Chronic hepatitis C: effect of alcohol on hepatitic activity and viral titre

Hepatitis C infection in African Americans: its natural history and histological progression

OBJECTIVE

The aim of this retrospective analysis was to determine the natural history of hepatitis C virus infection in African Americans versus non-African Americans by evaluating the clinical, virological, and histological findings.

METHODS

We examined in a retrospective manner the demographics, mode of infection, virological features, and histological progression of HCV infection in African Americans versus non-African Americans. There were 355 patients who met criteria based on adequate liver biopsy specimens and exclusion of other hepatic diseases.

RESULTS

African Americans (n = 112) were significantly more likely to be infected with genotype 1 virus (88%) than were non-African Americans (n = 243; 67%; p < or = 0.001). Baseline HCV RNA levels were similar, although baseline ALT values were significantly lower in African Americans (80.0 microl +/- 5.5 vs 112.1 microl +/- 6.2; p < or = 0.001). African Americans were significantly older at the time of presentation and were significantly more likely to be women (p < or = 0.02). In African Americans, there was a trend toward less cirrhosis (22% vs 30%; p < or = 0.1) and significantly less piecemeal necrosis on liver biopsy. Non-African Americans had significantly higher fibrosis scores, ALT values, and piecemeal necrosis ratings, and tended to progress more rapidly to cirrhosis. This difference in histological progression between the two groups was not explained by differences in alcohol consumption.

CONCLUSION

The lower ALT, piecemeal necrosis scores, and slower progression of fibrosis in African Americans may reflect less immunological recognition of HCV-infected liver cells.

Expression of interferon alfa signaling components in human alcoholic liver disease

Interferon alfa (IFN-alpha) is currently the only well-established therapy for viral hepatitis. However, its effectiveness is much reduced (<10%) in alcoholic patients. The mechanism underlying this resistance is not fully understood. In this study, we examined the expression of IFN-alpha signaling components and its inhibitory factors in 9 alcoholic liver disease (ALD) and 8 healthy control liver tissues. In comparison with normal control livers, expression of IFN-beta, IFN-alpha receptor 1/2, Jak1, and Tyk2 remained unchanged in ALD livers, whereas expression of IFN-alpha, signal transducer and activator of transcription factor 1 (STAT1), and p48 were up-regulated and expression of STAT2 was down-regulated. Expression of antiviral MxA a karyophilic 75 kd protein induced by IFN in mouse cells carrying the influenza virus resistance allele Mx(+) and 2'-5' oligoadenylate synthetase (OAS) proteins was not regulated, whereas expression of double-stranded RNA-activated protein kinase (PKR) was decreased by 55% in ALD livers. Three families of inhibitory factors for the JAK-STAT signaling pathway were examined in ALD livers. Members of the suppressor of cytokine signaling (SOCS) family, including SOCS 1, 2, 3, and CIS, and the protein tyrosine phosphatases, including Shp-1, Shp-2, and CD45, were not up-regulated in ALD livers, whereas the phosphorylation of and protein levels of p42/44 mitogen-activated protein kinase (p42/44MAP kinase) were increased about 3.9- and 3.2-fold in ALD livers in comparison with normal control livers, respectively. In conclusion, these findings suggest that chronic alcohol consumption down-regulates STAT2 and PKR, but up-regulates p42/44 mitogen-activated protein kinase (p42/44MAP kinase), which may cause down-regulation of IFN-alpha signaling in the liver of ALD patients.

Limited success of HCV antiviral therapy in United States veterans

OBJECTIVE

The treatment of hepatitis C virus (HCV) infection in United States veterans has become a major task for the Veterans Administration Healthcare System. Although the comprehensive diagnosis and treatment of HCV-infected patients has been mandated, little is known about the performance characteristics of HCV clinics and about the outcomes of antiviral therapy in this unique patient population.

METHODS

We retrospectively examined clinic show rates, treatment eligibility, and the response to antiviral therapy in a dedicated HCV outpatient clinic in a large urban Veterans Affairs medical center.

RESULTS

Our data demonstrate that few veterans--regardless of their age or ethnic background--pursue evaluation and treatment of their HCV infection by hepatologists. A minority of those patients who undergo a comprehensive clinic evaluation meet the standard eligibility criteria for antiviral therapy. The overall efficacy of antiviral treatment, as measured by the sustained virological response rate, is substantially lower than previously reported in randomized clinical trials. HCV-infected veterans are characterized by a unique combination of risk factors that are predictive of a poor response to antiviral therapy, including a preponderance of male gender, HCV genotype I, age > 40 yr, and histologically advanced degrees of liver disease.

CONCLUSIONS

Our study demonstrates the limitations of outpatient HCV treatment initiatives in the United States veteran population, and suggests that the overall impact of current HCV treatment programs may be small.

Intrahepatic hepatitis C virus replication is increased in patients with regular alcohol consumption

AIMS

To assess clinical significance of liver hepatitis C virus RNA levels and their relationship with epidemiological, biochemical and histological factors.

METHODS

A total of 50 patients (mean age 35.5+/-7 years) with biopsy-proven chronic hepatitis C infection were recruited. Risk factors were drug abuse (n=21), transfusion (n=16), other parental routes (n=8; surgery=3, tattooing=5), and idiopathic (n=5). Duration of infection was 16+/-9 years. All patients showed abnormal alanine aminotransferase levels and positive serum hepatitis C virus RNA. Hepatitis C virus genotype was assessed by Inno-Lipa. Liver biopsy was performed for histology and for hepatitis C virus RNA quantification by Amplicor-HCV-Monitor Daily alcohol consumption was recorded on two occasions by anamnesis. Inflammation grade was mild (n=31) or severe (n=19). Fibrosis was early stage (n=42) or advanced (n=8).

RESULTS

Mean hepatitis C virus RNA levels were 9.4x10(5)+/-1.5x10(6) copies/microg of total RNA in liver tissue, and 9.1x10(5)+/-1.3x10(6) copies/ml in serum. Viral load in liver was positively correlated with that in serum (r=0.51, p<0.001) and there was a significant relationship between daily alcohol consumption and intrahepatic hepatitis C virus burden (r=0.53; p<0.001). Patients infected with genotype 3a showed lower intrahepatic hepatitis C virus load than patients infected with genotype 1b; albeit without reaching statistical significance (0.49x10(6)+/-0.89x10(6) vs 1.44x10(6)+/-1.9x10(6) copies/microg of total RNA; p=NS). No relationships were observed between liver viral burden and age, risk factor status, duration of infection, ferritin and alanine aminotransferase levels or with grading and staging.

CONCLUSIONS

Hepatitis C virus load in serum is a mirror of intrahepatic hepatitis C virus levels. Chronic alcohol consumption enhances intrahepatic hepatitis C virus concentration.

Liver transplantation for alcoholic cirrhosis: long term follow-up and impact of disease recurrence

BACKGROUND

Alcoholic liver disease has emerged as a leading indication for hepatic transplantation, although it is a controversial use of resources. We aimed to examine all aspects of liver transplantation associated with alcohol abuse.

METHODS

Retrospective cohort analysis of 123 alcoholic patients with a median of 7 years follow-up at one center.

RESULTS

In addition to alcohol, 43 (35%) patients had another possible factor contributing to cirrhosis. Actuarial patient and graft survival rates were, respectively, 84% and 81% (1 year); 72% and 66% (5 years); and 63% and 59% (7 years). After transplantation, 18 patients (15%) manifested 21 noncutaneous de novo malignancies, which is significantly more than controls (P=0.0001); upper aerodigestive squamous carcinomas were overrepresented (P=0.03). Thirteen patients had definitely relapsed and three others were suspected to have relapsed. Relapse was predicted by daily ethanol consumption (P=0.0314), but not by duration of pretransplant sobriety or explant histology. No patient had alcoholic hepatitis after transplantation and neither late onset acute nor chronic rejection was significantly increased. Multiple regression analyses for predictors of graft failure identified major biliary/vascular complications (P=0.01), chronic bile duct injury on biopsy (P=0.002), and pericellular fibrosis on biopsy (P=0.05); graft viral hepatitis was marginally significant (P=0.07) on univariate analysis.

CONCLUSIONS

Alcoholic liver disease is an excellent indication for liver transplantation in those without coexistent conditions. Recurrent alcoholic liver disease alone is not an important cause of graft pathology or failure. Potential recipients should be heavily screened before transplantation for coexistent conditions (e.g., hepatitis C, metabolic diseases) and other target-organ damage, especially aerodigestive malignancy, which are greater causes of morbidity and mortality than is recurrent alcohol liver disease.

Influence of chronic alcohol abuse on hepatitis C virus replication

BACKGROUND

Patients with alcoholic liver disease have a high prevalence of hepatitis C virus (HCV) infection. Several workers have shown that HCV-infected alcoholics have more severe biochemical and histological evidence of liver disease than anti-HCV-negative patients. One possible mechanism for the increased liver damage is that alcohol may have a stimulatory effect on HCV replication. The present study was carried out to examine this issue in detail.

METHODS

Sixty-eight HCV-infected patients, comprising of 50 chronic alcoholics, consuming 80 g or more of alcohol daily for at least 5 years, and 18 completely abstinent subjects were included in the study. Quantitative HCV-RNA was performed by the branched chain DNA (bDNA) technique.

RESULTS

There was no significant difference in the mean serum HCV titers in chronic alcoholics compared to nonalcoholic subjects. Linear regression analysis showed no correlation between the daily ethanol consumption and HCV titers. Seven of the chronic alcoholics, 4 of whom were continuing to drink and 3 who had become abstinent, were retested after 6 months. There was no definite trend in the viral titers, either in abstinent individuals or in those who continued to drink.

CONCLUSIONS

These findings suggest that chronic alcohol abuse does not influence the HCV load in the serum. Therefore, the observation that alcoholics with HCV infection have more severe liver damage requires some other explanation than increased HCV viral titers.

Commercial tattooing as a potentially important source of hepatitis C infection. Clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status

Tattooing in commercial tattoo parlors is known to transmit blood-borne viral infections, including hepatitis C virus (HCV), in other countries, but its contribution to the high population prevalence of HCV infection in the United States has been incompletely evaluated. Risk factors for blood-borne infection were assessed by physician's interview of 626 consecutive patients undergoing medical evaluation for spinal problems in 1991 and 1992 while unaware of their HCV status. Later all were screened for HCV infection with enzyme-linked immunosorbent assay (EIA-1 and EIA-2), and positives were confirmed with second-generation recombinant immunoblot assay (RIBA). Forty-three patients were seropositive for HCV (sample prevalence 6.9%, population-standardized prevalence 2.8%). Logistic regression analysis identified 4 independent risk factors for HCV infection: injection-drug use (adjusted prevalence odds ratio [OR] = 23.0; 95% confidence intervals [CI] = 7.5-70.6), ancillary hospital jobs held by men (OR = 9.6; 95% CI = 3.8-24.3), tattoos from commercial tattoo parlors (OR = 6.5; 95% CI = 2.9-14.8), and drinking > or = 3 6-packs of beer per month (OR = 4.0; 95% CI = 1.8-8.7). If causal, these 4 risk factors account for 91% of HCV infections, with tattooing explaining 41%, heavy beer drinking 23%, injection-drug use 17%, and ancillary health care jobs for men 8%. Transfusions, promiscuous sexual activity, bone grafts, acupuncture, perinatal or intimate transmission in families, and other modes were not independently associated with serologic evidence of HCV infection. Unlikely to be explained by confounding or incomplete disclosure of other risk factors, tattooing in commercial tattoo parlors may have been responsible for more HCV infections than injection-drug use.

Hepatitis C: an update on the silent epidemic

Hepatitis C virus (HCV) currently infects an estimated 2-3 million people in the United States and 175 million people globally. Over 80% of infected patients go on to develop chronic disease. Most patients remain asymptomatic despite silent, insidious progression of the disease. The sequelae of HCV-induced chronic liver disease accounts for 8,000-10,000 deaths annually in the United States and is currently the leading indication for liver transplantation. The cost of this epidemic to the United States was estimated in 1991 at $600 million in terms of medical expenses (excluding costs related to liver transplantation) and work lost. Over the last decade, since the viral genome of HCV was first sequenced in 1989, there has been a great increase in understanding of this infection. This review summarizes current knowledge about the hepatitis C epidemic with particular reference to epidemiology of infection, viral characteristics, risk factors for disease, diagnostic testing, clinical manifestations, and current, as well as potential, therapeutic options.

Alcohol-induced liver disease

Hepatic changes resulting from the regular ingestion of alcohol are many and include fat infiltration, alcoholic hepatitis, and cirrhosis. Only 10% to 15% of chronic alcoholics develop liver disease. Women are more susceptible. An area of considerable importance is the high prevalence of concomitant infection with hepatitis C virus in chronic alcoholics. Patients who have hepatitis C and alcohol-induced liver injury are much more likely to develop progressive liver disease and cirrhosis. Corticosteroid therapy has proven useful in the treatment of patients with severe acute alcoholic hepatitis.

Hepatitis C and alcohol

A close relationship and possible interaction has been noted between alcohol intake and hepatitis C virus infection, since the discovery of HCV markers. It is not understood whether these are additive or synergistic effects in causing liver injury. Interactions between alcohol and HCV may be studied at several levels, including epidemiology, virology (including viral load), histology (effect on the severity of liver lesions), carcinogenesis (the role of alcohol in the occurrence of hepatocellular carcinoma), and the effect on the extrahepatic manifestations or severity of HCV infection. At the epidemiological level, a high prevalence of HCV infection was noted in patients with alcoholic liver diseases (14-37%), also characterized by a high rate of viral replication as detected by PCR, which was present in over 90% of patients tested. Moreover, the prevalence of anti-HCV antibodies increased proportionally with the severity of liver lesions. Virological analysis based on the determination of HCV RNA levels in the serum showed variations of HCV RNA levels with diet, and a clear relationship between self reported alcohol consumption and the levels of serum HCV RNA (r = .26, p = .001). At the histologic level the role of alcohol may be evaluated either through the development of fibrosis or by determination of the incidence of cirrhosis. A study on the effect of alcohol intake below or over 40 g per day on the histologic progression of liver lesions has confirmed a more rapid increase in fibrosis and a doubling in the incidence of cirrhosis in patients admitting to alcohol consumption >40 g per day. The role of alcohol in the occurrence of hepatocellular carcinoma in patients with cirrhosis due to HCV infection has been extensively studied with controversial results. A recent case control study performed in Italy showed that the relative risk of HCC in patients with HCV infection and heavy alcohol consumption doubled. Finally, alcohol consumption potentially worsens the evolution of dermatological diseases associated with HCV infection such as porphyria cutanea tarda. All of the above are strong arguments which should be used to advise HCV patients against alcohol consumption, regardless of the degree of liver injury. However, the deleterious effect of the occasional intake of small amounts of alcohol has not been demonstrated and therefore an occasional drink may be allowed in some cases.

The alcoholic patient with hepatitis C virus infection

Chronic alcoholism in patients with chronic hepatitis C hastens disease progression toward development of cirrhosis and hepatocellular carcinoma. Approximately 30% of alcoholic patients with liver disease are infected with the hepatitis C virus (HCV), the primary risk factor being a history of injection drug use. The histologic pattern in alcoholics is typically indistinguishable from nonalcoholic patients similarly infected with chronic hepatitis C. The mechanism(s) involved in alcohol-induced enhancement of chronic hepatitis C have not entirely been established but may involve increased viral replication, iron overload, and immune suppression. Still to be determined is the minimum amount of daily alcohol intake, if any, that can be ingested without enhancing progressive liver injury. However, chronic hepatitis C patients undergoing treatment with interferon must abstain from any alcohol intake, because the efficacy of interferon therapy is significantly lower in those who continue to drink. Future research efforts are needed in order to further delineate the epidemiology and pathogenesis of chronic hepatitis C in the alcoholic patient.

Factors contributing to the evolution and outcome of cirrhosis in hepatitis C

A number of factors are important in the evolution of chronic hepatitis C to cirrhosis. These include the length of time that the patient has been infected, the age at exposure, dual infection with other viruses, alcohol use, and genotypes, especially in liver transplant recipients. The diagnosis of cirrhosis is made by clinical assessment of the patient, the use of imaging studies, a thoughtful laboratory evaluation, and histologic examination of liver tissue.

Hepatitis C: role of the advanced practice nurse

Hepatitis C virus (HCV) is a common but insidious and indolent viral infection that can lead to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. This article provides the advanced practice nurse with current information on prevalence, incidence, spread, and clinical course of hepatitis C. It presents a discussion of the methods of diagnosis, treatment, and management of affected patients. To date, the diagnosis of hepatitis C in the United States has been serendipitous because no surveillance and screening programs have been established. It has been estimated that approximately 4 million persons in the United States are infected with HCV, with only 30% presently diagnosed. Patients with hepatitis C must make informed choices regarding their care and treatment. As more people are diagnosed with hepatitis C, the advanced practice nurse is at the forefront of providing information about spread and diagnosis, treatment options available, and potential side effects of antiviral therapy. The decision to treat chronic HCV must be made in collaboration with other medical experts in hepatology and antiviral therapy, and it must be made with knowledge and understanding of all facets of the disease process and adverse effects of therapy.

Hepatitis cRNA quasispecies complexity in patients with alcoholic liver disease

Alcohol abuse is described as a major cofactor in the development of hepatitis C (HCV) associated liver disease and may play a role in the outcome of interferon-based treatment interventions. The association between HCV viral heterogeneity and alcohol has not been previously described. This study was designed to evaluate the quasispecies nature of the HCV population in patients with compensated and decompensated alcoholic liver disease, to test the hypothesis that alcoholics have greater complexity than matched nonalcoholic controls. A nonisotopic heteroduplex complexity assay (HCA) was first validated by comparison with results of quasispecies complexity determined by subcloning and sequencing of amplicon products from the E2/NS1 hypervariable coding region (HVR). Subsequently, this methodology was applied to comparison of 20 compensated (Child's-Pugh A) and decompensated (Child's-Pugh B/C) alcoholic and 20 nonalcoholic controls. The complexity of the HVR, as well as the 5' Untranslated (5'UT) and the NS5b coding domains were evaluated. The HCA methodology provided a reasonable semiquantitative measure of HCV RNA quasispecies variability compared with subclone sequence homology comparison. Overall, alcoholic patients had greater quasispecies complexity (2.65 bands) than nonalcoholic controls (1.6 bands; P =.01). Subset analysis revealed that compensated alcoholic patients had a mean of 3.1 homo/heteroduplex bands per sample whereas Child's-Pugh B/C alcoholics showed intermediate complexity. A similar quasispecies complexity difference was seen in the 5'UTR, but not in the NS5b coding domain. Quasispecies complexity was not associated with viral titer, complementary DNA concentration, or genotype. The differences in quasispecies complexity may help explain reports of poor interferon responsiveness in alcoholic patients.

Hepatitis C in state correctional facilities

BACKGROUND

No previous studies have examined the extent to which correctional facilities in the United States screen for and treat hepatitis C (HCV) infection.

METHODS

Medical directors of state correctional facilities responded to a survey assessing the degree to which prisons screen for and treat hepatitis C. To estimate numbers of inmates eligible for interferon treatment and to examine costs associated with HCV management, we constructed a feasibility model that incorporated screening criteria used in California and Rhode Island.

RESULTS

Thirty-six states and Washington, DC, responded, resulting in a survey response rate of 73%, representing 77% of all inmates in state facilities nationwide. Colorado alone reported routine screening. Only California reported conducting a systematic seroprevalence study, which found that 39.4% of male inmates were hepatitis C antibody positive in 1994. Seventy-three percent of the respondents sometimes consider treating with interferon. Four states follow a standard protocol. The feasibility model suggests that treating suitably screened inmates is a reasonable expenditure for correctional systems.

CONCLUSION

Prison may be an appropriate setting for treatment of hepatitis C. If accompanying substance abuse issues are addressed, instituting HCV treatment for certain eligible incarcerated individuals may be a worthy target for public health dollars.

Effect of alcohol consumption on serum hepatitis C virus RNA and histological lesions in chronic hepatitis C

The role of alcohol intake in the occurrence of severe liver disease in chronic hepatitis C virus (HCV) carriers is still debated. A cross-sectional study has been conducted in 233 chronic hepatitis C virus carriers. Weekly self-reported alcohol consumption (SRAC) was evaluated, serum HCV RNA levels were measured by a branched DNA technique (Quantiplex 2.0) and HCV genotypes were determined. A liver biopsy was performed simultaneously and liver lesions were graded with the Knodell histological activity index. Data were examined by uni- and multivariate analyses. Alcohol consumption was relatively low (< 140 g/per week in 193/233 patients [80%]). We found a highly significant correlation between SRAC and serum HCV RNA levels (r = .26, P = .001). Fibrosis was significantly correlated with age and alcohol consumption. These results suggest that in HCV carriers, alcohol consumption, even with low alcohol intake, increases viremia and hepatic fibrosis. Chronic HCV carriers should be advised to avoid regular alcohol intake.

Long-term outcome of chronic hepatitis C infection in a low-prevalence area

BACKGROUND

Although hepatitis C virus (HCV) infection is recognized as an important causative factor in the development of liver cirrhosis and hepatocellular cancer (HCC), the strength of this correlation has been difficult to confirm in low-prevalence areas.

METHODS

Stored serum samples from 987 consecutive (1978-88) patients with chronic liver disease were tested with an enzyme-linked immunosorbent assay for anti-HCV and further confirmed by immunoblot. To evaluate the long-term outcome, the cohort was followed up until 1995, for a median observation time of 10 years.

RESULTS

Anti-HCV, confirmed by immunoblot, was found in 9.5% (94 of 987) of the patients, and at inclusion most patients were asymptomatic irrespective of anti-HCV status. Of the 445 patients who died during the study period, 44 were HCV-positive. A liver-related cause of death was far commoner and the age-adjusted survival shorter among HCV-positive patients than among HCV-negative ones. At death 68% (30 of 44) of the HCV-positive subgroup had developed cirrhosis, and 30% (13 of 44) had concurrent HCC, as compared with 36% (142 of 393) (P = 0.001) and 8% (31 of 393) (P = 0.001), respectively, of the HCV-negative subgroup. HCV infection (P < 0.001), alcohol abuse (P < 0.001), and immigrant status (P = 0.045) were independent factors with regard to the development of cirrhosis, whereas HCV infection (P = 0.040) and immigrant status (P = 0.012) were independent factors with regard to HCC.

CONCLUSIONS

HCV infection is common among patients with chronic liver disease, even when clinical evidence of viral infection is sparse, and constitutes a significant cause of death even in a low-prevalence area.

The inheritance of alcoholic liver disease

Available evidence supports the concept that alcoholic liver disease (ALD) is a multifactorial disease with a heritable component. A number of polymorphic genes with small and additive effects will thus encode susceptibilty to this 'polygenic' disease. Molecular genetic studies of ALD are in their infancy, and methods available for the genetic dissection of complex traits are discussed. Some candidate genes have been identified, and studies have been undertaken to test for association between specific alleles and ALD susceptibility. There is evidence to support a role for alleles of two genes encoding enzymes involved in the oxidative metabolism of alcohol (acetaldehyde dehydrogenase2*2 and cytochrome P4502E1 c2 allele) in susceptibility to ALD. More recently, attention has focused on cytokines, and there are now data showing association of specific alleles of both tumour necrosis factor alpha and interleukin-10 with predisposition to ALD. These candidate genes need to be subjected to rigorous evaluation in different populations. Such research should help to define more precisely the molecular mechanisms underlying the development of ALD in a sub-population (< 20%) of alcoholics, thereby improving the hepatologist's ability to develop rational treatments.

How much does alcohol contribute to the variability of hepatic fibrosis in chronic hepatitis C?

In order to determine the contribution of alcohol intake to the severity of hepatic fibrosis in patients with chronic hepatitis C, we studied associations between various levels of alcohol intake, other demographic variables and semiquantitative liver histology in 434 cases of chronic hepatitis C. Clinical, demographic and disease-related data were entered into a relational database. Liver histology was scored according to Scheuer. The average daily alcohol intake for the year preceding liver biopsy (recent exposure) and for earlier periods (past exposure) was categorized into five levels of intake. One-third of patients gave a history of alcohol intake that had exceeded 40 g/day for at least 5 years. By univariate analysis, age, but not recent or past alcohol intake or other baseline variables, was associated with portal score (r = 0.14, P = 0.004), fibrosis score (r = 0.46, P < 0.001), total Scheuer score (r = 0.35, P < 0.001). However, by multivariate analysis, age (P < 0.001), past (but not present) alcohol intake (P < 0.001) and birth in Egypt (P = 0.006) were independently associated with fibrosis score. Age, past alcohol and birth place in Egypt contributed 27% to total variance of the hepatic fibrosis score, while age alone accounted for 23%. Age also independently predicted portal activity (P = 0.02) and total Scheuer score (P < 0.001), whereas past alcohol intake correlated with total Scheuer score (P = 0.002) but not with other histological indices. A separate multivariate analysis was performed on a more homogeneous subgroup of 196 patients who acquired hepatitis C by injection drug use. In this subgroup, age (P < 0.05) and past alcohol (P < 0.05) were independently associated with fibrosis score. In both the overall and subgroup analyses, there was a threshold level of past alcohol intake (>80 g/day) beyond which the risk of fibrosis increased significantly. It is concluded that toxic levels of alcohol exposure for at least 5 years accentuate hepatic fibrosis in hepatitis C but the influence of alcohol appears to be minor compared with age and other variables and is exerted only at toxic levels of intake.

Is alcohol a risk factor for liver cirrhosis in HBsAg and anti-HCV negative subjects? Collaborative Groups for the Study of Liver Diseases in Italy

BACKGROUND/AIMS

In order to evaluate the association between alcohol intake and the risk of liver cirrhosis in the absence of B and C hepatitis viruses, we analyzed data from three hospital-based case-control studies performed in various Italian areas.

METHODS

From the case and control series we excluded HBsAg and/or anti-HCV positive patients. Cases were 221 cirrhotic patients admitted for the first time to hospital for liver decompensation. Controls were 614 patients admitted to the same hospitals during the same period as the cases for acute diseases unrelated to alcohol. Alcohol consumption was expressed as lifetime daily alcohol intake (LDAI).

RESULTS

We found a dose-effect relationship between LDAI and the risk of liver cirrhosis (LC). Considering the extreme LDAI categories (LDAI = 0 g: lifetime teetotallers and LDAI > or = 100 g), the LC odds ratio (OR) increased from 1.0 (reference category) to 44.7 (95% confidence interval: 95% CI: 20.0-99.9). An increased risk of LC associated with the female gender independent of alcohol consumption was also observed (OR = 2.9; 95% CI: 1.8-4.6).

CONCLUSIONS

Alcohol intake acts as a risk factor for symptomatic liver cirrhosis also in the absence of HBV and/or HCV infection. Besides alcohol and viruses, some unknown gender-related factors might be involved in the occurrence of the disease.