Management of hepatitis C virus genotype 4: recommendations of an international expert panel

HCV has been classified into no fewer than six major genotypes and a series of subtypes. Each HCV genotype is unique with respect to its nucleotide sequence, geographic distribution, and response to therapy. Genotypes 1, 2, and 3 are common throughout North America and Europe. HCV genotype 4 (HCV-4) is common in the Middle East and in Africa, where it is responsible for more than 80% of HCV infections. It has recently spread to several European countries. HCV-4 is considered a major cause of chronic hepatitis, cirrhosis, hepatocellular carcinoma, and liver transplantation in these regions. Although HCV-4 is the cause of approximately 20% of the 170 million cases of chronic hepatitis C in the world, it has not been the subject of widespread research. Therefore, this document, drafted by a panel of international experts, aimed to review current knowledge on the epidemiology, natural history, clinical, histological features, and treatment of HCV-4 infections.

Pioglitazone improves virological response to peginterferon alpha-2b/ribavirin combination therapy in hepatitis C genotype 4 patients with insulin resistance

BACKGROUND & AIM

Insulin resistance (IR) affects sustained virological response (SVR). The use of insulin-sensitizing agents has been proposed to improve therapy outcome. The safety and efficacy of pioglitazone on insulin sensitivity and SVR in treatment-naïve patients with chronic hepatitis C (CHC) genotype 4 with IR receiving standard antiviral therapy were evaluated in a randomized-controlled study.

METHODS

Ninety-seven previously untreated patients with CHC and IR [homeostasis model assessment (HOMA>2)] were randomly assigned into two arms; (arm A; n=48) were given pioglitazone 30 mg/day combined with peginterferon (Peg-IFN)-alpha-2b/ribavirin (RBV) for 48 weeks, and (arm B; n=49) were given standard of care (Peg-IFN-alpha-2b/RBV for 48 weeks); HOMA index and hepatitis C virus RNA (HCV RNA) levels were measured at baseline, during therapy and follow-up. Treatment was stopped in patients without an early virological response or those who were HCV RNA positive at 24 weeks.

RESULTS

Baseline data of both groups were comparable, with no significant statistical differences. The percentages of rapid virological response (RVR) and SVR were significantly higher in patients given triple therapy compared with standard of care (27.08 vs. 6.1%; P=0.006 and 60.4 vs. 38.7%; P=0.04 respectively); patients in arm A showed a greater decrease in the HOMA index than those in arm B (-1.8 +/- 0.3, -2.1 +/- 0.3 vs. -1.1 +/- 0.6, -1.3 +/- 0.7) at week 24 and at the end of follow-up (P=0.001 at both time points). The triple therapy was well tolerated.

CONCLUSIONS

A combination of pioglitazone, Peg-IFN-alpha-2b and ribavirin increased RVR, SVR and decreased IR, compared with patients given Peg-IFN plus ribavirin without an increase in adverse events.

Insulin resistance predicts rapid virologic response to peginterferon/ribavirin combination therapy in hepatitis C genotype 4 patients

OBJECTIVES

In patients with chronic hepatitis C (CHC) of genotype 4, the predictors of rapid virologic response (RVR) have not been determined adequately. We aimed to assess which pretreatment variables might predict an RVR and a sustained virologic response (SVR).

METHODS

A total of 131 non-diabetic, genotype 4 CHC patients were enrolled for analysis and treated with peginterferon-alpha-2b/ribavirin. Insulin resistance (IR) was evaluated by homeostasis model assessment-IR (HOMA-IR). Hepatitis C virus (HCV)-RNA levels were measured at baseline, during therapy and at follow-up.

RESULTS

The overall SVR rate was 60.3%. The SVR rate in patients with an RVR was 100%. Age, HOMA-IR, fibrosis, severity of the steatosis, and HCV viral load were all significantly associated with RVR in the univariate analysis. After logistic regression, both HOMA-IR (odds ratio: 0.12, P=0.002) and HCV viral load (odds ratio: 1.43, P=0.02) remained independent variables associated with RVR. Age, HOMA-IR, viral load, fibrosis, RVR, and "complete" early virological response were all significantly associated with SVR in the univariate analysis. After logistic regression, fibrosis (odds ratio: 5.23, P=0.007), HOMA-IR (odds ratio: 14.29, P=0.004), and viral load (odds ratio: 0.16, P=0.005) were independent factors associated with SVR. By linear regression, body mass index (P=0.001) and waist circumference (P=0.0003) were independently associated with HOMA-IR.

CONCLUSIONS

IR is a major determinant of both RVR and SVR in genotype 4 CHC patients. HOMA-IR would seem to be a useful tool for predicting the response to therapy.

Targeting host factors: a novel rationale for the management of hepatitis C virus

Hepatitis C is recognized as a major threat to global public health. The current treatment of patients with chronic hepatitis C is the addition of ribavirin to interferon-based therapy which has limited efficacy, poor tolerability, and significant expense. New treatment options that are more potent and less toxic are much needed. Moreover, more effective treatment is an urgent priority for those who relapse or do not respond to current regimens. A major obstacle in combating hepatitis C virus (HCV) infection is that the fidelity of the viral replication machinery is notoriously low, thus enabling the virus to quickly develop mutations that resist compounds targeting viral enzymes. Therefore, an approach targeting the host cofactors, which are indispensable for the propagation of viruses, may be an ideal target for the development of antiviral agents because they have a lower rate of mutation than that of the viral genome, as long as they have no side effects to patients. Drugs targeting, for example, receptors of viral entry, host metabolism or nuclear receptors, which are factors required to complete the HCV life cycle, may be more effective in combating the viral infection. Targeting host cofactors of the HCV life cycle is an attractive concept because it imposes a higher genetic barrier for resistance than direct antiviral compounds. However the principle drawback of this strategy is the greater potential for cellular toxicity.

Association between metabolic abnormalities and hepatitis C-related hepatocellular carcinoma

BACKGROUND AND AIM

Metabolic syndrome is recognised as a potential risk factor for the development of hepatocellular carcinoma (HCC). The association between metabolic factors and hepatitis C (HCV)-related HCC has not yet been well clarified. This study was conducted to elucidate the role of metabolic factors in HCV-related HCC.

MATERIAL AND METHODS

We recruited 147 HCC patients and compared them with 147 matched CHC patients and 320 controls. The plasma levels of homeostasis model assessment-IR (HOMA-IR), adiponectin and lipids for all participants were assessed.

RESULTS

The HCC group showed significantly higher levels of insulin, glucose, HOMA-IR and adiponectin as well as lower levels of total cholesterol, HDL-C, LDL-C, and triglycerides compared with the matched CHC patients and controls. HOMA-IR did not correlate with pathologic features of HCC, whereas serum adiponectin levels correlated positively with the size of tumour nodules (P = 0.009). Based on stepwise logistic regression analysis, age (OR: 1.456, 95% CI: 1.072-1.979, P < 0.01), HOMA-IR (OR: 2.50, 95% CI: 1.70-3.69, P = 0.001), and adiponectin (OR: 1.585, 95% CI: 1.269-1.980, P = 0.001) were independently associated with HCC.

CONCLUSIONS

Metabolic abnormalities are closely associated with the occurrence and development of HCV-related HCC. Patients with CHC and high serum adiponectin levels face a higher risk of developing liver cancer. Insulin resistance, as measured by HOMA-IR, is significantly associated with HCV-related HCC.

Seroprevalence of hepatitis C and B among blood donors in Egypt: Minya Governorate, 2000-2008

It is an interesting issue to study the prevalence of hepatitis C and B viruses in Egypt in the last decade. In this study, the overall hepatitis B surface antigen and antibody to hepatitis C virus prevalence were 1.65% and 9.02%, respectively. Antibody to hepatitis C virus and hepatitis B surface antigen prevalence estimates dropped from 11.06% to 6.3% (P = .001) and 1.24% to 1.17% (P = .2), respectively.

Serum lipids and chronic hepatitis C genotype 4: interaction and significance

BACKGROUND & AIM

Metabolic abnormalities are common in chronic hepatitis C infection (CHC). However, the genotypic differences of these disarrangements in patients infected with CHC genotype 4 (HCV-4) and its association with liver histology and viral loads remain unknown.

MATERIAL AND METHODS

We consecutively enrolled 183 HCV-4 patients and 106 healthy matched controls; to compare metabolic profiles and assess pattern of association of HCV RNA levels as well as histological factors with the serum lipid profile.

RESULTS

HCV-4 infection is associated with higher homeostasis model assessment of insulin resistance (HOMA-IR) index, despite that, a favourable lipid pattern, consisting of an elevation in HDL- C and a reduction in serum cholesterol (TC), LDL-C and triglyceride (TG) levels, in comparison with normal matched adults. Significant fibrosis was independently associated with HOMA-IR, portal/periportal inflammation grade, serum cholesterol and age. Univariate association was elucidated between lower LDL-C and TC and Metavir activity score and between higher TG and TC and steatosis. In multivariate analysis, severe hepatitis activity, milder hepatic fibrosis, and triglyceride levels are associated with higher HCV RNA levels.

CONCLUSION

HCV-4 is associated with wide metabolic changes. A proportional relationship is found between serum lipid profiles and hepatitis C viral load and liver histology in patients with HCV-4.

Role of biomarkers in the prediction and diagnosis of hepatocellular carcinoma

The prevalence of hepatocellular carcinoma (HCC) has progressively increased in recent years and is now the fifth and the second most common cancer in the World and in Egypt, respectively. Much work has focused in the development of assays for detecting hepatic carcinogensis before the observance of hepatic focal lesions. Particular attention has been directed towards HCC-specific biomarkers for use in the early diagnosis of HCC and in the confirmation of radiological studies. Although a number of biomarkers have been identified, none have been considered reliable indicators of early HCC lesions. This review presents a few of the most relevant HCC biomarkers and suggests improvements to the accuracy of diagnostic assays through their combined use. Furthermore, we present an algorithm for the biomarker-based diagnosis of HCC and highlight its important role in the early prediction of HCC.

Association of serum adipocytokines with insulin resistance and liver injury in patients with chronic hepatitis C genotype 4

BACKGROUND

Hepatitis C virus (HCV) infection, especially genotypes 1 and 4, is associated with metabolic dysfunction. We investigated the potential role of adipocytokines in HCV-induced insulin resistance (IR) and modulating the progression of liver disease in patients with HCV-4.

METHODS

Serum adiponectin, high molecular weight adiponectin, leptin, tumor necrosis factor-α, interluekin-6, homeostasis model for the assessment of insulin resistance, and M30 protein were measured in 147 HCV patients and 89 controls. Liver biopsies were evaluated for steatosis/inflammation/fibrosis, adiponectin mRNA/protein, AdipoR1/-R2 mRNA, and phosphoenolpyruvate carboxykinase gene expression, and adiponectin and CD95 immunoreactivity.

RESULTS

CD95 immunoreactivity and adiponectin immunoreactivity were detected in all biopsies examined. Hepatic adiponectin immunostaining correlated positively with the intensity of hepatic CD95/Fas immunostaining (r=0.424; P=0.001). Hepatocyte CD95/Fas upregulation correlated with fibrosis, inflammation, and steatosis (r=0.52, P=0.0001; r=0.16, P=0.04; r=0.24, P=0.0001; respectively). Significant correlations of serum adiponectin, its receptors mRNA expression, hepatic adiponectin immunostaining, and mRNA transcription for phosphoenolpyruvate carboxykinase were identified with steatosis. A positive association between adiponectin and hepatic inflammation and fibrosis was identified. This correlation remained significant even after adjusting for age, sex, and body mass index. Among body mass index, age, and sex-matched HCV-negative controls, patients with HCV-4 have higher serum leptin, adiponectin, and high molecular weight adiponectin, and these changes are independently correlated with IR.

CONCLUSIONS

Our findings in patients with HCV-4 show that adiponectin correlates with IR and with the different stages of liver injury. Steatosis upregulates hepatocyte CD95/Fas and thus increases apoptosis, which facilitates inflammation and fibrosis. These findings may provide potential clues for novel therapeutic intervention.

Hepatic steatosis in genotype 4 chronic hepatitis C patients: implication for therapy

BACKGROUND AND AIM

The association of hepatitis C virus genotype 4 (HCV-4) with hepatic steatosis has not been clarified. We aimed to determine the parameters associated with steatosis among HCV-4 patients and to assess the effect of steatosis on treatment with peginterferon and ribavirin.

METHODS

In a prospective study; 131 nondiabetic genotype 4 CHC patients were enrolled for analysis, treated with peginterferon-α-2b/ribavirin. Histopathologic, anthropometric, clinical, biochemical features, and insulin resistance (IR) estimated by the homeostasis model assessment index (HOMA-IR).

RESULTS

Hepatic steatosis was present in 58 patients (44.2%); 62% of them experienced mild steatosis. In univariable analysis, steatosis was associated with HOMA-IR, body mass index, waist circumference, serum triglycerides, cholesterol level, systolic hypertension, and histologic scores for inflammation and fibrosis. Multivariate analysis revealed that body mass index, waist circumference, and HOMA-IR were found to be significantly associated with steatosis. IR but not steatosis was associated with a lower rate of sustained virologic response when adjusted for known factors that predict response (odds ratio: 0.16, 95% CI 0.046-0.59, P=0.005).

CONCLUSIONS

In HCV-4 patients, the prevalence of steatosis was 44.2%; the majority (62%) has mild steatosis. Steatosis was significantly associated with metabolic factors. IR but not steatosis was independently associated with lower sustained virologic response.

Novel non-invasive biological predictive index for liver fibrosis in hepatitis C virus genotype 4 patients

AIM

To investigate the diagnostic ability of a non-invasive biological marker to predict liver fibrosis in hepatitis C genotype 4 patients with high accuracy.

METHODS

A cohort of 332 patients infected with hepatitis C genotype 4 was included in this cross-sectional study. Fasting plasma glucose, insulin, C-peptide, and angiotensin-converting enzyme serum levels were measured. Insulin resistance was mathematically calculated using the homeostasis model of insulin resistance (HOMA-IR).

RESULTS

Fibrosis stages were distributed based on Metavir score as follows: F0 = 43, F1 = 136, F2 = 64, F3 = 45 and F4 = 44. Statistical analysis relied upon reclassification of fibrosis stages into mild fibrosis (F0-F) = 179, moderate fibrosis (F2) = 64, and advanced fibrosis (F3-F4) = 89. Univariate analysis indicated that age, log aspartate amino transaminase, log HOMA-IR and log platelet count were independent predictors of liver fibrosis stage (P < 0.0001). A stepwise multivariate discriminant functional analysis was used to drive a discriminative model for liver fibrosis. Our index used cut-off values of ≥ 0.86 and ≤ -0.31 to diagnose advanced and mild fibrosis, respectively, with receiving operating characteristics of 0.91 and 0.88, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio were: 73%, 91%, 75%, 90% and 8.0 respectively for advanced fibrosis, and 67%, 88%, 84%, 70% and 4.9, respectively, for mild fibrosis.

CONCLUSION

Our predictive model is easily available and reproducible, and predicted liver fibrosis with acceptable accuracy.

Detection of hepatitis C virus (HCV) RNA in the peripheral blood mononuclear cells of HCV-infected patients following sustained virologic response

It is unclear whether direct-acting antiviral drugs (DAAs) result in the complete eradication of HCV infection or whether some quantities of the virus may persist after achieving a sustained virologic response (SVR). Aim The aim of this work was to study the possibility of the persistence of HCV RNA in peripheral blood mononuclear cells (PBMCs) after achieving SVR following DAA treatment. This study included 100 patients infected with HCV genotype 4, who were candidates for receiving DAAs and who achieved SVR during follow-up, as determined at 12 and/or 24 weeks following the end of treatment. All patients were subjected to demographic, biochemical and hematological assessments. Detection of HCV RNA in the serum and PBMCs and determination of the HCV genotype were performed with real-time PCR. We detected HCV RNA in the PBMCs of 20 out of 100 (20%) patients infected with HCV genotype 4, who achieved SVR. However, the persistent viral load in the PBMCs was very low (range: 400-900 U/mL; mean ± SD: 645.45 ± 153 U/mL). Multiple logistic regression analysis showed that only the higher posttreatment levels of aspartate transaminase (AST) were significantly predictive of HCV RNA persistence in the PBMCs (OR: 1.29; 95% CI: 1.08-1.55). Additionally, according to the Cox proportional hazard model, liver cirrhosis was the only significant risk factor for the persistence of HCV infection in PBMCs (HR: 5.8; 95% CI: 1.3-26.1; P < 0.02). Our results indicated the persistence of HCV RNA in some HCV patients who achieved SVR after treatment with DAAs.

Hepatitis C virus as a multifaceted disease: a simple and updated approach for extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus infection is an emerging disease and a public health problem in the world. There are accumulating data regarding extra hepatic manifestation of HCV, such as rheumatologic manifestations, endocrine, hematologic, dermatologic, renal, neurologic, and systemic manifestations. The therapy of them needs more attention to some exacerbations of extra hepatic manifestation and in some situation it needs different approaches. In this review we tried to provide latest evidence for extra hepatic manifestation and management of them.

Changes in adipocytokines and insulin sensitivity during and after antiviral therapy for hepatitis C genotype 4

BACKGROUND

Hepatitis C virus (HCV) infection, especially genotypes 1 and 4, is associated with wide metabolic disarrangements.

AIM

To assess whether host metabolic factors influence sustained virological response (SVR) in patients with chronic hepatitis C genotype 4 (HCV-4) treated with peginterferon / ribavirin and to evaluate the impact of antiviral therapy on insulin resistance (IR) and serum levels of adipocytokines.

METHODS

Changes in levels of adiponectin, leptin, TNF-α and the homeostasis model assessment for insulin resistance (HOMA-IR) on antiviral combination in patients with HCV-4 were analyzed and effect on response was studied.

RESULTS

107 patients were included (M/F 86/21; mean age 41.4±5.6 years). Neither serum adipocytokines nor HOMA-IR was correlated with viral load. SVR was achieved by 57% of patients and was associated with fibrosis score (odds ratio: 6.5; P = 0.001) and adiponectin level (odds ratio: 1.3; P = 0.01). At the end of follow-up, HOMA-IR, adiponectin, leptin and TNF-α were reduced, all these changes unrelated to predicting the outcome of treatment. At follow-up, HOMA-IR and adiponectin continued to decrease in patients with SVR, but remained unchanged significantly in patients who did not response or relapse.

CONCLUSIONS

Serum adiponectin at baseline appears to be an independent predictor for the achievement of SVR and can be utilized as an additional predictive marker. Changes of IR and adipocytokines occur under treatment which is more evident with the resolution of HCV infection, suggesting that HCV could have a direct role in these metabolic changes.