Michel Duffaut

Longitudinal Analysis of Hepatitis C Virus Replication and Liver Fibrosis Progression in Renal Transplant Recipients

The pathogenesis of hepatitis C virus (HCV) infection was investigated by analysis of changes in viral and histologic parameters in 36 renal transplant recipients who were infected with HCV before transplantation. Each patient was classified according to development of liver fibrosis as assessed by 2 liver biopsies done 45 and 81 months after transplantation: 13 had progressing liver fibrosis (fibrosers) and 23 did not (nonfibrosers). All developed high-titer posttransplant viremia with a significant increase of 1.2 log RNA copies/mL. There were no significant differences in the increases in serum HCV RNA or genotype distributions in fibrosers and nonfibrosers. The hypervariable region (HVR)-1 of the HCV genome was analyzed by cloning and sequencing 20 clones per sample from 5 fibrosers and 5 nonfibrosers. Comparison of samples revealed that liver fibrosis progression was significantly associated with slower HVR-1 quasispecies diversification, suggesting the selection of more aggressive variants in fibrosers.

Maintenance therapy with gradual reduction of the interferon dose over one year improves histological response in patients with chronic hepatitis C with biochemical response: results of a randomized trial.

BACKGROUND/AIMS Our aim was to assess whether histological response was improved by continuing interferon-alpha (IFN) treatment in patients with chronic hepatitis C (HCV) with a biochemical response and no viral clearance after a usual IFN treatment. METHODS Fifty-seven patients with normal alanine aminotransferase (ALAT) levels and positive HCV RNA at the end of a 1 year IFN treatment were randomly assigned to either group 1 (n = 28) where IFN was stopped, or group 2 (n = 29) where IFN was continued for 1 more year with gradual reduction of the dose to keep serum ALAT activity below the upper limit of normal. Liver biopsies were obtained before, and then 6 months after the end of treatment. RESULTS Knodells index improved between paired biopsies in group 2 (8.2+/-2.4 vs. 5.5+/-2.1), but not in group 1 (8+/-2.3 vs. 6.5+/-2). In post-treatment biopsies, the METAVIR activity score was significantly lower in group 2 than in group 1 (0.7+/-0.2 vs. 1.1+/-0.3, P < 0.05). In group 2, an improvement of the METAVIR fibrosis score was observed (1.3+/-0.4 vs. 1.1+/-0.2), whereas fibrosis progressed in group 1 (1.3+/-0.4 vs. 1.6+/-0.4). CONCLUSIONS Maintenance therapy by the minimal dose of IFN able to maintain biochemical response prevents histological progression in the sub-group of patients without virological response.

Baseline level and early suppression of serum HCV RNA for predicting sustained complete response to alpha-interferon therapy

The relationship between serum hepatitis C virus (HCV) RNA and the outcome of alpha‐interferon (α‐IFN) therapy in patients with chronic hepatitis C has important implications for therapeutic research and clinical care. Serum HCV RNA was tested for HCV genotype and quantified by a standardized reverse transcriptase–polymerase chain reaction assay as a measure of viral load in a cohort of 130 patients with chronic hepatitis C treated with α‐IFN at a standard dose of 3 million units three times a week scheduled for 6 (n = 50) or 12 months (n = 76). Twenty‐one of 126 evaluable patients (16.7%) developed a sustained complete response to α‐IFN according to biochemical and virological criteria. The 3 pretreatment independent factors associated with a sustained complete response were a low baseline serum HCV RNA concentration, non‐1 HCV genotype, and female sex. A multivariate logistic regression model, with pretreatment and month 1 variables, showed that a lower baseline serum HCV RNA concentration, female sex, and a greater suppression of RNA were the significant predictors of sustained complete response. The lowest baseline serum HCV RNA concentration was observed in patients with genotype 2 infection and the greatest decrease in HCV RNA from baseline to month 1 in those with genotype 3. The findings suggest that measuring HCV RNA in serum before and soon after begining treatment can be helpful for selecting patients who are most likely to have a sustained complete response to standard schedule of α‐IFN and for identifying patients in whom alternative strategies should be examined. J. Med. Virol. 54:86–91, 1998.

Impact of hepatitis C virus duration and hepatitis C virus genotypes on renal transplant patients: correlation with clinicopathological features.

BACKGROUND The aim of this study was to evaluate the long-term impact of chronic hepatitis C virus (HCV) infection on the liver in renal transplant patients. METHODS We studied 78 patients for whom at least one posttransplant liver biopsy (LB) was available and for whom the duration of HCV infection was precisely defined. The LB were graded according to a histological activity index, i.e., the Knodell score, divided into the activity score and the fibrosis score. They were also classified as either normal or showing evidence of chronic persistent hepatitis, chronic active hepatitis (CAH), or cirrhosis. RESULTS The study comprised 7 HCV-positive/hepatitis B surface antigen-positive patients (group 1); 4 HCV-positive/RNA-negative patients (group 2); and 67 HCV-positive/RNA-positive patients (group 3). The three groups were comparable according to demographic data and baseline immunosuppression. The median time from transplantation to LB was 38 months (range, 10-306 months). At that time, alanine aminotransferase (ALT) levels had increased in 71.4%, 0%, and 42% of patients from groups 1, 2, and 3, respectively (P=0.07). The total Knodell score showed significantly more severe lesions in group 1 patients (6.2+/-3.2) than in group 2 (1+/-1.2) or in group 3 (4.6+/-2.4) patients (P=0.007). The Knodell score also showed that the fibrosis score was significantly higher in group 1 (2.3+/-1.6) than in group 2 (0) or in group 3 (0.9+/-1.1) patients (P=0.007). Overall, there were 28 cases of CAH (36%) and 4 cases of cirrhosis (5%). We did not observe any correlation between liver histology and characteristics of HCV infection or the type of chronic immunosuppression (double-drug versus triple-drug therapy). However, liver histology (total Knodell score) and the activity score were significantly correlated with ALT levels. Multivariate analysis did identify (i) four independent variables that could explain the degree of liver fibrosis-the sex of the patient, the number of blood units received before transplantation, increased ALT levels at the time of LB, and the occurrence of at least one acute rejection episode (thus the receipt of methylprednisolone pulses); and (ii) two independent variables associated with the occurrence of CAH-the number of blood units before transplantation and increased ALT levels at the time of LB. CONCLUSION This study showed that renal transplant patients infected by HCV for more than 10 years, with a mean posttransplant follow-up of more than 5 years, showed more severe liver lesions when coinfected by hepatitis B virus. Overall, we observed only four cases of cirrhosis (5%) and evidence of histological CAH lesions in 36% of the patients.

Study of the association between major histocompatibility complex class II genes and the response to interferon alpha in patients with chronic hepatitis C infection

OBJECTIVE The aim of the study was to determine the influence of HLA class II genes on the response to interferon-alpha (IFN-alpha) in patients with chronic hepatitis C. METHODS The distribution of HLA DRB1 and DQB1 alleles was assessed in 170 caucasoïd patients treated with IFN-alpha for chronic hepatitis C. 50 patients had a long term sustained response to treatment whereas 120 patients were nonresponders. RESULTS Female sex, non-1 HCV genotype particularly genotype 2 and pretreatment low serum HCV RNA level were associated with long-term sustained response to IFN-alpha. A trend towards a higher prevalence of DRB1*07 allele in non responders than in patients with sustained response (45% vs. 28%, odds ratio 2.1; P < 0.05) on the one hand and of DQB1*06 allele in HCV genotype 1 patients with sustained response than in HCV genotype 1 nonresponders (75% vs 27.3%, odds ration 7.9; P < 0.02) on the other hand, were observed. However, none of these two differences remained significant after Bonferronis correction. CONCLUSION Accordingly, we conclude that the response to IFN-alpha therapy is more tightly related to virus factors than to hosts HLA class II genes.

Long-term impact of superinfection by hepatitis G virus in hepatitis C virus-positive renal transplant patients.

BACKGROUND The hepatitis G virus (HGV) has been recently cloned. Studies in immunocompetent patients have shown that HGV superinfection in hepatitis C virus (HCV)-positive patients does not affect (i) clinical presentation, HCV RNA level, or response to interferon-alpha therapy; or (ii) the histopathologic severity and characteristics of chronic hepatitis. No data are currently available on the impact of HGV infection on liver histology of renal transplant (RT) patients although the reported prevalence of serum HGV RNA in this population is high, ranging from 14% to 55%. PATIENTS AND METHODS We determined the prevalence of HGV infection in 103 HCV-positive RT patients for whom HGV RNA was retrospectively determined by reverse transcription-polymerase chain reaction before, at the time of, and after transplantation (last follow-up). We evaluated the impact of HGV on liver function tests, liver histology (by means of the Knodell score), and renal parameters such as the prevalence of acute rejection and renal function. RESULTS A total of 29 (28%) of the HCV-positive RT patients had a positive HGV RNA (group 1). The mean duration of HGV infection was at least 119+/-64 months (range: 18-240 months). Group 1 patients were compared to the 74 HGV RNA-negative/HCV-positive RT patients (group 2). Liver histology showed a significantly lower degree of fibrosis in group 1 (0.4+/-0.5) than in group 2 (1+/-1.2; P=0.02); two patients from group 2 but none from group 1 had overt cirrhosis. Conversely, the extent of hepatic inflammation and hepatocellular destruction was not statistically different between the two groups. The number of patients who experienced at least one acute rejection episode was significantly higher in group 1 (69%) than in group 2 (42%; P=0.01). However, the multivariate analysis did not identify the presence of HGV RNA at the time of renal transplantation as an independent factor of acute rejection; conversely, (i) the occurrence of cytomegalovirus infection or disease and (ii) the duration of HCV infection significantly increased the likelihood of having acute rejection. CONCLUSIONS This study shows that: (i) HGV infection was often present when the patients seroconverted for HCV, (ii) HGV RNA-positive/HCV-positive RT patients experienced acute rejection more frequently than HGV RNA-negative/HCV-positive RT patients, and (iii) HGV infection seems to have no detrimental effect upon liver enzymes or liver histology in HCV-positive RT patients.

Serological Markers of Autoimmunity in Renal Transplant Patients with Chronic Hepatitis C

The aims of this prospective study were to assess the frequency of serological markers of autoimmunity and cryoglobulins in renal transplant (RT) patients presenting with chronic hepatitis C, and to correlate them with serum alanine aminotransferase (ALT) levels, hepatitis C virus (HCV) genotypes and viremia, and HLA-DR phenotypes. Three groups of patients were studied: group I comprised 74 HCV+ve RT patients; group II, 33 HCV–ve RT patients, and group III, 13 HCV–ve/hepatitis B virus (HBV)-positive RT patients. The three groups did not differ significantly according to their mean age, sex ratio and baseline immunosuppression.Serum specimens of these patients were tested for complement (hemolytic activity (CH50), C3, C4 and properdin factor B (PFB) components, rheumatoid factor (RF), immunoglobulin patterns, circulating immune complexes, and autoantibodies including antinuclear (ANA), anti-smooth muscle (ASMA), antimitochondrial, antithyroid microsomal (ATM), antithyroglobulin (ATG) and anti-LKM1 autoantibodies. We also looked for the presence of cryoglobulins in groups I and III. Cryoglobulinemia of type II was present in 2 patients of group I (2.7%) which was associated in 1 case with de novo membranoproliferative glomerulonephritis but was not found in any of the patients of group III. RF (>40 U/ml) were more frequently observed in groups I (55.4%) and III (46%) than in group II (20.6%), although the difference was not statistically significant (p = 0.06). Oligoclonal or monoclonal serum immunoglobulin patterns were present in 16.2% of the patients in group I, 15.4% in group III and only 3.3% in group II (p = 0.07). There was no significant difference between the prevalence of at least one autoantibody in the three groups (ranging from 38.5 to 50%), and neither was the frequency of ANA (23–36.6%), even at a high titer i.e. above 1:320, or ASMA (13.5–23%) significantly different. Conversely, tissue-specific autoantibodies, i.e. ATM, ATG and anti-LKM1, were only observed in HCV+ve patients. CH50, C3, C4 and PFB levels were significantly lower in group I than in group II, although values below the normal ranges were observed only for CH50 and C3 and were mostly found in the HCV+ve RT patients. Circulating immune complexes detected by nephelometry were at similar levels in the three groups, within the normal ranges. The occurrence of at least one autoantibody and/or the presence of RF >40 U/ml did not correlate with either serum ALT levels or a given HLA-DR phenotype in any of the three groups, nor did they correlate with HCV genotype or HCV viremia in group I. In conclusion, this study shows that contrary to HCV+ve immunocompetent patients, HCV+ve RT patients rarely present with cryoglobulinemia and have the same frequency of non-organ-specific autoantibodies as HCV–ve RT patients. Conversely, antithyroid autoantibodies are only observed in the former group. Finally, serological markers of autoimmunity are not related to serum ALT levels, HLA-DR phenotype, HCV viremia or HCV genotype in HCV+ve RT patients.

Ureteral stenosis as the sole manifestation of Wegener's granulomatosis.

In Wegeners granulomatosis, necrotizing lesions are typically located in the upper and lower respiratory tract and kidneys, and ureteral involvement is uncommon. We report 2 cases in which intrinsic ureteral stenosis was the sole manifestation of this small-vessel vasculitis. Excisional surgery evidenced characteristic granulomatous inflammation that allowed adjuvant elective medical treatment. Urologists, nephrologists, and internists should be aware of this atypical presentation of Wegeners granulomatosis. Thorough clinical and biologic assessments are warranted in the initial workup of isolated intrinsic ureteral stenosis.

Kinetics of HCV Viremia in Kidney Transplant Recipients During and After α-lnterf eron Therapy

Fifteen kidney transplant recipients with chronic hepatitis C were given 3 million units recombinant α 2b -interferon for 142 ± 35 days. There were significant decreases in hepatitis C virus (HCV) RNA 1 month after the initiation of treatment (p < 0.01), and at the end of treatment (p < 0.05). HCV RNA was undetectable by PCR analysis during treatment in 5 patients. But HCV RNA reappeared in all patients 1 month after the cessation of therapy, and the level of viremia returned to baseline. While all patients had normalized alanine aminotransferase (ALT) activities at the end of therapy, 11 experienced a relapse during the follow-up period (1 year). There was a correlation between the amount of HCV RNA at the end of treatment and the time of relapse. Serum IgM against core protein of HCV were detected in 7/15 patients. Anti-core IgM remained detectable during treatment and afterwards. There was no correlation between IgM status and other virological parameters, or ALT activity.

Association between Genes of the Major Histocompatibility Complex Class II and the Outcome of Hepatitis C Virus Infection

To the Editor—We would like to thank E. J. Minton and colleagues [1] for their recent paper confirming that DRB1∗11 and DQB1∗0301 alleles were associated with clearance of circulating hepatitis C virus (HCV) [1]. They confirmed the results of a study that we published 1 year ago [2]. We showed that the frequency of DQB1∗0301 and DRB1∗1101 alleles was higher among a group of French patients with transient infection than in those with persistent infection (84% vs. 30.8%, 40% vs. 9.8%, respectively); these findings are remarkably similar to those of Minton et al. among British patients [1]. In our study, the association between HCV clearance and major histocompatibility complex (MHC) class II alleles was stronger with DQB1∗0301 than with DRB1∗1101. It was the opposite in the study by Minton et al. Our results argued in favor of a stronger association of HCV clearance with DQB1∗0301 than with DRB1∗11, because the P value was lower for DQB1∗0301 than for DRB1∗1101. On the other hand, a linkage disequilibrium between DQB1∗0301 and DRB1∗1101 or DRB1∗04 is well known. In our healthy control population consisting of 800 healthy unrelated subjects, DQB1∗0301 was closely linked with DRB1∗1101 (190%) and in a lesser way with DRB1∗04 (∼60%). In accordance with this linkage disequilibrium in our controls, there was a significant increase of DRB1∗1101 frequency in subjects with transient HCV infection compared with patients with persistent infection (40% vs. 9.8%, respectively), whereas no statistical difference was observed for DRB1∗04 (32% vs. 15.7%, respectively). In the study by Minton et al. [1], the absence of data concerning the reference population, especially on DRB1∗04 haplotypes, does not allow the authors to conclude in favor of DRB1∗11 rather than DQB1∗0301 susceptibility. On the other hand, the possibility that the DQB1∗0301 and DRB1∗11 alleles described in both studies could be markers for tightly linked genes involved in HCV protection cannot be ruled out. New data from various populations with different haplotypic DRB1∗ and DQB1∗ combinations would be of great interest. In the study by Minton et al. [1], only host response through HLA genotyping was studied, without taking into account virologic parameters, such as viral genotype. Because, as reported by the authors, virologic factors could influence virus clearance, it is crucial to make sure that there is no difference in virus genotype between subjects with transient or persistent infection. By definition, serum HCV RNA cannot be detected in subjects with transient infection; therefore, virus serotyping must be used [3]. In our study, virus serotypes could be determined in 68% of patients with transient infection. In this group, 32% of the serologic assay was unreactive, because the level of antibodies against HCV was probably low, as reported by Lechmann et al [4]. For the serotyped subjects, no differences were observed in the distribution of HCV serotypes between subjects with transient infection and those with persistent HCV infection. These data suggest that hostrather than virus-related factors are probably involved in the spontaneous clearance of HCV. To test this hypothesis, it would be interesting to perform virus serotyping in the population studied by Minton et al. [1]. Many other studies have reported that MHC class II alleles could play a role in the natural history of HCV infection [5–9]. In all these works, the involvement of MHC class II genes in the outcome of HCV infection could be related to the ability of HLA molecules to modulate the activation of T lymphocytes [10]. Differences in binding affinities of antigenic peptides to HLA molecules might modify the degree of T cell activation. Taking into account the remarkable similarities between our studies among French patients and those of Minton et al. among British patients, further studies in different populations are required to determine whether DQB1∗0301 and DRB1∗11 alleles modulate immune response, leading to spontaneous clearance of HCV.