title: Predicting the liver histology in chronic hepatitis C: how good is the clinician?
abstract: OBJECTIVE
  Liver biopsy is believed to be necessary before antiviral treatment in hepatitis C. Studies have found symptoms and biochemistry poorly predictive of grade and stage. In practice, a combination of factors is used to anticipate histology. The aim of this study is to evaluate the ability of global clinical assessment to predict histology in hepatitis C.
  
  
  METHODS
  Fifty-four consecutive patients referred to a university center for consideration of antiviral therapy were enrolled. Clinical and laboratory data were recorded as was a prediction of the inflammatory grade (0-3) and fibrotic stage (0-3), with fibrotic stage 3 referring to cirrhosis. Liver biopsies were read by a blinded pathologist. The predictive value of the clinical assessment and individual parameters was assessed.
  
  
  RESULTS
  All predictions were < or = 1 point off the actual grade and stage. Thirty-six (66.7%) patients' grades and 41 (75.9%) patients' stages were exactly predicted. All four cirrhotic patients (sensitivity 100%, specificity 94%) and one case of hemochromatosis were correctly predicted. Spider nevi, organomegaly, white blood cell count < or = 4 x 10(9)/L, ALT > 120 U/L, bilirubin > 20 micromol/L, albumin < or = 35 g/L, and ferritin > 200 microg/L predicted grade > or =2. Stage > or =2 was associated with age > 40 yr, previous decompensation, spider nevi, organomegaly, white blood cell count < or = 4 x 10(9)/L, albumin < or = 35 g/L, platelets < or = 150 x 10(9)/L, and international normalized ratio > 1.2. Grade correlated with stage (Spearman coefficient = 0.54, p < 0.001). By multivariate analysis, ferritin plus spider nevi or hypoalbuminemia was independently predictive of inflammation. Spider nevi and thrombocytopenia, with either splenomegaly or hypoalbuminemia, were useful three-variable models for predicting fibrosis. The corresponding scoring systems produced useful likelihood ratios.
  
  
  CONCLUSIONS
  Global clinical assessment mirroring clinical practice in a tertiary liver transplant center is moderately accurate in predicting grade and stage in hepatitis C. Liver biopsy is the current gold standard; however, the amount of new information gleaned is less than was perceived. The need for routine biopsy before antiviral treatment in hepatitis C should be reevaluated in a multicenter study.
authors.affiliation: Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Romagnuolo
authors.forename: G S
authors.initials: GS
authors.lastname: Jhangri
authors.forename: L D
authors.initials: LD
authors.lastname: Jewell
authors.forename: V G
authors.initials: VG
authors.lastname: Bain
mesh_terms: D000328:Adult; D001706:Biopsy; D002983:Clinical Competence; D005260:Female; D019698:Hepatitis C, Chronic / Q000473:pathology*; D006801:Humans; D008099:Liver / Q000473:pathology*; D008103:Liver Cirrhosis / Q000473:pathology; D008297:Male; D015999:Multivariate Analysis; D010865:Pilot Projects; D015203:Reproducibility of Results