Monitoring disease progression
 

David Bernstein MD: The tests used to monitor disease progression in hepatitis C are really those that monitor the progression of cirrhosis in any patient who has liver disease. And those would be tests of liver function, namely the albumin, the prothrombin time or the bilirubin.

The level of ALT does not correlate with the amount of disease that's present. And there are many patients - as many as 25 to 30% - who have hepatitis C, who have a normal ALT.

Rajender Reddy MD: Radiologic imaging has a relatively limited role, unless the patient has cirrhosis. If the patient has cirrhosis, radiologic imaging primarily serves to do surveillance for hepatocellular carcinoma. It might demonstrate some features of portal hypertension, as noted by varices or enlarged spleen.

David Bernstein MD: Most people will obtain an ultrasound when they first meet a patient with hepatitis C to look for lesions that may be present, whether those be benign or malignant. In the patient who does not have cirrhosis, there is no role for repeated radiologic imaging. In the patient with cirrhosis, there may be a role for the use of ultrasound or CT scan for the screening or looking for the development of hepatocellular carcinoma. An adequate liver biopsy is a liver biopsy that gets an approximate 2 cm core piece of liver with an average of 9 to 12 portal areas that can be appropriately evaluated.

In my opinion, liver biopsy is indicated in almost every patient that has chronic hepatitis C, because it is the only test which determines where a patient stands and enables us to determine what the progression of the disease may be and to tell a patient what their prognosis is. Having said that, there certainly are patients with hepatitis C who I wouldn't perform a liver biopsy on. And those are patients that have obvious risks or contraindications to the performance of a liver biopsy.

There's a growing interest in finding subsets of patients who may not require a liver biopsy. The most common group that's talked about are those patients who are genotypes 2 or 3 who are young and who the feeling is - based on other tests, which are difficult to determine - do not have cirrhosis. So if you were to consider this, you can make a strong argument for not biopsying young patients who are genotypes 2 or 3 because of the high response rates, 80 to 90% chance of being sustained viral responders.

However, in those patients with genotypes 2 or 3 who did not respond to therapy, I would perform a liver biopsy at the conclusion of treatment.

David Bernstein MD: The problem is, is we get a baseline biopsy on most patients and we don't know when to get the next biopsy. Certainly, in those patients who have cirrhosis on initial liver biopsy, there's no indication to repeat a liver biopsy in the future.

There's a school of thought that states that every five to eight years in those patients who are either untreated or haven't responded to therapy, a liver biopsy should be repeated. That probably makes some sense, but there's no hard data to support that and no studies to back up that recommendation.

Robert Brown MD: The minimum interval in my practice is three years. Most people recommend 3- to 5-year intervals between biopsies. Obviously, as you follow patients longer and longer, that interval will likely increase rather than decrease over time.

Robert Brown MD