June 26, 2011

Gastroenterology

Article in Press
 
Graham R. Foster, Christophe Hézode, Jean-Pierre Bronowicki, Giampiero Carosi, Ola Weiland, Lieselotte Verlinden, Rolf van Heeswijk, Ben van Baelen, Gaston Picchio, Maria Beumont

Received 8 December 2010; received in revised form 12 April 2011; accepted 16 May 2011. published online 01 June 2011.
Accepted Manuscript

Abstract

Background & Aims
We evaluated antiviral activity of 2 weeks therapy with telaprevir alone (T), peginterferon alfa-2a and ribavirin (PR), or all 3 drugs (TPR) in treatment-naïve patients with chronic hepatitis C virus (HCV) genotype (G) 2 or 3 infections.

Methods
We performed a randomized, multicenter, partially-blinded study of patients (23 with HCV G2, 26 with G3) who received telaprevir (750 mg every 8 hours) , placebo plus PR (Peg-IFN, 180 μg, once weekly and RBV, 400 mg, twice daily), or TPR for 15 days, followed by PR for 22 or 24 weeks. We quantified levels of HCV RNA in plasma.

Results
Levels of HCV RNA decreased in all patients with HCV G2, including those that received telaprevir monotherapy. The decrease was faster among patients that received telaprevir. By Day 15, 0 (telaprevir), 40% (TPR), and 22% (PR) of patients with HCV G2 had undetectable levels of HCV RNA; rates of sustained virologic response (SVR) were 56%, 100%, and 89%, respectively. Overall, 6/9 HCV G2 patients that received only telaprevir had viral breakthrough within 15 days. HCV RNA levels decreased slightly among patients with HCV G3 who received telaprevir, and decreased rapidly among patients given PR or TPR (telaprevir had no synergistic effects). SVR rates were 50%, 67%, and 44% among patients given telaprevir, TPR, or PR respectively; 7 patients with HCV G3 relapsed after therapy (2 given telaprevir, 3 given TPR, and 2 given PR) and 3 patients with HCV G3 had viral breakthrough during telaprevir monotherapy. The incidence of adverse events was similar among groups.

Conclusions
Telaprevir monotherapy reduces levels of HCV RNA in patients with chronic HCV G2 infections, but has limited activity in patients with HCV G3.

Keywords: C209, VX-950, liver disease, clinical trial

Source

Telaprevir Isn't Useful for All HCV Genotypes

Telaprevir-based triple therapy showed some promise against hepatitis C virus genotype 2 infection but had limited activity against genotype 3 infection.

Recently, telaprevir received FDA approval for use in triple therapy to treat hepatitis C virus (HCV) genotype 1 infection. The new triple regimens — peginterferon, ribavirin, and a protease inhibitor — are more efficacious than combination therapy (peginterferon and ribavirin) in patients with such infection. Although patients with HCV genotype 2 (G2) or genotype 3 (G3) infection generally respond well to combination therapy, 20% to 30% do not attain a sustained virologic response (SVR).

To evaluate the antiviral activity of telaprevir in treatment-naive adults with chronic HCV G2 or G3 infection, researchers conducted a phase IIa, manufacturer-sponsored, randomized, partially blinded study involving 23 G2-infected patients and 26 G3-infected patients.

Participants received one of three regimens for 2 weeks:

• Telaprevir 750 mg orally every 8 hours (monotherapy)
• Telaprevir plus peginterferon alfa-2a 180 µg once weekly plus ribavirin 400 mg twice daily (triple therapy)
• Placebo (every 8 hours) plus peginterferon and ribavirin

Thereafter, all participants received peginterferon and ribavirin for 22 or 24 weeks.

Among HCV G2-infected patients, SVR rates were 56% (5 of 9) with telaprevir monotherapy, 100% (5 of 5) with triple therapy, and 89% (8 of 9) with peginterferon plus ribavirin. However, among the HCV G3-infected patients, SVR rates were 50% (4 of 8), 67% (6 of 9), and 44% (4 of 9), respectively.

Comment: In this small exploratory study, telaprevir-based triple therapy showed some promise against HCV G2 but had limited activity against HCV G3. These findings highlight the fact that although protease inhibitor–based HCV treatment regimens are superior to peginterferon plus ribavirin for treating genotype 1 infection, the same might not be true for treating infections caused by other genotypes.

— Atif Zaman, MD, MPH

Published in Journal Watch Gastroenterology June 10, 2011

Citation(s):
Foster GR et al. Telaprevir alone or with peginterferon and ribavirin reduces HCV RNA in patients with chronic genotype 2 but not 3 infections. Gastroenterology 2011 Jun 1; [e-pub ahead of print]. (http://dx.doi.org/10.1053/j.gastro.2011.05.046)

Source
Gastroenterology
Volume 140, Issue 7 , Pages 1990-1999, June 2011.

Jordi Bruix, Thierry Poynard, Massimo Colombo, Eugene Schiff, Kelly Burak, Elizabeth J.L. Heathcote, Thomas Berg, Jorge–Luis Poo, Carlos Brandao Mello, Rainer Guenther, Claus Niederau, Ruben Terg, Pierre Bedossa, Navdeep Boparai, Louis H. Griffel, Margaret Burroughs, Clifford A. Brass, Janice K. Albrecht, EPIC3 Study Group

Received 1 October 2010; accepted 4 March 2011. published online 18 March 2011.

Abstract

Background & Aims

Several studies have reported that low doses of interferon can delay the development of hepatocellular carcinoma (HCC) and progression of chronic hepatitis C. We investigated the incidence of clinical events among participants of the Evaluation of PegIntron in Control of Hepatitis C Cirrhosis (EPIC)3 program.

Methods
Data were analyzed from an open-label randomized study of patients with chronic hepatitis C who had failed to respond to interferon alfa plus ribavirin. All patients had compensated cirrhosis with no evidence of HCC. Patients received peginterferon alfa-2b (0.5 μg/kg/week; n = 311) or no treatment (controls, n = 315) for a maximum period of 5 years or until 98 patients had a clinical event (hepatic decompensation, HCC, death, or liver transplantation). The primary measure of efficacy was time until the first clinical event.

Results
There was no significant difference in time to first clinical event among patients who received peginterferon alfa-2b compared with controls (hazard ratio [HR], 1.452; 95% confidence interval [CI]: 0.880–2.396). There was no decrease in the development of HCC with therapy. The time to disease progression (clinical events or new or enlarged varices) was significantly longer for patients who received peginterferon alfa-2b compared with controls (HR, 1.564; 95% CI: 1.130–2.166). In a prospectively defined subanalysis of patients with baseline portal hypertension, peginterferon alfa-2b significantly increased the time to first clinical event compared with controls (P = .016). There were no new safety observations.

Conclusions
Maintenance therapy with peginterferon alfa-2b is not warranted in all patients and does not prevent HCC. However, there is a potential clinical benefit of long-term suppressive therapy in patients with preexisting portal hypertension.

Keywords: Liver Cancer, Evaluation of PegIntron in Control of Hepatitis C Cirrhosis Program, EPIC3 Program, Clinical Trial

Source
Gastroenterology
Volume 140, Issue 7 , Pages 1970-1979.e3, June 2011.

Julien Vergniol, Juliette Foucher, Eric Terrebonne, Pierre–Henri Bernard, Brigitte le Bail, Wassil Merrouche, Patrice Couzigou, Victor de Ledinghen

Received 28 November 2010; accepted 18 February 2011. published online 03 March

Abstract

Background & Aims

Liver stiffness can be measured noninvasively to assess liver fibrosis in patients with chronic hepatitis C. In patients with chronic liver diseases, level of fibrosis predicts liver-related complications and survival. We evaluated the abilities of liver stiffness, results from noninvasive tests for fibrosis, and liver biopsy analyses to predict overall survival or survival without liver-related death with a 5-year period.

Methods
In a consecutive cohort of 1457 patients with chronic hepatitis C, we assessed fibrosis and, on the same day, liver stiffness, performed noninvasive tests of fibrosis (FibroTest, the aspartate aminotransferase to platelet ratio index, FIB-4), and analyzed liver biopsy samples. We analyzed data on death, liver-related death, and liver transplantation collected during a 5-year follow-up period.

Results
At 5 years, 77 patients had died (39 liver-related deaths) and 16 patients had undergone liver transplantation. Overall survival was 91.7% and survival without liver-related death was 94.4%. Survival was significantly decreased among patients diagnosed with severe fibrosis, regardless of the noninvasive method of analysis. All methods were able to predict shorter survival times in this large population; liver stiffness and results of FibroTest had higher predictive values. Patient outcomes worsened as liver stiffness and FibroTest values increased. Prognostic values of stiffness (P < .0001) and FibroTest results (P < .0001) remained after they were adjusted for treatment response, patient age, and estimates of necroinflammatory grade.

Conclusions
Noninvasive tests for liver fibrosis (measurement of liver stiffness or FibroTest) can predict 5-year survival of patients with chronic hepatitis C. These tools might help physicians determine prognosis at earlier stages and discuss specific treatments, such as liver transplantation.

Keywords: Survival, Cirrhosis, FibroTest, FibroScan, Hepatitis C

Source
Gastroenterology
Volume 140, Issue 7 , Pages 1952-1960, June 2011.

D. Leise, W. Ray Kim, Walter K. Kremers, Joseph J. Larson, Joanne T. Benson, Terry M. Therneau

Received 30 June 2010; accepted 14 February 2011. published online 21 February 2011.

Abstract

Background & Aims
The Model for End Stage Liver Disease (MELD) was originally developed based on data from patients who underwent the transjugular intrahepatic portosystemic shunt procedure. An updated MELD based on data from patients awaiting liver transplantation should improve mortality prediction and allocation efficiency.

Methods
Wait-list data from adult primary liver transplantation candidates from the Organ Procurement and Transplantation Network were divided into a model derivation set (2005–2006; n = 14,214) and validation set (2007–2008; n = 13,945). Cox regression analysis was used to derive and validate an optimized model that updated coefficients and upper and lower bounds for MELD components and included serum levels of sodium. Main outcomes measure was ability to predict 90-day mortality of patients on the liver transplantation wait list.

Results
Optimized MELD score updated coefficients and implemented new upper and lower bounds for creatinine (0.8 and 3.0 mg/dL, respectively) and international normalized ratio (1 and 3, respectively). Serum sodium concentrations significantly predicted mortality, even after adjusting for the updated MELD model. The final model, based on updated fit of the 4 variables (ie, bilirubin, creatinine, international normalized ratio, and sodium) had a modest yet statistically significant gain in discrimination (concordance: 0.878 vs 0.865; P < .01) in the validation dataset. Utilization of the new score could affect up to 12% of patients (based on changed score for 459 of 3981 transplants in the validation set).

Conclusions
Modification of MELD score to update coefficients, change upper and lower bounds, and incorporate serum sodium levels improved wait-list mortality prediction and should increase efficiency of allocation of donated livers.

Keywords: Liver Disease, Surgery, Prognosis, Survival

Source
Journal of Hepatology
Volume 55, Issue 1, Pages 69-75 (July 2011)

Michael W. Fried 1, Stephanos J. Hadziyannis 2, Mitchell L. Shiffman 3, Diethelm Messinger 4, Stefan Zeuzem 5

Received 21 June 2010; received in revised form 12 October 2010; accepted 18 October 2010. published online 09 December 2010.

Background & Aims
The probability of response to peginterferon and ribavirin is associated with numerous host and virological factors. Attainment of a rapid virological response (RVR), defined as undetectable HCV RNA at week 4 during treatment with peginterferon and ribavirin, is highly predictive of sustained virological response (SVR). The aim of the present study was to determine the relative importance of the kinetics of antiviral response compared to baseline host and virological factors for predicting SVR.

Methods
A retrospective analysis of 1383 patients, encompassing genotypes 1–4, treated with peginterferon alfa-2a and ribavirin, was performed. Baseline characteristics were compared across HCV genotypes and pretreatment factors associated with RVR were identified. The relative significance of RVR compared to other baseline factors for predicting SVR was analyzed by multiple logistic regression analysis.

Results
RVR was achieved by 16% of patients with genotype 1 and 71% and 60% of those with genotype 2 and 3, respectively. Among patients who achieved RVR, the rate of SVR was high across all genotypes and ranged from 88% to 100% (genotypes 1–4). Baseline factors predictive of RVR included genotype, younger age, lower initial viral load, higher ALT ratio, absence of advanced fibrosis, and younger age. Notably, the presence of RVR generated the highest odds ratio (5.47, 95% confidence interval 3.97–7.52) for predicting SVR in multiple logistic regression analysis of these factors.

Conclusions
Attainment of RVR varies by genotype and is associated with several baseline factors. Patients who achieve RVR have the highest rates of SVR, regardless of genotype. These findings have important implications for predicting and managing response-guided combination antiviral therapies.

1 University of North Carolina, Chapel Hill, NC 27599, USA
2 Henry Dunant Hospital, Athens, Greece
3 Bon Secours Health System, Liver Institute of Virginia, Newport News, VA, USA
4 IST, Mannheim, Germany
5 J.W. Goethe University Hospital, Frankfurt, Germany

Corresponding author. Address: University of North Carolina at Chapel Hill, CB# 7584, Room 8015 Burnett-Womack Building, Chapel Hill, NC 27599, USA. Tel.: +1 919 966 2516 fax: +1 919 966 1700.

PII: S0168-8278(10)01093-7
doi:10.1016/j.jhep.2010.10.032
© 2011 Published by Elsevier Inc.

Source
Journal of Hepatology
Volume 55, Issue 1, Pages 38-44 (July 2011)

Eric Trépo 12†, Andrej Potthoff 6† , Pierre Pradat 345, Rakesh Bakshi 6, Bradford Young 7, Robert Lagier8, Christophe Moreno 12, Laurine Verset8, Richard Cross 9, Delphine Degré 12, Arnaud Lemmers 12, Thierry Gustot 12, Pascale Berthillon 45, William Rosenberg 10, Christian Trépo 345, John Sninsky7, Michael Adler 2, Heiner Wedemeyer 6

Received 20 April 2010; received in revised form 22 September 2010; accepted 1 October 2010. published online 09 December 2010.

Background & Aims
Fibrosis progression in patients with chronic hepatitis C (CHC) is highly variable. A Cirrhosis Risk Score (CRS) based on seven genetic variants has been recently developed for identifying patients at risk for cirrhosis. The objective of this study was to assess the role of the CRS for the early prediction of fibrosis progression in CHC patients with mild liver fibrosis. In addition, we evaluated the potential benefit, for prediction accuracy, of a recently described non-invasive fibrosis staging assay, the Enhanced Liver Fibrosis (ELF) test.

Methods
Two separate cohorts of HCV patients (Brussels, Belgium/Hannover, Germany) were retrospectively analyzed. Only patients with a fibrosis Ishak or METAVIR score of F0–F1 at baseline were included. Patients were classified as progressors if they showed an increase 2 fibrosis stages at the second histological evaluation after a follow-up 5years. The CRS was calculated locally. Genotyping was performed by PCR and oligonucleotide ligation with the resulting signal detected with a Luminex® 200TM and computer analysis.

Results
In Brussels, 12/25 patients progressed (48%); similarly in Hannover, 16/31 (52%) patients progressed. In both sample sets, the CRS was significantly associated with fibrosis progression (p=0.050 in Brussels; p=0.018 in Hannover). The ELF test was only a significant predictor in Hannover (p=0.015). In multivariate analysis the CRS remained the only variable associated with fibrosis progression (odds-ratio=2.23, 95%CI 1.21–4.11 p=0.01).

Conclusions
Although conducted on a limited number of patients, this study in two independent centres confirms that the CRS predicts fibrosis progression in initially mild CHC.

See Editorial, pages 3–4

Abbreviations: HCV, hepatitis C virus, CHC, chronic hepatitis C, CRS, cirrhosis risk score, ELF, enhanced liver fibrosis, BMI, body mass index, OR, odds ratio, CI, confidence interval

Keywords: Hepatitis C, Cirrhosis risk score (CRS), Fibrosis progression, Minimal liver disease

1 Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
2 Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
3 Hospices Civils de Lyon, Hôtel Dieu, Service d’hépatogastroentérologie, Lyon, France
4 INSERM, U871, Lyon, France
5 Université Lyon 1, IFR62 Lyon-Est, Lyon, France
6 Department of Gastroenterology and Hepatology, Medizinische Hochschule, Hannover, Germany
7 Celera, Alameda, CA, USA
8 Department of Pathology, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
9 iQur Ltd., Southampton General Hospital, Southampton, UK
10 Centre for Hepatology, University College London, London, UK

Corresponding author. Address: Department of Hepatogastroenterology, Hôpital de la Croix-Rousse, 103 grande rue de la Croix-Rousse, 69317 Lyon Cedex 4, France. Tel: +33 4 26 73 27 15

☆ Orally presented in part at the Digestive Disease Week May 30–June 4 2009 in Chicago – USA.

† These authors contributed equally to this work.
PII: S0168-8278(10)01078-0
doi:10.1016/j.jhep.2010.10.018
© 2010 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.

Source
Journal of Hepatology  Volume 55  Issue 1 Pages 3-4 July 2011

Hermann E. Wasmuth, Christian Trautwein

Received 10 December 2010; received in revised form 9 February 2011; accepted 9 February 2011. published online 21 February 2011.

Refers to article:

Role of a cirrhosis risk score for the early prediction of fibrosis progression in hepatitis C patients with minimal liver disease , 09 December 2010
Eric Trépo, Andrej Potthoff, Pierre Pradat, Rakesh Bakshi, Bradford Young, Robert Lagier, Christophe Moreno, Laurine Verset, Richard Cross, Delphine Degré, Arnaud Lemmers, Thierry Gustot, Pascale Berthillon, William Rosenberg, Christian Trépo, John Sninsky, Michael Adler, Heiner Wedemeyer
Journal of Hepatology
July 2011 (Vol. 55, Issue 1, Pages 38-44)
Abstract Full Text Full-Text PDF (702 KB)

See Article, pages 38–44

Article Outline

Conflict of interest
Financial support
References
Copyright

Chronic hepatitis C virus (HCV) infection is a leading cause of end-stage liver disease worldwide and results in complications, such as decompensated cirrhosis and hepatocellular carcinoma. However, large epidemiological studies have suggested that only about half of all HCV infected patients show significant fibrosis and only a fraction of these are at risk of developing end-stage liver disease [1]. These large inter-individual differences in the progression of HCV infection are partly due to exogenous factors (e.g. alcohol intake, co-infections, diabetes) [2]. Nevertheless, recent studies have demonstrated that fibrosis development significantly depends on host genetic factors. In this respect, liver fibrosis is considered to be a complex genetic trait, in which multiple genes and their interactions contribute to the severity of liver fibrosis.

This hypothesis has been supported by multiple cross-sectional case-control studies which were based on the a priori hypothesis that the distribution of polymorphic alleles is different between subjects with mild versus patients with severe fibrosis. A major limitation of these studies was their lack of reproducibility and the limited number of polymorphisms investigated within the respective cohorts [3]. The elucidation of the genetic basis for liver fibrosis was taken a step further by the first large-scale genetic screen in patients with HCV induced liver fibrosis in 2007 [4]. In this analysis more than 20,000 single polymorphisms were analyzed in two independent cohorts of patients of Caucasian ethnicity in a genome-wide scan. The genetic data were subsequently analyzed in depth and a genetic score was calculated which predicted the presence of severe fibrosis in the investigated patients [4]. This gene signature was termed the “cirrhosis risk score” (CRS) and consisted of single nucleotide polymorphisms in seven different genes (AP3S2, AQP2, AZIN1, DEGS1, STXBP5L, TLR4, and TRPM5). Such a combination of SNPs into a score has also been applied in studies on the genetic basis of cholesterol levels and prostate cancer [5].

The validity and potential clinical applicability of the CRS was subsequently validated in a cohort from Italy [6]. All of the patients in this study had mild fibrosis at initial biopsy but did not undergo antiviral therapy due to various clinical reasons. After a median follow-up of 60months the subjects underwent a second liver biopsy. Overall, 24.4% showed no histologic progression, while 75.6% progressed by at least one stage. In this group 45.0% progressed by at least two stages, and 10.3% by more than two stages. When the CRS was applied to this cohort, the mean CRS values were significantly higher in patients with fibrosis progression compared with those without progression [6].

In the current issue of the Journal of Hepatology, the clinical value of the CRS in predicting fibrosis progression has now been prospectively validated in two further cohorts of HCV infected patients with minimal liver fibrosis at baseline [7]. Although both cohorts were significantly smaller than the number of patients investigated by Marcolongo et al. [6], the CRS was again significantly associated with fibrosis progression in untreated patients for a follow-up period of at least five years. These results suggest that the CRS remains a prognostic marker even in relatively low powered studies. An additional strength of the study by Trepo et al. is that the CRS was also analyzed together with a recent non-invasive fibrosis staging score, the enhanced liver fibrosis (ELF) test [8]. This biomarker based score includes the serum levels of hyaluronic acid, amino-terminal propeptide of type III collagen (PNIIIP), and tissue inhibitor of matrix metalloproteinase 1 (TIMP1) and has been validated as a non-invasive marker of liver fibrosis in cross-sectional studies of different liver disease etiologies. Notably, this score has now been identified to predict histologic fibrosis progression in the study by Trepo et al. [7]. Since the ELF score is a combination of matrix components and functional inhibitors of their degradation, this new and interesting observation again underscores that fibrosis is a dynamic process involving different aspects of matrix biology. Clinically, the association of the ELF score with fibrosis progression in HCV infection needs confirmation in larger cohorts, but might lead to new predictive parameters in the future.

In a regression model, the CRS was associated with an OR of 2.23 for fibrosis progression, an effect size which is low for combined SNP scores but in the range of large-scale SNP analysis in complex diseases [9]. In ROC analysis the combination of the CRS with the ELF test together with readily available clinical parameters (gender, alcohol consumption and presence of diabetes) yielded an area under the curve of 0.87, which is better than the predictive value of clinical parameters (AUC 0.74) or the CRS (AUC 0.85) score alone [7]. These analyses indeed suggest that the specificity and sensitivity of the combined markers are sufficient for predicting fibrosis progression in clinical practice.

The findings by Trepo et al. stress the question whether there is a clinical need for predicting fibrosis progression in patients with chronic HCV infection since some current guidelines [10] recommend the treatment of almost all HCV-RNA positive patients. Indeed, prediction of fibrosis progression might be reserved for subjects with relative contraindications to interferon and ribavirin treatment (e.g. psychiatric disorders, hemoglobin abnormalities, concurrent autoimmune diseases), patients who failed to achieve a sustained virological response to current regimens or who are candidates for clinical studies which assess the utility of anti-fibrotic treatments. However, these populations represent a significant number of individuals seen at specialised centers and the CRS might help to personalise clinical care of these individuals. Personalised decision making might even be supplemented by genetic determination of the likelihood of treatment response by genotyping the IL28B locus [11] and by estimation of the risk for ribavirin induced anemia by ITPA variants [12]. However, with such genetic parameters on the horizon, the question arises about how to deal with persons who carry the at-risk alleles for fibrosis progression, treatment failure, or anemia. These aspects need to be thoroughly discussed with the affected patients prior to starting antiviral therapy and a clinical consensus needs to be established in the hepatologists community.

What other lessons can be drawn from the validated association of the CRS with fibrosis progression in HCV infection? Despite the fact that all genes included into the score have now been identified, only one (TLR4) has yet been functionally associated with liver fibrosis in vitro and in vivo [13]. However, the other genes of the CRS might also point to interesting molecular pathways of fibrogenesis, such as aquaporins which seem to be implicated in chronic kidney injury [14]. According to this hypothesis, we have learned from large-scale genetic association studies in age-related macular degeneration and Crohn’s disease that strong and reliable associations might lead to new molecular driven concepts for these diseases. This has already led to the first clinical trials in age-related macular degeneration by blocking the complement pathway [15], although a few years ago the involvement of this inflammatory pathway in the disease had not even been suspected. Thus, it remains a great scientific challenge to further elucidate the functional importance of the genes involved in the CRS with regards to fibrogenesis in HCV infection. Based on this knowledge new interventional anti-fibrotic strategies for patients who fail to respond to current or future antiviral therapies might be developed. In such studies the CRS might guide the selection of patients who would most benefit from anti-fibrotic therapies. Furthermore, the CRS should be tested in other fibrotic liver diseases (including alcoholic, NASH, or biliary disease) in order to better understand the predictive and pathophysiological impact of this score and its genes across different etiologies.

Conflict of interest

The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

Financial support

Work in the lab of the authors is supported by the Deutsche Forschungsgemeinschaft (SFB-TRR57) and Aachen University (IZKF grants to HEW).

References

[1]Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet. 1997;349:825–832.

[2]Mallat A, Hezode C, Lotersztajn S. Environmental factors as disease accelerators during chronic hepatitis C. J Hepatol. 2008;48:657–665.

[3]Weber SN, Wasmuth HE. Liver fibrosis: from animal models to mapping of human risk variants. Best Pract Res Clin Gastroenterol. 2010;24:635–646.

[4]Huang H, Shiffman ML, Friedman S, Venkatesh R, Bzowej N, Abar OT, et al. A 7 gene signature identifies the risk of developing cirrhosis in patients with chronic hepatitis C. Hepatology. 2007;46:297–306.

[5]Manolio TA. Genomic association studies and assessment of the risk of disease. N Engl J Med. 2010;363:166–176.

[6]Marcolongo M, Young B, Dal Pero F, Fattovich G, Peraro L, Guido M, et al. A seven-gene signature (cirrhosis risk score) predicts liver fibrosis progression in patients with initially mild chronic hepatitis C. Hepatology. 2009;50:1038–1044.

[7]Trepo E, Potthoff A, Pradat P, Bakshi R, Young B, Lagier R, et al. Role of a cirrhosis risk score for the early prediction of the fibrosis progression in hepatitis C patients with minimal liver disease. J Hepatol. 2011;55:38–44.

[8]Rosenberg WM, Voelker M, Thiel R, Becka M, Burt A, Schuppan D, et al. Serum markers detect the presence of liver fibrosis: a cohort study. Gastroenterology. 2004;127:1704–1713.

[9]Hardy J, Singleton A. Genomewide association studies and human disease. N Engl J Med. 2009;360:1759–1768.

[10]Sarrazin C, Berg T, Ross RS, Schirmacher P, Wedemeyer H, Neumann U, et al. Prophylaxis, diagnosis and therapy of hepatitis C virus (HCV) infection: the German guidelines on the management of HCV infection. Z Gastroenterol. 2010;48:289–351.

[11]Suppiah V, Moldovan M, Ahlenstiel G, Berg T, Weltman M, Abate ML, et al. IL28B is associated with response to chronic hepatitis C interferon-alpha and ribavirin therapy. Nat Genet. 2009;41:1100–1104.

[12]Fellay J, Thompson AJ, Ge D, Gumbs CE, Urban TJ, Shianna KV, et al. ITPA gene variants protect against anaemia in patients treated for chronic hepatitis C. Nature. 2010;464:405–408.

[13]Seki E, De Minicis S, Osterreicher CH, Kluwe J, Osawa Y, Brenner DA, et al. TLR4 enhances TGF-beta signaling and hepatic fibrosis. Nat Med. 2007;13:1324–1332.

[14]Bedford JJ, Leader JP, Walker RJ. Aquaporin expression in normal human kidney and in renal disease. J Am Soc Nephrol. 2003;14:2581–2587.

[15]Wagner E, Frank MM. Therapeutic potential of complement modulation. Nat Rev Drug Discov. 2010;9:43–56.

Medical Department III, University Hospital Aachen, RWTH Aachen, Pauwelsstrasse 30, D-52057 Aachen, Germany

PII: S0168-8278(11)00157-7
doi:10.1016/j.jhep.2011.02.003
© 2011 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.

Source
Hepatology. 2011 Jun 14. doi: 10.1002/hep.24480. [Epub ahead of print]

Di Martino V, Richou C, Cervoni JP, Sanchez-Tapias JM, Jensen DM, Mangia A, Buti M, Sheppard F, Ferenci P, Thévenot T.

Service d'hépatologie, CHU Jean Minjoz, Besançon, France; EA API 4266, Université de Franche Comté. vdimartino@chu-besancon.fr.

Abstract

Response-guided peg-interferon plus ribavirin (P/R) therapy trials on genotype(G)1 and G2/G3 HCV-infected patients provide contradictory results. We conducted meta-analyses of randomized controlled trials to address 1) the benefit of a 72 week-extended duration therapy in G1-slow responders and 2) adequate shortened duration therapy in G1 and G2/G3-rapid responders. Seventeen trials were selected, including 624 G1-rapid responders, 570 G1-slow responders and 2062 G2/G3-rapid responders. Virologic outcomes and treatment discontinuation data were collected from published papers and by asking authors. Pooled estimates of sustained virologic response (SVR), relapse and dropouts were calculated using the random effects model, considering the variability of shortened duration, ribavirin dose, genotype and baseline viral load. In G1-slow responders, a 72 week-extended duration increased SVR (+10.7%, 95%CI:+4.4%-+17.1%), decreased relapse (-12.3%, 95%CI:-25.4%-0%), and did not significantly increase drop-out rates (+4.5%, 95%CI:-0.6%-+9.6%). The benefit of extended duration was lower when using weight-based ribavirin regimen (+8.7%, 95%CI:+1.7%-+15.8%). In G1-rapid responders, a 24 week-shortened duration decreased SVR (-12.5%, 95%CI:-19.2%--5.8%), and increased relapse rates (+8.8%, 95%CI:+2.9%- +14.8%). Such differences were not significant in patients with baseline viral load <400,000UI/mL (-4.4%, 95%CI:-9.8%-+1%). In G2/G3-rapid responders, SVR was more common for standard 24-week duration than for shortened durations (+4.1%, 95%CI:+0.1%-+8.5), but this benefit was not significant when the ribavirin was weight-adjusted and the short duration was 16 weeks (-1.7%, 95%CI:-6.1% -+2.7%), and for G2 patients (+1.6%, 95%CI: -0.2%-+5.5%). In Conclusion, long durations of P/R therapy improve SVR, regardless of genotype. This effect is nonetheless negligible in rapid responders with the most favourable conditions for SVR (G2, G1 with low viral load, and G3 with weight-adjusted ribavirin regimen). (HEPATOLOGY 2011.).

Copyright © 2011 American Association for the Study of Liver Diseases.

Source

A Comparison of Four Fibrosis Indexes in Chronic HCV

Development of New Fibrosis-cirrhosis Index (FCI)

Waqar Ahmad; Bushra Ijaz; Fouzia T Javed; Sana Gull; Humera Kausar; Muhammad T Sarwar; Sultan Asad; Imran Shahid; Aleena Sumrin; Saba Khaliq; Shah Jahan; Asim Pervaiz; Sajida Hassan
Posted: 06/24/2011; BMC Gastroenterology. 2011;11 © 2011 BioMed Central, Ltd.

Abstract and Introduction

Abstract

Background: Hepatitis C can lead to liver fibrosis and cirrhosis. We compared readily available non-invasive fibrosis indexes for the fibrosis progression discrimination to find a better combination of existing non-invasive markers.

Methods: We studied 157 HCV infected patients who underwent liver biopsy. In order to differentiate HCV fibrosis progression, readily available AAR, APRI, FI and FIB-4 serum indexes were tested in the patients. We derived a new fibrosis-cirrhosis index (FCI) comprised of ALP, bilirubin, serum albumin and platelet count. FCI = [(ALP × Bilirubin)/(Albumin × Platelet count)].

Results: Already established serum indexes AAR, APRI, FI and FIB-4 were able to stage liver fibrosis with correlation coefficient indexes 0.130, 0.444, 0.578 and 0.494, respectively. Our new fibrosis cirrhosis index FCI significantly correlated with the histological fibrosis stages F0-F1, F2-F3 and F4 (r = 0.818, p < 0.05) with AUROCs 0.932 and 0.996, respectively. The sensitivity and PPV of FCI at a cutoff value < 0.130 for predicting fibrosis stage F0-F1 was 81% and 82%, respectively with AUROC 0.932. Corresponding value of FCI at a cutoff value ≥1.25 for the prediction of cirrhosis was 86% and 100%.

Conclusions: The fibrosis-cirrhosis index (FCI) accurately predicted fibrosis stages in HCV infected patients and seems more efficient than frequently used serum indexes.

Background

Hepatitis C virus (HCV) is considered as a major basis of liver associated diseases throughout the world. More than 350 million people (3% of the world's populations)[1,2] and almost 10 million people in Pakistan are infected with HCV.[3] The genotypes 3a, 3b, 1a and 4a are most prevalent in Pakistan.[4] It is predicted that hepatocellular carcinoma (HCC) develops in 1–4% of HCV infected patients in the first five years following the onset of cirrhosis, but cirrhosis may occur with in the range of 10–50 years.[5] In HCV infected patients, liver biopsy is considered essential to stage liver fibrosis. Procedure of liver biopsy is invasive, expensive and not suitable for all patients. Patients can have severe side effects like pain andharsh complications also leading to death [[1,3] and.[5]] Many previous studies reported that host factors reflect fibrosis development leading to HCC,[6,7] so these can be used as non-invasive means to overcome the weaknesses arise from biopsy procedures. Chronic hepatitis C is known as hepatic lesions associated with increased levels of aminotransferases more than 6 months. Moreover, treatment with interferon therapy should be based on the liver fibrosis stage.[8] Various authors tried to find accurate non-invasive markers and develop correlations between the serum aminotransferases levels, hyluronic acid level, collagen level, platelet count and HCV viral titer with fibrosis stages but no clear conclusions were formed. Several scoring systems like AST to ALT ratio (AAR), AST-Platelet ratio (APRI), Fibrotest (FT), Fibrosis Index (FI) and FIB-4 with different thresholds to predict presence or absence of fibrosis or cirrhosis in patients infected with HCV had been proposed. However, mild fibrosis (F0) to end stage cirrhosis cannot be predicted accurately using a single system.[9–18]

In this study, we compared and evaluated diagnostic accuracy of the readily available non-invasive serum indexes including AAR, APRI, FI and FIB-4 to find accurate and reliable non-invasive markers for evaluating fibrosis progression. We also developed a new non-invasive serum marker index for this purpose by evaluating several clinic-pathological features. A marker with high predictive values would eliminate the need of liver biopsy that also reduces the cost and risks associated to it.

Methods

Patients

This study was conducted at the Department of Pathology, Jinnah Hospital, Lahore; Mayo Hospital, Lahore and Liver Centre, Faisalabad in collaboration with Applied and Functional Genomics Lab, National Centre of Excellence in Molecular Biology (CEMB), University of the Punjab, Lahore, Pakistan. HCV RNA-positive patients were identified among HCV antibody (anti-HCV) positive patients. Later, the study plan was discussed with patients and the biopsy was taken only from those patients who were willing for this procedure. The purpose of this study was to design a new Index so that disease progression can be evaluated non-invasively and future need of biopsy can be eliminated. This was a retrospective cross-sectional study. This analytical study was carried out from March 2008 to September 2010.

Patients who received a previous course of INF or immunosuppressive therapy or who had clinical evidence of HBV or HIV and any type of liver cancer were excluded from the study. Patients who refused to have a liver biopsy or for whom it was contraindicated, i.e., because of a low platelet count, prolonged prothrombin time or decompensated cirrhosis were also excluded from the study. The liver biopsy procedure, its advantages and possible adverse effects were explained to the patients. Informed consent were obtained from patients contained information about demographic data, possible transmission route of HCV infection, clinical, virological and biochemical data. This study included 157 patients (M/F 114/43; mean age 38.1 ± 10.2, age range 19–58 years). The study was approved by Institutional Review Board (IRB, CEMB). The Federal-wide Assurance document (ID: FWA00001758) was approved by the local office for Human Research Protection.

Histological Evaluation of Biopsy Samples

The histological evaluation of paraffin-embedded liver specimens was carried out at the Pathology Department, Jinnah Hospital, Lahore, according to METAVIR scoring system.[19] Liver biopsies were evaluated by two independent pathologists without prior information to patient's history. Histological staging based on the degree of fibrosis have five degrees of fibrosis: as F0 (no fibrosis), F1 (mild fibrosis without septa), F2 (moderate fibrosis with few septa), F3 (severe fibrosis with numerous septa without cirrhosis) and F4 (cirrhosis). We further grouped fibrosis stages as F0-F1 (minimal fibrosis), F2-F3 (advanced fibrosis), F4 (cirrhosis) and F2-F4 (significant fibrosis).

HCV RNA Detection and Quantitative PCR

RNA was extracted from 140 μl serum samples using QIAamp viral RNA extraction kit (Qiagen USA cat # 52906) according to the manufacturer's protocol. cDNA was synthesized using Moloney murine leukemia virus (MmLV) reverse transcriptase (Invitrogen, USA). First round and nested PCRs were carried out with Taq Polymerase (Fermentas USA) and analyzed on 2% agarose gel. Qiagen HCV quantitative kit was used to perform HCV RNA quantification with 10 ul of the extracted RNA on Roche Real Time PCR using fluorescent probes to detect amplification after each replicating cycle.

HCV Genotyping

HCV genotyping was carried out using Invader HCV genotyping assay (Third wave technology USA). Briefly, about 100 ng of the HCV RNA was reverse transcribed to cDNA using 200U of MmLV (Invitrogen, USA). From the amplified product, 2 μl was taken and the genotyping assay was performed for 12 different HCV types.

Comparison of Already Available Non-invasive Serum Biomarkers to Evaluate Patient's Liver Biopsy Data

Serum samples and liver specimens collected from each patient were stored at -70°C for further biochemical analysis. The routine liver function tests (LFTs), Hb, serum albumin and direct bilirubin levels were anticipated for each patient. All biochemical tests and their scores were made without knowledge of liver biopsy results and all patients were evaluated for AAR, APRI, Fibrosis Index (FI) and FIB-4 indexes.

The following formulas were used to review the predicted scores with the particular cut-off values as mentioned previously.

Statistical Analysis

The data was analyzed using statistical package SPSS version 16 for windows. A p value of 0.05 was considered statistically significant. All data was presented as mean values or no. of patients. Spearman's rank correlation was used to assess the significant association between continuous variables and liver fibrosis stages. The student t-test was used to compare arithmetic means and parameters while Chi-square (X2) test was used to compare categorical data, correlation with Fisher's exact test was used when appropriate. Patients were divided into three main groups as, patients with no or minimal fibrosis (F0-F1), patients with significant fibrosis (F2-F3) and patients with clinically significant cirrhosis (F4). The independently distinguished values of biochemical markers and AAR, APRI, FIB-4 and FI indexes for the prediction of significant fibrosis and cirrhosis were evaluated using univariate and multiple regression analysis. Area under the receiver operating characteristic (ROC) curves (AUROCs) was used to compare and deduce the diagnostic accuracies of the selected bio-markers.

Results

Patient's Data

The demographic and clinical outcomes of the 157 HCV infected patients are briefly explained in Table 1. The evaluation of chronic HCV activity (inflammatory grade) showed mild chronic hepatitis in 51 patients, moderate chronic hepatitis in 67 patients and severe chronic hepatitis in 39 patients. The determination of liver fibrosis showed stage F0 in 29, F1 in 39, 34 patients in F2 and F3 stage each and 21 patients in F4 or advanced fibrosis leading to cirrhosis. Our data showed the presence of genotype 1a in 22 and 3a in 135 patients, 95 patients were < 40 years of age, while 62 were > 40 years of age.

Relationship Between Clinical Findings and Fibrosis

Liver fibrosis stages were statistically significant between age groups (p< 0.05). Mild and moderate fibrosis was diagnosed mostly in younger patients while more advanced stages were observed in patients over 40 years old. Patients with F0 fibrosis were too young as compared to those who developed moderate or severe fibrosis leading to cirrhosis (Mean age ± SD, 25.9 ± 2.4 years). The distribution of liver fibrosis stages with regard to gender and genotypes of patients illustrated in Table 2 showed no significant differences (for gender: p = 0.247 and for genotypes: p = 0.258). Univariate analysis revealed that serum viral loads, bilirubin, albumin, platelet count, AST and ALP levels were significantly different in various fibrosis stages (Table 2).

Diagnosis of Fibrosis Using Already Available AAR, APRI, F-Index, and FIB-4 Serum Indexes

The relationship between the fibrosis stages and four serum indexes: AAR, APRI, FI and FIB-4 is illustrated in Figure 1 (see also Table 2). There was a significant relationship between fibrosis stages and serum indexes except AAR (p > 0.05). A gradual increase in the level of APRI, FI and FIB-4 indexes was observed in fibrosis stages.


Figure 1.
Box plots of the AAR, APRI, FIB-4 and FI for different fibrosis stages. The horizontal line inside each box represents the median, while the top and bottom of boxes represent the 25th and 75th percentiles, respectively. Vertical lines from the ends of the box encompass the extreme data points.
 
The AUROCs of the serum non-invasive indexes scores are shown in Table 3. AUROC of FI was higher than APRI (p< 0.05) for differentiating minimal fibrosis from significant fibrosis (Figure 2). To predict cirrhosis, FI showed high AUROC than AAR. Spearman correlation between each serum index score and fibrosis stages was high for F-Index, FIB-4 and APRI, while, AAR showed significantly low 'r' index indicated in Table 3. By using published cut-off values for each index, we analyzed the sensitivity and specificity of each index for significant fibrosis and cirrhosis. Patients with minimal fibrosis can be identified from advanced/significant or cirrhotic patients using FIB-4, AAR, APRI and F-Index with sensitivity 51%, 67.6%, 19.1% and 100% and specificity 85.4%, 42.8%, 97.7% and 58.4%, respectively. At a cut-off value > 3.25 for FIB-4, > 1.5 for APRI, > 1 for AAR and > 3.3 for F-Index have 59.2%, 34.8%, 42.8% and 38.1% sensitivity and 82.3%, 67.6%, 67.6% and 100% specificity, respectively, to discriminate advanced fibrosis stages from minimal.
 
 
Figure 2.
Receiver operating characteristic curves generated by four serum markers, AAR, APRI, FIB-4 and FI for differentiation between patients in fibrosis stage F0-F1, F2-F3 and F4.
 
Diagnosis of Fibrosis with Clinic-pathological Features Including Viral Load, Hb Level, Bilirubin, ALT, ALP, AST, Albumin and Platelet Count


Viral load was significant among fibrosis stages. It gradually increased in advanced fibrosis, and then suddenly dropped in cirrhosis. ALT and Hb levels were not significant, while AST levels were noteworthy to differentiate liver fibrosis stages. Meanwhile, only 16 (10.1%) and 21 (13.3%) patients showed normal ALT and AST levels, respectively, independent of fibrosis stage. The discriminative values of the biochemical markers for the prediction of different fibrosis stages were determined by logistic regression analysis. By univariate analysis (p < 0.05, Table 2), viral load, bilirubin, ALP, AST, albumin and platelet count were significantly associated with various fibrosis stages. However, in multivariate analysis, bilirubin, ALP, albumin and platelet count were found to be independently predictive (Table 4). This information related to these biochemical markers can also be helpful in differentiating liver fibrosis stages. Figure 3 shows the box plot of these four markers with liver histological stages. It is clear from Figure 3 and Table 2 that as the fibrosis increased, bilirubin and serum ALP level also increased, while platelet count and albumin level gradually reduced in cirrhosis. It was interesting to note that serum ALP and bilirubin was 2 times and 5 times higher in cirrhotic patients, respectively, than normal limits.


Figure 3.
Relationship between fibrosis stages and the ALP, bilirubin, serum albumin and fibrosis-cirrhosis index (FCI). The lines through the middle of the boxes represent the median, while the top and bottom of the boxes are the 25th and 75th percentiles. The error bars represent measurement range (maximum and minimum values).

Based on ROC curve analysis as illustrated in Figure 4, four significant serum markers ALP, bilirubin, albumin and platelet count showed superior diagnostic power with high AUROCs for differentiating various fibrotic stages and cirrhosis as given in Table 5. Our data showed that if these four serum markers ALP, bilirubin, albumin and platelet count are used simultaneously, they have high PPV and NPV for predicting cirrhosis and differentiating no/minimal fibrosis from significant fibrosis.
 
 
Figure 4.
Receiver operating characteristic curves for individual serum markers; ALP, bilirubin, platelet count and serum albumin for the predication of F0-F1, F2-F3 and F4 fibrosis stages.
 
For the detection of significant cirrhosis, platelet count less than 100 showed 81% sensitivity, 98% specificity, 89% PPV and 97% NPV. For the same outcome, ALP > 240 IU/l had sensitivity, specificity, PPV and NPV of 90%, 92%, 60.7% and 97%, respectively. The bilirubin and albumin were also quite sensitive for the presence of cirrhosis. Bilirubin level > 1.5 had a sensitivity 66.6%, specificity 95.5%, PPV 70% and NPV 94%, while albumin < 3.85 g/dl has sensitivity, specificity, PPV and NPV 71.4%, 93%, 60% and 95%, respectively.
 
In no/minimal fibrosis, ALP < 120 IU/l showed sensitivity, specificity, PPV and NPV 85%, 70%, 68% and 86%, respectively. At cut-off value > 150, platelet count also showed high sensitivity (98%) and specificity (70%) with 71.2% PPV and 98% NPV. Serum bilirubin and albumin also showed same pattern with high sensitivity, specificity, PPV and NPV as shown in Table 5.

Construction of a New Index for the Prediction of Fibrosis Stage

Based on the relationship of the regression coefficients of four-biochemical markers, ALP, bilirubin, albumin and platelet count, we developed a new fibrosis-cirrhosis index for the prediction of HCV disease progression from initial fibrosis stage to end stage cirrhosis.

It can be represented as

The FCI distribution for the patients in the respective fibrosis stages is represented in Figure 5. The median values for FCI in F0-F1, F2-F3 and F4 patients were 0.085, 0.32 and 1.9, respectively. FCI significantly correlated with the liver fibrosis stages (Spearman's rank correlation coefficient, r = 0.818, P< 0.05). The diagnostic values of F1 to differentiate F0-F1 and F4 patients were evaluated using the AUROCs (Figure 6). The AUC for F0-F1 and F4 was 0.932 (CI: 0.895–0.969) and 0.996 (CI: 0.989–1.002), respectively. The cutoff values obtained from the respective ROC curves were < 0.130 and > ≥1.25 in discriminating F0-F1 and F4 patients, respectively. Table 5 illustrates the diagnostic accuracy of FCI. Using a cutoff value of < 0.130, FCI had a sensitivity of 81%, PPV of 82% also with a specificity of 87% and NPV of 82% for the prediction of F0-F1. On the other hand, at a cutoff value of 1.25 or more, FCI had a sensitivity of 86%, specificity and PPV of 100% and 98% NPV for the prediction of cirrhosis (F4).
 

Figure 5.
Box plot of fibrosis-cirrhosis index (FCI) for each fibrosis stage. The horizontal line inside each box represents the median, while the top and bottom of boxes represent the 25th and 75th percentiles, respectively. Vertical lines from the ends of the box encompass the extreme data points.
 

Figure 6.
Receiver operating characteristic curves generated by the fibrosis-cirrhosis index (FCI) to discriminate fibrosis stages F0-F1 and F4. FCI showed maximum AUC for prediction of F4 (cirrhosis).
 
Discussion
 
Hepatocellular carcinoma and hepatic cirrhosis are consequences of chronic hepatitis C. The mean infection time to onset of cirrhosis is approximately 30 years, but cirrhosis may occur within a range of 10–50 years.[20] Fibrosis and its extension in hepatic tissue is most common evidence of cirrhosis. Several indexes are available to predict cirrhosis but no method or score is available on exclusive basis to diagnose earlier fibrosis stages.

Genotype 3a is the most common one followed by 1a in Pakistan [,[3,21] and[22] and same was also observed in this study. Almost, 86% patients had genotype 3a while remaining 14% had genotype 1a. A recent study also reported high prevalence of genotype 3 in HCC patients in Pakistan.[23] Patients with none or initial stage (F0-F1) of fibrosis showed a remarkable difference of age with advanced stages (F2 and F3) of fibrosis and cirrhosis. Most patients with age more than 40 years showed severe fibrosis and cirrhosis. These results confirmed the previous studies that patients with mild fibrosis stage were younger than the moderate and severe disease grade and stage is independent of gender.[24–26]

Our results showed positive correlation of ALT with APRI and FI, and negative correlation with AAR and platelet, however, no correlation was established between ALT levels with disease severity and fibrosis stages. Our observation is in agreement with previous reports that serum ALT levels do not accurately predict the presence of hepatic liver damage.[27,28] Several authors reported persistently normal ALT levels (< 42 IU/l) in patients with chronic HCV. Almost, 30% of patients with chronic HCV infection reflect steadily normal serum ALT levels,[29–32] however, in our data only 10% (n = 16) patients showed normal ALT levels.

Our data showed gradual increase in serum ALP and bilirubin levels (Table 2) in fibrosis stages when compared to early infection. Both ALP and bilirubin showed strapping significant correlation with disease progression. These results lead them to an important predictor of disease severity. An increased ALP is usually associated with liver metastasis, extraheptic bile obstruction, intraheptic cholestasis, infiltrative liver disease and hepatitis.[33,34] According to Lee et al, elevated serum ALP levels were common in liver abscess patients.[35] High bilirubin levels are associated with liver metastases and liver tumor involvement leading to hepatocellular carcinoma and liver cirrhosis by active or non-active HCV or HBV.[36] Limited literature is available on the role of elevated ALP and bilirubin levels in liver fibrosis stages. However, according to Imbert-Bismut et al.,[37] bilirubin may be used as marker of liver injury, while a change in ALP levels greater than 120 U/L can be indicative of advanced disease progression.[12] These findings suggest that serum ALP and bilirubin may be used as serum markers to assess the disease progression and fibrosis stages in chronic HCV patients.

Many studies supported that platelet count alone may be clinically valuable as a non-invasive serum marker for liver fibrosis and cirrhosis.[38,39] Platelets not only predict fibrosis but also correlate with fibrotic stages.[40–42] Lackner et al,[43] showed high AUROC of 0.89 for predicting cirrhosis at platelet value < 150 × 109/L and AUROC of 0.71 for non-cirrhotic patients at a cutoff value > 150 × 109/L. Our data is also in accordance with these results as platelet count showed high AUROC (≥ 0.900) to differentiate different liver fibrosis stages as given in Table 5 and Figure 4. In our study, platelet count was significantly low in cirrhotic patients. At a cutoff value of platelet, < 100 × 109/L has an AUROC of 0.990 for prediction of cirrhosis with 81% sensitivity and 98% specificity. Ginnani et al, reported platelet < 130 × 109/L for prediction of cirrhosis in HCV patients with 91.1% sensitivity, 88.3% specificity, PPV 81.2% and NPV 94.7%.[44]

We also examined the ability of AAR, APRI, FIB-4 and F-Index for staging liver fibrosis and to differentiate them from cirrhosis. Giannini et al, reported a high diagnostic accuracy of AAR > 1.16 with 81.3% sensitivity and 55.3% specificity for the prediction of cirrhosis.[44] However, AAR was not able to differentiate among liver fibrosis stages in our sample data. At value of > 1.0, AAR has 43% sensitivity and 70% specificity for differentiating fibrosis from cirrhosis (Table 3). This poor performance of AAR is similar to that reported by Lackner et al.[43]

We observed comparatively high APRI (1.24 ± 0.8) and FIB-4 (1.76 ± 1.35) values in F0-F1 patients. The group F0-F1 contains two subgroups, patients with no fibrosis (F0) and with minimal fibrosis (F1). The mean value of APRI and FIB-4 in F0 was 1.04 and 1.21, and in F1 1.39 and 2.17, respectively (Table 2). It is reported that APRI < 0.42 predict mild fibrosis and APRI > 1.2, significant fibrosis in HCV patients with 90% NPV for absence of fibrosis and 91% PPV for fibrosis presence.[45–47] Our results showed that APRI > 1.5 could predict fibrosis with 55% sensitivity, 67% specificity. Moreover, by using same cutoff value of APRI > 1.5 in a recent study by Macias et al,[48] found that it has 28% sensitivity, 92% specificity, 79% PPV and 55% NPV for predicting significant fibrosis, and for absence of fibrosis APRI < 0.5 has 78%, 44%, 59% and 66% sensitivity, specificity, PPV and NPV, respectively.

FIB-4 was developed by Sterling et al in 2006 for diagnosis of fibrosis and cirrhosis in HIV/HCV co-infected patients. We examined this index only for HCV infected patients. A cutoff value of < 1.45 FIB-4 has a NPV for the exclusion of advanced fibrosis of 90%, while a cutoff value > 3.25 has a PPV for the diagnosis of extended fibrosis of 65%.[49] At a cutoff value of < 1.45, Vallet-Pichard observed a high NPV of 94.7% with a sensitivity of 74.3% to exclude severe fibrosis. Where as, for confirming the presence of advanced fibrosis at cutoff value > 3.25, FIB-4 had a PPV of 82.1% with specificity of 98.2%.[18] Our results are not in agreement with Sterling or Vallet-Pichard, as we observed a low NPV (70%) for excluding significant fibrosis, however, we detected a PPV of 83% with specificity of 45% for the presence of advanced fibrosis at cutoff value > 3.25. Trang et al,[50] proposed new cutoff values of FIB-4 ≤ 1.39 for F0-F1 and ≥2.05 for F2-F4 stage in HCV/HIV co infected patients. At these cutoffs, we observed sensitivity 52%, specificity 76%, PPV 63% and NPV 68% for no/minimal fibrosis and 60%, 63%, 68% and 55% for advanced fibrosis, respectively. Although, we observed low statistical values, our results were in accordance to advance stage prediction. The cut off values proposed by Trang et al better predict fibrosis stages in co infected patients and we applied on only HCV infected patients.

Fibrosis index (FI) showed high sensitivity, specificity, PPV, NPV and AUROC for discriminating different fibrosis stages. Ohta developed this simple index in 2006. At cutoff value < 2.1 FI showed sensitivity and specificity for predicting F0–1 stage 66.8% and 78.8% in initial cohort and 68.5% and 63.6% in validation cohort, respectively.[17] At same cutoff, our data showed 100% sensitivity and 58.4% specificity with AUROC 0.939 for the prediction of none/minimal fibrosis. While for predicting cirrhosis in HCV patients, FI value > 3.30 has sensitivity and specificity 67.7% and 75% in initial cohort, and 70.8% and 81% in validation cohort, respectively. However, at this value we observed 33% sensitivity and 100% specificity for predicting cirrhosis (Table 3). We proposed that a new cutoff value of FI > 2.5 can better predict cirrhosis with 95.2% sensitivity and 94% specificity.

The readily available indexes are associated with some limitations like population discrepancy, not able to distinguish all fibrosis stages individually or some primarily developed for co-infected patients. So there is a need to develop a new index that can distinguish minimal fibrosis (F0-F1) from significant (F2-F4) and advanced (F2-F3) from cirrhosis (F4). While considering substantial relationship of routinely applied tests; serum ALP, ALT, AST, Hb level, bilirubin, albumin and platelet count with liver fibrosis stages, we found that four serum markers ALP, bilirubin, albumin and platelet count have high potential to differentiate different fibrosis stages and cirrhosis at given cutoff values (Table 5 and Figure 4). We also observed that combination of these serum markers could better differentiate among fibrosis stages with high sensitivity, specificity, PPV and NPV.

Our newly derived index FCI showed better performance for discriminating between fibrosis stages as compared to AAR, APRI and FI. In initial cohort, the AUROC for predicting F0-F1 stage for FCI was 0.932 when compared to recently used non-invasive serum markers like AAR (AUROC = 0.570),[15] APRI (AUROC = 0.880),[16] FI (AUROC = 0.741),[17] FIB-4 (AUROC = 0.793),[18] Forn's index (AUROC = 0.860),[51] and Fibrotest (AUROC = 0.870).[52] Moreover, FCI (AUROC = 0.996) showed better performance for predicting cirrhosis than above mentioned serum indexes. Although in our study, platelet count showed high AUROC to predict fibrosis stages, systematic literature reviews consistently shown that panel of fibrosis markers are more accurate than single marker. Combination of two or more serum markers in a mathematical algorithm provide better chance of predicting phase of disease progression instead of individual one.[37,53–57] This analysis showed that FCI has tendency to reflect respective fibrosis stages from no/minimal to cirrhosis with great accuracy (Table 5, Figure 5 and 6). However, several studies are needed to verify these results. Secondly, because of poverty and fear of biopsy, we are not yet able to get enough patient data for verification of our FCI results in new cohort.

Conclusions

For Pakistani population the mostly used markers were failed to predict fibrosis stages in patients with HCV with accuracy. This study concluded that a simple index (FCI) containing ALP, bilirubin, albumin and platelet count may accurately classify different fibrosis stages from none to cirrhosis. Future studies are required to assess the applicability of this fibrosis-cirrhosis index within different populations and in patients with HBV or other fatty liver diseases.

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37.Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T: Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: a prospective study. Lancet 2001, 357:1069–1075.

38.Myres RP, De Torres M, Imbert-Bismut F, Ratziu V, Charlotte F, Poynard T, MULTIVIRC Group: Biochemical markers of fibrosis in patients with chronic hepatitis C: a comparison with prothrombin time, platelet count, and age-platelet index. Dig Dis Sci 2003, 48:271–278.

39.Ghany MG, Lok AS, Everhart JE, Everson GT, Lee WM, Cuto TM, Wright EC, Stoddard AM, Sterling RK, Di Bisceglie AM, Bonkovsky HL, Morishima C, Morgan TR, Dienstag JL, HALT-C Trial Group: Predicting clinical and histologic outcomes based on standard laboratory tests in advanced chronic hepatitis C. Gasteroenterology 2010, 138:136–146.

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Source
Articles in Press

Paola Dongiovanni, Anna Ludovica Fracanzani, Silvia Fargion, Luca Valenti

Received 22 February 2011; received in revised form 29 May 2011; accepted 31 May 2011. published online 20 June 2011.
Accepted Manuscript

Abstract

The dysmetabolic iron overload syndrome (DIOS) is now a frequent finding in the general population, as is detected in about one third of patients with nonalcoholic fatty liver disease (NAFLD) and the metabolic syndrome. The pathogenesis is related to altered regulation of iron transport associated with steatosis, insulin resistance, and subclinical inflammation, often in the presence of predisposing genetic factors. Evidence is accumulating that excessive body iron plays a causal role in insulin resistance through still undefined mechanisms, that probably involve a reduced ability to burn carbohydrates and altered function of adipose tissue. Furthermore, DIOS may facilitate the evolution to type 2 diabetes by altering beta-cell function, the progression of cardiovascular disease by contributing to the recruitment and activation of macrophages within arterial lesions, and the natural history of liver disease by inducing oxidative stress in hepatocytes, activation of hepatic stellate cells, and malignant transformation by promotion of cell growth and DNA damage.

Based on these premises, the association among DIOS, metabolic syndrome, and NAFLD is being investigated as a new risk factor to predict the development of overt cardiovascular and hepatic diseases, and possibly hepatocellular carcinoma, but most importantly, represents also a treatable condition. Indeed, iron depletion, most frequently achieved by phlebotomy, has been shown to decrease metabolic alterations and liver enzymes in controlled studies in NAFLD. Additional studies are warranted to evaluate the potential of iron reductive therapy on hard clinical outcomes in patients with DIOS.

Keywords: Iron, Insulin Resistance, Nonalcoholic Fatty Liver Disease, Metabolic Syndrome, Vascular Damage, Hereditary Hemochromatosis, Nonalcoholic Steatohepatitis, Oxidative Stress

No full text is available. To read the body of this article, please view the PDF online.

Department of Internal Medicine, Centro Malattie Metaboliche del Fegato, Università degli Studi di Milano, and Fondazione IRCCS “Ca’ Granda” Ospedale Maggiore Policlinico, Milan, Italy

PII: S0168-8278(11)00442-9
doi:10.1016/j.jhep.2011.05.008
© 2011 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.

Source
Neal D. Freedman; Teresa M. Curto; Karen L. Lindsay; Elizabeth C. Wright,; Rashmi Sinha; James E. Everhart 
Posted: 06/24/2011; Gastroenterology. 2011;140(7):1961-1969. © 2011 AGA Institute

Abstract and Introduction

Abstract

BACKGROUND & AIMS: High-level coffee consumption has been associated with reduced progression of pre-existing liver diseases and lower risk of hepatocellular carcinoma. However, its relationship with therapy for hepatitis C virus infection has not been evaluated.

METHODS: Patients (n = 885) from the lead-in phase of the Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis Trial recorded coffee intake before retreatment with peginterferon α-2a (180 μg/wk) and ribavirin (1000–1200 mg/day). We assessed patients for early virologic response (2 log10 reduction in level of hepatitis C virus RNA at week 12; n = 466), and undetectable hepatitis C virus RNA at weeks 20 (n = 320), 48 (end of treatment, n = 284), and 72 (sustained virologic response; n = 157). RESULTS: Median log10 drop from baseline to week 20 was 2.0 (interquartile range [IQR], 0.6 –3.9) among nondrinkers and 4.0 (IQR, 2.1– 4.7) among patients that drank 3 or more cups/day of coffee (P trend <.0001). After adjustment for age, race/ethnicity, sex, alcohol, cirrhosis, ratio of aspartate aminotransferase to alanine aminotransferase, the IL28B polymorphism rs12979860, dose reduction of peginterferon, and other covariates, odds ratios for drinking 3 or more cups/day vs nondrinking were 2.0 (95% confidence interval [CI]: 1.1–3.6; P trend = .004) for early virologic response, 2.1 (95% CI: 1.1–3.9; P trend = .005) for week 20 virologic response, 2.4 (95% CI: 1.3–4.6; P trend = .001) for end of treatment, and 1.8 (95% CI: 0.8 –3.9; P trend = .034) for sustained virologic response. CONCLUSIONS: Highlevel consumption of coffee (more than 3 cups per day) is an independent predictor of improved virologic response to peginterferon plus ribavirin in patients with hepatitis C.

Introduction

Approximately, 70%–80% of individuals exposed to hepatitis C virus (HCV) become chronically infected.[1] Worldwide these individuals are estimated to number between 130 and 170 million.[2] Treatment with peginterferon and ribavirin resolves chronic hepatitis C in about half of patients.[3,4] However, those who fail or are unable to tolerate treatment have few current treatment options.

A number of factors affect response to therapy,[5] including African-American race,[6–8] presence of cirrhosis,[8] baseline aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio,[8] baseline serum HCV level,[8] insulin resistance,[9,10] particular single nucleotide polymorphisms, including rs12979860 or rs8099917 near IL28B,[11–15] genotype 1 of HCV,[8,16,17] and patients' ability to tolerate full doses of peginterferon during treatment.[18]

Coffee drinking has been associated with several aspects of liver health, including concentrations of the liver enzymes ALT, AST, and γ-glutamyltransferase,[19–24] progression of pre-existing liver disease,[25] and hepatocellular carcinoma.[26,27] It is not known whether coffee affects spontaneous HCV clearance or, among chronically infected individuals, patients' response to HCV therapy.[28]

Therefore, we investigated the association between coffee intake and virologic response to peginterferon plus ribavirin treatment in the lead-in phase of the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) Trial of patients with baseline fibrosis or cirrhosis who had failed previous interferon therapy.[29]

Materials and Methods

Patient Population

As described previously,[8,18,29,30] the lead-in phase of HALT-C enrolled 1145 HCV-positive patients who had an Ishak fibrosis score ≥3, had failed previous interferon treatment, and had no evidence of hepatic decompensation or hepatocellular carcinoma. During lead-in, patients received 180 μg per week of peginterferon α-2a and 1000 mg/day ribavirin for those weighing ≤75 kg and 1200 mg/day for those weighing >75 kg. Patients with declining neutrophil, platelet, or hemoglobin counts, or other adverse effects, were managed by dose reduction of peginterferon and or ribavirin.[18] The amount of medication taken by each patient during the first 20 weeks was expressed as a proportion of the original prescribed dosage. The study protocol was approved by the institutional review board of each participating institution and written consent was obtained from all patients.

Assessment of Coffee and Tea Consumption

At the beginning of the lead-in-phase, patients completed a previously validated[31,32] Block 98.2 food frequency questionnaire (FFQ; NutritionQuest, Berkeley, CA). Patients reported typical intake of 110 food items during the past year using 9 frequency categories ranging from "never" to "every day" and 4 categories of portion size (ie, 1 cup, 2 cups, 3–4 cups, and 5+ cups). One question assessed coffee intake and did not distinguish decaffeinated from caffeinated coffee. A second question assessed tea intake and did not distinguish black from green tea. Patients failing lead-in therapy entered the randomized phase and completed a second Block FFQ approximately 1 year after beginning the randomized phase.

For analysis, we created categorical variables of coffee (never, >0 to <1, ≥1 to <3, and ≥3 cups/day) and tea intake (never, >0 to ≥1, ≥1 to <2, and ≥2 cups/day). We excluded 259 patients who did not complete an FFQ and 1 patient with extreme caloric intake (>2 interquartile ranges [IQR] from the median), leaving 885 patients for the current analysis. Patients completing the FFQ were similar to those who did not, other than being more typically white (76.2% vs 65.3%; P = .034) and having a lower baseline AST/ALT ratio (median = 0.78 vs 0.82; P = .0056).

Assessment of Outcomes

Serum samples obtained from all subjects enrolled in the HALT-C Trial were tested in real-time at the University of Washington Virology Laboratory with both the quantitative Roche COBAS Amplicor HCV Monitor Test, v. 2.0 assay (lower limit of detection 600 IU/mL) and, if negative, by the Roche COBAS Amplicor HCV Test, v. 2.0 assay (Roche Molecular Systems, Branchburg, NJ) with lower limit of detection 100 IU/mL as described previously.[8,33] HCV genotypes were determined with the INNO-LiPA HCV II kit (Siemens Medical Solutions Diagnostics, Tarrytown, NY). Serum HCV RNA level was assessed at baseline, along with week 12, week 20, and week 48 of treatment. Early virologic response was de- fined as a ≥2-log10 decline in serum HCV RNA level at week 12. Week 20 virologic response was defined as the absence of detectable serum HCV RNA (<100 IU/mL) at week 20. Week 20, as opposed to the traditional week 24, was chosen in order to provide sufficient time to identify nonresponders for randomization into the main HALT-C trial. Patients with undetectable virus at week 20 continued to receive peginterferon plus ribavirin treatment for an additional 28 weeks (48 weeks total), at which point treatment was stopped. Sustained virologic response was defined as the absence of detectable serum HCV RNA at week 72, twenty-four weeks after the end of treatment. For analysis, we set undetectable viral levels at the detection limit (100, ie, 2 log10, IU/mL).

Statistical Analysis

All tests were 2-sided and α < .05 was considered to be statistically significant. Analyses were performed with SAS software (release 9.2, SAS Institute, Cary, NC). We tabulated baseline behavioral and clinical, demographic, and genetic features by categories of coffee intake. The Jonckheere-Terpstra test for trend for continuous variables and the Mantel-Haenszel test for trend for categorical variables were used to assess variation across categories of coffee intake. Variation across categories of race/ethnicity was assessed by the Pearson χ[2] test. Associations between coffee and tea intake with virologic response were determined using logistic regression. Linear trend tests were performed by assigning participants the median intake for their categories and entering that term as a continuous variable in the regression models. We present results from unadjusted crude models, along with models adjusted for continuous baseline age, AST/ALT ratio, log HCV RNA level, hemoglobin, neutrophils, platelets, and categories of sex, race/ethnicity, alcohol use at baseline, cirrhosis, HCV genotype 1, previous use of ribavirin, dose reduction of peginterferon during the first 20 weeks of treatment, and rs12979860 genotype. Additional adjustment for Short Form-36[34] general health, physical function, or vitality quality of life scores, packyears of cigarettes, rs8099917 genotype, dose reduction of ribavirin during the first 20 weeks of treatment, body mass index, the homeostatic model assessment score of insulin resistance (HOMA2), total serum cholesterol, high-density lipoprotein cholesterol, or triglycerides had no appreciable effect on risk estimates for virologic response (data not shown). Additionally, we performed propensity score analysis[35] in order to better balance possible confounders between coffee drinkers and nondrinkers. We created a propensity score for coffee intake using the following covariates: age (continuous), sex, race/ethnicity (white, African American, Hispanic, other), alcohol use (current, former, and never), cirrhosis at baseline, genotype 1, AST/ALT ratio (continuous), log HCV RNA level at baseline (continuous), previous use of ribavirin, hemoglobin (continuous), neutrophils (continuous), platelets (continuous), categories of peginterferon medication dose during first 20 weeks of treatment (≥98%–100%, ≥80%–<98%, ≥60%–<80%, and <60%), and rs12979860 genotype (TT, CT, CC). We then adjusted risk estimates for coffee with virologic response for quintiles of the propensity score using indicator variables. Risk estimates were also calculated across strata of propensity score quintiles.

We investigated possible interactions between coffee intake and number of clinical and behavioral features by examining the association between coffee and virologic response by stratum of each clinical and behavioral feature. We formally tested for effect modification by including an interaction term between each stratifying variable and continuous coffee intake in the model.

Results

Of the 885 patients who began full-dose peginterferon and ribavirin therapy, 85% drank coffee and 14.9% of patients drank 3 or more cups per day. At baseline, those consuming higher quantities of coffee were more likely to be white; drink alcohol and smoke cigarettes; have the CC genotype of rs12979860 (near IL28B); have higher hemoglobin, neutrophils, platelets, and total cholesterol; less likely to have cirrhosis at baseline; and have lower serum AST/ALT and HOMA2 score of insulin resistance (P < .05 for all; Table 1). Although 50.4% of noncoffee drinkers tolerated the full dose of peginterferon α-2a during treatment, 60.6% of 3 or more cups per day coffee drinkers tolerated the full dose (P = .0015). Among determinants of peginterferon dose reduction, 58% were due to low neutrophils and 22.6% were due to low platelets. During treatment, coffee drinkers were less likely to have a dose reduction due to either low neutrophils (P = .016) or platelets (P = .059). The relationships between coffee and clinical and demographic variables were generally similar in analyses restricted to white patients (n = 674), although we noted one difference. The association for coffee with rs8099917 genotype became statistically significant (P = .001).

More coffee consumption was associated with slightly higher baseline HCV RNA levels (P for trend = .007) (Table 2). Yet with increasing coffee intake, the decline in patients' serum HCV RNA level from baseline was greater and absolute levels of patients' serum HCV RNA at weeks 12 and 20 were lower (Table 2). For example, the median log10 HCV RNA at week 20 was 4.6 (IQR, 2.0 –5.8) for nondrinkers and 2.0 (IQR, 2.0–4.3) for those who drank 3 or more cups per day (P trend <.0001). Consistent results were observed for the log decrease in HCV RNA from baseline to week twelve, 1.7 (IQR, 0.7–3.6) in nondrinkers vs 3.7 (IQR, 1.8–4.2) for 3 or more cups per day drinkers; P trend <.0001) and from baseline to week twenty, 2.0 (IQR, 0.6 –3.9) in nondrinkers vs 4.0 (IQR, 2.1–4.7) for 3 or more cups per day drinkers; P trend < .0001).

Coffee drinkers were also more likely to have a virologic response according to the predefined end points (Table 3). Among nondrinkers, 45.7% had an early virologic response (≥2 log drop in their serum HCV RNA level at week 12), 26.3% had no detectable serum HCV RNA at week 20, 21.8% had no detectable serum at week 48, and 11.3% had a sustained virologic response. In contrast, the corresponding proportions for 3 or more cups per day coffee drinkers were 72.7%, 52.3%, 49.2%, and 25.8%, respectively. From crude logistic regression models, patients who drank 3 or more cups per day of coffee were about 3 times more likely to have a virologic response at the 4 time points of interest (Table 3). Ability to tolerate treatment had minimal effect on the relationship of coffee and virologic response. For example, the odds ratio for patients who drank 3 or more cups per day relative to nondrinkers for week 20 response changed slightly from 3.07 (crude: Table 3) to 2.92 (data not in Table) with control for peginterferon dose and the P trend remained highly statistically significant (P trend <.0001). Multivariate adjustment for age, sex, race/ethnicity, alcohol use, cirrhosis at baseline, genotype 1, AST/ALT ratio, log HCV RNA level at baseline, previous use of ribavirin, hemoglobin, neutrophils, platelets, peginterferon medication dose during first 20 weeks of treatment, and rs12979860 genotype, attenuated associations with coffee, although associations remained significant for each virologic response end point (Table 3). Risk estimates using propensity score methods were similar to those from multivariate adjusted models (data not shown).

In contrast to results for coffee, no effect was observed for drinking tea (P trend = .92, .96, .89, and .49 for early, week 20, week 48, and sustained virologic response, respectively).

In stratified analyses, we investigated effect modification (interaction) for week 20 HCV negativity across stratum of HCV genotype, race/ethnicity, cirrhosis at baseline, baseline AST/ALT ratio, hemoglobin, neutrophils, platelets, total cholesterol, HOMA2 score, Short Form-36 general health score, dose reduction of peginterferon, alcohol use, cigarette smoking, or rs12979860 genotype. Results are presented for week 20 virologic response, but were similar for early virologic response (week 12), end of treatment response (week 48), and sustained virologic response (week 72; data not shown). Risk estimates generally appeared similar in each stratum and the P values for interaction were all >.05 (Figure 1). For example, of the 454 patients who tolerated full dose, 43.4% had a week 20 virologic response compared with 28.5% of the 431 patients who took less than full dose. The relative benefit of coffee on virologic response was similar in these two groups (odds ratio = 1.26 for full dose and 1.18 for lower dose) despite the absolute difference in response. The relationships between coffee and virologic responses were also very similar in analyses restricted to white patients. Specifically, there was a statistically significant increase in week 20 virological response per cup increase in coffee consumption among white patients. Associations between coffee intake and virologic response were apparent in patients with both fibrosis and cirrhosis at baseline; although stronger in those with fibrosis. Finally, risk estimates for coffee appeared stronger in patients with the less favorable IL28B rs12979860 TT or CT genotype, although again, differences in risk estimates were not statistically significant. We were unable to determine coffee intake during lead-in therapy. But for patients failing lead-in therapy, coffee intake was assessed on a second occasion, 18 months after baseline, ie, 12 months after these patients had been randomized to low-dose peginterferon or no treatment. Median coffee intake was the same (1 cup per day) at baseline and at the second time point for patients in both randomization groups. The weighted κ for the 2 assessments was .58 overall (P < .0001), .54 in those receiving treatment (P < .0001), and .63 in those receiving no-treatment (P < .0001), indicating good agreement.


Figure 1.
Stratified analysis of the association of baseline coffee intake with week 20 virologic response in the Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis (HALT-C) Trial. Odds ratios shown are for an increase in coffee consumption of 1 drink per day and are adjusted for age (continuous), sex, race/ethnicity (white, African American, Hispanic, other), alcohol use (current, former, and never), cirrhosis at baseline, genotype 1, aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio (continuous), log hepatitis C virus (HCV) RNA level at baseline (continuous), previous use of ribavirin, hemoglobin (continuous), neutrophils (continuous), platelets (continuous), categories of peginterferon medication dose during first 20 weeks of treatment (≥98%–100%, ≥80%–<98%, ≥60%–<80%, and <60%), and rs12979860 genotype (TT, CT, CC). Median values were used to define cut-points for the starred characteristics. Black diamond indicates the overall point estimate. Black circles, squares, and triangles represent the point estimate for each indicated subgroup. Horizontal lines represent 95% confidence intervals (CI). The solid vertical line indicates an odds ratio of 1. P values are for the interaction between coffee intake and each stratifying variable and are taken from the Wald test for the cross-product term of each stratifying variable and continuous coffee intake.
 
Discussion
 
In patients with advanced HCV-related chronic liver disease in the HALT-C trial receiving peginterferon plus ribavirin treatment, 3 or more cups per day coffee drinkers were 3 times more likely to have a virologic response than nondrinkers. Associations were attenuated but persisted after adjustment for a wide range of behavioral, clinical, and genetic features, suggesting an effect independent of other known risk factors. In contrast to results for coffee, no effect was observed for tea drinking.

Coffee intake has been associated with lower level of liver enzymes, reduced progression of chronic liver disease,[25] and reduced incidence of hepatocellular carcinoma.[26,27] Because few other data on the association of coffee drinking with virologic response are available, the association observed here needs replication in other studies.

A number of risk factors have previously been associated with virologic response in HALT-C and in other studies,[5,8,12,14,15,18,25] including African American race, presence of cirrhosis, AST/ALT ratio, serum HCV RNA level, particular genotypes near the IL28B gene, and ability to tolerate full doses of peginterferon during treatment. Intriguingly, coffee was modestly associated with nearly all of these factors. African Americans in our study tended to drink less coffee than white patients, and coffee drinking was associated with lower AST/ALT ratio, ability to tolerate full doses of peginterferon α-2a during treatment, and particular genotypes of single nucleotide polymorphisms near to the IL28B gene, which have recently been linked to virologic response.[11–15] Yet, the association for coffee persisted after adjustment for these and other potential confounders and was similar across stratums of each of these risk factors, eg, a similar effect for coffee on virologic response was observed for both those receiving a full dose of peginterferon and those having a dose reduction. These results suggest that coffee drinkers had a better response to treatment that was independent of other risk factors, including higher tolerance for peginterferon treatment.

Associations between coffee and features associated with virologic response raise the possibility of reverse causality, ie, sicker patients were less likely to drink coffee and, in this way, less likely to respond to treatment. But in HALT-C, patients drinking coffee reported a worse quality of life on the Short Form-36 quality of life questionnaire than nondrinkers. Quality of life was also not associated with virologic response. As in all observational studies, we cannot exclude unmeasured or residual confounding as an explanation for our results. Observed associations could also simply be due to chance.

Coffee has >1000 compounds, any one of which could be involved in virologic response. One major constituent of coffee is caffeine. Although we could not distinguish caffeinated from decaffeinated coffee in our study, we found no association with consumption of black or green tea. Fewer individuals consumed tea in our study and tea contains less caffeine than coffee. It is unlikely that coffee and its constituents have a direct antiviral effect. If so, HCV RNA levels at baseline would have been expected to be lower with greater coffee consumption. In fact, baseline levels were actually higher with greater consumption (Table 2). More likely coffee would have a facilitating effect on response to peginterferon and ribavirin treatment by a mechanism yet to be understood. It is intriguing that the C allele of rs12979860 near the IL28B gene has been associated with higher baseline viral levels, lower levels of interferon-stimulated gene expression, and better treatment response.[14,36,37] The IL28B genotype effect on virologic response may be through the Janus kinasesignal transducer and activator of transcription pathway.[38] Recently published results potentially link kahweol, a diterpene in coffee, to Janus kinase-signal transducer and activator of transcription pathway,[39] suggesting one of many possible mechanisms for the observed association in our study.

A number of studies have linked high serum total and low-density lipoprotein (LDL) cholesterol with increased virologic response to peginterferon plus ribavirin therapy.[40–42] LDL has also been recently posited to mediate, at least partly, the effect of the rs12979860 C allele.[41,43] Coffee intake was associated with higher serum total cholesterol in our study and has also been linked to higher serum total cholesterol and LDL in past observational and interventional studies.[44] Adjustment for total cholesterol, however, did not affect risk estimates in the current analysis. We lacked assessment of LDL. Alternatively, insulin resistance has been associated with poor virologic response in a number of previous studies.[9,10] Consistent with previous studies of type 2 diabetes,[45,46] coffee intake was inversely associated with insulin resistance in HALT-C. Adjustment for HOMA2 score did not affect risk estimates for coffee with virologic response in the current analysis.

Our study has several advantages, including a large number of patients with histological staging of liver fibrosis, careful assessment of virologic response using a central virology laboratory, and comprehensive assessment of clinical and histologic features. Limitations include a lack of information on caffeine and coffee brewing methods and the assessment of coffee via self-report at a single time point. As such, we do not know patients' coffee intake at the time of initial treatment or whether coffee consumption was maintained during the course of the lead-in phase. However, for patients failing lead-in therapy subsequently randomized to half-dose peginterferon treatment or to no treatment, coffee consumption was similar at baseline and 18 months later (6 months after randomization). Because patients in HALT-C also had previously failed interferon therapy, it is not clear whether our results can be generalized to other patient populations, such as those with less advanced disease, those who are treatment-naïve to prior therapy, or who are being treated with newer antiviral agents.

In summary, we observed an independent association between coffee intake and virologic response to peginterferon plus ribavirin retreatment in the lead-in phase of the HALT-C trial. Future studies are needed to replicate this finding in other populations.

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Coffee Consumption Is Associated With Response to Peginterferon and Ribavirin Therapy in Patients With Chronic Hepatitis C