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Noninvasive tests in the post–liver transplantation setting

We read the letter of Cholongitas et al. regarding our recently published article. There are several points we would like to make in response to their letter. First of all, the authors did probably not read the methods section of our study with sufficient attention. In the manuscript by Blasco et al., we assessed liver biopsies performed 3 months and 1 year after liver transplantation (LT) in patients who underwent transplantation from October 2000 to May 2003 (last biopsy May 2004). In the study by Carrion et al., liver biopsies were performed between July 2004 and October 2005. Thus, not a single biopsy from the first study was included in the most recent paper. Second, we never stated that transjugular liver biopsies (TJLB) could not correlate with HVPG due their inferior quality compared to percutaneous liver biopsy (PLB). We only stated that the size of TJLB was smaller than PLB; nevertheless, the correlation of TJLB and PLB to assess liver fibrosis 1 year after LT was good (kappa 0.6). Moreover, the association between the fibrosis stage assessed in TJLB (1 year after LT) and HVPG was similar than that seen with PLB (Figure 1). For space reasons, only the latter association was included in the manuscript. Indeed, we believe that the biopsy samples used in both studies were adequate; the good correlation between biopsy findings and HVPG (and more importantly with clinical outcomes) strongly support our data. Third, we did not include the size of our specimens in the study by Carrion et al. The median size was 12 mm for TJLB (size of the largest fragment if more than one) and 19 mm for PLB biopsies. We agree with the authors that it is better to have larger specimens. In fact, our tendency in TJLB is to perform two or even three passes (if required to obtain a good fragment), as it is stated in the methods section of the manuscript. Fourth, the authors certainly obtain transjugular biopsies of greater length than our group. However, we obtained TJLB of significantly greater width: because we use 16-gauge needles, our median TJLB width is 1 mm, practically double that that obtained by Cholongitas et al.. This explains why the total number of complete portal tracts is similar between both studies. As a result, the arguments by Cholongitas have no basis. Finally, the most important fact of the studies by Blasco et al. and Carrion et al. is the clear association between the fibrosis stage assessed in liver biopsies and HVPG, which supports that the information provided by our liver biopsies was adequate. We agree with the authors that a liver biopsy is the only method to perform a diagnosis; this is the reason why we perform so many biopsies at our center. Nevertheless, once a diagnosis is established (i.e., hepatitis C recurrence), our study demonstrates that transient elastography (TE) detects with high accuracy individuals with significant liver fibrosis and/or portal hypertension. The latter is clinically relevant, because portal hypertension is what ultimately leads to graft loss in patients with hepatitis C recurrence after LT.