February 8, 2012

From Journal of Viral Hepatitis

Y. Ueda; H. Marusawa; T. Kaido; Y. Ogura; F. Oike; A. Mori; K. Ogawa; A. Yoshizawa; E. Hatano; A. Miyagawa-Hayashino; H. Haga; H. Egawa; Y. Takada; S. Uemoto; T. Chiba

Authors and Disclosures

Posted: 02/07/2012; J Viral Hepat. 2012;19(1):32-38. © 2012 Blackwell Publishing

Abstract and Introduction
Abstract

Approximately 30% of patients who have recurrent hepatitis C after liver transplantation achieve sustained virological response (SVR) by taking a combination therapy of pegylated interferon and ribavirin. For the remaining non-SVR patients, an effective management treatment has not yet been established. In this study, efficacy of long-term peginterferon maintenance therapy for non-SVR patients was evaluated. Forty patients who had previously received the combination therapy for hepatitis C after living donor liver transplantation were classified into one of the following three groups: the SVR group (n = 11); the non-SVR-IFN group (n = 17), which received low-dose peginterferon maintenance therapy for non-SVR patients; and the non-SVR-Withdrawal group (n = 12), which discontinued the interferon treatment. We then compared histological changes among these three groups after 2 or more years follow-up. Activity grade of liver histology improved or remained stable in patients in the SVR and non-SVR-IFN groups, but deteriorated in half of the patients in the non-SVR-Withdrawal group. Fibrosis improved or remained stable in 10 of 11 SVR patients and in 13 of 17 non-SVR-IFN patients, but deteriorated in all non-SVR-Withdrawal patients. Mean changes in fibrosis stage between pretreatment and final liver biopsy were −0.18, +0.06 and +2.2 in the SVR, non-SVR-IFN and non-SVR-Withdrawal groups, respectively. Fibrosis stage deteriorated to F3 or F4 significantly more rapidly in the non-SVR-Withdrawal group than in the other two groups. In conclusion, continuing long-term maintenance therapy with peginterferon prevented histological progression of hepatitis C in patients who had undergone living donor liver transplantation.

Introduction

Cirrhosis and hepatocellular carcinoma caused by hepatitis C virus (HCV) infection is the leading indication for liver transplantation in Japan, the United States and western Europe. However, liver allograft infection with HCV following liver transplantation is universal, and almost all patients develop recurrent liver injury.[1–6] The progression of recurrent hepatitis C is often accelerated and, without appropriate antiviral therapy, 10–25% of patients develop cirrhosis within 5 years after transplantation, resulting in poorer prognosis for HCV-positive recipients than HCV-negative recipients.[7]

To prevent the progression of hepatitis C after liver transplantation, a combined therapy of pegylated interferon plus ribavirin is commonly administered.[8,9] However, the efficacy of this combination therapy is limited: The mean sustained virological response (SVR) rate among patients with recurrent hepatitis C after liver transplantation was only 30% (range, 8–50%).[10] Effective management of the remaining 70% of the patients who are unable to achieve SVR has not been established.[11]

We recently reported the change in liver histology after combination therapy with interferon plus ribavirin in patients who have recurrent hepatitis C after living donor liver transplantations (LDLT). Among patients who did not achieve SVR, activity grade was not improved and fibrosis stage deteriorated. On the other hand, SVR was associated with reduced hepatic inflammation and suppression of liver fibrosis progression.[12] Because the histological progression of non-SVR patients occurred mainly after interferon therapy was discontinued, we hypothesized that long-term, continuous interferon administration might be effective in slowing the progression of liver damage in these patients. Therefore, after our previous study, we prescribed a low-dose peginterferon maintenance therapy for non-SVR patients. Here, we evaluated the efficacy of this treatment by investigating long-term histological changes in these patients, as well as comparing them to the changes observed in SVR patients and non-SVR patients who did not receive maintenance treatment.

Methods

Eighty patients who had previously received the combination therapy with interferon and ribavirin (n = 40) or peginterferon and ribavirin (n = 40) for recurrent hepatitis C after LDLT at Kyoto University between January 2001 and April 2007 were retrospectively analysed.

Patients

Between March 1999 and December 2006, 141 patients with HCV-related liver diseases underwent LDLT at Kyoto University. Of these, 100 patients had been followed up for more than 6 months after LDLT in our hospital. Antiviral therapy was given to 80 patients with recurrent hepatitis C between January 2001 and April 2007. The remaining 20 patients did not receive the antiviral therapy because of no histological recurrence of hepatitis C in the follow-up period. To evaluate the histological progression caused by hepatitis C, patients who were diagnosed as having other causes of liver injury, such as biliary complications, chronic rejection, and de novo autoimmune hepatitis (AIH), were excluded. Patients who discontinued the treatment within 3 months because of worsening of liver function caused by hepatitis C were also excluded, because the rapid progression of these patients is not comparable to the long-term progression and inclusion of these patients would have led to overestimation of the progression in the patients who discontinued treatment. Patients were also excluded if they did not have a liver biopsy more than 2 years after the initiation of treatment, because this prevented an analysis of long-term histological changes.

Treatment Protocol and Definition of Responses to Treatment

After liver transplantation, patients with recurrent HCV liver disease underwent treatment with interferon–α–2b (3 or 6 mega units thrice weekly) plus ribavirin (400–800 mg/day orally) for the first 6 months. This was followed by interferon monotherapy for 6 months.[12] This treatment protocol was employed between January 2001 through April 2004 inclusive. From May 2004 to April 2007, patients underwent combination antiviral therapy comprising peginterferon–α–2b (1.5 μg/kg body weight, weekly) and ribavirin (400–800 mg/day orally).[13] Patients who became negative for serum HCV RNA within 12 months after initiating the treatment continued to receive the full (initial) dose for 8–22 months to achieve SVR; then, the treatment ended. Patients who were negative for serum HCV RNA for more than 6 months after completion of interferon therapy were defined as achieving SVR.

Patients who did not become negative for serum HCV RNA within 12 months of initiating the combination therapy, as well as patients who experienced a relapse after transient discontinuation of the treatment, continued to receive a low-dose peginterferon maintenance therapy (0.5–0.75 μg/kg of peginterferon-α-2b with or without ribavirin at 200 mg/day). Treatments occurred during the study period, May 2005–December 2009. During this time, the therapy was discontinued in patients with severe adverse events. Additionally, peginterferon treatments were discontinued when neutrophil and platelet counts fell below 500 and 30 000/μL, respectively, and ribavirin was discontinued when haemoglobin levels fell below 8 g/dL.

Histological Assessment

Liver biopsies were performed when patients' alanine aminotransferase (ALT) levels were more than twice the upper limit of normal, or at yearly intervals, with informed consent. Biopsy specimens were evaluated by two pathologists (H.H. and A.M.) with extensive experience in the pathology of liver transplantation. Necroinflammatory activity (A0–A3) and fibrosis stage (F0–F4) were assessed using METAVIR scores.[14,15] Grading was defined as A0 (no activity), A1 (mild activity), A2 (moderate activity) or A3 (severe activity); staging was defined as F0 (no fibrosis), F1 (mild fibrosis), F2 (moderate fibrosis), F3 (severe fibrosis) or F4 (cirrhosis).[14,15]

The following equations were used to analyse the histological changes:

  1. Changes in activity grade = grade at final biopsy − grade at pretreatment biopsy, and
  2. Changes in fibrosis stage = stage at final biopsy − stage at pretreatment biopsy.

Immunosuppression

Tacrolimus and low-dose steroid therapies were administered to induce immunosuppression.[12,13,16] The lower limit of the target for whole blood tacrolimus level was 10–15 ng/mL during the first 2 weeks, 10 ng/mL during weeks 2–8 and 5–8 ng/mL thereafter. Four patients received cyclosporine microemulsions, rather than tacrolimus, to induce immunosuppression (Table 1). Steroid therapy was initiated at a dose of 10 mg/kg before graft reperfusion and then tapered from 1 mg/kg per day on the first day to 0.3 mg/kg per day until the end of the first month, followed by 0.1 mg/kg per day until the end of the third month. After that, steroid administration was terminated. Mycophenolate mofetil (MMF) was administered to patients who experienced refractory rejection or required reduction in tacrolimus or cyclosporine doses because of adverse events.

Virological Assays

Hepatitis C virus genotype was determined using a genotyping system based on polymerase chain reaction (PCR) of the core region using genotype-specific PCR primers.[17] Serum HCV RNA load was evaluated once a month during treatment and 24 weeks after treatment, using PCR and an Amplicor HCV assay (Cobas Amplicor HCV Monitor; Roche Molecular Systems, Pleasanton, CA, USA).

Statistical Analysis

Wilcoxon and Kruskal–Wallis tests, chi-square tests and t-tests were used to analyse the continuous variables, categorical variables and histological changes, respectively. The Kaplan–Meier method was used to estimate the rates of patients who showed a progression of fibrosis to stage F3 or F4 after the initiation of the interferon therapy; log-rank tests were used to compare these rates among groups. Significance was defined as P < 0.05.

Results
Characteristics of Patients

Hepatitis C virus RNA concentrations and histological evidence were used to diagnose 80 patients with recurrent hepatitis C after LDLT. These patients were given one of two combination therapies: interferon and ribavirin (n = 40) or peginterferon and ribavirin (n = 40) at Kyoto University between January 2001 and April 2007. Thirty-one of the 80 patients who received the combination therapy achieved SVR (Fig. 1). Among the remaining 49 non-SVR patients, 23 (47%) received the low-dose peginterferon maintenance therapy, while 26 (53%) discontinued treatment within 12 months and did not receive low-dose peginterferon maintenance therapy as this was the patients' wish (n = 4), because of general fatigue (n = 4), recurrent hepatocellular carcinoma (n = 4), worsening of liver function (n = 3), biliary complications (n = 3), heart failure (n = 2), brain haemorrhage (n = 1), dementia (n = 1), sinusitis (n = 1), anaemia (n = 1), neutropenia (n = 1), and haemosputum (n = 1).

756036-fig1

Figure 1. Flow diagram showing the outcome of interferon therapy for patients with recurrent hepatitis C after living donor liver transplantation and indicating the classification of patients in this study.

Of the 31 SVR patients, five were excluded because of chronic rejection (n = 3), biliary complications (n = 1) and de novo AIH (n = 1). Fifteen patients did not have liver biopsies more than 2 years after the initiation of the interferon therapy, mainly because liver function tests were normal. The remaining 11 patients were classified as the SVR group for analysis in this study. Among the 23 patients who received maintenance therapy, one patient with biliary complications and five patients who did not have liver biopsy more than 2 years after the initiation of therapy were excluded from the study. The remaining 17 patients were classified into the non-SVR-IFN group. Among the 26 patients who discontinued treatment within 12 months, three patients who initially experienced worsening of liver function were excluded because of the rapid progression of HCV; an additional three patients were excluded because of biliary complications. Eight patients were excluded because they had no liver biopsies taken more than 2 years after the initiation of the treatment. The remaining 12 patients were classified into the non-SVR-Withdrawal group. Cumulatively, we analysed the long-term histological changes of 40 patients: 11 in the SVR group (27.5% of the total), 17 in the non-SVR-IFN group (42.5% of the total) and 12 in the non-SVR-Withdrawal group (30% of the total).

There were no significant differences in the baseline characteristics among patients in the SVR, non-SVR-IFN, and non-SVR-Withdrawal groups (Table 1). The median age of patients at the beginning of therapy was 56.5 years (range, 15–70 years). The treatment started at a median of 9.5 months (range, 1.1–85.3 months) after LDLT. Thirty-five patients (88%) were infected with HCV genotype 1b. HCV genotypes of the remaining patients were 2a (n = 3), 2b (n = 1) and undetermined (n = 1). Median serum HCV RNA load was 2290 kIU/mL (range, 73.7–5000 kIU/mL); i.e. most patients had an extremely high viral load. Before the treatment, the necroinflammatory activity of all patients was A1 or greater, and 33 patients (83%) had a fibrosis score of F1 or greater. Among patients receiving tacrolimus for immunosuppression, the median serum trough level was 5.95 ng/mL (range, 3.3–10.9).

Effect of Maintenance Interferon Therapy on Liver Histology

To evaluate the efficacy of long-term peginterferon therapy on histological changes, we compared scores between final biopsy samples (median, 44.0 months; range, 24.0–81.3 months) and those taken prior to treatment. Five patients in the non-SVR-IFN group discontinued maintenance therapy between 26.5 and 53.1 months after the initiation of the treatment because of the adverse events. For these patients, the biopsies taken just before or within 3 months after discontinuation of the treatment were analysed as final biopsies. Despite the variation in time between pretreatment and final biopsy sample collection, there were no significant differences in the duration among the three groups (P = 0.547). Median duration from initiation of interferon therapy to final liver biopsy was 41.9 months (range, 24.0–81.3 months) in the SVR group, 41.7 months (range, 26.5–68.4 months) in the non-SVR-IFN group and 46.5 months (range, 30.4–79.6 months) in the non-SVR-Withdrawal group.

There were no significant differences in baseline activity grades or fibrosis stages of patients in the three treatment groups when they were first diagnosed with recurrent hepatitis C (Table 1). However, there were noticeable differences among the three groups by the end of treatment (Fig. 2a). The activity grade of all patients in the SVR and non-SVR-IFN groups improved or remained stable, whereas it deteriorated in 6 (50%) of 12 patients in the non-SVR-Withdrawal group. The fibrosis stage deteriorated in all patients in the non-SVR-Withdrawal group; nine of these patients (75%) deteriorated by more than one stage. In contrast, only four patients (24%) in the non-SVR-IFN group deteriorated, all by only a single stage. Furthermore, three patients actually improved. In the SVR group, fibrosis stage decreased or remained stable in 10 of 11 patients (91%).

756036-fig2

Figure 2. Effect of maintenance interferon therapy on liver histology: (a) Changes in activity grade (upper) and fibrosis score (lower) of individual patients before interferon therapy (Pre) and at final biopsy (final). (b) Mean changes of liver activity grade (left) and fibrosis stage (right) between pretreatment liver biopsy and the final liver biopsy in each of the three treatment groups. The error bars represent 2 SEs. (c) Kaplan–Meier estimates of the progression rates among patients whose fibrosis advanced to F3 or F4. The dashed line indicates the sustained virological response (SVR) group, the solid line indicates the non-SVR-IFN group and the dotted line indicates the non-SVR-Withdrawal group

In patients in the SVR and non-SVR-IFN groups, the mean activity grade was markedly reduced in the final biopsy, compared to the pretreatment biopsy (Fig. 2b). In contrast, patients in the non-SVR-Withdrawal group experienced an increase in activity grade. The differences between the non-SVR-Withdrawal group and both the SVR and the non-SVR-IFN groups were statistically significant (P <0.001). The mean changes in fibrosis stage in the SVR and non-SVR-IFN groups were −0.18 and +0.06, respectively, suggesting that fibrosis did not change during the follow-up period. However, there was an obvious increase (+2.2) among patients in the non-SVR-Withdrawal group, indicating marked progression of fibrosis.

The Kaplan–Meier analysis allowed us to investigate whether patients in the three treatment groups experienced different progression rates to late-stage fibrosis (Fig. 2c). No patient in the SVR group and only 1 patient (6%) in the non-SVR-IFN group developed fibrosis stage F3 or F4, whereas nine patients (75%) in the non-SVR-Withdrawal group progressed to these stages. The rates of fibrosis progression were significantly higher in the non-SVR-Withdrawal group than in the non-SVR-IFN and SVR groups (P = 0.0049 and P = 0.0086, respectively). There was no significant difference between the SVR group and the non-SVR-IFN group (P = 0.3980). Five-year progression rates to F3 or F4 were 0% in the SVR group, 14% in the non-SVR-IFN group and 54% in the non-SVR-Withdrawal group.

Safety and Tolerability of Maintenance Interferon Therapy

Five of 17 patients (29%) who received low-dose maintenance peginterferon treatment discontinued interferon therapy because of biliary complications (n = 2), neutropenia (n = 1), anaemia (n = 1) and de novo AIH (n = 1), between 26.5 and 53.1 months after its initiation. The biliary complications were not related to interferon therapy. Patients with neutropenia and anaemia recovered after discontinuing interferon therapy and were able to resume therapy within months (3 and 10, respectively). Steroid therapy alleviated the de novo AIH, but the patients did not resume interferon therapy.

Discussion

Studies have repeatedly shown the benefits of achieving SVR via interferon therapy after liver transplantation. For instance, the durability of the SVR is associated with improvements in hepatic inflammation and histological regression of fibrosis over the long-term.[18–23] In contrast, efficacy of interferon therapy for non-SVR patients after liver transplantation had not previously been investigated. Here, we have demonstrated that long-term peginterferon maintenance therapy suppresses histological progression of recurrent hepatitis C after LDLT.

Maintenance interferon therapy was recently shown to have no influence on either histological or clinical outcomes in patients with nontransplant hepatitis C.[24] This conclusion was drawn after observing that the rate of fibrosis progression was similar between treatment and control groups following a 3.5-year randomized controlled trial of low-dose peginterferon. As a large number of patients with advanced fibrosis were enrolled in the randomized controlled trial, it is difficult to compare with our study in which the number of patients studied is much smaller and patients with advanced fibrosis were not enrolled. In the current study after liver transplantation, however, we demonstrated that low-dose maintenance interferon therapy reduced necroinflammatory activity and fibrosis scores in non-SVR patients to levels similar to those in SVR patients. Furthermore, we found that non-SVR patients who discontinued treatment had significantly worse scores once no longer receiving therapy.

Although these results clearly suggest that low-dose peginterferon maintenance therapy is beneficial for non-SVR patients with recurrent hepatitis C after liver transplantation, the mechanism behind this positive response is unknown. Progression of hepatitis C and development of fibrosis after discontinuation of interferon treatment has been shown to proceed more rapidly in patients who have undergone liver transplantation.[20,21] Our results, indicating that activity grade and fibrosis stage markedly deteriorated in non-SVR patients who discontinued maintenance treatment, support these previous findings. Thus, such a rapid progression of recurrent hepatitis C in patients who discontinued interferon therapy may have highlighted the beneficial effect of the low-dose peginterferon maintenance therapy.

Another issue is the tolerability and safety of long-term peginterferon maintenance treatment. In this study, five patients (29%) discontinued the treatment during the peginterferon maintenance treatment, but only three did so for reasons directly related to the treatment. While two of these patients recovered simply by discontinuing the treatment, the third did require steroid pulse therapy to treat de novo AIH. Overall, however, the maintenance therapy did not result in the incidence of major adverse events, suggesting that it is both a tolerable and a safe treatment method.

Our work shows that long-term, low-dose peginterferon administration is an effective method for inhibiting the progression of liver damage for recurrent hepatitis C after liver transplantation. Unfortunately, this was not a randomized control study, and only a small number of patients were eligible for research. Therefore, we recommend further work to more fully explore the effects of this treatment and to improve the outcomes for patients who do not achieve SVR.

References

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  2. Feray C, Caccamo L, Alexander GJ et al. European collaborative study on factors influencing outcome after liver transplantation for hepatitis C. European Concerted Action on Viral Hepatitis (EUROHEP) Group. Gastroenterology 1999; 117(3): 619–625.
  3. Forman LM, Lewis JD, Berlin JA, Feldman HI, Lucey MR. The association between hepatitis C infection and survival after orthotopic liver transplantation. Gastroenterology 2002; 122(4): 889–896.
  4. Gane E. The natural history and outcome of liver transplantation in hepatitis C virus-infected recipients. Liver Transpl 2003; 9(11): S28–S34.
  5. Prieto M, Berenguer M, Rayon JM et al. High incidence of allograft cirrhosis in hepatitis C virus genotype 1b infection following transplantation: relationship with rejection episodes. Hepatology 1999; 29(1): 250–256.
  6. Sanchez-Fueyo A, Restrepo JC, Quinto L et al. Impact of the recurrence of hepatitis C virus infection after liver transplantation on the long-term viability of the graft. Transplantation 2002; 73(1): 56–63.
  7. Velidedeoglu E, Mange KC, Frank A et al. Factors differentially correlated with the outcome of liver transplantation in hcv+ and HCV- recipients. Transplantation 2004; 77(12): 1834–1842.
  8. Gordon FD, Kwo P, Vargas HE. Treatment of hepatitis C in liver transplant recipients. Liver Transpl 2009; 15(2): 126–135.
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  10. Berenguer M. Systematic review of the treatment of established recurrent hepatitis C with pegylated interferon in combination with ribavirin. J Hepatol 2008; 49(2): 274–287.
  11. Kuo A, Terrault NA. Antiviral therapy in liver transplant recipients: is SVR the only endpoint that matters? J Hepatol 2007; 46(3): 359–361.
  12. Ueda Y, Takada Y, Haga H et al. Limited benefit of biochemical response to combination therapy for patients with recurrent hepatitis C after living-donor liver transplantation. Transplantation 2008; 85(6): 855–862.
  13. Ueda Y, Takada Y, Marusawa H, Egawa H, Uemoto S, Chiba T. Individualized extension of pegylated interferon plus ribavirin therapy for recurrent Hepatitis C genotype 1b after living-donor liver transplantation. Transplantation 2010; 90(6): 661–665.
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  16. Ueda Y, Takada Y, Marusawa H et al. Clinical features of biochemical cholestasis in patients with recurrent hepatitis C after living-donor liver transplantation. J Viral Hepat 2010; 17(7): 481–487.
  17. Ohno O, Mizokami M, Wu RR et al. New hepatitis C virus (HCV) genotyping system that allows for identification of HCV genotypes 1a, 1b, 2a, 2b, 3a, 3b, 4, 5a, and 6a. J Clin Microbiol 1997; 35(1): 201–207.
  18. Abdelmalek MF, Firpi RJ, Soldevila-Pico C et al. Sustained viral response to interferon and ribavirin in liver transplant recipients with recurrent hepatitis C. Liver Transpl 2004; 10(2): 199–207.
  19. Bizollon T, Ahmed SN, Radenne S et al. Long term histological improvement and clearance of intrahepatic hepatitis C virus RNA following sustained response to interferon-ribavirin combination therapy in liver transplanted patients with hepatitis C virus recurrence. Gut 2003; 52(2): 283–287.
  20. Bizollon T, Pradat P, Mabrut JY et al. Benefit of sustained virological response to combination therapy on graft survival of liver transplanted patients with recurrent chronic hepatitis C. Am J Transplant 2005; 5(8): 1909–1913.
  21. Carrion JA, Navasa M, Garcia-Retortillo M et al. Efficacy of antiviral therapy on hepatitis C recurrence after liver transplantation: a randomized controlled study. Gastroenterology 2007; 132(5): 1746–1756.
  22. Fernandez I, Meneu JC, Colina F et al. Clinical and histological efficacy of pegylated interferon and ribavirin therapy of recurrent hepatitis C after liver transplantation. Liver Transpl 2006; 12(12): 1805–1812.
  23. Toniutto P, Fabris C, Fumo E et al. Pegylated versus standard interferon-alpha in antiviral regimens for post-transplant recurrent hepatitis C: comparison of tolerability and efficacy. J Gastroenterol Hepatol 2005; 20(4): 577–582.
  24. Di BisceglieAM,ShiffmanML,Everson GT et al. Prolonged therapy of advanced chronic hepatitis C with low-dose peginterferon. N Engl J Med 2008; 359(23): 2429–2441.

Source

From Journal of Gastroenterology and Hepatology

Masashi Namikawa; Satoru Kakizaki; Yutaka Yata; Yuichi Yamazaki; Norio Horiguchi; Ken Sato; Hitoshi Takagi; Masatomo Mori

Authors and Disclosures

Posted: 02/07/2012; J Gastroenterol Hepatol. 2012;27(1):69-75. © 2012 Blackwell Publishing

Abstract and Introduction
Abstract

Background and Aim: This study evaluated whether the assessment of hepatitis C virus (HCV)-RNA at 12 weeks (FW+12) post-treatment follow-up was as applicable as FW+24 to evaluate sustained virological response (SVR) using the highly sensitive real-time polymerase chain reaction (PCR) HCV assay.
Methods and Results: Two hundred and twenty-two patients with chronic hepatitis C were included in this study. Pegylated interferon (Peg-IFN) and ribavirin were administered for 24–72 weeks based on the genotype and viral load. Serum HCV-RNA was measured using real-time PCR at pretreatment, the end of treatment, FW+4, FW+8, FW+12, FW+16, FW+20 and FW+24. Two hundred patients had a virological response at the end of treatment. One hundred and forty-eight of 200 (74.0%) patients with a virological response at the end of treatment had an SVR at the FW+24. The positive predictive value (PPV) to identify patients with SVR at FW+4, FW+8, FW+12 was 87.1, 96.1, 98.0%, respectively. The viral load showed a reversion to the basal level as early as 8 weeks in relapse patients. There were only three patients who relapsed after FW+12 and all three of these patients were females with genotype Ib and a high viral load.
Conclusion: The assessment of serum HCV-RNA FW+12, using the highly sensitive real-time PCR assay, is almost as effective as FW+24 to predict SVR. However, there are false negatives in female patients with a high viral load of genotype Ib when the SVR is predicted by FW+12. The current standard with FW+24 is reasonable, but the assessment of serum HCV-RNA FW+12 may be effective in most patients.

Introduction

The recommended therapy for chronic hepatitis C is a combination of pegylated interferon (Peg-IFN) and ribavirin, and the major purpose of therapy to reach the sustained virological response (SVR).[1–4] The current standard for the determination of SVR is undetectable serum hepatitis C virus (HCV)-RNA 24 weeks (FW+24) after the end of treatment[5] and the continued viral response after FW+24.[1–4] This standard is based on the results of many previous reports that late relapse is rarely observed after FW+24.[6,7] This criterion is based on investigations using qualitative HCV-RNA assays with the lowest limits of detection of 50–100 IU/mL, to establish undetectable serum HCV-RNA at the end of therapy and after treatment.[6,7]

A highly sensitive method to detect HCV-RNA was recently developed and applied in clinical settings.[8,9] The highly sensitive methods include transcription-mediated amplification (TMA) and a real-time polymerase chain reaction (PCR) HCV assay.[8–12] Martinot-Peignoux et al.[8] reported the efficacy of a new assay based on TMA to predict SVR at FW+12. The TMA assay has a lowest detection limit of 5–10 IU/mL.[8] Theoretically, this highly sensitive method could detect residual serum HCV-RNA in a proportion of patients, who had been classified as having a virological response with a less sensitive assay.[8] Therefore, the assessment of HCV-RNA FW+12, using the TMA assay, is considered to be as effective as FW+24 to predict SVR.[8]

The real-time PCR assay is also highly sensitive to detect HCV-RNA and a popular method to assess the HCV-RNA.[9–12] Bortoletto et al.[9] reported that TMA and the real-time PCR HCV assay have comparable sensitivity and specificity in identifying minimal residual HCV-RNA. The lower limit of quantitative detection of the real-time PCR assay is 15 IU/mL[10–12] in comparison to the lowest detection limit of 5–10 IU/mL of the TMA assay.[8] However, even HCV-RNA signals below the quantitative limit are detected by the real-time PCR assay. Therefore, it is difficult to determine whether the TMA or the real-time HCV assays are optimal for the detection of minimal residual viremia at the end of antiviral therapy with Peg-IFN and ribavirin and in predicting relapse after withdrawal of treatment.

This study evaluated whether the assessment of HCV-RNA FW+12 by the real-time PCR HCV assay was as effective as FW+24 to evaluate SVR.

Methods
Patients

Two hundred and twenty-two patients with chronic hepatitis C treated with combination Peg-IFN and ribavirin therapy from April 2008 to March 2010 at Gunma University Hospital and its affiliated hospitals were included in this study. All patients fulfilled the following inclusion criteria: (i) more than 5 log IU/mL of HCV-RNA in the baseline serum, and (ii) an elevated serum ALT level for least 6 months before initiation of treatment. In addition, patients were excluded if they presented any of the following conditions: (i) decompensated liver disease; (ii) other causes of liver disease such as hepatitis B infection; (iii) autoimmune disorders; (iv) hemoglobin value < 11 g/dL; (v) white blood cell count < 3000/μL; (vi) thrombocytopenia < 70 000/μL; (vii) neoplastic disease; (viii) severe cardiac disease; (ix) other severe concurrent disease such as a preexisting psychiatric conditions; or (x) pregnancy or lactation. Informed consent was obtained from all patients enrolled in the study after a thorough explanation of the aims, risks and benefits of this therapy.

Treatment Regimens

Peg-IFN and ribavirin were administered for 24–72 weeks according to the genotype and viral load. One hundred and seventy-five patients received Peg-IFN α2b (PegIntron, Schering Plough, Tokyo, Japan) at a dose of 1.5 μg/kg per week and ribavirin (Rebetol, Schering Plough, Tokyo, Japan) at a dose of 600–1000 mg/kg per day adjusted according to body weight (600 mg for patients weighing under 60 kg, 800 mg for those between 60 kg and 80 kg, 1000 mg for those over 80 kg) for 24–72 weeks. Forty-seven patients received Peg-IFN α2a at a dose of 180 μg/week (Pegasys, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan) and weight-based ribavirin 600–1000 mg/kg per day same dosage as described above (Copegus, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan). Patients infected with genotype I and all previously treated patients were treated for 48 weeks. The genotype I patients who remained positive for HCV-RNA at 12 weeks after the start of treatment, but who become negative for HCV-RNA after 13–36 weeks of treatment received an additional 24 weeks (total 72 weeks) treatment according to the 2008 Japanese guidelines for the treatment of patients with chronic hepatitis C.[13] Patients infected with genotype II were treated for 24 weeks. The patients were followed-up for another 24 weeks after the treatment. The clinical characteristics including age, gender, body weight, and previous treatment were recorded. The aspartate aminotransferase (AST) to platelets ratio index (APRI) was calculated as the serum liver fibrosis scores according to previously published formulas: APRI = [AST (U/L)/upper limit of normal (U/L)] × 100/platelets count (109/L).[14] The time of undetectable HCV-RNA was defined as the first time that achieved undetectable HCV-RNA during the treatment period.

Study Design

The patients were included if they completed a full course of therapy. The end of treatment virological response was defined as undetectable serum HCV-RNA levels at the end of therapy. A nonresponse was defined as detectable serum HCV-RNA levels at the end of treatment. Patients with a virological end of treatment response were followed. Serum biochemistry and the HCV RNA titer were measured at pre-treatment (Pre), the end of treatment (FW+0), as well as at 4 (FW+4), 8 (FW+8), 12 (FW+12), 16 (FW+16), 20 (FW+20), and 24 (FW+24) weeks after the end of treatment. An SVR was defined as undetectable HCV-RNA in serum 24 weeks (FW+24) after the end of treatment. A virological relapse (VR) was defined as undetectable serum HCV-RNA levels at the end of treatment and detectable serum HCV-RNA at the FW+24 post treatment follow-up. Among VR patients, late VR was defined as patients with relapse occurring after FW+12. Early VR was defined as patients with relapse occurring before and/or at FW+12. The serum samples were evaluated by the real-time PCR assay (Cobas TaqMan HCV assay, Roche Diagnostics Japan, Tokyo, Japan), in which the lower limit of quantitative detection is 15 IU/mL.[10–12] HCV-RNA signals below the quantitative limit (15 IU/mL, 1.2 log IU/mL) were also detected and referred to as "low positive." HCV-RNA were measured pre-treatment and every 4 weeks after the treatment (FW+0, FW+4, FW+8, FW+12, FW+16, FW+20, FW+24) in all cases until a VR was proven. HCV-RNA assessment after the VR was optional in the cases with agreement to visit. The first time point in which viral relapse was proven was defined as VR+0, and 4 and 8 weeks after the VR+0 were defined as VR+4 and VR+8, respectively.

Single Nucleotide Polymorphisms of Interleukin-28B

The VR patient relapsed after FW+8 were genotyped for three interleukin-28B (IL28B) single nucleotide polymorphisms (SNPs), which were previously reported to be associated with therapy outcome: rs8099917, rs11881222, and rs8103142. Blood samples were genotyped using the Invader assay, as described previously.[15,16]

Statistical Analysis

Continuous variables are presented as the mean ± standard deviation (SD). Fisher's exact probability test for frequency tables was used for the statistical analysis. Distributions of continuous variables were analyzed by the Mann–Whitney U-test. The positive predictive value (PPV) was defined as the probability that the patients fulfilling the criteria at each week become SVR. Results are expressed as odds ratios (ORs) with 95% confidence intervals (CIs). The comparison of continuous variables at different time points was performed using the Wilcoxon signed-rank test. A P-value < 0.05 was considered to be significant.

Results
Clinical Characteristics and Response to Therapy

Two hundred of 222 patients demonstrated a virological response at the end of treatment. The characteristics of the 200 patients with a virological response at the end of treatment are shown in Table 1. The male : female ratio was 94:106. The mean patient age was 57.3 ± 11.1 years old (range 20–75). The mean body weight was 59.5 ± 11.5 kg. One hundred and fifty-three patients were naïve to IFN treatment, while 47 patients had received previous treatment. A schematic tree of the follow-up protocol is illustrated in Figure 1. Serum HCV-RNA outcomes during the 24 weeks post-treatment follow-up are shown in Table 2.

756516-fig1

Figure 1. Schematic tree of the follow-up protocol.

FW+4 to FW+12 Post Treatment Follow Up

The serum HCV-RNA levels were undetectable at FW+4 in 170 (85.0%) patients of the 200 patients with a virological response at the end of treatment, and 148 of these demonstrated an SVR (PPV 87.1%, 95% CI 82.0–92.1; Table 2A). The serum HCVRNA levels were undetectable at FW+8 in 154 of 200 (77.0%) patients, and the PPV for SVR was 96.1% (95% CI 93.0–99.2). The serum HCV-RNA levels were undetectable at FW+12 in 151 of 200 (75.5%) patients; the PPV for SVR was 98.0% (95% CI 95.8–100). Therefore, 49 of 52 patients with virological relapse (VR) showed a relapse within FW+12. In the patients with genotype I, the PPV of SVR was 73.1% at FW+4, 89.1% at FW+8, 94.2 % at FW+12, respectively (Table 2B). In the patients with genotypes IIa and IIb, the PPV of SVR was 96.0% at FW+4, 100.0% at FW+8, 100.0 % at FW+12, respectively (Table 2C). In the patients with genotypes IIa and IIb, the PPV of SVR was 100.0% at and after FW+8.

FW+16 to FW+20 Post Treatment Follow Up

The serum HCV-RNA levels were undetectable at FW+16 in 150 of 200 (75.0%) patients, and the PPV for SVR was 98.7% (95% CI 96.8–100 Table 2A). The serum HCV-RNA levels were undetectable at FW+20, in 149 of 200 (74.5%) patients, and the PPV for SVR was 99.3% (95% CI 98.0–100). There was only one patient with VR at each time point. In the patients with genotype I, PPV of SVR was 96.1% at FW+16, 98.0% at FW+20, respectively (Table 2B). In the patients with genotypes IIa and IIb, PPV of SVR was 100.0% at both FW+16 and FW+20 (Table 2C).

Sustained Virological Response and Virological Relapse

One hundred and forty-eight (74%) patients were SVR at the end of the post-treatment follow-up (FW+24), and 52 (26%) patients had a VR (Table 2A). The characteristics of the patients with SVR and VR are shown in Table 1. The mean age and the ratio of female patients were significantly higher in VR patients in comparison to SVR patients. The pretreatment viral load was significantly higher in VR patients in comparison to SVR patients (P < 0.05). The ratios of genotype I and retreatment patients were significantly higher in VR patients in comparison to SVR patients (P < 0.01). The adherence of ribavirin and the time of undetectable HCV-RNA were found to be significantly worse in the VR patients in comparison to SVR patients (P < 0.01). There were no differences in the serum alanine aminotransferase, hemoglobin, platelet levels, APRI, and adherence of Peg-IFN between the SVR and VR patients.

There were six patients that showed a viral relapse after FW+8 (Table 2A). Furthermore, there were only three patients who relapsed after FW+12 (late VR). Therefore, the PPV for SVR was 98.0% at FW+12. In the patients with genotypes IIa and IIb, the PPV for SVR was 100% at FW+12. The characteristics of six patients that showed a viral relapse after FW+8 are shown in Table 3. All six of these patients were female with genotype Ib and with a high viral load. The genotypes of the IL28B SNPs were major homo type in all six of these patients. As a result, the genotypes were T/T in rs8099917, A/A in rs11881222, and T/T in rs8103142, respectively. The patient demonstrating a relapse at FW+24 (Case 6) was a 67-year-old genotype Ib patient treated for 72 weeks with the combination therapy Peg-IFN α-2a plus ribavirin. The pretreatment serum HCV-RNA load was 6.5 log IU/mL, and the liver histology showed moderate liver disease (A2/F2; Metavir scoring system). The serum HCV-RNA levels were undetectable 8 weeks after the initiation of treatment. The adherence to Peg-IFN and ribavirin therapy was 91.4% and 72.7%, respectively. A comparison of the three late VR patients (after FW+12 VR) and the other 49 early VR patients (before and/or at FW+12) is shown in Table 4. No statistical differences were found in the characteristics, including the HCV genotype, viral load, age, sex, body weight, APRI, type of Peg-IFN, adherence of Peg-IFN, adherence of ribavirin, time of undetectable HCV-RNA and previous treatment between the late VR patients and early VR patients.

Serum HCV-RNA Outcome in Relapse Patients

Fifty-two of 200 patients with an end of treatment virological response showed virological relapse during the follow-up periods. After VR was proven in these cases, some patients then had their HCV-RNA levels regularly measured every 4 weeks, but other patients did not do so. In the end, only 28 patients had their HCV-RNA levels measured every 4 weeks after VR. The first time point at which viral relapse is proven is defined as VR+0. Serum HCV-RNA levels in relapse patients at baseline, the VR+0, and 4 (VR+4), 8 (VR+8) week after the VR+0 are shown in Figure 2. Serum HCV-RNA levels were: 6.4 ± 0.7 log IU/mL at baseline, 4.3 ± 1.7 log IU/mL at VR+0, 5.5 ± 1.2 log IU/mL at VR+4, and, 5.8 ± 0.9 log IU/mL at VR+8. The viral titers of VR+0 (P < 0.01), and VR+4 (P < 0.05) were significantly smaller than those at baseline. However, there were no differences in the viral titers between baseline and VR+8. The viral load showed a reversion to the basal level at 8 weeks after VR. Forty-nine of 52 patients with VR relapsed within FW+12 and the serum HCV-RNA levels in VR patients reverted to the basal level at 8 weeks after VR. These results show that the viral load increases rapidly in patients who have relapsed; namely, reaching close to baseline levels as early as 24 weeks post-treatment.

756516-fig2

Figure 2. Serum hepatitis C virus (HCV)-RNA outcome in 28 virological relapse (VR) patients. Baseline, pre-treatment; VR0, the first time point in which viral relapse was proved; VR+4, 4 weeks after VR+0; VR+8, 8 weeks after VR+0. **P < 0.01, *P < 0.01 in comparison to baseline.

Discussion

The findings of this study demonstrated that the assessment of serum HCV-RNA 12 weeks after the end of treatment, using the highly sensitive real-time PCR assay (PPV 98.0%), is closely similar to that after 24 weeks for predicting SVR. There were only three patients who relapsed after FW+12 (late VR) and all three of these patients were female patients with a high viral load of genotype Ib. As a result, in the patients with genotypes IIa and IIb, the PPV of SVR was 100.0% at FW+12. Therefore, the assessment of serum HCV-RNA FW+12 is as applicable as FW+24 to predict SVR except in female patients with a high viral load of genotype Ib.

Martinot-Peignoux et al.[8] reported the usefulness of a new assay based on TMA to predict SVR at the FW+12. They reported that the assessment of HCV-RNA FW+12 is as effective as that after 24 weeks to predict SVR with 99.7% PPV. The real-time PCR method, used in the current study, is also highly sensitive to detect HCV-RNA and it is commonly used in Japan. Bortoletto et al.[9] reported that TMA and the real-time PCR HCV assay have comparable sensitivity and specificity in identifying the minimal residual serum level of HCV. This study demonstrated that the assessment of HCV-RNA by real-time PCR at FW+12 was almost as effective as that at FW+24 to evaluate SVR in 200 Japanese patients. PPV (98.0%) of FW+12 in our study was almost as relevant as those of TMA assay (99.7%).[8] However, there were some false negative results with real-time PCR, especially in female patients demonstrating a high viral load of genotype Ib. Bortoletto et al.[9] reported that minimal residual viremia was detectable with the real-time PCR assay in patients with genotype II and with genotype IV, but not with TMA. They noted increased sensitivity of the real-time PCR assay across all major HCV genotypes in comparison to TMA.[9,17,18] Although the current standard at FW+24 is reasonable for Japanese patients by real-time PCR, the assessment of serum HCV-RNA FW+12 may therefore be appropriate for almost all patients, except for genotype Ib female patients.

Zeuzem et al.[19] reported similar results in patients treated with standard interferon α2a or Peg-IFN α2a by PCR (Amplicor HCV Monitor vs 2.0). Only six of 348 patients (2%) became HCV-RNA positive between FW+12 and FW+24.[17] These results suggest that the addition of ribavirin to Peg-IFN enhances the SVR rates but does not affect the timing of relapse.[9,19] Our study also showed that the adherence of ribavirin enhances the SVR rate but it does not affect the timing of relapse. Martinot-Peignoux et al. found no differences in VR patients treated with Peg-IFN α2a and ribavirin and in patients treated with Peg-IFN α2b and ribavirin.[8] The present study also found no differences between Peg-IFN α2a and Peg-IFN α2b. Therefore, the type of Peg-IFN does not affect the VR.

Early determination of post-treatment response status in patients can help patients make decisions and might allow relapse patients to begin alternative therapy earlier.[9] Viral load showed a reversion to the basal level within 8 weeks after the relapse in this study. The viral load increases rapidly after relapse, nearly reaching basal levels, confirming the importance of identifying relapse patients early. Patients might benefit from early retreatment with different regimens when the viral load is still low. Indeed, some patients received additional treatment just after the appearance of VR in this study.

The baseline characteristics associated with virological relapse were age, sex, HCV genotype, viral load and past history of IFN. Patients with these characteristics showed a poor response to combination Peg-IFN and ribavirin therapy.[20–22] Therefore, genotype I female old patients with previous treatment had risk factors for VR. Three of 52 VR patients showed late VR patients (5.8%). There were no significant differences in characteristics between late VR and early VR patients. Although female patients with genotype I, and a history of receiving previous treatment tended to be included in the late VR group, it did not reach the statistical significance. This may be due to the small number of late VR patients. The adherence to Peg-IFN and ribavirin by late VR patients was 95.1 + 7.6%, and 67.8 + 9.4%, respectively. The adherence to Peg-IFN and ribavirin in early VR patients was 81.5 + 21.6%, and 60.5 + 24.8%, respectively. There were no significant differences in adherence to Peg-IFN and ribavirin between the late VR and early VR patients. A genetic polymorphism near the IL28B gene, encoding interferon-lambda-3 (IFN-lambda-3), has been reported to be strongly associated with response to treatment.[23,24] In this study, the genotypes of the IL28B SNPs were major homo type in all three late VR patients. Because IL28B SNPs predict null virological response, it seems to have no value for predicting the late VR in this study. Further study is needed to clarify the differences between late VR and early VR patients because of the small number of late VR patients.

In conclusion, testing for HCV-RNA, using the highly sensitive real-time PCR assay, at FW+12, is therefore considered to be as effective as testing at FW+24 to assess a sustained virological response in patients receiving combination Peg-IFN and ribavirin therapy. As a result, the post-treatment follow-up to identify patients with SVR or VR could be shortened to 12 weeks post-treatment. However, there was a low incidence of false negatives in female patients with a high viral load of genotype Ib for predicting the SVR by FW+12. The current standard with FW+24 is reasonable, but the assessment of serum HCV-RNA FW+12 may be also be relevant and useful for evaluating similar patients other than Ib female patients.

References

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  2. Marcellin P, Boyer N, Gervais A et al. Long-term histological improvement and loss of detectable intrahepatic HCV RNA in patients with chronic hepatitis C and sustained response to interferon-alpha therapy. Ann. Intern. Med. 1997; 127: 875–81.
  3. Maylin S, Martinot-Peignoux M, Moucari M et al. Eradication of hepatitis C virus in patients successfully treated for chronic hepatitis C. Gastroenterology 2008; 135: 821–9.
  4. Suzuki H, Kakizaki S, Horiguchi N et al. Clinical characteristics of null responders to Peg-IFNa2b/ribavirin therapy for chronic hepatitis C. World J. Hepatol. 2010; 2: 401–5.
  5. Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. Diagnosis, management and treatment of hepatitis C: an update. Hepatology 2009; 49: 1335–74.
  6. Reichard O, Glaumann H, Fryden A, Norkrans G, Wejstal R, Weiland O. Long-term follow-up of chronic hepatitis C patients with sustained virological response to alpha-interferon. J. Hepatol. 1999; 30: 783–7.
  7. McHutchison JG, Poynard T, Esteban-Mur R et al. International Hepatitis Interventional Therapy Group. Hepatic HCV RNA before and after treatment with interferon alone or combined with ribavirin. Hepatology 2002; 35: 688–93.
  8. Martinot-Peignoux M, Stern C, Maylin S et al. Twelve weeks posttreatment follow-up is as relevant as 24 weeks to determine the sustained virologic response in patients with hepatitis C virus receiving pegylated interferon and ribavirin. Hepatology 2010; 51: 1122–6.
  9. Bortoletto G, Campagnolo D, Mirandola S et al. Comparable performance of TMA and Real-Time PCR in detecting minimal residual hepatitis C viraemia at the end of antiviral therapy. J. Clin.Virol. 2011; 50: 217–20.
  10. Sandres-Sauné K, Abravanel F, Nicot F et al. Detection and quantitation of HCV RNA using real-time PCR after automated sample processing. J. Med. Virol. 2007; 79: 1821–6.
  11. Sizmann D, Boeck C, Boelter J et al. Fully automated quantification of hepatitis C virus (HCV) RNA in human plasma and human serum by the COBAS AmpliPrep/COBAS TaqMan system. J. Clin. Virol. 2007; 38: 326–33.
  12. Ogawa E, Furusyo N, Toyoda K et al. Excellent superiority and specificity of COBAS TaqMan HCV assay in an early viral kinetic change during pegylated interferon alpha-2b plus ribavirin treatment. BMC Gastroenterol. 2010; 10: 38.
  13. Kumada H, Okanoue T, Onji M et al. The Study Group for the Standardization of Treatment of Viral Hepatitis Including Cirrhosis, Ministry of Health, Labour and Welfare of Japan. Guidelines for the treatment of chronic hepatitis and cirrhosis due to hepatitis C virus infection for the fiscal year 2008 in Japan. Hepatol. Res. 2010; 40: 8–13.
  14. Wai CT, Greenson JK, Fontana RJ et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology 2003; 38: 518–26.
  15. Ohnishi Y, Tanaka T, Ozaki K, Yamada R, Suzuki H, Nakamura Y. A high-throughput SNP typing system for genome-wide association studies. J. Hum. Genet. 2001; 46: 471–7.
  16. Suzuki A, Yamada R, Chang X et al. Functional haplotypes of PADI4, encoding citrullinating enzyme peptidylarginine deiminase 4, are associated with rheumatoid arthritis. Nat. Genet. 2003; 34: 395–402.
  17. Sabato MF, Shiffman ML, Langley MR, Wilkinson DS, Ferreira-Gonzalez A. Comparison of performance characteristics of three Real-Time reverse transcription-PCR test systems for detection and quantification of hepatitis C virus. J. Clin. Virol. 2007; 45: 2529–36.
  18. Chevaliez S, Bouvier-Alias M, Pawlotsky JM. Performance of the Abbott Real-Time PCR assay using m2000sp and m2000rt for hepatitis C virus RNA quantification. J. Clin. Microbiol. 2009; 47: 1726–32.
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Bread a culprit in Americans eating too much salt

Bread

Bread basket is photographed in a shop in Warsaw February 7, 2012. Credit: Reuters/Peter Andrews

By David Beasley

Tue Feb 7, 2012 6:00pm EST

(Reuters) - Nine out of 10 American adults consume too much salt and the leading culprit is not potato chips or popcorn but slices of bread and dinner rolls, the Centers for Disease Control and Prevention said on Tuesday.

Forty-four percent of salt consumed can be linked to 10 types of foods, CDC said. Bread and rolls lead the list followed by cold cuts and cured meat, pizza, poultry, soups, sandwiches, cheese, pasta dishes, meat dishes and snacks such as pretzels and potato chips.

Bread may not have much salt in a single serving, but when eaten several times a day can raise daily salt intake. A single slice of white bread could contain as many as 230 milligrams of salt, according to the CDC.

High salt intake can raise blood pressure, which can lead to heart disease and stroke, the CDC said.

The average American consumes 3,266 milligrams of salt daily, not counting salt added at the table, which is far above the recommended 2,300 milligrams, the CDC said.

For six out of 10 Americans, including those who are over age 51 or have high blood pressure or diabetes, 1,500 milligrams is the recommended daily salt limit.

Even foods that seem healthy such as cottage cheese may be high in salt, the agency reported. Even raw chicken and pork is often injected with salt.

The CDC recommended eating more fruits and vegetables and carefully reading the labels on food products to find those with the lowest salt content.

"Heart disease and stroke are leading causes of death in the United States and are largely dependent on the high rate of high blood pressure," CDC Director Dr. Thomas R. Frieden told reporters in a telephone news conference Tuesday.

One in three American adults has high blood pressure, he added.

"One of the things that is driving blood pressure up is that most adults in this country eat or drink about twice the amount of sodium as is recommended," Frieden said. "Most of that extra sodium comes from common grocery store and restaurant items and a very small proportion from the salt shaker at the table."

Nearly two-thirds of the salt consumed by Americans is found in store products, 24.8 percent from restaurants and the remainder from other sources such as vending machines and the home salt shaker, the study found.

Salt per calorie of food consumed was much higher at restaurants than from store-bought food, the CDC said.

Frieden recommended that food producers and restaurants voluntarily reduce the amount of salt in their food. A 25-percent drop in the salt content of the top 10 sodium sources would save 28,000 lives a year, he added. It would also give consumers more choice, he said.

"People can choose how much food to add at the table," he said. "They can't take it out once it's there."

The Grocery Manufacturer's Association said that the food industry has been trying to reduce the salt content of thousands of products while keeping it tasty for consumers.

"While progress is being made, reducing sodium in products without affecting the taste or consumer acceptance of products is no easy task," the industry group said in a statement emailed to Reuters.

The group said that challenges of reducing salt include finding substitutes for it that maintain the taste, and making sure that food safety standards are met because salt is a major preservative in many foods.

(Editing by Greg McCune)

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A newly published study on Alcoholic Liver Disease (Steatohepatitis) suggests that alteration in the metabolism of an essential nutrient (methionine) leads to the reduced levels of molecules (glutathione) needed to counter alcohol-induced liver injury and reviews the dietary supplementation of methionine, as a treatment. Nutri-Med Logic Corp agrees that consumption of alcohol causes such alteration but states that another culprit in alcohol-induced liver injury is the hyperactivity of a gene, which could be moderated through supplementation of another nutrient: Poly-Enyl-Phosphatidyl-Choline

Miami, Florida (PRWEB) February 08, 2012

A newly published study investigates the dietary supplementation of an essential nutrient (methionine) as a potential treatment for the alcohol-induced liver damage. Concurring, in most part, with the investigation of this study, Nutri-Med Logic Corp states that countering alcohol-induced liver injury depends on the proper activities of a pro-oxidant gene (CYP2E1), as well as the availability of nutrients such folate and choline (methyl group), which increase the levels of methionine and ultimately the production of a potent anti-oxidant (glutathione). However, Nutri-Med Logic Corp adds that any nutrient capable of contemporaneously providing the methyl group as well as directly moderating the activities of the pro-oxidant gene takes precedence.

One such important nutrient is Poly-Enyl-Phosphatidyl-Choline, an extract of soy that has been the target of studies for more than two decades, for its therapeutic potentials in Alcohol-induced Fatty Liver, Hepatitis, Fibrosis and Cirrhosis.

Elimination of alcohol takes place in two parts: converting alcohol to acetaldehydes and then to acetate. While acetate is harmless, known and used by the body, but acetaldehydes are one of the most damaging molecules implicated in pathology of alcohol-induced liver diseases, vitamin inactivation, hangover and even suggested to alter neurotransmitter, thus causing addiction.

The xenobiotics, elimination of foreign substances such as alcohol, is mainly done through a process called phase II enzymes. Glutathione, an endogenous anti-oxidant, represents the most powerful component of the phase II enzymes.

According to this published study, alcohol alteration of methionine reduces the availability of glutathione, which together with the hyperactivity of the pro-oxidant gene CYP4502E1 exert injuries to the liver.

Production of glutathione through methionine is dependent on the methyl group of folate or choline; the difference being that folate contains one methyl group but choline (betaine) contains three methyl groups. Studies going back to 1954 have established that alcohol consumption increases the requirement of choline intake. J Exp Med. 1954 Dec 1;100(6):615-27In conclusion.

Availability of methyl, through choline, increases the production of glutathione, needed to counter acetaldehydes. Poly-Enyl-Phosphatidyl-Choline is a pure and potent dietary source of choline.

On the other hand, alcohol-induced hyperactivity of the gene CYP2E1 not only results in accumulation of fat in the liver, producing alcoholic fatty liver, alcoholic hepatitis but also results in conversion of liver’s stellate cells to myofibroblasts and the subsequent production of collagens, which ultimately results in fibrosis and cirrhosis.

Poly-Enyl-Phosphatidyl-Choline, contains a component called DLPC (dilinoleoy-Phosphatidylcholine), which a plethora of studies have conclusively demonstrated its ability to moderate the alcohol-induced hyperactivities of the pro-oxidant gene CPY2E1.

In conclusion, Nutri-Med logic Corp agrees with this recently published study and the role of methionine in Steatohepatitis as well as the inconclusive results from supplementation of methionine but adds that more than two decade of studies have produced credible and favorable results from supplementation of another nutrient: Poly-Enyl-Phoshaptidyl-Choline.

Nutri-Med Logic Corp is the producer of PolyEnylPhosphatidylCholine (PPC 425mg), an extract of soy and the recommended dietary supplement for those with Fatty Liver and Alcoholic Liver Disease, in Europe for decades.

Nutri-Med Logic Corp is also the producer of the Natural, Balanced, Deodorized and Concentrated Omega-3, which is also a Pharmaceutical Grade Omega-3;
Producer of a Pharmaceutical Grade R-Alpha Lipoic Acid, the dietary supplement of choice for the Diabetics, in Germany for more than 40 years;

Nutri-Med Logic Corp invites you to visit its News Archives and Review other News Releases on the potential benefits of PolyEnylPhosphatidylcholine, Omega-3 and R-Alpha Lipoic Acid.

Nutri-Med Logic's products are Formulated Based on Nutritional Logic, made from the highest quality raw materials that are manufactured in pharmaceutical facilities, encapsulated in pharmaceutical facilities and packaged in pharmaceutical facilities.

It must be noted that the studies, sources or statements above have not been evaluated by The FDA and, thus, one should not relate the cause of any diseases, stated herein, to lack of the dietary supplements, stated herein, nor equate their supplementation to prevention, treatment or cure.

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