Transjugular Liver Biopsy in Hemophilia Is Safe with a Minimum of Two Doses of Factor.

Over 80% of adults with hemophilia are infected with hepatitis C (HCV) infection through exposure to clotting factor concentrates 20 or more years ago. Although liver biopsy is considered the gold standard to assess the severity of HCV liver disease, the majority of those with hemophilia do not undergo biopsy, even by the less invasive transjugular route. Little is known about the actual or perceived bleeding risks which may affect patient decisions about biopsy. Further, little is known about the minimal hemostatic dose of factor replacement which may affect physician decisions about biopsy. Of 161 hemophilic men enrolled in the multicenter HIV and HCV in Hemophilia (HHH) study which evaluates extent of and risks for HCV disease progression, 112 (69.6%) have decided against biopsy. Among the reasons, given by 75 of the latter, were fear of the procedure, in 23 (30.7%); lack of insurance, in 11 (14.7%); past biopsy, in 11 (14.7%); lack of time, in 10 (13.3%); lack of perceived indication, in 6 (8.0%); presence of an inhibitor, in 5 (6.7%); fear of bleeding, in 5 (6.7%); and other illness or uncertainty, in 4 (5.3%). The 49 (30.4%) agreeing to liver biopsy were more likely than those declining biopsy to be HIV+ (53.1% vs. 34.8%, p < 0.05) and less likely to have an inhibitor (0% vs. 13.4%, p = 0.002), but were as likely to have hemophilia A, 81.6% vs. 83.0%; be over 35 years of age, 49.0% vs. 53.1%; Caucasian, 81.6% vs. 85.7%; and HCV genotype 1, 80.8% vs. 79.5%, all p > 0.05. At the time of biopsy, the median platelet count was 185,000/ul (38,000–366,000/ul), the median PT was 12.0 seconds (9.4–15.4 sec), and the median INR was 1.0 (0.9–1.2). All patients received two doses of factor, and 25 (71.4%) received a third dose; three (8.6%) received a fourth dose for unrelated procedures. The median pre- and post-biopsy F.VIII doses were 49.5 U/kg, 26.6 U/kg at 1–4 hours and 45.0 U/kg at 24–48 hours; and the median F.IX doses were 74.0 U/kg, 44.3 U/kg, and 45.0 U/kg, respectively. No biopsy-related bleeding occurred. Minor adverse events included fever in two, liver function abnormality in one, and duodenal ulcer bleeding in one. The median Knodell, Ishak, and Metavir scores did not differ significantly by HIV status (+ vs.), type hemophilia (A vs. B), age (>35 vs ≤ 35 yr), HCV genotype (1 vs. non-1), or race (Caucasian vs. non-Caucasian). Although preliminary, these findings suggest that fear of the procedure is the most common deterrent to liver biopsy in patients with hemophilia. Yet, when performed by the transjugular route, liver biopsy appears to be safe, with excellent hemostasis achieved with a minimum of two doses of factor, including a 100% dose pre- and a 50% dose post-biopsy. These findings will require confirmation in larger numbers of subjects.