An update on the management of chronic hepatitis C: 2015 Consensus guidelines from the Canadian Association for the Study of the Liver

2015 Canadian Journal of Gastroenterology & Hepatology 29, 1 (19-34)

Assessment of the severity of hepatic fibrosis is vital for determining the prognosis of HCV-infected patients and the necessity of antiviral treatment. Identification of patients with cirrhosis is particularly important due to their increased risk of hepatic complications, reduced likelihood of treatment response, and their requirement for surveillance for HCC and esophageal varices. Although the diagnosis of cirrhosis is obvious in some cases based on routine tests (eg, a nodular shrunken liver, splenomegaly or portal hypertensive collaterals on ultrasound), traditionally, liver biopsy has been the reference method for staging liver fibrosis, determining the severity of other histological lesions (eg, necroinflammation, steatosis) and ruling out coexistent liver diseases (eg, iron overload). Various validated scoring systems have demonstrated sufficient reproducibility and interobserver variability to justify clinical use (eg, METAVIR, Scheuer, Ishak, and Knodell’s Hepatic Activity Index). However, liver biopsy has several limitations, including invasiveness and the potential for serious complications including hemorrhage (approximately one in 1000) and death (approximately one in 10,000), sampling error and variability in pathological interpretation, high cost, limited availability in many centres, and the difficulty of repeating biopsies to monitor temporal changes in fibrosis. In light of these limitations, numerous noninvasive alternatives to biopsy have been developed including serum markers (eg, aspartate aminotransferase/platelet ratio index, FibroTest (FibroSure, LabCorp, USA), transient elastography (TE; FibroScan, Echosens, France) and other imaging-based tools. Although not universally available, a wealth of literature has confirmed that these noninvasive tools can be used instead of liver biopsy to stage HCV-related fibrosis at acceptable levels of accuracy and reproducibility. In a recent survey of Canadian specialists who manage patients with chronic liver disease, TE was the primary mode of fibrosis assessment in HCV-infected individuals in 53% of respondents, followed by liver biopsy in 37%. Nearly one-half of respondents estimated that these noninvasive alternatives have reduced their use of liver biopsy by over 50%. In general, these tests are highly accurate for diagnosing cirrhosis and have acceptable, but lower, performance for moderate to severe fibrosis (F2 or greater). The identification of mild fibrosis (F1) and the differentiation between individual stages is poor; however, these limitations also apply to liver biopsy. Emerging data have also demonstrated a correlation between these tests and HCV-related clinical outcomes, their cost-effectiveness compared with biopsy and responsiveness to viral eradication. Future studies are necessary to determine the minimal clinically important changes in these markers to facilitate serial monitoring of fibrosis. Recommendations - Acceptable methods of fibrosis assessment include liver biopsy, TE (FibroScan) and serum biomarkers panel (eg, FibroTest), either alone or in combination. All juridictions should provide access to at least one accurate, noninvasive method to assess fibrosis (Class 1, Level A).

Pubmed : 25585348