors. The matched case-control study showed that the SVR rates of N-ALT patients were equivalent to those of E-ALT patients; at 49 and 40% in the HCV-1 group (P = 0.146), and 78 and 81% in the HCV-2 group (P = 0.691). However, in N-ALT patients with non-SVR, approximately 40% showed ALT elevation at 24 weeks post-treatment. CONCLUSION Our findings indicate that the antiviral effect of Peg-IFN plus ribavirin therapy in N-ALT patients is comparable to that for E-ALT patients irrespective of their advantageous background; however, the application of this therapy for N-ALT patients, especially for those with HCV-1, should be considered carefully.
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Derbala MF, Amer AM, Almohanadi M, John A, Amin A, John A, Sharma M, Alkaabi SR, Al Dweik NZ, Pasic F, Yaqoob R, Butt MT, Shebl FM. Hepatitis C virus genotype 4 with normal transaminases: histological changes, schistosomiasis and response to treatment. J Viral Hepat 2011; 18:e258-62. [PMID: 21108700 PMCID: PMC3101275 DOI: 10.1111/j.1365-2893.2010.01403.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Among individuals with chronic hepatitis C virus (HCV) infection, approximately 30% of patients show persistently normal alanine aminotransferase (PNALT). Individuals with PNALT have been historically excluded from antiviral treatment. However, some studies have reported sudden worsening of disease in patients with PNALT, suggesting the need to treat such individuals. To evaluate this further, we compared fibrosis severity and response to treatment in patients with PNALT to patients with abnormal ALT. In addition, we investigated whether liver histology and schistosomiasis affect response to treatment differently in those with PNALT and abnormal ALT. A retrospective cohort study of 176 HCV-Genotype 4 (HCV-G4) patients treated with pegylated interferon (PEG-IFN) and ribavirin. Of 176 cases studied, 53 (30.1%) had normal ALT. Prevalence of pretreatment severe fibrosis, sustained virological response (SVR) and relapse were not significantly different in patients with PNALT (26%, 66% and 5.7% respectively) compared to those with abnormal ALT (32.5%, 60.7%, and 6.6% respectively). Multivariable logistic regression revealed that pretreatment ALT, pretreatment viral load, inflammation and schistosomiasis were not significantly associated with SVR [OR (95% CI), 0.75 (0.34-1.65); 0.92 (0.61-1.37); 1.64 (0.64-4.18); 0.90 (0.44-1.84) respectively]. Severe fibrosis was the only significant predictor of SVR [OR (95% CI), 0.38 (0.14-0.99)]. PNALT does not reflect the degree of fibrotic changes or predict SVR. Furthermore, schistosomiasis is a predictor of neither fibrosis nor poor response in patients with PNALT. Severe fibrosis is a strong and independent predictor of response to treatment. Therefore, it is important to treat individuals with PNALT levels regardless of schistosomiasis.
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Affiliation(s)
- M F Derbala
- Department of Gastroenterology and Hepatology, Hamad Hospital and Weill Cornell Medical College in Qatar, Egypt.
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Puoti C, Barbarini G, Picardi A, Romano M, Pellicelli A, Barlattani A, Mecenate F, Guarisco R, Costanza OM, Spilabotti L, Bellis L, Bonaventura ME, Dell' Unto O, Elmo MG, Nicolini AM, Nosotti L, Soccorsi F. Rapid virological response as a predictor of sustained response in HCV-infected patients with persistently normal alanine aminotransferase levels: A multicenter study. J Viral Hepat 2011; 18:393-9. [PMID: 20546499 DOI: 10.1111/j.1365-2893.2010.01319.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rapid virological response (RVR) is now considered the strongest predictor of sustained virological response (SVR) in patients with HCV undergoing antiviral treatment, and thus, shorter antiviral treatment for these patients has been suggested. However, no data exist on the predictive value of RVR in HCV carriers with normal ALT values. A total of 137 patients with persistently normal ALT treated with peginterferon alfa 2a and ribavirin were studied. Fifteen patients dropped out early because of side effects, and in 10 patients with HCV-1 treatment was discontinued because of lack of early virological response (EVR). RVR was observed in 68% of the patients (42% patients with HCV-1, 90% HCV-2 and 64% HCV-3). An end-of-treatment response was observed in 86% of the patients (68% HCV-1, 100% HCV-2 and 91% HCV-3). SVR was maintained in 91 patients (46% HCV-1, 97% HCV-2 and 82% HCV-3). Overall, 92% patients with rapid response did obtain HCV eradication vs only 38% of those without rapid response. HCV-1 patients with baseline HCV RNA <400×10(3) IU/mL were more likely to achieve RVR and SVR than those with higher HCV RNA levels. We conclude that patients with genotype 1 and normal ALT who achieve HCV RNA negativity at week 4 may have a higher probability of eradicating their infection. Because of the concomitant favourable demographic and virological features often found in this particular subset of patients, the duration of therapy in these people might be shortened in the case of RVR. Persistently normal alanine aminotransferase levels patients with genotype 2 or 3 have a high chance of achieving SVR, so retesting of HCV RNA during treatment may have no additional practical value in these subjects.
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Affiliation(s)
- C Puoti
- Department of Internal Medicine and Liver Unit, Marino Hospital, Rome, Italy.
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Puoti C, Guarisco R, Spilabotti L, Bellis L. Sustained virological response following extremely short antiviral treatment in selected HCV carriers with persistently normal ALT. Dig Liver Dis 2010; 42:745. [PMID: 20303840 DOI: 10.1016/j.dld.2010.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 01/20/2010] [Accepted: 01/31/2010] [Indexed: 12/11/2022]
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Puoti C, Bellis L, Guarisco R, Dell' Unto O, Spilabotti L, Costanza OM. HCV carriers with normal alanine aminotransferase levels: healthy persons or severely ill patients? Dealing with an everyday clinical problem. Eur J Intern Med 2010; 21:57-61. [PMID: 20206870 DOI: 10.1016/j.ejim.2009.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 11/24/2009] [Accepted: 12/07/2009] [Indexed: 12/17/2022]
Abstract
Approximately 30% of patients with chronic HCV infection show persistently normal ALT levels. Although formerly referred to as 'healthy' or 'asymptomatic' HCV carriers, and thus historically excluded from antiviral treatment, it has now become clear that the majority of these patients have some degree of histological liver damage that may be significant in up to 20% of patients and might progress toward a more severe degree of liver fibrosis. A significant proportion of patients (> or =20%) experience periods of increased serum ALT (flare) associated with enhanced disease progression. However, controversies still exist in clinical practice regarding the definition of 'persistent' ALT normality, the virological and histological features of these subjects, the need for liver biopsy, the role of non invasive tools for the assessment of liver fibrosis (transient hepatic elastography, fibroscan), and the natural history and optimal management of chronic hepatitis C with normal ALT. The advent of new therapeutic options (pegylated interferons plus ribavirin) has shifted treatment targets toward eradication of underlying infection, with therapy decision based on age, severity of disease and likelihood of response rather than on aminotransferase levels. This review does approach the main unresolved issues on this topic in the form of a dialog between a hepatologist and a patient with HCV infection but normal alanine aminotransferase levels, trying to give evidence-based answers to the more frequently asked questions from patients and their physicians.
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Affiliation(s)
- Claudio Puoti
- Dept. of Internal Medicine and Liver Unit, Marino Hospital, Rome, Italy.
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