Racial differences in the relationship between hepatitis C infection and iron stores

Role of hepatocyte nuclear factor 4-alpha in gastrointestinal and liver diseases

Hepatocyte nuclear factor 4-alpha (HNF4α) is a highly conserved member of nuclear receptor superfamily of ligand-dependent transcription factors that is expressed in liver and gastrointestinal organs (pancreas, stomach, and intestine). In liver, HNF4α is best known for its role as a master regulator of liver-specific gene expression and essential for adult and fetal liver function. Dysregulation of HNF4α expression has been associated with many human diseases such as ulcerative colitis, colon cancer, maturity-onset diabetes of the young, liver cirrhosis, and hepatocellular carcinoma. However, the precise role of HNF4α in the etiology of these human pathogenesis is not well understood. Limited information is known about the role of HNF4α isoforms in liver and gastrointestinal disease progression. There is, therefore, a critical need to know how disruption of the expression of these isoforms may impact on disease progression and phenotypes. In this review, we will update our current understanding on the role of HNF4α in human liver and gastrointestinal diseases. We further provide additional information on possible use of HNF4α as a target for potential therapeutic approaches.

Serum Markers of Iron Metabolism in Chronic Liver Diseases

BACKGROUND:

Disorders in the metabolism of iron in the direction of iron overload are observed not only in primary hemochromatosis but also in some chronic liver diseases other aetiology. Elevation of serum iron, ferritin and transferrin saturation is reported in nonalcoholic fatty liver disease and alcohol, chronic hepatitis C and liver cirrhosis.

AIM:

Aim of the study was to evaluate and compare the frequency of the iron serum markers in patients with various chronic liver diseases.

MATERIAL AND METHODS:

The study included a total of 246 persons -186 patients with chronic liver disease without cirrhosis (-115 men, women -71; average age of 50.41 ± 12.85, from 23 to 77 years) and 60 healthy controls (-30 men, women -30, middle-aged 50.50 ± 11.31, from 29 to 83 years). Medical history, physical examination and demographic data including height, weight, laboratory and instrumental studies were performed.

RESULTS:

The highest incidence of elevated serum iron, transferrin saturation and ferritin and decreased serum hepcidin found in cases of alcoholic liver disease (ALD), nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis C (CHC).

CONCLUSION:

Finally, analysis of the changes in serum markers of iron metabolism shows that the difference between healthy and sick with liver disease is primarily due to changes in alcoholic and nonalcoholic fatty liver disease, particularly steatohepatitis, and chronic hepatitis C.

Clinical and Laboratory Associations with Persistent Hyperferritinemia in 373 Black Hemochromatosis and Iron Overload Screening Study Participants

BACKGROUND

373 black participants had elevated screening and post-screening serum ferritin (SF) (> 300 μg/L men; > 200 μg/L women).

MATERIAL AND METHODS

We retrospectively studied SF and post-screening age; sex; body mass index; transferrin saturation (TS); ALT; AST; GGT; elevated C-reactive protein; ß-thalassemia; neutrophils; lymphocytes; monocytes; platelets; metacarpophalangeal joint hypertrophy; hepatomegaly; splenomegaly; diabetes; HFE H63D positivity; iron/alcohol intakes; and blood/erythrocyte transfusion units. Liver disease was defined as elevated ALT or AST. We computed correlations of SF and TS with: age; body mass index; ALT; AST; GGT; C-reactive protein; blood cell counts; and iron/alcohol. We compared participants with SF > 1,000 and ≤ 1,000 μg/L and performed regressions on SF.

RESULTS

There were 237 men (63.5%). Mean age was 55 ± 13 (SD) y. 143 participants had liver disease (62 hepatitis B or C). There were significant correlations of SF: TS, ALT, AST, GGT, and monocytes (positive); and SF and TS with platelets (negative). 22 participants with SF > 1,000 μg/L had significantly higher median TS, ALT, and AST, and prevalences of anemia and transfusion > 10 units; and lower median platelets. Regression on SF revealed significant associations: TS; male sex; age; GGT; transfusion units (positive); and splenomegaly (negative) (p < 0.0001, 0.0016, 0.0281, 0.0025, 0.0001, and 0.0096, respectively). Five men with SF > 1,000 μg/L and elevated TS had presumed primary iron overload (hemochromatosis). Four participants had transfusion iron overload.

CONCLUSION

Persistent hyperferritinemia in 373 black adults was associated with male sex, age, TS, GGT, and transfusion. 2.4% had primary iron overload (hemochromatosis) or transfusion iron overload.

Genomic variants link to hepatitis C racial disparities

Chronic liver diseases are one of the major public health issues in United States, and there are substantial racial disparities in liver cancer-related mortality. We previously identified racially distinct alterations in the expression of transcripts and proteins of hepatitis C (HCV)-induced hepatocellular carcinoma (HCC) between Caucasian (CA) and African American (AA) subgroups. Here, we performed a comparative genome-wide analysis of normal vs. HCV+ (cirrhotic state), and normal adjacent tissues (HCCN) vs. HCV+HCC (tumor state) of CA at the gene and alternative splicing levels using Affymetrix Human Transcriptome Array (HTA2.0). Many genes and splice variants were abnormally expressed in HCV+ more than in HCV+HCC state compared with normal tissues. Known biological pathways related to cell cycle regulations were altered in HCV+HCC, whereas acute phase reactants were deregulated in HCV+ state. We confirmed by quantitative RT-PCR that SAA1, PCNA-AS1, DAB2, and IFI30 are differentially deregulated, especially in AA compared with CA samples. Likewise, IHC staining analysis revealed altered expression patterns of SAA1 and HNF4α isoforms in HCV+ liver samples of AA compared with CA. These results demonstrate that several splice variants are primarily deregulated in normal vs. HCV+ stage, which is certainly in line with the recent observations showing that the pre-mRNA splicing machinery may be profoundly remodeled during disease progression, and may, therefore, play a major role in HCV racial disparity. The confirmation that certain genes are deregulated in AA compared to CA tissues also suggests that there is a biological basis for the observed racial disparities.

Secondary analysis of large databases for hepatology research

Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.

Hepatic iron in African Americans who underwent liver biopsy

Background:

Primary iron overload in African Americans has been reported predominantly from autopsy studies.

Methods:

We characterized hepatic iron phenotypes in 83 African Americans who underwent liver biopsy during the interval 1990 to 1995. We tabulated pathology report form data, iron grades in hepatocytes (0–4) and Kupffer cells (0–3) and abnormal liver histology. Increased iron was defined as hepatocyte or Kupffer iron grades ≥2, respectively. Heavy iron was defined as hepatocyte iron grade 3 or 4. Primary iron overload was defined as the presence of grade 3 or 4 hepatocellular iron in the absence of evidence of chronic alcohol effect, viral hepatitis, steatosis, unexplained inflammation, chronic erythrocyte transfusion or chronic ingestion of iron supplements.

Results:

There were 37 men and 46 women (mean age: 53 ± 15 [SD] years). We observed heavy ethanol consumption, 12.0%; viral hepatitis, 26.5%; steatosis without heavy ethanol consumption, 43.4%; inflammation, 45.6%; fibrosis, 26.2% and bridging fibrosis/cirrhosis, 29.4%. Logistic regression on bridging fibrosis/cirrhosis revealed positive associations with heavy ethanol consumption (P = 0.0410) and viral hepatitis (P = 0.0044). The 22 patients (26.5%) with increased iron had greater mean age, proportion of men and heavy ethanol consumption. Five patients had heavy iron staining, among whom were 3 women (mean age: 54 years) with primary iron overload. Two of the 3 women had cirrhosis and diabetes mellitus.

Conclusions:

Among 83 adult African Americans who underwent liver biopsy, 3.6% had hepatic iron phenotypes consistent with primary iron overload.

Quantitative proteomic analysis in HCV-induced HCC reveals sets of proteins with potential significance for racial disparity

Background

The incidence and mortality of hepatitis C virus (HCV)-induced hepatocellular carcinoma (HCC) is higher in African Americans (AA) than other racial/ethnic groups in the U.S., but the reasons for this disparity are unknown. There is an urgent need for the discovery of novel molecular signatures for HCV disease progression to understand the underlying biological basis for this cancer rate disparity to improve the clinical outcome.

Methods

We performed differential proteomics with isobaric labeling tags for relative and absolute quantitation (iTRAQ) and MS/MS analysis to identify proteins differentially expressed in cirrhotic (CIR) and HCC as compared to normal tissues of Caucasian American (CA) patients. The raw data were analyzed using the ProteinPilot v3.0. Searches were performed against all known sequences populating the Swiss-Prot, Refseq, and TrEMBL databases. Quality control analyses were accomplished using pairwise correlation plots, boxplots, principal component analysis, and unsupervised hierarchical clustering. Supervised analysis was carried out to identify differentially expressed proteins. Candidates were validated in independent cohorts of CA and AA tissues by qRT-PCR or Western blotting.

Results

A total of 238 unique proteins were identified. Of those, around 15% were differentially expressed between normal, CIR & HCC groups. Target validation demonstrates racially distinct alteration in the expression of certain proteins. For example, the mRNA expression levels of transferrin (TF) were 2 and18-fold higher in CIR and HCC in AA as compared to CA. Similarly; the expression of Apolipoprotein A1 (APOA1) was 7-fold higher in HCC of AA. This increase was mirrored in the protein expression levels. Interestingly, the level of hepatocyte nuclear factor4α (HNF4α) protein was down regulated in AA, whereas repression of transcription is seen more in CA compared to AA. These data suggest that racial disparities in HCC could be a consequence of differential dysregulation of HNF4α transcriptional activity.

Conclusion

This study identifies novel molecular signatures in HCV-induced HCC using iTRAQ-based tissue proteomics. The proteins identified will further enhance a molecular explanation to the biochemical mechanism(s) that may play a role in HCC racial disparities.

Polymorphisms near interleukin 28B gene are not associated with hepatitis B virus clearance, hepatitis B e antigen clearance and hepatocellular carcinoma occurrence

BACKGROUND

Polymorphisms near the IL28B gene have been proposed to be strongly associated with treatment response and the rate of spontaneous clearance of hepatitis C virus infection, and treatment response of hepatitis B virus (HBV) infection. In this study, we aimed to determine whether these polymorphisms could affect natural courses of HBV infection.

METHODS

Genetic variations were identified through direct DNA sequencing using TaqMan assay in 1,439 patients with past or present HBV infection. Subjects included 404 spontaneously recovered patients, 313 chronic hepatitis B (CHB) patients, 305 liver cirrhosis (LC) patients and 417 hepatocellular carcinoma (HCC) patients. Three polymorphisms near the IL28B gene, rs8099917T>G, rs12979860C>T and rs12980275A>G, were identified. Associations between these polymorphisms and HBV clearance, hepatitis B e antigen (HBeAg) clearance as well as HCC occurrence among patients were analyzed using logistic regression analyses adjusted for age and gender.

RESULTS

There were no significant associations between these polymorphisms and the HBV clearance both in CHB and LC groups. Similarly, these polymorphisms showed no significant associations with HBeAg clearance and the occurrence of HCC either.

DISCUSSION

No significant association was identified between polymorphisms near the IL28B gene and the natural courses of chronic HBV infection, including the HBV clearance and HCC occurrence.

Predictive role of acute phase reactants in the response to therapy in patients with chronic hepatitis C virus infection

BACKGROUND/AIMS

Biochemical parameters and acute-phase proteins (APPs) may provide complementary data in patients with chronic hepatitis C (CHC). We aimed to evaluate the predictive role of APPs in the response to antiviral therapy.

METHODS

Forty-five patients underwent antiviral therapy. Serum ferritin, C-reactive protein (CRP), transferrin, albumin, alpha-1 acid glycoprotein (A1AG), and alpha-2 macroglobulin (A2MG) levels were examined at the initial evaluation and at the 4th, 12th, and 48th weeks. HCV RNA levels were examined at the initial evaluation and at the 12th and 48th weeks.

RESULTS

Ferritin, transferrin, A1AG, and A2MG levels were significantly higher in the patient group (p<0.05). CRP, ferritin, A1AG, and A2MG levels were significantly increased from baseline to the 4th week (p<0.05). The responders and nonresponders to antiviral therapy had insignificantly but remarkably different levels of CRP, ferritin, transferrin, A1AG, A2MG, and alanine aminotransferase (ALT) both at the initial evaluation and at the 12th week.

CONCLUSIONS

Variations in ferritin, A1AG, A2MG, albumin, CRP, and transferrin levels are not alternatives to virological and biochemical parameters for predicting an early response to therapy in patients with CHC. However, the investigation of ALT levels and hepatitis C virus RNA in combination with acute-phase reactants may provide supplementary data for evaluating responses to antiviral therapy.

Polymorphism near the IL28B gene in Korean hepatitis C virus-infected patients treated with peg-interferon plus ribavirin

BACKGROUND

Single nucleotide polymorphisms (SNPs) near the IL28B gene have recently been described as predictors of antiviral therapy responses in patients with hepatitis C virus (HCV) genotype-1.

OBJECTIVES

The aim of this study was to investigate the association between genetic variation near the IL28B gene and treatment outcome prediction in Korean patients receiving peg-interferon (PEG-IFN) plus ribavirin therapy.

STUDY DESIGN

The allelic discrimination assay by Taqman real-time PCR was developed to determine genotypes of SNPs, rs12979860 and rs8099917, which were analyzed in 65 Korean patients with HCV genotype-1.

RESULTS

For rs12979860, the frequency of patients with sustained virological response (SVR) was 70.2% in those with the CC genotype and 25% in those with the CT genotype. Early virological response (EVR) in patients with the CC genotype (84.2%) was higher than in those with the CT genotype (25.0%). For rs8099917, patients with the TT genotype showed significantly higher in SVR and EVR than those with the TG/GG genotype (69.6% vs 33.3% and 82.1% vs 44.4%, respectively). With regards to the genotype frequency of the SNPs, the homozygous genotypes for rs12979860 (CC) or rs8099917 (TT) in Korean patients showed a significantly higher frequency as compared with other ethnicities; Caucasians, African-American, Hispanic, and Japanese.

CONCLUSIONS

These results demonstrate that the genotypes rs12979860 CC and rs8099917 TT were more frequently observed in Korean patients compared to other ethnicities, and suggest that the genetic characteristics of patients may be prognostic factor that predicts antiviral response to PEG-IFN therapy for chronic hepatitis C.

Serum lipids and their associations with viral levels and liver disease severity in a treatment-naïve chronic hepatitis C type 1-infected cohort

In patients with chronic hepatitis C virus (HCV) infection, steatosis and fibrosis have been shown to be inversely associated with total cholesterol (TC) and low-density lipoprotein cholesterol. Steatosis and fibrosis have also been found to be associated with triglyceride (TG) levels; though, the direction of the relationship is inconsistent across studies. The objective of this study was to assess whether viral level and histological factors are associated with the serum lipid profile in a treatment-naïve cohort with chronic HCV genotype 1 infection. Participants were from the prospective Study of Viral Resistance to Antiviral Therapy (Virahep-C). Fasting lipid profiles were analysed for 160 African Americans and 170 Caucasian Americans. Linear regression was used to evaluate associations of each lipid with viral load and liver disease. TG levels were significantly and directly associated with HCV levels (P = 0.0034) and steatosis (P < 0.0001). Other lipid parameters were significantly lower in those with fibrosis [HDLc (P = 0.001) and TC levels (P = 0.004)] than in those without fibrosis. In patients with HCV genotype 1 infection, more severe liver disease was associated with lower lipid levels, with the exception of TG levels that were directly related to steatosis. The direct relationship between viral load and TG levels is consistent with proposed the mechanisms of very low density lipoprotein/HCV particle secretion. In contrast, the direct relationship between TG level and steatosis is inconsistent with posited mechanisms of HCV-induced steatosis, a possible reflection of HCV genotype 1 infection and a metabolic aetiology of steatosis.

Gender-related variations in iron metabolism and liver diseases

The regulation of iron metabolism involves multiple organs including the duodenum, liver and bone marrow. The recent discoveries of novel iron-regulatory proteins have brought the liver to the forefront of iron homeostasis. The iron overload disorder, genetic hemochromatosis, is one of the most prevalent genetic diseases in individuals of Caucasian origin. Furthermore, patients with non-hemochromatotic liver diseases, such as alcoholic liver disease, chronic hepatitis C or nonalcoholic steatohepatitis, often exhibit elevated serum iron indices (ferritin, transferrin saturation) and mild to moderate hepatic iron overload. Clinical data indicate significant differences between men and women regarding liver injury in patients with alcoholic liver disease, chronic hepatitis C or nonalcoholic steatohepatitis. The penetrance of genetic hemochromatosis also varies between men and women. Hepcidin has been suggested to act as a modifier gene in genetic hemochromatosis. Hepcidin is a circulatory antimicrobial peptide synthesized by the liver. It plays a pivotal role in the regulation of iron homeostasis. Hepcidin has been shown to be regulated by iron, inflammation, oxidative stress, hypoxia, alcohol, hepatitis C and obesity. Sex and genetic background have also been shown to modulate hepcidin expression in mice. The role of gender in the regulation of human hepcidin gene expression in the liver is unknown. However, hepcidin may play a role in gender-based differences in iron metabolism and liver diseases. Better understanding of the mechanisms associated with gender-related differences in iron metabolism and chronic liver diseases may enable the development of new treatment strategies.

An overview about hepatitis C: a devastating virus

Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.

Quantification of hepatic iron deposition in patients with liver disease: comparison of chemical shift imaging with single-echo T2*-weighted imaging

OBJECTIVE

The purpose of this study was to determine the diagnostic performance of chemical shift imaging, compared with that of single-echo T2*-weighted imaging, for hepatic iron quantification in patients with liver disease, and to examine the confounding effect of steatosis.

MATERIALS AND METHODS

Sixty-three patients who underwent liver MRI and who had concomitant liver histopathologic analysis were retrospectively assessed. Chemical shift imaging and T2*-weighted imaging (n = 49) of the liver were reviewed by two independent observers. An iron index for each sequence (I(Fe-CSI) and I(Fe-T2*), respectively) was correlated with pathologic iron grade (0-4). Receiver operating characteristic curve analysis was performed to assess the accuracy of both sequences for the diagnosis of iron deposition (grades >or= 1, >or= 2, and >or= 3), and the impact of steatosis on accuracy was evaluated.

RESULTS

Forty-seven (74.6%) patients had hepatic siderosis. There was a significant correlation between both I(Fe-CSI) and I(Fe-T2*) with pathologic iron grade (r = 0.65 and -0.61, respectively; p < 0.0001 for both). I(Fe-CSI) and I(Fe-T2*) were significantly higher or lower in iron grades 2-4 versus grades 0-1 and in grades 3-4 versus grades 0-2 (p < 0.001). Area under the curve values for detecting iron grade >or= 1, >or= 2, and >or= 3 were 0.75, 0.88, and 0.90 for I(Fe-CSI) and 0.72, 0.81, and 0.98 for I(Fe-T2*). Accuracy was lower for both sequences in steatotic patients for detection of iron grades >or= 1 and >or= 2, without reaching significance.

CONCLUSION

Routine chemical shift imaging and single-echo T2*-weighted imaging have excellent diagnostic performance for detection of significant hepatic siderosis (grade >or= 2). Concomitant steatosis lowers the diagnostic performance of both sequences without reaching significance.

Similar treatment response to peginterferon and ribavirin in Asian and Caucasian patients with chronic hepatitis C

OBJECTIVES

Previous studies have found ethnicity to be an important predictor of outcomes of treatment with peginterferon (PEG-IFN) and ribavirin (RBV) in chronic hepatitis C. Although the expected sustained virological response (SVR) rates of Hispanics and African Americans are lower than those of Caucasians, SVR rates in Asians appear to be more favorable. However, in some of these studies, hepatitis C virus (HCV) genotype was identified by INNO-LiPA assay, which can mistype the easier-to-treat HCV genotype 6 as genotype 1. Our goal was to compare SVR rates among Caucasian and Asian-American patients with genotype 1 and 2/3 infection whose HCV genotypes were accurately classified by core sequencing testing.

METHODS

A cohort of 269 consecutive treatment-naive HCV-infected patients with genotype 1 or 2/3 (157 Caucasians and 112 Asians) treated with PEG-IFN+RBV from January 2001 to November 2007 at four community-based gastroenterology clinics in Northern California were studied. The analysis of data was by intention-to-treat.

RESULTS

The SVR rates for patients with genotype 1 were 45% for Caucasians and 52% for Asians (P=0.37). The SVR rates for patients with genotype 2/3 infection was 77% for Asians and 74% for Caucasians (P=0.7). On multivariate logistic regression analyses adjusting for age, alanine aminotransferase (ALT), baseline viral load, HCV genotype, and treatment adherence, we did not find Asian ethnicity to predict SVR. On a separate analysis, we found that Asians who had HCV genotype 1 or 1b by the less accurate INNO-LiPA assay had significantly higher SVR rates than Caucasians with genotype 1 (64% vs. 45%, respectively, P=0.03).

CONCLUSIONS

SVR rates were similar in Asian Americans and Caucasians infected with HCV genotype 1 or 2/3 when HCV genotype classification was accurately determined.

Equally poor outcomes to pegylated interferon-based therapy in African Americans and Hispanics with chronic hepatitis C infection

OBJECTIVES

Treatment response to pegylated interferon based regimen is different between African Americans and Whites, but little comparable data is available comparing Hispanics and African Americans.

PATIENTS

We retrospectively evaluated the rate of success in the treatment completion and response to peginterferon alpha-2a or alpha-2b plus ribavirin in 103 (male:female-69:34) hepatitis C virus (HCV)-polymerase chain reaction positive patients that included 68 Hispanic and 35 African Americans.

METHODS

Patients were treated with peginterferon alpha-2a 180 mcg/wk (n=25) or peginterferon alpha-2b 1.5 mcg/kg/wk (N=78) and ribavirin 1000 to 1200 mg/d for 24 weeks (genotype 2 and 3) or 48 weeks (genotype 1 and 4) based on the genotype of the patient. Treatment was discontinued if the patients failed to have a 2-log drop in viral load after 12 weeks of treatment. Primary aim of the study was to evaluate success in completing a scheduled duration of pegylated interferon and ribavirin treatment in patients with chronic HCV infection and the reasons for discontinuation of the treatment. The secondary aim was to look for the end of treatment virologic response and sustained virologic response. The analysis was conducted by intention-to-treat.

RESULTS

Of the 103 patients included in the study, 50 (48.5%) patients dropped out of the treatment because of side effects of the drug or noncompliance to the treatment protocol or alternate reasons; 44 (42.7%) of them could not continue beyond 12 weeks of therapy. There were no significant differences in the drop out rate between the African American [15 (43%)] and Hispanic [35 (51.5%)] patients (P=0.41). Overall, 41% of the patients completed the scheduled 24 week or 48 week treatment. HCV genotype-1 was the most prevalent genotype in both African Americans and Hispanics (88.6% vs. 75%, P=0.10). Overall end of the treatment response (ETR) was 29.1% (30/103) and sustained virologic response (SVR) was 23.3% (24/103) in this population. No significant differences were noted in the ETR (20% vs. 34%, P=0.14) and the SVR (20% vs. 25%, P=0.57) between the African Americans and Hispanics. When data were analyzed by genotype, overall SVR rates were 14.6% (12/82) in genotype 1 versus 57% (12/21) in genotype 2/3/4 (P<0.0001). Both these ethnic groups had comparable response rates when only patients with genotype-1 were considered 5/31 (16.1%) versus 7/51 (13.7%, P=0.76).

CONCLUSIONS

A significant proportion of the African Americans and Hispanics referred for HCV treatment with pegylated interferon dropped out early in the therapy, suggesting possible racial, socioeconomic, and cultural barriers in successful treatment for chronic HCV infection. Overall, both groups had similar poor response rates, well below those reported for White patients. As is true for the general population, patients with nongenotype 1 infection had a significantly better ETR and SVR.

A comparison between whites and blacks with severe multi-organ iron overload identified in 16,152 autopsies

BACKGROUND & AIMS

Little is known about differences in the prevalence of severe iron overload at death in whites and blacks. We evaluated data and samples from 16,152 autopsies (8484 whites, 7668 blacks) performed at a single university hospital.

METHODS

Cases of severe multi-organ iron overload were identified by review of autopsy protocols and Perls-stained tissue specimens, analysis of hepatocyte and Kupffer cell iron levels, and measurement of liver tissue iron concentrations.

RESULTS

We analyzed autopsy data from 10,345 adults (age > or =21 years), 1337 children (1-20 years), and 4470 infants (<1 year). Iron overload without reports of excessive exogenous iron was observed in 18 adults; the prevalence in whites and blacks was 0.0019 and 0.0015, respectively (P = .6494). Twenty-nine adults and 2 children had iron overload with reports of excessive exogenous iron. In adults, the prevalences of iron overload with reports of excessive exogenous iron in whites and blacks were 0.0040 and 0.0013, respectively (P = .0107). Among adults, the prevalence of cirrhosis was 6-fold greater in those with iron overload. In adults with severe iron overload, 67% without reports of excessive exogenous iron and 14% with reports of excessive exogenous iron died of hepatic failure or cardiomyopathy caused by siderosis. The overall prevalence of deaths caused by severe iron overload in whites and blacks was 0.0021 and 0.0009, respectively (P = .0842).

CONCLUSIONS

The prevalence of severe iron overload without reports of excessive exogenous iron did not differ significantly between whites and blacks. The prevalence of iron overload with reports of excessive exogenous iron was greater in whites. Hepatic failure and cardiomyopathy were common causes of death in severe iron overload cases.

Racial differences in the evaluation and treatment of hepatitis C among veterans: a retrospective cohort study

OBJECTIVES

We examined the association between race and hepatitis C virus (HCV) evaluation and treatment of veterans in the Northwest Network of the Department of Veterans Affairs (VA).

METHODS

In our retrospective cohort study, we used medical records to determine antiviral treatment of 4263 HCV-infected patients from 8 VA medical centers. Secondary outcomes included specialty referrals, laboratory evaluation, viral genotype testing, and liver biopsy. Multiple logistic regression was used to adjust for clinical (measured through laboratory results and International Classification of Diseases, Ninth Revision, codes) and sociodemographic factors.

RESULTS

Blacks were less than half as likely as Whites to receive antiviral treatment (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.23, 0.63). Both had similar odds of referral and liver biopsy. However, Blacks were significantly less likely to have complete laboratory evaluation (OR=0.67; 95% CI=0.52, 0.88) and viral genotype testing (OR=0.68; 95% CI=0.51, 0.90).

CONCLUSIONS

Race is associated with receipt of medical care for various medical conditions. Further investigation is warranted to help understand whether patient preference or provider bias may explain why HCV-infected Blacks were less likely to receive medical care than Whites.

Racial disparity in liver disease: Biological, cultural, or socioeconomic factors

Chronic liver diseases are a major public health issue in the United States, and there are substantial racial disparities in liver cirrhosis-related mortality. Hepatitis C virus (HCV) is the most significant contributing factor in the development of chronic liver disease, complications such as hepatocellular carcinoma, and the need for liver transplantation. In the United States, African Americans have twice the prevalence of HCV seropositivity and develop hepatocellular carcinoma at more than twice the rate as whites. African Americans are, however, less likely to respond to interferon therapy for HCV than are whites and have considerably lower likelihood of receiving liver transplantation, the only definitive therapy for end-stage liver disease. Even among those who undergo transplantation, African Americans have lower 2-year and 5-year graft and patient survival compared to whites. We will review these racial disparities in chronic liver diseases and discuss potential biological, socioeconomic, and cultural contributions. An understanding of their underlying mechanisms is an essential step in implementing measures to mollify racially based inequities in the burden and management of liver disease in an increasingly racially and ethnically diverse population.

Inferior response of Asian vs non-Asian hepatitis C genotype 3 infection to combination antiviral therapy

Racial differences in response to treatment of hepatitis C virus (HCV) have been noted in several trials. In this study, we compared the response rate to treatment of Asian patients infected by genotype 3 HCV with non-Asians treated for the same genotype. Sixteen of 38 (42.1%) Asians achieved a sustained virological response (SVR), compared with 41 of 66 (62.1%) Caucasians (P = 0.063). At baseline prior to treatment, Asians had a higher histological fibrosis stage (P = 0.0014), indicating more advanced disease at presentation. In univariable analysis of baseline factors predicting failure to achieve an SVR, Asian ethnicity, fibrosis stage, higher serum aspartate transaminase, bilirubin and alkaline phosphatase, as well as lower white cell count, haemoglobin and platelet count were statistically significant. None of these factors achieved significance in multivariate analysis, possibly because of the relatively small number of patients studied. We have observed an inferior response to treatment of Asian vs Caucasian patients. The poor response probably reflects the more advanced liver disease at baseline observed for Asian British patients.

Impact of asian race on response to combination therapy with peginterferon alfa-2a and ribavirin in chronic hepatitis C

BACKGROUND

Prior investigation has identified factors associated with response to treatment in hepatitis C including viral genotype and titre, body weight, hepatic fibrosis, and adherence to therapy. The lower response rate of African-Americans relative to whites has been previously described, but studies of other racial or ethnic groups remain limited.

OBJECTIVE

To determine whether Asian race is an independent marker for response to antiviral therapy in hepatitis C.

METHODS

Data on treatment-naïve patients from a large multicenter study of combination therapy with peginterferon alfa-2a (180 mug SC each week) and ribavirin (800 mg daily) were analyzed retrospectively to identify factors associated with an SVR, defined as an undetectable serum HCV RNA at least 24 wk after completion of therapy.

RESULTS

SVR occurred in 45% of 384 whites and 65% of 52 Asians (P= 0.0047) who were treatment naïve. In a multivariate logistic regression analysis that adjusted for all the aforementioned factors known to be associated with treatment response, Asian race was shown to be an independent predictor of achieving an SVR (OR 2.22, 95% CI 1.11-4.46). Other independent predictors of SVR include viral genotype, body mass index, degree of hepatic fibrosis, and adherence with ribavirin.

CONCLUSIONS

Asians are more likely to achieve an SVR to treatment with peginterferon alfa-2a and ribavirin than whites with chronic hepatitis C, suggesting a genetic influence on the antiviral response.

Relationship between transferrin-iron saturation, alcohol consumption, and the incidence of cirrhosis and liver cancer

BACKGROUND & AIMS

Excessive alcohol consumption and iron overload might act in synergy to promote hepatic fibrogenesis and carcinogenesis. We examined the relation between baseline serum transferrin-iron saturation (TS) and the incidence of hospitalizations or deaths related to cirrhosis and liver cancer as well as the influence of alcohol consumption on this relationship.

METHODS

Participants included 8767 persons aged 25-74 years without evidence of cirrhosis at entry into the study or during the first 5 years of follow-up who were subsequently followed for a mean of 13.3 years as part of the first National Health and Nutrition Examination Survey.

RESULTS

During 116,656 person-years of follow-up, 115 participants were hospitalized for or died of cirrhosis and 4 more of liver cancer. Compared with persons with low TS (<40%) and low alcohol consumption (</=1 drink/day) who had an incidence of cirrhosis/liver cancer of 70/100,000 person-years, the incidence was increased in persons with elevated TS (>/=40%) and low alcohol consumption (154/100,000; adjusted hazard ratio, 2.2; 95% confidence interval, 1.3-3.8) and in persons with low TS and elevated (>1 drink/day) alcohol consumption (198/100,000; adjusted hazard ratio, 2.9; 95% confidence interval, 1.7-5.0). The incidence of cirrhosis/liver cancer was particularly high among persons with both elevated TS and elevated alcohol consumption (480/100,000; adjusted hazard ratio, 6.8; 95% confidence interval, 3.6-12.9), exceeding the rate predicted by the addition of the separate attributable risks associated with drinking and elevated serum TS.

CONCLUSIONS

Elevated serum TS is associated with an increased incidence of cirrhosis or liver cancer particularly in the presence of elevated alcohol consumption.

Liver iron is a surrogate marker of severe fibrosis in chronic hepatitis C

BACKGROUND/AIMS

Patients with chronic hepatitis C have frequently mild to moderate liver iron overload which increases with fibrosis stage. Thus, it has been postulated that iron could enhance the progression of fibrosis. However, the real impact of iron is still controversial. The study was undertaken to determine the effect of confounding variables. All factors known to influence both iron overload and fibrosis were taken into account.

METHODS

Five hundred and eighty-six patients, who had liver biopsy performed prior to antiviral treatment, were included. Serum ferritin and liver iron were correlated with clinical, biological and histological variables in univariate and multivariate analysis. The impact of iron on fibrosis was evaluated in multivariate analysis in the whole group and in the subgroup of 380 patients with available date of infection.

RESULTS

Hyperferritinemia, encountered in 27%, was associated with liver iron deposits in only 46% of cases. Liver iron was elevated in 17%, and correlated with age, male sex, and alcohol intake. The univariate strong link which existed between liver iron and fibrosis disappeared after adjustment for confounding variables.

CONCLUSIONS

According to the results of this study, liver iron should be considered more as a surrogate marker for disease severity than as a fibrogenic factor per se.

Hepatitis C in African Americans

Hepatitis C is one of the most common etiologies for chronic liver disease, cirrhosis, and hepatocellular carcinoma. The majority of liver transplants performed today are due to end stage liver disease induced by chronic hepatitis C. The prevalence of the disease is not the same across various races and a great epidemiologic disparity exists. Hepatitis C virus is more prevalent in the African American population with a higher rate of detectable viremia, predominance of genotype 1, and a higher viral load. Paradoxically the natural history of the disease and the progression to cirrhosis is less accelerated, although the development of hepatocellular carcinoma is more evident. African Americans in particular are resistant to antiviral regimens and the response to treatment with interferon monotherapy, a combination of interferon and ribavirin or pegylated interferon and ribavirin is significantly less. There are on going studies that determine the mechanisms in the lack of response in African Americans. An underrepresentation of African Americans in various study trials that are consequently on a list for a liver transplant have been noted and is postulated that the survival after liver transplantation is not equivalent to the one reported for other races, for unclear reasons.

Treatment of hepatitis C in special populations

Hepatitis C virus (HCV) is a major cause of liver disease worldwide and is the most common chronic blood-borne infection in the United States. Experience has shown that the epidemiology and the response to treatment of HCV vary in certain patient groups. Differences have been observed in people from different racial and ethnic groups and in patients who have HIV and end-stage renal disease. These groups generally were not included in the early large clinical trials of HCV treatment. This article reviews recent findings in these patients groups and examines future directions.

Review article: predicting response in hepatitis C virus therapy

The introduction of combination therapy with ribavirin and of pegylated interferons has improved treatment results in patients with chronic hepatitis C. However, overall rates of sustained virologic response following antiviral therapy of chronic hepatitis C still do not exceed 54-63%. Because of several virus- and patient-related factors, treatment is even less successful in some patient subpopulations. The major viral factors associated with impaired response are hepatitis C virus genotype 1 infection and a high viral load. Among patient-related factors cirrhosis is of special importance. Baseline predictive factors for sustained virologic response become less important for prediction of treatment outcome when quantifications of hepatitis C virus RNA during early therapy are taken into account. This article provides a summary of virus- and patient-related parameters, which are prognostic for response to antiviral therapy in chronic hepatitis C and focuses on the prediction of treatment response by quantification of hepatitis C virus RNA concentration during therapy.

Progression of liver fibrosis among injection drug users with chronic hepatitis C

Although most hepatitis C virus (HCV) infections are acquired by injection drug use, prospective data on the progression of liver fibrosis are sparse. Baseline liver biopsies were obtained (1996-1998) on a random sample of 210 out of 1667 HCV-positive injection drug users (IDUs). Subjects were followed biannually, with a second biopsy offered to those eligible. Paired biopsies were scored 0 to 6 (modified Ishak score), significant fibrosis was defined as score 3 or greater, and progression of fibrosis was defined as an increase 2 or more units or clinical evidence of end-stage liver disease. Predictive values of blood markers [FibroSURE, aspartate aminotransferase-to-platelet-ratio index (APRI) and alanine aminotransferase (ALT)] were assessed for detection of contemporaneous and future liver fibrosis. Among 119 prospectively followed IDUs, 96% were African American; 97% HCV genotype 1a/b; 27% HIV-infected, and median age was 42 years. Most (90.7%) did not have significant liver fibrosis at first biopsy. Although predictive value for detecting insignificant fibrosis at first biopsy was greater than 95% for FibroSURE, APRI, and ALT, specificities were 88.9%, 72.7%, and 72.7%, respectively. After 4.2 years median follow-up, 21% had progression of fibrosis, which was significantly associated with serum level of HCV RNA and ALT. No serological test had predictive value greater than 40% for contemporaneous or future significant fibrosis. Even initial biopsy result had only a 30.4% value for predicting future significant fibrosis. In conclusion, significant liver fibrosis and progression were detected in some, but not most, IDUs in this cohort. In this setting with low fibrosis prevalence, FibroSURE, ALT, and APRI tests predict insignificant fibrosis; however, further work is needed to find noninvasive markers of significant liver fibrosis.

Initial screening transferrin saturation values, serum ferritin concentrations, and HFE genotypes in whites and blacks in the Hemochromatosis and Iron Overload Screening Study

We compared initial screening data of 44,082 white and 27,124 black Hemochromatosis and Iron Overload Screening (HEIRS) Study participants. Each underwent serum transferrin saturation (TfSat) and ferritin (SF) measurements without regard to fasting, and HFE C282Y and H63D genotyping. Elevated measurements were defined as: TfSat more than 50% (men), more than 45% (women); and SF more than 300 ng/ml (men), more than 200 ng/ml (women). Mean TfSat and percentages of participants with elevated TfSat were significantly greater in whites than in blacks. Mean SF and percentages of participants with elevated SF were significantly greater in blacks than in whites. TfSat and SF varied by gender and age in whites and blacks. Prevalences of genotypes that included either C282Y or H63D were significantly greater in whites than in blacks. The prevalence of elevated TfSat and SF plus genotypes C282Y/C282Y, C282Y/H63D, or H63D/H63D was 0.006 in whites and 0.0003 in blacks. Among whites with HFE C282Y homozygosity, 76.8% of men and 46.9% of women had elevated TfSat and SF values. Three black participants had HFE C282Y homozygosity; one had elevated TfSat and SF values. Possible explanations for differences in TfSat and SF in whites and blacks and pertinence to the detection of hemochromatosis, iron overload, and other disorders with similar phenotypes are discussed.

Hyperglycemia among persons with hepatitis C: not the classical diabetic phenotype

Using data from the Third National Health and Nutrition Examination Survey (United States, 1988-1994), we compared clinical phenotypes of hepatitis C virus (HCV)-seropositive and seronegative adults aged 20-89 years with hyperglycemia (impaired fasting glucose (IFG) or type 2 diabetes, n=3566 including 86 with HCV). Seroprevalence was higher among younger persons (3.4% for ages 20-59 versus 0.9% for ages 60-89, p=0.002), while traditional correlates of diabetes (hypertension, coronary heart disease) were more prevalent among older persons (both comparisons, p<0.0001). To prevent confounding by age, younger and older persons were analyzed separately. In both age groups, HCV was associated with signs of hepatic impairment and B-cell clonal expansion (higher alanine aminotransferase (ALT) and serum globulin, lower total cholesterol and platelet count). Only among younger persons, however, was HCV also associated with a marker for advanced hepatic fibrosis (elevated serum ferritin) and absence of the classical diabetic phenotype (overweight, coronary heart disease). In addition, among younger persons, HCV was currently associated with family history of diabetes, positively in persons with diabetes and inversely in those with IFG, suggesting that family history of diabetes may serve as a cofactor for progression from HCV-associated IFG to diabetes.

Hepatitis C virus infection in African Americans

Hepatitis C is more prevalent among African Americans than among persons of any other racial group in the United States. However, comparatively little data are available on the natural history and treatment of hepatitis C in this population. Compared with white persons, African American persons have a lower rate of viral clearance and, consequently, a higher rate of chronic hepatitis C. Nonetheless, African American persons may have a lower rate of fibrosis progression than do white persons. African American persons with hepatitis C-related cirrhosis have higher rates of both hepatocellular carcinoma and liver cancer-related mortality than do white persons with hepatitis C-related cirrhosis. In nearly all treatment trials that enrolled a significant proportion of African American subjects, such patients had inferior treatment responses, compared with those of white subjects. The prevalence of infection with hepatitis C virus genotype 1 is higher among African American patients than white patients, although this difference does not account for a greatly dissimilar response to therapy. Some of the postulated mechanisms for these disparate treatment responses and natural histories of infection are also reviewed.

Chronic hepatitis C in African Americans

The prevalence of hepatitis C virus infection is higher in the African American population in comparison with Caucasians and Hispanics. The majority of African Americans are infected with genotype 1 and have a high viral load, but the rate of progression to cirrhosis is lower. After the development of cirrhosis, the chance of developing hepatocellular carcinoma is higher. African Americans have been under-represented in clinical trials, and the initial preliminary observations pointing toward a lower sustained virologic response with interferon monotherapy has been confirmed in larger studies. A lower response to antiviral therapy has been demonstrated in African Americans receiving combination interferon plus ribavirin and combination peginterferon plus ribavirin. The reasons for these differences in natural history and outcomes of therapy are not understood but are the subject of ongoing study.

Treatment of hepatitis C

The combination of pegylated interferon alpha and ribavirin has improved treatment success rates in patients with hepatitis C with sustained response rates of just over 50% overall and more than 70% for those with genotypes 2 and 3. This article reviews the use of combination therapy, contraindications, factors influencing response and describes approaches to specific patient groups.

Relationship between serum ferritin, hepatic iron staining, diabetes mellitus and fibrosis progression in patients with chronic hepatitis C

BACKGROUND

Chronic infection with the hepatitis C virus affects over 170 million individuals worldwide and 20% of patients develop cirrhosis after 20 years. Increased iron stores and hepatic iron content have been suggested to be important in fibrosis progression. The increased prevalence of diabetes mellitus has been associated with increased iron deposits in patients with chronic hepatitis C.

AIM

To assess the potential relationship between serum ferritin and hepatic iron staining and liver fibrosis in patients with chronic hepatitis C virus infection and whether these factors are increased in diabetic patients with hepatitis C virus.

METHODS

This was a cross-sectional, multi-centre study involving hospitals in the north-east of London between 1992 and 2003. Chronic hepatitis C patients with a liver biopsy and data concerning age, sex, basal metabolic index, diabetes mellitus or impaired glucose tolerance, alcohol intake, serum ferritin level and ethnicity were enrolled. Each biopsy was scored for fibrosis and stained for hepatic iron.

RESULTS

Three hundred and thirty nine patients (200 Caucasian; 139 Asian) were enrolled. Fifty three patients had no fibrosis, 131 had mild fibrosis (stage one to two Modified Ishak), 68 moderate fibrosis (stage three to four) and 87 cirrhosis (stage five to six). 4.4% of patients had elevations in serum ferritin, whilst 11% had increased hepatic iron staining. The serum ferritin and hepatic iron staining were unrelated to the degree of fibrosis. Serum ferritin was significantly higher in patients with diabetes or impaired glucose tolerance compared to non-diabetics. No association was seen between diabetes and hepatic iron staining.

CONCLUSIONS

Many patients with chronic hepatitis C virus infection may have elevated serum ferritin and/or iron deposition within the liver. However, both played no significant role in the progression of hepatitis C virus related liver injury. The association between chronic hepatitis C virus infection and type II diabetes mellitus exists, however the biological mechanism of this association still remains to be elucidated.

Association of hepatitis C virus infection with serum iron status: analysis of data from the third National Health and Nutrition Examination Survey

BACKGROUND

There is growing evidence that mildly increased amounts of iron in the liver can increase hepatic injury, particularly if combined with other hepatotoxic factors, such as alcohol use, use of porphyrogenic drugs, or chronic viral hepatitis. In the present study, the association of hepatitis C virus (HCV) infection with serum measurements of iron status was assessed in the US population.

METHODS

We analyzed data from a total of 14,462 participants in the Third National Health and Nutrition Examination Survey. We excluded subjects who were aged <12 years, subjects for whom measurements of serum levels of iron or ferritin or the results of liver function tests were missing, and subjects who had a serum transferrin saturation of > or =50% (to help exclude subjects with hemochromatosis).

RESULTS

Mean serum levels of ferritin and iron (+/- standard error) were significantly higher among subjects with HCV infection (100+/-3 ng/mL and 229+/-17 microg/dL, respectively) than among subjects without liver disease (83+/-0.3 ng/mL and 101+/-2.1 microg/dL, respectively) (P<.0001). Serum levels of ferritin were directly and significantly correlated with serum levels of alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transpeptidase (r=0.25, r=0.24, and r=0.28, respectively; P<.0001), whereas platelet counts were inversely correlated with serum levels of ferritin (r=-0.12; P<.0001).

CONCLUSION

HCV infection is significantly associated with higher serum levels of ferritin and iron in the US population.

Stainable hepatic iron in 341 African American adults at coroner/medical examiner autopsy

Background

Results of previous autopsy studies indicate that increased hepatic iron stores or hepatic iron overload is common in African Americans dying in hospitals, but there are no reports of hepatic iron content in other cohorts of African Americans.

Methods

We investigated the prevalence of heavy liver iron deposition in African American adults. Using established histochemical criteria, we graded Perls' acid ferrocyanide-reactive iron in the hepatocytes and Kupffer cells of 341 consecutive African American adults who were autopsied in the coroner/medical examiner office. Heavy staining was defined as grade 3 or 4 hepatocyte iron or grade 3 Kupffer cell iron.

Results

There were 254 men and 85 women (mean age ± 1 SD: 44 ± 13 y vs. 48 ± 14 y, respectively; p = 0.0255); gender was unstated or unknown in two subjects. Approximately one-third of subjects died of natural causes. Heavy staining was observed in 10.2% of men and 4.7% of women. 23 subjects had heavy hepatocyte staining only, six had heavy Kupffer cell staining only, and one had a mixed pattern of heavy staining. 15 subjects had histories of chronic alcoholism; three had heavy staining confined to hepatocytes. We analyzed the relationships of three continuous variables (age at death in years, hepatocyte iron grade, Kupffer cell iron grade) and two categorical variables (sex, cause of death (natural and non-natural causes)) in all 341 subjects using a correlation matrix with Bonferroni correction. This revealed two positive correlations: hepatocyte with Kupffer cell iron grades (p < 0.01), and male sex with hepatocyte iron grade (p < 0.05). We also analyzed the relationship of steatosis, inflammation, and fibrosis/cirrhosis in 30 subjects with heavy iron staining using a correlation matrix with Bonferroni correction. There were significant positive correlations of steatosis with inflammation (r = 0.5641; p < 0.01), and of inflammation with fibrosis/cirrhosis (r = 0.6124; p < 0.01).

Conclusions

The present results confirm and extend previous observations that heavy liver iron staining is relatively common in African Americans. The pertinence of these observations to genetic and acquired causes of iron overload in African Americans is discussed.

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Genotypic and phenotypic heterogeneity of African Americans with primary iron overload

Primary iron overload may be relatively common in African Americans, but its cause is incompletely understood. Thus, we evaluated genotype and phenotype characteristics of unselected African American index patients with primary iron overload who reside in central Alabama. All had hepatic iron concentration > or =30 micromol/g dry wt or > or =2.0 g of iron mobilized by phlebotomy to achieve iron depletion. Genotype analyses were performed in African American control subjects from the same region. There were 23 patients (19 men, 4 women); mean age at diagnosis was 52 +/- 12 years (1 SD) (range 32-69 years). Nine (39.1%) reported that they consumed > or =45 g of ethanol daily; five had chronic hepatitis C. Eight had some form of hemoglobinopathy or thalassemia. Mean serum transferrin saturation was 56 +/- 28% (range 15-100%). The geometric mean serum ferritin at diagnosis was 1076 ng/mL [95% confidence interval 297-3473 ng/mL]. Increased stainable liver iron was observed in hepatocytes only in 4 patients, in macrophages only in 8 patients, and in hepatocytes and macrophages in 8 patients. The mean quantity of iron mobilized by phlebotomy (corrected for iron absorbed during treatment) was 5.3 +/- 2.0 g (range 4.0-8.4 g). Iron removed by phlebotomy was greater in patients with hemoglobinopathy or thalassemia than in those without these forms of anemia (6.6 +/- 1.3 g vs 3.9 +/- 1.6 g, respectively; P = 0.0144). Daily consumption of > or =45 g of ethanol or chronic hepatitis C was not associated with an increased or decreased amount of phlebotomy-mobilized iron, on the average. The percentage of index patients positive for HFE C282Y was greater than that of controls (P = 0.0058). The respective percentages of phenotype positivity for HFE H63D, D6S105(8), and HLA-A*03 were similar in patients and controls. HFE S65C, I105T, and G93R were not detected in index or control subjects. Two of 13 patients were heterozygous for the ferroportin allele nt 744 G-->T (Q248H), although the phenotype frequency of this allele was similar in patients and 39 controls. Synonymous ferroportin alleles were also detected in some patients. The ceruloplasmin mutation nt 1099C-->T (exon 6; Arg367Cys) was detected in 1 of 2 patients tested. Abnormal alleles of beta-2 microglobulin, Nramp2, TFR2, hepcidin, or IRP2 alleles were not detected in either of the 2 patients so tested. We conclude that primary iron overload in African Americans is not the result of the mutation of a single gene. HFE C282Y, ferroportin 744 G-->T, and common forms of heritable anemia appear to account for increased iron absorption or retention in some patients.

Peginterferon alfa-2b and ribavirin for the treatment of chronic hepatitis C in blacks and non-Hispanic whites

BACKGROUND

Several small studies have reported a lower response rate to interferon alfa among black patients with chronic hepatitis C infection than among white patients. The increased prevalence of infection with hepatitis C virus (HCV) genotype 1, which has a lower response rate than other genotypes, has been suggested as the cause.

METHODS

We treated 100 black patients and 100 non-Hispanic white patients with chronic hepatitis C with peginterferon alfa-2b and ribavirin for 48 weeks. Enrollment was controlled so that the two groups had similar proportions of patients with genotype 1 infection. The primary end point was a sustained virologic response, which was defined as a negative test for serum HCV RNA six months after the completion of therapy.

RESULTS

In both cohorts, 98 percent of patients had genotype 1 infection. The rate of sustained virologic response was higher among non-Hispanic white patients than among black patients (52 percent vs.19 percent, P<0.001). The black patients also had significantly lower rates of virologic response at 12 weeks and at the end of treatment. Multivariable analyses examining sociodemographic and clinical characteristics found that black race was the only variable significantly associated with the difference in response rate.

CONCLUSIONS

Black patients with chronic hepatitis C have a lower rate of response to treatment with peginterferon alfa-2b and ribavirin than non-Hispanic white patients, a difference that is not explained by differences in the viral genotype.

Up-regulating effect of hepatitis C virus NS5A protein on NS3TP6 gene promoter

AIM: To investigate the regulatory effects of non-structural protein 5A of hepatitis C virus (HCV NS) protein on NS3TP6 gene promoter.

METHODS: The sequence of NS3TP6 gene promoter was identified in GenBank by bioinformatics and amplified from HepG2 genome by polymerase chain reaction (PCR), which was cloned into pCAT3 reporter vector. The HepG2 cell line was transfected by pCAT3-NS3TP6-p, and co-tranfected by pCAT3-NS3TP6-p and pcDNA3.1(-)-NS5A, respectively. The chloramphenicol acetyltransferase (CAT) activity was detected by an enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS: The recombinant vector of reporter gene expressive vector pCAT3-NS3TP6-p was approved correctly by restriction enzyme digestion and sequencing analysis. In the transfection experiment of HepG2, pCAT3-NS3TP6-p had higher activity of CAT expression than that of pCAT3-basic demonstrated by an ELISA kit. The expression level of CAT in co-transfection of pCAT3-NS3TP6-p and pcDNA3.1(-)-NS5A was 1.87 times as higher as that of pCAT3- NS3TP6-p plasmid alone.

CONCLUSION: Cell transfection and ELISA technology are successfully used to prove the results from microarray of HCV NS5A, which brings some new clues for studying the trans-regulated and immune regulation mechanism of NS5A.

Chronic hepatitis C in African Americans and other minority groups

Chronic hepatitis C virus (HCV) is the most common bloodborne infection in the United States. An estimated 2.7 million Americans are infected, with the greatest prevalence of infection in African Americans at 3.2%. African Americans account for 22% of Americans with HCV. Recent studies have shown that African Americans are less likely to have cirrhosis than similarly infected non-Hispanic white patients and are more likely to have genotype 1 infection and to develop hepatocellular carcinoma. Several studies have shown that the response rates of African Americans to interferon and ribavirin are significantly lower than those for non-Hispanic whites. Despite the relatively low percentage of African-American patients in these early studies, similar preliminary results are being found in larger prospective studies with the newer treatment regimens of pegylated interferon and ribavirin. Differences in immunologic status, viral kinetics, and iron studies have also been found in HCV-infected African-American patients. Less is known about Mexican Americans and other minority groups because they are poorly represented in clinical trials. Efforts at increasing racial diversity in clinical trials are ongoing.

Genes trans-regulated by nonstructural protein 5A of hepatitis C virus with microarray assay

AIM

To study genes trans-regulated by nonstructural protein 5A of hepatitis C virus by microarray assay.

METHODS

The recombined expression plasmid pcDNA3.1(-)-NS5A was constructed, and HepG2 cells were transfected. Total mRNA was isolated from the HepG2 cells transfected with pcDNA3.1(-) and pcDNA3-NS5A, respectively. Microarray was employed for detecting and analyzing of both mRNA from the HepG2 cells.

RESULTS

After transfecting HepG2 cells, we found 28 genes have been up-regulated, and 26 genes down-regulated. Their encoding proteins were involved in cell signal transduction, cell proliferation and differentiation.

CONCLUSION

Microarray technology is successfully used to screen the genes trans-regulated by nonstructural protein 5A of hepatitis C virus, which brings some new clues for studying the trans-regulated and immune regulation mechanism of NS5A.