Hepatitis C genotypes in haemophilic patients treated with alpha-interferon

Multitypic hepatitis C virus infection identified by real-time nucleotide sequencing of minority genotypes

The prevalence of concurrent multitypic hepatitis C virus (HCV) infection is uncertain. A sensitive and specific approach to identifying minority HCV genotypes in blood is presented. Following serum extraction and reverse transcription PCR to amplify cDNA originating from the viral 5' noncoding region, the amplified product mixture was treated with genotype-specific restriction endonuclease to digest the dominant genotype. Residual amplicons were subjected to PCR cloning and then to real-time DNA sequencing using a Pyrosequencer to identify the remaining genotypes. Dilution experiments showed that minority genotypes may be detected when they represent 1:10,000 of the total population and in serum specimens with viral loads as low as 1,000 IU/ml. Of 37 patients with bleeding disorders and 44 injecting drug users, infection by more than one HCV genotype was found in 7 (19%) and 4 (9%) patients, respectively. The low rate of detection in people at high risk of repeated HCV infection suggests that multitypic HCV carriage is uncommon.

HIV and HCV co-infection: situation at six French university hospitals in the year 2000

The aims of this study were to assess the sociodemographic, epidemiological, clinical, and biological characteristics of French patients co-infected with human immunodeficiency virus-hepatitis C virus (HIV-HCV), as well as the management of their HCV infection. Data on 509 HIV-HCV co-infected patients, followed up at six French University Hospitals, were collected using a questionnaire. Student's t-test, Pearson's chi-square, Fisher's exact, and Fisher-Freeman-Halton's exact tests were used. The mean age of the patients was 38.3 years, and the male to female sex ratio 2.08; 88% of patients were born in Metropolitan France, and 20% were dependent on health benefits; 74% were intravenous drug users and 14% blood or blood product recipients. Forty-seven percent were in CDC classification stage A, 18% had a CD4+ count of <200, and 79% were undergoing current antiretroviral treatment. HCV RNA was positive in 84% (50% type 1, 13% untypable). Forty-four percent had normal alanine aminotransferase (ALT) levels, 24% alcohol consumption >15 g/day, and 51% had undergone liver biopsy (10% of which had cirrhosis). Histological grade was not related to ALT level or CD4+ count. Overall, 40% of patients had been treated for HCV infection. HCV treatment was significantly associated with performance of liver biopsy, histological grade, ALT level, CD4+ count, Centers for Disease Control (CDC) classification, but not with age or alcohol consumption. Rate of early response to treatment was fifty percent among patients treated with bitherapy. Eighty-nine percent of all patients with previous or current anti-HCV treatment had undergone liver biopsy. In conclusion, despite the difficulties in managing hepatitis C in HIV-infected patients, almost one-half of all patients in this study had received anti-HCV treatment.

The natural history and antiviral treatment of hepatitis C in haemophilia

People with haemophilia who received non-virucidally treated large-pool clotting factor before 1986 were infected with hepatitis C virus (HCV), previously referred to as non-A, non-B hepatitis. Approximately one-tenth of patients have been shown to clear infection naturally and shown persistently negative HCV PCR. Patients have been infected with genotypes 1, 2 and 3 reflecting the plasma donors in Northern Europe and the United States. Several studies have shown that HCV mono-infection has a very slow progression. Co-infection with human immunodeficiency virus (HIV), however, can hasten the progression to cirrhosis and liver failure. Genotype 1 and older age at first infection also increase the progression rate. Candidates with detectable HCV RNA are candidates for therapy. The combination of standard interferon-alpha and ribavirin doubles the effectiveness of interferon-alpha alone and is the current standard of care for the treatment of chronic hepatitis C. The duration of therapy depends on the genotype and level of viraemia. Patients with genotypes 2 or 3 should have 6 months' therapy while those with genotype 1 and > 2 million copies mL-1 should have 1 year of therapy. Pegylated interferon is an emerging therapy. Patients co-infected with HIV, in whom treatment has stabilized the HIV infection, may be able to tolerate therapy for HCV infection. Liver transplantation is indicated for patients with haemophilia who have decompensated hepatitis C infection.

Interferon alpha therapy in haemophilic patients with chronic hepatitis C: a French multicentre pilot study of 58 patients

BACKGROUND AND OBJECTIVES

Information about the long-term efficacy of interferon alpha (interferon-alpha) in haemophilic patients with chronic hepatitis not co-infected with the human immunodeficiency virus (HIV-1) is still limited. Previous studies seemed to indicate a low rate of response. The aim of this study was to evaluate the safety and long-term efficacy of interferon treatment in multi-transfused haemophiliacs.

METHODS

Fifty-eight haemophiliacs were scheduled to receive 3 MU of interferon-alpha 2b three times a week for 12 months. The patients were followed up for at least 24 months post-treatment. Response was assessed by measurements of serum hepatitis C virus (HCV) RNA.

RESULTS

Twenty-four patients (41.4%) dropped out. Except for seven patients, the symptoms that led to interrupting interferon treatment would probably not have resulted in the same decision in non-haemophilic patients. One patient developed an inhibitor to the deficient clotting factor without haemorrhagic consequences. In an intent to treat, the sustained virological response rate was 14%. However, when considering only the 34 patients who received the full treatment, HCV-RNA was cleared in eight patients (23%).

CONCLUSIONS

This study suggests that multi-transfused haemophiliacs with chronic hepatitis not co-infected with HIV-1 respond to prolonged treatment with interferon-alpha in a similar proportion to that observed in non-haemophiliacs. There was a high rate of patients who did not complete the interferon-alpha treatment, and this seems to be characteristic of this patient population.

Methodological issues in papers on IFN therapy: time for reappraisal

We conducted an analytical review of 194 full papers on interferon (IFN) therapy for chronic hepatitis C to evaluate current methodology (i.e. study design, criteria for evaluating the efficacy of therapy and predictors of response). Of the papers evaluated, 64 were randomized controlled trials (RCT), 40 were non-randomized controlled trials (NRCT) and 90 were observational studies (OS). The methodological analysis was focused mainly on clinical trials. The number of patients enrolled in RCT was higher compared with the number enrolled in NRCT. Uniform enrolment criteria were used in less than 50% of the trials. Only 20% of RCT and 2.5% of NRCT used criteria for defining sample size. The response rate was calculated on an intention-to-treat basis in 36 of the RCT and in 14 of the NRCT. The outcome of treatment and the criteria employed to define the response to treatment were found to be far from standardized. In 51.5% of the RCT and 42.5% of the NRCT, normalization of alanine aminotransferase (ALT) level at the end of follow-up was the only marker of response studied. Only 57.6% of the trials considered histological evidence as an important outcome. Among the clinical trials, 71.1% evaluated predictors of good response to IFN therapy. In 51% of the OS, ALT normalization by the end of follow-up was the only criterion for defining response. In conclusion, to ensure a high level of reliability in comparing or combining the results of different studies, some basic general requirements must be followed when planning trials on antiviral therapy.

Hepatitis C virus genotypes in hemophiliacs in the state of Minas Gerais, Brazil

BACKGROUND

Hepatitis C virus (HCV) is a positive-strand RNA virus composed of at least 10 genotypes and dozens of subtypes. Six major genotypes can be distinguished by restriction fragment length polymorphism (RFLP) analysis of the amplified 5' noncoding region (NCR) of the genome. The genotypes are unequally distributed throughout the world. Types 1 and 3 are most common in Europe and the United States. Although fewer studies have been performed in Brazil, the pattern seems to mirror that in the other areas. HCV infection is highly prevalent among hemophiliacs and is a major cause of chronic liver disease.

STUDY DESIGN AND METHODS

This study investigated a sample of the hemophiliac population in the state of Minas Gerais, Brazil, by RFLP analysis of the 5' NCR.

RESULTS

It was observed that 84.1 percent were of genotype 1 and 13.6 percent of genotype 3. Sequence analysis of nine isolates confirmed the RFLP results and determined that all of the type 1 isolates belonged to subtype 1a. Phylogenetic analysis by parsimony and distance revealed that lineages of genotypes 1, 2, and 3, and 4 could be separated. The isolates of type 3 from this study were distinct from published sequences, which possibly indicated their different geographical origin.

CONCLUSION

Although the frequency of genotypes observed (types 1 and 3) among hemophiliacs in the state of Minas Gerais was higher than that in the southern part of the country, these frequencies were not different from those in other groups of patients in Brazil and other countries studied. Further investigation is needed of the evidence that the type 3 isolates observed in these studies are significantly different from other isolates previously characterized by sequence analysis.

Therapy for chronic hepatitis B and C infection in haemophilia

Haemophiliacs, until recently, have been at risk of hepatitis B and C infection. Substantial numbers of patients remain persistently infected. Several lines of evidence suggest that these diseases will cause considerable morbidity unless therapy can successfully reduce viraemia and prevent disease progression. Cessation of viral replication may prevent progression to hepatic fibrosis.

Hepatitis C virus and HIV coinfection

The world-wide prevalence of hepatitis C virus (HCV) is approximately 1%. Being primarily a blood-borne virus, the major risk factors for HCV include the receipt of blood and blood products, as well as intravenous drug use. As a result, many individuals infected with HIV are also infected with HCV. Any effect of coinfection on progression of either HIV or HCV is likely to have a tremendous impact on the mortality and morbidity of these individuals and should be considered when managing coinfected individuals. This review will describe the epidemiology and clinical manifestations of HCV and will consider the evidence for an impact of coinfection on the progression of both viruses.

Alpha interferon therapy in Danish haemophiliac patients with chronic hepatitis C: results of a randomized controlled open label study comparing two different maintenance regimens following standard interferon-alpha-2b treatment

Following a survey among all Danish haemophiliac patients 49 HIV-negative patients with chronic hepatitis C were offered enrollment in a randomized controlled open label study comparing two different maintenance regimens following standard interferon-alpha-2b treatment. Dose modifications and treatment discontinuation were based upon changes in transaminase levels. Forty-seven patients enrolled received 3 MU of alpha interferon thrice weekly (TIW) for 3 months. Twenty-six nonresponders had their dose increased to 6 MU TIW for an additional 3 months, while 21 responding patients continued on 3 MU TIW. At 6 months, 25 patients with a complete or a partial biochemical response were randomly allocated to either a fixed dose regimen (13 patients) (3 or 6 MU thrice weekly) or an individualized dose regimen (12 patients) tapering interferon dose from 3 or 6 MU by one-third every 2 months if transaminases were persistently normal. The remaining 22 biochemical nonresponders were followed for an additional 6 months without further treatment. After 12 months of treatment, 18 patients (38%) had a virological response, irrespective of regimen, and seven patients (16%) had a sustained virological and biochemical response after 6 months of follow up. Overall, the individualized treatment regimen did not seem to offer any advantage over the fixed dose regimen. The response to alpha interferon treatment in Danish haemophiliac patients with chronic hepatitis C immediately after treatment is comparable to that obtained in previous studies among nonhaemophiliacs. However, a sustained virological and biochemical response was seen in only 16% of treatment patients.

Hepatitis C virus genotypes in a cohort of Australian blood donors and haemophiliac and liver transplant patients

The aim of the present study was to characterize hepatitis C virus (HCV) genotypes using the INNO-LiPA HCV line probe assay and direct sequencing from three different HCV-RNA-positive (serum) groups: (i) blood donors (n = 59); (ii) haemophiliacs (n = 43); and (iii) patients undergoing liver transplantation (n = 26). Of 128 HCV-RNA-positive samples, 74 (58%) were genotype 1. Of these, 41 were genotype 1a, 32 were genotype 1b and one was genotype 1 indeterminate. Of the remaining 54 samples, seven (5%) were genotype 2a, two (2%) were genotype 2b, 26 (20%) were genotype 3a, three (2%) were genotype 4a, while 16 (12.5%) were of a mixed genotype. There was no significant difference between the three groups with regard to the prevalence of any specific genotype. However, in blood donors and haemophiliac patients there was a statistically significant difference in the occurrence of genotype 3a in patients with elevated alanine aminotransferase (ALT) levels (30.3%) compared with those patients with persistently normal ALT levels (5.6%; P = 0.004; chi 2). Genotype 3a was also uncommon in liver transplant patients (one of 14) with "sporadic' HCV infection. Genotype 4a was detected only in liver transplant patients. These patients had originated from Egypt (n = 1), Italy (n = 1) and Romania (n = 1).

Hepatitis C virus genotypes in the liver and serum of patients with chronic hepatitis C

OBJECTIVE: To evaluate the prevalence of hepatitis C virus (HCV) genotypes in a central area of Italy (Umbria); to analyze the correspondence of the genotypes detected in serum and liver samples; to study the relationship between HCV genotypes and severity of liver disease; to test whether co-infection with more than one HCV subtype could be influenced by the source of infection. METHODS: Genotyping by polymerase chain reaction with core-specific primers (Okamoto method) was performed in the serum and liver from 48 consecutive patients with histologically confirmed chronic C hepatitis. RESULTS: HCV genotype 1b was the prevalent strain and was not associated with more severe histologic damage. Data show a very good correspondence between genotypes identified in serum and liver specimens (91%). Mixed infections (with subtypes 1b and 2a) correlated significantly with intravenous drug abuse (p=0.001). CONCLUSION: We confirmed that subtype 1b is prevalent in central Italy. Co-infection with more than one subtype is not rare in intravenous drug abusers.

Transfusion-transmitted disease

Many patients with haemophilia are infected with viruses, due to treatment with blood products--particularly from large pool clotting factor concentrates before 1985. AIDS in haemophilic patients was first described in 1982 and it has significantly reduced the life expectancy of these patients. Although no new sero-conversions have occurred since 1986, management of HIV in haemophilia remains a clinical challenge. Transfusion-associated hepatitis was recognized in 1943, and it is now an important complication of haemophilia treatment. Vaccination against HAV is recommended. Intensively-treated older haemophilic patients usually have serological evidence of HBV infection. HBV transmission has been stopped, but hepatitis B vaccination is still practised, because HDV requires HBV for propagation. Many patients are infected with HCV: before 1985 almost all patients who received clotting factor concentrate developed non-A, non-B hepatitis, now recognized as HCV. Treatment strategies are being developed for HCV in haemophilic patients. Parvo virus can be transmitted by clotting factor concentrate; it is very resistant to sterilization processes, transmission causing severe illness even in immuno-competent individuals. New blood-borne viruses responsible for sero-negative hepatitis include: GBV-A, B and C, and HGV. Although there is no link between CJD and haemophilia, there is concern about possible blood product transmission.

Longitudinal genotype analysis and quantification of hepatitis C virus in haemophilic patients receiving interferon-alpha therapy

Haemophilic patients have a high prevalence of hepatitis C virus (HCV) infection because of the use of unsterilized clotting factor concentrates. Six major genotypes of HCV have been distinguished so far, with epidemiological evidence suggesting that genotypes 1-3 are common in the indigenous UK and US populations. The aim of this study was to analyse the changes in viral load and composition of the HCV quasispecies in haemophilic patients receiving therapy with interferon-alpha (IFN-alpha) using the four major methods currently available for HCV genotyping. The most consistent genotype results were obtained using restriction fragment-length polymorphism (RFLP) analysis when compared with the DNA sequence analysis, and showed that the dominant genotype can change in patients with mixed genotype infections treated with IFN-alpha. This study indicates the difficulties in studying this group of patients with mixed HCV genotype infections, and that frequent sampling is necessary, together with viral load measurement to monitor response to IFN-alpha therapy.

Persistent hepatitis C virus RNA replication in haemophiliacs: role of co-infection with human immunodeficiency virus

In order to evaluate the evolution of transfusional hepatitis C in haemophiliacs, we performed a retrospective study of ALT levels and HCV viraemia with a RNA PCR assay in 57 patients. We found that the vast majority of HCV-infected patients remained viraemic (43/57 = 75%) and higher ALT levels correlated with HCV viraemia. Although indicators of the transfusional viral load (age, severity of haemophilia) and HBV co-infection did not correlate with HCV RNA replication, HIV seropositivity was strongly associated with persistence of HCV viraemia (23/25 = 92% in HIV-positive versus 20/32 = 62% in HIV-negative patients), without any correlation with CD4 counts. Genotyping of HCV in the 43 viraemic patients shows more frequent genotype 1 in the HIV-seropositive group (14/23) than in the seronegative group (6/20). Our data emphasize that besides the role of the immunodeficiency status, the genotypes of HCV might be involved in the differences observed in terms of HCV RNA replication between the HIV-seropositive and seronegative haemophiliacs.