Clinical approach to the patient with chronic hepatitis C infection and normal aminotransferases

Approximately 30% of patients with chronic HCV infection have persistently normal alanine aminotransferase levels (PNALT). Most of these patients have minimal or mild inflammation and absent or minimal fibrosis, although occasionally cirrhosis and hepatocarcinoma may be seen. Overall, liver histology is significantly less severe than in patients with elevated ALT levels, and most follow-up studies have reported stability of the disease, with minimal fibrosis progression over years, and thus a disease with a favorable prognosis. Nevertheless, a few studies have shown more recently that many patients with PNALT, may have elevations in ALT over time, and almost 20-30% have a significant progression of fibrosis, being eligible for antiviral therapy. During the last decade it has been demonstrated that in chronic HCV infection with PNALT, combination antiviral therapy with peg interferon-alpha plus ribavirin is efficacious, safe, and associated with significant improvements in health-related quality of life, and the decision whether to treat or not this patients should be based on multiple factors including: age, HCV genotype, histology, patients motivation and adherence, symptoms and comorbidity, rather than on ALT levels alone.