Biopsy Re HCV
Jun 18, 2006
In reading your answers over the past few months, I've noticed that you very fervently advocate liver biopsy. I'm on my second round of HCV treatment; 1st was peg-intron only with relapse, 2nd with another doctor is pegasys + ribavirin. (Didn't switch Drs. because of relapse, but rather due to falling CD4s after 20 yrs. of non-treatment for HIV). The 1st Dr. vacillated re biopsy every other appt., but in the end we didn't do it; 2nd Dr. hasn't mentioned it at all. I'm curious as to why some Drs. advocte for biopsy so much. I can't see where it has affected anyone's treatment choices. Is it a matter of the liver possibly being too far gone to bother with treatment? What information do you gather from biopsies, and how may it affect your next move?
Response from Dr. McGovern
Excellent questions. The reasons I like to get a biopsy in HIV-infected patients are the following:
1. If the patient has minimal disease, I offer the options of treatment versus no treatment.
2. If the patient has mild, moderate or severe hepatitis I recommend treatment. If the patient has significant side effects on treatment, I will still push on treatment in the patient with more advanced disease more than in the patient who has only mild disease.
3. Patients can have cirrhosis without any tell-tale signs on examination or in their laboratories. This has been demonstrated in several studies in the hepatology literature. If my patient has cirrhosis, then I may want to change the dosing of their protease inhibitor for example. I would also want to investigate for esophageal varices that can come with cirrhosis. I would also want to treat to cure their hepatitis C; if I didn't get the result I wanted then I would want to refer them to a clinical trial looking at maintenance therapy.
There are more data now on using non-invasive markers of fibrosis - like fibrotest. These tests are not well-studied in HIV but the data are getting better and they may be helpful in telling who has mild versus advanced liver disease. They are not as helpful in between.
Also liver biopsies tell you a lot of information about fatty liver, which you can't get from a non-invasive marker. There are emerging data that the amount of steatosis is important in terms of risk of fibrosis progression - in patients with HCV alone and also now in HIV/HCV coinfected patients. There will be more data very soon.
Hope this is helpful.
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