EASL Clinical Practice Guidelines: management of hepatitis C virus infection

2011 Journal of Hepatology 55, 2 (245-264)

Assessment of liver disease severity. Assessment of the severity of hepatic fibrosis is important in decision making in chronic hepatitis C treatment and prognosis. Liver biopsy is still regarded as the reference method to assess the grade of inflammation and the stage of fibrosis. The shortcomings of biopsy have been highlighted in recent years and alternate non-invasive methods have been developed and extensively evaluated in patients with chronic HCV infection. They include serological markers and transient elastography. Their performance, when used alone or together, has been reported to be comparable with liver biopsy. Both non-invasive methods have been shown to accurately identify patients with mild fibrosis or cirrhosis. They are less able to discriminate moderate and severe fibrosis.
Assessment of liver disease severity. [...] Based on the abundant literature in chronic hepatitis C, alternative, non-invasive methods can now be used instead of liver biopsy in patients with chronic hepatitis C to assess liver disease severity prior to therapy at a safe level of predictability.
Transient elastography (TE) [a] can be used to assess liver fibrosis in patients with chronic hepatitis C, provided that consideration is given to factors that may adversely affect its performance such as obesity, age, and biochemical necroinflammatory activity. TE results should be evaluated relative to interquartile range and to the success rate of measurements. TE performs better at detecting cirrhosis than lesser degrees of fibrosis. [...] The well established panels of biomarkers of fibrosis can be broadly categorized as those that include commonly performed biochemical and hematological tests, such as ALT, AST, prothrombin time, platelets (APRI, AST/ALT ratio, Forns Index); those that include specific indirect markers of liver fibrosis, such as a-2 macroglobulin; those that incorporate only direct markers of liver fibrosis, or combinations of direct and indirect markers [d]. [...] The combination of blood tests or the combination of TE and a blood test improve accuracy and reduce the necessity of using liver biopsy to resolve uncertainty. However, they increase the cost.
Recommendations [...]
Transient elastography (TE) can be used to assess liver fibrosis in patients with chronic hepatitis C (A2). [...]
The combination of blood tests or the combination of transient elastography and a blood test improve accuracy and reduce the necessity of using liver biopsy to resolve uncertainty (C2). [...]
[a] TE: Fibroscan
[d] Tests including combinations of indirect and direct markers of fibrosis: Hepascore(tm); Fibrometer(tm).
HIV coinfection. [...]The severity of liver disease must be assessed prior to therapy by means of a liver biopsy or by non-invasive assessment (serological tests or transient elastography).

Pubmed : 21371579