Association between cryoglobulinemia and liver fibrosis in chronic hepatitis C patients

Post-Treatment Occurrence of Serum Cryoglobulinemia in Chronic Hepatitis C Patients

BACKGROUND

Persistent cryoglobulinemia after the completion of antiviral treatment is an important consideration of clinical management in chronic hepatitis C patients. We aimed to investigate the occurrence of serum cryoglobulinemia in chronic hepatitis C patients without cryoglobulinemia at the initiation of antiviral treatment.

METHODS

In total, 776 patients without cryoglobulinemia were assessed for serum cryoglobulinemia after the completion of anti-HCV treatment. Serum cryoglobulinemia precipitation was assessed upon both the initiation and the completion of the treatment and analyzed for the clinical laboratory factors associated with chronic hepatitis C.

RESULTS

One hundred eighteen (118) patients were checked for serum cryo-precipitation after the completion of the treatment, and eight patients (4.6%) were positive for serum cryoglobulinemia. The patients who tested positive for cryoglobulinemia included a higher proportion of liver cirrhosis patients (4/50%, p = 0.033) and other organ cancer patients (5/62.5%, p = 0.006) than patients who showed no signs of cryoglobulinemia after treatment. In a multivariate analysis, liver cirrhosis (odds ratio [OR]-17.86, 95% confidence interval [95% CI]-1.79-177.35, p = 0.014) and other organ cancer (OR-25.17 95% CI-2.59-244.23, p = 0.005) were independently and significantly associated with positive cryoglobulinemia 3 months after antiviral treatment.

CONCLUSIONS

Three months after the antiviral DAA therapy had concluded, eight patients tested positive for cryoglobulinemia, representing a 6.7% prevalence. Liver cirrhosis and other organ cancer were independently and significantly associated with positive cryoglobulinemia after antiviral treatment. Further investigation into the causes of positive cryoglobulinemia after DAA antiviral therapy is warranted.

Transient elastography score is elevated during rheumatoid factor-positive chronic hepatitis C virus infection and rheumatoid factor decline is highly variable over the course of direct-acting antiviral therapy

Background

Elevated rheumatoid factor (RF) levels and systemic immune activation are highly prevalent during chronic hepatitis C virus (HCV) infection. Direct-acting antiviral (DAA) therapy has been associated with normalization of various soluble immune activation parameters. Whether the RF levels relate to soluble immune activation markers during chronic HCV infection, and over what time frame RF levels normalize during and after DAA treatment is unknown and was investigated here.

Methods

In a longitudinal study, plasma and serum was obtained from HCV infected RF positive (RF+) and RF negative (RF-) participants. The levels of RF, HCV RNA and soluble markers of inflammation were determined before (week 0), during (weeks 4, 8 and 12) and after (week 24) treatment with HCV DAA therapy. In a subset of RF+ participants, the analysis was extended to over 70 weeks after therapy initiation. Hepatic and other clinical parameters were determined at baseline (week 0) in all participants.

Results

Before therapy, transient elastography (TE) score was greater in RF+ compared to RF- HCV infected participants, while the systemic levels of soluble inflammatory markers were comparable. Following DAA therapy initiation, HCV RNA levels became undetectable within 4 weeks in both the RF+ and RF- groups. RF levels declined in the first 6 months in most RF+ persons but most commonly remained positive. The levels of some soluble inflammatory markers declined, mainly within 4 weeks of DAA therapy start, in both the RF+ and RF- groups. The baseline (week 0) TE score correlated with RF levels before, during and after DAA therapy, while plasma IL-18 levels correlated with RF level after DAA therapy.

Conclusion

During chronic HCV infection, TE score is elevated in RF+ HCV infected individuals and factors other than HCV viremia (including liver stiffness or fibrosis and select markers of inflammation) likely contribute to persistence of RF after treatment of HCV with DAA.

The association between hepatitis C virus infection and renal function

BACKGROUND

The association between hepatitis C virus (HCV) infection and chronic kidney disease (CKD) still remains controversial. We aimed to investigate whether HCV really affects renal function, and to analyze the association between clinical effects of CHC and decreased kidney function (assessed by glomerular filtration rate (eGFR) level).

METHODS

An estimated 3360 patients with HCV infection and 3360 age- and sex-matched community-based control individuals without HCV were enrolled (1:1, case and control ratio) in this study between 2004 and 2016. We used the modification of diet in renal diseases to calculate eGFR. Demographic and laboratory parameters were assessed, and appropriate statistical methods were performed for the analysis.

RESULTS

Multivariate logistic regression analysis revealed that serum alanine aminotransferase level (odds ratio [OR] 0.998; 95% confidence interval [CI] 0.997-0.999; P = 0.001), platelet count (OR 0.997; 95% CI 0.995-0.999; p = 0.002), and hypertension (OR 1.31; 95% CI 1.03-1.66; P = 0.027) were significantly associated with HCV infection and serum triglyceride levels (OR 1.001; 95% CI 1.00-1.002; p = 0.005), platelet count (OR 0.996; 95% CI 0.995-0.997; p < 0.001), body mass index (BMI) >25 (OR 1.43; 95% CI 1.23-1.67; p < 0.001), hypertension (OR 1.69; 95% CI 1.42-1.99; p < 0.001), hyperlipidemia (OR 1.32; 95% CI 1.02-1.71; p = 0.035), and diabetes (OR 1.33; 95% CI 1.03-1.71; p = 0.032) were significantly associated with a low eGFR (<90 mL/min/m3) in control subjects. The BMI >25 kg/m2, hypertension, and diabetes were found to be associated with low eGFR interaction with the HCV infection, via a multivariate analysis.

CONCLUSION

Our study found that the patients with HCV infection are associated with a low eGFR compared with non-HCV-infected patients. This association is consistent in obese, diabetic, and hypertensive patients.

Characteristics of patients with hepatitis C virus infection and antiviral treatment initiation in Taiwan: The MOSAIC study

Hepatitis C virus (HCV) infection is the leading cause of chronic liver diseases worldwide. Monitoring its epidemiology, diagnosis, and treatment patterns are important for the management of patients with chronic HCV infection from both individual and public health perspectives. The MOSAIC study was an observational study conducted in 20 countries, including Taiwan; its primary objective was to describe epidemiology and treatment initiation patterns in patients seeking HCV care. Of the 111 chronic HCV patients enrolled from Taiwan, 58 (52.3%) had not previously received treatment. HCV genotype 1 was reported in 58 (52.3%) patients, of whom the majority (n = 47; 81.0%) were identified as having subtype 1b. Sixty-two (55.9%) patients had HCV RNA level > 800 000 IU/mL. Liver cirrhosis was found in 35 (29.3%) patients and was more prevalent in patients who previously received treatment (71.0%). Interferon (IFN)-based treatment was started within 12 weeks from study inclusion in 12 (10.8%) patients, of whom 11 (91.7%) who had not previously received treatment. Anti-HCV treatment was not recommended by physicians in 70 (71.4%) and was refused by 23 (23.5%) patients. The MOSAIC study provides data on the epidemiology of HCV infection and IFN-based treatment decision patterns in Taiwan. Further studies are needed to observe the impact of IFN-free treatment on the treatment selection pattern.

Impact of mixed cryoglobulinemia on patients with spontaneous hepatitis C virus clearance: A 13-year prospective cohort study

BACKGROUND

The prevalence and associations of mixed cryoglobulinemia (MC) in patients with spontaneous clearance of hepatitis C virus (HCV) remain elusive.

MATERIALS AND METHODS

A 13-year prospective cohort study of patients with spontaneous HCV clearance was conducted in a tertiary care centre. Baseline characteristics, incident cardiovascular and neurologic events and cancers were analysed.

RESULTS

Of 104 consecutive patients (mean age: 54.08 years old; females: 71 [68%]), 37 (34.6%) had MC and 6 (5.8%) had cirrhosis. MC (+) patients were more female (86% vs 58%, P = .002), had higher rate of cirrhosis (14% vs 1.5%, P = .012), higher levels of Immunoglobulin G (IgG; P = .001), IgM (P = .002) and fibrosis-4 (FIB-4) (P = .004), but lower levels of complement C4 (P = .034) than the MC (-) patients. Female gender (95% confidence interval [CI] of odds ratio: 1.402-26.715), levels of IgG (1.000-1.004), IgM (1.009-1.037) and FIB-4 (1.217-3.966) were independently associated with MC. Baseline rheumatoid factor (RF) levels were independently associated with incident cancer (95% CI hazard ratio [HR]: 1.001-1.030 [HR: 1.015], P = .039). With a cut-off value of 11.3 IU/mL, RF levels significantly predicted incident cancer (area under curve: 0.865, P = .002). No different cumulative incidences of cardiovascular and neurologic events, cancers or mortalities were identified between MC (+) and MC (-) patient.

CONCLUSIONS

Approximately 1/3 of patients with spontaneous HCV clearance yielded MC, which harboured similar characteristics of MC in patients with chronic hepatitis C. Despite the negligible role of MC in the prognosis of patients with spontaneous HCV clearance, the connection between RF and incident cancer demands further investigation.

Rheumatoid factor and immunoglobulin M mark hepatitis C-associated mixed cryoglobulinaemia: an 8-year prospective study

OBJECTIVES

The prevalence and factors of hepatitis C virus (HCV) -associated mixed cryoglobulinaemia in Asia remain elusive, and we aimed to investigate these topics.

METHODS

An 8-year prospective cohort study was conducted in 678 consecutive Taiwanese individuals with chronic HCV infection (438 completed an anti-HCV therapy course).

RESULTS

Of 678 individuals, 437 (64.5%) had mixed cryoglobulinaemia and 20 (2.9%) had mixed cryoglobulinaemic syndrome. At baseline, IgM (cut-off >122 mg/dL), triglycerides and IgG levels, and HCV genotype 3 were independently associated with mixed cryoglobulinaemia. Rheumatoid factor (RF) levels were associated with mixed cryoglobulinaemic syndrome (cut-off >12.2 IU/mL). At 24 weeks post-therapy, the 362 individuals with a sustained virological response (SVR) had higher cured (106/362 (29.3%) versus 10/76 (13.2%), p = 0.003) and lower persistent (100/362 (27.6%) versus 33/76 (43.4%), p = 0.003) mixed cryoglobulinaemia rates than non-SVR patients. Among SVR patients, compared with baseline levels, RF, IgG and IgM levels decreased, except in individuals with new mixed cryoglobulinaemia. Pre-therapy IgM levels were associated with 24-week post-therapy new (95% CI of OR 1.002-1.023) and persistent (95% CI of OR 1.004-1.015) mixed cryoglobulinaemia in SVR patients. After up to 8 years, 24-week post-therapy IgM levels were associated with mixed cryoglobulinaemia in SVR patients (9/51; 17.64%; 95% CI of HR 1.004-1.011). Among 17 SVR patients with pre-therapy mixed cryoglobulinaemic syndrome, 5 (29.4%) had long-term mixed cryoglobulinaemia and 4 (23.5%) had mixed cryoglobulinaemic syndrome.

CONCLUSIONS

Over 60% of chronic HCV-infected individuals had mixed cryoglobulinaemia, and 17.64% of SVR patients had mixed cryoglobulinaemia 8 years post-therapy. Pre-therapy RF and IgM levels marked HCV-associated mixed cryoglobulinaemic syndrome and mixed cryoglobulinaemia, respectively.