B Schlosser

Viscoelasticity-based Staging of Hepatic Fibrosis with Multifrequency MR Elastography

PURPOSE To analyze the dynamics of the shear modulus of the liver to assess the optimal driving frequency and to determine the diagnostic accuracy of generalized frequency-independent elasticity cutoff values for staging hepatic fibrosis. MATERIALS AND METHODS This institutional review board-approved prospective study included 16 healthy volunteers and 72 patients with biopsy-proved liver fibrosis. After obtaining written informed consent, imaging was performed at 1.5-T by using a motion-sensitized echo-planar imaging sequence. Wave excitation was performed by an actuator introducing a superposition of four frequencies (25.0, 37.5, 50.0, 62.5 Hz) of shear waves. The elasticity µ value and the structure geometry parameter α were calculated by using the two-parameter springpot model. The performance of magnetic resonance (MR) elastography in staging liver fibrosis was assessed with area under the receiver operating characteristic curve (AUROC) analysis and Spearman correlation analysis. RESULTS Elasticity increased with stage of fibrosis, with mean values as follows: for volunteers, 2.25 kPa ± 0.43 (standard deviation); stage F1, 2.61 kPa ± 0.43; stage F2, 3.00 kPa ± 0.63; stage F3, 3.86 kPa ± 0.61; and stage F4, 5.86 kPa ± 1.22. Frequency-independent cutoff values derived for fibrosis and AUROC values, respectively, were as follows: stage F1 or higher, 2.84 kPa and 0.9128; stage F2 or higher, 3.18 kPa and 0.9244; stage F3 or higher, 3.32 kPa and 0.9744; and equivalent to stage F4, 4.21 kPa and 0.9931. The geometry of the tissue (α value) did not correlate with fibrosis. Frequencies of 50.0 Hz and 62.5 Hz displayed the highest diagnostic accuracy. CONCLUSION The diagnostic performance of multifrequency MR elastography in determining the degree of hepatic fibrosis increases with stage of fibrosis. Metrics obtained at the higher frequencies provide better diagnostic performance compared with the lower frequencies. Results of the AUROC analysis demonstrate the high accuracy of frequency-independent cutoff values for staging higher grades of hepatic fibrosis.

Isoforms of Retinol binding protein 4 (RBP4) are increased in chronic diseases of the kidney but not of the liver

BackgroundThe levels of retinol-binding protein 4 (RBP4) – the carrier protein for Vitamin A in plasma – are tightly regulated under healthy circumstances. The kidney, the main site of RBP4 catabolism, contributes to an elevation of RBP4 levels during chronic kidney disease (CKD) whereas during chronic liver disease (CLD) RBP4 levels decrease. Little is known about RBP4 isoforms including apo-RBP4, holo-RBP4 as well as RBP4 truncated at the C-terminus (RBP4-L and RBP4-LL) except that RBP4 isoforms have been reported to be increased in hemodialysis patients. Since it is not known whether CLD influence RBP4 isoforms, we investigated RBP4 levels, apo- and holo-RBP4 as well as RBP4-L and RBP4-LL in plasma of 36 patients suffering from CKD, in 55 CLD patients and in 50 control subjects. RBP4 was determined by ELISA and apo- and holo-RBP4 by native polyacrylamide gel electrophoresis (PAGE). RBP4-L and RBP4-LL were analyzed after immunoprecipitation by mass spectrometry (MALDI-TOF-MS).ResultsRBP4 isoforms and levels were highly increased in CKD patients compared to controls (P < 0.05) whereas in CLD patients RBP4 isoforms were not different from controls. In addition, in hepatic dysfunction RBP4 levels were decreased whereas the amount of isoforms was not affected.ConclusionThe occurrence of RBP4 isoforms is not influenced by liver function but seems to be strongly related to kidney function and may therefore be important in investigating kidney function and related disorders.

High Prevalence of Anti-HCV Antibodies in Two Metropolitan Emergency Departments in Germany: A Prospective Screening Analysis of 28,809 Patients

Background and Aims The prevalence of hepatitis C virus (HCV) antibodies in Germany has been estimated to be in the range of 0.4–0.63%. Screening for HCV is recommended in patients with elevated ALT levels or significant risk factors for HCV transmission only. However, 15–30% of patients report no risk factors and ALT levels can be normal in up to 20–30% of patients with chronic HCV infection. The aim of this study was to assess the HCV seroprevalence in patients visiting two tertiary care emergency departments in Berlin and Frankfurt, respectively. Methods Between May 2008 and March 2010, a total of 28,809 consecutive patients were screened for the presence of anti-HCV antibodies. Anti-HCV positive sera were subsequently tested for HCV-RNA. Results The overall HCV seroprevalence was 2.6% (95% CI: 2.4–2.8; 2.4% in Berlin and 3.5% in Frankfurt). HCV-RNA was detectable in 68% of anti-HCV positive cases. Thus, the prevalence of chronic HCV infection in the overall study population was 1.6% (95% CI 1.5–1.8). The most commonly reported risk factor was former/current injection drug use (IDU; 31.2%) and those with IDU as the main risk factor were significantly younger than patients without IDU (p<0.001) and the male-to-female ratio was 72% (121 vs. 46 patients; p<0.001). Finally, 18.8% of contacted HCV-RNA positive patients had not been diagnosed previously. Conclusions The HCV seroprevalence was more than four times higher compared to current estimates and almost one fifth of contacted HCV-RNA positive patients had not been diagnosed previously.

Soluble urokinase plasminogen activator receptor is associated with progressive liver fibrosis in hepatitis C infection.

Background: Progressive liver fibrosis is the main predictor of disease outcome in chronic hepatitis C viral (HCV) infection. Although the importance of the coagulation cascade has been suggested in liver fibrogenesis, the role of the fibrinolytic pathway is yet unclear. Goal: We evaluated the association of serum levels of the fibrinolysis-associated soluble urokinase plasminogen activator receptor (suPAR) with the severity of liver fibrosis in HCV infection. Study: suPAR serum levels were assessed in 146 chronically HCV-infected patients of 2 independent cohorts (64 subjects in the screening cohort, 82 in the validation cohort) by enzyme-linked immunosorbent assay and correlated with biopsy-proven histologic stage of liver fibrosis and noninvasive liver fibrosis markers (aspartate transaminase to platelets ratio index score, transient elastography). Results: suPAR serum levels were strongly associated with the histologic stage of liver fibrosis in both cohorts (P<0.0001). Although mean suPAR levels in patients with F1 and F2 fibrosis were not different from healthy control subjects, they were significantly increased at higher stages of liver fibrosis (F3 and F4, P<0.0001). suPAR values had a high diagnostic specificity and sensitivity to differentiate mild/moderate fibrosis (F1/F2) from severe fibrosis (F3/F4) with an area under curve of 0.774 (P=0.0001) and for the differentiation of noncirrhosis from cirrhosis (F1/F2/F3 vs. F4, area under curve 0.791, P=0.0001). SuPAR serum levels were also strongly correlated to the noninvasive fibrosis markers aspartate transaminase to platelets ratio index score (r=0.52) and transient elastography (r=0.44, both P<0.0001). Conclusions: Serum suPAR levels were robust markers of liver fibrosis in 2 cohorts with a comparable diagnostic accuracy for prediction of severe liver fibrosis as established noninvasive marker.

High-dose silibinin rescue treatment for HCV-infected patients showing suboptimal virologic response to standard combination therapy.

Summary.  Incomplete suppression of hepatitis C virus (HCV) replication with persistence of minimal viremia (partial virologic response) leading to treatment failure can be observed in a significant proportion of HCV type 1‐infected patients during antiviral therapy. Recently, high‐dose intravenous silibinin has demonstrated strong antiviral activity against HCV. We were therefore interested in whether patients with partial virologic response can be rescued by the on‐treatment addition of a short‐term course of high‐dose intravenous silibinin infusions. Twenty patients who failed to achieve a complete virologic response to different interferon‐based regimens qualified for the rescue strategy and received 1400 mg/day silibinin infusions on two consecutive days. Complete viral suppression (below the limit of detection <6 IU/mL, TMA assay) could be induced in 13 of 20 patients within the first week after the short‐term silibinin infusion, and all but one of them also remained HCV RNA negative during the subsequent follow‐up period on continued peginterferon plus ribavirin treatment. In the remaining seven patients, no complete suppression could be achieved although four showed a significant HCV RNA reduction in response to silibinin. Silibinin infusions were generally well tolerated, and activation of abdominal peristalsis with nausea, diarrhoea and vomiting were the most prominent side effects. Of the twelve patients who exhibited a durable response to peginterferon and ribavirin treatment, three achieved an SVR, two achieved a week 12 SVR and four suffered a viral relapse. Three patients could not complete the assigned antiviral treatment with peginterferon alpha and ribavirin for nonvirological reasons. Short‐term administration of high‐dose intravenous silibinin might be an interesting approach to rescue patients with ongoing minimal residual viremia while on interferon‐based therapy. These preliminary findings may stimulate further studies to evaluate more refined therapeutic strategies.

Bezafibrate maintenance therapy in patients with advanced chronic hepatitis C.

Background Bezafibrate exerts multiple effects on lipid metabolism by activating the peroxisome proliferator-activated receptor-&agr;, which modulates the expression of key genes of lipid transport, lipoprotein metabolism as well as inflammation. The aim of the present study was to assess the efficacy and safety of bezafibrate in patients with advanced chronic hepatitis C. Materials and methods A total of 34 patients received oral bezafibrate treatment (400 mg/day) on the basis of a prospective observational open-label study design. Clinical, biochemical and virological data were evaluated during a mean treatment duration of 19 months. In a subpopulation (n=8), cytokine expression analysis was carried out and compared with an hepatitis C virus treatment-naive control group (n=7). Results A significant improvement in aspartate aminotransferase (P=0.007), alanine aminotransferase (P<0.0001), alkaline phosphatase (P=0.001), &ggr;-glutamyltranspeptidase levels (P=0.001) and aspartate aminotransferase-to-platelets ratio index Score (P=0.026) could be found at the end of observation. No significant effect on viral load was observed. Bezafibrate treatment for at least 4 months markedly increased interferon-&ggr; expression compared with the treatment-naive patients (4.81 vs. 1.63 arbitrary units; P=0.005), whereas tumour necrosis factor-&agr; and interleukin-6 levels were not significantly influenced. Conclusion This observational study provides evidence that bezafibrate is effective for patients with advanced chronic hepatitis C by reducing liver enzymes significantly and should be further evaluated as a potentially beneficial maintenance therapy.

A Preliminary Study on the Relationship between Platelet Serotonin Transporter Functionality, Depression, and Fatigue in Patients with Untreated Chronic Hepatitis C

Objective and Methods. Although the interaction between fatigue and depression in patients with chronic hepatitis C infection (HCV) has been recognized, the biological correlates of this observation have yet to be reported. We addressed this issue by examining serotonin transporter- (SERT-) driven [14C]-serotonin uptake rate (SUR) and serotonin content in platelets of 65 untreated HCV patients and 65 healthy control subjects (HCS). All patients completed report questionnaires for fatigue, depression, and general psychopathology. Structured interviews were conducted by a board-certified psychiatrist. Results. Whereas 36 of the patients experienced fatigue of moderate-to-severe intensity, only 16 reported symptoms of depression (BDI score > 10). Mean SUR in patients with depressive symptoms was significantly higher relative to the HCS, corresponding to a large Cohens effect size of d = 1.45 (95% CI = 0.66—1.83). Patients who rated their fatigue to have a marked impact on mood and activity displayed a moderate relationship between the BDI score and SUR (n = 18, r = 0.563, P = 0.015), which becomes stronger after controlling for age, gender, and thrombocytopenia (r part = 0.710, P = 0.003). In the univariate analysis, high fatigue interference score, thrombocytopenia, and high SUR were all significant predictors of depression. Conclusions. High SERT activity could be implicated in the expression of depressive symptoms especially in a subgroup of HCV patients who are feeling fatigue as markedly distressing.

Long-term evaluation of patients with sustained virologic remission by highly sensitive HCV RNA assays: no evidence for viral persistence.

The induction of a sustained virologic response (SVR) in hepatitis virus (HCV) infected patients, defined as undetectable serum HCV NA levels 6 months after stopping therapy, is believed to herald he determination of the chronic HCV infection.1,2 However, recent ndings suggest that residual HCV RNA can persist in PBMC, lymhatic or liver tissue3–5 indicating that minimal residual hepatitis viremia can escape standard HCV RNA assays.6 Now Fytili et al. eported in this Journal that, minimal residual HCV RNA can be etected in more than 20% of SVR patients when serum samples ere tested with a highly sensitive RealTime PCR assay (Abbott, 2000 RealTime PCR).7 To further substantiate these findings, we re-evaluated 160 erum samples of 145 SVR patients with two different highly senitive HCV RNA assays, the Abbott RealTime PCR (m2000rt) system nd the Siemens Versant TMA® assay. Two different RNA extraction ethods were applied for the RealTime PCR assay: the manual RNA xtraction method was used in 97 patients while the automated ersion was employed in 63 patients. Median time after EOT was .1 years (range: 0.5–12 y). By using the TMA assay, only one sample out of 160 was found to e HCV-RNA positive (0.6%). In contrast, in 10% (n = 16) of the SVR atients HCV RNA was detectable by the RealTime PCR. 14 out of hese 16 positive samples have been treated by the manual extracion method (14.5% of those analysed manually, 9% of all), whereas CV RNA could be detected only in 2 out of 63 patients (3.2%, 1.4% of ll) when the fully automated version of the assay was applied. All ut one of the HCV RNA positive samples had levels below the limit f quantification of the assay (i.e. <12 IU/mL) see Fig. 1. But most mportantly, in none of the patient the positive HCV RNA result ould be confirmed by the TMA assay or vice versa. These findings ould be also confirmed by testing a second serum sample from a ifferent time point in 8 out of the 16 HCV RNA positive patients. oth assays, the TMA and the fully automated RealTime PCR test ave negative results. Thus our study contradicts Fytili’s conclusion and rather indiates that positive HCV RNA signals detectable by RealTime PCR re due to either unspecific amplification or contamination. This nterpretation is strengthens by our finding that the ratio of HCV NA positive samples by real time PCR was significantly higher hen using the manual extraction (14.5%) as compared to the fully utomated system (3%). We argue that most probably false posi-

259 ANTIVIRAL EFFICACY OF RIBAVIRIN MONOTHERAPY FOLLOWED BY STANDARD COMBINATION TREATMENT IN CHRONIC HEPATITIS C

(IP-10 or CXCL10) level might be a predictive factor for sustained virological response (SVR) to pegylated IFN plus ribavirin (PegIFN/RBV) therapy in patients infected with hepatitis C virus (HCV) genotype 1. We aimed to evaluate association of pretreatment and during treatment serum IP-10 levels with virological response to PegIFN/RBV therapy in genotype 1-infected Japanese patients with chronic hepatitis C (CHC). Methods: A total of 110 patients treated with PegIFN/RBV therapy. Serum IP-10 levels were determined by enzyme linked immunosorbent assay before therapy, after 12 weeks of treatment, and endpoint of therapy. Results: 40 (36.4%) patients obtained SVR and 72 (63.6%) resulted in non-responder (NR). From univariate analysis, age (51.8 vs. 57.8: P = 0.004); IFN treatment (First/Re-treatment) (30/10 vs. 33/37: P = 0.005); Stage (F0–2 vs. F3–4) (29/11 vs. 34/36: P = 0.015); Total volume of PegIFN (3194.8 vs 2494.4: P = 0.005); Total volume of RBV (192.4 vs.161.3: P = 0.004); HCV-RNA levels (1615.7 vs. 2110.0: P = 0.046); AST level (60.1 vs.80.4: P = 0.005); PLT level (17.8 vs.16.5: P = 0.021); g-GTP level (44.2 vs.72.9: P < 0.001); AFP level (6.4 vs. 24.2: P < 0.001); treatment period (weeks) (46.4 vs. 40.1: P = 0.005); pretreatment IP-10 levels (448.9 vs. 590.1: P = 0.008); after 12 weeks of treatment IP-10 levels (243.1 vs. 328.4: P = 0.033); endpoint of therapy IP-10 levels (280.7 vs. 374.8: P = 0.047); Rapid virological response (RVR) (12/28 vs. 1/69: P < 0.001); Early virological response (EVR) (36/4 vs. 14/56: P < 0.001); wild type at amino acid 70 in the HCV core region (30/10 vs. 33/37: P = 0.005). By multivariate analysis, Age (odds ratio (OR) 9.19 (95% confidence interval (CI) 1.52–55.72; P = 0.016), treatment period (OR 153.54 (95%CI 3.44–6860.09; P = 0.009), early virological response (EVR) (OR 126.32 (95%CI 7.87-.2026.60; P < 0.001) and after 12 weeks of treatment (OR 16.14 (95%CI 1.29-.202.13; P = 0.031) were identified as predictive factor of SVR. Conclusions: Our data suggest that pretreatment and after 12 weeks of treatment serum IP-10 levels predict SVR to PegIFN/RBV therapy in CHC genotype 1 infected patients.