Dept. of Internal Medicine and Liver Unit, Marino Hospital, Rome, Italy.
Eur J Intern Med. 2010 Apr;21(2):57-61. doi: 10.1016/j.ejim.2009.12.006. Epub 2009 Dec 29.
Approximately 30% of patients with chronic HCV infection show persistently normal ALT levels. Although formerly referred to as 'healthy' or 'asymptomatic' HCV carriers, and thus historically excluded from antiviral treatment, it has now become clear that the majority of these patients have some degree of histological liver damage that may be significant in up to 20% of patients and might progress toward a more severe degree of liver fibrosis. A significant proportion of patients (> or =20%) experience periods of increased serum ALT (flare) associated with enhanced disease progression. However, controversies still exist in clinical practice regarding the definition of 'persistent' ALT normality, the virological and histological features of these subjects, the need for liver biopsy, the role of non invasive tools for the assessment of liver fibrosis (transient hepatic elastography, fibroscan), and the natural history and optimal management of chronic hepatitis C with normal ALT. The advent of new therapeutic options (pegylated interferons plus ribavirin) has shifted treatment targets toward eradication of underlying infection, with therapy decision based on age, severity of disease and likelihood of response rather than on aminotransferase levels. This review does approach the main unresolved issues on this topic in the form of a dialog between a hepatologist and a patient with HCV infection but normal alanine aminotransferase levels, trying to give evidence-based answers to the more frequently asked questions from patients and their physicians.
约 30%的慢性 HCV 感染患者 ALT 水平持续正常。虽然以前被称为“健康”或“无症状”HCV 携带者，因此在历史上被排除在抗病毒治疗之外，但现在已经清楚，这些患者中的大多数都有一定程度的组织学肝损伤，在多达 20%的患者中可能会导致更严重的肝纤维化。相当一部分患者（≥20%）会出现血清 ALT 升高（ flares ）的时期，伴有疾病进展的增强。然而，在临床实践中，关于“持续”ALT 正常的定义、这些患者的病毒学和组织学特征、肝活检的必要性、非侵入性工具（瞬时肝弹性成像、fibroscan）评估肝纤维化的作用，以及正常 ALT 的慢性丙型肝炎的自然史和最佳管理，仍然存在争议。新的治疗选择（聚乙二醇干扰素加利巴韦林）的出现将治疗目标转向消除潜在感染，治疗决策基于年龄、疾病严重程度和应答可能性，而不是基于转氨酶水平。这篇综述以肝病专家和丙型肝炎感染但正常丙氨酸氨基转移酶水平患者之间的对话形式探讨了该主题中未解决的主要问题，试图为患者及其医生经常提出的问题提供基于证据的答案。
