Viral and metabolic factors influencing alanine aminotransferase activity in patients with chronic hepatitis C

Dysmetabolism, Diabetes and Clinical Outcomes in Patients Cured of Chronic Hepatitis C: A Real-Life Cohort Study

The aim of this study was to examine the impact of features of dysmetabolism on liver disease severity, evolution, and clinical outcomes in a real‐life cohort of patients treated with direct acting antivirals for chronic hepatitis C virus (HCV) infection. To this end, we considered 7,007 patients treated between 2014 and 2018, 65.3% with advanced fibrosis, of whom 97.7% achieved viral eradication (NAVIGATORE‐Lombardia registry). In a subset (n = 748), liver stiffness measurement (LSM) was available at baseline and follow‐up. Higher body mass index (BMI; odds ratio [OR] 1.06 per kg/m², 1.03‐1.09) and diabetes (OR 2.01 [1.65‐2.46]) were independently associated with advanced fibrosis at baseline, whereas statin use was protective (OR 0.46 [0.35‐0.60]; P < 0.0001 for all). The impact of BMI was greater in those without diabetes (P = 0.003). Diabetes was independently associated with less pronounced LSM improvement after viral eradication (P = 0.001) and in patients with advanced fibrosis was an independent predictor of the most frequent clinical events, namely de novo hepatocellular carcinoma (HCC; hazard ratio [HR] 2.09 [1.20‐3.63]; P = 0.009) and cardiovascular events (HR 2.73 [1.16‐6.43]; P = 0.021). Metformin showed a protective association against HCC (HR 0.32 [0.11‐0.96]; P = 0.043), which was confirmed after adjustment for propensity score (P = 0.038). Diabetes diagnosis further refined HCC prediction in patients with compensated advanced chronic liver disease at high baseline risk (P = 0.024). Conclusion: Metabolic comorbidities were associated with advanced liver fibrosis at baseline, whereas statins were protective. In patients with advanced fibrosis, diabetes increased the risk of de novo HCC and of cardiovascular events. Optimization of metabolic comorbidities treatment by a multi‐disciplinary management approach may improve cardiovascular and possibly liver‐related outcomes.

Necessity of lowering the upper limit of normal of alanine aminotransferase in patients with chronic hepatitis B

AIM

To explore the necessity of lowering the upper limit of normal of alanine aminotransferase (ALT) in patients with chronic hepatitis B (CHB).

METHODS

A total of 715 CHB patients with undetectable HBV DNA were studied. Of them, 57 were inactive HBsAg carriers (carrier group), 455 were those who previously met antiviral criterion and achieved viral and biochemical response (hepatitis group), and 203 underwent liver biopsy due to their baseline ALT less than 2 times the upper limit of normal (ULN) and accepted antiviral treatment (including 133 cases with ALT < 1 x ULN and 70 cases with ALT 1-2 x ULN) (biopsy group). Clinical data including age, gender, weight, liver function, blood glucose, blood lipids, routine blood parameters, HBV markers, HBV DNA, alpha fetoprotein, and ultrasound findings were collected. Inflammation grade, fibrosis stage and liver function data were also collected for patients in the biopsy group after one year of antiviral therapy.

RESULTS

ALT median value was 19 IU/L and the 95% percentile was 31.2 IU/L (95%CI: 30-34 IU/L) in all patients (n = 715). The 95% percentile was 34 IU/L in males (95%CI: 31-35 IU/L), and 26.2 IU/L in females (95%CI: 25-30 IU/L). ALT value decreased significantly in the biopsy group after antiviral treatment, and median ALT decreased from 37 IU/L to 23 IU/L, which showed a significant difference (F = 111.497, P = 0.000). Based on four different ALT ULN, the detection rates of significant inflammation (≥G2) were 0, 38.78%, 63.27% and 84.69%, respectively, in the biopsy group. When ROC was used to analyze ALT and significant histological inflammation, the AUC value was 0.751. Logistic regression analysis showed that ALT was not associated with significant histological inflammation (P = 0.331).

CONCLUSION

The current ALT ULN is relatively high for assessment of liver inflammation in patients with CHB, and there may be a necessity to lower the threshold.

Liver Transplantation: the Role of Metabolic Syndrome

OPINION STATEMENT

The long-term survival in liver transplant recipients (LTRs) is currently at an historical high level stemming from improvement in perioperative care, infection control, and immunosuppression medications. However, compared to the general population, LTRs have decreased survival. Metabolic diseases like hypertension, dyslipidemia, type 2 diabetes, and obesity are key determinants of long-term mortality in LTRs. The incidence and prevalence of these metabolic comorbidities is considerably higher in LTRs and likely results from a combination of factors including exposure to chronic immunosuppression, weight gain, and recurrence of chronic liver disease after liver transplantation (LT). Although there is currently little guidance in managing these metabolic conditions post-LT, recommendations are often extrapolated from non-transplant cohorts. In the current review, we explore the relationship between metabolic syndrome and its comorbidities in LTRs.

Association of SCARB1 Gene Polymorphisms with Virological Response in Chronic Hepatitis C Patients Receiving Pegylated Interferon plus Ribavirin Therapy

The scavenger receptor type B class I(SR-BI) is a receptor for high-density lipoproteins(HDL) and one of entry factors for hepatitis C virus(HCV). We examined the association of single nucleotide polymorphisms(SNPs) of the SCARB1 gene, which encodes SR-BI, with virologic responses to pegylated interferon-based treatment in Asian chronic hepatitis C(CHC) patients. Human genomic and clinical data were collected from 156 consecutive Taiwanese HCV genotype 1 or 2 patients who received pegylated interferon plus ribavirin therapy and 153 non-HCV healthy subjects. Three SNPs(rs10846744, rs5888, and rs3782287) of the SCARB1 gene that have been linked to humans diseases were investigated. rs10846744 rather than rs5888 or rs3782287 was associated with serum HCV RNA level and sustained virologic response(SVR) to pegylated interferon plus ribavirin therapy in CHC patients(GG vs. non-GG genotype, Adjusted Odds Ratio, 95% CI: 0.32, 0.11–0.95, P = 0.039). Among patients with IL28B rs8099917 non-TT genotypes, those with rs10846744 non-GG genotype had a higher SVR rate than those with GG genotypes. In addition, patients with GG genotype had a higher fasting blood glucose level than those with CC genotype. In conclusion, SCARB1 gene polymorphisms may serve as a potential predictor of treatment responses in CHC patients receiving interferon-based therapy. (ClinicalTrials.gov number, NCT02714712).

Alcohol intake alters immune responses and promotes CNS viral persistence in mice

Chronic hepatitis C virus (HCV) infection leads to progressive liver disease and is associated with a variety of extrahepatic effects, including central nervous system (CNS) damage and neuropsychiatric impairments. Alcohol abuse can exacerbate these adverse effects on brain and behavior, but the molecular mechanisms are not well understood. This study investigated the role of alcohol in regulating viral persistence and CNS immunopathology in mice infected with lymphocytic choriomeningitis virus (LCMV), a model for HCV infections in humans. Female and male BALB/c mice (n=94) were exposed to alcohol (ethanol; EtOH) and water (or water only) using a two-bottle choice paradigm, followed one week later by infection with either LCMV clone 13 (causes chronic infection similar to chronic HCV), LCMV Armstrong (causes acute infection), or vehicle. Mice were monitored for 60days post-infection and continued to receive 24-h access to EtOH and water. Animals infected with LCMV clone 13 drank more EtOH, as compared to those with an acute or no viral infection. Six weeks after infection with LCMV clone 13, mice with EtOH exposure evidenced higher serum viral titers, as compared to mice without EtOH exposure. EtOH intake was also associated with reductions in virus-specific CD8(+) T cell frequencies (particularly CD11a(hi) subsets) and evidence of persistent CNS viremia in chronically infected mice. These findings support the hypothesis that EtOH use and chronic viral infection can result in combined toxic effects accelerating CNS damage and neuropsychiatric dysfunction and suggest that examining the role of EtOH in regulating viral persistence and CNS immunopathology in mice infected with LCMV can lead to a more comprehensive understanding of comorbid alcohol use disorder and chronic viral infection.

A novel approach to identify candidate prognostic factors for hepatitis C treatment response integrating clinical and viral genetic data

The combined therapy of pegylated interferon (IFN) plus ribavirin (RBV) has been for a long time the standard treatment for patients infected with hepatitis C virus (HCV). In the case of genotype 1, only 38%–48% of patients have a positive response to the combined treatment. In previous studies, viral genetic information has been occasionally included as a predictor. Here, we consider viral genetic variation in addition to 11 clinical and 19 viral populations and evolutionary parameters to identify candidate baseline prognostic factors that could be involved in the treatment outcome. We obtained potential prognostic models for HCV subtypes la and lb in combination as well as separately. We also found that viral genetic information is relevant for the combined treatment assessment of patients, as the potential prognostic model of joint subtypes includes 9 viral-related variables out of 11. Our proposed methodology fully characterizes viral genetic information and finds a combination of positions that modulate inter-patient variability.

Clinicobiochemical prediction of biopsy-proven cases of severe hepatic fibrosis in patients with chronic hepatitis C infection

OBJECTIVE

To evaluate clinicobiochemical factors predicting severe hepatic fibrosis in patients with chronic hepatitis C virus (HCV) infection.

SETTING

Tertiary institution.

PARTICIPANTS

859 treatment-naïve Korean patients with HCV who underwent liver biopsy. Severe fibrosis was defined as fibrosis stage ≥3 based on the METAVIR system.

PRIMARY OUTCOME MEASURES

Clinicobiochemical factors predicting severe hepatic fibrosis.

RESULTS

The median serum alanine aminotransferase (ALT) level was 68 IU/L and body mass index (BMI) was 24.2 kg/m(2). Severe fibrosis was observed in 326 (39.7%) of the 859 patients. The frequencies of severe fibrosis were 0%, 37.8%, 41.9% and 42% in patients with serum ALT concentrations (IU/L) of ≤20, 20-30, 30-40 and >40 (p<0.01), respectively, and 10.7%, 19.8%, 30.5%, 39.2% and 55.6% in patients <30, 30-40, 40-50, 50-60 and ≥60 years old, respectively (p<0.01). Categorised age in years (50-60 (OR 4.26, p=0.03) and ≥60 (OR 7.53, p<0.01) compared with <30), categorised ALT level in IU/L (20-30 (OR 16.76, p<0.01), 30-40 (OR 20.02, p<0.01) and >40 (OR 21.49, p<0.01) compared with ≤20) and BMI >27.5 kg/m(2) (OR 1.65, p=0.03) were independently related to severe fibrosis in patients with chronic HCV. The severe fibrosis rate was 60.6% in patients aged ≥50 years with ALT >20 IU/L and BMI >27.5 kg/m(2).

CONCLUSIONS

More advanced age (≥50 years), obesity and serum ALT>20 IU/L are associated with severe fibrosis in patients with chronic HCV. Anti-HCV therapy may be considered for these patients without histological confirmation, regardless of HCV genotype. A wait-and-see policy may be justified for patients with serum ALT ≤20 IU/L.

Comparison of hepatitis C virus testing strategies: birth cohort versus elevated alanine aminotransferase levels

BACKGROUND

Hepatitis C virus (HCV) infection is unidentified in an estimated 40%-85% of infected adults. Surveillance and modeling data have found significant increases in HCV-associated morbidity and mortality.

PURPOSE

To compare two HCV antibody (anti-HCV) testing strategies based on (1) elevated alanine aminotransferase levels (ALT) and (2) a birth cohort approach for people born during 1945-1965.

METHODS

Data from 19,055 adults aged 20-70 years who completed the National Health and Nutrition Examination Survey in 1999-2008 were analyzed in 2013. Two independent models were evaluated, based on membership in the 1945-1965 birth cohort or elevated ALT, to compare the number of identified anti-HCV-positive (anti-HCV+) individuals; proportion of total identified cases; and the number of people that would be tested using either strategy.

RESULTS

The prevalence of anti-HCV among adults aged 20-70 years was estimated at 2.0% (95% CI=1.8%, 2.3%), representing about 3.6 million people. The birth cohort strategy would result in testing about 85.4 million people and identifying nearly 2.8 million anti-HCV+ people with a sensitivity of 76.6%. The ALT strategy would test about 21.5 million adults and identify approximately 1.8 million anti-HCV+ people with a sensitivity of 50.0%. Implementing both strategies concurrently would identify 87.3% of anti-HCV+ adults.

CONCLUSIONS

The birth cohort strategy, which is recommended by both the CDC and the U.S. Preventive Services Task Force, would identify 1 million more anti-HCV+ people than the elevated ALT approach. Concurrent implementation would identify an even larger number of individuals ever infected.

Distinct patterns of the lipid alterations between genotype 1 and 2 chronic hepatitis C patients after viral clearance

BACKGROUND

The hepatitis C virus (HCV) genotype-specific impacts on the host metabolic alterations remained inconclusive.

METHODS

A prospective study including 229 (118 genotype 1 (G1) and 111 G2) consecutive chronic HCV patients who had completed a course of anti-HCV treatment and underwent pre- and 24 weeks post-treatment surveys of metabolic profiles was conducted. Patients were stratified according to the therapeutic response, viral genotype and baseline insulin resistance (IR: homeostasis model assessments of IR (HOMA-IR) ≥ 2.5). Paired t-tests were used to compare the pre- and post-treatment variables.

RESULTS

Significant post-therapeutic increases in cholesterol, triglyceride, HDL, LDL, apolipoprotein A1 and apolipoprotein B were observed in patients with sustained virological response (SVR) but not in those without. Among those with SVR, post-therapeutic increases in HDL (p<0.001) and apolipoprotein A1 (p = 0.012) were only found in G2, whereas increased triglyceride/HDL (p = 0.01) ratios were only found in G1 patients. When stratified by baseline IR among those with SVR, a significant increase in post-treatment HDL (p = 0.019) and apolipoprotein A1 (p = 0.012) but a decrease in HOMA-IR (p = 0.04), C-peptide (p = 0.019) and hemoglobin A1c (p = 0.047) were found in patients with baseline IR; a significant increase in HOMA-IR (p = 0.002) was found in patients without baseline IR. The latter change was observed only in G1 (p = 0.01) but not G2 patients. Although the pre-treatment metabolic profiles of G1 and G2 patients were indifferent, G1 had higher post-treatment triglyceride/HDL ratios (p = 0.041) and triglyceride (p = 0.044) levels than G2 patients.

CONCLUSIONS

G2 benefit more than G1 patients from viral clearance in metabolic alterations, particularly in those without baseline IR.

A pilot study of add-on oral hypoglycemic agents in treatment-naïve genotype-1 chronic hepatitis C patients receiving peginterferon alfa-2b plus ribavirin

BACKGROUND/PURPOSE

Insulin resistance (IR) affects sustained virological response (SVR) to peginterferon alfa plus ribavirin (PR) in patients with chronic hepatitis C (CHC). Whether add-on oral hypoglycemic agents (OHAs) to PR improve SVR remains unclear; therefore, we conducted a prospective, randomized pilot trial on 23 consecutive patients with genotype 1 CHC and IR in Taiwan.

METHODS

Patients were randomized to receive acarbose (Arm A; n = 7) or metformin (Arm B; n = 6) or pioglitazone (Arm C; n = 5) in addition to peginterferon alfa-2b (1.5 μg/kg/week) plus ribavirin (1000-1200 mg/day) or just PR (Arm D; n = 5). The primary end point was SVR, and secondary end points were viral clearance at Weeks 17, 29, and 53. There were no differences among all arms at baseline.

RESULTS

Using intent-to-treat analysis, SVR was observed in 66.7% (4/6), 83.3% (5/6), 66.7% (4/6), and 60% (3/5) in Arms A, B, C, and D, respectively. SVR was higher in female patients receiving OHA [90% (9/10)] than in male patients [50% (4/8)]. Results of per protocol analysis showed that SVR was 80.0% (4/5) in Arm A, 100% (5/5) in Arm B, 66.7% (4/6) in Arm C, and 60% (3/5) in Arm D. Patients receiving OHA had a higher rapid virologic response: 11/18 (61%) versus 2/5 (40%). Complete early virologic response was comparable between patients receiving OHA and PR [15/18 (83%) vs. 4/5 (80%)].

CONCLUSION

Our preliminary data show add-on OHAs to PR might achieve better early viral kinetics and SVR. However, further larger studies are needed to confirm these findings.

An individualized strategy for treatment of hepatitis C virus carriers with normal aminotransferase levels: Analysis of 73 cases

AIM: To evaluate the efficacy and safety of peginterferon alpha-2a (PEG-IFN α-2a) combined with ribavirin (RBV) in the treatment of chronic hepatitis C (CHC) patients with normal aminotransferase levels.

METHODS: Patients with CHC and at least three normal aminotransferase values over an 18-month period or increased aminotransferase were offered a treatment with PEG-IFN α-2a 180 μg/wk and ribavirin (800 mg/d for weight ≤ 65 kg; 1000 mg/d for weight > 65 and < 75 kg; 1200 mg/d for weight ≥ 75 kg). All patients were followed for 24 wk post treatment. Curative effects were evaluated at 4 and 12 wk during the treatment and 24 wk post treatment. The adverse effects were also recorded.

RESULTS: A total of 161 patients completed the therapy. The 73 patients with normal transaminase and the 88 patients with increased transaminase had similar baseline characteristics. Overall, the two groups showed similar rapid virologic response (RVR) rate (78.1% vs 75.0%, P > 0.05), complete early virologic response (cEVR) rate (93.2% vs 92.0%, P > 0.05) and sustained virologic response (SVR) rate (92.7% vs 91.9%, P > 0.05).

CONCLUSION: Combination therapy with PEG-IFN α-2a and RBV is safe and effective in CHC patients with persistently normal aminotransferase levels.

Hepatitis C genotype 4 with normal transaminases: correlation with fibrosis and response to treatment, a cohort Egyptian study of 4277 patients

BACKGROUND AND OBJECTIVE

Chronic hepatitis C virus (HCV) patients with persistently normal transaminases represent a subgroup of patients with mild, slowly progressive disease, natural history, and optimal management of these patients needs to be investigated in Egypt. Our aim is to assess the severity of hepatic fibrosis and response to therapy in a cohort of Egyptian HCV patients with normal transaminases.

PATIENTS AND METHODS

Retrospective demographics, laboratory, histological features and treatment outcome of patients included in the national program for the control of viral hepatitis in Egypt since 2007 were collected. Combined pegylated IFN/ribavirin therapy was given for patients with fibrosis stage ≥ F1 and elevated transaminases while those with normal transaminase; therapy was initiated only in patients with fibrosis stage ≥ F2.

RESULTS

Normal ALT and AST were detected in 1308/4277 (30.6%) and 1662/4277 (38.9%) patients, respectively, while both enzymes were normal in 943 patients (22%). Multivariate regression analysis showed that lower AFP and higher platelets count (compared with elevated transaminases group) were significantly correlated with normal transaminases (P<0.01), however, HCV-RNA levels did not show such significance. The number of patients with HAI score ≥ A1 was significantly lower in normal than elevated transaminases (36.5% vs 40.9%, respectively, P<0.01) and patients with fibrosis ≥ F2 was significantly lower in normal than elevated transaminases (36.4%) and (43%), respectively (P<0.01). There was no significant correlation between baseline transaminases levels and response to treatment.

CONCLUSION

Normal transaminases are frequently encountered in chronic HCV Egyptian patients (22%). They show low AFP level, mild degree of activity and stage of fibrosis with no correlation with response to therapy.

Disease progression in chronic hepatitis C patients with normal alanine aminotransferase levels

AIM: To investigate whether the disease progression of chronic hepatitis C patients with normal alanine aminotransferase (ALT) levels differs by ALT levels.

METHODS: A total of 232 chronic hepatitis C patients with normal ALT (< 40 IU/L) were analyzed. The patients were divided into “high-normal” and “low-normal”ALT groups after determining the best predictive cutoff level associated with disease progression for each gender. The incidence of disease progression, as defined by the occurrence of an increase of ≥ 2 points in the Child-Pugh score, spontaneous bacterial peritonitis, bleeding gastric or esophageal varices, hepatic encephalopathy, the development of hepatocellular carcinoma, or death related to liver disease, were compared between the two groups.

RESULTS: Baseline serum ALT levels were associated with disease progression for both genders. The best predictive cutoff baseline serum ALT level for disease progression was 26 IU/L in males and 23 IU/L in females. The mean annual disease progression rate was 1.2% and 3.9% for male patients with baseline ALT levels ≤ 25 IU/L (low-normal) and > 26 IU/L (high-normal), respectively (P = 0.043), and it was 1.4% and 4.8% for female patients with baseline ALT levels ≤ 22 IU/L (low-normal) and > 23 IU/L (high-normal), respectively (P = 0.023). ALT levels fluctuated during the follow-up period. During the follow-up, more patients with “high-normal” ALT levels at baseline experienced ALT elevation (> 41 IU/L) than did patients with “low-normal” ALT levels at baseline (47.7% vs 27.9%, P = 0.002). The 5 year cumulative incidence of disease progression was significantly lower in patients with persistently “low-normal” ALT levels than “high-normal” ALT levels or those who exhibited an ALT elevation > 41 U/L during the follow-up period (0%, 8.3% and 34.3%, P < 0.001).

CONCLUSION: A “high normal” ALT level in chronic hepatitis C patients was associated with disease progression, suggesting that the currently accepted normal threshold of serum ALT should be lowered.

Interferon-associated hepatic steatosis is related to discrepancies in biochemical and virological responses of chronic hepatitis C to IFN-based therapy

BACKGROUND AND AIMS

A discrepancy in virological and biochemical responses may occur throughout interferon-based therapy for hepatitis C virus (HCV). We aimed to explore the risk, associated factors, potential mechanisms, and impact on the treatment outcome of the discrepancy.

SUBJECTS AND METHODS

Consecutive 496, chronic HCV-infected patients receiving interferon/ribavirin or peginterferon/ribavirin for 24 weeks with a 24-week follow-up period were enrolled. Of 433 patients with pretreatment liver biopsy, 46 received serial liver biopsies at the end of treatment and end of follow-up to explore the corresponding change in liver histopathology. A virological/biochemical discrepancy was defined as persistently elevated alanine aminotransferase levels throughout the treatment period, despite the seronegativity for HCV RNA at least at the end of treatment. The sustained virological response (SVR) was defined as seronegativity for HCV RNA 6 months after the end of treatment.

RESULTS

Virological/biochemical discrepancy was observed in 28.7 % (137/478) patients. The SVR rate was comparable between patients with (75.2 %, 103/137) and without discrepancy (81.2 %, 277/341, p = 0.14). For patients with discrepancy and SVR, 78 (75.7 %) had a subsequent normalization of alanine aminotransferase. Hepatic steatosis, advanced fibrosis, obesity, older age, peginterferon preparation, and low viral load were independently predictive of a virological/biochemical discrepancy. Serial liver histology showed that significant transient aggravation of hepatic steatosis during interferon-based therapy was observed among patients with a virological/biochemical discrepancy (difference 0.64 ± 0.93, p = 0.022), but not among those without it (difference 0.09 ± 0.69, p = 0.447).

CONCLUSIONS

A virological/biochemical discrepancy no longer exists after treatment cessation in most patients, and had little impact on the HCV treatment outcome. Treatment-related hepatic steatosis might play an important role in the pathogenesis of the discrepancy.

IL-21R gene polymorphisms and serum IL-21 levels predict virological response to interferon-based therapy in Asian chronic hepatitis C patients

BACKGROUND

IL-21R polymorphisms have been identified as potential predictors of virological outcomes in Western chronic hepatitis C (CHC) patients receiving interferon-based treatment. We aimed to examine the associations of IL-21R genotypes and serum IL-21 levels with virological responses to interferon-based treatment in Asian CHC patients.

METHODS

Genomic and clinical data were collected from 178 consecutive Taiwanese HCV genotype 1 patients who received interferon-based therapy and 72 non-HCV healthy subjects. Among them, serum IL-21 levels, IL-21R and IL-28B genotypes were determined in 124 CHC patients and healthy controls.

RESULTS

Among patients with IL28B rs8099917 non-TT genotypes, patients with IL-21R rs3093390 CC genotype had a higher sustained virological response rate than those with non-CC genotypes (CC versus non-CC 14/24 versus 0/4; P = 0.031). Compared with non-HCV controls, CHC patients had higher serum IL-21 levels (mean ± sd HCV versus non-HCV 377.8 ± 780.9 versus 70.5 ± 33.2 pg/ml; P = 0.001). Patients with sustained virological response had higher pretreatment serum IL-21 levels than those without (adjusted OR 0.23, 95% CI 0.07, 0.80; P = 0.021).

CONCLUSIONS

CHC patients have higher serum IL-21 levels than healthy adults. Higher pretreatment serum IL-21 levels and IL-21R polymorphisms may serve as potential factors predictive of treatment outcomes in CHC patients with interferon-based therapy.

Alanine transaminase level in a healthy population in Morocco

A little is known about the prevalence of elevated alanine transaminase in a Moroccan healthy population. Our aim was to search for the upper limit of normal alanine transaminase in the blood donors and then to apply the upper limit of normal alanine found in the population so as to assess the prevalence of subjects with abnormal transaminase level. We then, investigated for factors associated with increased level of transaminase in our population. This study was carried out on 14071 blood donors, (74.1% of men and 25.9% female) aged between 18 to 60 years, randomly chosen. Serum transaminase activity was measured using on IEMS Reader, Labsystems. Hepatitis B and C were performed by ELISA. The upper limit of normal transaminase found were 64 for men and 52 for women. Consequently, 2.08% blood donors had an abnormal level of transaminase. Follow up results revealed that drug was the first cause of elevated transaminase in our cohort followed by diet and alcohol consumption. One seroconversion for hepatitis C was identified. In conclusion, this study showed that even though there is an evident lack of efficiency in using alanine aminotransferase testing qualifying blood donors in our country, preventing viral potential transmission through transfusions was possible.

Impact of hepatitis B virus infection on metabolic profiles and modifying factors

The metabolic syndrome may cause disease progression in patients with chronic hepatitis B (CHB). However, the interactions between hepatitis B virus (HBV) infection and metabolic factors remain unknown. We investigated the association of HBV infection with metabolic profiles in HBV-infected and noninfected subjects. In addition, the impacts of serum HBV DNA level on metabolic profiles were studied. Initially, a case-control analysis of patients with and without chronic HBV infection was performed. The HBV group consisted of 322 patients with chronic HBV infection, and the control group consisted of 870 matched subjects without HBV infection. Fasting blood glucose, lipid profiles and adiponectin levels were compared. The results were then confirmed in a second retrospective cohort study in 122 CHB patients with serum HBV DNA levels and HOMA-IR index values. In the case-control analysis, the HBV group had significantly higher serum adiponectin, but lower triglyceride (TG) and high-density lipoprotein cholesterol (HDL) levels than the control group. These relationships already existed in subjects younger than 45 years of age and were modified by serum alanine aminotransferase (ALT) levels. In the retrospective cohort, serum HBV DNA levels were negatively proportional to TG levels, but not to other metabolic parameters. Moreover, this relationship was significant only in subjects with higher ALT levels. Compared with healthy adults, patients with chronic HBV infection have significantly higher serum adiponectin, but lower TG and HDL levels. These relationships are modified by ALT levels and already exist in middle-age patients with chronic HBV infection, implying HBV may interact with host metabolism.

Impact of insulin resistance on sustained response in HCV patients treated with pegylated interferon and ribavirin: a meta-analysis

BACKGROUND & AIMS

Recent studies suggested that SVR rates might be lower in HCV patients with insulin resistance (IR) than in patients without IR, but the extent of the impact of IR on treatment response has not been established. We aimed to confirm the role of IR assessed by the homoeostasis model assessment (HOMA-IR) on SVR and to determine its magnitude.

METHODS

We performed meta-analysis of studies evaluating the impact of IR in HCV patients treated with pegylated interferon and ribavirin.

RESULTS

Fourteen studies involving 2732 patients were included. SVR was less frequent in patients with IR than in patients without IR (mean difference: -19.6%, 95% CI: -29.9% to -9.4%, p<0.001). In sensitivity analyses according to HCV-1 patients, patients with IR also less frequently attained a SVR than patients without IR (mean difference: -13.0%, 95% CI: -22.6% to -3.4%, p=0.008). In addition, the baseline HOMA-IR index was lower in responders than in non-responders (mean difference: -0.92, 95% CI: -1.53 to -0.32, p<0.001). In sensitivity analyses restricted to HCV-1 patients, the baseline HOMA-IR index remained lower in responders than in non-responders (mean difference: -0.63, 95% CI: -1.13 to -0.14, p<0.001).

CONCLUSIONS

HCV patients with IR have a 20% lower SVR than patients without IR. The baseline HOMA-IR index is a major determinant of SVR.

Lipid Profiles and Hepatitis C Viral Markers in HCV-Infected Thalassemic Patients

BACKGROUND/AIMS

The distribution of blood lipids, glucose and their determinants in thalassemic patients with chronic hepatitis C virus (HCV) infection has rarely been investigated. Thus, we aimed to investigate the relationship between both liver histologic findings and viral markers and serum lipids in thalassemic patients chronically infected with HCV.

METHODS

We enrolled 280 polytransfused thalassemic patients with chronic hepatitis C. HCV viral load was determined using the Amplicor test. Genotyping was performed using genotype specific primers. Fasting serum lipid, glucose, ferritin and liver function enzyme concentrations were measured. A modified Knodell scoring system was used to stage liver fibrosis and to grade necroinflammatory activity. Perls' staining was used to assess hepatic siderosis.

RESULTS

Just one subject had total cholesterol >200 mg/dL, and 7% had triglycerides >150 mg/dL. The mean high-density lipoprotein cholesterol (HDL-C) and glucose levels were 37 and 104 (97-111) mg/dL, respectively. Viral markers, liver histological findings and aminotransferase activity were not associated with serum lipid levels. Serum triglycerides, total cholesterol and ferritin were independent risk factors for impaired glucose tolerance or diabetes in these patients.

CONCLUSIONS

The majority of the patients had blood lipid levels (with the exception of HDL) within the defined normal range; viral and liver histological factors do not appear to play a significant role in changing the levels of serum lipids or glucose in these patients.

Metabolic factors are associated with serum alanine aminotransferase levels in patients with chronic hepatitis C

BACKGROUND

Although serum alanine aminotransferase (ALT) activity is an important marker for the management of chronic hepatitis C (CHC), the factors associated with serum ALT levels remain to be fully understood. This study aimed to clarify the association between serum ALT levels and clinical, histological, and virological factors in patients with CHC.

METHODS

We retrospectively analyzed 256 patients with CHC who underwent liver biopsy, and classified them into three groups according to serum ALT levels: normal to minimal (<40 IU/L), mild (40-80 IU/L), and moderate to severe elevation (≥80 IU/L). All demographic and laboratory data were collected at the time of liver biopsy. All biopsies were evaluated for fibrosis, inflammation, and steatosis. Glucose metabolism was assessed by various indices derived from oral glucose tolerance tests, including the homeostasis model assessment for insulin resistance (HOMA-IR). In 180 patients, visceral fat area was measured at the umbilical level by abdominal computed tomography.

RESULTS

Ordered logistic regression analysis showed that higher serum ALT levels were significantly associated with male sex, lower high-density lipoprotein cholesterol (HDL-C), higher HOMA-IR, and higher grades of histological inflammation and steatosis. HOMA-IR, HDL-C, and hepatic steatosis were associated with visceral fat accumulation.

CONCLUSIONS

Metabolic factors, as well as sex and hepatic inflammation, are independent risk factors for serum ALT elevation in hepatitis C virus (HCV)-infected patients. Metabolic factors may offer targets to decrease serum ALT levels.

Estimation of the healthy upper limits for serum alanine aminotransferase in Asian populations with normal liver histology

A recent study in young Italian subjects suggested that the healthy thresholds for serum alanine aminotransferase (ALT) levels should be adjusted to 30 IU/L for men and 19 IU/L for women when assessing risk factors for nonalcoholic fatty liver disease. Our aim was to assess serum ALT concentrations in healthy Korean individuals and to determine the factors affecting ALT levels in these populations. We included 1,105 potential liver donors (643 men and 462 women) with biopsy-proven normal livers. Median ages were 25 years in men and 30 years in women, with a median body mass index (BMI) of 22.3 kg/m(2) in men and 21.4 kg/m(2) in women. The calculated thresholds for ALT values in these subjects were 35 IU/L for men and 26 IU/L for women. Age and BMI were independently correlated with ALT levels in both sexes, whereas serum total cholesterol concentration was significant only in men and blood glucose level only in women (P < 0.05). When we chose a subgroup of 665 individuals (346 men and 319 women) using Prati criteria, modified by the BMI cutoff points for Asians (<23 kg/m(2)), we found that the healthy ALT values were 33 IU/L for men and 25 IU/L for women. The mean ALT concentrations for subjects within the Prati criteria were significantly lower than for those outside the criteria (16.7 versus 19.5 IU/L for men, 12.8 versus 14.9 IU/L for women; P < 0.001).

CONCLUSION

The healthy ALT thresholds in biopsy-proven normal Asians were clearly lower than the previously accepted thresholds, as has also been noted in Europeans. Age, BMI, and/or other metabolic parameters significantly affect ALT levels, even in subjects with normal livers.

Clinical expression of insulin resistance in hepatitis C and B virus-related chronic hepatitis: differences and similarities

AIM

To investigate the prevalence of the clinical parameters of insulin resistance and diabetes in patients affected by chronic hepatitis C (CHC) or chronic hepatitis B (CHB).

METHODS

We retrospectively evaluated 852 consecutive patients (726 CHC and 126 CHB) who had undergone liver biopsy. We recorded age, sex, ALT, type 2 diabetes and/or metabolic syndrome (MS), body mass index (BMI), and apparent disease duration (ADD).

RESULTS

Age, ADD, BMI, prevalence of MS and diabetes in patients with mild/moderate liver fibrosis were significantly higher in CHC. However, the degree of steatosis and liver fibrosis evaluated in liver biopsies did not differ between CHC and CHB patients. At multivariate analysis, age, sex, BMI, ALT and diabetes were independent risk factors for liver fibrosis in CHC, whereas only age was related to liver fibrosis in CHB. We also evaluated the association between significant steatosis (>30%) and age, sex, BMI, diabetes, MS and liver fibrosis. Diabetes, BMI and liver fibrosis were associated with steatosis >30% in CHC, whereas only age and BMI were related to steatosis in CHB.

CONCLUSION

These data may indicate that hepatitis C virus infection is a risk factor for insulin resistance.

Hepatitis C virus infection enhances insulin resistance induced by visceral fat accumulation

BACKGROUND/AIMS

To clarify the impact of visceral obesity on hepatitis C virus (HCV)-infected patients, we examined the relationship between insulin resistance development and visceral fat accumulation.

METHODS

We analyzed 87 HCV-infected patients with mild fibrosis (stage 1 or 2) in comparison with 125 sex- and age-matched patients with non-alcoholic fatty liver disease (NAFLD). The degree of visceral fat area (VFA; cm(2)) at the umbilical level was measured by abdominal computed tomography and divided into two grades: no visceral obesity, VFA<100 and visceral obesity, VFA>/=100. Insulin resistance was evaluated by homeostasis model assessment of insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI). Pancreatic beta-cell function was evaluated by homeostasis model assessment of beta-cell function (HOMA-beta). Serum soluble tumour necrosis factor (TNF)-receptors 1 and 2 and adiponectin were measured.

RESULTS

Insulin resistance evaluated by HOMA-IR and QUICKI was correlated with visceral fat accumulation, and was higher in HCV patients than in NAFLD patients with visceral obesity. HOMA-beta was higher in HCV patients than in NAFLD patients for each VFA grade. Serum-soluble TNF-receptors 1 and 2 were higher in HCV patients than in NAFLD patients with visceral obesity.

CONCLUSIONS

Hepatitis C virus infection is a risk factor for development of insulin resistance, particularly in patients with visceral obesity.

Clinical expression of insulin resistance in hepatitis C and B virus-related chronic hepatitis: differences and similarities

AIM

To investigate the prevalence of the clinical parameters of insulin resistance and diabetes in patients affected by chronic hepatitis C (CHC) or chronic hepatitis B (CHB).

METHODS

We retrospectively evaluated 852 consecutive patients (726 CHC and 126 CHB) who had undergone liver biopsy. We recorded age, sex, ALT, type 2 diabetes and/or metabolic syndrome (MS), body mass index (BMI), and apparent disease duration (ADD).

RESULTS

Age, ADD, BMI, prevalence of MS and diabetes in patients with mild/moderate liver fibrosis were significantly higher in CHC. However, the degree of steatosis and liver fibrosis evaluated in liver biopsies did not differ between CHC and CHB patients. At multivariate analysis, age, sex, BMI, ALT and diabetes were independent risk factors for liver fibrosis in CHC, whereas only age was related to liver fibrosis in CHB. We also evaluated the association between significant steatosis (>30%) and age, sex, BMI, diabetes, MS and liver fibrosis. Diabetes, BMI and liver fibrosis were associated with steatosis >30% in CHC, whereas only age and BMI were related to steatosis in CHB.

CONCLUSION

These data may indicate that hepatitis C virus infection is a risk factor for insulin resistance.

Serum alanine aminotransferase levels, hematocrit rate and body weight correlations before and after hemodialysis session

PURPOSE

To evaluate alanine aminotransferase levels before and after a hemodialysis session and to correlate these values with the hematocrit rate and weight loss during hemodialysis.

PATIENTS AND METHODS

The serum alanine aminotransferase levels, hematocrit rate and body weight were measured and correlated before and after a single hemodialysis session for 146 patients with chronic renal failure. An receiver operating characteristic (ROC) curve for the serum alanine aminotransferase levels collected before and after hemodialysis was plotted to identify hepatitis C virus-infected patients.

RESULTS

The mean weight loss of the 146 patients during hemodialysis was 5.3% (p < 0.001). The mean alanine aminotransferase levels before and after hemodialysis were 18.8 and 23.9 IU/, respectively, denoting a significant 28.1% increase. An equally significant increase of 16.4% in the hematocrit rate also occurred after hemodialysis. The weight loss was inversely correlated with the rise in both the alanine aminotransferase level (r = 0.3; p < 0.001) and hematocrit rate (r = 0.5; p < 0.001). A direct correlation was found between the rise in alanine aminotransferase levels and the hematocrit during the hemodialysis session (r = 0.4; p < 0.001). Based on the ROC curve, the upper limit of the normal alanine aminotransferase level should be reduced by 40% relative to the upper limit of normal if the blood samples are collected before the hemodialysis session or by 60% if blood samples are collected after the session.

CONCLUSION

In the present study, significant elevations in the serum alanine aminotransferase levels and hematocrit rates occurred in parallel to a reduction in body weight after the hemodialysis session. These findings suggest that one of the factors for low alanine aminotransferase levels prior to hemodialysis could be hemodilution in patients with chronic renal failure.

The impact of diet on liver fibrosis and on response to interferon therapy in patients with HCV-related chronic hepatitis

BACKGROUND AND AIMS

A deranged metabolic status and alcohol intake may trigger induction and progression of chronic hepatitis C virus (HCV) liver disease. The aim of this study was to evaluate whether dietary composition affects the severity of liver damage and response to therapy in patients with HCV-related chronic hepatitis.

METHODS

We enrolled 1,084 patients with biopsy-proven HCV-related chronic hepatitis (432 treated with interferon plus ribavirin) and 2,326 healthy subjects in this prospective study conducted in a university hospital. Dietary habits were recorded in enrolled individuals, and their alcohol consumption was evaluated with a questionnaire (AUDIT). Body mass index, and plasma levels of blood glucose, nitrogen, creatinine, cholesterol, and triglycerides were also measured. All individuals underwent routine liver tests and HCV genotyping.

RESULTS

At study onset, there were no differences in metabolic status or alcohol consumption between patients and controls. About 50% of each group was overweight, and about 60% consumed alcohol. Patients and controls had similar dietary habits. Intake of carbohydrates, lipids and polyunsaturated fatty acids, and alcohol consumption were independent factors of liver damage at histology (logistic regression analysis). Some dietary components (unsaturated fatty acids, iron, zinc, vitamin A, and niacin) and alcohol intake differed significantly (P < 0.05 and P 0.01, respectively; univariate analysis) between responders and nonresponders to interferon therapy. Genotype, age, body mass index, steatosis, and fibrosis were independent predictors of therapy outcome (P < 0.02; multivariate analysis).

CONCLUSIONS

The severity of HCV-related chronic hepatitis depends on a variety of factors. Our results show that dietary composition is related to the extent of liver damage. Although traditional risk factors independently affected treatment response, some dietary components were associated with nonresponse to therapy in our patients. This suggests that HCV patients may benefit from instructions regarding their diet.

Factors predictive of significant hepatic fibrosis in adults with chronic hepatitis B and normal serum ALT

GOAL

This study examines the prevalence and correlates of significant liver fibrosis among patients with immunotolerant hepatitis B.

BACKGROUND

Adults with chronic hepatitis B infection acquired early in life often have normal serum alanine aminotransferase (ALT) activity and high serum hepatitis B virus deoxyribonucleic acid loads (HBV DNA), known as "immunotolerant" hepatitis B.

STUDY

We conducted a cross-sectional study of 28 hepatitis B patients with serum HBV DNA titer >10 copies/mL, positive hepatitis B envelope antigen, and persistently normal serum ALT in a tertiary care setting. Liver biopsies were reviewed by a single pathologist who was blinded to other data. The prevalence of significant hepatic fibrosis was determined using the hospital-defined upper limit of normal for ALT and 2 more stringent criteria proposed by recent studies. Statistical analyses were conducted to identify factors associated with hepatic fibrosis.

RESULTS

The prevalence of stage 2 fibrosis using the hospital laboratory, more stringent, and most stringent definitions of normal serum ALT, was 32%, 32%, and 13%, respectively, corresponding to negative predictive values of 68%, 68%, and 88%, respectively. Age greater than 30 years (P=0.035), grade 2 liver inflammation (P=0.005), and lower serum HBV DNA level (mean 7.45 vs. 8.42 log10 copies/mL, P<0.001) were independently associated with stage 2 fibrosis on liver biopsy.

CONCLUSIONS

These results highlight the need to use stringent definitions of normal serum ALT when making clinical decisions for patients with chronic hepatitis B. Older age and lower serum HBV DNA level predict significant hepatic fibrosis on biopsy. Our findings may guide decisions regarding liver biopsy among patients with immunotolerant hepatitis B.

Consensus recommendations for managing asymptomatic persistent non-virus non-alcohol related elevation of aminotransferase levels: suggestions for diagnostic procedures and monitoring

A persistent increase in non-virus non-alcohol related aminotransferase levels can have multiple causes, which differ in terms of prevalence and clinical importance. In the general population, the most frequent cause is non-alcoholic hepatic steatosis, which can evolve into steato-hepatitis and cirrhosis. The treatment for steatosis and non-alcoholic steato-hepatitis consists of modifying lifestyles, whereas the effectiveness of drug treatment remains to be determined. Other much less frequent (yet not rare) causes of persistent non-virus non-alcohol related elevations in aminotransferase levels are celiac disease and hemochromatosis, whereas autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and alpha-1-anti-trypsin deficit are rare. Given that some of these conditions are susceptible to treatment, early diagnosis is important. No epidemiological data are available for evaluating the prevalence of elevated aminotransferase levels correlated with the toxicity of drugs or other xenobiotics, including herbal products. The present document, created by a panel of experts based on a systematic review of scientific evidence, is mainly geared towards physicians working in General Medicine and Transfusion Centres, who generally represent the first contact of persons with elevated aminotransferase levels. The document includes suggestions for diagnosing causes of persistent non-virus non-alcohol related increases in aminotransferase levels, considering the frequency and response to treatment. The conditions requiring specialized visits are also indicated.

Metabolic profiles in patients with chronic hepatitis C: a case-control study

BACKGROUND

The clinical implications of metabolic profiles in patients with chronic hepatitis C remain controversial. To study the association of metabolic abnormalities with chronic hepatitis C, we conducted a case-control study with special emphasis on serum lipid pattern, fasting blood glucose, and adiponectin.

METHODS

We enrolled 500 patients with chronic hepatitis C and 536 sex and age-matched controls. Unadjusted and adjusted associations of demographic and metabolic variables were estimated.

RESULTS

Chronic hepatitis C patients had higher alanine aminotransferase (ALT) and high-density lipoprotein-cholesterol levels, but lower total cholesterol (TC), triglyceride (TG), and low-density lipoprotein-cholesterol levels than controls. Stratifying ALT level according to its upper limit of normal, HCV infection was associated with younger age, female gender, and higher TC levels in chronic hepatitis C patients with normal ALT levels, but with lower TC and lower TG levels in those with abnormal ALT levels. By using multiple linear regression analyses for subjects with available adiponectin data, presence of HCV infection was independently associated with higher serum adiponectin levels.

CONCLUSIONS

Metabolic profiles of chronic hepatitis C patients are affected by age, gender, serum adiponectin, and ALT levels. Further longitudinal studies are needed to clarify the complex interplay between HCV infection and metabolic profiles.

Guidelines for the antiviral therapy of hepatitis C virus carriers with normal serum aminotransferase based on platelet counts

AIM

We aimed to identify the candidates for antiviral therapy, among patients who are hepatitis C virus (HCV) carriers with normal serum aminotransferase (ALT), focused on the inhibition of hepatocellular carcinoma (HCC).

METHODS

Four hundred and sixty-four HCV carriers with normal serum ALT and 129 HCV carriers with persistently normal ALT (PNALT) and platelet (PLT) counts >/=150 000/muL who received liver biopsies were enrolled. HCV carriers with normal serum ALT were divided into four groups according to their ALT levels (</=30 U/L or 31-40 U/L) and PLT counts (>/=150 000/muL or <150 000/muL).

RESULTS

In 129 HCV carriers with PNALT, the rate of progression of fibrosis stage was 0.05/year and no HCC was detected during the follow up for 10 years. Approximately 20% of patients with ALT </=40 U/L and PLT counts >/=150 000/muLwere at stage F2-3; however, approximately 50% of patients with ALT </= 40 U/L and PLT counts <150 000/muL were at stage F2-4. An algorithm for the management of HCV carriers with normal serum ALT was advocated based on ALT and PLT counts.

CONCLUSION

The combination of ALT and PLT counts is useful for evaluating the fibrosis stage in HCV carriers with normal serum ALT. Most patients with PLT counts <150 000/muL are candidates for antiviral therapy, especially those with ALT levels >/=31 U/L when we focus on the inhibition of the development of HCC.

Management of HIV/hepatitis C virus-coinfected patient non-responders to hepatitis C virus antiviral therapy and relapsers

PURPOSE OF REVIEW

To examine recent developments in the management of HIV/hepatitis C virus-coinfected patients who relapsed or who responded poorly to initial therapy, with particular emphasis on peginterferon plus ribavirin.

RECENT FINDINGS

End-stage liver disease is the first cause of non-AIDS-related mortality in patients on antiretroviral therapy. A pool analysis of recent studies suggested that only 33% of HIV/hepatitis C virus-coinfected patients will achieve sustained virological response with peginterferon plus ribavirin. A substudy of the APRICOT trial shows that this strategy will benefit liver histology even in non-responding patients. The management of side effects is important and, according to a recent study, erythropoietin can improve clinical outcomes of hepatitis C virus therapy, although no direct association between response and the control of haematological toxicity was demonstrated. Patients who did not clear hepatitis C virus RNA with a slow virological response to previous courses of peginterferon and ribavirin might benefit from prolonging therapy to up to 72 weeks.

SUMMARY

Re-treatment strategies in non-responders to previous interferon-based therapies and relapsers should consider the previous virological response profile and ensure that treatment-related toxicity is controlled to avoid dose reductions or premature treatment interruptions. Further studies are needed to optimize therapeutic regimens.

Impact of diabetes on the severity of liver disease

The prevalence of type 2 diabetes is higher in patients who have liver diseases, such as nonalcoholic fatty liver disease, chronic viral hepatitis, hemochromatosis, alcoholic liver disease, and cirrhosis. The development of diabetes in patients with cirrhosis is well recognized, but evidence is emerging that the development of chronic liver disease and progression to cirrhosis may occur after the diagnosis of diabetes and that diabetes plays a role in the initiation and progression of liver injury. This article provides an overview of the evidence for an increased prevalence of diabetes in a range of liver diseases; the effect of diabetes on the severity of disease; the potential mechanisms whereby coexistent diabetes exacerbates progression of hepatic fibrosis; and the impact of obesity, insulin resistance, and type 2 diabetes on clinical outcomes.

Factors affecting serum concentrations of hepatitis C virus (HCV) RNA in HCV genotype 1-infected patients with chronic hepatitis

The serum concentration of hepatitis C virus (HCV) RNA is usually stable (4 to 8 log(10) IU/ml) in untreated patients with chronic hepatitis C. While this baseline HCV RNA concentration ([HCV RNA](BL)) is predictive of a sustained virologic response to treatment, its determinants are only partially identified. We therefore analyzed the baseline characteristics of 2,472 HCV genotype 1-infected patients to identify correlations with gender, age, race, weight, body mass index (BMI), HCV acquisition mode, HCV subtype, alanine aminotransferase concentration, or histopathologic changes in the liver. After separation of the data according to four [HCV RNA](BL) groups (< or =5.0, >5.0 to 5.6, >5.6 to 5.9, and >5.9 log(10) IU/ml), we determined that increasing [HCV RNA](BL) correlated (P < 0.05) with increasing proportions of patients who were male, >40 years of age, or heavier (a weight of >85 kg or a BMI of >27 kg/m(2)). Histologic activity index (HAI) data were available for 1,304 of these patients: increasing [HCV RNA](BL) correlated with higher fibrosis and necrosis-inflammation scores. As a continuous variable, [HCV RNA](BL) correlated with age, gender, weight (continuous or < or =85 versus >85 kg), BMI (continuous or < or =27 versus >27 kg/m(2)), subtype, fibrosis score, and necrosis-inflammation score; however, multiple-regression analysis yielded P values of <0.1 only for age, gender, BMI (< or =27 versus >27 kg/m(2)), and fibrosis score. While our findings are suggestive of a role for these factors in maintenance of the pretreatment state of HCV infection, the multiple-regression model accounted for only < or =4.6% of the [HCV RNA](BL) differences between individuals (R(2) = 0.046 for 1,304 patients with HAI scores; 0.043 for all 2,472 patients).