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The degree of portal hypertension in cirrhotic patients does not correlate with the cause of the disease. Thus, current statements on the management of portal hypertension, although based upon studies including mainly patients with alcoholic cirrhosis, can be applied also to patients with viral-related cirrhosis.

We read with great interest and enthusiasm the updated American Association for the Study of Liver Diseases practice guidelines, "Diagnosis, Management, and Treatment of Hepatitis C" by Strader et al., who comprehensively reviewed the current status and pointed out areas requiring more studies. 1 Unfortunately, a group of hepatitis C patients-those with hepatitis B virus (HBV) coinfection-were not addressed at all. In most countries, hepatitis C patients usually have only one hepatotropic virus infection. However, in areas where HBV infection is endemic, such as Southeast Asia, Far East and southern Europe, the number of subjects infected with both hepatitis C and B is substantial. 2,3 More specifically, antibody to hepatitis C virus (anti-HCV) was present in 7% to 11% of patients with HBV-related chronic liver diseases. 2,3 If the prevalence of anti-HCV positivity is around 1% to 2% in the general population, then the number of HCV/HBV coinfection worldwide will be around 3 million to 7 million among the 350 million HBV carriers. Moreover, the HCV-and HBV-coinfected patients have been shown to carry a significantly higher risk of developing cirrhosis or hepatocellular carcinoma than those with HCV or HBV infection alone. 4 -6 Therefore, patients dually infected with hepatitis C and B need more attention from the medical profession, and they should be urgently treated with effective regimens. At present, unfortunately, hepatitis C and B coinfected patients are frequently neglected.Nevertheless, some regimens have been used to treat dual chronic hepatitis C and B. A recent study reported that standard interferon 9 million units thrice weekly for 6 months could clear HCV in 31% of these patients. 7 We have treated hepatitis C and B dually infected patients in a pilot study by using standard interferon in combination with ribavirin for 6 months. 8 We found that a sustained HCV clearance rate in hepatitis C and B dually infected patients could be achieved to an extent comparable to that in hepatitis C alone. After a follow-up of Ն2 years, HCV RNA remained undetectable in 89% of patients, with sustained clearance of serum HCV RNA 6 months posttreatment. To our surprise, 21% of these patients lose serum hepatitis B surface antigen. We anticipate that the efficacy may be enhanced by pegylated interferon, and therefore we propose using pegylated interferon plus ribavirin to treat the dually infected patients. Accordingly, a multicenter clinical trial is being undertaken at present in Taiwan, and we hope our results can culminate in a better treatment for hepatitis C patients coinfected with HBV. HCV Carriers With Persistently Normal Aminotransferase LevelsTo the Editor:We read with great interest the AASLD Practice Guideline 1 on the diagnosis, management and treatment of hepatitis C (HCV). However, we have some concerns about the definition of HCV carriers with normal alanine aminotransferase (ALT) given by Strader et al. 1 In this paper, a person is considered to have normal ALT levels when "there have been two ...

We read with interest a paper by Kudo et al. published in a recent issue of HEPATOLOGY that compared the predictive power between Japan Integrated Staging (JIS) system and Cancer of the Liver Italian Program (CLIP) system in a large patient cohort with hepatocellular carcinoma (HCC). 1 The authors concluded that the JIS system is better and may be a preferred staging model. Because the CLIP system has been prospectively validated and proposed as the primary staging system, it would be interesting to examine how these commonly used staging systems were derived and to explore the potential limitations of their conclusion.The vast majority (96%) of patients in the Kudo et al. study had undergone radical treatment (resection or loco-regional therapy), suggesting that most of them belonged to an early or intermediate stage. This distinct feature made the JIS system, which is intrinsically similar to the Barcelona-ClÌnic Liver Cancer (BCLC) system proposed by the Barcelona group, 2 more favorable. A recent study showed that the BCLC system was the best one compared with the CLIP, Okuda, and other systems in a surgically oriented referral center. 3 It should be noted that the CLIP and Okuda systems were originally derived from a large, unselected population, and the majority of patients were treated conservatively. Therefore, although the selected prognostic predictors are not mutually exclusive, certain risk factors (tumor size Ͻ 3 or 2 cm in the BCLC or tumor-node-metastasis [TNM]/JIS system) may only be meaningful in the population that is predominantly treated with radical therapy. This may explain why the JIS system is better, because the outcome is intimately associated with baseline demographics and subsequent treatment strategy. In keeping with these findings, another study in which more than half (52%) of patients were treated conservatively because of advanced stage demonstrated that CLIP was a good predictive model. 4 Moreover, in a multicenter survey we have recently shown that the CLIP system was not superior to the JIS system in patients undergoing resection. 5 Therefore, it is not surprising that the JIS system can beat others in an appropriate study environment.Another important factor that may alter the predictive ability of a staging system is the distribution of patients. The proportion in each category was considered fairly balanced for JIS scores 0 (12%), 1 (31%), 2 (33%), 3 (17%), and 4 or 5 (7%), whereas the distribution in the CLIP model was rather skewed. 1 There will be a substantial degree of swing in the survival curves if the denominator is too small or the predictors are analyzed in an otherwise unbalanced population.Collectively, the JIS system contains treatment-derived parameters and is similar to the BCLC system that may work well in areas where HCC is diagnosed at a relatively early stage, whereas the CLIP system would only prevail when patients predominantly belonged to an intermediate or late stage, a condition in which aggressive therapy is less likely. It is necessary to consid...