Liver Disease

How to Stage Liver Disease in HCV

Raymond T. Chung, MD
Massachusetts General Hospital

Chung RT. How to stage liver disease in HCV. Published online April 2, 2019. Consultant360.


Once a patient has been diagnosed with hepatitis C virus (HCV), it is very important to stage the disease.

First, it is imperative that a patient understands where in the natural history spectrum their disease lies—do they have early stage fibrosis or no fibrosis; or, on the other end of the spectrum, do they have more advanced fibrosis or cirrhosis?

Understanding where a patient stands is important because it will provide him or her with prognostic information about how close he or she is to cirrhosis and/or the development of decompensated cirrhosis, which is characterized by liver failure and/or portal hypertension.

When a patient with HCV presents to discuss treatment options, the health care provider should determine whether the patient has advanced fibrosis or cirrhosis, as it will influence subsequent management, including choice and duration of regimen.

Awareness of disease stage is also important because it affects other aspects of care, including screening for hepatocellular carcinoma (HCC). Liver cancer screening should be performed in patients with cirrhosis or advanced fibrosis (stage F4 or F3) in view of the elevated risk for HCC in these patients. For patients with cirrhosis, routine screening for esophageal varices is also an important dimension of hepatology care.

Historically, staging was performed using liver biopsy, which provides accurate information   regarding extent of inflammation and fibrosis. While a biopsy is still thought to be the gold standard, it may not fully reflect the histology of the liver, since it represents a sampling of a very small fraction of the organ, and fibrosis can be a patchy or spotty condition. Thus, sampling error can be an issue. To this end, we have observed that fibrosis stages may differ by 1 or more stages between 2 areas of the liver in the same patient at the same time. And we have also certainly seen instances where a biopsy, due to the narrow sampling, might understage that patient by failing to sample evidence of more-advanced fibrosis due to the angle of the cut through the fibrotic sample.

A Less Invasive Alternative to Liver Biopsy

A liver biopsy procedure is invasive and carries a finite risk of complications, including hemorrhage, and the possible need for interventions, including hospitalization and procedures to stanch hemorrhage. This has spurred a move toward noninvasive approaches to assess fibrosis, which include both blood-based tests and radiologic approaches.

Blood tests, some of which are based on routine labs, and others that are more proprietary, can offer reasonably accurate information about liver disease stage, particularly at the extremes of fibrosis. As the most frequent example of a radiologic approach, elastography measures the liver’s stiffness, which is considered a proxy for fibrosis. One modality, known as transient elastography (Fibroscan)—is also capable of providing fairly accurate information about a patient’s stage of fibrosis, particularly in ruling in or out cirrhosis.  

These approaches have gained much more widespread favor among clinicians because they are risk-free and more than 80% accurate in staging liver disease.

Raymond T. Chung, MD, is the vice chief of the Gastrointestinal Division, director of Hepatology, and medical director of the Liver Transplant Program at Massachusetts General Hospital in Boston.