Hepatitis C is an insidious, slowly progressive killer. It is estimated that approximately 2.7 million persons in the United States are infected, and the worldwide prevalence approaches 170 million. 1,2 In those patients who progress to decompensated cirrhosis, liver failure, or hepatocellular carcinoma, the typical duration of infection is 20 to 30 years. The majority of individuals will have no complications despite prolonged infection, but a subset will have progressive disease. 3 Numerous studies have shown that liver-related complications in early or histologically mild hepatitis C virus (HCV) infection are rare. 4,5 However, it has also been shown that patients with histologically proven cirrhosis are at significant risk of developing hepatic decompensation or hepatocellular carcinoma over the subsequent 5 to 10 years. 6 The ability to prognosticate accurately any given patient' s likelihood of developing clinically deleterious or fatal complications is important to strategies for aggressive primary prophylaxis, screening, and treatment as well as to the timing of liver transplantation in those with HCV cirrhosis.
The report by Khan et al 7 in this issue of HEPATOLOGY seeks to identify predictors of adverse outcomes in patients with HCV infection. The study looked at a variety of demographic, virological, biochemical, and behavioral variables to identify those independently associated with a high probability of liver-related complications. In multivariate analysis, the independent predictive variables for development of hepatic decompensation, death, or liver transplantation were (1) serum albumin Ͻ30 g/L, (2) stage 3 or 4 fibrosis, and (3) unknown route of HCV acquisition. A number of additional variables were identified in univariate but not multivariate analysis. These included birth outside of Australia/New Zealand, infection with genotype 1b or 4, elevated bilirubin, and increased prothrombin time. The investigators were unable to show any predictive value of alcohol consumption, concomitant hepatitis B infection (anti-hepatitis B core positive), or serum alanine transaminase levels. This is one of the first studies that attempts to ascertain risk factors for development of liver complications in patients with chronic hepatitis C in a prospective manner. It is notable for the inclusion of an ethnically heterogeneous population as well as for a high rate of completed follow-up. However, Abbreviations: HCV, hepatitis C virus; HBV, hepatitis B virus.