Treatment of chronic hepatitis C virus in African Americans with genotypes 2 and 3

Associations between responses to interferon therapy and genetic variation in interleukin-28B and the core region of hepatitis C virus genotype 3a

The single-nucleotide polymorphism (SNP) of interleukin-28B (IL-28B) and mutations in the core region of hepatitis C virus (HCV) genotype 1b have been associated with response to interferon (IFN) therapy. However, whether this IL-28B SNP affects responses to INF therapy for HCV genotype 3a is not known. The aim of this study is to investigate whether this IL-28B SNP (rs8099917) and specific missense mutations in the HCV core region affect the response to IFN therapy for HCV genotype 3a. Patients (n = 19; median age 44.5) infected with HCV genotype 3a who received IFN therapy were studied. Of the 19 patients, 12 (63.1%) achieved sustained virological response. Of those 12 patients, 11 had the TT genotype (11/16; 68.7%), and one had the TG genotype (1/3; 33.3%). The difference in the sustained virological response rate between IL-28B genotype groups was not significant (P = 0.5232). HCV core region was well conserved; however, polymorphisms at position 72 were identified. Of the 19 HCV samples; 15 carried a glutamic acid at position 72, and these were defined as E type; the others (4/19) were defined as non-E type. Notably, there was a significant difference in the sustained virological response rate between E type and non-E-type; 12 of the 15 patients with E-type achieved sustained virological response, but none of the four patients with non-E-type achieved sustained virological response (P = 0.009). A glutamic acid at position 72 in the core region of HCV genotype 3a was associated with a good response to IFN therapy. J. Med. Virol. 87:1361-1367, 2015. © 2015 Wiley Periodicals, Inc.

Factors Associated with Failure to Achieve SVR in Hepatitis C Genotype 3 Patients Within an Integrated Care Delivery System

BACKGROUND

Achievement of sustained virologic response (SVR) and factors associated with treatment failure in hepatitis C virus (HCV) genotype 3 have been described in tertiary and referral care settings, with rates of SVR reported to range between 72% and 89%. Fewer data exist on SVR outside of these settings.

OBJECTIVE

To describe rates of SVR and characterize factors associated with achievement of SVR within an integrated health care delivery system.

METHODS

A retrospective cohort study of genotype 3 HCV patients treated with dual therapy (pegylated interferon-alpha plus ribavirin) was conducted at Kaiser Permanente Southern California. Adult patients diagnosed with HCV and testing positive for HCV-RNA genotype 3 were identified from electronic medical records. Data were collected on patient demographics, baseline health status, and comorbid conditions. A multivariate logistic regression model was used to determine the association between baseline patient factors and SVR.

RESULTS

A total of 484 HCV genotype 3 patients met the eligibility criteria. The median age was 49 years, and 65.7% were male. Overall, 252 (52.1%) achieved SVR. Aged ≥ 45 years and male gender were associated with lower rates of SVR; cirrhosis and chronic diseases (diabetes and chronic obstructive pulmonary disease) were also associated with lower rates of SVR.

CONCLUSIONS

SVR was lower in patients within an integrated care delivery system than in those in tertiary and referral centers. Males and older patients had lower rates of SVR, as well as patients with cirrhosis, diabetes, and chronic obstructive pulmonary disease.

The Impact of IFN-γ Gene Polymorphisms on Spontaneous Clearance of HCV Infection in Fars Province, Southern of Iran

BACKGROUND

Certain polymorphisms in cytokine genes such as IFN-γ may influence the outcome of hepatitis C virus (HCV) infection. Here the frequency of the genotype, allele, and haplotype of IFN-γ gene at some loci is investigated in HCV-infected patients.

METHODS

Totally 255 patients with chronic HCV infection and 44 spontaneously cleared individuals were included. The chronic or clearance states were confirmed using enzyme-linked immunosorbent assay (ELISA) and two different qualitative reverse transcriptase polymerase chain reaction (RT-PCR) techniques. IFN-γ gene polymorphisms were performed by PCR using sequence-specific primers and PCR-RLFP on extracted genomic DNA.

RESULTS

The frequency of GG genotype (P = 0.0001, OR: 5.69 and CI: 2.21-14.62) and allele (P = 0.0003, OR: 2.73 and CI: 1.54-4.83) of IFN-γ gene at +2109 locus was significantly higher in cases that spontaneously cleared the infection. Haplotype analysis showed the association of AG haplotype (P = 0.0046, OR = 6.14 and CI = 1.56-25) with spontaneous clearance of the infection.

CONCLUSION

Our finding indicated that individuals with GG genotype at +2109 loci of IFN-γ gene and also AG haplotype (A allele at +874 loci and G allele at +2109 loci) may clear HCV infection more frequently than those with AA and AG genotype at +2109 loci and AA, TA, and TG haplotype.

Hepatitis C in African Americans

The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.

Genetic variation in NOS2A is associated with a sustained virological response to peginterferon plus ribavirin therapy for chronic hepatitis C in Taiwanese Chinese

This study aimed to evaluate whether genetic polymorphisms of the inducible nitric oxide synthase (iNOS) gene NOS2A could be associated with a sustained virological response (SVR) among patients infected with hepatitis C virus genotypes 1 and 2 (HCV-1 and HCV-2) who were treated with peginterferon plus ribavirin (PEG-IFNα-RBV). We analyzed the associations between SVR to PEG-IFNα-RBV therapy and two single nucleotide polymorphisms (SNPs) in NOS2A. This study included Taiwanese Chinese patients infected with either HCV-1 (n = 265) or HCV-2 (n = 195) with or without a SVR. Among the NOS2A SNPs examined, the combination of genotypes A/A and A/G of rs2248814 was inversely correlated with SVR in patients infected with HCV-1 (P = 0.0048), particularly in males (P = 0.0281). This effect was not observed in patients infected with HCV-2. The AC NOS2A haplotype comprising two SNPs (rs2248814 and rs2072324) was found to be associated with SVR, and its presence may decrease the chances for a successful outcome of treatment of patients infected with HCV-1 (P = 0.0053). HCV-1 infected patients who carried the A-C diplotype will have a lower success rate of achieving a SVR (P = 0.0117). In addition, a multivariate logistic regression model for predicting a SVR revealed that the presence of the A-C diplotype interactively affected the outcome of PEG-IFNα-RBV treatment. The presence of NOS2A SNPs and the association with SVR showed that NOS2A polymorphisms may influence the therapeutic outcomes of patients infected with HCV-1 under standard of care treatment.

Role of IL28B for chronic hepatitis C treatment toward personalized medicine

Genome-wide association studies recently revealed that certain interleukin-28B (IL28B) polymorphisms are strongly associated with responses to pegylated interferon (PEG-IFN) and ribavirin (RBV) therapy in patients chronically infected with hepatitis C virus (HCV) genotype 1, as well as with spontaneous clearance of HCV. Subsequent reports revealed that IL28B genotypes also affect treatment efficacy in chronic infection with other HCV genotypes. Furthermore, there have been several reports that implicate IL28B genotypes in inflammatory status, progression of fibrosis and adverse clinical outcomes in chronic hepatitis C (CHC). Therapy of CHC recently entered a new era with the deployment of direct-acting antivirals. These include nonstructural 3/4A protease inhibitors which have shown promise in combination with PEG-IFN/RBV in several clinical trials. IFN-free therapy is expected to be useful especially in IFN-resistant patients and may become the standard of care in the future. Several clinical trials have revealed an association between IL28B genotype and treatment efficacy in triple therapy or IFN-free regimens. On the other hand the mechanism of the effect of IL28B on HCV infection has not yet been elucidated. Recently, it was shown that the polymorphism of IFN-lambda 4 (IFNL4) is in high linkage disequilibrium with that of near IL28B, and more strongly associated with spontaneous or treatment-induced HCV clearance than IL28B genotypes, especially in individuals of African ancestry. This finding provides new insights into the genetic regulation of HCV clearance and its clinical management. IL28B genotyping will be also useful for personalized CHC treatment in the forthcoming era of direct-acting antivirals.

Serum RANTES level influences the response to pegylated interferon and ribavirin therapy in chronic hepatitis C

AIM

Prediction of treatment responses to pegylated interferon (PEG IFN) plus ribavirin (RBV) therapy is uncertain for genotype 1b chronic hepatitis C.

METHODS

In this study, 96 patients were investigated for the correlation between 36 pretreatment serum chemokine/cytokine levels and PEG IFN/RBV treatment efficacy by a sandwich enzyme-linked immunoassay (ELISA) and a bead array.

RESULTS

First, chemokines/cytokines were measured semiquantitatively by sandwich ELISA in 31 randomly-selected patients and the serum regulated on activation normal T-cell expressed and secreted (RANTES) level was found to be significantly higher in the sustained virological response (SVR) group than the non-SVR group (P = 0.048). Precise RANTES measurement in all 96 patients using a bead array confirmed this correlation (P = 0.002). However, the genetic RANTES haplotype was not significantly related to the serum level. The serum RANTES level was extracted by multivariate analysis (odds ratio = 4.09, 95% confidence interval = 1.02-16.5, P = 0.048) as an independent variable contributing to SVR.

CONCLUSION

The serum RANTES level is an important determinant influencing the virological response to PEG IFN/RBV therapy in chronic hepatitis C.

Accessing Hepatitis C patients who are difficult to reach: it is time to overcome barriers

With the arrival of simple, efficient and safe interferon-free treatment regimens, hepatitis C virus (HCV) therapy will have the potential to be successfully used for the majority of infected patients and prevent the associated morbidity and mortality. With the current treatment uptake rates, only a very small proportion of HCV-infected patients are reached. Paradoxically, treatment rates are lowest in the most affected at-risk group - people who inject drugs (PWID) - which is the major driving force behind the spread of HCV infection. To conquer the increasing problem of HCV-related liver disease, many existing but modifiable obstacles, which prevent detection, assessment and treatment uptake, have to be overcome in this population. This review article summarizes the existing literature on the most relevant barriers preventing HCV care and describes measures to overcome these obstacles.

Association of genetic variations in GNB1 with response to peginterferon plus ribavirin therapy for chronic hepatitis C in a Chinese population in Taiwan

Background

The aim of this study was to evaluate whether polymorphisms in the guanine nucleotide binding (G protein), beta polypeptide 1 (GNB1) gene are associated with a rapid virological response (RVR) among HCV genotype 1 (HCV-1) and 2 (HCV-2) infected patients receiving peginterferon plus ribavirin treatment (PEG-IFNα-RBV).

Methods

We analyzed the association between RVR to PEG-IFNα-RBV therapy and 4 tagging single nucleotide polymorphisms (SNPs) of the GNB1 gene. This study included 265 HCV-1 and 195 HCV-2 infected patients in a Chinese population in Taiwan.

Results

Among the GNB1 SNPs examined, the combination of genotypes G/G and G/T populations of rs12126768 was significant inversely correlated with RVR in HCV-1 infected patients (P = 0.0330), whereas HCV-2 infected patients, combination of A/A and A/C genotypes populations at rs4648727 responded better to the PEG-IFNα-RBV treatment (P = 0.0089). However, there were no significant differences in the allele frequencies of those SNPs between RVR responders and non-responders. Several RVR susceptibility GNB1 haplotypes were identified, and the ACAT haplotype of the 4 SNPs may increase the successful outcomes of HCV-1 and HCV-2 infected patients (P = 0.0261 and P = 0.0253, respectively).

Conclusion

The data for GNB1 SNPs and the association of RVR showed that GNB1 polymorphisms might be associated with the therapeutic outcomes of HCV-1 and HCV-2 infected patients under standard of care (SOC) treatment.

The role of viral and host genetics in natural history and treatment of chronic HCV infection

Understanding of the natural history and treatment responsiveness of chronic hepatitis C virus (HCV) infection has evolved rapidly in recent years. Advances in HCV molecular virology and host genetics can now better predict spontaneous clearance and treatment outcomes. HCV genotype is the most important viral factor predicting interferon-α treatment responsiveness; HCV-1 subtype is emerging as a key determinant of the efficacy of direct acting antiviral therapy. Genome-wide association studies have recently identified several clinically important host determinants of the outcomes of peginterferon-α and ribavirin treatment outcome: IL28B polymorphism is associated with spontaneous clearance and treatment responsiveness; ITPA polymorphism protects against ribavirin-induced anaemia and dose reductions; genetic determinants of liver fibrosis progression rate have been proposed. In this review, we evaluate the role of viral and host genetics in the natural history and treatment outcomes of chronic HCV infection, and consider how this knowledge might help individualize clinical management in the era of DAA therapy.

IL28B favorable genotype and ultrarapid viral response as the earliest treatment predictors of a sustained viral response in a Georgian cohort infected with the hepatitis C genotype 1

OBJECTIVES

The early identification of factors contributing to the successful treatment of hepatitis C infection is important for researchers and clinicians. Studies carried out on the role of an ultrarapid viral response (URVR) for the prediction of a sustained viral response (SVR) have shown its high positive predictive value (PPV). However, data on the combined effect of URVR with IL28B genotypes for the prediction of SVR are lacking. Our aim was to study the role of URVR and IL28B genotypes in the prediction of SVR among patients in Georgia infected with genotype 1.

METHODS

Of a total of 156 patients enrolled in the study, 143 were included in the final analyses. Viral load testing for monitoring the viral response was carried out at 3, 24, 48, and 72 h and at 1, 2, and 4 weeks after the initiation of treatment. IL28B single nucleotide polymorphisms in rs12979860 were genotyped using real-time PCR methods.

RESULTS

Our study showed that URVR was the earliest treatment predictor among genotype 1 patients harboring the IL28B C/C genotype (PPV-100%). Moreover, the C/C genotype was found to have a high PPV among genotype 1 patients without URVR or a rapid viral response, unlike patients infected with genotype 2 or 3. URVR and IL28B C/C genotypes were not as predictive of an SVR among genotype 2 and 3 patients; however, rapid viral responses were highly predictive of an SVR in these patients.

CONCLUSION

Our results suggest that testing for IL28B genotypes and viral load at weeks 1 and 2 may improve the ability to predict an SVR among hepatitis C virus genotype 1 patients; this information may be useful to ensure patient compliance with treatment.

Mutations in two PKR-binding domains in chronic hepatitis C of genotype 3a and correlation with viral loads and interferon responsiveness

Interferon (IFN) induces the double-stranded RNA-dependent protein kinase (PKR) to inhibit viral replication. Two motifs of the PKR-binding domain exist in the E2 and the NS5A regions of the hepatitis C virus (HCV). These regions are called the PKR-eukaryotic transcription factor (elF2-alpha) phosphorylation homology domain (PePHD), and the IFN sensitivity-determining region (ISDR). Both regions are inhibited by PKR. Thus, several studies have reported the relationship between these regions and IFN responsiveness and the HCV viral load. However, the data obtained from these studies remain controversial. The aim of this study was to investigate the genomic heterogeneity of the PePHD and the ISDR in patients with genotype 3a and how this impacts HCV replication and the response to IFN therapy. Twenty-one male patients infected with HCV genotype 3a were studied. The PePHD was well conserved, and mutations were found in only one amino acid position in two patients. Patients with three or more mutations in the ISDR had lower viral loads than those with fewer than two mutations (192.2 ± 176.7 vs. 1279.4 ± 997.6 KIU/ml, P = 0.0277). Ten (71.4%) of 14 patients achieved a sustained virological response to IFN therapy. No specific amino acid substitutions in the PePHD and the ISDR were associated with IFN responsiveness; however, the number of mutations in the ISDR was significantly associated with the HCV viral load. The findings from this study suggest that the ISDR plays an important role in regulating viral replication in patients infected with HCV genotype 3a.

Gaps in the achievement of effectiveness of HCV treatment in national VA practice

BACKGROUND & AIMS

Antiviral treatment for hepatitis C virus (HCV) has high efficacy rates for achieving sustained viral response (SVR) in randomized controlled trials (RCTs) (40-80%); however, it can be lower in community-based practice settings. We wanted to determine the effectiveness of HCV treatment in Veterans Administration (VA) hospitals nationwide.

METHODS

Using the nationwide VA HCV Clinical Case Registry (CCR), we examined a cohort of veterans who had HCV viremia between 2000 and 2005 and identified patients who received pegylated-interferon (PEG-INF) and ribavirin. The duration of treatment and proportion of patients completing treatment was calculated. The effectiveness of treatment was measured as the proportion of patients who achieved SVR (negative viremia at least 12 weeks after the end of treatment) in the entire cohort, and among patients who initiated and completed treatment.

RESULTS

We identified 99,166 patients with HCV viremia. Of those, 11.6% received PEG-INF with ribavirin and 6.4% completed treatment. Contraindications were present in 57.2% of the patients that did not receive treatment. SVR was documented in 39.9% and 58.3% of patients who completed treatment; 23.6% and 50.6% of patients who initiated treatment; and 3.9% and 11.2% of the entire HCV cohort for genotype 1 or 4 and 2 or 3, respectively. Overall, only 3.5% of the entire HCV viremic cohort had a documented SVR.

CONCLUSIONS

Treatment effectiveness for HCV is low. In addition to fixed factors, such as race and virus genotype, the drop in effectiveness is due to low rates of antiviral treatment initiation and treatment completion.

IL28B polymorphism and genetic biomarkers of viral clearance in hepatitis C virus infection

Infection with hepatitis C virus (HCV) is a major global health issue. Only a small proportion of patients clear the virus spontaneously and the majority develop chronic hepatitis C infection. Chronic hepatitis C is one of the most common causes of advanced liver disease in the western world and is now the leading indication for liver transplantation. Unfortunately, the standard treatment, consisting of pegylated-interferon and ribavirin, is suboptimal. Less than 50% of patients infected with HCV genotype 1 are cured, treatment is costly and is associated with significant toxicity. Therefore, there has been a need to identify accurate predictors of treatment outcome to facilitate treatment decision-making. Four independent genome-wide association studies have recently confirmed an association between genetic variation in the region of the IL28B gene and treatment outcome in HCV-1 patients. Patients who carry the good response variant are two- to three-fold more likely to be cured. The difference in the frequency of the good response variant between patients of different ethnic background explains much of the recognized ethnic disparity in treatment response rates. The IL28B variants are also associated with likelihood of spontaneous clearance of HCV infection. This discovery represents a significant advance in our ability to personalize HCV therapy, as well as suggesting novel avenues for research into viral pathogenesis and therapeutic development.

Interferon-free regimens: the near future, the likely and the not so likely

Remarkable progress has been achieved in the treatment of chronic hepatitis C virus (HCV) since interferon was first used to treat this pathogen more than 20 years ago. This article reviews the mechanisms through which interferon is believed to suppress HCV and lead to SVR. These observations are used to speculate as to whether an all-oral antiviral cocktail could "cure" HCV in the near future.

Virological rather than host factors are associated with transaminase levels among HIV/HCV-coinfected patients

Alanine aminotransferase (ALT) is a routine parameter in the assessment and monitoring of chronic hepatitis C viral (HCV) infection. Hepatitis C virus-infected African Americans (AAs) have been reported to have lower ALT levels. In this retrospective, cross-sectional, multicenter study, host and virological factors possibly associated with ALT levels were analyzed by multivariate regression analyses among HIV/HCV-coinfected patients. Of the 289 patients included, 142 were African Americans and 144 Caucasians. In multivariate analysis, only HCV genotype 3 (B 0.2 [95% CI 13.39-52.33]; P = .001) and HCV RNA >500 000 IU/mL (B 3.1 [95% CI 7.67-34.75]; P = .002) were independent predictors of higher ALT levels. Per the American Association for the Study of Liver Disease (AASLD) definition, 18.2% had ALT levels within normal limits. Male sex and HCV RNA <500 000 IU/mL predicted ALT within normal limits. Hepatitis C viral factors rather than race were associated with ALT levels in this HIV/HCV-coinfected population. ALT were within normal limits in 18% of patients, who more often were male and had lower Hepatitis C viral load.

Novel findings for the development of drug therapy for various liver diseases: Genetic variation in IL-28B is associated with response to the therapy for chronic hepatitis C

Hepatitis C infection is a global health problem. Spontaneous viral clearance was observed in approximately 30% of individuals with acute infection. In the therapy using a combination of pegylated interferon-α and ribavirin, approximately 50% of chronic hepatitis C patients infected with high viremia of hepatitis C virus infection (HCV) genotype 1 reached a sustained viral response. These findings were strongly expected to reflect variations of the host genome. To reveal genetic effects against viral clearance or treatment response, four independent groups applied a genome-wide association study (GWAS) to HCV infection. These groups almost simultaneously reported a strong association of interleukin (IL)-28B polymorphisms with viral clearance or final decision of HCV therapy. The discovered single nucleotide polymorphisms (SNPs) also revealed the enigma that the viral clearance rate was dependent on ethnic type. The significant SNPs are useful for prediction prior to treatment because of the strong association with clinical outcome. In addition, the unexpected results revealed by GWAS could promote the development of a novel drug related to IL-28B. Herein, we present current understanding in regard to the relationship between host variations and clinical outcome of hepatitis C.

Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: a case-control study

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p<.01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p<.001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

A polymorphism near IL28B is associated with spontaneous clearance of acute hepatitis C virus and jaundice

BACKGROUND & AIMS

A single nucleotide polymorphism (SNP) upstream of the IL28B gene has been associated with response of patients with chronic hepatitis C to therapy with pegylated interferon and ribavirin and also with spontaneous clearance of acute hepatitis C in a heterogeneous population. We analyzed the association between IL28B and the clinical presentation of acute hepatitis C virus (HCV) infection in a homogeneous population.

METHODS

We analyzed the SNP rs12979860 in 190 women from the German anti-D cohort (infected with HCV genotype 1b via contaminated rhesus prophylaxis) and its association with spontaneous clearance. Clinical data were available in 136 women with acute infection who were also evaluated for IL28B genotype. Based on results of a TaqMan polymerase chain reaction assay, the rs12979860 SNP genotypes studied were C/C, C/T, or T/T.

RESULTS

Spontaneous clearance was more common in patients with the C/C genotype (43/67; 64%) compared with C/T (22/90; 24%) or T/T (2/33; 6%) (P < .001). Jaundice during acute infection was more common among patients with C/C genotype (32.7%) than non-C/C patients (with C/T or T/T) (16.1%; P = .032). In C/C patients, jaundice during acute infection was not associated with an increased chance of spontaneous clearance (56.3%) compared with those without jaundice (60.6%). In contrast, in non-C/C patients, jaundice was associated with a higher likelihood of spontaneous clearance (42.9%) compared with those without jaundice (13.7%).

CONCLUSIONS

The SNP rs12979860 upstream of IL28B is associated with spontaneous clearance of HCV. Women with the C/T or T/T genotype who did not develop jaundice had a lower chance of spontaneous clearance of HCV infection.

Treatment options for hepatitis C and the rationale for low response rates in African Americans

Hepatitis C virus (HCV), the leading cause for liver transplantation, is emerging as1 of the infections that pose public health problems in the world since about 170 million people worldwide are infected with this virus. Inequality in addressing racial/ethnic disparities in treatment for hepatitis C is a pressing problem. HCV is more common among African Americans than among other racial groups in the United States. Although African Americans have been shown to have a lower rate of viral clearance and a higher rate of chronic hepatitis C, they may have at the same time a much lower rate of fibrosis progression compared to Caucasians. The purpose of this study is to summarize treatment options available for hepatitis C in African Americans and to describe the different mechanisms thought to be the reasons for the disparate response to treatment in African Americans.

Effectiveness of hepatitis C treatment with pegylated interferon and ribavirin in urban minority patients

Randomized controlled trials of hepatitis C virus (HCV) therapy with pegylated interferon and ribavirin have demonstrated sustained viral response rates (SVRs) of 54%-63% (efficacy). Treatment results in clinical practice (effectiveness) may not be equivalent. The goal of this study was to assess the effectiveness of HCV treatment with pegylated interferon and ribavirin in a treatment-naïve, human immunodeficiency virus (HIV)-negative, United States urban population with many ethnic minority patients. We evaluated 2,370 outpatients for HCV therapy from 2001 to 2006 in the Faculty Practice of the Albert Einstein College of Medicine or the attending-supervised Montefiore Medical Center Liver Clinic. Care was supervised by one experienced physician under conditions of everyday clinical practice, and appropriate ancillary resources were made available to all patients. Two hundred fifty-five patients were treated with a mean age of 50 years (60% male, 40% female; 58% Hispanic, 20% African American, 9% Caucasian, 13% other; 68% genotype 1, the remainder genotypes 2 or 3). Patients had at least one liver biopsy. Intention-to-treat analysis (ITT) showed SVR in 14% of genotype 1 patients and 37% in genotype 2/3 patients (P < 0.001). SVR was significantly higher in faculty practice (27%) than in clinic patients (15%) by intention-to-treat (P = 0.01) but not per-protocol analysis (46% faculty practice, 34% clinic). 3.3% of 1,656 treatment-naïve, HIV antibody-negative individuals ultimately achieved SVR. Current hepatitis C therapies may sometimes be unavailable to, inappropriate for, and ineffective in United States urban patients. Treatment with pegylated interferon and ribavirin was less effective in this population than is implied by multinational phase III controlled trials. New strategies are needed to care for such patients.

Pharmacokinetics and response of obese patients with chronic hepatitis C treated with different doses of PEG-IFN alpha-2a (40KD) (PEGASYS)

AIMS

To evaluate whether higher doses of peginterferon alpha-2a (40KD) [PEG-IFN alpha-2a (40KD)] can compensate for lower exposure observed among obese patients with chronic hepatitis C (CHC) treated with the standard dose of PEG-IFN alpha-2a (40KD).

METHODS

Noncirrhotic, obese (body mass index > or =30 kg m(-2)) patients with CHC participated in a single-centre, open-label study. Patients were randomized to 180 or 270 microg week(-1) PEG-IFN alpha-2a (40KD) + ribavirin (1000/1200 mg day(-1)) for 48 weeks. Blood samples were collected predose and up to 168 h after the first dose and at week 12 for pharmacokinetic analysis. Trough serum concentrations (C(trough)) were determined up to week 24.

RESULTS

In the 180 microg week(-1) group mean +/- SD steady-state (week 12) estimates of AUC(0-168) (ng h(-1) ml(-1)), C(max) (ng ml(-1)) and CL/F (l h(-1)) were 2154 +/- 919, 13.8 +/- 6.7 and 0.102 +/- 0.051, respectively. In the 270 microg week(-1) group, estimates were 3374 +/- 1844, 23.4 +/- 10.7 and 0.090 +/- 0.042, respectively. The mean (range) C(trough) (ng ml(-1)) was 11.2 (4.4-18.5) in the 180 microg week(-1) group and 16.1 (0.4-44.2) in the 270 microg week(-1) group. Overall, 14 of 20 (70%) and 16 of 20 (80%) patients in the 180 microg week(-1) and 270 microg week(-1) groups were infected with hepatitis C virus genotype 1 or 4. In the 180 microg week(-1) and 270 microg week(-1) groups 14 of 20 (70%) and 15 of 19 (79%) patients, respectively, achieved a sustained viral response. Safety was similar between groups.

CONCLUSIONS

Mean PEG-IFN alpha-2a (40KD) exposure was dose proportional from 180 to 270 microg week(-1). Increasing PEG-IFN alpha-2a (40KD) from 180 to 270 microg week(-1) achieves higher serum drug exposure in obese patients.

Predicting the probable outcome of treatment in HCV patients

Hepatitis C virus (HCV) is a major cause of chronic liver disease infecting more than 170 million people worldwide. HCV produces a wide gamut of manifestations varying from mild self-limiting disease to cirrhosis and hepatocellular carcinoma. A variety of viral, environmental and host genetic factors contribute to the clinical spectrum of patients infected with HCV and influence response to interferon (IFN) therapy. Predicting the probable outcome of treatment in patients with HCV infection has always been a challenging task. Treatment of HCV by pegylated interferon (peg-IFN) plus ribavirin eradicates the virus in approximately 60% of patients - HCV genotype 1 (42-51% response rates) and genotypes 2 and 3 (76-84% response rates); however, a significant number of patients do not respond to therapy or relapse following discontinuation of treatment or have significant side effects that preclude further treatment. Accurately predicting the patients who will respond to therapy is becoming increasingly important, both from the point of patient care and also with respect to the healthcare cost as clinicians need to continue treatment in patients who will respond and stop treatment in patients who are unlikely to respond. Viral RNA measurements and genotyping are used to optimize treatment as a low viral load and nongenotype 1 is more likely to be associated with sustained virological response (SVR). Rapid virological response (RVR) defined by undetectable HCV RNA at 4 weeks of treatment is increasingly being recognized as a powerful tool for predicting treatment response. A variety of host factors including single nuclear polymorphisms (SNPs) of IFN response genes, insulin resistance, obesity, ethnicity, human leukocyte antigens and difference in T-cell immune response has been found to modulate the response to antiviral treatment. The presence of severe fibrosis/cirrhosis on pretreatment liver biopsy predicts a poor response to treatment. Recent studies on gene expression profiling and characterization of the liver and serum proteome provide options to accurately predict the outcome of patients infected with HCV in the future. Future studies on the factors that predict treatment response and tailoring treatment based on this is required if we are to conquer this disease.

Long-term outcomes after treatment with interferon and ribavirin in HCV patients

Hepatitis C is a leading indication for transplantation and a common cause of liver-related death worldwide. Treatment for hepatitis C has evolved from interferon therapy alone, which yielded relatively poor response rates compared with the currently recommended and more effective combination of pegylated interferon and ribavirin. Factors such as hepatitis C viral genotype, pretreatment viral load, race, renal function, degree of hepatic fibrosis, and comorbid conditions such as HIV coinfection have clinical importance in that they influence viral kinetics, which play a large role in determining a sustained response to therapy or virologic "cure." However, the goal of therapy is to reduce liver-related morbidity and mortality by decreasing rates of progression or improvement of fibrosis, reducing risk of hepatocellular carcinoma, improving posttransplant graft and patient survival, and resolving or improving some of the extrahepatic manifestations of hepatitis C. Studies generally infer long-term success from the more tangible goal of sustained viral suppression; however, increasing data suggest that effective therapy does result in decreased morbidity and mortality. Given the heterogeneity of patients who are infected with hepatitis C, treatment decisions should be specifically tailored to each individual patient on the basis of their predisposing conditions and anticipated clinical outcomes.

Response to therapy with pegylated interferon and ribavirin for chronic hepatitis C in hispanics compared to non-Hispanic whites

OBJECTIVES

Ethnicity has been shown to play an important role in hepatitis C virus (HCV) treatment response. However, few studies have examined the treatment response of Hispanics to combination therapy with pegylated interferon and ribavirin. The aim of this study was to compare the treatment responses of Hispanics and non-Hispanic whites (NHW) treated with pegylated interferon and ribavirin for chronic HCV.

METHODS

A retrospective review was conducted of all treatment-naive Hispanics and NHW with HCV who were treated at the University of New Mexico Hospital or Albuquerque VA Medical Center between October 2001 and January 2007. Genotype 1 patients received 48 weeks of therapy with pegylated interferon and ribavirin; genotype 2 and 3 patients received 24 weeks of treatment.

RESULTS

A total of 396 patients were included in the analysis, consisting of 179 Hispanics and 217 NHW. Overall, fewer Hispanics completed therapy compared with NHW (64.8% vs. 80.2%, P<0.001). In genotype 1 patients, early virologic response (EVR), end-of-treatment response (ETR), and sustained virologic response (SVR) did not differ significantly between the two ethnic groups. In genotype 2 and 3 patients, Hispanics had similar EVR compared with NHW (81.3% vs. 88.2%, P=0.25), but lower ETR (64.1% vs. 83.1%, P=0.01) and SVR (45.3% vs. 75.3%, P<0.001). After correcting for patients who prematurely discontinued therapy, genotype 2 and 3 Hispanics continued to have a reduced SVR compared with NHW (65.9% vs. 87.3%, P=0.014). The attenuated SVR in Hispanics was because of a higher relapse rate after achieving ETR compared with NHW (25% vs. 7.5%, P=0.02).

CONCLUSIONS

Hispanics with genotype 2 and 3 HCV infection treated with pegylated interferon and ribavirin are less likely to achieve SVR compared with NHW. The lower rate of SVR in Hispanic patients is, in part, because of an increased rate of relapse after ETR.

Management of Hepatitis C virus Genotype 2 or 3 Infection: Treatment Optimization on the Basis of Virological Response

Current guidelines recommend a full 24-week regimen for all patients undergoing treatment for genotype 2 or 3 hepatitis C virus (HCV) infection. Recent data from two large randomized studies, one with pegylated interferon-α2a plus ribavirin (RBV) and one with pegylated interferon-α2b plus RBV assessed treatment duration and on-treatment predictors, such as rapid virological response (RVR; HCV RNA <50 IU/ml at week 4) or sustained virological response rates. Overall, these studies have shown that abbreviated regimens are generally less effective than standard 24-week regimens in genotype 2 or 3 patients because of a higher rate of relapse. However, abbreviated treatment might be offered to selected patients with an RVR provided that they have a low baseline viral load and minimal hepatic fibrosis.

Ethnic variations in chronic liver diseases

Chronic liver disease is a major source of morbidity and mortality in the United States today. There is little information on the interethnic variation in the clinical presentation, therapeutic responses and prognosis of individuals with liver disease. This review will discuss the ethnic variations and implications of the most common liver diseases.

The impact of race on liver transplant outcomes in the MELD era: still more questions than answers

Liver transplantation is a life-saving therapy for patients with end-stage liver disease (ESLD); however, donor livers are scarce. Several studies have demonstrated racial disparities in access to liver transplant as well as patient and graft survival after liver transplantation. These studies used data gathered before the model for end-stage liver disease (MELD) was used to determine priority for liver transplant. In this issue of the journal, Drs. Ananthakrishnan and Saeian examine survival after transplant in the MELD era by race and ethnicity, and show that the racial disparities in posttransplant outcomes persist despite MELD. This study provides further evidence that race, which is likely a proxy for a variety of biological and sociological factors, must be considered in any prognostic model for liver transplantation. The impact of race on liver transplantation outcomes should be evaluated further in a well-designed, multicentered, prospective study.

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.