Hepatic steatosis in chronic hepatitis B and C: predictors, distribution and effect on fibrosis

Impact of liver steatosis on response to pegylated interferon therapy in patients with chronic hepatitis B

AIM

To evaluate the impact of liver steatosis upon response to given therapy in chronic hepatitis B (CHB) patients.

METHODS

84 consecutive CHB patients treated with 48-wk PEGylated interferon (PEG-IFN) therapy were enrolled. Baseline characteristics and sustained viral response (SVR) to PEG-IFN therapy were evaluated.

RESULTS

Mean body mass index (BMI) was 27.36 ± 4.4 kg/m². Six (7.1%) had hypertension and three (3.5%) had diabetes mellitus. Steatosis was present in 22.6% (19/84) of liver biopsy samples. Age, BMI, and triglyceride levels of the patients with hepatic steatosis were significantly higher than those without hepatic steatosis (P < 0.05). SVR to PEG-IFN therapy was 21.4% (18/84). Sixteen of these 18 CHB patients with SVR (88.9%) did not have any histopathologically determined steatosis. On the other hand, only two of the 19 CHB patients with hepatic steatosis had SVR (10.5%). Although the SVR rate observed in patients without steatosis (16/65, 24.6%) was higher compared to those with steatosis (2/19, 10.5%), the difference was not statistically significant (P > 0.05).

CONCLUSION

Occurrence of hepatic steatosis is significantly high in CHB patients and this association leads to a trend of decreased, but statistically insignificant, SVR rates to PEG-IFN treatment.

Hepatic fat quantification using chemical shift MR imaging and MR spectroscopy in the presence of hepatic iron deposition: validation in phantoms and in patients with chronic liver disease

PURPOSE

To compare the accuracy of four chemical shift magnetic resonance imaging (MRI) (CS-MRI) analysis methods and MR spectroscopy (MRS) with and without T2-correction in fat quantification in the presence of excess iron.

MATERIALS AND METHODS

CS-MRI with six opposed- and in-phase acquisitions and MRS with five-echo acquisitions (TEs of 20, 30, 40, 50, 60 msec) were performed at 1.5 T on phantoms containing various fat fractions (FFs), on phantoms containing various iron concentrations, and in 18 patients with chronic liver disease. For CS-MRI, FFs were estimated with the dual-echo method, with two T2*-correction methods (triple- and multiecho), and with multiinterference methods that corrected for both T2* and spectral interference effects. For MRS, FF was estimated without T2-correction (single-echo MRS) and with T2-correction (multiecho MRS).

RESULTS

In the phantoms, T2*- or T2-correction methods for CS-MRI and MRS provided unbiased estimations of FFs (mean bias, -1.1% to 0.5%) regardless of iron concentration, whereas the dual-echo method (-5.5% to -8.4%) and single-echo MRS (12.1% to 37.3%) resulted in large biases in FFs. In patients, the FFs estimated with triple-echo (R = 0.98), multiecho (R = 0.99), and multiinterference (R = 0.99) methods had stronger correlations with multiecho MRS FFs than with the dual-echo method (R = 0.86; P ≤ 0.011). The FFs estimated with multiinterference method showed the closest agreement with multiecho MRS FFs (the 95% limit-of-agreement, -0.2 ± 1.1).

CONCLUSION

T2*- or T2-correction methods are effective in correcting the confounding effects of iron, enabling an accurate fat quantification throughout a wide range of iron concentrations. Spectral modeling of fat may further improve the accuracy of CS-MRI in fat quantification.

Potential role of leptin, adiponectin and three novel adipokines--visfatin, chemerin and vaspin--in chronic hepatitis

Chronic hepatitis C (CHC) is generally a slowly progressive disease, but some factors associated with rapid progression have been identified. Steatosis, independently of its metabolic or viral origin, leads to liver injury and fibrosis. It is suggested that hepatitis C virus may contribute to a wide spectrum of metabolic disturbances-namely, steatosis, insulin resistance, increased prevalence of impaired glucose tolerance, type 2 diabetes mellitus and lipid metabolism abnormalities. Adipokines, which are produced mainly by adipose tissue, may influence the inflammatory response and insulin sensitivity and contribute to the development of metabolic abnormalities in CHC and also regulate fibrogenesis and angiogenesis. Visfatin was described as an adipokine with immunomodulating and proinflammatory properties that promotes B-cell maturation and enhances activation of leukocytes, synthesis of adhesion molecules and production of proinflammatory cytokines. Visfatin exerts insulin-mimetic effects, decreases plasma glucose levels and regulates cell energy balance. Chemerin stimulates chemotaxis of dendritic cells, macrophages and natural killer (NK) cells toward the site of inflammation. On the other hand, it inhibits synthesis of proinflammatory mediators and enhances adiponectin production, influences adipocyte differentiation and maturation and regulates glucose uptake in adipocytes. Vaspin expression in human adipose tissue seems to be a compensatory mechanism associated with obesity and insulin resistance. Vaspin suppresses leptin, tumor necrosis factor (TNF)-α and resistin expression. Leptin protects against liver steatosis but accelerates fibrosis progression and exacerbates the inflammatory process. In contrast, adiponectin exerts a hepatoprotective effect. In this report, data indicating a possible role of these adipokines in the pathogenesis of chronic hepatitis are summarized.

Aromatase (CYP19) promoter gene polymorphism and risk of nonviral hepatitis-related hepatocellular carcinoma

BACKGROUND

Experimental studies suggest that sex hormones may induce or promote the development of hepatocellular carcinoma (HCC). Androgens are converted to estrogens by the CYP19 gene product, aromatase. Hepatic aromatase level and activity have been shown to be markedly elevated in HCC. Aromatase expression in liver tumors is driven by a promoter upstream of CYP19 exon I.6.

METHODS

First, the authors identified an A/C polymorphism in the exon I.6 promoter of the CYP19 gene. To determine whether allelic variants in the CYP19 I.6 promoter differ in their ability to drive gene expression, we carried out an in vitro reporter gene assay. Then, the authors studied the association between this polymorphism and HCC risk in 2 complementary case-control studies: 1 in high-risk southern Guangxi, China, and another in low-risk US non-Asians of Los Angeles County.

RESULTS

Transcriptional activity was 60% higher for promoter vectors carrying the rs10459592 C allele compared with those carrying an A allele (P = .007). In both study populations, among subjects negative for at-risk serologic markers of hepatitis B or C, there was a dose-dependent association between number of high activity C allele and risk of HCC (P(trend) = .014). Risk of HCC was significantly higher (odds ratio [OR], 2.25; 95% confidence interval (CI), 1.18-4.31) in subjects homozygous for the C allele compared with those homozygous for the A allele.

CONCLUSIONS

This study provides epidemiologic evidence for the role of hepatic aromatization of androgen into estrogen in the development of nonviral hepatitis-related HCC.

Insulin resistance, steatosis, and fibrosis in Egyptian patients with chronic Hepatitis C virus infection

BACKGROUND/AIM

Both nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis C virus (HCV) infection are common in Egypt, and their coexistence is expected. There is controversy regarding the influence of NAFLD on chronic HCV disease progression. This study evaluates the effect of NAFLD on the severity of chronic hepatitis C (CHC) (necroinflammation and fibrosis) and assesses the relative contribution of insulin resistance syndrome to the occurrence of NAFLD in patients with chronic HCV infection.

PATIENTS AND METHODS

Untreated consecutive adults with chronic HCV infection admitted for liver biopsy were included in this study. Before liver biopsy, a questionnaire for risk factors was completed prospectively, and a blood sample was obtained for laboratory analysis.

RESULTS

Our study included 92 male patients. Their mean ± SD age and aspartate aminotransferase (AST) level were 42 ± 7.7 years (range 20-56) and 68 ± 41.7 U/L (range 16-214), respectively. The mean insulin level and insulin resistance index were 15.6 ± 18.3 mIU/mL (range 5.1-137.4) and 5.9 ± 15.2 (range 0.9-136.2), respectively. Fifty four percent of patients had steatosis and 65% had fibrosis. In multivariate analyses, steatosis was associated with insulin resistance and fibrosis was associated with high AST level, age ≥40 years, and steatosis.

CONCLUSIONS

Steatosis is a histopathologic feature in >50% of patients with chronic HCV infection. Insulin resistance has an important role in the pathogenesis of steatosis, which represents a significant determinant of fibrosis together with high serum AST level and older age.

Adiponectin, a downstream target gene of peroxisome proliferator-activated receptor γ, controls hepatitis B virus replication

In this study, HepG2-hepatitis B virus (HBV)-stable cells that did not overexpress HBx and HBx-deficient mutant-transfected cells were analyzed for their expression of HBV-induced, upregulated adipogenic and lipogenic genes. The mRNAs of CCAAT enhancer binding protein α (C/EBPα), peroxisome proliferator-activated receptor γ (PPARγ), adiponectin, liver X receptor α (LXRα), sterol regulatory element binding protein 1c (SREBP1c), and fatty acid synthase (FAS) were expressed at higher levels in HepG2-HBV and lamivudine-treated stable cells and HBx-deficient mutant-transfected cells than in the HepG2 cells. Lamivudine treatment reduced the mRNA levels of PPARγ and C/EBPα. Conversely, HBV replication was upregulated by adiponectin and PPARγ agonist rosiglitazone treatments and was downregulated by adiponectin siRNAs. Collectively, our results demonstrate that HBV replication and/or protein expression, even in the absence of HBx, upregulated adipogenic or lipogenic genes, and that the control of adiponectin might prove useful as a therapeutic modality for the treatment of chronic hepatitis B.

The H63D genetic variant of the HFE gene is independently associated with the virological response to interferon and ribavirin therapy in chronic hepatitis C

BACKGROUND

Conflicting results have been reported in studies evaluating the relationship between serum markers of iron overload, liver iron deposits, and HFE mutations (C282Y and H63D) in chronic hepatitis C patients, and also their impact on the response to therapy in these patients.

AIM

To evaluate the role of HFE mutations in the severity of liver disease and in the response to therapy in chronic hepatitis C.

METHODS

Two hundred and sixty-four hepatitis C patients treated with standard interferon and ribavirin were divided into two groups according to type of antiviral response: sustained virological response (SVR) and nonresponse or relapse. We evaluated the relationship between HFE mutation and the type of antiviral response, clinical data, biochemical tests, liver histopathology, virological data, and HFE mutations.

RESULTS

Of the 264 patients, 88 (32.1%) had SVR whereas 67.9% had nonresponse or relapse. Liver iron deposits were observed in 49.2% of the patients. The factors associated with SVR were hepatitis C virus genotype 2 or 3, transferrin saturation value of 45% or less, and detection of the H63D mutation. HFE mutation was more frequent in patients with iron deposits, but without association with serum iron biochemistry or severity of liver disease. Steatosis was more frequent in patients with liver iron deposits. CONCLUSION THE: H63D mutation was an independent factor associated with SVR in chronic hepatitis C patients, as also were hepatitis C virus genotype 2 or 3 and transferrin saturation value of 45% or less. Moreover, the H63D mutation was associated with liver iron deposits.

Predictors of hepatic steatosis in HBeAg-negative chronic hepatitis B patients and their diagnostic values in hepatic fibrosis

OBJECTIVE

To investigate predictors of hepatic steatosis in HBeAg-negative chronic hepatitis B (CHB) patients and their diagnostic values in hepatic inflammation and fibrosis.

METHODS

A total of 106 HBeAg-negative CHB patients with clinically and pathologically proven steatosis and 98 patients without steatosis were recruited into this study. The levels of fasting blood glucose (FBG), fasting insulin (FINS), triglyceride (TG), cholesterol (CHOL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin (Alb), globulin (Glb), HBV DNA, body mass index (BMI), homeostatic model assessment of insulin resistance (HOMA-IR) and pathological changes of the liver in inflammation, fibrosis and fatty deposition were examined in all patients.

RESULTS

The levels of BMI, HOMA-IR, FBG, insulin, TG, and CHOL were significantly higher in patients with steatosis than those without steatosis (all P<0.05). But ALT, AST and HBV DNA levels were significantly lower in patients with steatosis (all P<0.05). Logistic regression analysis showed that only FINS was a significant predictor for hepatic steatosis (P<0.05); FINS and Glb were significant predictors for hepatic inflammation (all P<0.05); BMI and TC were significant predictors for hepatic fibrosis (all P<0.05).

CONCLUSIONS

Hepatic steatosis, a common disease in HBeAg-negative CHB patients, was positively associated with BMI, FBG, FINS, TG, TC, GGT, ALP and HOMA-IR. In these patients, the prevalence of hepatic inflammation and fibrosis was also increased.

Advances in understanding the roles of leptin and adiponectin in the pathogenesis of chronic liver diseases

Leptin and adiponectin are adipokines that are abundantly expressed in adipose tissue and have multiple biological effects related to the development of human diseases. More and more studies have demonstrated that adipokines play important roles in the pathogenesis of steatosis, steatohepatitis and liver fibrosis, especially nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis C (CHC). This paper reviews the recent advances in understanding the roles of leptin and adiponectin in the pathogenesis of liver diseases.

Obesity and diabetic hyperglycemia were associated with serum alanine aminotransferase activity in patients with hepatitis B infection

Several studies have reported that obesity and diabetes are important risk factors for elevated blood aminotransferase activity in individuals with no underlying causes of liver disease. The aim of this study was to determine whether obesity and fasting glucose level were associated with hepatic dysfunction in patients with hepatitis B infection. A total of 934 patients with hepatitis B infection were enrolled, among whom increased alanine aminotransferase (ALT) activity (> or =40 IU/L) was observed in 25.1%. By univariate analysis, factors associated with increased ALT activity among patients with hepatitis B infection included body mass index (BMI), fasting blood glucose level, and blood triglyceride and high-density cholesterol levels. By multivariate logistic regression analysis, BMI and fasting blood glucose level were independent predictors of elevated ALT activity, with odds ratios of 1.73 (95% confidence interval, 1.17-2.56) for subjects with a BMI greater than or equal to 25 kg/m2 and 1.88 (95% confidence interval, 1.06-3.33) for subjects with a fasting blood glucose greater than or equal to 126 mg/dL. Even in subjects with ALT activity within the reference range, ALT activity was found to be associated with BMI. In conclusion, a BMI greater than or equal to 25 kg/m2 and a fasting blood glucose level greater than or equal to 126 mg/dL were risk factors for increased ALT activity in subjects with hepatitis B infection, suggesting that obesity and diabetic fasting hyperglycemia may aggravate liver injury in this population.

Hepatitis B virus infection among American patients with chronic hepatitis C virus infection: prevalence, racial/ethnic differences, and viral interactions

Little is known about hepatitis B virus (HBV) infection among patients with chronic hepatitis C virus (HCV) infection in the United States. We prospectively enrolled 1,257 patients with chronic HCV infection from two medical centers in New York City. A total of 61.5% (95% confidence interval, 58.8%-64.2%) had evidence of prior exposure to HBV (hepatitis B core antibody-positive), whereas 5.8% (95% confidence interval, 4.5%-7.1%) had dual infection with HBV (hepatitis B surface antigen-positive). Multivariable logistic regression analysis identified age <40 years, Asian race, injection drug use, and a greater number of lifetime sexual partners as independent risk factors for HBV-HCV dual infection. Liver biopsy results in 26 HBV-HCV-infected and 658 HCV-monoinfected patients showed that stage 3 or 4 fibrosis was significantly more common in those with HBV-HCV dual infection (84.6% versus 29.9%; P < 0.001). Patients infected with HBV and HCV had significantly lower median HCV RNA levels (1.3 versus 4.5 x 10(6) copies/mL; P < 0.001) and were less likely to have HCV RNA levels > or =5 x 10(6) copies/mL (12.3% versus 45.4%; P < 0.001) than those who had HCV monoinfection. All five patients with HBV-HCV dual infection who had undetectable HBV DNA levels had HCV RNA levels > or =5 x 10(6) copies/mL.

CONCLUSION

American patients with chronic HCV infection should be tested for HBV, especially younger patients, Asians, injection drug users, and those with an increased number of lifetime sexual partners. The presence of severe liver disease and HBV-HCV viral interactions in patients with dual infection necessitates careful but aggressive clinical management, although the optimal strategy remains to be determined.

The prevalence and clinical correlates of elevated ALT levels in an urban Chinatown community

Alanine aminotransferase (ALT) levels are a primary consideration in treatment decisions regarding hepatitis B virus (HBV) infection. Levels can be elevated as a result of HBV-related liver injury or to other causes. The aim of this study was to assess the background prevalence and clinical correlates of elevated ALT levels in Chinese immigrants who were HBsAg negative. Subjects consisted of adults seen in an urban Chinatown Internal Medicine practice between 1, 2006 and 12, 2007. Clinical information was collected retrospectively. An elevated ALT level was defined as >19 U/L for women and >30 U/L for men. The primary analysis focused on 2457 persons who were HBsAg negative. Their mean age was 55 +/- 18 years, 64% were female and 36% were obese. All subjects were ethnically Chinese and 96% were born in Asia. Thirty percent had an elevated ALT level. In univariate analysis, factors associated with elevated ALT included older age (P < 0.001), female gender (P = 0.001), obesity (P < 0.001), diabetes (P < 0.001), hypercholesterolemia (P < 0.001) and hypertension (P < 0.001). In multivariate analysis BMI, diabetes, female gender and hypercholesterolemia were significantly associated with elevated ALT level. An additional analysis focused on a group of patients who were HBsAg positive, HBeAg negative and had HBV-DNA levels <1000 copies/mL. Fifty percent had elevated ALT levels. In conclusion, elevated ALT levels are common among Chinese immigrants without HBV (30%) and are associated with features of the metabolic syndrome. Liver biopsy should be performed in selected patients with HBV to distinguish the cause of ALT elevation before initiating antiviral therapy.

Adipokines in liver diseases

Adipokines are polypeptides secreted in the adipose tissue in a regulated manner. While some of these molecules are expressed only by adipocytes, resident and infiltrating macrophages and components of the vascular stroma markedly contribute to expression of other adipokines. As a result, adipose tissue inflammation is associated with a modification in the pattern of adipokine secretion. Leptin, adiponectin, and resistin are the best-studied molecules in this class, but cytokines such as tumor necrosis factor or interleukin-6 are also secreted at high levels by the adipose tissue. Several other molecules have been recently identified and are actively investigated. Adipokines interfere with hepatic injury associated with fatty infiltration, differentially modulating steatosis, inflammation, and fibrosis. Several studies have investigated plasma levels of adiponectin in patients with nonalcoholic fatty liver disease, to establish correlations with the underlying state of insulin resistance and with the type and severity of hepatic damage. Hepatitis C is another disease where adipokines may represent a link between viral infection, steatosis, and metabolic disturbances. Identification of the mediators secreted by expanded adipose tissue and their pathogenic role is pivotal in consideration of the alarming increase in the prevalence of obesity and of the detrimental role that this condition exerts on the course of liver diseases.

Mechanisms of glucose intolerance in patients with chronic hepatitis C: Implications for treatment

Both diabetes and chronic hepatitis C virus (HCV) infection are common conditions that often coexist in the same subject. Studies seem to confirm the presence of an association between them. Mechanisms leading to HCV-induced insulin resistance and glucose intolerance are beginning to be elucidated. Insulin resistance in the setting of chronic HCV infection could be related etiologically to viral factors but is also often seen with concomitant nonalcoholic fatty liver disease, the hepatic manifestation of the metabolic syndrome. Insulin resistance decreases the likelihood of response to interferon-based therapies and may be an independent risk factor for the progression of HCV-related liver disease.

Hepatic steatosis and fibrosis in young men with treatment-naïve chronic hepatitis B

OBJECTIVES

The clinical significance of liver steatosis has been studied because steatosis plays a role in the progression of liver fibrosis. Nevertheless, the impact of steatosis in the early stage of fibrosis in non-obese young men with chronic hepatitis B (CHB) is poorly understood. Thus, the purpose of this study was to investigate the prevalence of hepatic steatosis, assess the relationship between hepatic steatosis and fibrosis and to assess the laboratory parameters for predicting clinically significant liver fibrosis in non-obese young men with CHB.

METHODS

We prospectively evaluated liver biopsies in young male patients with CHB with a serum alanine aminotransferase level of more than two times the upper limit of normal for at least 3 months before enrollment. Patients were excluded when they had co-infection with another virus and prior antiviral treatment. Demographical, anthropometric and laboratory parameters were analysed. Liver steatosis, necroinflammation and fibrosis were also assessed.

RESULTS

A total of 86 young male patients with CHB were included in this study. The median age was 21 years (range, 20-26 years) and the median body mass index was 23.0 kg/m2 (range, 18.0-28.3 kg/m2). Steatosis was present in 44 patients (51.2%). Significant fibrosis (beyond periportal fibrosis) was present in 50 patients (58.1%). Steatosis was associated with insulin, homeostasis model for insulin resistance (HOMA-IR), total cholesterol and triglycerides. On multiple regression analysis, steatosis was independently associated with triglyceride and HOMA-IR. Significant fibrosis was independently associated with gamma-glutamyltransferase (GGT) and necroinflammation activity. However, there was no significant association between significant fibrosis and the presence of steatosis.

CONCLUSIONS

The prevalence of hepatic steatosis is a common finding in young male patients with CHB. Hepatic steatosis in CHB patients seems to be associated with insulin resistance, but it is not associated with hepatic fibrosis. GGT levels can provide useful information on the stage of CHB.

Liver steatosis in patients with chronic hepatitis B infection: host and viral risk factors

BACKGROUND

Liver steatosis (LS) and chronic infection with hepatitis B virus (HBV) are two common causes of chronic liver disease in Iran. LS is also a common histopathological feature of chronic hepatitis B (CHB). Association of chronic HBV infection and LS has not been extensively studied.

AIM

We investigated the prevalence of histological evidence of LS in a group of patients with chronic HBV infection undergoing liver biopsy and compared clinical data, laboratory features, and severity of hepatic fibrosis between patients both with and without steatosis.

METHODS

A total of 132 patients with CHB, undergoing liver biopsy for diagnostic purposes over a 2-year period were enrolled in this study. Clinical, biochemical, and histological factors that might have any kind of association with the presence of steatosis were evaluated.

RESULTS

Of the 132 patients with a liver biopsy, steatosis was present in 56 (42.4%) of the patients, of whom 36 (64%) had grade 1, 14 (25%) grade 2, and six (10.7%) grade 3. Our data showed that LS is not associated with age, sex, HBeAg, viral load, amount of fibrosis, serum cholesterol level, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Although body mass index, serum triglyceride, fasting blood glucose, and gamma-glutamyl transpeptidase showed significant correlation with LS in univariate analysis, in multivariate analysis only the serum triglyceride level was significantly correlated with LS.

CONCLUSION

Steatosis is a relatively common finding in CHB and metabolic host factors rather than viral factors responsible for the presence of steatosis in these patients.

Insulin resistance is not associated with histologic severity in nondiabetic, noncirrhotic patients with chronic hepatitis B virus infection

OBJECTIVES

It is still debated whether hepatitis B virus (HBV) infection is associated with the development of diabetes. Our primary objective was to determine whether insulin resistance is associated with HBV-induced histologic severity.

METHODS

This study included consecutive 80 nondiabetic, noncirrhotic patients with HBV infection who underwent liver biopsy. We evaluated the relationship between histologic findings and clinical parameters and insulin resistance determined by the homeostasis model assessment (HOMA-IR).

RESULTS

Patients with minimal fibrosis (stage 0 or 1) had significantly higher levels of insulin and HOMA-IR (P = 0.004, P = 0.028, respectively) compared with matched healthy controls. HOMA-IR is independently associated with body mass index (coefficient, 0.16; 95% confidence interval, CI, 0.03-0.28) but not with HBV-induced histologic activity or fibrosis. Insulin resistance was not significantly different among patients with or without significant fibrosis (stage 2 or 3). In multivariate analysis, Hepatitis B e antigen (HBeAg) positivity (odds ratio, OR, 0.04; 95% CI, 0.01-0.31) and portal/periportal inflammation (OR, 18.6; 95% CI, 3.9-88.2) were independent predictors of significant fibrosis.

CONCLUSIONS

The observed hyperinsulinemia in HBV-infected patients seems to be from altered insulin metabolism rather than HBV-specific effects. Insulin resistance is not associated with significant fibrosis. The data suggest that hepatic fibrosis in HBV-infected patients is attributable to the virus-induced liver injury, but not to insulin resistance.

Peroxisome proliferator-activated receptors in HBV-related infection

Thirty years after its discovery, the hepatitis B virus (HBV) still remains a major global public health problem. Worldwide, two billion subjects have been infected, 350 million have a chronic infection and more than 600 000 die annually of HBV-related liver disease or hepatocellular carcinoma; new infections occur because of the presence of a large reservoir of chronic carriers of the virus. Since a decade several studies describe the interrelations between HBV and nuclear receptors and more particularly the peroxisome proliferator-activated receptors (PPARs). After a brief introduction, this review will make a rapid description of HBV incidence and biology. Then a report of the literature on the role of PPARs on viral transcription and replication will be developed. Finally, the role of HBV on PPARγ expression and activity will be discussed. Concluding remarks and perspectives will close this review.

Liver X receptor mediates hepatitis B virus X protein-induced lipogenesis in hepatitis B virus-associated hepatocellular carcinoma

Although hepatitis B virus X protein (HBx) has been implicated in abnormal lipid metabolism in hepatitis B virus (HBV)-associated hepatic steatosis, its underlying molecular mechanism remains unclear. Liver X receptor (LXR) plays an important role in regulating the expression of genes involved in hepatic lipogenesis. Here we demonstrate that LXRalpha and LXRbeta mediate HBV-associated hepatic steatosis. We have found that HBx induces the expression of LXR and its lipogenic target genes, such as sterol regulatory element binding protein-1c (SREBP-1c), fatty acid synthase (FAS), and peroxisome proliferator-activated receptor, and this is accompanied by the accumulation of lipid droplets. RNA interference with LXR expression decreases the amount of lipid droplets as well as the expression of the lipogenic genes, and this indicates that HBx-induced lipogenesis is LXR-dependent. LXRalpha and HBx colocalize in the nucleus and are physically associated. HBx induces the transactivation function of LXRalpha by recruiting CREB binding protein to the promoter of the target gene. Furthermore, we have observed that expression of LXR is increased in the livers of HBx-transgenic mice. Finally, there is a significant increase in the expression of LXRbeta (P = 0.036), SREBP-1c (P = 0.008), FAS, and stearoyl-coenyzme A desaturase-1 (P = 0.001) in hepatocellular carcinoma (HCC) in comparison with adjacent nontumorous nodules in human HBV-associated HCC specimens.

CONCLUSION

Our results suggest a novel association between HBx and LXR that may represent an important mechanism explaining HBx-induced hepatic lipogenesis during HBV-associated hepatic carcinogenesis.

Morphometric analysis of hepatic steatosis in chronic hepatitis C infection

BACKGROUND/AIMS

To quantitatively assess steatosis by a morphometric method and to study its relationship with other histological features of chronic hepatitis C (CHC). This was a comparative descriptive study. The study was carried out in the Department of Histopathology, Army Medical College, Rawalpindi, Pakistan, from March 2006 to March 2007.

METHODS

Patients who had undergone a liver biopsy for the evaluation of hepatitis C virus (HCV) infection were included in the study. Demographic characteristics and laboratory data were collected at the time of biopsy. The first hundred biopsy specimens that met the inclusion criteria were assessed for grades of steatosis (semiquantitatively), diameter of fat globules (by a morphometric method), necroinflammation, and fibrosis (semiquantitatively). Liver biopsies were processed for paraffin embedding, stained with hematoxylin and eosin, whereas Gomori's Reticulin stain was used for the evaluation of fibrosis.

RESULTS

Out of 46 cases showing fatty change, pansteatosis was observed in 24 (52%) patients: 12 (26%) cases had a pericentral and mid zonal distribution of fat globules and eight (17.5%) cases revealed a mid zonal pattern only. There were two (4.5%) cases in which fat globules were found in periportal and mid zonal areas. None of the histological parameters (the stage of fibrosis and grades of inflammation) had any significant correlation with these distribution patterns of steatosis. The diameter of fat droplets was quantified by morphometry. A mixed pattern of steatosis was observed more frequently (21 out of 46 cases): 17 cases had microglobules and eight biopsies showed macroglobules. The size of the fat globules exhibited a significant correlation with the stage of fibrosis (P < 0.0001). The analysis of the grades of necroinflammation did not reveal any significant relationship with the diameter of fat globules.

CONCLUSIONS

A mixed pattern of fat globules is more frequently observed in CHC, but macrovesicular steatosis is associated with a higher stage of fibrosis. Morphometry is recommended as one of the important tools for the follow-up of HCV-infected patients. Whether an accurate assessment of fat globule size by morphometry is preferred for the evaluation of patients before and after the antiviral therapy needs further research.

Insulin resistance in chronic hepatitis B virus infection

OBJECTIVES

Chronic hepatitis C virus infection is associated with insulin resistance (IR), and both host and viral factors are important in its development. The association and the predictors of IR in chronic hepatitis B virus (CHBV) infection remain unclear.

METHODS

A total of 69 CHBV-infected subjects were examined to study the relationship between histological findings and anthropometric and biochemical data, including IR determined by the homeostasis model assessment (HOMA-IR). To assess the influence of CHBV infection on IR independent of any effect of hepatic fibrosis, overweight, or sex we also compared fasting serum insulin, C-peptide, HOMA-IR, HOMA-beta (measure of beta-cell function) and C-peptide-insulin ratio (to distinguish impaired insulin degradation (low ratio) from insulin hypersecretion (normal ratio)) levels between the subset of 14 male normal weight (body mass index, BMI<23) CHBV patients with stage 0 or 1 hepatic fibrosis and 50 male normal weight healthy controls matched by age and anthropometry (BMI and waist circumference).

RESULTS

A total of 31 (44.9%) CHBV-infected patients were overweight (BMI>23 kg/m(2)) and 18 (26.1%) were obese (BMI>25 kg/m(2)). IR was seen in 34 (49.3%) patients. BMI (Spearman's coefficient=-0.436; P<0.001) and serum triglyceride levels (Spearman's coefficient=-0.307; P=0.010) were univariate predictors of IR. In multiple linear regression analysis, only BMI (P<0.001) was an independent predictor of HOMA-IR. The subgroup of CHBV-infected patients and the controls had comparable levels of all markers of IR, including fasting glucose, insulin, C-peptide, and HOMA-IR.

CONCLUSIONS

IR in CHBV-infected patients is a reflection of the host metabolic profile and CHBV infection is not in itself correlated with IR.

Hepatitis B virus X protein induces lipogenic transcription factor SREBP1 and fatty acid synthase through the activation of nuclear receptor LXRalpha

HBV (hepatitis B virus) is a primary cause of chronic liver disease, which frequently results in hepatitis, cirrhosis and ultimately HCC (hepatocellular carcinoma). Recently, we showed that HBx (HBV protein X) expression induces lipid accumulation in hepatic cells mediated by the induction of SREBP1 (sterol-regulatory-element-binding protein 1), a key regulator of lipogenic genes in the liver. However, the molecular mechanisms by which HBx increases SREBP1 expression and transactivation remain to be clearly elucidated. In the present study, we demonstrated that HBx interacts with LXRalpha (liver X receptor alpha) and enhances the binding of LXRalpha to LXRE (LXR-response element), thereby resulting in the up-regulation of SREBP1 and FAS (fatty acid synthase) in the presence or absence of the LXR agonist T0901317 in the hepatic cells and HBx-transgenic mice. Furthermore, HBx also augments the ability to recruit ASC2 (activating signal co-integrator 2), a transcriptional co-activator that controls liver lipid metabolic pathways, to the LXRE with LXRalpha. These studies place LXRalpha in a key position within the HBx-induced lipogenic pathways, and suggest a molecular mechanism through which HBV infection can stimulate the SREBP1-mediated control of hepatic lipid accumulation.

Clinical characteristics and outcome of morbidly obese bariatric patients with concurrent hepatitis B viral infection

BACKGROUND

Bariatric surgery is the only effective and long-lasting treatment of morbidly obese patients. However, the safety and efficacy of bariatric surgery in patients with hepatitis B viral (HBV) infection is not clear. The aim of the present study is to investigate whether HBV infection influences clinic features and outcomes of bariatric surgery.

METHODS

The preoperative seropositivity of HBV surface antigen (HBsAg) using radioimmunoassay was determined in 592 patients (481 female, 111 male: mean age 30.5 +/- 8.1 years; mean body mass index [BMI] 43.1 +/- 6.0) who had undergone bariatric surgery (209 banding and 383 gastric bypass) for their morbid obesity in the past 5 years. All the clinical data were prospectively collected and stored.

RESULTS

The overall seroprevalence of HbsAg was 18.8%. Morbidly obese patients positive for HBV infection were associated with older age and higher diastolic blood pressure, but not with sex, BMI, liver enzyme, blood lipid, and glucose levels. Although minigastric bypass (MGB) had a better weight reduction than gastric banding, there was no difference in weight reduction between patients who were positive and negative for HBV infection. The weight loss curves and resolution of obesity-related comorbidities were similar between the two groups except the postoperative aspartate transaminase (AST) and alanine transaminase (ALT) were significantly higher in patients who were positive for HBV infection. During follow-up, two patients developed fulminating hepatitis after MGB with one mortality.

CONCLUSION

Morbidly obese patients with the existence of HBV infection do not influence the outcome of bariatric surgery, but continuing monitor of the liver function is indicated.

Prevalence and risk factors of hepatic steatosis and its impact on liver injury in Chinese patients with chronic hepatitis B infection

BACKGROUND AND AIMS

The clinical significance of hepatic steatosis in chronic hepatitis B infection (CHB) is unclear. The aims of this study were thus to investigate the prevalence and risk factors for hepatic steatosis in patients with CHB and its relationship with liver injury.

METHODS

Consecutive patients with biopsy-proven CHB at Hangzhou Sixth People's Hospital between January 2005 and June 2007 were included. Patients co-infected with other viruses or suffering from liver disease of any other cause were excluded. Liver steatosis, necroinflammation and fibrosis were assessed by both Brunt and Scheuer classifications.

RESULTS

A total of 1915 patients (1497 men) with a mean age of 31 +/- 9.5 years were analyzed. Hepatic steatosis was present in 260 (14%) patients. The steatosis involved < 33% of hepatocytes in 90% of cases, and was more frequent among men than women (15% vs 8%, P < 0.001). Two-thirds (178 of 260) of patients with steatosis were hepatitis B e antigen (HBeAg)-positive, but there was no correlation with either serum HBeAg status or hepatitis B virus DNA titer. Degree of inflammation and fibrosis were more mild among those with steatosis than those without. Multivariate analysis showed that steatosis was independently associated with body mass index, serum triglyceride, apolipoprotein B, uric acid, and fasting blood glucose. However, fibrosis was only independently associated with age and inflammatory grade, and the latter associated with viral load and fibrosis stage.

CONCLUSIONS

Hepatic steatosis is common in CHB, it is associated with metabolic factors not viral ones, and does not appear to affect the severity of liver disease.

Retinol-binding protein 4: a new marker of virus-induced steatosis in patients infected with hepatitis c virus genotype 1

Retinol-binding protein 4 (RBP4) is an adipocytokine associated with insulin resistance (IR). We tested serum levels of RBP4 to assess its link with steatosis in patients with genotype 1 chronic hepatitis C (CHC) or nonalcoholic fatty liver disease (NAFLD). Nondiabetic patients with CHC (n = 143) or NAFLD (n = 37) were evaluated by liver biopsy and anthropometric and metabolic measurements, including IR by the homeostasis model assessment. Biopsies were scored by Scheuer classification for CHC, and Kleiner for NAFLD. Steatosis was tested as a continuous variable and graded as absent-mild <30%, or moderate-severe > or =30%. Thirty nondiabetic, nonobese blood donors served as controls. RBP4 levels were measured by a human competitive enzyme-linked immunosorbent assay kit (AdipoGen). Mean values of RBP4 were similar in NAFLD and CHC (35.3 +/- 9.3 microg/L versus 36.8 +/- 17.6; P = 0.47, respectively), and both were significantly higher than in controls (28.9 +/- 12.1; P = 0.02 and P = 0.01, respectively). RBP4 was higher in CHC patients with steatosis than in NAFLD (42.1 +/- 19.7 versus 35.2 +/- 9.3; P = 0.04). By linear regression, RBP4 was independently linked to steatosis only (P = 0.008) in CHC, and to elevated body mass index (P = 0.01) and low grading (P = 0.04) in NAFLD. By linear regression, steatosis was independently linked to homeostasis model assessment score (P = 0.03) and high RBP4 (P = 0.003) in CHC. By logistic regression, RBP4 was the only variable independently associated with moderate-severe steatosis in CHC (odds ratio, 1.045; 95% confidence interval, 1.020 to 1.070; P = 0.0004), whereas waist circumference was associated with moderate-severe steatosis in NAFLD (odds ratio, 1.095; 95% confidence interval, 1.007 to 1.192; P = 0.03).

CONCLUSION

In nondiabetic, nonobese patients with genotype 1 CHC, serum RBP4 levels might be the expression of a virus-linked pathway to steatosis, largely unrelated to IR.

Hepatic steatosis in chronic hepatitis B patients is associated with metabolic factors more than viral factors

BACKGROUND AND AIMS

Hepatic steatosis is commonly seen in chronic hepatitis C (CHC) patients. It has been reported to be associated with both metabolic factors and viral factors, and affects the severity of fibrosis in CHC. However, the relationship between hepatic steatosis and chronic hepatitis B (CHB) is unclear. The aims of this study were to investigate the frequency of hepatic steatosis in CHB patients, to identify the factors associated with its presence, and assess the relationship between the stage of steatosis and the severity of fibrosis.

METHODS

Medical records of 153 adult patients with CHB who had undergone a liver biopsy within the past 4 years were included in the study.

RESULTS

Body mass index (BMI) and age of CHB patients with steatosis was significantly higher than the patients without steatosis (P < 0.05), as determined by the univariate analysis. Steatosis was found to correlate with the BMI values and alanine aminotransferase (ALT) levels, and ALT levels were associated with hepatitis B virus (HBV)-DNA levels and histology activity index (HAI) scores, stages of fibrosis were associated with the HAI score and HBV-DNA, as determined by the multivariate analysis. In contrast, there was no significant association between advanced stages of fibrosis and steatosis.

CONCLUSION

Our data indicate that hepatic steatosis is more frequently present in CHB patients than in the general population. We hypothesize that steatosis in CHB patients may be due to metabolic factors and the ability of HBV to indirectly facilitate the development of steatosis. In the present study, steatosis in CHB patients was not found to be associated with the severity of fibrosis.

Hepatitis C virus core protein, lipid droplets and steatosis

Lipid droplets are intracellular organelles involved not only in lipid storage but also in cell signalling and the regulation of intracellular vesicular trafficking. Recent basic studies have suggested that interactions between hepatitis C virus (HCV) core protein and lipid droplets are required for the HCV infection cycle. In infected cells, the HCV core protein is associated with the surface of lipid droplets and the endoplasmic reticulum membranes closely surrounding these droplets, and its self-assembly drives virion budding. This interaction also seems to be directly linked to a virus-induced steatosis, which involves the deposition of triglycerides in the liver and contributes to the progression of fibrosis in patients with chronic hepatitis C. Many clinical studies have reported that virus-induced steatosis is significantly more severe with HCV genotype 3 than with other genotypes, and this phenomenon has been modelled in recent basic studies based on the production of HCV core proteins of various genotypes in vitro. The association of HCV core protein with lipid droplets seems to play a central role in HCV pathogenesis and morphogenesis, suggesting that virus-induced steatosis may be essential for the viral life cycle.

Specific polymorphisms in hepatitis C virus genotype 3 core protein associated with intracellular lipid accumulation

BACKGROUND

Steatosis is a common histological finding and a poor prognostic indicator in patients with hepatitis C virus (HCV) infection. In HCV genotype 3-infected patients, the etiology of steatosis appears to be closely correlated with unknown viral factors that increase intracellular lipid levels. We hypothesize that specific sequence polymorphisms in HCV genotype 3 core protein may be associated with hepatic intracellular lipid accumulation.

METHODS

Using selected serum samples from 8 HCV genotype 3-infected patients with or without steatosis, we sequenced the HCV core gene to identify candidate polymorphisms associated with increased intracellular lipid levels.

RESULTS

Two polymorphisms at positions 182 and 186 of the core protein correlated with the presence (P= .03) and absence (P= .005) of intrahepatic steatosis. Transfected liver cell lines expressing core protein with steatosis-associated polymorphisms had increased intracellular lipid levels compared with non-steatosis-associated core isolates, as measured by oil red O staining (P= .02). Site-specific mutagenesis performed at positions 182 and 186 in steatosis-associated core genes yielded proteins that had decreased intracellular lipid levels in transfected cells (P= .03).

CONCLUSIONS

We have identified polymorphisms in HCV core protein genotype 3 that produce increased intracellular lipid levels and thus may play a significant role in lipid metabolism or trafficking, contributing to steatosis.

Prevalence of elevated liver enzymes in Type 2 diabetes mellitus and its association with the metabolic syndrome

The occurrence of liver disease and raised liver enzymes is common in Type 2 diabetes, and may be multifactorial in origin. Very few studies are available on the exact prevalence of the phenomenon, however. We carried out an observational point-prevalence study of elevated liver enzymes in eight hospital-based Italian diabetes units. Data of 9621 consecutive Type 2 diabetes patients (males, 52.4%; median age, 65 yr) were analyzed, and alanine and aspartate aminotransferase (ALT, AST) and gamma-glutamyltransferase (GGT) levels were related to body mass index (BMI), metabolic control and the presence of the metabolic syndrome. ALT, AST, and GGT levels exceeding the upper limit of normal were present in 16.0%, 8.8%, 23.1%, respectively, the prevalence being higher in males, increasing with obesity class and poor metabolic control, and decreasing with age. Elevated enzymes were systematically associated with most parameters of the metabolic syndrome. After correction for age, gender, BMI, and differences across centers, elevated triglyceride levels/fibrate treatment [odds ratio (OR), 1.57; 95% confidence interval (CI), 1.34- 1.84] and an enlarged waist circumference (OR, 1.47; 95% CI, 1.17-1.85) were the only parameters independently associated with high ALT. In a separate analysis, the presence of metabolic syndrome (Adult Treatment Panel III criteria) was highly predictive of raised liver enzymes. After exclusion of hepatitis B and C positive cases, tested in 2 centers, the prevalence of raised enzymes decreased by approximately 4%, but the association with the metabolic syndrome did not change significantly. In conclusion, the high prevalence of elevated liver enzymes in Type 2 diabetes is in keeping with the well-demonstrated risk of progressive liver disease. A large amount of diabetes patients may require a thorough clinical, laboratory and histological investigation.

Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors

The natural history of chronic hepatitis B virus (HBV) infection and disease is complex and highly variable. We review the natural history of chronic hepatitis B with emphasis on the rates of disease progression and factors influencing the course of the liver disease. Chronic hepatitis B is characterized by an early replicative phase (HBeAg positive chronic hepatitis) and a late low or non-replication phase with HBeAg seroconversion and liver disease remission (inactive carrier state). Most patients become inactive carriers after spontaneous HBeAg seroconversion with good prognosis, but progression to HBeAg negative chronic hepatitis due to HBV variants not expressing HBeAg occurs at a rate of 1-3 per 100 person years following HBeAg seroconversion. The incidence of cirrhosis appears to be about 2-fold higher in HBeAg negative compared to HBeAg positive chronic hepatitis. In the cirrhotic patient the 5-year cumulative risk of developing hepatocellular carcinoma is 17% in East Asia and 10% in the Western Europe and the United States and the 5-year liver related death rate is 15% in Europe and 14% in East Asia. There is a growing understanding of viral, host and environmental factors influencing disease progression, which ultimately could improve the management of chronic hepatitis B.

Hepatic steatosis in Iranian patients with chronic hepatitis C

OBJECTIVES

To evaluate the frequency and severity of fibrosis, and also the association of various viral and host factors of steatosis in Iranian patients with hepatitis C (CHC).

SUBJECTS AND METHODS

Eighty treatment-naive CHC patients, age 37.6 +/- 11.77 years, were studied. Percutaneous liver biopsy was performed for all patients. Based on pathology reports, patients were divided into two groups: with and without significant steatosis. Hepatitis C virus RNA (HCV-RNA), various viral and host factors, and biochemical findings and genotyping of HCV were compared in the two groups.

RESULTS

Of the 80 patients, 42 (52.5%) had pathologic evidence of significant steatosis. The mean serum level of cholesterol, triglyceride, glucose, and gamma-glutamyl transpeptidase as well as the mean body mass index, viral load, stage of fibrosis and frequency of genotype 3 were significantly higher in the patients with than those without steatosis (p < 0.05). In multivariate analysis, only genotype 3 and viral load had significant association with steatosis. In patients with genotype 3 infection, the mean viral load in those with and without steatosis was 1,623,357 +/- 833,543.46 and 821,262.1 +/- 924,480 copies/ml, respectively, and the difference was statistically significant (p = 0.009). The mean viral load in patients with genotype 1 infection was not significantly different between the two groups. The mean stage of fibrosis was higher in the group that had significant steatosis (p < 0.05).

CONCLUSION

Steatosis is a common finding in Iranian patients with CHC. Infection with HCV genotype 3 and high viral load in these patients are associated with significant steatosis.

Hepatitis B and end-stage liver disease

Hepatitis B virus (HBV) is the most common cause of chronic hepatitis and end-stage liver disease worldwide. Untreated, chronic hepatitis B acquired early in life results in cirrhosis, liver failure, or hepatocellular carcinoma in up to 40% of individuals. Until recently, the options for a patient who had end-stage hepatitis B cirrhosis were severely limited, but during the past 15 years great strides have been made in prevention and treatment of hepatitis B cirrhosis. This article reviews recent advances in the understanding of the natural history, prevention, and medical management of HBV-related end-stage liver disease.

Hepatic steatosis in chronic hepatitis B develops due to host metabolic factors: a comparative approach with genotype 1 chronic hepatitis C

BACKGROUND/AIMS

Hepatic steatosis has not been adequately studied in chronic hepatitis B, while it is considered to be a cardinal feature in chronic hepatitis C and to be mainly metabolically induced in patients infected with genotype 1. We investigated the prevalence of and the parameters associated with steatosis in HBeAg-negative chronic hepatitis B.

METHODS

We studied 213 patients with HBeAg-negative chronic hepatitis B and compared them with 163 patients with genotype-1 chronic hepatitis C. Steatosis was semi-quantitatively graded.

RESULTS

Steatosis was significantly less frequent in chronic hepatitis B than chronic hepatitis C (60% versus 72%, P=0.016), but there was no difference in the prevalence of moderate/severe steatosis. In chronic hepatitis B, steatosis was associated only with higher body mass index (P=0.002), while moderate/severe steatosis was associated only with higher body mass index (P=0.043) and diabetes (P=0.031). Steatosis was relatively less frequent in chronic hepatitis B than chronic hepatitis C non-diabetic, normal-weight patients (45.6% versus 62.5%, P=0.063), but it did not differ in diabetic and/or overweight/obese patients with chronic hepatitis B or chronic hepatitis C.

CONCLUSIONS

Hepatic steatosis in HBeAg-negative chronic hepatitis B (a) is less frequent than in genotype-1 chronic hepatitis C, (b) is mainly associated with presence of host metabolic factors, such as high body mass index and diabetes and (c) does not seem to be associated with the severity of liver histological lesions.

Female hepatology: Favorable role of estrogen in chronic liver disease with hepatitis B virus infection

Chronic hepatitis B virus (HBV) infection is the most common cause of hepatic fibrosis and hepatocellular carcinoma (HCC), mainly as a result of chronic necroinflammatory liver disease. A characteristic feature of chronic hepatitis B infection, alcoholic liver disease and nonalcoholic fatty liver disease (NAFLD) is hepatic steatosis. Hepatic steatosis leads to an increase in lipid peroxidation in hepatocytes, which, in turn, activates hepatic stellate cells (HSCs). HSCs are the primary target cells for inflammatory and oxidative stimuli, and these cells produce extracellular matrix components. Chronic hepatitis B appears to progress more rapidly in males than in females, and NAFLD, cirrhosis and HCC are predominately diseases that tend to occur in men and postmenopausal women. Premenopausal women have lower hepatic iron stores and a decreased production of proinflammatory cytokines. Hepatic steatosis has been observed in aromatase-deficient mice, and has been shown to decrease in animals after estradiol treatment. Estradiol is a potent endogenous antioxidant which suppresses hepatic fibrosis in animal models, and attenuates induction of redox sensitive transcription factors, hepatocyte apoptosis and HSC activation by inhibiting a generation of reactive oxygen species in primary cultures. Variant estrogen receptors are expressed to a greater extent in male patients with chronic liver disease than in females. These lines of evidence suggest that the greater progression of hepatic fibrosis and HCC in men and postmenopausal women may be due, at least in part, to lower production of estradiol and a reduced response to the action of estradiol. A better understanding of the basic mechanisms underlying the sex-associated differences in hepatic fibrogenesis and carciogenesis may open up new avenues for the prevention and treatment of chronic liver disease.

Psoriasis patients with diabetes type 2 are at high risk of developing liver fibrosis during methotrexate treatment

BACKGROUND/AIMS

We investigated the impact of diabetes mellitus type 2, overweight, alcohol over-consumption, and chronic hepatitis B or C as risk factors, for liver fibrosis in psoriasis patients treated with methotrexate.

METHODS

One hundred and sixty-nine liver biopsies from 71 patients who underwent liver biopsies as part of the monitoring of methotrexate treatment for psoriasis were reviewed. Fibrosis, steatosis and inflammation were staged according to the NAFLD activity score.

RESULTS

Twenty-six patients had one or more of the risk factors and 25 (96%) of these (median cumulative dose methotrexate 1500 mg) developed liver fibrosis. Of those without risk factor, 26 (58%) (p=0.012) developed fibrosis (median cumulative dose methotrexate 2100 mg). Ten (38%) of the patients with risk factor(s) had severe fibrosis (stage 3-4) (mean cumulative dose methotrexate 1600 mg), while four (9%) (p=0.0012) of those without risk factors had severe fibrosis (median cumulative dose methotrexate 1900 mg).

CONCLUSIONS

Patients with methotrexate treated psoriasis and risk factors for liver disease, especially diabetes type 2 or overweight, are at higher risk of developing severe liver fibrosis compared to those without such risk factors, even when lower cumulative methotrexate doses are given.

Impact of non-alcoholic fatty liver disease on chronic hepatitis B

BACKGROUND

The impact of superimposed non-alcoholic fatty liver disease (NAFLD) is well established in patients with chronic hepatitis C (CH-C), but the impact in patients with chronic hepatitis B (CH-B) is less clear.

AIM

This study aims to evaluate the prevalence of NAFLD in patients with CH-B and the association with viral and host factors, particularly in patients with metabolic syndrome (MS).

DESIGN

Data from patients with CH-B was obtained from our databases. Patients with excessive alcohol use were excluded. Hepatitis B virus (HBV) genotyping by INNO-LIPA was available for some patients. The presence of MS was defined according to the Adult Treatment Panel III (ATP III). All biopsies were read by two hepatopathologists using Metavir, modified histologic activity index (MHAI), as well as a NAFLD pathologic protocol. Patients were classified as (1) those without NAFLD; (2) those with simple hepatic steatosis; (3) and those with superimposed non-alcoholic steatohepatitis (NASH). Factors associated with superimposed NAFLD, its subtypes, and hepatic fibrosis were also analysed.

RESULTS

Subjects included 153 HBV patients [66% male, age 50.5+/-27.5 years, body mass index 24.7+/-3.7 kg/m(2), waist 83.2+/-10.9 cm; 8.5% Caucasian, 67% Asian, aspartate aminotransferase (AST) 63.2+/-88.2 IU/l, alanine aminotransferase (ALT) 98.6+/-164.6 IU/l, glucose 111.6+/-50.5 mg/dl, HBV-DNA 1.8 x 10(8)+/-1.9 x 10(6) copies/ml, 7% with MS, 13% with diabetes, 20% with arterial hypertension and 8.5% with dyslipidaemia]. Liver biopsy was available for 64 subjects [19% had superimposed NAFLD, 13% had superimposed NASH, 86% had some degree of fibrosis, and 39% had advanced fibrosis (Ishak >3)]. Patients with HBV and superimposed NASH were significantly older (55 vs. 42 years, P=0.008), more likely to have hypertension (63% vs. 15%, P=0.006) and dyslipidaemia (50% vs. 8%, P=0.006), and had a larger waist circumference (92 vs. 83 cm, P=0.03). The presence of fibrosis was associated with higher waist circumference (84 vs. 80 cm, P=0.03), higher HBV-DNA (1.9 x 10(8) vs. 5 x 10(6) copies/ml, P=0.005), and elevated ALT >40 IU/l (73.6% vs. 33.3%, P=0.02).

CONCLUSIONS

The components of MS (obesity, hypertension, and dyslipidaemia) are associated with the presence of NASH in patients with CH-B. The presence of hepatic fibrosis seems to be associated with known host and viral factors as well as the presence of abdominal obesity.

A growing burden: the pathogenesis, investigation and management of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic disorder in western countries, and its incidence is increasing. This review outlines the significant health burden posed by NAFLD and discusses what is presently known about its pathogenesis, including the roles of the metabolic syndrome, obesity, insulin resistance, hepatic steatosis, reactive oxygen species, inflammatory cytokines and adipocytokines. The way in which NAFLD is clinically diagnosed is described, and areas of uncertainty surrounding its investigation are identified, before discussing the relative merits of the limited treatment options available and looking ahead to potential therapeutic strategies for the future.

Hepatitis B virus X protein induces hepatic steatosis via transcriptional activation of SREBP1 and PPARgamma

BACKGROUND & AIMS

Hepatic steatosis occurs frequently in patients with chronic hepatitis B virus (HBV) or chronic hepatitis C virus (HCV) infection. Recently, several studies suggested that steatosis plays an important role as a cofactor in other liver diseases such as hepatic fibrosis, hepatitis, and liver cancer. In contrast to HCV, however, the molecular mechanism by which HBV mediates hepatic steatosis has not been clearly studied. Here, we show the molecular mechanism by which hepatitis B virus X protein (HBx) induces hepatic steatosis.

METHODS

Lipid accumulation and the expression of various lipid metabolic genes were investigated in HBx-transfected Chang liver cells, HepG2-HBx stable cells, and HBx-transgenic mice.

RESULTS

Overexpression of HBx induced hepatic lipid accumulation in HepG2-HBx stable cells and HBx-transgenic mice. It also up-regulated the messenger RNA and protein levels of sterol regulatory element binding protein 1, but not peroxisome proliferator-activated receptor alpha (PPARalpha). Moreover, we also determined that the expression of HBx increases PPARgamma gene expression as well as its transcriptional activity in hepatic cells, mediated by CCAAT enhancer binding protein alpha activation. Finally, we showed that HBx expression is able to up-regulate the gene expressions of various lipogenic and adipogenic enzymes in hepatic cells.

CONCLUSIONS

We showed that the increased HBx expression causes lipid accumulation in hepatic cells mediated by sterol regulatory element binding protein 1 and PPARgamma, which could be a putative molecular mechanism mediating the pathophysiology of HBV infection.

Hepatic steatosis has no impact on the outcome of treatment in patients with chronic hepatitis B infection

BACKGROUND

Hepatic steatosis, as a predictive factor in treatment outcome, was not investigated in chronic hepatitis B (CHB). The aim of this retrospective analysis is to determine possible relationships between hepatic steatosis and treatment response in patients with CHB.

METHODS

One hundred forty patients with CHB [42 hepatitis B e antigen (HBeAg)-positive, 98 HBeAg-negative] were analyzed. Seventy-eight patients (55.7%) received pegylated interferon alpha 2a 180 mug/wk subcutaneously and 62 patients (44.3%) received pegylated interferon alpha 2a 180 mug/wk plus lamivudine 100 mg/d combination therapy.

RESULTS

The presence of steatosis was associated with increased body mass index and hyperlipidemia. The sustained virologic response (SVR) rates in HBeAg-negative patients were 36.2% and 31.5% in patients with and without steatosis, respectively (P>0.05). The SVR rates in HBeAg-positive patients were 39.6% and 33.3% in patients with and without steatosis, respectively (P>0.05). The prevalence of hepatic steatosis did not significantly affect the outcome of treatments in both groups. In pegylated interferon monotherapy group (group 1), SVR was 18/78 (23%) and in the pegylated interferon plus lamivudine combination group (group 2) SVR was 16/62 (26%), (P>0.05, NS). The independent factors affecting the treatment outcome were higher baseline alanine aminotransferase level and lower baseline viral load.

CONCLUSIONS

The prevalence of steatosis is a common finding in CHB infection; however, it is not associated with viral load and treatment outcome.

[Steatosis and non-alcoholic steatohepatitis in patients with chronic hepatitis due to hepatitis C virus infection]

BACKGROUND

[corrected] Hepatic steatosis is a common finding in patients with hepatitis C, mainly virus C genotype 3. Steatosis in these cases might be associated with antiviral treatment response and with prognosis of chronic hepatitis.

AIMS

To determine the presence of steatosis and non-alcoholic steatohepatitis in chronic hepatitis C and its correlation with genotype and hepatic fibrosis.

PATIENTS AND METHODS

One hundred and twenty patients with chronic hepatitis C were retrospectively evaluated; genotype was done in 102 patients. All specimens were stained with hematoxylin-eosin, picrosirius and perls. Staging of hepatitis C was scored by Brazilian Classification and the diagnosis of non-alcoholic steatohepatitis by the American Association for the Study of Liver Diseases criteria

RESULTS

Steatosis was found in 65 of 120 cases (54.2%); it was mild in 37/65 (56.9%), moderate in 12/65 (18.5%) and severe in 10/65 (15.4%). In relation to fibrosis, 80 of 120 patients had mild fibrosis F0-F2 (66.6%) and 40 (33.3%) had more advanced fibrosis (F3 or F4). Steatosis was associated with genotype 3 (76.7%) in comparison with other genotypes (49,0%). There were no relationship between steatosis and advanced fibrosis F3/F4 (52,5%) or mild fibrosis (54,4%). Non-alcoholic steatohepatitis was diagnosed in 8/120 cases (6.7%) and was significantly associated with hepatitis C virus genotype 3 and with advanced fibrosis (F3 and F4)

CONCLUSIONS

The presence of steatosis and non-alcoholic steatohepatitis in chronic hepatitis C are associated to genotype 3; moreover non-alcoholic steatohepatitis was correlated with more advanced fibrosis.

Sonographic fatty liver and hepatitis B virus carrier status: Synergistic effect on liver damage in Taiwanese adults

AIM: To examine the epidemiology of hepatitis B virus carrier status (HBVC) and sonographic fatty liver (SFL) in Taiwanese adults, and to evaluate their possible interaction in inducing liver damage (LD). From an epidemiological viewpoint, we analyzed previous studies which indicated that fatty liver sensitizes host immune response to HBV infection and enhances liver damage.

METHODS: A cross-sectional retrospective analysis of health records including medical history, physical examination, abdominal sonogram, blood biochemistry and hepatic virological tests. We utilized the Student’s t-test, chi-square, multivariate logistic regression and synergy index to assess risks for LD.

RESULTS: Among a total of 5406 Taiwanese adults (mean age 46.2 years, 51.5% males), the prevalence of LD, HBVC and SFL were 12.3%, 15.1% and 33.4%, respectively; 5.1% of participants had SFL plus HBVC. Multivariate logistic regression analysis demonstrated that male gender (odds ratio (OR) = 2.8, 95% confidence interval (CI): 2.3-3.5), overweight state (OR = 1.6, 95% CI: 1.3-2.0), HBVC (OR = 2.5, 95% CI: 2.0-3.1) and SFL (OR = 4.2, 95% CI: 2.2-5.3) were independently associated with LD. Synergism analysis showed that the adjusted OR for LD in adults with HBVC-alone was 3.3 (95% CI: 2.4-4.6), SFL-alone, 4.7 (95% CI: 3.7-6.1) and combined HBVC and SFL, 9.5 (95% CI: 6.8-13.3); the synergy index was 1.4 (95% CI: 1.001-2.0).

CONCLUSION: In Taiwanese adults, SFL plus HBVC have a significant synergistic association with LD.

Histological assessment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is an important complication of the metabolic syndrome, which is becoming an increasingly common cause of chronic liver disease. Histological changes typically mainly affect perivenular regions of the liver parenchyma and include an overlapping spectrum of steatosis, steatohepatitis and persinusoidal or pericellular fibrosis, in some cases leading to cirrhosis. Once cirrhosis has developed, typical hepatocellular changes are often no longer conspicuous, leading to such cases being mistakenly diagnosed as 'cryptogenic'. Portal inflammation, ductular reaction and periportal fibrosis can also be seen as part of the morphological spectrum of NAFLD, particularly in the paediatric population. Hepatocellular carcinoma has also been described as a complication of NAFLD-associated cirrhosis. NAFLD is also an important cofactor in other chronic liver diseases, especially hepatitis C. Histological assessments have an important role to play in the diagnosis and management of NAFLD. These include making the potentially important distinction between simple steatosis and steatohepatitis and providing pointers to the aetiology, including cases where a dual pathology exists. A number of systems have been devised for grading and staging the severity of fatty liver disease. These require further evaluation, but have a potentially important role to play in determining prognosis and monitoring therapeutic responses.

The evolving role of leptin and adiponectin in chronic liver diseases

Leptin and adiponectin, the main metabolic products of adipose tissue, have been implicated in a wide spectrum of human diseases. Given the frequent presence of hepatic steatosis in several chronic liver diseases, there is currently increasing interest in the role of these adipokines in the development of hepatic steatosis and also in necroinflammation and fibrosis, mostly in patients with nonalcoholic fatty liver disease or chronic hepatitis C. According to experimental data, reduced adiponectin levels and increased leptin levels associated with leptin resistance, which are usually observed in obese patients with or without metabolic syndrome, may result in fat accumulation in the liver and in the enhancement of liver inflammation and mostly fibrogenesis. Increased leptin and decreased adiponectin serum levels have been detected initially in patients with nonalcoholic steatohepatitis and more recently in patients with chronic hepatitis C compared to healthy controls in most but not all studies, while the data on the associations between these adipokine levels and the severity of hepatic steatosis or fibrosis are still rather conflicting. However, several potential confounding parameters were not evaluated in all studies. Therefore, the associations between adipokines and liver histological lesions and their effects on liver cells should be evaluated further in prospective, carefully designed studies, including larger cohorts of patients with detailed assessment of metabolic and other potential confounding factors.

Chronic hepatitis B viral infection independently predicts renal outcome in type 2 diabetic patients

AIMS/HYPOTHESIS

We examined the association between chronic hepatitis B virus (HBV) infection and clinical outcomes in a consecutive cohort of Chinese patients with type 2 diabetes.

SUBJECTS, MATERIALS AND METHODS

Between 1995 and 1999, 2,838 type 2 diabetes patients underwent comprehensive assessments and blood screening for hepatitis B surface antigen (HBsAg). The risk of occurrence of cardiovascular events and end-stage renal disease (defined as need for dialysis, doubling of serum creatinine or serum creatinine > or =500 micromol/l) was compared between HBsAg-positive and HBsAg-negative groups.

RESULTS

At baseline, HBV-infected patients (n=286, 10.1%) were younger (51.0+/-11.5 vs 53.7+/-12.7 years, p=0.004), had earlier onset of diabetes (51.0+/-11.5 vs 53.7+/-12.7 years, p=0.001) and a higher frequency of retinopathy (28 vs 22%, p=0.03) than non-HBV-infected patients. After a median follow-up of 3.5 years (interquartile range: 1.7-5.9 years) and adjustment of age, glycaemic control and other potential confounding factors, HBV-infected patients were more likely to develop end-stage renal disease than non-HBV infected patients (8.7 vs 6.4%) with a hazard ratio of 4.5 (95% CI 1.1-18.6). The difference in the frequency of cardiovascular endpoints was not statistically significant.

CONCLUSIONS

In Chinese type 2 diabetes patients, chronic HBV infection was associated with increased risk of end-stage renal disease, and this was independent of other potential confounding factors. Early identification of HBV status and close surveillance of renal function are important in patients with type 2 diabetes who are living in areas where HBV is endemic or who are at risk of chronic HBV infection.

Prevalence of liver steatosis in patients with chronic hepatitis B: a study of associated factors and of relationship with fibrosis

OBJECTIVES

The clinical significance of hepatic steatosis in chronic hepatitis B virus patients is poorly understood. The purpose of this study was to determine risk factors for liver steatosis in chronic hepatitis B patients and its relationship with fibrosis.

METHODS

We retrospectively evaluated liver biopsies from patients with chronic hepatitis B treated in our department. Patients co-infected with other viruses (hepatitis C virus, HIV) or suffering from liver disease of any other cause were excluded from the study, as well as patients consuming alcohol above 30 g/day for males or 20 g/day for females. Liver steatosis, necroinflammation and fibrosis were assessed.

RESULTS

A total of 233 patients with chronic hepatitis B were included in the study. The mean age was 44.7+/-16.2 years. There were 164 men (70.4%) and 69 women (29.6%). The majority of patients were HbeAg-negative, 196/233 (84.1%). Thirty-seven patients had cirrhosis (15.9%). Steatosis was present in 42 patients (18%). Steatosis was independently associated with fasting glucose level (P=0.019) and being overweight (body mass index >or=25; P=0.021). No correlation was found with stage of fibrosis, grade of inflammation, alcohol use or other parameters. Ninety-four out of 233 patients (40.3%) had advanced fibrosis. Patients with advanced fibrosis were older than those with minimal or no fibrosis (47.6+/-17 versus 42.3+/-15.2 years, P=0.024) and more frequently had a higher grade of necroinflammation activity (57/94 (60.6%) versus 26/139 (18.7%), P<0.0001). There was no significant association between advanced fibrosis and the presence of steatosis or mild alcohol consumption.

CONCLUSION

Hepatic steatosis is present in 18% of our patients with biopsy-proven chronic hepatitis B. Steatosis is independently associated only with body mass index and fasting glucose level, risk factors for metabolic steatohepatitis, and was not correlated with the degree of fibrosis.

Hepatitis C -- identifying patients with progressive liver injury

Hepatitis C follows a variable course with some patients developing progressive liver fibrosis, cirrhosis and hepatocellular carcinoma, while others have minimal or no significant liver disease after decades of infection. Studies have identified both host and viral factors associated with disease progression. The importance of general factors such as age at infection, gender, immune status and alcohol consumption has long been recognized; however recently, polymorphisms in a wide array of genes have also been shown to be associated with progressive fibrosis. How specific viral proteins may contribute to disease progression has also been studied. This review highlights what is currently known about the factors associated with progressive liver injury in patients with hepatitis C. A greater understanding of the determinants of disease progression will hopefully lead to improved utilization of existing treatments and ultimately may aid in identification of new therapeutic targets.