We read with interest the paper by Foucher et al (Gut 2006;55: 403–8) where the authors assessed the accuracy of transient elastography for the detection of cirrhosis. Its use in assessing the severity of chronic liver disease in other clinical scenarios warrants further evaluation. According to large population studies, the prevalence of chronic hepatitis C virus (HCV) infected patients who have persistently normal serum alanine aminotransferase (PN-ALT) levels is most likely 30–50%.¹ A major problem is defining whether or not these patients will suffer a progressive disease; additionally, although no consensus exists regarding who must be treated and when antiviral therapy should be initiated, positive decisions have been reinforced by recent results of a large clinical trial indicating that pegylated interferon plus ribavirin combination therapy is effective and safe in these patients with PN-ALT.²

In a recent review, the schedule of antiviral combination treatment of patients with chronic hepatitis C and normal aminotransferases was described, and indications for antiviral therapy in some cases was decided on the basis of …