Late presentation of chronic viral hepatitis for medical care: a consensus definition

Table 1 Consensus definition of late presentation with chronic viral hepatitis for medical care

Definition	Description
Presentation with advanced liver disease in untreated patients with chronic hepatitis B and C	A patient with chronic hepatitis B or C and significant fibrosis assessed by one of the following: serologic fibrosis score ≥ F3 (assessed by APRI score > 1.5, FIB-4 > 3.25, Fibrotest > 0.59 or alternatively a transient elastography (FibroScan) > 9.5 kPa) or liver biopsy (≥ METAVIR stage F3) in patients with no previous antiviral treatment^a.
Presentation with late stage liver disease in untreated patients with chronic hepatitis B and C	Presence of at least one symptom of decompensated cirrhosis (jaundice, hepatic encephalopathy, clinically detectable ascites, variceal bleeding) and/or hepatocellular carcinoma in patients with no previous antiviral treatment^b.

^aGeneral comments: advanced liver disease in patients with chronic hepatitis B and C is a definition for capturing all cirrhotics and patients with pre-cirrhosis. On the basis of regular testing of the aspartate transaminase level (AST), alanine transaminase level (ALT), gamma glutamyl transferase level (GGT), cholesterol and platelet count, it is possible to calculate the aspartate transaminase to platelets radio index (APRI) as: APRI = (AST/upper limit of normal [ULN])/platelet (109/L) x 100), or to calculate the FIB-4 as FIB-4 = (age x AST) / (platelets x (sqr (ALT) or with more extensive laboratory assessments the commercially available Fibrotest. APRI and FIB-4 may have lower sensitivity and specifity in calculating advanced fibrosis and cirrhosis patients with chronic hepatitis B compared to chronic hepatitis C. The APRI score may not be reliable if a patient suffers from another condition that affects the platelet count (e.g. HIV infection, immune thrombopenia etc), and therefore transient elastography (e.g. FibroScan) is preferred.
^bIn the absence of other explanatory factors/aetiologies aside HBV, HCV or HDV

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