Virological characterization and liver histology in HCV positive subjects with normal and elevated ALT levels

Significance of Serum Alpha-Glutathione S-Transferase Assessment in Hepatitis C Patients with Different Alanine Aminotransferase Patterns

BACKGROUND

Alpha-Glutathione S-transferase (α-GST) is a liver enzyme which showed properties making it useful in assessment of liver cell damage. A number of studies demonstrated its early elevation in different hepatic insults, but its pattern in HCV was controversial. Consequently, we planned this work to study the significance of Serum Alpha-Glutathione S-Transferase (α-GST) assessment in hepatitis C patients with different alanine aminotransferase (ALT) patterns.

METHODS

Sixty-five untreated male patients with history of hepatitis C virus (HCV) positive antibodies and 21 healthy age- and sex-matched control subjects were enrolled in this study. Sera were collected for confirmation of the presence of HCV antibodies (by ELISA) as well as for assessment of the levels of α-GST, ALT, aspartate aminotransferase, alkaline phosphatase, gamma glutamyl-transferase, total proteins, albumin and HCV RNA. HCV RNA was detected by the reverse transcription polymerase chain reaction (RT-PCR). Based on ALT level, patients were divided into three groups. Twelve patients with normal ALT levels (NALT), 29 with near normal ALT levels (NNALT), and 24 with high ALT levels (HALT). All data were statistically analyzed for significance and correlation as well as sensitivity, specificity, positive and negative predictive values.

RESULTS

The mean value of α-GST in HCV patients was significantly higher compared to the control with 82% sensitivity, 85% specificity, 98% positive predictive value and 63% negative predictive value. These results were more or less similar to the results of ALT and higher than the results of all the other assayed liver function tests. The sensitivity, and positive and negative predictive values of α-GST were lower than aminotransferases, but higher than the other assayed liver function tests in NNALT and HALT groups. Nevertheless, in NALT, these parameters were higher for α-GST than all the other assayed liver function tests including aminotransferases.

CONCLUSIONS

Assay of α-GST has an adjuvant in evaluation of liver cell damage in HCV patients. However, its role is much more valuable in patients with normal aminotransferases for early detection of liver cell damage.

Review article: management of patients with chronic hepatitis C virus infection and "normal" alanine aminotransferase activity

BACKGROUND

Hepatitis C virus infection, a major cause of chronic liver disease, occurs with normal serum alanine aminotransferase activity in approximately 25% of patients. These patients have historically remained untreated but substantial evidence indicates liver damage, progression of disease and impaired quality of life in some individuals.

AIM

To review the current management of patients with chronic hepatitis C and normal alanine aminotransferase activity.

METHODS

This review represents the summary of discussions at a Clinical Workshop with a comprehensive literature searching of available databases (PubMed and Embase).

RESULTS

Current limits defining normal serum alanine aminotransferase activity are not representative of a "healthy" status. Most patients with hepatitis C and normal alanine aminotransferase levels have histologically proven liver damage that, although generally mild, may be significant (> or =F2) in up to 20% of patients and progresses at approximately 50% of the rate in patients with elevated alanine aminotransferase levels. Some patients have persistently normal alanine aminotransferase activity and may have a more benign outcome, but a significant proportion (> or =20%) experience periods of increased serum alanine aminotransferase activity which may be associated with enhanced disease progression.

CONCLUSIONS

A treatment approach that considers host and virus-related variables and optimizes patient and cost benefits may therefore provide more effective management of patients with chronic hepatitis C and normal alanine aminotransferase activity.

Evaluation of The Federal Bureau of Prisons protocol for selection of which hepatitis C-infected inmates are considered for treatment

The Federal Bureau of Prisons limits hepatitis C therapy to those inmates with certain biochemical abnormalities. To evaluate this protocol, an analysis was done on data collected on hepatitis C infected inmates in the Louisiana Department of Corrections. A quality assurance database of hepatitis C infected inmates evaluated in the Louisiana Department of Corrections was reviewed for liver biopsy and laboratory results. Patients were compared as to whether they would have been biopsied under the Federal Bureau of Prisons protocol and if there were histologic differences between those who would and those who would not have been biopsied. Of 490 inmates biopsied, 26% (129) had an alanine aminotransferase level between one and two times the upper limit of normal without other biochemical abnormalities. If treating stages 2-4, 48% of these would qualify for treatment (15% if treating stages 3-4). There was no statistical difference between this group and either the group with an alanine aminotransferase level between one and two times the upper limit of normal and with other laboratory abnormalities or the group with an alanine aminotransferase level greater than or equal to two times the upper limit of normal and without other abnormalities. In the Louisiana Department of Corrections, the Federal Bureau of Prisons protocol was neither sensitive nor specific enough at identifying those that should be considered for hepatitis C therapy.

Correlation of serum aminotransferases with HCV RNA levels and histological findings in patients with chronic hepatitis C: the role of serum aspartate transaminase in the evaluation of disease progression

OBJECTIVES

To investigate whether HCV RNA levels can be considered to be predictors of hepatocellular injury in patients with chronic hepatitis C, and whether aminotransferase levels are markers of liver damage.

METHODS

We performed a retrospective study on 112 patients with chronic hepatitis C. For each patient, we considered the baseline alanine aminotransferase (ALT) and serum aspartate transaminase (AST) levels, baseline HCV RNA, HCV genotype, histological evaluation and the mean aminotransferase levels measured in the 6 months following liver biopsy.

RESULTS

We found a statistically significant correlation between HCV RNA and aminotransferase levels measured during the follow-up (AST: r = 0.24, P = 0.01; ALT: r = 0.27, P = 0.004). We also observed a statistically significant correlation between HCV RNA levels and histological activity index (HAI) (r = 0.25, P = 0.008), as well as between the HAI and both baseline AST (r = 0.34, P = 0.0002) and ALT levels (r = 0.23, P = 0.01). These findings were confirmed by the mean aminotransferase values during follow-up. In the regression analysis, the fibrosis score was significantly and independently associated with baseline AST and ALT values.

CONCLUSIONS

Our results demonstrate a statistically significant correlation of aminotransferase values with the histological parameters, and an even stronger correlation with the AST values. Our study therefore suggests that aminotransferase values, especially AST, may correlate with liver damage.

The role of liver biopsy in chronic hepatitis C

The report of the 1997 National Institutes of Health Consensus Development Conference on hepatitis C endorsed pretreatment liver biopsy. We revisit the following questions: Does liver histology help determine the urgency of, and predict the likelihood of response to, antiviral therapy, and can surrogate markers supplant histological assessment? Because the rate of progression of chronic hepatitis C is influenced by baseline histological grade/stage, patients can be stratified into those with moderate to severe hepatitis, who merit imminent therapy, and those with mild hepatitis, in whom therapy can be postponed until more effective/tolerable treatments become available. Less advanced baseline histology has been shown to be an independent predictor of responsiveness to antiviral therapy. Although the predictive value of biopsy is insufficient to withhold therapy from patients with advanced fibrosis, baseline biopsy helps gauge expectations for the outcome of therapy. Reports have been published recently suggesting that laboratory markers can predict distinctions between low-grade fibrosis and therapy-indicating septal fibrosis/cirrhosis. These indices, however, are insufficiently reliable to predict histological distinctions in populations with varying prevalences of fibrosis/cirrhosis or to provide anything more than broad qualitative distinctions, far short of the potential information in a liver biopsy. For most patients, the value of pretreatment liver biopsy outweighs its risks, provides information about the urgency of treatment, and should be retained. Studies to identify noninvasive laboratory markers of histological activity and stage, especially genetic predictors of accelerated disease progression, command a high priority.

The role of liver biopsy in chronic hepatitis C

The report of the 1997 National Institutes of Health Consensus Development Conference on hepatitis C endorsed pretreatment liver biopsy. We revisit the following questions: Does liver histology help determine the urgency of, and predict the likelihood of response to, antiviral therapy, and can surrogate markers supplant histological assessment? Because the rate of progression of chronic hepatitis C is influenced by baseline histological grade/stage, patients can be stratified into those with moderate to severe hepatitis, who merit imminent therapy, and those with mild hepatitis, in whom therapy can be postponed until more effective/tolerable treatments become available. Less advanced baseline histology has been shown to be an independent predictor of responsiveness to antiviral therapy. Although the predictive value of biopsy is insufficient to withhold therapy from patients with advanced fibrosis, baseline biopsy helps gauge expectations for the outcome of therapy. Reports have been published recently suggesting that laboratory markers can predict distinctions between low-grade fibrosis and therapy-indicating septal fibrosis/cirrhosis. These indices, however, are insufficiently reliable to predict histological distinctions in populations with varying prevalences of fibrosis/cirrhosis or to provide anything more than broad qualitative distinctions, far short of the potential information in a liver biopsy. For most patients, the value of pretreatment liver biopsy outweighs its risks, provides information about the urgency of treatment, and should be retained. Studies to identify noninvasive laboratory markers of histological activity and stage, especially genetic predictors of accelerated disease progression, command a high priority.

Factors associated with severity of hepatic fibrosis in people with chronic hepatitis C infection

OBJECTIVE

To determine factors associated with hepatic fibrosis development in people with chronic hepatitis C virus (HCV) infection.

METHODS

As a requirement for access to interferon therapy through the S100 scheme in Australia, individual pretreatment demographic and clinical information was collected on 2986 patients from 61 hospital-based liver clinics from 1 October 1994 through 31 December 1996. Patients with both a hepatic fibrosis score and an estimated duration of HCV infection (910) were divided into 540 with no or minimal hepatic fibrosis (stage 0-1) and 370 with moderate to severe hepatic fibrosis (stage 2-3). Seven factors were examined: age at HCV infection, sex, ethnicity, source of infection, duration of infection, alcohol intake, and mean ALT level. A further analysis was performed for all 1135 patients with a hepatic fibrosis score disregarding age at and duration of HCV infection.

RESULTS

In multivariate analysis, four factors were significantly associated with moderate to severe hepatic fibrosis: age at infection (OR, 2.33 for age 31-40 years, 5.27 for age > 40 years, and 0.20 for age < 15 years, compared with 15-20 years); duration of infection (OR, 1.44 for 11-20 years, 2.74 for 21-30 years, and 8.71 for > 30 years, compared with < 11 years); alcohol intake in previous six months (OR, 1.51 for any intake, compared with none); and mean ALT level (OR, 1.81 for 2-3 times, 2.27 for > 3 times, compared with 1.5-2 times the upper limit of normal). In the analysis disregarding age at HCV infection and duration of HCV infection, older age was strongly associated with moderate to severe hepatic fibrosis (OR, 2.32 for age 36-40 years, 2.46 for age 41-50 years, 7.87 for age 51-60 years, and 7.15 for age > 60 years, compared with 16-30 years). There was no association in either analysis with sex or source of HCV infection.

CONCLUSION

These factors may assist in targeting patients for both liver biopsy-based investigation and therapeutic intervention.

Characteristics of hepatitis C virus infection in HIV-infected people

Knowledge pertaining to hepatitis C virus (HCV)/human immunodeficiency virus (HIV) co-infection is currently incomplete or conflicting. Several points are well studied, however. Plasma HCV RNA levels are higher in matched HIV-infected people than in HIV-seronegative control subjects and are inversely correlated with CD4(+) T lymphocyte counts. HCV genotype does not appear to influence this value. Co-infected individuals develop histological and clinical features of HCV liver disease more rapidly than HIV-seronegative patients. Co-infected individuals appear to respond to interferon-alpha therapy equally as well as HIV-seronegative HCV-infected adults, but minimal information exists regarding the efficacy and toxicity of combination HCV therapy (interferon-alpha plus ribavirin) in this population. Adverse consequences of highly active antiretroviral therapy in co-infected patients include hepatic toxicity and, in a minority of patients, an 'immune restoration syndrome'. It is unclear whether long term, highly active antiretroviral therapy positively or negatively influences the natural history of HCV infection.

[Why are not all patients with chronic liver disease associated with hepatitis C virus treated?]

AIMS

To analyze the prevalence of patients with chronic liver disease associated with hepatitis C virus (HCV) not undergoing antiviral treatment and the reasons for which this treatment was not indicated.

PATIENTS AND METHODS

718 patients with HCV infection referred for therapeutic evaluation between January 1990 and January 1998. Demographic, clinical, biological and histological variables were prospectively analyzed. The patients were divided into two groups: treated and untreated.

RESULTS

393 patients were treated and in 325 patients antiviral treatment was not considered to be indicated. The most frequent reasons for not starting therapy were advanced age, the presence of decompensated cirrhosis and the patients' refusal to undergo antiviral treatment.

CONCLUSIONS

A broad subgroup of patients with chronic liver disease associated with HCV do not receive antiviral treatment. This is related with: a) patients' advanced age at diagnosis, b) diagnosis at the advanced stages of the disease, and c) patients' refusal to undergo such treatment after being informed of its potential risks and benefits.

Hepatitis C virus carriers with persistently normal aminotransferase levels: healthy people or true patients?

Since the discovery of hepatitis C virus, the availability of serological hepatitis C virus screening has led to the identification of many subjects with normal aminotransferase levels who are chronically infected by the hepatitis C virus. To date, the epidemiology and natural history of subjects with normal aminotransferase levels are far from being clarified. Further, whether subjects with persistently normal aminotransferase levels should routinely undergo liver biopsy is still extremely controversial, and benefit from interferon treatment in this group of patients is yet to be proven. On account of the consistent normality of aminotransferases, it is not easy to calculate the rate of persons with normal aminotransferase levels among chronic hepatitis C virus carriers, nor their prevalence in the general population. It has been estimated that up to 25% of patients with chronic hepatitis C virus infection have persistently normal aminotransferase levels (10% to 40%, according to different studies). Most studies showed a clear prevalence of females, ranging from 58% to 90%. Liver biopsy shows some degree of chronic liver disease in up to 80% of these subjects, although in the majority, histological damage is mild and probably does not progress to more severe liver disease, moreover, the progression to fibrosis is slower than in patients with elevated aminotransferase levels. Virological features of these subjects (hepatitis C virus genotype distribution, viral load, quasispecies diversity) do not differ with respect to patients with elevated aminotransferase levels although a higher frequency of non 1 hepatitis C virus types has been reported. To date, no biochemical or virological tools to assess the presence and severity of liver damage exist. Antiviral treatment with interferon may induce a long-term response in only a small proportion of hepatitis C virus carriers with persistently normal aminotransferase levels, and many patients develop aminotransferase-flare-up during or shortly after treatment. Thus, interferon or combination antiviral treatment of hepatitis C virus carriers with normal aminotransferase values should be avoided in clinical practice.

Utility of alpha-glutathione S-transferase assessment in chronic hepatitis C patients with near normal alanine aminotransferase levels

OBJECTIVES

To study whether determining alpha-glutathione S-transferase (alpha-GST) might improve the assessment of chronic hepatitis C (CHC) patients with near normal alanine aminotransferase levels (NNA).

DESIGN AND METHODS

We studied 119 viraemic CHC patients. They were subdivided into two groups according to the pattern of alanine aminotransferase (ALT) alteration, i.e. consistently above (HA) or below (NNA) twice the upper normal value. In these patients we assessed alpha-GST and correlated its levels to clinical, histological, and virological findings, further evaluating whether alpha-GST might improve the assessment of CHC patients with NNA.

RESULTS

alpha-GST showed a significant correlation with aminotransferases, though not with histological necroinflammatory activity and fibrosis or with hepatitis C virus RNA levels. Twenty-seven patients had NNA (23%), and within this subgroup of patients alpha-GST identified a subset of patients with a higher viral load.

CONCLUSIONS

alpha-GST in CHC patients is related to hepatocellular necrosis parameters, but unrelated both to histology and to viraemia. However, in patients with NNA, alpha-GST identified a subgroup of patients with a higher viral load. In this subgroup of patients alpha-GST alteration likely represents the expression of a more severe damage. Because this injury is not detectable by the usual biochemical or histological work-up, we suggest that alpha-GST could a useful tool for monitoring liver damage over time.

Hepatitis C: the clinical spectrum of the disease

The hepatitis C virus (HCV) infects nearly 170 million people worldwide and is responsible for approximately 20% of cases of acute hepatitis and 70% of cases of chronic hepatitis. Acute hepatitis is icteric in only 20% of patients and is rarely severe. Eighty-five percent of infected patients develop chronic infection which is generally asymptomatic, resulting in most cases in fortuitous diagnosis, which may be made at a late stage. Twenty-five percent of the HCV chronic carriers have persistently normal serum alanine aminotransferase (ALT) levels despite having detectable HCV RNA in serum; 75% have elevated ALT levels. The former patients usually have mild histologic lesions, probably with a good long-term prognosis. In the latter patients, a liver biopsy is the most accurate way to distinguish patients with mild chronic hepatitis from those with moderate or severe chronic hepatitis. While most patients with mild chronic hepatitis have a slowly progressive liver disease, the patients with moderate or severe chronic hepatitis may develop cirrhosis within a few years. In patients with HCV-related cirrhosis, the incidence of hepatocellular carcinoma is 2-5% per year. At presently, HCV-related end-stage cirrhosis is the first cause of liver transplantation.

Clinical significance of hepatitis C virus genotypes

The advent of genotyping assays has stimulated investigators around the world to study the molecular epidemiology of hepatitis C virus (HCV) infection in specific patient categories, as well as possible correlations with the clinical and histological features of chronic liver disease and response to antiviral treatment. While a general consensus has been reached on the worldwide epidemiology and distribution of HCV types in certain risk categories (i.e. intravenous drug users), the association between genotype 1b and severe liver disease is still controversial. Although generalized use of genotyping is not presently recommended for clinical or epidemiological monitoring, several studies emphasize to the importance of HCV genotyping as part of a therapeutic algorithm. This recommendation is based on overwhelming evidence in support of a correlation between genotype 1 and a poor response to interferon-a alone or in combination with ribavirin.

Treatment of hepatitis C patients with normal aminotransferases levels

An important subset of patients with chronic hepatitis C have normal ALT levels despite having detectable HCV RNA in serum. These patients are typically identified after donating blood and being found positive for antibody to HCV (anti-HCV). A strict definition of this patient population is needed, which should include the presence of anti-HCV, detectable HCV RNA by PCR and persistently normal ALT levels. These patients are usually asymptomatic, but on liver biopsy almost all have histologic evidence of chronic hepatitis. The histologic findings generally are mild, and cirrhosis is rare. The long-term outcome of this group of patients with chronic HCV infection is not known, but the prognosis is probably good. In small, uncontrolled trials of IFN-alpha in patients with normal ALT levels, end-of-treatment virologic responses occurred in 42% of patients, and sustained responses 6 to 12 months afterwards in 13% of patients. These rates of response are not very different from those reported in patients with elevated ALT levels. Importantly, in most studies, serum ALT levels became elevated during IFN therapy in approximately one half of patients, and levels remained elevated in some of these patients after therapy. These findings suggest that IFN-alpha therapy is not usually beneficial and may be harmful in chronic hepatitis C patients with normal ALT levels. Combination therapy with IFN and ribavirin has not been evaluated in this group of patients.

Serum HCV RNA titer does not predict the severity of liver damage in HCV carriers with normal aminotransferase levels

AIMS/BACKGROUND

Many HCV RNA positive subjects with normal aminotransferase levels have significant liver damage despite normal liver biochemistry. In these patients it is not possible to discriminate between "healthy" carriers and subjects with chronic liver damage, unless liver biopsy is performed. The aim of this study was to evaluate the usefulness of HCV RNA quantitation as a non invasive tool to predict the severity of liver injury in a group of HCV carriers with normal amino-transferase levels.

METHODS

59 HCV RNA positive subjects (20 males) with persistently normal ALT levels were studied. All patients underwent HCV RNA quantitation and percutaneous liver biopsy.

RESULTS

No correlation was found between serum HCV RNA titers and grading, while viraemia did correlate with staging. Patients were categorized into four subgroups, according to arbitrary serum HCV RNA cut-offs. Grading was not different between the four groups. Staging was significantly higher among subjects with viraemia > 1000 x 10(3) copies/mL than in patients with HCV RNA titers < 1000 x 10(3) copies/mL.

CONCLUSIONS

In HCV carriers with normal aminotransferase levels viraemia does not predict the grade of HCV-related chronic liver disease (CLD), although subjects with higher HCV RNA levels seem to have more severe fibrosis. Although these data suggest that patients with higher viraemia might have more intense architectural changes and more severe progression of liver disease than those with lower levels of HCV replication, the weak and imprecise correlation leads us to conclude that HCV RNA quantitation is not a useful indicator in clinical practice in the selection of patients for liver biopsy.

Clinical evaluation and applications of the Amplicor HBV Monitor test, a quantitative HBV DNA PCR assay

Viral load has emerged recently as a reliable marker of disease progression and therapeutic efficacy in chronic infections, including AIDS and hepatitis C. The clinical management of type B hepatitis could also be improved by monitoring viremia levels in patients with chronic liver disease undergoing anti-viral treatment. To address this question we evaluated the performance of a newly developed, quantitative PCR assay (Amplicor HBV Monitor test, Roche Diagnostic Systems) in the assessment of viremia changes over time in a group of 45 patients with chronic active hepatitis (CAH) who received interferon treatment. Of the 45 patients, 14 were HBsAg and anti-HBeAg positive and 31 HBsAg, HBeAg positive. Follow-up extended up to 24 months. An average of ten samples per patient were analyzed for levels of ALT, IgM anti-HBc (Abbott Laboratories), HBV DNA by in-house dot-blot hybridization and hybridization-capture assays (HBV-DNA hybrid capture kit, Murex Diagnostics) and by Amplicor HBV Monitor. A sustained biochemical response was observed at the end of treatment in 12 HBeAg-positive and in seven anti-HBeAg positive patients. This was accompanied by the disappearance of HBeAg and of HBV DNA (hybridization assays) in all cases and by the clearance of IgM anti-HBc in 70% of the cases. Viremia (quantitative PCR assay) became undetectable only in 25-30% of cases and was associated with the loss of HBsAg. A good correlation was observed between the time course of IgM anti-HBc, quantitative PCR and dot-blot hybridization although the latter missed 33% of viremic samples. Together, these results indicate that the Amplicor HBV Monitor test is a robust and standardized assay for quantifying HBV viremia levels in the range from 10(2) to 10(7) copies/ml. Compared to other current markers, viral load may provide additional clinical information by predicting long term virologic response and HBsAg clearance in patients with normal ALT at the end of interferon therapy.