High prevalence of antibody to hepatitis C virus in heavy drinkers with chronic liver diseases in Japan

Effects of alcohol consumption on viral hepatitis B and C

The liver is the main target organ for hepatitis viruses and the vital organ for alcohol metabolism. These two factors of viral hepatitis and alcohol abuse in combination can exert dual harmful actions, leading to enhanced damage to the liver. Epidemiological studies have revealed a higher prevalence of hepatitis C virus (HCV) infection among alcoholics than the general population. The interaction of alcohol with viral hepatitis [e.g., hepatitis B virus (HBV), HCV] and the underlying mechanisms are not fully understood. The effects of alcohol on viral hepatitis include promoted viral replication, weakened immune response, and increased oxidative stress. Clinically, alcohol abuse is correlated with an increased risk of developing end-stage liver cirrhosis and hepatocellular carcinoma in patients with chronic hepatitis B and C, suggesting that the combination of alcohol and HBV/HCV lead to more severe liver damage. The influence of mild to moderate alcohol drinking on the HBV-induced liver fibrosis, cirrhosis, and hepatocellular carcinoma among patients infected with HBV remains unclear. Unlike HBV infected patients, no safe level of alcohol intake has been established for patients with HCV. Even light to moderate alcohol use can exert a synergistic effect with viral hepatitis, leading to the rapid progression of liver disease. Furthermore, interferon-based therapy is less effective in alcohol drinkers than in control patients, even after abstinence from alcohol for a period of time. Therefore, abstaining from alcohol is highly recommended to protect the liver, especially in individuals with HBV/HCV infection, to improve the clinical efficacy of antiviral treatment and prevent the rapid progression of chronic viral hepatitis.

Fatty Liver Disease and Hepatocellular Carcinoma: The Pathologist's View

Chronic alcohol misuse and progressed nonalcoholic fatty liver disease (NAFLD) due to the metabolic syndrome and resulting to nonalcoholic steatohepatitis (NASH) are prime causes of hepatocellular carcinoma (HCC) in Western industrialized countries. The incidence of HCC in NASH-cirrhosis is lower than that of HCC occuring in HCV-related or alcoholic cirrhosis. Up to 20% of cases of alcohol-associated HCC may develop in pre-cirrhotic liver while HCC is also increasingly recognised in pre-cirrhotic NASH raising questions on appropriate surveillance measures for these patient populations. The recently described steatohepatitic subtype of HCC presents with higher frequency in NAFLD compared to alcoholic liver disease (ALD) patients. This review will mainly focus on histopathology and summarize current data on the epidemiology, pathogenesis, diagnosis and management of NAFLD- and ALD-related HCC.

Hepatic steatosis in HCV-infected persons in the direct-acting antiviral era

Hepatitis C virus (HCV) infects 130-170 million people worldwide. Recently, direct-acting antivirals have been shown to eradicate HCV infection in 90-95 % of non-cirrhotic patients depending on genotype, treatment experience, and regimen used. Similar rates are achieved among compensated cirrhotics, although longer treatment duration and/or ribavirin may be required. HCV uses host lipid metabolism for its lifecycle and can cause hepatic steatosis and insulin resistance. Hepatic steatosis, defined as excessive triglyceride deposition in hepatocytes, affects approximately half of HCV-infected individuals. Genetic factors and co-morbidities can drive further steatosis, which in turn can instigate fibrosis and progression to cirrhosis and hepatocellular carcinoma. Polymorphisms in genes that modulate lipid deposition in hepatocytes such as patatin-like phospholipase domain-containing protein 3 (PNPLA3) and transmembrane six superfamily member 2 (TM6SF2) predispose people to steatosis. Metabolic syndrome, obesity, and insulin resistance are increasing worldwide and further contribute to hepatic steatosis, and alcohol has long been recognized as a cause of lipid deposition in the liver. HIV and antiretroviral drugs, but not HBV, may further drive hepatic steatosis. While many of these factors limit response to interferon-based regimens for treating HCV, responses to direct-acting antivirals appear not to be impaired. The effect of HCV eradication on hepatic steatosis and progression to fibrosis, cirrhosis, and hepatocellular carcinoma warrants further study in the era of direct-acting antivirals.

Hepatitis C virus and alcohol

This review will focus on the prevalence of hepatitis c virus (HCV) infection in alcoholics with and without liver disease. Evidence will be presented to demonstrate that ethanol and chronic HCV infection synergistically accelerate liver injury. Some of the major postulated mechanisms responsible for disease progression include high rates of apoptosis, lipid peroxidation, and generation of free radicals and reactive oxygen species with reduced antioxidant capacity of the liver. Acquisition and persistence of HCV infection may be due to the adverse effects of ethanol on humoral and cellular immune responses to HCV. Dendritic cells (DC) appear to be one of the major targets for ethanol's action and DC dysfunction impairs the ability of the host to generate viral specific cluster of differentiation 4 (CD4+) and cluster of differentiation 8 (CD8+) immune responses. There is a relationship between increased alcohol intake and decreased response to interferon (IFN) therapy, which may be reversed by abstinence. Clinical studies are needed to optimize treatment responses in alcoholic patients with chronic HCV infection.

Effect of alcohol on viral hepatitis and other forms of liver dysfunction

Alcohol is a known hepatotoxic agent, which may exacerbate liver injury caused by other agents. The wide prevalence of alcohol use and abuse in society makes it an important cofactor in many other liver diseases. Examples of liver diseases that are significantly influenced by ingestion of alcohol include chronic viral hepatitis, disorders of iron overload, and obesity-related liver disease.

Alcohol and hepatitis C

BACKGROUND/AIMS

Alcohol use and hepatitis C are prominent risk factors for liver injury and this review offers the current understanding of each factor's effects on liver disease.

METHODS

A Medline database search was preformed for English articles with a focus on alcohol, hepatitis C and liver disease. Article citations were also considered for further applicable articles, and the strongest studies were included in our review.

RESULTS

Up to 60% of patients with hepatitis C have a past history of alcohol use. In patients with hepatitis C, chronic alcohol consumption of more than 5 drinks/day increases the rate of liver fibrosis, risk for cirrhosis, hepatocellular carcinoma, and, possibly, death from liver disease. Numerous studies have further found that even moderate amounts of alcohol can be detrimental to hepatitis C patients. The prevalence of hepatitis C is higher in alcoholics with advanced liver disease than in alcoholics without liver disease. Also, recent alcohol use decreases the response rate to interferon treatment.

CONCLUSIONS

Hepatitis C and alcohol use are often co-occurring risk factors for liver disease, and though their interaction is not clear, it is known that heavy drinking significantly promotes liver disease progression.

Liver disease in alcohol and hepatitis C

The prevalence of hepatitis C is 7-10-fold higher in alcoholics than it is in the general population. Among alcoholics, the prevalence of hepatitis C is higher in alcoholics with advanced liver disease. Serum ALT and hepatitis C viral load may improve if alcoholic patients with hepatitis C stop drinking for more than 4 months.Up to 60% of patients with hepatitis C have a past history of alcohol use. In patients with hepatitis C, chronic alcohol consumption of more than 5 drinks per day increases the rate of liver fibrosis. Hepatitis C patients who ingest more than 5 alcoholic drinks per day are at increased risk for cirrhosis, hepatocellular carcinoma and, possibly, death from liver disease. Recent alcohol use decreases the response rate to interferon treatment. The detrimental effects of small amounts (3 or fewer drinks per day) of alcohol consumption in patients with hepatitis C are not known.

Alcohol consumption induces hepatocyte apoptosis in patients with chronic hepatitis C infection

BACKGROUND

Epidemiological studies have established that heavy alcohol consumption in persons with chronic hepatitis C infection is associated with advanced liver disease, including cirrhosis. The cellular mechanisms underlying this process, which appear to occur over decades, are unknown. Increased hepatocyte apoptosis has been observed in association with hepatitis C infection. The aim of this study was to evaluate the relationship between alcohol consumption and hepatocyte apoptosis in hepatitis C-infected patients.

METHODS

Liver tissue from 20 hepatitis C-infected patients with variable alcohol consumption, and 10 normal control subjects was examined for hepatocyte apoptosis, proliferation and bcl-2 expression.

RESULTS

Hepatocyte apoptosis was significantly greater in hepatitis C-infected patients than in controls. In hepatitis C-infected patients, significantly more hepatocyte apoptosis was seen in those consuming at least 30 g per day of alcohol compared with those drinking less than 10 g daily. Bcl-2, an inhibitor of apoptosis, was not detected in liver tissue from patients with the highest ethanol intake and rate of hepatocyte apoptosis. In contrast, patients drinking lesser amounts of ethanol had lower rates of hepatocyte apoptosis and more frequent bcl-2 expression.

CONCLUSIONS

This study confirms that both hepatitis C infection and ethanol consumption induce hepatocyte apoptosis in humans. Ethanol-induced hepatocyte apoptosis has previously been shown only in animal models of alcohol-related liver injury. The precise role of apoptosis in the pathogenesis of hepatitis C-related liver injury remains unclear, but its induction may be related to downregulation of bcl-2 expression associated with ethanol consumption.

Chronic liver disease in the extremely elderly of 80 years or more: clinical characteristics, prognosis and patient survival analysis

BACKGROUND/AIMS

This study aimed to elucidate the clinical characteristics of patients with chronic liver disease aged 80 years or more, especially the factors affecting prognosis and carcinogenesis.

METHODS

A total of 135 patients aged 80 years or above were divided into chronic liver disease without cirrhosis (non-LC) and cirrhosis (LC) groups according to the severity of fibrosis, and the clinical characteristics and prognoses were evaluated.

RESULTS

Seventy-three (54.1%) of 135 patients were in the LC group and 79 patients (58.5%) had hepatitis C virus. Various concomitant diseases were seen in 122 patients (90.4%). Liver-related deaths occurred in only 19 (36.5%) of 52 patients who died during observation, although 28 patients (53.8%) had liver cancer at the time of death. Cumulative survival rates in the non-LC and the LC groups were 85.7% and 58.8% at the 5th year, and 69.4% and 19.4% at the 9th year, respectively. Cumulative liver cancer appearance rates in the non-LC and the LC groups were 1.6% and 6.1% at the 1st year, 12.4% and 19.9% at the 5th year, and 12.4% and 32.0% at the 7th year, respectively. A multivariate Cox regression analysis revealed that the presence of liver cancer (p=0.0001), platelet count (p=0.0242), and fibrotic stage (p=0.0118) were independently associated with survival period, and alfa-fetoprotein (p=0.0194) and bilirubin (p=0.0282) were independently associated with carcinogenesis.

CONCLUSIONS

Cirrhosis is the major risk factor affecting the prognosis. On the other hand, we must pay more attention to concomitant diseases specific to advanced age.

Interrelationship between alcohol intake, hepatitis C, liver cirrhosis, and hepatocellular carcinoma

The discovery of a cDNA clone of hepatitis C virus (HCV) genome in 1989 has resulted in numerous reports of high rates of the prevalence of HCV antibody in patients with alcoholic liver disease, in particular, alcoholic liver cirrhosis and hepatocellular carcinoma. Thus, the interaction between alcohol intake and HCV infection has become of great importance. In terms of the effect of alcohol on HCV-RNA levels, the data are controversial; in some reports, alcohol increases HCV-RNA levels, and in the other reports it does not. There are several reports suggesting the possibility of an elevated quasi-species of hypervariable region 1 in the HCV genome caused by alcohol drinking. Recent studies have documented that alcohol intake exaggerates the responsiveness of interferon therapy for chronic hepatitis C; however, its mechanism is still obscure. Several studies have suggested the promoting effect of alcohol on the development of hepatocellular carcinoma in type C liver cirrhosis, which has been similarly observed in type B chronic liver disease, whereas its mechanism is limited to speculations.

Toxicological effects of ethanol on human health

Moderate ethanol consumption reduces stress and increases feelings of happiness and well-being, and may reduce the risk of coronary heart disease. Heavy consumption of alcohol, however, may cause addiction and increases all types of injury and trauma. Environmental and genetic factors are involved in susceptibility to alcoholism. Ethanol can lead to malnutrition, and can exert a direct toxicological effect due to its interference with hepatic metabolism and immunological functions. A causal effect has been observed between alcohol and various cancers. Cessation of alcohol consumption and balanced nutrition are recommended primary nonspecific therapeutic measures for alcoholics. Drug therapies for alcoholics suffering from liver injury has resulted in mixed results. In end-stage liver disease, liver transplantation may be considered.

Efficacy of interferon therapy in patients with chronic hepatitis C. Comparison between non-drinkers and drinkers

BACKGROUND

Alcohol has been reported to be an important factor that modulates the development and prognosis of chronic viral hepatitis; however, little is known about interaction of alcohol intake and chronic hepatitis C. The aim of this study was to examine whether alcohol drinking affects the effectiveness of interferon (IFN) therapy for chronic hepatitis C.

METHODS

Thirty-nine patients with chronic hepatitis C were divided into three groups on the basis of the amount of alcohol intake before IFN therapy: group I (n = 15), non-drinkers; group II (n = 14), less than 70 g/day; and group III (n = 10), more than 70 g/day of ethanol intake for at least 10 years. The IFN (total dose, 330 +/- 206 MU) was administered daily for 2 weeks and then intermittently. Drinkers stayed abstinent for at least 1 month before, during, and after IFN therapy. The sustained responder was defined as the patient who showed normal alanine aminotransferase (ALAT) levels continuously for more than 6 months after the therapy. The liver histology (HAI score) and serum hepatitis C virus (HCV) RNA were also examined before and after the therapy.

RESULTS

There was no significant difference among the three groups in the level of ALAT before IFN therapy, age, total dose of IFN, and liver histology. The rates of sustained responders in groups I, II, and III were 53.3%, 42.9%, and 0%, respectively, resulting in a significantly lower rate in group III than in groups I (p < 0.01) and II (p < 0.01). The serum HCV-RNA turned negative after the therapy in 58.3%, 20.0%, and 12.5% of groups I, II, and III, respectively, leading to a significantly lower rate of disappearance of HCV-RNA in group III than in group I (p < 0.05).

CONCLUSION

The IFN therapy for chronic hepatitis C was less effective in heavy drinkers than in non-drinkers.

Focal hepatocellular necrosis and portal lymphocytic infiltration of the liver in chronic alcoholics: histopathological study of 40 liver biopsies

Forty liver biopsies of hepatitis B surface antigen negative chronic alcoholics were histologically studied to assess the influence of hepatitis C virus (HCV)-infection. A moderate degree of focal hepatocellular necrosis and/or portal lymphocytic infiltration (FHN-PLI) was observed in 28% of the specimens, being especially prevalent in advanced cases of fibrosis and cirrhosis, and significantly correlated with HCV-infection. Eleven of these cases were examined in detail: HCV-infection was detected in eight and lymphocytic infiltration was apparent in the portal area, accompanied by formation of lymph follicles. The FHN-PLI was ascribed to alcoholic hepatitis in two HCV-negative cases and was concluded to be of unknown etiology in the remaining one HCV-negative case. This study thus indicated that over two-thirds of cases of chronic hepatitis in alcoholics can be attributed to HCV-infection, with the remainder being at least partly related to alcoholic hepatitis. The prevalence of alcohol-induced chronic hepatitis based on immunopathological findings was unclear, but was probably less frequent than previously reported.

Chronic liver disease in Peru: role of viral hepatitis

The prevalence of antibodies to hepatitis C virus (anti-HCV) was determined in 105 patients with biopsy-proven chronic liver disease and 128 comparison patients without any evidence of liver pathology living in Lima, Peru. Using a second-generation EIA screening and supplemental immunoblot assay, anti-HCV was detected in four of 13 patients with chronic hepatitis, in 11% of 85 patients with cirrhosis, and in none of seven patients with hepatocellular carcinoma. Only two (1.6%) comparison patients without liver disease had anti-HCV. Hepatitis B surface antigen (HBsAg) was found in 23% of patients with chronic hepatitis, 12% of patients with cirrhosis, and three of seven patients with hepatocellular carcinoma. There was no evidence of chronic viral hepatitis or alcohol abuse (reported by one-third of subjects) in 48% of chronic liver disease patients. These preliminary data suggest that among this South American population neither hepatitis B nor hepatitis C infection is the predominate cause of chronic liver disease and that other infectious or environmental factors may be important.

New trends in hepatocellular carcinoma

This review discusses the etiological association of hepatitis C virus with hepatocellular carcinoma and recent progress in the understanding of early histopathological changes that occur in cirrhotic livers leading to hepatocarcinogenesis. In some parts of the world (for example Japan) hepatitis C virus infection is becoming a more important etiological factor in the pathogenesis of hepatocellular carcinoma than infection with hepatitis B virus. Biopsy-proven adenomatous hyperplasia often progresses to hepatocellular carcinoma and adenomatous hyperplasia should be treated as a potentially malignant lesion.