[Alcoholic liver disease - 2023]

Alcoholic liver disease represents a spectrum of liver injuries from fatty liver, steatohepatitis, fibrosis and cirrhosis to hepatocellular carcinoma. Progression of the disease depends on the amount of alcohol consumption and risk factors or comorbidities, e.g., genetic predisposition, female susceptibility, diet, smoking, obesity, viral infection. Patients with alcoholic liver disease have two pathologies to be diagnosed and treated: the liver disease per se, and the harmful, excessive alcohol consumption (alcohol use disorder) or even dependence. The early diagnosis is important for both conditions and for achieving abstinence. For the diagnosis, there are several biomarkers and non-invasive tests, including psychological tools. To maintain abstinence, pharmacological and non pharmacological interventions can be applied. Concerning the liver disease, the main aims of treatment are to decrease inflammation and oxidative stress, to inhibit cell injury and fibrosis, to modulate liver-gut axis and to support regeneration. Management of patients with alcoholic hepatitis and cirrhosis often needs a psychological support, delivered by a multidisciplinary integrated care model, a close cooperation between addiction experts and hepatologists. Patients with severe alcoholic hepatitis not responding to medical (corticosteroid) therapy should be carefully selected and considered for early liver transplantation. Orv Hetil. 2023; 164(47): 1846-1864.

[The challenge of the age of hepatitis C virus elimination: why is HCV vaccination necessary?]

Hepatitis C virus is a common cause of chronic liver disease, that may lead to cirrhosis, hepatocellular cancer and liver transplanation. The advent of highly efficacious direct-acting antivirals and their success in the treatment of hepatitis C virus infection, generated soon an optimism. Thus, the World Health Organization has adopted a global strategy of reducing the incidence of new hepatitis B and C virus infection by 90 % by 2030. However, it turned out, that this goal is not achievable by drug treatment alone without a vaccination, because of the high number of infected persons, low rate of screening and poor access to treatment in several countries, and even the cost of the therapy. The paper discusses the virological and imunological feaures of the HCV infection, and the possibility of an effective vaccination against hepatitis C virus. In addition, we overview the types of potential vaccines and the models for the assessment of vaccine efficacy. The controlled human infection model using healthy volunters, became a real possibility, due to the availability of direct-acting antiviral treatment for hepatitis C. On the ground of the newest results of vaccine researches, we are confident to achive the goal of eliminating hepatitis C virus in the near future. Orv Hetil. 2023; 164(9): 322-331.

A nem alkoholos zsírmájbetegség és a 2-es típusú cukorbetegség

A nem alkoholos zsírmájbetegség ma a krónikus májbetegség leggyakoribb oka, agresszív formája, a nem alkoholos steatohepatitis fibrosisba, cirrhosisba progrediálhat, és végstádiumú májbetegséghez vezethet. A kórkép gyakran társul obesitassal és 2-es típusú cukorbetegséggel, valamint cardiovascularis és renalis szövődményekkel, ugyanakkor nincs jóváhagyott, specifikus terápiája. Kezelése a kockázati tényezők (obesitas, diabetes, dyslipidaemia) kontrollálásán és az életmód-változtatás, testsúlycsökkentés, kalóriabevitel megszorítása és fizikai aktivitás javaslatán alapul, amit azonban nehéz elérni és fenntartani. A betegség hatékony farmakoterápiájára ezért különösen nagy szükség lenne. A dolgozatban tárgyaljuk azokat a farmakonokat, amelyek az obesitas vagy a diabetes kezelésére elérhetők, és amelyek az előzetes vizsgálatok alapján potenciálisan a nem alkoholos steatohepatitis terápiájában is hasznosíthatók. Jelenleg egyedül az antidiabetikumként ismert pioglitazon és az antioxidáns E-vitamin adása javasolt a nem alkoholos steatohepatitis bizonyos eseteiben. Az említetteken kívül áttekintjük azokat a fejlesztés alatt álló készítményeket, amelyek a nem alkoholos zsírmáj különböző patogenetikai útjait célozzák meg, és specifikusan a steatohepatitis kezelésére szolgálnának. Ezeknek a farmakonoknak a terápiás hatása a májzsírtartalom és a de novo lipogenezis csökkentésén, a farnezoid X-receptor–epesav tengely és a bélmikrobiom módosításán, az oxidatív stressz, a gyulladás és a fibrogenezis gátlásán alapulna. A jövőben feltehetően a különböző támadáspontú farmakonok kombinációi jelentik a nem alkoholos steatohepatitis hatékony terápiáját. A nem alkoholos zsírmájbetegség szisztémás metabolikus kórképnek tekinthető, kezelése ezért a diabetológusok, nefrológusok, kardiológusok és hepatológusok együttműködését igényli. Orv Hetil. 2022; 163(22): 855–862.

A nem alkoholos zsírmájbetegség és a 2-es típusú cukorbetegség

A nem alkoholos zsírmájbetegség (NAFLD) ma a leggyakoribb májbetegség, a világ népességének 25%-át érinti. A kórkép és progresszív formája, a nem alkoholos steatohepatitis gyakran társul obesitassal és 2-es típusú cukorbetegséggel. NAFLD-ben 2–3-szoros a diabetes kockázata, ami párhuzamosan nő a májbetegség súlyosságával. Mivel komplex kapcsolat van a két kórkép között, a zsírmáj és a diabetes szinergikusan hat a kedvezőtlen klinikai kimenetelre. Cukorbetegekben gyakori a zsírmáj, és a diabetes NAFLD-ben prediktora a steatohepatitisbe, fibrosisba, cirrhosisba való progressziónak. A genetikai faktorok mellett a túlzott kalóriabevitel, a zsírszövet diszfunkciója, az inzulinrezisztencia, a szabad zsírsavak és gyulladásos citokinek, valamint a lipo- és glükotoxicitás szerepe meghatározó a NAFLD és a diabetes kialakulásában. A dolgozatban áttekintjük a két kórképet összekötő patomechanizmusokat. Orv Hetil. 2022; 13(21): 815–825.

Sarcopenia - 2021: Pathophysiology, diagnosis, therapy

Összefoglaló. A sarcopenia progresszív, generalizált vázizombetegség az izomtömeg fogyásával és az izomfunkció romlásával, számos szövődménnyel, rossz prognózissal. A sarcopeniát eredetileg életkorfüggő, idősekben jelentkező kórképnek írták le (primaer sarcopenia). Később derült ki, hogy fiatal- és középkorú személyeknél is előfordul, különböző betegségekhez társulva (secundaer sarcopenia). A közlemény áttekintést ad a betegség patofiziológiájáról, a fizikai inaktivitás, az inzulinrezisztencia, a krónikus gyulladás, a citokinek, hepatokinek és miokinek szerepéről az izomkárosodásban, valamint az izom, a zsírszövet és a máj funkcionális kapcsolatairól nem alkoholos zsírmájban és cirrhosisban. A diagnózis felállítását számos funkcionális próba, illetve vizsgálóeljárás teszi lehetővé. Az izomerő-csökkenés igazolása a legfontosabb paraméter (kézszorító erő). Az izomtömegvesztést kettős energiájú röntgenabszorpciometria, bioelektromosimpedancia-analízis, komputertomográfia vagy mágneses rezonanciás képalkotó vizsgálat mutathatja ki, megerősítve a kórismét, a fizikai teljesítmény csökkenése pedig a sarcopenia súlyosságát jelzi. A sarcopenia kezelése és a progresszió prevenciója a fiatalkorban elkezdett és élethosszig tartó rendszeres fizikai aktivitáson, a protein-kalória túltápláláson és a gyógyszeres terápián alapul, beleértve a D-vitamin és a tesztoszteron pótlását, az elágazó láncú aminosavak és az L-karnitin adását. Másodlagos sarcopeniában az alapbetegség kezelése is szükséges. Orv Hetil. 2021; 162(1): 3-12. Summary. Sarcopenia is a progressive, generalized skeletal muscle disease with the loss of muscle mass and function, associated with adverse outcomes and poor prognosis. Sarcopenia first was regarded as an age-related disorder of older people (primary sarcopenia). Later it turned out that it can also occur in young age due to a range of chronic disorders such as cancer, anorexia or malnutrition (secondary sarcopenia). This paper overviews the pathophysiology of sarcopenia and the factors involved in the muscle mass loss, i.e., physical inactivity, insulin resistance, low-grade chronic inflammation, hepatokines and myokines. The basic feature is the imbalance between proteolysis and protein synthesis that leads to muscle atrophy. We discuss the relationship between liver, muscle and adipose tissue in non-alcoholic fatty liver disease and cirrhosis. To diagnose sarcopenia, there are a range of tests and tools that measure muscle strength and muscle mass as well as physical performance. The low muscle strength (hand grip strength) is the primary parameter of the diagnosis, the best measure of muscle function. The loss of skeletal muscle mass assessed by dual-energy X-ray absorptiometry, bioelectric impedance analysis, computer tomography, or magnetic resonance imaging confirms diagnosis, while the decrease in physical performance reflects severe sarcopenia. For the treatment and prevention of progression, the most important is the regular physical activity started from early adulthood, and healthy diet containing protein-calorie hyperalimentation. In addition, a pharmacotherapy with the supplementation of vitamin D and testosterone, furthermore, the administration of L-carnitine and branched-chain amino acids can be recommended. In the case of secondary sarcopenia, the underlying disease also requires treatment. Orv Hetil. 2021; 162(1): 3-12.

[Alcoholic liver disease: the roles of genetic-epigenetic factors and the effect of abstinence]

The pathogenesis of alcoholic liver disease depends not only on the toxic effects of alcohol, but also on the complex interaction of host's and environmental factors. Thus, the genetic pre-disposition, co-morbidities and behavioral factors all play a role in the individual variations in the disease outcomes. On the other hand, the essential part of the therapeutic strategy is the complete withdrawal of the harmful etiological agent. The present paper is devoted to overview the genetics, the environmental factors and the effects of abstinence in alcoholic liver disease. Genetic variants in two enzymes involved in the metabolism of ethanol, alcohol-dehydrogenase ADH1B *2 and aldehyde-dehydrogenase ALDH2 *2 through increasing the blood level of acetaldehyde, may play a "protective" role against alcoholism. The P450 CYP2E1 *5 c2, an inducible microsomal oxidase, upregulated by ethanol and by formation of acetaldehyde and reactive oxygen species, increases liver toxicity. Three novel gene polymorphisms - such as the patatin-like phospholipase domain-containing 3 (PNPLA3 I148M C>G), the transmembrane 6 superfamily member 2 (TM6SF2 E167K), and the membrane-bound O-acyltransferase domain-containing 7 (MB0AT7 rs641738 C>T) - have been proven as risk factors of steatosis, fibrosis and even hepatocellular carcinoma in both alcoholic and non-alcoholic fatty liver disease patients. Alcohol-induced epigenetic effects, reversible but inheritable gene expression alterations - as histon modulations, DNA methylation and micro-RNA-s - are of importance in the pathogenesis as well, and in the future, they may serve as diagnostic markers and therapeutic targets. Women are at greater risk of developing alcoholic cirrhosis, furthermore, malnutrition, obesity, diabetes, smoking, and hepatitis virus infections are also risk factors. Alcoholic liver disease should be regarded as a preventable disease. Several clinical studies revealed that abstinence may result in the regression of steatohepatitis and fibrosis, compensation of cirrhosis, improving disease outcome and increasing survival even in patients with advanced stages. Early diagnosis and multidisciplinary interventions are highly required to achieve long-term abstinence and to prevent alcoholic cirrhosis. Orv Hetil. 2019; 160(14): 524-532.

[Screening, diagnosis, treatment, and follow up of hepatitis C virus related liver disease. National consensus guideline in Hungary from 22 September 2017]

The treatment of hepatitis C is based on a national consensus guideline updated six-monthly according to local availability and affordability of approved therapies through a transparent allocation system in Hungary. This updated guideline incorporates some special new aspects, including recommendations for screening, diagnostics, use and allocation of novel direct acting antiviral agents. The indication of therapy in patients with no contraindication is based on the demonstration of viral replication with consequent inflammation and/or fibrosis in the liver. Non-invasive methods (elastographies and biochemical methods) are preferred for liver fibrosis staging. The budget allocated for these patients is limited. Interferon-based or interferon-free therapies are available for the treatment. Due to their limited success rate as well as to their (sometimes severe) side-effects, the mandatory use of interferon-based therapies as first line treatment can not be accepted from the professional point of view. However, they can be used as optional therapy in treatment-naïve patients with mild disease. As of interferon-free therapies, priority is given to those with urgent need based on a pre-defined scoring system reflecting mainly the stage of the liver disease, but considering also additional factors, i.e., hepatic decompensation, other complications, activity and progression of liver disease, risk of transmission and other special issues. Approved treatments are restricted to the most cost-effective combinations based on the cost per sustained virological response value in different patient categories with consensus amongst treating physicians, the National Health Insurance Fund of Hungary and patients' organizations. Interferon-free treatments and shorter therapy durations are preferred. Orv Hetil. 2018; 159(Suppl 1): 3-23.

[Diagnosis and treatment of chronic hepatitis B and D. National consensus guideline in Hungary from 15 October 2016]

Diagnosis and treatment of HBV/HDV infection means for the patient to be able to maintain working capacity, to increase quality of life, to prevent cancer, and to prolong life expectancy, while society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms for 2017 set by a consensus meeting of physicians involved in the treatment of these diseases. The prevalence of HBV infection in the Hungarian general population is 0.5-0.7%. The indications of treatment is based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for cost-effective approach the guideline stresses the importance of quick and detailed virologic evaluations, the applicability of elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection can be pegylated interferon for 48 weeks or continuous entecavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection. Orv. Hetil., 2017, 158(Suppl. 1) 23-35.

[Screening, diagnosis, treatment, and follow up of hepatitis C virus related liver disease. National consensus guideline in Hungary from 15 October 2016]

Treatment of hepatitis C is based on a national consensus guideline updated six-monthly according to local availability and affordability of approved therapies through a transparent allocation system in Hungary. This updated guideline incorporates some special new aspects, including recommendations for screening, diagnostics, use and allocation of novel direct acting antiviral agents. Indication of therapy in patients with no contraindication is based on demonstration of viral replication with consequent inflammation and/or fibrosis in the liver. Non-invasive methods (elastographies and biochemical methods) are preferred for liver fibrosis staging. The budget allocated for these patients is limited. Therefore, expensive novel direct acting antiviral combinations as first line treatment are reimbursed only, if the freely available, but less effective and more toxic pegylated interferon plus ribavirin dual therapy deemed to prone high chance of adverse events and/or low chance of cure. Priority is given to those with urgent need based on a pre-defined scoring system reflecting mainly the stage of the liver disease, but considering also additional factors, i.e., hepatic decompensation, other complications, activity and progression of liver disease, risk of transmission and other special issues. Approved treatments are restricted to the most cost-effective combinations based on the cost per sustained virological response value in different patient categories with consensus amongst treating physicians, the National Health Insurance Fund and patient's organizations. Interferon-free treatments and shorter therapy durations are preferred. Orv. Hetil., 2017, 158(Suppl. 1), 3-22.

[Three decades of the hepatitis C virus from the discovery to the potential global elimination: the success of translational researches]

More than 25 years after the discovery of hepatitis C virus, the development of the direct acting antivirals can lead to the regional or long-term global elimination of the virus with over 90% efficacy. This is the success of basic and clinical translational research. Yet, some unsolved challanges remain, such as the great number of unidentified patients who are not aware of their condition, the limited access to the therapy due to the high prices of the drugs, and the treatment of resistance-associated variants. In addition, the lack of vaccine is also an obstacle. In 2016, the World Health Organization (WHO) developed the first global health sector strategy for the elimination of viral hepatitis by 2030. Its evidence-based guidelines are primarily targeted at the national hepatitis programme managers who are responsible for the national testing and treatment plans. According to these recommendations, it is of basic importance to perform focused risk-based testing in higher-risk populations and after diagnosis to start treatment as "cure as prevention", furthermore, to limit the risk of reinfection. We review the events of the HCV story from the discovery to these days, including virology, epidemiology, pathogenesis, diagnosis and therapy. Orv Hetil. 2018; 159(12): 455-465.

Ombitasvir/paritaprevir/ritonavir + dasabuvir + ribavirin in HCV genotype 1 infected patients who failed previous protease inhibitor therapy

AIM OF THE STUDY

Combination of ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (3DDA±RBV) therapy is shown to be effective in HCV genotype 1 (GT1) infected patients. However, sparse data exist in patients who failed previous boceprevir or telaprevir based therapies. Real life efficacy and safety of this combination were evaluated in HCV GT1b infected patients (mostly cirrhotics) with compensated liver disease who failed previous boceprevir or telaprevir based therapies more than a year before.

MATERIAL AND METHODS

Data of previous protease inhibitor failure patients, treated with 3DAA+RBV for 12 weeks (GT1b and/or non-cirrhotics) or 24 weeks (non-GT1b cirrhotics), were retrospectively collected.

RESULTS

Population characteristics: boceprevir/telaprevir-failure: 82/45, GT1b: 117, cirrhotic: 111 (87.4%). SVR12/24 was observed in 103/105 patients (98.1%) of those who reached either time point. Four SAEs reported: one death due to myocardial infarction, another due to recurrent hepatocellular carcinoma after achieving SVR12, two hospitalizations (elevation of transaminases, pneumonia). Grade ≥ 3 AEs or laboratory abnormalities were reported in < 10% of patients; they were transient in all patients. No early discontinuation of drugs due to SAE has been reported.

CONCLUSIONS

One year after previous failure of boceprevir or telaprevir based therapy, 12 weeks of 3DAA+RBV combination in HCV GT1b infected patients is similarly effective and safe as in those with no previous HCV therapy, even in the presence of cirrhosis. These findings might be of particular interest in settings where alternative therapies for such patients are not available or not affordable.

[Diagnosis and treatment of chronic hepatitis B and D. National consensus guideline in Hungary from 22 September 2017]

Diagnosis and treatment of hepatitis B virus (HBV) and hepatitis D virus infection mean for the patient to be able to maintain working capacity, to increase quality of life, to prevent cancer, and to prolong life expectancy, while the society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms from 22 September 2017 set by a consensus meeting of physicians involved in the treatment of these diseases. The prevalence of HBV infection in the Hungarian general population is 0,5-0,7%. The indications of treatment are based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for a cost-effective approach, the guideline stresses the importance of quick and detailed virologic evaluations, the applicability of transient elastography as an acceptable alternative of liver biopsy in this regard as well as the relevance of appropriate consistent follow-up schedule for viral response during therapy. The first choice of therapy in chronic HBV infection can be pegylated interferon for 48 weeks or continuous entecavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Lamivudine is no longer the first choice; patients currently taking lamivudine must switch if the response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection. Orv Hetil. 2018; 159(Suppl 1): 24-37.

[Advances in the pathogenesis of non alcoholic fatty liver disease]

Non alcoholic fatty liver disease is the hepatic manifestation of metabolic syndrome, and the most common liver disease. Its more aggressive form is the non alcoholic steatohepatitis. Multiple genetic and environmental factors lead to the accumulation of triglicerides and the inflammatory cascade. High fat diet, obesity, adipocyte dysfunction with cytokine production, insulin resistance and increased lipolysis with free fatty acid flux into the liver - all are the drivers of liver cell injury. Activation of inflammasome by damage- or pathogen-associated molecular patterns results in "steril inflammation" and immune response, while the hepatic stellate cells and progenitor cells lead to fibrogenesis. Small intestinal bacterial overgrowth and gut dysbiosis are also of pivotal importance in the inflammation. Among the susceptible genetic factors, mutations of patatin-like phospholipase domain containing 3 and the transmembrane 6 superfamily 2 genes play a role in the development and progression of the disease, similarly as do epigenetic regulators such as microRNAs and extracellular vesicles. Better understanding of the pathogenesis of non alcoholic fatty liver disease may identify novel therapeutic agents that improve the outcome of the disease. Orv Hetil. 2017; 158(23): 882-894.

[Non-alcoholic fatty liver disease and hepatocellular carcinoma - 2016]

In the past decade non-alcoholic liver disease became the most frequently diagnosed liver disease in developed countries. At the same time, the dramatic rise in the incidence of hepatocellular carcinoma is attributed to this common metabolic disorder, and mainly to its severe form, non-alcoholic steatohepatitis. The risk factors of these associated diseases are genetic predisposition, obesity and diabetes as well as chronic low grade necro-infammation, which often leads to liver fibrosis. Free fatty acids, cytokines, lipotoxicity, insulin resistance, microRNS dysregulation and alteration in intestinal microbiota play a pivotal role in the pathogenesis. Treatment of non-alcoholic fatty liver disease - weight reduction and physical exercise in obesity, metformin in diabetes, statins in dyslipidemia and, as a new option, obeticholic acid - may diminish the risk of the hepatocellular carcinoma related to this metabolic disease.

[Immune response and oxidative stress in hepatitis C virus infection]

This review summarizes our current knowledge of the innate and adaptive immune responses induced by hepatitis C virus, and of the genetic polymorphisms that may determine the outcome of the disease. In addition, the authors discuss the role of reactive oxygen species and oxidative stress in hepatitis C virus-related pathogenic processess, such as hepatitis, fibrosis, hepatocellular carcinoma, steatosis and insulin resistance.

A hepatitis B- és D-vírus-fertőzés diagnosztikája, antivirális kezelése. Magyar konszenzusajánlás. Érvényes: 2015. szeptember 12-től

Diagnosis and treatment of HBV/HDV infection means for the patient to be able to maintain working capacity, to increase quality of life, to prevent cancer, and to prolong life expectancy, while society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms for 2016 set by a consensus meeting of physicians involved in the treatment of these diseases. The prevalence of HBV infection in the Hungarian general population is 0.5–0.7%. The indications of treatment is based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for cost-effective approach the guideline stresses the importance of quick and detailed virologic evaluations, the applicability of elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection can be pegylated interferon for 48 weeks or continuous ente- cavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection. Orv. Hetil., 2015, 156(Suppl. 2) 25–36.

[In Process Citation]

Approximately 70.000 people are infected with hepatitis C virus in Hungary, more than half of whom are not aware of their infection. From the point of infected individuals early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases and complications (liver cirrhosis, liver failure and liver cancer) and can increase work productivity and life expectancy on one hand. From socioeconomic aspect, this could also prevent further spread of the virus as well as reduce substantially long term financial burden of related morbidity. Available since 2003 in Hungary, pegylated interferon + ribavirin dual therapy can clear the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of a direct acting first generation protease inhibitor drug (boceprevir or telaprevir) to the dual therapy increases the chance of sustained virologic response to 63-75% and 59-66%, respectively. These two protease inhibitors are available and financed for a segment of Hungarian patients since May 2013. Between 2013 and February 2015, other direct acting antiviral interferon-free combination therapies have been registered for the treatment of chronic hepatitis C, with a potential efficacy over 90% and typical short duration of 8-12 weeks. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and or fibrosis in the liver. Non-invasive methods (eleastography and biochemical methods) are accepted and preferred for staging liver damage (fibrosis). For initiation of treatment accurate and timely molecular biology tests are mandatory. Eligibility for treatment is a subject of individual central medical review. Due to budget limitations tharpy is covered only for a proportion of patients by the National Health Insurance Fund. Priority is given to those with urgent need based on a Hungarian Priority Index system reflecting primarily the stage of liver disease, and considering also additional factors, i.e., activity and progression of liver disease, predictive factors of treatment and other special issues. Approved treatments are restricted to the most cost-effective combinations based on the cost per sustained virologic response value in different patient categories with consensus between professional organizations, National Health Insurance Fund and patient organizations. More expensive therapies might be available upon co-financing by the patient or a third party. Interferon-free treatments and shorter therapy durations preferred as much as financially feasible. A separate budget is allocated to cover interferon-free treatments for the most-in-need interferon ineligible/intolerant patients, and for those who have no more interferon-based therapy option. Orv. Hetil., 2015, 156(Suppl. 2), 3-24.

[Non-invasive diagnostic methods of fibrosis in chronic hepatitis C virus infection: their role in treatment indication, follow-up and assessment of prognosis]

Chronic hepatitis C virus infection associated with necroinflammation predisposes to liver fibrosis and cirrhosis, which lead to severe end-stage complications. Staging of fibrosis is of basic importance for the indication of antiviral treatment, for monitoring the response and predicting the prognosis of patients with hepatitis C virus related liver disease. Since liver biopsy, the "gold standard" diagnosis of fibrosis is invasive and it has some other limitations, non-invasive methods have been developed and widely used in the clinical practice. Serum biomarkers and physical approaches measuring liver stiffness by elastography as well as combination algorithms have been gradually been integrated into guidelines resulting in a reduction of the need for liver biopsy. The authors review these non-invasive fibrosis markers and discuss their role in the indication of treatment, follow-up, and assessment of prognosis of patients with chronic hepatitis C virus infection.

[In Process Citation]

Approximately 70,000 people are infected with hepatitis C virus in Hungary, and more than half of them are not aware of their infection. From the point of infected individuals early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases and complications (liver cirrhosis, liver failure and liver cancer) and can increase work productivity and life expectancy. From a socioeconomic aspect, this could also prevent further spread of the virus as well as reduce substantially long term financial burden of related morbidity. Pegylated interferon + ribavirin dual therapy, which is available in Hungary since 2003, can clear the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of a direct acting first generation protease inhibitor drug (boceprevir or telaprevir) to the dual therapy increases the chance of sustained viral response to 63-75% and 59-66%, respectively. These two protease inhibitors are available and financed for a segment of Hungarian patients since May 2013. Between 2013 and February 2015, other direct acting antiviral interferon-free combination therapies have been registered for the treatment of chronic hepatitis C, with a potential efficacy over 90% and typical short duration of 8-12 weeks. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and / or fibrosis in the liver. Non-invasive methods (elastography and biochemical methods) are accepted and preferred for staging liver damage (fibrosis). For initiation of treatment as well as for on-treatment decisions, accurate and timely molecular biology tests are mandatory. Eligibility for treatment is a subject of individual central medical review. Due to budget limitations therapy is covered only for a proportion of patients by the National Health Insurance Fund. Priority is given to those with urgent need based on a Hungarian Priority Index system reflecting primarily the stage of liver disease, and considering also additional factors, i.e., activity and progression of liver disease, predictive factors of treatment and other special issues. Approved treatments are restricted to the most cost-effective combinations based on the cost per sustained viral response value in different patient categories with consensus between professional organizations, National Health Insurance Fund and patient organizations. More expensive therapies might be available upon co-financing by the patient or a third party. Interferon-free treatments and shorter therapy durations preferred as much as financially feasible. A separate budget is allocated to cover interferon-free treatments for the most-in-need interferon ineligible/intolerant patients, and for those who have no more interferon-based therapy option. Orv. Hetil., 2015, 156(Suppl. 1), 3-23.

[Hepatitis C: diagnosis, anti-viral therapy, after-care. Hungarian consensus guideline]

Approximately 70,000 people are infected with hepatitis C virus in Hungary, and more than half of them are not aware of their infection. From the point of infected individuals early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases and complications (liver cirrhosis, liver failure and liver cancer) and can increase work productivity and life expectancy. Furthermore, these could from prevent further spread of the virus as well as reduce substantially long term financial burden of related morbidity, as a socioeconomic aspect. Pegylated interferon + ribavirin dual therapy, which is available in Hungary since 2003, can clear the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of a direct acting first generation protease inhibitor drug (boceprevir or telaprevir) to the dual therapy increases the chance of sustained viral response to 63-75% and 59-66%, respectively. These two protease inhibitors are available and financed for a segment of Hungarian patients since May 2013. Between 2013 and February 2015, other direct acting antivirals and interferon-free combination therapies have been registered for the treatment of chronic hepatitis C with a potential efficacy over 90% and typically with a short duration of 8-12 weeks. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and/or fibrosis in the liver. Non-invasive methods (elastography and biochemical methods) are accepted and preferred for staging liver damage (fibrosis). For initiation of treatment accurate and timely molecular biology tests are mandatory. Eligibility for treatment is a subject of individual central medical review. Due to budget limitations therapy is covered only for a proportion of patients by the National Health Insurance Fund. Priority is given to those with urgent need based on a Hungarian Priority Index system reflecting primarily the stage of liver disease, and considering also additional factors, i.e., activity and progression of liver disease, predictive factors of treatment and other special issues. Approved treatments are restricted to the most cost-effective combinations based on the cost per sustained viral response value in different patient categories with consensus between professional organizations, National Health Insurance Fund and patient organizations. More expensive therapies might be available upon co-financing by the patient or a third party. Interferon-free treatments and shorter therapy durations preferred as much as financially feasible. A separate budget is allocated to cover interferon-free treatments for the most-in-need interferon ineligible/intolerant patients, and for those who have no more interferon-based therapy option.

Diagnosis and treatment of chronic hepatitis B and D.Hungarian national consensus guideline

Diagnosis and treatment of hepatitis B and D virus infections mean that the patient is able to maintain working capacity, increase quality of life, prevent cancer, and prolong life expectancy, while the society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms for 2015, which is agreed on a consensus meeting of specialists involved in the treatment of the above diseases. The prevalence of hepatitis B virus infection in the Hungarian general population is 0.5–0.7%. The indications of treatment is based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for cost-effective approach the guideline emphasizes the importance of quick and detailed virologic evaluations, the applicability of transient elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection can be pegylated interferon for 48 weeks or continuous entecavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection. Orv. Hetil., 2015, 156(Suppl. 1), 25–35.

[Transient elastography as a predictor of oesophageal varices in patients with liver cirrhosis]

INTRODUCTION

One of the most serious complications of liver cirrhosis is variceal bleeding. Early recognition of the oesophageal varices is of primary importance in the prevention of variceal bleeding. Endoscopy is the only means to directly visualize varices and measure their size, as one of the most important predictor of the risk of bleeding. During the course of cirrhosis repeated oesophago-gastro-bulboscopic examinations are recommended. As these interventions are expensive and often poorly accepted by patients who may refuse further follow-up, there is a need for non-invasive methods to predict the progression of portal hypertension as well as the presence and the size of oesophageal varices. After several combinations of biological and ultrasonographical parameters proposed for the detection of advanced fibrosis, it was suggested that liver stiffness measured by transient elastography, a novel non-invasive technology may reflect not only fibrosis and portal pressure but it may even predict the presence or absence of large oesophageal varices in patients with cirrhosis.

AIM

The aim of the authors was to study the diagnostic accuracy of transient elastography using FibroScan for selecting patients who are at risk of bearing large (Paquet-grade ≥ II) oesophageal varices and high risk of bleeding.

METHOD

The authors performed upper tract endoscopy and transient elastography in 74 patients with chronic liver disease (27 patients with chronic hepatitis and 47 patients with liver cirrhosis). The relationships between the presence of oesophageal varices (Paquet-grade 0-IV) and liver stiffness (kPa), as well as the hematological and biochemical laboratory parameters (prothrombine international normalized ratio, platelet count, aspartate aminotransferase, alanine aminotransferase, albumin, and aspartate aminotransferase/platelet ratio index) were investigated. The predictive role of liver stiffness for screening patients with varices and those who are at high risk of variceal bleeding was also analysed.

RESULTS

Liver stiffness values significantly correlated with the grade of oesophageal varices (Paquet-grade) (r = 0.67, p<0.0001). The liver stiffness value of 19.2 kPa was highly predictive for the presence of oesophageal varices (AUROC: 0.885, 95% CI: 0.81-0.96) and for the presence of high grade varices (P≥II) (AUROC: 0.850, 95% CI: 0.754-0.94). Using the cut-off value of 19.2 kPa, the sensitivity of transient elastography was 85%, specificity was 87%, positive predictive value was 85%, negative predictive value was 87% and validity was 86% for the detection of varices. Liver stiffness values less than 19.2 kPa were highly predicitive for the absence of large (P≥II) varices (sensitivity, 95%; specificity, 70%; positive predictive value, 54%; negative predictive value, 97%).

CONCLUSIONS

Transient elastography may help to screen patients who are at high risk of bearing large (P≥II) oesophageal varices which predict variceal bleeding and, therefore, need endoscopic screening. Lives stiffness values higher than 19.2 kPa indicate the need for oesophageal-gastro-bulboscopy, while liver stiffness values lower than 19.2 kPa make the presence of large oesophageal varices unlikely.

[Diagnosis, treatment, and follow-up of hepatitis C-virus related liver disease. Hungarian national consensus guideline]

Approximately 70 000 people are infected with hepatitis C virus in Hungary, more than half of whom are not aware of their infection. Early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases (liver cirrhosis and liver cancer) and its complications. In addition, it may increase work productivity and life expectancy of infected individual, and can prevent further viral transmission. Early recognition can substantially reduce the long term financial burden of related morbidity from socioeconomic point of view. Pegylated interferon + ribavirin dual therapy, which is available in Hungary since 2003, can kill the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of two direct acting first generation protease inhibitor drugs (boceprevir and telaprevir) to the dual therapy increased the chance of sustained clearance of virus to 63-75% and 59-66%, respectively. These two protease inhibitor drugs are available and financed for a segment of Hungarian patients since May 2013. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and/or fibrosis in the liver. For initiation of treatment as well as for on-treatment decisions accurate and timely molecular biology tests are mandatory. Staging of liver damage (fibrosis) non-invasive methods (transient elastography and biochemical methods) are acceptable to avoid concerns of patients related to liver biopsy. Professional decision for treatment is balanced against budget limitations in Hungary, and priority is given to those with urgent need using a national Priority Index system reflecting stage of liver disease as well as additional factors (activity and progression of liver disease, predictive factors and other special circumstances). All naïve patients are given a first chance with dual therapy. Those with genotype 1 infection and with on-treatment or historic failure to dual therapy are eligible to receive protease inhibitor based triple therapy provided, they reach financial cutoff eligibility based on Priority Index. Duration of therapy is usually 48 weeks in genotype 1 with a response-guided potential to reduce duration for non-cirrhotic patients. Patients with non-1 genotypes are treated with dual therapy (without protease inhibitors) for a genotype and response driven duration of 16, 24, 48, or 72 week. Careful monitoring for early recognition and management of side-effects as well as viral response and potential breakthrough during protease-inhibitor therapy are recommended.

[Diagnosis and treatment of chronic hepatitis B and D. Hungarian national consensus guideline]

Diagnosis and treatment of hepatitis B and D virus infections mean that the patient is able to maintain working capacity, increase quality of life, prevent cancer, and prolong life expectancy, while the society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms for 2014, which is agreed on a consensus meeting of specialists involved in the treatment of the above diseases. The prevalence of hepatitis B virus infection in the Hungarian general population is 0.5-0.7%. The indications of treatment is based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for cost-effective approach the guideline emphasizes the importance of quick and detailed virologic evaluations, the applicability of transient elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection can be pegylated interferon for 48 weeks or continuous entecavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection.

IL28B and IL10R -1087 polymorphisms are protective for chronic genotype 1 HCV infection and predictors of response to interferon-based therapy in an East-Central European cohort

BACKGROUND

Previous studies have shown that single nucleotide polymorphisms (SNP) in IL28B and IL10R are associated with sustained virological response (SVR) in chronic hepatitis C patients treated with pegilated interferon plus ribavirin (P/R). The present study extends our earlier investigations on a large East-Central European cohort. The allele frequencies of IL28B and IL10R in genotype 1 HCV infection were compared with that of healthy controls for the purpose of examining the relationship between the polymorphisms and the SVR to P/R treatment.

METHODS

A total of 748 chronic HCV1 infected patients (365 male, 383 female; 18-82 years) and 105 voluntary blood donors as controls were enrolled. Four hundred and twenty HCV patients were treated with P/R for 24-72 weeks, out of them 195 (46.4%) achieved SVR. The IL28 rs12979860 SNP was determined using Custom Taqman SNP Genotyping Assays. The IL10R -1087 (also known as IL10R -1082 (rs1800896) promoter region SNP was determined by RT-PCR and restriction fragment length polymorphism analysis.

RESULTS

The IL28B CC genotype occurred with lower frequency in HCV patients than in controls (26.1% vs 51.4%, p<0.001). P/R treated patients with the IL28B CC genotype achieved higher SVR rate, as compared to patients with CT (58.6% vs 40.8%, p=0.002). The prevalence of IL10R -1087 GG genotype was lower in patients than in controls (31.8 % vs 52.2%, p<0.001). Among patients achieving SVR, the IL10R -1087 GG genotype occurred with higher frequency than the AA (32.0% vs 17.4%, p=0.013). The IL28B T allele plus IL10R A allele combination was found with higher prevalence in patients than in controls (52% vs 20.7%, p<0.001). The IL28B CC plus IL10R A allele combination occurred with higher frequency among patients with SVR than in non-responders (21.3% vs 12.8%, p=0.026). Both the IL28B CC plus IL10R GG and the IL28B CC plus IL10R A allele combinations occurred with lower frequency in patients than in controls.

CONCLUSIONS

In our HCV1 patients, both the IL28B CC and IL10R GG genotypes are associated with clearance of HCV. Moreover, distinct IL28B and IL10R allele combinations appear to be protective against chronic HCV1 infection and predictors of response to P/R therapy.

Molecular epidemiology of hepatitis C virus genotypes and subtypes among injecting drug users in Hungary

The aim of this study was to determine the geographical distribution of hepatitis C virus genotypes/subtypes among people who inject drugs (PWID) recruited at 22 needle exchange sites and drug outpatient services in all seven Planning and Statistical Regions of Hungary. Of 198 such PWID, 147 (74.2%), 45 (22.7%) and six (3.0%) carried genotype 1, 3 or 4, respectively, and 31 (72.1%) of the 43 genotype 1 sequences were of subtype 1a. Genotype 3 was significantly more prevalent in provincial towns than in the capital, Budapest. Injecting for a longer period and an older age both correlated with a higher prevalence of genotype 3, suggesting possible future changes in genotype distribution. The distributions of hepatitis C virus genotypes/ subtypes differed significantly between the tested PWID and the general population. The identification of genotype 3 reflected its worldwide occurrence among PWID. Our results underline the importance of genotyping before treatment, especially among people who have ever injected drugs in Hungary.

[IL28B CC genotype: a protective factor and predictor of the response to interferon treatment in chronic hepatitis C virus infection]

INTRODUCTION

In chronic hepatitis C-virus infection the possible role of gene variants encoding cytokines has become the focus of interest.

AIM

The aim of the study was to investigate the effect of IL28B polymorphisms on the outcome of chronic hepatitis C-virus genotype 1 infection in the Hungarian population. In addition, the association between IL28B genotypes and the Th1/Th2 cytokine production of activated peripheral blood monocytes and lymphocytes was evaluated.

METHOD

Total of 748 chronic hepatitis C-virus genotype 1 positive patients (365 males and 383 females, aged between 18 and 82 years; mean age, 54±10 years) were enrolled, of which 420 patients were treated with pegylated interferon plus ribavirin for 24-72 weeks. Of the 420 patients, 195 patients (46.4%) achieved sustained virological response. The IL28B rs12979860 polymorphism was determined using Custom Taqman SNP Genotyping Assays (Applied Biosystems, Life Technologies, Foster, CA, USA). For cytokine studies, tumour necrosis factor-α, interleukin-2, interferon-γ, interleukin-2 and interleukin-4 production by LPS-stimulated monocytes and PMA-ionomycine activated lymphocytes were measured from the supernatant of the cells obtained from 40 hepatitis C-virus infected patients, using FACS-CBA Becton Dickinson test. The cytokine levels were compared in patients with different (CC, CT, TT) IL28B genotypes.

RESULTS

The IL28B rs12979860 CC genotype occurred in lower frequency in hepatitis C-virus infected patients than in healthy controls (26.1% vs 51.4%, OR 0.333, p<0.001). Patients carried the T allele with higher frequency than controls (73.9%, vs 48.6%, OR 3.003, p<0.001). Pegylated interferon plus ribavirin treated patients with the IL28B CC genotype achieved higher sustained virological response rate than those with the CT genotype (58.6% vs 40.8%, OR 2.057, p = 0.002), and those who carried the T allele (41.8%, OR1.976, p = 0.002). LPS-induced TLR-4 activation of monocytes resulted in higher tumour necrosis factor-α production in patients with the IL28B CC genotype compared to non-CC individuals (p<0.01). Similarly, increased tumour necrosis factor-α, interleukin-2 and interferon-γ production by lymphocytes was found in the IL28B CC carriers (p<0.01) CONCLUSIONS: The IL28B CC genotype exerts protective effect against chronic hepatitis C-virus infection and may be a pretreatment predictor of sustained virological response during interferon-based antiviral therapy. The IL28B CC polymorphism is associated with increased Th1 cytokine production of activated peripheral blood monocytes and lymphocytes, which may play a role in interferon-induced rapid immune control and sustained virological response of pegylated interferon plus ribavirin treated patients.

[Non-alcoholic fatty liver disease and steatohepatitis]

Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, the hepatic manifestations of metabolic syndrome with close association with inzulin resistance and obesity, are the most common liver diseases, affecting up to a third of the population worldwide. They confer increased risk for hepatocellular carcinoma as well as cardiovascular diseases. The review aims to summarize advances in epidemiology, pathogenesis and clinical management of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. Besides liver biopsy and biomarkers, a novel non-invasive diagnostic tool the called "controlled attenuation parameter" measuring the attenuation of ultrasound generated by the transient elastography transducer, can quantitatively assess the hepatic fat content and differentiate between steatosis grades. At the same time, liver stiffness (fibrosis) can also be evaluated. The authors present their own results obtained with the latter procedure. In non-alcoholic fatty liver disease, the lifestyle intervention, weight loss, diet and exercise supported by cognitive behavioural therapy represent the basis of management. Components of metabolic syndrome (obesity, dyslipidaemia, diabetes and arterial hypertension) have to be treated. Although there is no approved pharmacological therapy for NASH, it seems that long lasting administration of vitamin E in association with high dose ursodeoxycholic acid may be beneficial. In addition, omega-3 polyunsaturated fatty acid substitution can also decrease liver fat, however, the optimal dose is not known yet. Further controlled clinical studies are warranted to establish the real value of any suggested treatment modalities for non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, although these are in experimental phase yet.

Hungarian consensus guideline for the diagnosis and treatment of B, C, and D viral hepatitis

More than 1% of the Hungarian population is infected with hepatitis B, C, or D viruses. Since 2006 the diagnostics and therapy of these infections are carried out in treatment centers according to national guidelines – since 2010 according to financial protocols. The consensus-based guidelines for 2012 are published in this paper. The guidelines stress the importance of quick and detailed virologic evaluations, the applicability of transient elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection is pegylated interferon for 48 weeks or continuous entecavir therapy. The later must be continued for at least 6 months after hepatitis B surface antigen (HBsAg) seroconversion. Tenofovir disoproxil fumarat is not yet reimbursed by the National Health Insurance Fund. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection. Treatment naive chronic hepatitis C patients should initially receive pegylated interferon and ribavirin dual combination therapy. In genotype 1 infection if response is insufficient at 4 or 12 weeks one of the two new direct acting antivirals (boceprevir or telaprevir) should be added. The length of treatment is usually 48 weeks; in cases of extended early viral response shorter courses are recommended. Previous treatment failure patients with genotype 1 infection should receive a protease inhibitor backed triple combination therapy, mostly for 48 weeks. However, relapsers without cirrhosis and with extended rapid viral response, shorter telaprevir based combination therapy is sufficient. Drug-drug interactions as well as emergence of viral resistance are of particular importance. For genotype 2 or 3 HCV infections 24 weeks, for genotype 4 infections 24, 48 or 72 weeks of pegylated interferon plus ribavirin therapy is recommended in general. The guidelines published here become protocols when published as official publications of the Hungarian Health Authority. Orv. Hetil., 2012, 153, 375–394.

[Genetic polymorphisms as predictors of response to antiviral treatment in chronic hepatitis C virus infection]

The review discusses the genetic polymorphisms involved in the pathogenesis of hepatitis C virus (HCV) infection, that may determine the outcome of disease. In this field earlier both certain major histocompatibility complex (MHC) alleles and some cytokine gene variants have also been studied. Recently, the genome-wide association study (GWAS) and targeted single nucleotide polymorphism (SNP) analysis have revealed that a variant in the promoter region of interleukin-28B (IL-28B) gene is strongly linked to viral clearance and it may be the strongest pretreatment predictor of treatment response in chronic hepatitis C. Last year it was shown that two genetic variants leading to inosine triphosphatase deficiency protect against haemolytic anemia in patients receiving ribavirin during antiviral treatment for chronic HCV infection.

[New possibilities on the horizon for the treatment of hepatitis C virus infection: direct-acting antiviral therapy]

Current treatment for chronic hepatitis C virus (HCV) infection results 40-45% sustained virological response (SVR) rates in patients with HCV genotype 1, which is the most prevalent genotype in Europe and in Hungary. This therapy requires long duration, high costs and is associated with side effects. For these reasons, progress needs to develop more effective treatment regimes. In the past 5 years, advances have been made in better knowledge of HCV viral life cycle, and in the researches of HCV-specific directly acting antivirals. Recent data suggest that protease and polymerase inhibitors, in triple combinations with interferon plus ribavirin-based treatment are able to shorten treatment duration and improve SVR rates even in "hard to cure" HCV genotype 1 patients. The aim of this review is to summarize results obtained with novel anti-HCV compounds.

Non-invasive fibrosis assessment in chronic hepatitis C: aspartate-aminotransferase to platelet ratio index (APRI) and transient elastography (FibroScan)

Bár a májbiopszia ma is „arany standard” a hepatológiai diagnosztikában, újabban a nem invazív próbák is egyre inkább előtérbe kerülnek a májfibrosis értékelésében. A szerzők az aszpartát-aminotranszferáz/thombocyta hányados (APRI) és a májtömöttség (elaszticitás) vizsgálatán alapuló tranziens elasztográfia szerepét tanulmányozták krónikus hepatitis C-vírus- (HCV-) infekcióban.Betegek és módszerek:Száztizenkilenc HCV-fertőzött beteg közül 75 szenvedett biopsziával igazolt krónikus C-hepatitisben, 24 HCV-cirrhosisban, 20 egyén tünetmentes, tartósan normális alanin-aminotranszferáz enzim értéket mutató HCV-hordozó volt, és 30 egészséges véradó szerepelt kontrollként. AWaiszerinti APRI-score kiszámítása az aszpartát-aminotranszferáz- és a thrombocytaszám-értékek alapján, a fibrosisra utaló májtömöttség (liver stiffness, LS) vizsgálata ultrahangalapú tranziens elasztográfiával, FibroScan alkalmazásával, míg a METAVIR fibrosisscore megállapítása májbiopszia révén történt.Eredmények:Krónikus C-hepatitisben mindkét fibrosismarker értékei szignifikánsan magasabbak voltak, mint a kontrollcsoportban, legmagasabb HCV-cirrhosisban. A tünetmentes HCV-hordozók adatai alig tértek el az egészségesekétől. Mindkét mutató értékei korreláltak a hisztológiai stádiumokkal. Az LS-vizsgálat érzékenyebb volt a fibrosis diagnosztizálásában, mint az APRI. A két fibrosismarker adatain alapuló szekvenciális algoritmus szerint a krónikus C-hepatitises betegek 47,8%-ában a szignifikáns (F≥2) fibrosis biopszia nélkül is feltételezhető.Következtetés:Az APRI-score és a tranziens elasztográfia, különösen kombinációban, hasznos nem invazív eljárás a fibrosis értékelésében krónikus HCV-infekcióban. Orv. Hetil., 2010,47,1951–1955.

[Hepatitis B virus (HBV) infection and hepatocarcinogenesis]

Hepatitis B virus is one of the most important etiologic factors of hepatocellular carcinoma. The present review discusses the molecular mechanisms of virus-induced carcinogenesis, indirect and direct effects of the infection. The cell damage-evoked regeneration and proliferation, as well as the viral proteins that induce chromosomal, genetic and epigenetic changes, play a key role in the multistep process leading to malignant cell transformation. Integration of HBV DNA in to the host DNA, activation of oncogenes and inactivation of tumor suppressor genes are of basic significance. The hepatitis B virus related complications such as cirrhosis and hepatocellular carcinoma can be prevented by vaccination or eradication of the virus with antiviral therapy.

[Hepatitis C virus infection--after 20 years]

The paper is devoted to the two decades of hepatitis C virus related basic researches and clinical experiences, from the discovery of the virus to the newest therapeutic options. Virology, epidemiology, pathology-pathogenesis, the virus-induced immunological and metabolic changes, the diagnosis and advances in antiviral treatment are discussed.

[Effects of supplementation with the antioxidant flavonoid, silymarin, in chronic hepatitis C patients treated with peg-interferon + ribavirin. A placebo-controlled double blind study]

Since oxidative stress may play a pathogenetic role in chronic hepatitis C, and sustained virological response to antiviral therapy is limited in HCV1 genotype infection, a double blind study was performed in HCV1 patients treated with pegylated interferon + ribavirin, to assess the efficacy of supplementation with the antioxidant flavonoid silymarin.

PATIENTS AND METHODS

Thirty-two naive HCV1 positive patients with biopsy proven chronic hepatitis C, to be treated with pegylated interferon + ribavirin, have been randomized: group A): 16 patients have been given the antiviral therapy for 6-12 months plus placebo for the first 3 months; group B): 16 patients have been treated with pegylated interferon + ribavirin for 6-12 months plus silymarin, 2 x 166 mg/day, was given for 3 months. Serum alanine aminotransferase and HCV-RNA levels as well as parameters of oxidative stress such as plasma or red blood cell hemolysate, malondialdehyde, superoxide dismutase, glutathione peroxidase, catalase and myeloperoxidase were determined after 0, 1, 3, 6 and 12 months during the treatment. Sustained virological response as undetectable serum HCV RNA was evaluated 24 weeks after the end of therapy.

RESULTS

In the silymarin group, a more rapid decrease in the malondialdehyde level as well as a marked decrease in superoxide dismutase and an increase in myeloperoxidase activity after month 12 were found, alanine aminotransferase normalized in 6/16 (vs control 9/16) cases, and sustained virological response occurred in 3/16 (vs 7/16) patients.

DISCUSSION/CONCLUSION

Although silymarin supportation to antiviral therapy improved oxidative stress, it was able to affect favourably neither the alanine aminotransferase nor the sustained virological response. These contradictory findings may be related to randomization bias as patients in study group B had more negative predictors of response: they were older with higher fibrosis score and even with more severe pretreatment baseline oxidative stress. Regarding the recently published in vitro experiments with silybinin on HCV replication as well as the newest convincing clinical observations, we do suggest further studies with more than three times higher doses of silymarin in controlled trials to assess the value of this supplementation in antivirally treated HCV patients.

[Prophylaxis and treatment of chronic viral hepatitis as the prevention of hepatocellular carcinoma]

As hepatitis B and C virus (HBV, HCV) play a pivotal role in the development of hepatocellular carcinoma (HCC), the prophylaxis and treatment of these infections may mean also the prevention of HCC. The primary prevention of HCC is vaccination against HBV as well as the screening of blood donors for HBV and HCV markers. The means of secondary HCC prevention are as follows: antiviral therapy of HBV and HCV-related hepatitis and cirrhosis, screening ("surveillance") of cirrhotic patients for HCC using alpha-fetoprotein and ultrasound, and adjuvant antiviral treatment of HCC patients following curative tumor resection/ablation. It may be anticipated that the world-wide spread of HBV vaccination, the more effective individual treatment and novel antivirals will lead to the decrease of HCC incidence in the not so distant future.

The recurrence of hepatitis C virus after liver transplantation

A hazai májátültetési programban magas a hepatitis C-vírus (HCV) okozta végstádiumú májbetegség miatt végzett májátültetések aránya. Célkitűzés: A szerzők dolgozatukban elemzik a C-hepatitis miatt májátültetésen átesett betegek adatait. Módszer: Az 1995 óta végzett 295 primer májátültetés adatainak retrospektív elemzése: donor- és recipiens-, valamint perioperatív és túlélési adatok, szérumvírus-RNS-titer, percutan májbiopsziák szövettani eredményei. Eredmények: A műtét 111 betegnél történt HCV-fertőzés miatt, ez az elvégzett májátültetések 37,6%-a. A vizsgált 111 beteg közül 22 beteg (20%) a posztoperatív időszakban, a vírus kiújulásának észlelése előtt, egyéb okból meghalt. A 89 beteg közül 16 esetben (18%) a vírus visszatérését még nem észlelték, 73 betegnél (82%) azonban a vírus kiújulása szövettanilag igazolható volt. Negyven betegnél (56%) a C-vírus okozta hepatitis kiújulását egy éven belül észlelték, közülük 28 esetben (39%) 6 hónapon belül, 12 esetben hat hónapon túl, de 1 éven belül (17%), és 32 betegnél (44%) egy éven túl. A végstádiumú C-cirrhosis miatt májátültetett betegek kumulatív 1, 3, 5 és 10 éves túlélése 73%, 67%, 56% és 49% volt. A HCV-negatív, májátültetett betegeknél ezek az értékek 80%, 74%, 70% és 70%, a különbség szignifikáns. A májgraft kumulatív túlélése HCV-pozitív betegeknél 72%, 66%, 56% és 49% volt, míg HCV-negatív betegeknél 76%, 72%, 68% és 68%, itt nem szignifikáns a különbség. Korai kiújulás esetén szignifikánsan magasabb szérumvírus-RNS-titert mértek az első 6 hónapban májátültetés után. A májátültetés után 6 hónappal vett protokollbiopszia korai kiújulás esetén magasabb Knodell-pontszámot eredményezett, mint késői kiújuláskor. A fibrosisindex esetében ez fordítva volt. A májátültetéstől az első antivirális kezelésig eltelt idő 1995–2002 között átlagosan 20 hónap volt, 2003 óta 8 hónap. Következtetések: Az idősebb donorokból származó, marginális májgraftok magasabb vértranszfúzió-igény mellett történő beültetése előrevetíti a hamarabb bekövetkező vírusrekurrenciát. Ezt a tendenciát erősíti a posztoperatív akut rejectio és az emiatt adott szteroid boluskezelés. A kombinált antivirális kezelés protokollja különbözik az általánosan alkalmazottól: az ún. „stopszabály” nem érvényes. Vírusnegatívvá a betegek csak kevesebb mint 10%-a válik, melynek a fenntartott immunszuppresszió az oka. A májátültetés után korán, akár fél éven belül elkezdett antivirális kezelés a beteg- és grafttúlélést pozitívan befolyásolja, és feltehetően csökkenti a HCV-reinfekció miatti retranszplantációk számát. A második májátültetésnél akkor várhatók jó eredmények, ha időben történik, a recipiens még megfelelő fizikai állapota mellett. Ennek megítélésében a MELD-score segít.

Experiences on antiviral treatment for chronic viral B and C hepatitis patients in Hungary. 1998–2004

Az utolsó évtizedben számos multicentrikus, randomizált vizsgálat bizonyította az előrehaladást a krónikus vírushepatitisek kezelésében. Ugyanakkor csak korlátozott számú és ellentmondásos adatokat közöltek az antivirális terápia reális értékéről a mindennapos rutin klinikai gyakorlatában. Cél: Retrospektív felmérést végeztünk a terápia hatékonyságának megállapítására krónikus B- és C-hepatitisben, egy 7 éves periódus alatt kezelt országos populációban. Emellett bemutatjuk még egy hazai prospektív vizsgálat néhány adatát is. Módszerek: 220 krónikus B-hepatitises beteget kezeltünk, közülük 112 standard interferon-, 23 pegilált interferon-, 85 lamivudin-terápiában részesült, akikben a HbeAg-szerokonverzió és/vagy HBV-DNS-negatívvá válás arányát vizsgáltuk. A retrospektív elemzésben szereplő 2442 krónikus C-hepatitises közül 333 standard interferon-monoterápiát, 1122 standard interferon + ribavirin kombinációt és 987 pegilált interferon + ribavirin-kezelést kapott. A prospektív vizsgálatban 69 HCV1-beteg pegilált interferon α-2a + ribavirin terápiában részesült 6–12 hónapon át. A tartós virológiai válasz mellett vizsgáltuk a kedvező kimenetel prediktorait és a mellékhatások előfordulását. Eredmények: Krónikus B-hepatitisben a standard interferon 31%-os, a pegilált interferon 30%-os, a lamivudin 31–33%-os tartós vírusnegativitáshoz vezetett. Krónikus C-hepatitisben a tartós virológiai válasz aránya az interferon-monoterápiával észlelt 13%-ról a pegilált interferon + ribavirin mellett 31%-ra nőtt, a prospektív vizsgálatban ez 48% volt. A jó prognózis prediktora a rapid (4 hetes) és a korai (12 hetes) virológiai válasz, a női nem, az életkor, BMI és az adherencia volt. A betegek 9%-ában fordult elő mellékhatás, leggyakrabban cytopenia, haemolysis és depresszió. Következtetés: A krónikus B-hepatitisszel ellentétben, a hepatitis C-vírusinfekció kezelésének effektivitása hazánkban is fokozatosan javult. A mindennapi gyakorlat országos adatai azonban elmaradnak a prospektív vizsgálat sikerességétől. A jövőben hatékonyabb terápiás stratégiák szükségesek, beleértve az individualizált dozírozást és az új antivirális szerek alkalmazását.

Immune-mediated liver diseases

A dolgozat áttekintést ad a három immunmediált májbetegség, az autoimmun hepatitis, a primer biliaris cirrhosis és a primer sclerotizáló cholangitis patogeneziséről, diagnosztikájáról és kezelésük lehetőségeiről.