What is the management plan for a 70-year-old patient with a positive anti-HCV (Hepatitis C Virus) test, undetectable HCV RNA, and elevated Serum Glutamic-Pyruvic Transaminase (SGPT) indicating liver injury?

Management of Anti-HCV Positive with Undetectable HCV RNA and Elevated ALT

This patient has cleared HCV infection (either spontaneously or from prior treatment) and does not require antiviral therapy; the elevated ALT demands investigation for alternative causes of liver injury. 1

Confirming HCV Status

• Repeat HCV RNA testing with a sensitive assay (<15 IU/ml detection limit) to definitively confirm viral clearance, as anti-HCV positive with negative HCV RNA indicates past resolved infection rather than active disease requiring treatment. 2, 1

• The positive anti-HCV antibody will remain detectable for life even after viral clearance, so this does not indicate active infection. 1

• Anti-HCV positive individuals who are HCV RNA negative should be retested for HCV RNA 3 months later to confirm true convalescence and rule out intermittent viremia, though this is uncommon in chronic infection. 2

Investigating the Elevated Transaminase

The ALT elevation (70 U/L, approximately 1.5-2x upper limit of normal) requires systematic evaluation for non-HCV causes of liver injury. 1

Essential Initial Workup

• Complete metabolic panel including repeat ALT/AST, bilirubin, albumin, alkaline phosphatase, and INR to characterize the pattern and severity of liver injury. 1, 3

• Hepatitis B testing (HBsAg and anti-HBc) to exclude concurrent viral hepatitis. 2, 1

• Fasting glucose, lipid panel, and assessment for metabolic syndrome as non-alcoholic fatty liver disease (NAFLD) is a leading cause of elevated transaminases in this age group. 1

• Detailed alcohol consumption history with specific quantification, as even moderate intake (>10 g/day) can cause liver injury and dramatically increases mortality risk when combined with prior HCV-related damage. 2, 1

• Complete medication review to identify potential hepatotoxic drugs. 2, 1

• Ferritin and iron studies to screen for hemochromatosis. 1

• Autoimmune markers (ANA, anti-smooth muscle antibody) to exclude autoimmune hepatitis. 1

Assessing for Residual Liver Damage

Even with cleared HCV, this patient may have residual fibrosis or cirrhosis that requires ongoing surveillance. 1

Fibrosis Assessment

• Calculate FIB-4 score using: age (years) × AST (IU/L) / [platelet count (10⁹/L) × √ALT (IU/L)]. 3

• A FIB-4 <1.45 has 90% negative predictive value for advanced fibrosis, while >3.25 suggests cirrhosis with 65% positive predictive value. 3

• Consider transient elastography (FibroScan) or APRI score as additional non-invasive fibrosis markers if FIB-4 is indeterminate or suggests advanced disease. 1

• Complete blood count with platelet count to assess for thrombocytopenia suggestive of portal hypertension. 3

Long-Term Management Strategy

If Advanced Fibrosis or Cirrhosis is Present

• Initiate hepatocellular carcinoma (HCC) surveillance with ultrasound ± AFP every 6 months, as patients with advanced fibrosis from prior HCV remain at risk for HCC even after viral clearance. 1

• Monitor for cirrhosis complications including portal hypertension, varices, ascites, and hepatic encephalopathy. 1

• Counsel on strict alcohol avoidance, as combined factors (prior HCV damage + alcohol) dramatically increase liver-related mortality. 2, 1

If No Advanced Fibrosis

• Address modifiable risk factors including weight loss if obese, diabetes control, and elimination of hepatotoxic medications. 1

• Repeat liver function tests in 3-6 months to determine if ALT elevation persists or resolves with treatment of underlying cause. 2

Critical Pitfalls to Avoid

• Do not assume the elevated ALT is residual HCV-related damage without excluding other treatable causes, particularly NAFLD and alcohol use in this age group. 1

• Do not order HCV genotyping or quantitative viral load testing, as these are irrelevant when HCV RNA is undetectable. 2

• Do not initiate antiviral therapy, as there is no active HCV infection to treat. 1

• Be aware that rare "occult HCV infection" (HCV RNA in liver tissue despite negative serum RNA) has been reported but is controversial and should not alter initial management. 4, 5

• Ensure the HCV RNA assay used has adequate sensitivity (<15 IU/ml), as older or less sensitive assays may miss low-level viremia. 2, 6