A case-control histological study on the effects of phlebotomy in patients with chronic hepatitis C

Difference in the Mechanism of Iron Overload-Enhanced Acute Hepatotoxicity Induced by Thioacetamide and Carbon Tetrachloride in Rats

Iron overload has been recognized as a risk factor for liver disease; however, little is known about its pathological role in the modification of liver injury. The purpose of this study is to investigate the influence of iron overload on liver injury induced by two hepatotoxicants with different pathogenesis in rats. Rats were fed a control (Cont), 0.8% high-iron (0.8% Fe), or 1% high-iron diet (1% Fe) for 4 weeks and were then administered with saline, thioacetamide (TAA), or carbon tetrachloride (CCl4). Hepatic and systemic iron overload were seen in the 0.8% and 1% Fe groups. Twenty-four hours after administration, hepatocellular necrosis induced by TAA and hepatocellular necrosis, degeneration, and vacuolation induced by CCl4, as well as serum transaminase values, were exacerbated in the 0.8% and 1% Fe groups compared to the Cont group. On the other hand, microvesicular vacuolation induced by CCl4 was decreased in 0.8% and 1% Fe groups. Hepatocellular DNA damage was increased by iron overload in both models, whereas a synergistic effect of oxidative stress by excess iron and hepatotoxicant was only present in the CCl4 model. The data showed that dietary iron overload exacerbates TAA- and CCl4-induced acute liver injury with different mechanisms.

Immunohistochemical expression of NRF2 is correlated with the magnitude of inflammation and fibrosis in chronic liver disease

BACKGROUND

The nuclear factor E2-related factor 2-Kelch-like Ech-associated protein (NRF2-KEAP1) pathway is a major cellular defense mechanism against oxidative stress. However, the role of NRF2-KEAP1 signaling in the development of chronic liver disease remains unclear.

METHODS

Clinical liver specimens from 50 hepatocellular carcinoma (HCC) developed from non-alcoholic steatohepatitis (NASH), 49 HCCs developed from chronic viral hepatitis C (CHc), and 48 liver metastases of colorectal cancer (CRC) from both tumorous and non-tumorous areas were collected during hepatic resection surgery. They were evaluated by immunohistochemical analyses of hematoxylin-eosin, Masson's trichrome, NRF2, and KEAP1, and compared with clinicopathological information.

RESULTS

Hepatic inflammation and fibrosis were more severe in the low-intensity NRF2 group than in the high-intensity NRF2 group both between CRC and NASH (Low vs. High: inflammation; p = 0.003, fibrosis; p = 0.014), and between CRC and CHc (Low vs. High: inflammation; p = 0.031, fibrosis; p = 0.011), which could indicate that NRF2 expression in cytosol of hepatocytes was inversely correlated with liver inflammation and fibrosis in non-tumorous areas. The dense staining of NRF2 in the nuclei of non-tumor hepatocytes positively correlated with liver inflammation (CRC and NASH; R = 0.451, p < 0.001, CRC and CHc; R = 0.502, p < 0.001) and fibrosis (CRC and NASH; R = 0.566, p < 0.001, CRC and CHc; R = 0.548, p < 0.001) in both NASH and CHc, and was inversely correlated with hepatic spare ability features such as platelet count (R = -0.253, p = 0.002) and prothrombin time (R = -0.206, p = 0.012). However, KEAP1 expression was not correlated with NRF2 expression levels and nuclear staining intensity.

CONCLUSIONS

Nuclear translocation of NRF2 was correlated with the magnitude of liver inflammation and fibrosis in chronic liver disease. These results suggest that NRF2 plays a protective role in the development of chronic liver diseases such as NASH and CHc.

MRI-Based Quantitative R2* Mapping at 3 Tesla Reflects Hepatic Iron Overload and Pathogenesis in Nonalcoholic Fatty Liver Disease Patients

BACKGROUND

The role of hepatic iron overload (HIO) in nonalcoholic fatty liver disease (NAFLD) pathogenesis has not been fully elucidated.

PURPOSE

This study aimed to investigate the effect of HIO and examine the diagnostic usefulness of magnetic resonance imaging (MRI)-based R2^* quantification in evaluating hepatic iron content (HIC) and pathological findings in NAFLD.

STUDY TYPE

Prospective and retrospective.

POPULATION

A prospective study of 168 patients (age, 57.2 ± 15.0; male/female, 80/88) and a retrospective validation study of 202 patients (age, 57.0 ± 14.4; male/female, 113/89) with liver-biopsy-confirmed NAFLD were performed.

FIELD STRENGTH/SEQUENCE

3 T; chemical-shift encoded multi-echo gradient echo.

ASSESSMENT

Using liver tissues obtained by liver biopsy, HIC was prospectively evaluated in 168 patients by atomic absorption spectrometry. Diagnostic accuracies of HIC and R2^* for grading hepatic inflammation plus ballooning (HIB) as an indicator of NAFLD activity were assessed.

STATISTICAL TESTS

Student's t-test and analysis of variance (ANOVA) with Scheffe's multiple testing correction for univariate comparisons; multivariate logistic analysis. P-value less than 0.05 is statistically significant.

RESULTS

HIC was significantly correlated with HIB grades (r = 0.407). R2^* was significantly correlated with HIC (r = 0.557) and HIB grades (r = 0.569). R2^* mapped an area under the receiver operating characteristic (AUROC; 0.774) for HIC ≥808 ng/mL (median value) with cutoff value of 62.5 s^-1 . In addition, R2^* mapped AUROC of HIB for grades ≥3 was 0.799 with cutoff value of 58.5 s^-1 . When R2^* was <62.5 s^-1 , R2^* correlated weakly with HIC (r = 0.372) as it was affected by fat deposition and did not correlate with HIB grades (P = 0.052). Conversely, when R2^* was ≥62.5 s^-1 , a significant correlation of R2^* with HIC (r = 0.556) and with HIB grades was observed (P < 0.0001) with being less affected by fat deposition.

DATA CONCLUSION

R2^*  ≥ 62.5 s^-1 is a promising modality for non-invasive diagnosis of clinically important high grades (≥3) of HIB associated with increased HIC.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Molecular pathogenesis and clinical consequences of iron overload in liver cirrhosis

BACKGROUND

The liver, as the main iron storage compartment and the place of hepcidin synthesis, is the central organ involved in maintaining iron homeostasis in the body. Excessive accumulation of iron is an important risk factor in liver disease progression to cirrhosis and hepatocellular carcinoma. Here, we review the literature on the molecular pathogenesis of iron overload and its clinical consequences in chronic liver diseases.

DATA SOURCES

PubMed was searched for English-language articles on molecular genesis of primary and secondary iron overload, as well as on their association with liver disease progression. We have also included literature on adjuvant therapeutic interventions aiming to alleviate detrimental effects of excessive body iron load in liver cirrhosis.

RESULTS

Excess of free, unbound iron induces oxidative stress, increases cell sensitivity to other detrimental factors, and can directly affect cellular signaling pathways, resulting in accelerated liver disease progression. Diagnosis of liver cirrhosis is, in turn, often associated with the identification of a pathological accumulation of iron, even in the absence of genetic background of hereditary hemochromatosis. Iron depletion and adjuvant therapy with antioxidants are shown to cause significant improvement of liver functions in patients with iron overload. Phlebotomy can have beneficial effects on liver histology in patients with excessive iron accumulation combined with compensated liver cirrhosis of different etiology.

CONCLUSION

Excessive accumulation of body iron in liver cirrhosis is an important predictor of liver failure and available data suggest that it can be considered as target for adjuvant therapy in this condition.

Fibrosing cholestatic hepatitis C in post-transplant adult recipients of liver transplantation

Hepatitis C recurrence continues to present a major challenge in liver transplantation (LT). Approximately 10% of hepatitis C virus (HCV)-positive recipients will develop fibrosing cholestatic hepatitis (FCH) after LT. FCH is clinically characterized as marked jaundice with cholestatic hepatic dysfunction and high titers of viremia. Pathologically, FCH manifests as marked hepatocyte swelling, cholestasis, periportal peritrabecular fibrosis and only mild inflammation. This progressive form usually involves acute liver failure, and rapidly results in graft loss. A real-time and precise diagnosis based on histopathological examination and viral measurement is indispensable for the adequate treatment of FCH. Typical pathological findings of FCH are shown. Currently, carefully selected combinations of direct-acting antivirals (DAAs) offer the potential for highly effective and safe regimens for hepatitis C, both in the pre- and post-transplant settings. Here, we review FCH caused by HCV in LT recipients, and current strategies for sustained virological responses after LT. Only a few cases of successfully treated FCH C after LT by DAAs have been reported. The diagnostic findings and therapeutic dilemma are discussed based on a literature review.

Gamma-Glutamyltransferase: A Predictive Biomarker of Cellular Antioxidant Inadequacy and Disease Risk

Gamma-glutamyltransferase (GGT) is a well-established serum marker for alcohol-related liver disease. However, GGT's predictive utility applies well beyond liver disease: elevated GGT is linked to increased risk to a multitude of diseases and conditions, including cardiovascular disease, diabetes, metabolic syndrome (MetS), and all-cause mortality. The literature from multiple population groups worldwide consistently shows strong predictive power for GGT, even across different gender and ethnic categories. Here, we examine the relationship of GGT to other serum markers such as serum ferritin (SF) levels, and we suggest a link to exposure to environmental and endogenous toxins, resulting in oxidative and nitrosative stress. We observe a general upward trend in population levels of GGT over time, particularly in the US and Korea. Since the late 1970s, both GGT and incident MetS and its related disorders have risen in virtual lockstep. GGT is an early predictive marker for atherosclerosis, heart failure, arterial stiffness and plaque, gestational diabetes, and various liver diseases, including viral hepatitis, other infectious diseases, and several life-threatening cancers. We review literature both from the medical sciences and from life insurance industries demonstrating that serum GGT is a superior marker for future disease risk, when compared against multiple other known mortality risk factors.

Iron homeostasis and its regulators over the course of chronic hepatitis C

ABSTRACT: 

Chronic infection with HCV has been diagnosed in approximately 170 million people worldwide. It is an important cause of chronic, progressive liver fibrosis. Late consequences of chronic HCV infection, including liver cirrhosis and hepatocellular carcinoma, have become the major indications for liver transplantation in developed countries. Particular attention is being paid to iron accumulation in chronic hepatitis C and its relation to the current antiviral therapy's efficacy and safety, risk of exacerbation of oxidative stress, development of metabolic disorders and hepatocarcinogenesis. HCV infection disrupts the synthesis of hepcidin, which regulates extracellular iron content. This article discusses the impact of iron on HCV multiplication and the involvement of impaired iron homeostasis in chronic hepatitis C in terms of the pathogenesis of insulin resistance, fatty liver and hepatocarcinogenesis.

Review article: management of chronic hepatitis C in patients with contraindications to anti-viral therapy

BACKGROUND

There are patients with chronic hepatitis C who are not eligible for the current interferon-based therapies or refuse to be treated due to secondary effects.

AIM

To provide information on alternative treatments for the management of these patients.

METHODS

A PubMed search was performed to identify relevant literature. Search terms included hepatitis C virus, anti-inflammatory treatment, antioxidant, natural products and alternative treatment, alone or in combination. Additional publications were identified using the references cited by primary and review articles.

RESULTS

Several approaches, such as iron depletion (phlebotomy), treatment with ursodeoxycholic acid or glycyrrhizin, have anti-inflammatory and/or anti-fibrotic effects. Life interventions like weight loss, exercise and coffee consumption are associated with a biochemical improvement. Other alternatives (ribavirin monotherapy, amantadine, silibinin, vitamin supplementation, etc.) do not have any beneficial effect or need to be tested in larger clinical studies.

CONCLUSION

There are therapeutic strategies and lifestyle interventions that can be used to improve liver damage in patients with chronic hepatitis C who cannot receive or refuse interferon-based treatments.

Serum ferritin and the risk of hepatocellular carcinoma in chronic liver disease of viral etiology: a case-control study

BACKGROUND

The worldwide incidence rates of hepatocellular carcinoma (HCC) vary widely. Some countries like India have a low incidence despite having a large burden of chronic hepatitis B (HBV) and C virus (HCV) infection. We hypothesized that long-term iron deficiency could attenuate the hepatic inflammation and lead to a lower incidence of HCC in India than expected.

METHODS

We evaluated the association of serum ferritin levels and HCC in Indian patients with HBV- or HCV-related chronic liver disease (CLD) using a case-control study design. We enrolled 141 patients with HCC (cases) and 240 patients having chronic HBV or HCV infection-related CLD (controls). Study participants were grouped on the basis of ferritin values into low-normal, high-normal, and high subgroups.

RESULTS

Mean ferritin values were higher in cases as compared to controls (425.8 vs. 135.6 ng/mL, p = 0.000). A significant dose-response effect for serum ferritin levels and HCC was seen with an odds ratio (95 % confidence interval) of 3.0 (1.6-5.9, p = 0.001) for subjects with high-normal ferritin levels and 8.2 (4.1-16.5, p = 0.000) for subjects with high ferritin levels in a multivariate model. Other significant independent risk factors in the multivariate model included older age, male gender, alcohol and tobacco use, elevated alanine aminotransferase, higher family income, and coffee drinking.

CONCLUSION

We found an independent association between serum ferritin levels and HCC in patients with CLD of viral etiology. Further prospective studies are needed to confirm the hypothesis that iron deficiency protects against HCC in CLD.

Phase II clinical trial of phlebotomy for non-alcoholic fatty liver disease

BACKGROUND

Elevated iron indices are described in non-alcoholic fatty liver disease and iron reduction has been suggested as a potential therapy.

AIM

To determine whether phlebotomy is an effective therapy for non-alcoholic fatty liver disease.

METHODS

Patients with biopsy proven non-alcoholic fatty liver disease underwent baseline evaluation to determine severity of metabolic and liver disease. A Phase II trial of phlebotomy was carried out to achieve near-iron depletion (serum ferritin ≤50 μg/L or haemoglobin 100 g/L). Repeat liver biopsy, anthropometric and biochemical measurements were performed 6 months following the end of treatment. Primary outcome was improvement in liver histology, assessed using the non-alcoholic fatty liver disease activity score.

RESULTS

Thirty-one patients completed follow-up. Iron reduction resulted in a significant improvement in the non-alcoholic fatty liver disease activity score (-0.74 ± 1.83, P = 0.019). Reductions in individual histological features of lobular inflammation (-0.29 ± 1.07, P = 0.182), steatosis (-0.26 ± 0.82, P = 0.134), hepatocyte ballooning (-0.19 ± 0.70, P = 0.213) did not achieve significance nor did the score for fibrosis (-0.32 ± 0.94, P = 0.099).

CONCLUSIONS

This prospective Phase II study of phlebotomy with paired liver biopsies evaluating phlebotomy therapy in non-alcoholic fatty liver disease patients suggests that iron reduction may improve liver histology. However, the effect size of phlebotomy raises questions of whether treatment could have sufficient clinical significance to justify a definitive Phase III trial. This trial has been registered with the US National Institute of Health (clinicaltrials.gov, Identifier NCT 00641524).

High-fat, high-fructose diet induces hepatic iron overload via a hepcidin-independent mechanism prior to the onset of liver steatosis and insulin resistance in mice

OBJECTIVE

Excess iron deposition in tissues leads to increased oxidative stress. The clinical observation that non-alcoholic fatty liver disease (NAFLD) is frequently associated with hepatic iron overload (HIO) indicates that iron-induced oxidative stress may be related to NAFLD pathology. Decreased expression of hepcidin, a hepatic hormone that suppresses dietary iron absorption in the duodenum, is frequently observed in NAFLD patients and has been postulated to be a cause of HIO.

MATERIALS/METHODS

Because dietary fat and fructose intake play roles in the onset of NAFLD, we fed C57BL/6J mice a high-fat, high-fructose (HFHFr) diet for 16 weeks to study the relationship between hepatic iron content and NAFLD.

RESULTS

Within 4 weeks after the start of the experiment, the mice exhibited significant increases in hepatic free fatty acid (FFA) content, serum insulin levels, and the homeostasis model assessment of insulin resistance. Interestingly, hepatic iron content and oxidative stress significantly increased with the HFHFr diet 2 weeks earlier than hepatic FFA accumulation and decreased insulin sensitivity. Moreover, hepatic hepcidin expression was significantly downregulated, as is also observed in NAFLD patients, but much later than the onset of HIO.

CONCLUSIONS

Accordingly, our data demonstrated that HIO may have a pathogenic role in the onset of liver steatosis and insulin resistance. Moreover, distinct mechanisms, in addition to hepcidin, may underlie NAFLD-related HIO. These data suggest that the HFHFr diet can be used for establishing a suitable model to study the precise mechanism of HIO in NAFLD patients.

Hepatitis C, porphyria cutanea tarda and liver iron: an update

Porphyria cutanea tarda (PCT) is the most common form of porphyria across the world. Unlike other forms of porphyria, which are inborn errors of metabolism, PCT is usually an acquired liver disease caused by exogenous factors, chief among which are excess alcohol intake, iron overload, chronic hepatitis C, oestrogen therapy and cigarette smoking. The pathogenesis of PCT is complex and varied, but hereditary or acquired factors that lead to hepatic iron loading and increased oxidative stress are of central importance. Iron loading is usually only mild or moderate in degree [less than that associated with full-blown haemochromatosis (HFE)] and is usually acquired and/or mutations in HFE. Among acquired factors are excessive alcohol intake and chronic hepatitis C infection, which, like mutations in HFE, decrease hepcidin production by hepatocytes. The decrease in hepcidin leads to increased iron absorption from the gut. In the liver, iron loading and increased oxidative stress leads to the formation of non-porphyrin inhibitor(s) of uroporphyrinogen decarboxylase and to oxidation of porphyrinogens to porphyrins. The treatment of choice of active PCT is iron reduction by phlebotomy and maintenance of a mildly iron-reduced state without anaemia. Low-dose antimalarials (cinchona alkaloids) are also useful as additional therapy or as alternative therapy for active PCT in those without haemochromatosis or chronic hepatitis C. In this review, we provide an update of PCT with special emphasis upon the important role often played by the hepatitis C virus.