Hepatitis C infection and diabetes

High incidence of hepatocarcinoma in patients with advanced fibrosis treated with direct-acting antiviral agents for hepatitis C: A real-world retrospective study

BACKGROUND

Patients treated with direct-acting antivirals for hepatitis C exhibit high cure rates and improved survival. However, there is limited knowledge on their long-term clinical evolution.

AIMS

In this study, we aimed to analyse the risk of hepatocarcinoma and hepatic decompensation in patients treated with direct-acting antivirals.

METHODS

We conducted a retrospective single-centre study of Portuguese patients with advanced fibrosis treated with direct-acting antiviral agents between 2015 and 2022 at a tertiary hospital.

RESULTS

Out of 460 patients, 50 (10.9 %) developed hepatocarcinoma and 36 (7.8 %) experienced hepatic decompensation. The risk for hepatocarcinoma was higher in patients aged over 55 (HR 4.87, 95 % CI 2.34-10.13, p < 0.001), with signs of portal hypertension (HR 3.83, 95 % CI 2.05-7.13, p < 0.001) and arterial hypertension (HR 1.98, 95 % CI 1.09-3.58, p = 0.024). Alcohol consumption (HR 3.30, 95 % CI 1.22-8.94, p = 0.019), signs of portal hypertension (HR 4.56, 95 % CI 2.19-9.48, p < 0.001) and hepatocarcinoma (HR 3.47, 95 % CI 1.69-7.10, p < 0.001) increased the risk of hepatic decompensation.

CONCLUSION

Our study found a high incidence of hepatocarcinoma and hepatic decompensation, along with high mortality, in patients with advanced fibrosis treated with direct-acting antivirals. We identified risk factors such as arterial hypertension, alcohol consumption, and signs of portal hypertension, highlighting their role in clinical management and patient monitoring.

Seroprevalence and associated risk factors of hepatitis C infection among diabetic patients in South-Kivu, Eastern Democratic Republic of the Congo: A cross-sectional study

Background and Aims

Hepatitis C virus (HCV) infection and diabetes mellitus (DM) are two frequent diseases in the Democratic Republic of the Congo (DRC) and several studies seem to show a link between the two diseases worldwide. However, no study has evaluated this link in our country. The present study aimed at determining the seroprevalence of HCV in diabetic patients as well as associated risk factors.

Methodology

A multicenter cross-sectional study allowed us to sample diabetic patients in two diabetic healthcare centers of Bukavu city in the eastern part of the DRC, from December 2020 to December 2022. A questionnaire was submitted to the diabetic patients to collect sociodemographic data, anamnestic data on risk factors for HCV infection, and clinical data on DM. These factors were analyzed based on anti-HCV serological results.

Results

Among the 180 selected patients, 19 (10.6%) were tested positive for anti-HCV antibodies. After multivariate analysis, the identified factors influencing these outcomes were male sex (adjusted odds ratio [aOR]: 3.5, p = 0.027), dental extraction (aOR: 7.6, p = 0.001), and living in a privileged environment (aOR: 0.29, p = 0.03). The factors related to DM such as the type, the disease duration, or the usual type of treatment did not influence the serological results.

Conclusion

This study shows that HCV seroprevalence in diabetic patients is very high compared with the general population. This suggests combined screening and management policies in this population.

LncRNA AC040162.3 Promotes HCV-Induced T2DM Deterioration through the miRNA-223-3p/NLRP3 Molecular Axis

Background

Diabetes is one of the most common diseases and major public health burdens worldwide. Type 2 diabetes mellitus (T2DM) is associated with chronic hepatitis C virus (HCV) infection, and lncRNAs play an important role in HCV-induced T2DM. We aimed to explore the effect of lncRNA AC040162.3 on HCV-induced T2DM.

Methods

HCV was used to infect MIN6 cells to establish an in vitro model. HCV copy number and miRNA expression were detected by Real Time Quantitative PCR (RT-qPCR). Enzyme-Linked Immunosorbent Assay (ELISA) was used to detect the secretion of insulin, and methyl thiazolyl tetrazolium (MTT) was applied to analyze cell viability. Apoptosis was analyzed by Western blotting and flow cytometry. In addition, Western blotting and TdT-mediated dUTP Nick End Labeling (TUNEL) were used to analyze pyroptosis. Luciferase reporter assays were used to investigate the targeting relationship.

Results

The expression of LncRNA AC040162.3 and NLRP3 was markedly increased in HCV-T2DM, while the expression of miR-223-3p was remarkably inhibited. In vitro experiments demonstrated that lncRNA AC040162.3 silencing or miR-223-3p overexpression remarkably alleviated HCV-induced T2DM deterioration by inhibiting cell apoptosis and pyroptosis and enhancing cell viability. We then demonstrated that silencing lncRNA AC040162.3 promoted the expression of miR-223-3p and that miR-223-3p bound to lncRNA AC040162.3 and the NLRP3 binding site. In addition, the protective effects of LncRNA AC040162.3 silencing in HCV-infected MIN6 cells were reversed by overexpression of NLRP3 or silencing of miR-223-3p.

Conclusion

Silencing of lncRNA AC040162.3 alleviates the process of HCV-induced T2DM by governing the miR-223-3p/NLRP3 axis.

Hepatitis C Infection as a Risk Factor for Hypertension and Cardiovascular Diseases: An EpiTer Multicenter Study

Hepatitis C infection is one of the main reasons for liver cirrhosis and hepatocellular carcinoma. In recent years, more and more is being heard about extrahepatic manifestations of the hepatitis C infection including its possible influence on the development of hypertension and cardiovascular diseases. In the given work, the frequency analysis of the incidence of hypertension and cardiovascular diseases among 2898 HCV-infected patients treated in Poland and the assessment of their relevance to the HCV genotype and the progression of liver fibrosis can be found. The prevalence of hypertension in the group of analyzed patients was 39% and was significantly associated with old age (OR = 1.08 (1.07-1.08)) and female sex, as well as the progression of liver fibrosis (OR = 1.54 (1.29-1.85)). Hypertension was found in 47.6% of patients with F4 fibrosis, 42.1% of patients with F3 fibrosis, and 25% of patients with F1 fibrosis. The incidence of cardiovascular disease in the studied group of patients was as follows: all incidents, 131 (4.52%); including ischemic heart disease 104, (3.95%); stroke, 2 (0.07%); atherosclerosis, 21 (0.72%); and aneurysms, 4 (0.14%). The obtained results prove that the prevalence of cardiovascular diseases is significantly associated with the advanced age of patients and the progression of liver fibrosis. The relevance of sex and the HCV genotype to the prevalence frequency of cardiovascular diseases in the study group has not been proven. This being the case, no differences in the frequency of their incidence depending on the HCV genotype, including genotype 3, was found. Hepatitis C infection as a non-classical risk factor for cardiovascular disease and hypertension does require further studying.

HCV Genotype Has No Influence on the Incidence of Diabetes-EpiTer Multicentre Study

HCV infection is one of the main reasons for liver cirrhosis and hepatocellular carcinoma. In recent years, one finds more and more extrahepatic manifestations of HCV infection, including its possible influence on the development of diabetes. In the presented work, one finds the frequency analysis of the incidence of diabetes among 2898 HCV infected patients treated in Poland, and the assessment of their relevance to the HCV genotype and the progression of fibrosis. The results indicate that the hepatitis C infection seems to be a risk factor for diabetes in persons with more advanced liver fibrosis, for older people, and for the male gender. Thus, one found no differences regarding the frequency of its incidence depending on HCV genotype, including genotype 3.

CURING HEPATITIS C WITH THE NEW DIRECT ACTING ANTIVIRALS DID NOT IMPROVE INSULIN RESISTANCE AFTER ONE YEAR

BACKGROUND

Chronic hepatitis C still figures as an important cause of morbidity among the Brazilian population, and is closely associated with metabolic disturbances, including insulin resistance (IR), which can be evaluated by the Homeostatic Model Assessment (HOMA-IR). IR may entail lower sustained virologic response (SVR) on certain therapeutic regimens and faster progression to advanced hepatic fibrosis. With the arrival of the direct acting agents (DAA) in hepatitis C treatment, there is an increased need in observing the impact in patients' IR profile while using such therapies.

OBJECTIVE

- 1) To compare the results of HOMA-IR in patients affected by chronic hepatitis C before treatment with DAA and 12 months after finishing it with SVR. 2) To evaluate the evolution of weight after curing chronic hepatitis C.

METHODS

We included patients older than 18 from two tertiary care in Curitiba - PR, of both sexes, with chronic hepatitis C, treated with DAA, from July 2015 to September 2017. We also evaluated the patients' levels of fasting insulin, fasting glucose and glycated hemoglobin before starting treatment and 12 months after finishing it. We also used epidemiologic data, such as age, sex, hepatic fibrosis degree, body mass index, abdominal circumference, viral genotype and the presence of diabetes mellitus before and after treatment. IR was assessed before and after treatment and calculated by the HOMA-IR score. Insulin resistance was defined by a HOMA-IR greater than 2.5. We excluded patients who lost follow-up, those who did not achieve SRV and those who did not have a laboratory profile. The results of quantitative variables were described by means, medians, and standard deviations. P values <0.05 indicated statistical significance.

RESULTS

We included 75 patients in this study, with a mean age of 55.2 years and 60% of males. Forty-three patients had advanced fibrosis. Twenty one (28%) had a previous diabetes mellitus diagnosis. We identified 31 (41.3%) patients with IR before antiviral treatment, and this number increased to 39 (52%) after 12 months of finishing treatment, according to HOMA-IR. There was no statistic difference between insulin, glucose and HOMA-IR measurements before and after curing hepatitis C. We observed a weight gain in patients shortly after curing hepatitis C, but this did not persist at the end of the study. We also had no significant difference in IR prevalence when viral genotype was concerned.

CONCLUSION

In this study, there was no statistically significant difference between HOMA-IR results in patients before and 12 months after treatment for hepatitis C. Even though patients gained weight after the cure, this was not statistically significant after a year (P=0.131).

Association between hepatitis C antiviral treatment and diabetes mellitus: A case series

The hepatitis C virus (HCV) infects 185 million people worldwide, and diabetes mellitus (DM) affects 415 million. There has long been a possible association between DM and liver outcomes for patients with HCV infection. We present two cases of worsening glucose resistance and one case of emergent type 1 DM after completion of HCV. The complex interactions between HCV infection and both type 1 and type 2 DM have not yet been elucidated. In addition, consequences and side effects of treatment options for HCV have not been fully studied in the diabetic population. Our case series illustrates a potential complication of HCV treatment, which may warrant additional consideration prior to initiation of therapy as well as monitoring and surveillance post-cure.

Inflammatory and cardiovascular diseases biomarkers in chronic hepatitis C virus infection: A review

Hepatitis C virus (HCV) infects 180 million people worldwide and over 4 million people in the United States. HCV infection is a major cause of chronic liver disease and is recognized as a risk factor for clinical cardiovascular disease (CVD). Many studies have shown increased prevalence of cardiac and inflammatory biomarkers in patients with chronic HCV infection (CHC), and though these markers may be used to risk stratify people for cardiac disease in the general population their role in the HCV population is unknown. Patients with CHC have elevated cardiac and inflammatory biomarkers compared to noninfected controls which may play a role in CVD risk stratification. We undertook a systematic review of inflammatory and cardiac biomarkers in people with HCV infection with a focus on the effect of CHC on serum levels of these markers and their utility as predictors of CVD in this population. Medline, EMBASE, and Cochrane databases were searched for relevant articles until June 2019. A total of 2430 results were reviewed with 115 studies included. Our review revealed that HCV infection significantly alters serum levels of markers of inflammation, endothelial function, and cardiac dysfunction prior to HCV treatment, and some of which may change in response to HCV therapy. Current risk stratification tools for development of CVD in the general population may not account for the increased inflammatory markers that appear to be elevated among HCV‐infected patients contributing to increased CVD risk.

Hepatitis C virus infection and development of type 2 diabetes mellitus: Systematic review and meta-analysis of the literature

Type 2 diabetes mellitus (T2DM) is an endocrine disorder encompassing multifactorial mechanisms, and chronic hepatitis C virus infection (CHC) is a multifaceted disorder, associated with extrahepatic manifestations, including endocrinological disorders. CHC and T2DM are associated, but the subject remains controversial. We performed a systematic review and meta-analysis evaluating such association, searching on PubMed until February 29, 2016. Inclusion criteria were: 1) presence of at least one internal control group age- and gender-matched (non-hepatopathic controls; and/or hepatopathic, not HCV-positive, controls); 2) sufficient data to calculate odds ratio and relative risk. Exclusion criteria were: 1) literature reviews on the topic; 2) publications regarding special populations [human immunodeficiency virus and human T-lymphotropic virus-1 coinfections, hepatocellular carcinoma (HCC), post-transplantation DM, gender selection]; 3) no clear differentiation among HCV patients with CHC, cirrhosis or HCC. Data from each study were independently extracted by two reviewers and cross-checked by AA. Our systematic review returned 544 records, and 33 were included in our meta-analysis. HCV infection is associated with an increased risk of T2DM independently from the severity of the associated liver disease, in CHC and cirrhotic HCV patients. As expected T2DM risk is higher in cirrhotic HCV patients, than CHC, and the prevalence of HCV infection in T2DM patients is higher than in non-diabetic controls. Regarding HBV infection prevalence, no difference exists in diabetic and non-diabetic subjects. An unequivocal CHC and T2DM association was shown. A proactive, integrated approach to HCV and T2DM therapies should maximize benefits of both diseases treatment.

Study on the relationship between insulin growth factor 1 and liver fibrosis in patients with chronic hepatitis C with type 2 diabetes mellitus

OBJECTIVE

To investigate the correlation between serum protein level of insulin growth factor 1 (IGF-1) and the degree of liver fibrosis in patients with chronic hepatitis C (CHC) combined with type 2 diabetes mellitus (T2DM).

METHODS

The cases are divided into four groups. Then serum levels of IFG-1, alanine aminotransferase (ALT), aspartate aminotransferase (AST), hepatitis C virus (HCV) RNA, and HCV genotypes were detected simultaneously in patients with hepatitis C, liver stiffness measurement (LSM) was measured by transient elastography, and aspartate aminotransferase platelet ratio (APRI) score was determined.

RESULTS

There was no significant difference between CHC with T2DM group and CHC group in diabetes family history (P > 0.05), but the difference between the two groups were significantly lower than that of T2DM group ( P < 0.05). The levels of fasting insulin and homeostatic model assessment of insulin resistance (HOMA-IR) in CHC group with T2DM group were significantly higher than those in the other two groups ( P < 0.05), while the IGF-1 RNA and the serum protein level in the two groups were significantly lower than those in the CHC group, and were lower than those in the control group ( P < 0.05). The level of serum IGF-1 was negatively correlated with HOMA-IR, LSM, and APRI score in CHC with T2DM group ( r = -0.71, -0.75, and -0.69; P < 0.01).

CONCLUSION

The degree of hepatic fibrosis in patients with CHC combined with T2DM was higher than that in non-T2DM patients with CHC, which was mainly related to insulin resistance (IR) induced by 1b genotype HCV infection. IR can lead to impaired synthesis of IGF-1, and the degree of damage has a corresponding relationship with hepatic fibrosis.

Risk of diabetes in viral hepatitis B or C patients compared to that in noninfected individuals in Korea, 2002-2013: A population-based cohort study

While the association between hepatitis C virus (HCV) infection and diabetes has been established, the relationship between hepatitis B virus (HBV) infection and diabetes remains unclear. Therefore, we compared the association between diabetes development in HBV, HCV and co-infected (HBV/HCV) patients to that in noninfected participants using population-based cohort data. We used the National Health Insurance Service-National Sample Cohort, which consists of 514 791 randomly selected persons among those who underwent health check-ups from 2002 to 2003 aged 40-79 years. Adults found to have HBV or HCV infection from 2002 to 2003, without a prior history of diabetes, were selected as subjects. Competing risk regression models were used to estimate cumulative incidence and hazards ratios (HRs) of diabetes development. The cumulative incidences, incidence densities and HRs of diabetes were highest in the co-infected group, followed by those in the HCV-, HBV- and noninfected groups. The 12-year cumulative incidences were as follows: 42.0% in HBV/HCV-, 32.9% in HCV-, 23.9% in HBV- and 18.3% in the noninfected groups. The incidence density per 1000 person-years was 55.0, 51.5, 38.2 and 28.2 for the HBV/HCV-, HCV-, HBV- and noninfected groups, respectively. The adjusted HRs for diabetes were 1.90, 1.68 and 1.41 for the HBV/HCV-, HCV- and HBV-infected groups, respectively. Our findings suggest that both HCV and HBV infections are associated with the development of diabetes; therefore, prevention of, screening for, and treatment of both may reduce the risk of diabetes in these patients.

New-onset diabetes mellitus after living-donor liver transplantation: association with graft synthetic function

BACKGROUND AND PURPOSE

It is now known that post-transplant graft function after deceased-donor liver transplantation and living-donor liver transplantation (LDLT) differ; however, there is no report assessing the relationship between graft function and the development of new-onset diabetes mellitus after transplantation (NODAT). We conducted this study to identify the predictive risk factors for NODAT, including graft function after LDLT.

METHODS

The subjects of this study were 175 adult recipients who underwent LDLT at Kyoto University Hospital between 2006 and 2010, and survived for more than 3 months (median observation period, 1046 days).

RESULTS

The 1-, 2-, and 3-year incidences of NODAT after LDLT were 26.1, 32.0, and 33.4%, respectively. Pre-transplant diabetes was associated with poor survival (p = 0.0048), whereas NODAT was not associated with patient survival. In the multivariate analysis, recipient age ≥40, a tacrolimus trough level ≥8 ng/mL 3 months after LDLT, and cholinesterase (ChE) <185 IU/L 3 months after LDLT were the independent risk factors for NODAT.

CONCLUSIONS

Poor graft synthetic function 3 months after LDLT as well as older age of the recipient and a higher tacrolimus concentration were strongly associated with NODAT development after LDLT.

Why do I treat my patients with mild hepatitis C?

The major advances achieved in the treatment of HCV by the development of new direct-acting antiviral agents (DAAs) allow treatment of almost the entire spectrum of patients with chornic infection. As a result of the exceedingly high cost of DAAs in many countries, IFN-free DAA regimens are mostly reserved to patients with advanced fibrosis or cirrhosis. Hence, treatment of patients with milder liver disease is often deferred. This could ultimately result in an increased burden of advanced liver disease and in increased long-term costs of management. Moreover, studies performed during the 'interferon era' and the early data on interferon-free regimens show that patients without severe fibrosis achieve higher rates of sustained virological response with less treatment-related adverse events. Unfortunately, there is no univocal way to predict the progression of liver fibrosis and therefore to identify the patients with early disease who would require urgent HCV treatment. Many studies have also demonstrated that treatment-induced HCV clearance reduces all-cause mortality regardless of the stage of liver fibrosis, pointing to an effect on extrahepatic manifestations of HCV infection. Last but not least, pharmacoeconomic studies show that DAA treatment of patients with mild HCV disease is cost-effective even at high prices of drugs, thus suggesting the opprtunity to treat regardless of the stage of liver disease.

Cytokines and HCV-related autoimmune disorders

Cytokines are intercellular mediators involved in viral control and liver damage being induced by infection with hepatitis C virus (HCV). The complex cytokine network operating during initial infection allows a coordinated, effective development of both innate and adaptive immune responses. However, HCV interferes with cytokines at various levels and escapes immune response by inducing a T-helper (Th)2/T cytotoxic 2 cytokine profile. Inability to control infection leads to the recruitment of inflammatory infiltrates into the liver parenchyma by interferon (IFN)-γ-inducible CXC chemokine ligand (CXCL)9, -10, and -11 chemokines, which results in sustained liver damage and eventually in liver cirrhosis. The most important systemic HCV-related extrahepatic diseases-mixed cryoglobulinemia, lymphoproliferative disorders, thyroid autoimmune disorders, and type 2 diabetes-are associated with a complex dysregulation of the cytokine/chemokine network, involving proinflammatory and Th1 chemokines. The therapeutical administration of cytokines such as IFN-α may result in viral clearance during persistent infection and revert this process. Theoretically agents that selectively neutralize CXCL10 could increase patient responsiveness to traditional IFN-based HCV therapy. Several studies have reported IL-28B polymorphisms and circulating CXCL10 may be a prognostic markers for HCV treatment efficacy in HCV genotype 1 infection.

Hepatitis C virus infection and type 1 and type 2 diabetes mellitus

Hepatitis C virus (HCV) infection and diabetes mellitus are two major public health problems that cause devastating health and financial burdens worldwide. Diabetes can be classified into two major types: type 1 diabetes mellitus (T1DM) and T2DM. T2DM is a common endocrine disorder that encompasses multifactorial mechanisms, and T1DM is an immunologically mediated disease. Many epidemiological studies have shown an association between T2DM and chronic hepatitis C (CHC) infection. The processes through which CHC is associated with T2DM seem to involve direct viral effects, insulin resistance, proinflammatory cytokines, chemokines, and other immune-mediated mechanisms. Few data have been reported on the association of CHC and T1DM and reports on the potential association between T1DM and acute HCV infection are even rarer. A small number of studies indicate that interferon-α therapy can stimulate pancreatic autoimmunity and in certain cases lead to the development of T1DM. Diabetes and CHC have important interactions. Diabetic CHC patients have an increased risk of developing cirrhosis and hepatocellular carcinoma compared with non-diabetic CHC subjects. However, clinical trials on HCV-positive patients have reported improvements in glucose metabolism after antiviral treatment. Further studies are needed to improve prevention policies and to foster adequate and cost-effective programmes for the surveillance and treatment of diabetic CHC patients.

Hepatitis C virus NS5A protein enhances gluconeogenesis through upregulation of Akt-/JNK-PEPCK signalling pathways

BACKGROUND & AIMS

Hepatitis C virus (HCV) infection is highly associated with the type 2 diabetes mellitus, but the detailed mechanisms by which the viral proteins are involved in the clinical outcome remain unclear.

METHODS

A cDNA microarray analysis was performed following introducing an NS5A-encoding plasmid or a control vector into a mouse system by hydrodynamics- based transfection. Differentially expressed genes that are associated with gluconeogenesis were selected and their expression levels in HCV patients, in NS5A-expressing systems, and in the viral subgenomic replicon system were further examined by real-time quantitative polymerase chain reaction and Western blot analysis.

RESULTS

Differential gene expression including an upregulation of the gluconeogenic rate-limiting enzyme phosphoenolpyruvate carboxykinase (PEPCK) compared with controls was detected in mouse hepatocytes expressing HCV NS5A and in HCV patients with diabetes. In addition, an NS5A-dependent increase in glucose production was demonstrated in human primary hepatocytes. The upregulation of PEPCK and peroxisome proliferator-activated receptor-c coactivator-1a (PGC-1a) were also detected in NS5A-expressing cells and in the viral genotype 1b subgenomic replicon system. Further studies demonstrated that the NS5A-mediated upregulation of PEPCK and PGC-1a genes were resulted from the activation of PI3K-Akt and JNK signalling pathways. In addition, the expression levels of the forkhead transcription factor FoxO1 and the liver-enriched transcription factor HNF-4a were increased in HCV NS5A expressing cells.

CONCLUSIONS

By upregulating the expression of PEPCK gene via its transactivators FoxO1 and HNF-4a, and the coactivator PGC-1a, the NS5A promotes the production of hepatic glucose which may contribute to the development of HCV-associated type 2 diabetes mellitus.

Latest insights into the risk of cancer in diabetes

A growing body of evidence from observational studies and meta‐analyses of the data suggest that diabetes mellitus is associated with an increased risk of cancer. Meta‐analyses have shown that diabetes increases the risks of total cancer, and of site‐specific cancers of the breast, endometrium, bladder, liver, colorectum and pancreas, and that it decreases the risk of prostate cancer. Insulin resistance and secondary hyperinsulinemia is the most frequently proposed hypothesis, and hyperglycemia itself might promote carcinogenesis. In addition to several facets of lifestyle including obesity, smoking and lack of exercise, treatment for diabetes might affect the risk of cancer. For instance, metformin, an insulin sensitizer, reportedly has a potential anticancer effect. In light of the exploding global epidemic of diabetes, even a modest increase in the cancer risk will translate into a substantial socioeconomic burden. The current insights underscore the need for clinical attention and better‐designed studies of the complex interactions between diabetes and cancer.

CXCR3, CXCL10 and type 1 diabetes

Type 1 diabetes (T1D) is due to antigen-specific assaults on the insulin producing pancreatic β-cells by diabetogenic T-helper (Th)1 cells. (C-X-C motif) ligand (CXCL)10, an interferon-γ inducible Th1 chemokine, and its receptor, (C-X-C motif) receptor (CXCR)3, have an important role in different autoimmune diseases. High circulating CXCL10 levels were detected in new onset T1D patients, in association with a Th1 autoimmune response. Furthermore β-cells produce CXCL10, under the influence of Th1 cytokines, that suppresses their proliferation. Viral β-cells infections induce cytokines and CXCL10 expression, inducing insulin-producing cell failure in T1D. CXCL10/CXCR3 system plays a critical role in the autoimmune process and in β-cells destruction in T1D. Blocking CXCL10 in new onset diabetes seems a possible approach for T1D treatment.

Immunological alterations in hepatitis C virus infection

A higher prevalence of immunological processes has recently been reported in patients with hepatitis C virus (HCV) infection, focusing the attention of physicians and researchers on the close association between HCV and immune disorders. HCV lymphotropism represents the most important step in the pathogenesis of virus-related immunological diseases and experimental, virologic, and clinical evidence has demonstrated a trigger role for HCV both in systemic autoimmune diseases, such as rheumatoid arthritis, Sjögren syndrome, hemolytic anemia and severe thrombocytopenia, and in organ-specific autoimmune diseases, such as autoimmune hepatitis, thyroid disorders and diabetes. This review will outline the principal aspects of such HCV-induced immunological alterations, focusing on the prevalence of these less characterized HCV extrahepatic manifestations.

Inhibition of hepatitis C virus infection by polyoxometalates

Hepatitis C virus (HCV) infects about 2% of the world population. The standard treatment of chronic HCV infection is still discontented because of the low sustained virological response rate. The development of new HCV antivirals is a healthcare imperative. We explored the potentials of polyoxometalates to inhibit HCV infection using newly developed HCVcc cell culture system. We found one polyoxometalate compound (named POM-12) can inhibit HCV infection at the nanomolar range while displayed little cytotoxicity. We showed that POM-12 inhibited pseudotyped HCV infection but had no effect on HCV RNA replication. Furthermore, we showed that POM-12 was virucidal and can disrupt HCV particles. Finally we demonstrated that POM-12 had no effect on the vesicular stomatitis virus infection while had weak inhibitory activity against the influenza virus infection. In conclusion, we identified a potent anti-HCV compound which may provide an attractive drug candidate to cure HCV infection.

Insulin resistance, serum visfatin, and adiponectin levels are associated with metabolic disorders in chronic hepatitis C virus-infected patients

OBJECTIVE

The aim of this study was to determine the serum levels of visfatin, adiponectin, and insulin resistance (IR) in patients with hepatitis C virus (HCV) infection and their relations to the biochemical markers of hepatitis C.

MATERIALS AND METHODS

This study was carried out on 40 HCV-infected patients and 40 sex/age/BMI-matched healthy adults. Lipid profile, liver function tests, IR, serum adiponectin, and visfatin of all patients were examined. Correlations between IR, adiponectin, visfatin, and other variables were analyzed.

RESULTS

The levels of visfatin and adiponectin were significantly lower in HCV patients compared with healthy controls. However, IR of HCV patients were higher than those of healthy controls. IR was significantly correlated to triglycerides, visfatin was closely related to low-density lipoprotein cholesterol, whereas adiponectin was associated with high-density lipoprotein cholesterol. These results suggest that IR, serum visfatin, and adiponectin levels are associated with metabolic disorders in chronic HCV-infected patients.

CONCLUSION

IR, adiponectin, and visfatin were related to several metabolic markers of HCV, suggesting the characteristics of HCV-related metabolic abnormalities.

Hepatitis C virus genotype distribution in Egyptian diabetic patients: a preliminary study

BACKGROUND AND STUDY AIMS

There is controversy regarding whether a specific hepatitis C virus (HCV) genotype is associated with diabetes mellitus. This study aimed to investigate HCV genotype distribution in diabetics and its relation to some clinical and laboratory variables in HCV-positive diabetic versus non-diabetic Egyptians in East Delta.

PATIENTS AND METHODS

The study included 100 HCV-positive patients of which 66 were diabetic in addition to 35 healthy adults as a control group. Clinical assessment, laboratory measurements of plasma glucose, insulin, C-peptide, C-reactive protein (CRP), tumour necrosis factor-α (TNF-α) and liver functions (alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT)) as well as HCV genotype determination were done, and AST/platelet ratio index (APRI) and Homoeostasis Model of Assessment-Insulin Resistance (HOMA-IR) were calculated.

RESULTS

The main results were the presence of HCV genotype 3, in 31.8% of the diabetic group and in 26.5% of the non-diabetic group, while the remainder of cases had genotype 4, the predominant genotype in Egypt. This is the first report of the presence of HCV genotype 3 in about 30% of an Egyptian cohort. However, there was no significant difference in genotype distribution between both groups. Further, there were significantly higher values of HOMA-IR, insulin and C-peptide in HCV-positive groups in comparison to the control group, while TNF-α was significantly higher in the HCV-positive diabetic group. However, there were no significant differences between both genotypes regarding these parameters.

CONCLUSION

Although this study reveals for the first time the presence of HCV genotype 3 in a significant percentage of a group of Egyptian patients, where the majority were diabetic, the association between diabetes and certain HCV genotypes could not be confirmed on the basis of our findings. Hence, taking into consideration the impact of such a finding on the treatment decisions of those patients, further studies are warranted to explore these findings to a greater extent.

Hepatitis C virus E2 protein involve in insulin resistance through an impairment of Akt/PKB and GSK3β signaling in hepatocytes

Background

Hepatitis C virus (HCV) infection may cause liver diseases of various severities ranging from primary acute infection to life-threatening diseases, such as cirrhosis or hepatocellular carcinoma with poor prognosis. According to clinical findings, HCV infection may also lead to some extra-hepatic symptoms, including type 2 diabetes mellitus (DM). Since insulin resistance is the major etiology for type 2 DM and numerous evidences showed that HCV infection associated with insulin resistance, the involvement of E2 in the pathogenesis of type 2 DM and underlying mechanisms were investigated in this study.

Methods

Reverse transcription and real-time PCR, Western blot assay, Immunoprecipitation, Glucose uptake assay and analysis of cellular glycogen content.

Results

Results showed that E2 influenced on protein levels of insulin receptor substrate-1 (IRS-1) and impaired insulin-induced Ser308 phosphorylation of Akt/PKB and Ser9 phosphorylation of GSK3β in Huh7 cells, leading to an inhibition of glucose uptake and glycogen synthesis, respectively, and eventually insulin resistance.

Conclusions

Therefore, HCV E2 protein indeed involved in the pathogenesis of type 2 DM by inducing insulin resistance.

Cytokines and HCV-related disorders

Cytokines are intercellular mediators involved in viral control and liver damage being induced by infection with hepatitis C virus (HCV). The complex cytokine network operating during initial infection allows a coordinated, effective development of both innate and adaptive immune responses. However, HCV interferes with cytokines at various levels and escapes immune response by inducing a T-helper (Th)2/T cytotoxic 2 cytokine profile. Inability to control infection leads to the recruitment of inflammatory infiltrates into the liver parenchyma by interferon (IFN)-gamma-inducible CXC chemokine ligand (CXCL)-9, -10, and -11 chemokines, which results in sustained liver damage and eventually in liver cirrhosis. The most important systemic HCV-related extrahepatic diseases--mixed cryoglobulinemia, lymphoproliferative disorders, thyroid autoimmune disorders, and type 2 diabetes--are associated with a complex dysregulation of the cytokine/chemokine network, involving proinflammatory and Th1 chemokines. The therapeutical administration of cytokines such as IFN-alpha may result in viral clearance during persistent infection and reverts this process.

Relation of serum insulin-like growth factor-1 (IGF-1) levels with hepatitis C virus infection and insulin resistance

The prospect of the growing worldwide epidemic of hepatitis C virus (HCV) infection and type 2 diabetes mellitus certainly merits attention toward their controversial relationship. Insulin-like growth factor-1 (IGF-1) plays an important role in glucose homeostasis. This study is a cross-sectional study considered as an initial investigation aimed to evaluate the effect of HCV infection on serum IGF-1, as well as to find out whether IGF-1 has a role in development of insulin resistance (IR) in HCV infection. A total of 45 subjects divided into 3 groups were included in the study: chronic HCV-infected patients (15 patients), chronic HCV-infected diabetic patients (15 patients), and diabetic patients without HCV infection (15 patients), along with 15 healthy controls. HCV RNA was quantified using real-time polymerase chain reaction (PCR). Serum IGF-1 levels were measured by enzyme-linked immunosorbent assay (ELISA). Homeostasis model assessment of insulin resistance [HOMA-IR], insulin sensitivity [HOMA-S], and β-cell function [HOMA-β] were determined by previously validated mathematic indexes. Fasting blood glucose, insulin levels, and liver parameters including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were determined. IGF-1 levels were significantly lower in the 3 patient groups compared with controls (P = 0.001). The HCV group demonstrated high HOMA-IR and HOMA-β with a positive correlation between HOMA-IR and either HOMA-β or fasting insulin (P < 0.001). In addition, a negative correlation was found between IGF-1 levels and both AST and ALT, and HOMA-IR was correlated positively with AST activity (P < 0.05). In HCV patients with detectable viremia, IGF-1 levels were correlated negatively with HOMA-β (P < 0.01) and with HOMA-IR. However, this correlation did not reach statistical significance (P = 0.074). No significant correlation was found between HCV viral load and the studied parameters. In conclusion, low IGF-I levels might have a role in IR among HCV viremic patients.

Rapid detection of hepatitis C virus RNA by a reverse transcription loop-mediated isothermal amplification assay

The usefulness of reverse transcription loop-mediated isothermal amplification (RT-LAMP) for the rapid diagnosis of hepatitis C virus (HCV) RNA was evaluated. This assay showed higher sensitivities than that of nested RT-PCR, with a detection limit of 600 IU mL(-1) , and no cross-reactivity was observed with hepatitis A virus, hepatitis B virus and hepatitis E virus. Furthermore, 106 stored sera from recently diagnosed cases were retrospectively investigated with real-time RT-PCR, the nested RT-PCR, in parallel with this new assay. The general detection rates of HCV RT-LAMP, real-time PCR and the nested RT-PCR for 106 stored sera samples were 95%, 96% and 88%, respectively. This study provides the first data on the usefulness of HCV RT-LAMP in the diagnosis of HCV RNA, especially in the early clinical diagnosis of acute HCV infection.

Pegylated-interferon-α(2a) in clinical practice: how to manage patients suffering from side effects

INTRODUCTION

The goal of antiviral therapy in patients with chronic hepatitis C is to slow or halt the progression of fibrosis and prevent the development of cirrhosis. Accordingly, antiviral treatment is proposed for a large population of patients with chronic hepatitis.

AREAS COVERED

The standard-of-care for chronic hepatitis C is the combination of pegylated IFN (PEG-IFN) and ribavirin. The use of these drugs has been correlated with a range of adverse effects, including influenza-like symptoms, hematological changes and neuropsychiatric disturbances. The effects of these adverse events associated with PEG-IFN therapy are manifold and are a major reason why patients decline or stop therapy. This review addresses the screening for adverse event risk factors and guides the patient to success with adherence strategies.

EXPERT OPINION

Knowledge of the side effects correlated with PEG-IFN is very relevant for clinicians because it can allow them to arrange the best methods for treating these effects and avoid the discontinuation of antiviral treatment. Moreover, the use of new antiviral drugs will considerably shorten treatment periods reducing many of the above-described side effects and, thus, increase adherence to scheduled therapy.

Hepatitis C virus experimental model systems and antiviral drug research

An estimated 130 million people worldwide are chronically infected with hepatitis C virus (HCV) making it a leading cause of liver disease worldwide. Because the currently available therapy of pegylated interferon-alpha and ribavirin is only effective in a subset of patients, the development of new HCV antivirals is a healthcare imperative. This review discusses the experimental models available for HCV antiviral drug research, recent advances in HCV antiviral drug development, as well as active research being pursued to facilitate development of new HCV-specific therapeutics.

Association of hepatitis C virus infection and diabetes in central Tunisia

AIM: To investigate hepatitis C virus (HCV) seroprevalence in Tunisian patients with diabetes mellitus and in a control group.

METHODS: A cross-sectional study was conducted to determine the HCV seroprevalence in 1269 patients with diabetes (452 male, 817 female) and 1315 non-diabetic patients, attending health centers in Sousse, Tunisia. HCV screening was performed in both groups using a fourth-generation enzyme immunoassay.

RESULTS: In the diabetic group, 17 (1.3%) were found to be HCV-infected compared with eight (0.6%) in the control group, although the difference was not significant (P = 0.057). Quantitative PCR was performed in 20 patients. Eleven patients were positive and showed HCV genotype 1b in all cases.

CONCLUSION: Frequency of HCV antibodies was low in patients with diabetes and in the control group in central Tunisia, with no significant difference between the groups.

Endocrine manifestations of hepatitis C virus infection

Chronic infection with hepatitis C virus (HCV) can result in both hepatic and extrahepatic disease and endocrine dysfunction represents an important class of HCV-related extrahepatic disease. The most frequently occurring--and clinically important--of these endocrine disorders are thyroid disease and type 2 diabetes mellitus. In this Review, we evaluate the evidence in support of a link between HCV infection and endocrine-system dysfunction, and discuss potential pathophysiological mechanisms. A meta-analysis of the literature has revealed significant associations between chronic HCV infection, thyroid autoimmunity and hypothyroidism. Furthermore, a high prevalence of thyroid cancer has been reported in HCV-positive patients. Several clinicoepidemiological studies have demonstrated that chronic HCV infection could lead to the development of type 2 diabetes mellitus, possibly as a result of HCV-induced metabolic disturbances. Some researchers have postulated that a type 1 T-helper -cell mediated immune response underpins the association of chronic HCV infection with endocrine disease. Indeed, the available data suggest that a common immunological, type 1 T-helper cell pattern of cytokine expression and activation (via interferon-gamma) could provide the pathophysiological basis for this association. Nonetheless, additional studies will be necessary to elucidate fully all the mechanisms involved in HCV-related endocrine dysfunction.

Hepatitis C infection and risk of diabetes: a systematic review and meta-analysis

BACKGROUND/AIMS

Several studies found hepatitis C (HCV) increases risk of Type II diabetes mellitus (DM). However, others found no or only sub-group specific excess risk. We performed meta-analyses to examine whether HCV infection does increase DM risk in comparison to the general population and in other sub-groups with increased liver disease rates including with hepatitis B (HBV).

METHODS

We followed standard guidelines for performance of meta-analyses. Two independent investigators identified eligible studies through structured keyword searches in relevant databases including PubMed.

RESULTS

We identified 34 eligible studies. Pooled estimators indicated significant DM risk in HCV-infected cases in comparison to non-infected controls in both retrospective (OR(adjusted)=1.68, 95% CI 1.15-2.20) and prospective studies (HR(adjusted)=1.67, 95% CI 1.28-2.06). Excess risk was also observed in comparison to HBV-infected controls (OR(adjusted)=1.80, 95% CI 1.20-1.40) with suggestive excess observed in HCV+/HIV+ cases in comparison to HIV+ controls (OR(unadjusted)=1.82, 95% CI 1.27-2.38).

CONCLUSIONS

Our finding of excess DM risk with HCV infection in comparison to non-infected controls is strengthened by consistency of results from both prospective and retrospective studies. The excess risk observed in comparison to HBV-infected controls suggests a potential direct viral role in promoting DM risk, but this needs to be further examined.

Immunopathogenesis of HCV-related endocrine manifestations in chronic hepatitis and mixed cryoglobulinemia

Hepatitis C Virus (HCV) is known to be responsible for both hepatic and extrahepatic diseases (HCV-related extrahepatic diseases = HCV-EHDs). The most important systemic HCV-EHDs are mixed cryoglobulinemia and lymphoproliferative disorders, while the most frequent and clinically important endocrine HCV-EHDs are thyroid disorders and type 2 diabetes mellitus (T2D). From a meta-analysis of the literature a significant association between HCV infection and thyroid autoimmunity and hypothyroidism has been reported. A high prevalence of thyroid cancer has been reported, too. Furthermore, several clinical epidemiologic studies have reported that HCV infection is associated to T2D. Many studies have linked Th1 immune response with HCV infection, thyroid autoimmunity, or diabetes. These findings suggest that a possible common immunological Th1 pattern could be the pathophysiological base of the association of HCV-EHDs, with thyroid autoimmunity and T2D. In fact, HCV infection of thyrocytes or beta-cells may act by upregulating CXCL10 secretion in these cells that is responsible for Th1 lymphocyte recruitment. Th1 response leads to increased IFNgamma and TNFalpha production that in turn stimulates CXCL10 secretion by the target cells, thus perpetuating the immune cascade. This process may lead to the appearance of thyroid autoimmune disorders or T2D in genetically predisposed subjects.

Extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus may cause hepatic and extrahepatic diseases. Extrahepatic manifestations range from disorders for which a significant association with viral infection is supported by epidemiologic and pathogenetic data, to anecdotal observations without clear proof of causality. This article describes the diagnosis and treatment of these diseases.

Cause of death in individuals with chronic HBV and/or HCV infection, a nationwide community-based register study

Studies on chronic viral hepatitis and mortality have often been made on selected populations or in high-endemic countries. The aim of this study was to investigate the causes of death and the mortality rates in the nationwide cohorts of people chronically infected with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) in Sweden, a low-endemic country. All notifications on chronic HBV infection and HCV infection 1990-2003 were linked to the Cause of Death Register. A total of 9517 people with chronic HBV infection, 34 235 people with HCV infection and 1601 with chronic HBV-HCV co-infection were included, and the mean observation times were 6.4, 6.3 and 7.9 years, respectively. The mortality in the cohorts was compared with age- and gender-specific mortality in the general population and standardized mortality ratios (SMR) were calculated. All-cause mortality was significantly increased, SMR 2.3 (HBV), 5.8 (HCV) and 8.5 (HBV-HCV), with a great excess liver-related mortality in all cohorts, SMR 21.7, 35.5 and 46.2, respectively. In HCV and HBV-HCV infected there was an increased mortality due to drug-related psychiatric diagnoses (SMR: 20.7 and 27.6) and external causes (SMR: 12.4 and 11.4), predominantly at younger age. To conclude, this study demonstrated an increased all-cause mortality, with a great excess mortality from liver disease, in all cohorts. In people with HCV infection the highest excess mortality in younger ages was from drug-related and external reasons.

Sudden onset of diabetic ketoacidosis during consensus interferon therapy for chronic viral hepatitis C

INTRODUCTION

Interferon (IFN)-alpha, used for the treatment of chronic hepatitis C, has rarely been associated with the development of diabetes. Consensus interferon (CIFN), which is used for nonresponders, has not been associated with this complication. We describe the first case of new onset diabetes in a patient on CIFN.

CASE

A 50-year-old man with chronic hepatitis C and no prior diabetes was started on IFN-alpha. After 24 weeks with a detectable viral load, he was switched to CIFN. Four weeks later, he presented in diabetic ketoacidosis which resolved with appropriate therapy without any ascertainable etiology (glutamic acid decarboxylase negative). Within 9 months he was off insulin, and is off all diabetic medications with an HgA1c of 5.6% 2 years after the episode.

Clinical significance of metabolic syndrome in the setting of chronic hepatitis C virus infection

BACKGROUND & AIMS

The metabolic syndrome (MS) is a unique condition in which the underlying mechanism is related to insulin resistance. In hepatitis C virus (HCV) patients, insulin resistance has been linked to treatment failure. The aim of this study was to estimate the prevalence of MS in HCV patients undergoing antiviral therapy and to assess its predictive value in treatment outcome.

METHODS

All HCV treatment-naive patients who met the inclusion/exclusion criteria were studied (n = 228). MS was defined using the National Cholesterol Education Program Adult Treatment Panel III criteria. A logistic regression analysis was performed to study multivariable associations. The final model contained sex, ethnicity, body mass index, viral load, genotype, steatosis, fibrosis stage, and MS.

RESULTS

MS was present in 59 of 228 (26%) patients. Genotype 1 (P = .002) and presence of steatosis (P < .001) were found to be associated significantly with MS. Overall, sustained virologic response (SVR) was achieved in 108 of 228 (47%) patients. Male sex, non-Caucasian ethnicity, higher body mass index, high viral load, genotype 1, higher fibrosis stage, and MS were associated significantly with a lack of SVR. After adjusting for confounding variables, MS remained independently associated with a lack of SVR (P < .01). Specifically, subjects with MS were 3.8 (95% confidence interval, 1.4-10.5) times more likely to fail treatment than those without MS.

CONCLUSIONS

MS is seen frequently in patients with chronic HCV and is associated independently to lack of SVR. These findings support the concept that an aggressive intervention approach comprising lifestyle modification alone or in combination with drug treatment of the MS components may play an important role in improving antiviral responses in these patients.

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.

Alanine aminotransferase and the 6-year risk of the metabolic syndrome in Caucasian men and women: the Hoorn Study

AIMS

To study the association between alanine aminotransferase (ALT) and the 6-year risk of the metabolic syndrome in a population-based study in Caucasian men and women.

METHODS

The association of ALT with the 6-year risk of the metabolic syndrome in 1097 subjects, aged 50-75 years, was assessed in the Hoorn Study with logistic regression analysis. Subjects with the metabolic syndrome at baseline, defined according to the Adult Treatment Panel III of the National Cholesterol Education Program, were excluded.

RESULTS

After 6.4 (range 4.4-8.1) years follow-up, 226 subjects (20.6%) had developed the metabolic syndrome. The odds ratio (95% confidence interval) for developing the metabolic syndrome, adjusted for age, sex, alcohol intake and follow-up duration was 2.25 (1.50-3.37) for subjects in the upper tertile compared with those in the lower tertile of ALT. This association persisted after additional adjustment for all the baseline metabolic syndrome features [1.62 (1.02-2.58)]. Among the individual components of the metabolic syndrome, ALT was significantly associated only with fasting plasma glucose at follow-up.

CONCLUSIONS

These data suggest that ALT is associated with risk of the metabolic syndrome in a general population of middle-aged Caucasian men and women, further strengthening the role of ALT as an indicator for future metabolic derangement. These findings warrant further studies to elucidate the role of non-adipose tissue fat accumulation in the pathogenesis of complications related to the metabolic syndrome.

Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach

Hepatitis C Virus is associated with a wide series of extrahepatic manifestations. Based on available data the link between the virus and some of these extrahepatic diseases is only suggested and needs further confirmation. Hepatitis C Virus-related lymphoproliferative disorders, whose prototype is mixed cryoglobulinaemia, represent the most closely related extrahepatic manifestations of Hepatitis C Virus. Other Hepatitis C Virus-associated disorders include nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, porphyria cutanea tarda, lichen planus, diabetes, chronic polyarthritis, cardiopathy and atherosclerosis. A pathogenetic link between Hepatitis C Virus and some extrahepatic manifestations was confirmed by their responsiveness to antiviral therapy, which is now deemed the first therapeutic option to consider. By contrast, there are diseases where treatment with interferon was ineffective or dangerous. The aim of the present paper is to outline the most recent evidence concerning extrahepatic disorders that are possibly associated with Hepatitis C Virus infection. Special emphasis will be given to discussion of the most appropriate clinical approaches to be adopted in order to diagnose, treat (possibly prevent) and follow-up extrahepathic diseases in patients with Hepatitis C Virus infection.