M. Marcolongo

A Seven-Gene Signature (Cirrhosis Risk Score) Predicts Liver Fibrosis Progression in Patients with Initially Mild Chronic Hepatitis C

Fibrosis progression is the main determinant of liver disease outcome in chronic hepatitis C, being influenced by environmental and host factors. Recently, a cirrhosis risk score (CRS) based on seven single‐nucleotide polymorphisms was proposed as genetic predictor of cirrhosis in hepatitis C. To assess the role of CRS in predicting fibrosis progression in patients with initially no or minimal to moderate fibrosis, we investigated 271 untreated patients with chronic hepatitis C having initial liver biopsy showing METAVIR stage F0 (n = 104), F1 (n = 101), or F2 (n = 59) who had been followed up without antiviral therapies for at least 60 months (mean 108.5 ± 71.5 months) and had a liver biopsy at the end of this observation period. Of these, 24.4% showed no histologic progression, 75.6% progressed by at least one stage, 45.0% progressed by at least two stages, and 10.3% progressed by more than two stages. The mean CRS was significantly higher (P = 0.005) in patients with fibrosis progression compared with those without progression, and this difference was particularly evident (P = 0.002) with F0 on initial biopsy. Mean CRS scores were not associated with degree of fibrosis progression. The relative risk of fibrosis progression increased with increasing CRS values. This association was significant in males but not in females and was most evident in males with F0 at initial biopsy (odds ratio 16.5, 95% confidence interval 1.6–166; P= 0.02) in the presence of high CRS. Multivariate analysis confirmed the significant association of CRS score with fibrosis progression. The predictive value of CRS was confirmed in hepatitis C virus patients admitting significant alcohol intake. Conclusion: Host genetics defined by CRS predict fibrosis progression in males with initially mild chronic hepatitis C and may become a useful parameter for prognostic evaluation and treatment decision. (HEPATOLOGY 2009.)

Large‐scale survey of naturally occurring HBV polymerase mutations associated with anti‐HBV drug resistance in untreated patients with chronic hepatitis B

Summary.  Drug resistance is a major limitation for the long‐term efficacy of antiviral therapy with nucleos(t)ide analogues (NAs) in chronic hepatitis B (CHB). Antiviral resistance mutations may pre‐exist in the overall viral population of untreated patients. We aimed to assess the prevalence of such hepatitis B virus (HBV) variants in a large cohort of NAs‐naïve patients with CHB and to explore possible association with viral and host variables. Serum samples from 286 NAs‐naïve consecutive patients with CHB were tested for serum HBV‐DNA, and 255 of them having HBV‐DNA > 1000 IU/mL were further analysed for drug resistance mutations by INNO‐LiPA HBV DRv2/v3. NAs‐naïve patients analysed were mainly men (73%), Caucasians (85%), hepatitis B e Antigen (HBeAg) negative (79%) and genotype D (69%), with a mean age of 43.2 ± 13.4 years. HBV mutations associated with antiviral drug resistance were detected in 13 (5%) patients: three patients infected with HBV genotype C had the rtM204V + rtL180M mutations associated with lamivudine (LMV) resistance. Four patients had the rtI233V mutation that may reduce sensitivity to adefovir, and three patients had the rtM250L/V mutation typical of entecavir resistance. LMV compensatory mutations rtL80V and rtV173L were seen in two and one patients, respectively. No relationship was seen between presence of resistant or compensatory mutations and HBV‐DNA levels, HBeAg/anti‐HBe status or previous IFN therapy. These results confirm that HBV mutations, which confer resistance against currently available anti‐HBV NAs, may already exist in patients who have never received the drug.

Hyperinsulinaemia reduces the 24-h virological response to PEG-interferon therapy in patients with chronic hepatitis C and insulin resistance

Summary.  Insulin resistance (IR) reduces response to pegylated‐interferon (PEG‐IFN)/ribavirin in chronic hepatitis C (CHC), but the mechanisms are still undefined. We examined the relationship between baseline insulin levels, the main component affecting homeostasis model of assessment – insulin resistance (HOMA‐IR) for assessment of IR in non‐diabetic patients, and the ‘acute’ virological response to PEG‐IFN measured 24 h after the first injection and taken as correlate of intracellular interferon signalling. In 62 patients treated with PEG‐IFN/Ribavirin, serum insulin and HOMA‐IR were assessed at baseline, while hepatitis C virus (HCV)‐RNA was measured at baseline and 24 h, 1, 2, 4 and 12 weeks after treatment initiation. Sustained virological response was examined 24 weeks after therapy discontinuation. Mean baseline insulin was 11.52 ± 8.51 U/L and mean HOMA‐IR was 2.65 ± 2.01 both being significantly higher with advanced liver fibrosis. Hepatitis C virus‐RNA decay observed 24 h after the first injection of PEG‐IFN was significantly lower (0.7 ± 0.8 log) in patients with HOMA ≥3 compared with those with HOMA <3 (1.7 ± 0.8, P = 0.001). A highly significant (r = −0.42) inverse correlation was observed between baseline insulin levels and the 24‐h HCV‐RNA decay. The difference in early viral kinetics between patients with HOMA ≥3 or <3 resulted in a significant difference in the percentage of patients achieving rapid (week 4) and sustained virological response. Multivariate analysis, inclusive of patient age, HCV genotype and fibrosis stage, identified baseline insulin levels as the main independent variable affecting the 24‐h response to PEG‐IFN. Hyperinsulinaemia reduces the cellular response to Pegylated‐interferon in CHC with IR. Strategies to reduce insulin levels before initiation of treatment should be pursued to improve efficacy of anti‐viral treatment.

Microsomal triglyceride transfer protein polymorphism (−493G/T) is associated with hepatic steatosis in patients with chronic hepatitis C

Background: Hepatic steatosis may promote progression of chronic hepatitis C (CHC). Microsomal triglyceride transfer protein (MTP) is required for assembly and secretion of ApoB lipoprotein and is implicated in hepatitis C virus (HCV)‐related steatosis. The MTP −493G/T polymorphism may promote liver fat accumulation, but its role in HCV‐related steatosis is still unclear.

Reciprocal interference between insulin and interferon‐alpha signaling in hepatic cells: A vicious circle of clinical significance?

Insulin resistance (IR) is common in chronic hepatitis C (CHC) and associates with reduced virological response to pegylated‐interferon (PEG‐IFN)/ribavirin therapy, but the underlying mechanisms are still unclear. We have previously shown that, in CHC patients, insulin plasma levels are inversely related to antiviral effect induced by PEG‐IFN. Therefore, we investigated the in vitro effect of insulin on interferon alpha (IFN‐α) intracellular signaling as well as that of IFN‐α on insulin signaling. HepG2 cells, preincubated with or without insulin, were stimulated with IFN‐α2b and messenger RNA (mRNA) and protein expression of IFN‐stimulated genes (ISGs) were measured at different timepoints. The role of intracellular suppressors of cytokine signaling 3 (SOCS3) was evaluated with the small interfering RNA (siRNA) strategy. To assess the effect of IFN‐α on insulin signaling, HepG2 were preincubated with or without IFN before addition of insulin and cells were then analyzed for IRS‐1 and for Akt/PKB Ser473 phosphorylation. Insulin (100 and 1000 nM) significantly reduced in a dose‐dependent fashion IFN‐induced gene expression of PKR (P = 0.017 and P = 0.0017, respectively), MxA (P = 0.0103 and P = 0.00186), and 2′‐5′ oligoadenylatesynthetase 1 (OAS‐1) (P = 0.002 and P = 0.006). Insulin also reduced IFN‐α‐induced PKR protein expression. Although insulin was confirmed to increase SOCS3 expression, siRNA SOCS3 did not restore ISG expression after insulin treatment. IFN‐α was found to reduce, in a dose‐dependent fashion, IRS‐1 gene expression as well as Akt/PKB Ser473 phosphorylation induced by insulin. Conclusion: These results provide evidence of reciprocal interference between insulin and IFN‐α signaling in liver cells. These findings may contribute to understand the role of insulin in CHC: IR might be favored by endogenous cytokines including IFN‐α, and the resulting hyperinsulinemia then reduces the antiviral response to exogenous IFN in a vicious circle of clinical significance. (HEPATOLOGY 2011;)

647 INSULIN DIRECTLY INHIBITS IFN-α SIGNALING IN HEPATIC CELLS THROUGH A SOCS3 INDEPENDENT PATHWAY

When HCVpp lacking the HVR were used (or when SRB1 was inhibited by BLT-4) serum enhancement was lost, particularly in HIV coinfected patients. In HIV patients, neutralization was positively and independently related to CD4 count (p < 0.01) and to antiretroviral therapy (p < 0.001). Selective pressure on HVR was higher in immunocompetent subjects and was related to the neutralization observed with serum immunoglobulin fraction. Conclusion: The sera of patients coinfected by HIV or liver transplanted are poorly neutralizing and facilitate the entry of HCVpp mainly through HVR and SRB1. Our findings are the first to show that low neutralization/high facilitation is related to the immune status and could be involved in the severity of HCV in immunocompromized subjects.