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VCU Researchers Evaluate Liver Biopsy in Hemophilia

Researchers from Virginia Commonwealth University (VCU) published a study in March 2007 on the safety of liver biopsy in hemophilia patients with hepatitis C and HIV. They evaluated percutaneous (through the skin) liver biopsy, a procedure performed by inserting a needle between the two lower ribs to extract a small portion of liver tissue, which is then sent to a laboratory for analysis. Although results can indicate a great deal about the overall condition of the liver, physicians treating hemophilia patients can be reluctant to order it because of an increased risk of bleeding.

More than 80% of adults with hemophilia are infected with hepatitis C (HCV). Many experience serious complications associated with chronic infection, such as permanent liver scarring and the breakdown of liver function. The researchers conducted a retrospective study to discern any difference in actual or perceived risk of liver biopsy in hemophilia patients with HCV. They also included patients co-infected with HIV, to determine how much of a factor the virus was in the progression of liver disease.

Investigators reviewed data on all patients with hemophilia who were referred to the Hepatology Department at the VCU Health System for evaluation of chronic HCV and liver biopsy from 1995 to 2004. In all, 29 male patients (24 with hemophilia A and five with hemophilia B), with a mean age of 36, underwent standard outpatient percutaneous liver biopsy. Factor replacement therapy was given to all patients before and after the procedure. The liver biopsy was performed successfully without bleeding complications, and all patients were released the same day.

Of the 29 patients, 13 were HIV positive and 16 were HIV negative. Co-infected patients had higher fibrosis scores and a higher proportion of advanced fibrosis compared to the HCV-only group (54% vs. 12%). The authors subsequently established that HIV co-infection, independent of age, is a risk factor for advanced fibrosis. “Therefore, it is important to accurately identify individuals with advanced hepatic fibrosis,” reported lead author Richard K. Sterling, MD, Division of Gastroenterology, Hepatology, and Nutrition at VCU. “They are the ones at highest risk of HCV-related morbidity and mortality and are most likely to benefit from anti-HCV therapy.”

Sterling and his team concluded that percutaneous liver biopsy can be peformed safely in hemophilia patients if accompanied by factor replacement. They added, however, that potential risks and the cost of the procedure may cause some patients and their doctors to opt for alternative, noninvasive tests to determine the severity of HCV-related liver disease.

One alternative cited by the authors was Fibroscan, a new ultrasound testing device that has performed well in predicting fibrosis in some chronic HCV patients. The authors noted that the noninvasive tests are suitable only for approximately half (40-60%) of either HCV or HCV/HIV co-infected patients. “Until noninvasive tests are readily available, accurate, and applicable to all patients, liver biopsy with factor replacement will continue to play an important role in the management of HCV in this challenging population,” summarized Sterling and co-authors.

The study, “Percutaneous Liver Biopsy in Adult Haemophiliacs with Hepatitis C Virus: Safety of Outpatient Procedure and Impact of Human Immunodeficiency Virus Coinfection on the Spectrum of Liver Disease,” was published in the March 2007 issue of the journal Haemophilia.

The National Hemophilia Foundation’s Medical and Scientific Advisory Council issued a recommendation on liver biopsy in individuals with hemophilia, MASAC Document #98 (June 2000).

Source: Disease Prevention Week, May 15, 2007


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