Spotlight Series on Hepatitis C

Canadian Physicians Reveal Their Choices for Assessing Liver Fibrosis

January 28, 2014

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According to researchers, the main causes of persistent liver disease include:

  • chronic hepatitis B virus (HBV) infection
  • chronic hepatitis C virus (HCV) infection
  • alcoholic liver disease (ALD)
  • non-alcoholic fatty liver disease (NAFLD)
  • autoimmune liver disease

Regardless of the instigator of chronic liver disease, liver damage usually proceeds along a common route, causing chronic inflammation, the death of formerly healthy liver tissue and its replacement by scar tissue. This process is called fibrosis. If the underlying cause of chronic liver disease is left untreated, the scarring eventually spreads throughout the liver and this vital organ becomes increasingly dysfunctional. This can lead to serious health complications, including in some cases, liver cancer.


Assessing fibrosis is important so that doctors and their patients can keep abreast of changes to this organ and determine if interventions to improve the health of the liver are having an effect. In the case of ALD and NAFLD, such interventions are behavioural, including cutting back on alcohol and incorporating exercise into daily routines. In the cases of viral infections -- HBV and HCV -- interventions include treatment with antiviral medicines.

Fibrosis Assessment

Historically, the most highly regarded way of assessing liver fibrosis has been a liver biopsy -- a procedure that involves removing a tiny piece of the liver for laboratory analysis. This procedure can be done relatively quickly. However, liver biopsies can have drawbacks:

  • They are invasive.
  • They can be painful and costly, particularly if complications occur.
  • As the biopsy involves removing only a tiny piece of the liver, damage in other parts of this organ can potentially be missed.

Blood Tests

There are several non-invasive means of assessing the degree of fibrosis in the liver, which are largely dependent on blood tests. These include:

  • Fibrotest -- this involves measuring levels of several proteins in the blood -- the liver enzyme GGT, the amount of the waste product bilirubin, alpha-2-macroglobulin, apolipoprotein A1 and haptoglobin. In addition to these levels, a person's age and gender are taken into account.
  • APRI -- this method involves dividing a person's level of the liver enzyme AST by the number of platelets (used for clotting) in their blood.

Tests that evaluate the physical state of the liver, or stiffness of the liver, can also assess injury. These include:

  • Fibroscan -- a specialized form of ultrasound (also called transient elastography)
  • Magnetic resonance elastography -- similar to an MRI (magnetic resonance imaging) scan of the liver.

No liver assessment technique or technology is perfect; each one has advantages and disadvantages. However, care and treatment guidelines across high-income regions in North America and Western Europe increasingly call for the use of non-invasive means for assessing liver health. As a result, researchers at McGill University and the University of Calgary were interested in determining how non-invasive technologies were being used to assess damage to the liver. The researchers developed an internet-based survey, which was disseminated with the help of scientific societies such as the Canadian Association of Gastroenterologists (CAG) and the CIHR Canadian HIV Trials Network (CTN). The survey asked doctors who cared for patients with chronic liver disease detailed questions about what they used to assess liver injury in patients.

The researchers found that the use of liver biopsy was still relatively common -- nearly 46% of participants reported using it. However, researchers stated that "non-invasive methods, particularly Fibroscan, have significantly reduced the need for liver biopsy in Canada." Further findings from the survey appear later in this CATIE News bulletin.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication CATIE News. Visit CATIE's Web site to find out more about their activities, publications and services.

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