ascites resolved and disappeared nearly completely without further paracenteses. The dose of diuretic therapy could be reduced (100 mg of spironolactone alone) and the patient was discharged in a good condition. TIPS implantation was no longer necessary. Therefore, we cannot exclude, that some patients in the TIPS group of Gine `s et al. 1 would not have needed shunt therapy, if adequate albumin therapy reestablishing physiological conditions had been performed. To our view, the term “refractory ascites” should be revised and applied only, if ascites is refractory to diuretic plus albumin therapy. Furthermore, this could be the most cost-effective and life saving 5 procedure. WILHELM NOLTE GIULIANO RAMADORI Gastroenterology and Endocrinology Medizinische Klinik Go ¨ttingen, Germany 1. Gines P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath PS, Del Arbol LR, Planas R, Bosch J, Arroyo V, Rodes J. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for re- fractory ascites in cirrhosis. Gastroenterology 2002;123:1839 – 1847. 2. Arroyo V, Gines P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, Reynolds TB, Ring-Larsen H, Scholmerich J. Definition and diag- nostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club Hepatology 1996;23:164 – 176. 3. Schindler C, Ramadori G. Albumin substitution improves urinary sodium excretion and diuresis in patients with liver cirrhosis and refractory ascites. J Hepatol 1999;31:1132. 4. Gentilini P, Casini-Raggi V, Di Fiore G, Romanelli RG, Buzzelli G, Pinzani M, La Villa G, Laffi G. Albumin improves the response to diuretics in patients with cirrhosis and ascites: results of a ran- domized, controlled trial. J Hepatol 1999;30:639 – 645. 5. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Gine `s P, Rode ´s J. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403– 409. doi:10.1053/S0016-5085(03)01307-6 Reply. We appreciate the comments of Nolte et al. about our randomized study comparing TIPS and repeated paracentesis plus intravenous albumin in the management of patients with cirrhosis and refractory ascites. 1 These comments deserve consideration and discussion due to the growing information on the possible beneficial effects of albumin in patients with cirrhosis. 2 Nolte et al. suggest that in our study albumin in addition of preventing the circulatory dysfunction associated with large-volume paracentesis could have had other beneficial effects, including an increased renal response to diuretics and decreased ascites formation rate. These effects, although possible, are unlikely with the dose of albumin used in our study (8 g per liter of ascites removed). 1 In fact, in previous randomized trials we found that repeated paracentesis associated with intravenous al- bumin, at doses similar to those used in the current study, did not improve renal function, decreased the activity of sodium-retaining systems, or reduced the ascites recurrence rate compared with values in a control group of patients treated only with diuretics without albumin. 3 It is possible, however, that larger amounts of albumin given for prolonged periods of time may have these beneficial effects, as suggested by a recent study. 4 However, these data would require confirmation in further trials, which should also evaluate the cost/ efficacy of this approach PERE GINE ` S, M.D. BLAS CALAHORRA, M.D. VICENTE ARROYO, M.D. Liver Unit Hospital Clı´nic Barcelona, Spain 1. Gine ` s P, Uriz J, Calahorra B, Garcı ´a-Tsao G, Kammath PS, Del Arbol LR, Planas R, Bosch J, Arroyo V, Rode ´ s J. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for re- fractory ascites in cirrhosis. Gastroenterology 2002;123:1839 – 1847. 2. Gine `s P, Guevara M, De las Heras D, Arroyo V. Review article: albumin for circulatory support in patients with cirrhosis. Aliment Pharmacol Ther 2002;16(Suppl 5):24 –31. 3. Gine `s P, Arroyo V, Quintero E, Planas R, Bory F, Cabrera J, Rimola A, Viver J, Camps J, Jime ´nez W, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234 – 241. 4. Gentilini P, Casini-Raggi V, Di Fiore G, Romanelli RG, Buzzelli G, Pinzani M, La Villa G, Laffi G. Albumin improves the response to diuretics in patients with cirrhosis and ascites: results of a ran- domized, controlled trial. J Hepatol 1999;30:639 – 645. doi:10.1053/S0016-5085(03)01308-8 The Interferon Sensitivity Determining Region in the Era of Combination Therapies and the Rational Use of Such Therapies for Patients With HCV Genotype 1b Infection Dear Sir: We read with an interest the recent article by McHutchison et al. 1 They suggested that HCV genotype 1 (HCV-1a and HCV- 1b)-infected patients who could be maintained on 80% of interferon (IFN) or pegylated IFN-2b and ribavirin (RBV) dos- age for the duration of treatment exhibited enhanced sustained virologic response (SVR) rates. 1 They also suggested, however, that adherence to the combination therapies beyond 12-24 weeks would be advantageous only for those who had achieved early virologic response. 1 Although they suggested the importance of early virologic response as a predictive factor for SVR in the postcombination therapies, we would like to show an important role of the IFN sensitivity determining region (ISDR; NS5A 2209 –2248) 2 as a predictive factor for SVR in the precombination therapies in patients with HCV-1b infection. We investigated the role of ISDR in patients with HCV-1b infection and high viral loads exceeding 1 Meq/mL in published data (group A; 6 –10 MU of IFN  or IFN  3 times a week for 6 months with initial daily administration for 2– 8 weeks) 3 and in clinical data in the U.S. and Japan (group B; 6 MU of IFN-2b daily for the initial 2 weeks and 3– 6 MU/week for 22 weeks plus RBV [800 –1200 mg/day] therapy). Patients enrolled in group B were monitored for serum alanine aminotransferase (ALT) and HCV RNA (Roche Am- plicor version 2.0) during treatments and for 6 months following the completion of therapies. The amino acid sequence of ISDR was determined as reported previously; the mutant type had more than 4 amino acid substitutions, the intermediate type had 1 to 3 substitu- 1284 CORRESPONDENCE GASTROENTEROLOGY Vol. 125, No. 4