Saturday Poster Sessions, October 28, 2006

HCV: Diagnosis and Natural History

 

# 211: Influence of Cannabis Use on Severity of Hepatitis C Disease

J. H. Ishida; C. Jin; P. Bacchetti; V. Tan; M. G. Peters; N. A. Terrault

 

Background:

Complications of hepatitis C virus (HCV) infection are primarily related to the development of advanced fibrosis. Risk factors for fibrosis include male gender, older age at HCV infection and heavy alcohol use, but the role of cannabis remains controversial.

 

Objective:

To study the association between cannabis use and fibrosis severity in persons with chronic HCV infection.

 

Methods:

Between 2001 and 2004, 328 HCV-infected subjects enrolled from university and community sources underwent in-person interviews (to assess demographics, risk factors for HCV, and use of cannabis and alcohol), virologic testing and liver biopsy. Biopsies were scored for fibrosis using the Ishak method (scale F0 to F6) by a single pathologist blinded to clinical data. Biopsy adequacy was assessed by length and number of portal tracts.  204 completed all the baseline requirements.  Included and excluded subjects were not significantly different except that the former used cannabis more frequently than the later group.

 

Results:

The median age of the cohort was 46.8 years, 69% were male, 49% were Caucasian, 61% earned ≤$15,000 per year, and the presumed route of infection was intravenous drug use in 70%.  Ninety-seven percent had at least one drink witin year prior to enrolment.  Current (within 12 months of enrollment) cannabis daily use frequency was daily (14%), used cannabis within the year prior to enrolment (20%). Fibrosis stage median was 1 (scale 0-6), necoinflammation median was 5.

 

Daily cannabis use was associated with moderate to severe fibrosis compared to mild fibrosis in univariate analysis.  Gender, race, enrollment age, HCV duration and infection source, HCV genotype, HIV, daily tobacco use, and lifetime alcohol use were not significantly associated with mild fibrosis or moderate to severe fibrosis stage in univariate and multivariate analysis. 

 

Conclusion:

·        Current daily cannabis use independently increased the odds of moderate to severe fibrosis by nearly 7-fold in persons with chronic HCV infection.

o       The duration of lifetime moderate to heavy alcohol use was also independent predictor of moderate to severe fibrosis

·        There was no association between current daily cannabis use and mild fibrosis.

o       HCV viral load was an independent predictor of mild fibrosis.

·        The number of portal tracts was associated with both mild and moderate to severe fibrosis, highlighting the importance of controlling for biopsy adequacy.

·        This cross-sectional design limits the ability to establish a temporal relationship between cannabis use and fibrosis stage.

·        Quantity, duration or method of cannabis use were not assessed in detail.

·        Our results indicate that HCV-infected individuals should be counseled to reduce or abstain from cannabis use.

 

Future Directions:

·        Confirm differential effect of cannabis use by severity of disease.

·        Prospective cohort study of cannabis versus non-cannabis users with chronic HCV using more detailed cannabis assessments.


# 212: Independent evaluation of 4 blood scores of liver fibrosis in chronic hepatitis C: FibroMeter, Fibrotest, Hepascore and APRI

P. Halfon; Y. Bacq; A. De Muret; G. Pénaranda; M. Bourlière; D. Ouzan; A. Tran; D. Botta-Fridlund; C. Renou; M. Brechot; C. Degott; V. Paradis

 

Introduction:

 

Several blood scores of liver fibrosis have been published. The most validated scores are the Fibrotest (FT) and APRI. However, possibly more accurate tests have been recently published: Fibrometer (FM) and Hepascore (HS). The aim of this study was to compare the diagnostic accuracy of those 4 tests in independent conditions and populations.

 

Methods:

356 patients with chronic viral hepatitis C from 2 different French areas with a liver specimen length ≥ 15 mm (22 ± 7 mm) were included. Liver specimens were evaluated by 2 independent pathologists according to the Metavir staging before reaching a consensus. Blood variables were determined on fresh or frozen blood samples.

 

Results:

The distribution of Metavir stages according to liver specimens was: F0: 4%, F1: 55%, F2: 26%, F3: 11%, F4: 4%. The AUROC are listed as a function of blood score and fibrosis cut-off in the Table 1.

 

The AUROC of those 4 blood scores were not significantly different in that population characterized by a high proportion of F1 and a low proportion of F4. On the other hand, those scores had different patterns. Therefore, we evaluated the rate of misclassified patients (%) as a function of F stages or cut-off, FT vs FM respectively in the following Table 2.

 

The comparison of misclassification (blood vs liver) rates indicated significantly different patterns, FT vs FM respectively: F0+1: 18 vs 28 % (p=0.002), ≥F2: 43 vs 31 % (p=0.005), ≥ F3: 28 vs 12 % (p=0.065), F4: 15 vs 0 % (p: NA).

 

Conclusions:

These results show that the accuracy of those tests is sensitive to the fibrosis stage prevalence which depends on the population studied. For the diagnosis of clinically significant fibrosis (F≥2), those 4 blood scores had a similar performance in this population that lies in the lower range of published results. However, those tests have performance profiles significantly different as a function of fibrosis stages or cut-off. This has to be taken into account during the interpretation process. Moreover, the diagnostic target (fibrosis cut-off) has to be clearly defined.

 

Table 1

AUROC

FT

FM

APRI

HS

P

≥ F2

0.79

0.78

0.76

0.76

NS

≥ F3

0.81

0.85

0.81

0.81

NS

F4

0.86

0.94

0.92

0.89

NS

 

Table 2

%

F0

F1

F2

F3

F4

FT

0

19

52

29

15

FM

0

30

41

16

0

 

#213. Hepatitis virus C RNA quantification by automated Cobas AmpliPrep-Cobas TaqMan 48 (CAP-CTM) real-time PCR assay: an evaluation of performance.

S. Chevaliez; M. Bouvier-Alias; G. Dameron; F. Darthuy; J. Remire; J. Pawlotsky

Introduction:

 

Accurate, sensitive and specific HCV RNA quantification is mandated to monitor the virological responses and individually tailor pegylated interferon-ribavirin combination therapy. Real-time PCR quantification is likely to become standard technology for HCV RNA quantification. The Cobas AmpliPrep-Cobas TaqMan48 (CAP-CTM48) real-time PCR platform (Roche Molecular Systems) provides almost fully automated real-time PCR quantification of HCV RNA.

 

Objective: 

The objective of this study was to assess the intrinsic performance of the CAP-CTM48 real-time PCR platform for HCV RNA detection and quantification.

 

Methods:

Analytical sensitivity, precision and reproducibility were assessed by testing serial dilutions of a standard containing 5x106 HCV RNA IU/ml three times in different experiments. The lower limit of detection was studied by testing serial dilutions of a standard containing 50 HCV RNA IU/ml. Specificity was assessed by testing 200 anti-HCV antibody-negative samples. Quantification of the different HCV genotypes was studied by testing 123 clinical samples (genotype 1, n=29; 2, n=27; 3, n=28; 4, n=30; 5, n=9; and 6, n=2) neat and after serial dilutions in comparison with third-generation bDNA (Versant HCV RNA 3.0, Bayer HealthCare).

 

Results: 

(i) Testing serial dilutions of a standard containing 5x106 HCV RNA IU/ml showed linear quantification over the full range of HCV RNA levels and a strong correlation with the expected values (slope: 0.9671, R=0.9981). (ii) The coefficient of variations of triplicate testing ranged from 0.2% to 7.2% (1.9% on average). (iii) Specificity was 100%. (iv) HCV RNA was detected in 8 repeat samples from 50 IU/ml down to 22 IU/ml, in 6/8 samples at the 15 IU/ml concentration, 4/8 samples at the 10 IU/ml concentration and 5/8 samples at the 7 IU/ml concentration. (v) Serial dilutions of genotype 1 to 6 clinical samples showed HCV RNA levels in IU/ml generally higher in CAP-CTM48 than in bDNA (difference of the order of 0.7 log on average) when neat samples were tested, but the difference was reduced after the first dilution. (vi) Quantification of clinical samples was linear over the full range of tested values whatever the HCV genotype. (vii) A few genotype 2 and 4 samples were underquantified in the CAP-CTM48 assay relative to bDNA. Full-length sequence analysis of the 5’UTR showed potential mismatch positions that could explain these differences.

 

Conclusion:

CAP-CTM48 real-time PCR has good intrinsic performance, but two issues remain: a global overestimation of HCV RNA levels in IU/ml relative to bDNA in neat (but not diluted) samples, and occasional underquantification of genotype 4 and, sometimes, genotype 2 samples.


#214. Liver stiffness cut-off values in HCV patients: validation and comparison in an independent population.

M. Ziol; P. Marcellin; C. Douvin; V. de Ledinghen; R. Poupon; M. Beaugrand

 

Background:

Liver stiffness measurement (LSM) has been proposed as a noninvasive tool to assess liver fibrosis in patients with chronic hepatitis C. Several publications(1-3) have presented diagnosis accuracies and cut-off values for the diagnosis of significant fibrosis and cirrhosis but with different cut-off values. The aim of this study was to validate the diagnosis accuracy and cut-off values of LSM in an independent HCV population.

 

Method:

We prospectively enrolled 639 HCV patients in five French centers (Clichy: 178; Bondy: 163; Creteil: 129; Pessac: 101; Paris: 68). Within six month each of them had a liver biopsy (LB) and LSM. Fibrosis stage and activity grade were assessed using the METAVIR scoring system. Steatosis was scored as follows: S0: no; S1:1-10%; S2:11-30% and S3 more than 30%. ROC analyses were performed and cut-off values chosen to maximize the sum of sensitivity and specificity.

 

Results:

Eighty-six (13%) LB were considered unsuitable for fibrosis assessment (less than 1cm and/or 10 portal tracts if no obvious cirrhosis) and 59 (9%) of LSM unreliable (less than 8 valid measurements or IQR/median>50%). Analysis was conducted in 494 patients (319 men; age: 49 ± 12 years; BMI 25 ± 4 kg/m2). Patients' distribution was: F0=30; F1=193; F2=155; F3=47; F4=69. LSM was significantly (p<0.001) correlated to fibrosis stage (Spearman: 0.70), activity (0.45) and steatosis (0.35) but in multivariate analysis LSM was correlated to fibrosis only (partial correlation coefficient: 0.57).AUROC (95%CI) were 0.84 (0.80-0.87), 0.93 (0.90-0.95) and 0.96 (0.94-0.98) for F≥2, F≥3 and F=4 respectively. Optimal cut-off values for this population and those previously published applied to this same population are presented in the Table.

 

Conclusion:

These results obtained in an independent HCV population confirmed those previously published. Optimal cut-off values are slightly different but their performances are very close. This emphasizes the fact that cut-off values depend on the chosen balance between sensitivity and specificity. Finally, LSM appears as an accurate noninvasive method to assess liver fibrosis in HCV patients.

1. Ziol Hepatology 2005:48-54.

2. Castera Gastroenterology 2005: 343-50.

3. Coco AASLD 2005.

 

 

Cut-off values (kPa)

Sensitivity

Specificity

VPP

VPN

Diagnosis accuracy

F01 / F2,3,4

7.5

67

87

86

68

76

F01 / F2,3,4

8.7 (1)

59

92

90

65

74

F01 / F2,3,4

7.1 (2)

71

81

82

70

76

F01 / F2,3,4

8.3 (3)

61

89

87

65

74

F01,2,3 / F4

10.2

99

85

51

100

87

F01,2,3 / F4

14.5 (1)

80

94

69

97

92

F01,2,3 / F4

12.5 (2)

84

93

65

97

92

F01,2,3 / F4

14.0 (3)

81

94

68

97

92

 

 

#215. Independent Assessment of Non Invasive Liver Fibrosis Biomarkers in HIV-HCV Co-infected Patients: the Fibrovic Study.

P. Cacoub; F. Carrat; P. Bedossa; J. Lambert; G. Pénaranda; C. Perronne; S. Pol; P. Halfon

Introduction:

Many non invasive liver fibrosis scores have been proposed as alternatives to liver biopsy (LB) in HCV infected patients, i.e. Fibrotest (FT), APRI, Forns, Hepascore (HS) and Fibrometer (FM). FT, SHASTA, and Fib-4 scores have been tested in small cohorts of HIV-HCV co-infected patients.

 

Aim:

To compare diagnostic accuracies of FT, APRI, Forns, HS, FM, SHASTA, and Fib-4 in a large cohort of HIV-HCV co-infected patients.

 

Patients & Methods:

274 HIV-HCV coinfected patients, naïve of HCV treatment, had a LB before inclusion in the prospective ANRS HC02 Ribavic trial: 198 (72%) men, age 39.9 years, LB 18.5 mm, fibrosis stage (Metavir) of F1 in 68 (25%) patients, F2 in 110 (41%), F3 in 67 (23%), and F4 in 29 (11%). Diagnostic accuracies of each score were determined by area under the roc curve (AUROCs), and the accuracy (rate of well classified patient) compared to LB. AUROCs were compared with Hanley-McNeil test, and accuracies with McNemar or Chi2 test. Note that low values of AUROCs were expected, since our sample did not include patients with F0.

 

Results:

FT, HS, and FM were more accurate than other scores with AUROCs of 0.64 [95% CI 0.58 ;0.70], 0.69 [0.63 ;0.74], and 0.70 [0.61 ;0.73] for the diagnosis of significant fibrosis (F2F3F4), respectively. Values for the diagnosis of F3F4 were 0.72 [0.66 ;0.77], 0.76 [0.71 ;0.81], and 0.78 [0.73 ;0.83], respectively. For the diagnosis of cirrhosis (F4), AUROCs were 0.81 [0.76 ;0.85], 0.83 [0.78 ;0.88], and 0.84 [0.78 ;0.88]. Comparison of these 3 tests (Table) showed that for global analysis, accuracy FM > FT but not different from HS. In a stage by stage fibrosis analysis, accuracy FM > HS > FT except for F1 where FT > FM. Search for a better test by using combination of FT, HS and FM did not increase significantly the diagnostic performances of each test.

 

Conclusion:

In HIV-HCV co-infected patients, use of non invasive liver fibrosis biomarkers can correctly classify only patients with severe fibrosis (≥ F3, accuracies 74%-97%). For global analysis, accuracy of FM is higher than FT but similar to HS. In a stage by stage fibrosis analysis, FM is better for the diagnosis of ≥F2 and ≥F3 stages whereas FT is better for the diagnosis of F1.

 

 

Accuracy = rate of well classified patients (%)

Liver biopsy fibrosis (Metavir)

Global Analysis

F1

F2

≥F2

F3

≥F3

Number of patients

274

68

110

206

67

96

FT*

61

60

51

62

67

74

HS*

68

47

61

75

88

81

FM*

71

37

70

82

97

97

FT vs. HS**

0.127

0.035

0.027

<0.001

<0.001

<0.001

FT vs. FM**

0.024

<0.001

<0.001

<0.001

<0.001

<0.001

HS vs. FM**

0.520

0.092

0.093

0.009

0.031

0.031

*cut-off=0.5 **p

 


#216. IMPACT OF CAFFEINE CONSUMPTION ON HISTOLOGICAL ACTIVITY IN PATIENTS WITH CHRONIC ACTIVE HEPATITIS C.

C. Costentin; F. Roudot-Thoraval; F. Medkour; E. Zafrani; J. Pawlotsky; D. Dhumeaux; A. Mallat; C. Hezode.

Introduction:

 

It has recently been suggested that caffeine consumption is associated with a lower risk of elevated serum alanine aminotransferase (ALT) activity in patients at high risk for liver disease and a lower incidence of chronic liver disease. This effect might be attributed to antioxidant properties of caffeine.

Aim:

Thus, the aim of this study was to evaluate the impact of caffeine consumption on activity grade and ALT levels in patients with chronic hepatitis C.

Methods:

238 consecutive naïve patients with histologically proven chronic hepatitis C were included. Data collected included demographics, route of transmission, daily consumptions of alcohol, tobacco, caffeine during the 6 months preceding liver biopsy, body mass index, genotype, ALT level at the time of liver biopsy, steatosis and activity grades, as well as fibrosis stage, according to METAVIR. Daily caffeine consumption was estimated as the sum of mean intakes of coffee, tea and caffeine-containing sodas. Patients (153 men, 84 women, mean age: 45.4*11.3 years) were classified into 4 groups according to caffeine consumption (table).

Results:

As shown in the table, there was a significant inverse relationship between activity grade and daily caffeine consumption, p<0.001 (test for linear trend). However, no relationship was found between daily caffeine consumption and ALT level.

 

In multivariate analysis, caffeine intake greater than 407 mg/day (3cups) predicted a lesser risk of moderate-marked activity grade (OR=0.46 (0.25-0.86) p=0.003). Other factors independently associated to activity grade included moderate-severe steatosis (OR=3.30 (1.48-7.35) p =0.004), age greater than 40 years (OR=2.15 (1.13-4.09) p=0.018) and ALT level (OR=1.02 (1.01-1.03) p <0.001).

Conclusion:

The results of this suggest that caffeine consumption have a positive impact on histological activity in patients with chronic hepatitis C.

 

Daily caffeine consumption
(mg)

Moderate-marked (A2-A3) activity grade
n (%)

< 224 n=59

45 (77.5)

225-407 n=57

35 (61.4)

408-679 n=62

32 (51.6)

>679 n=60

29 (48.3)

 


#217. Histologic And Clinical Features Of HCV Cirrhosis: Differences Associated With Race-Ethnicity.

S. Iwata; M. Kohla; S. Keyhan; R. Ea; M. Bonacini.

 

Introduction:

 

Race-ethnicity may be an important variable in the progression of liver fibrosis in hepatitis C. Little is known of the frequency of cirrhosis and its complications in Asians patients in the U.S.

 

Aim:  

To compare clinical and histological features of hepatitis C in Asian patients in San Francisco.

 

Methods:

Retrospective query of an electronic medical record for HCV patients evaluated between 1999-2005. We excluded patients who had died or received a liver transplant. Clinical cirrhosis was defined as any of the following: varices by endoscopy, ascites or splenomegaly (clinically or imaging). Histologic cirrhosis was defined as either stage 3/4 or 4 fibrosis (Metavir) at biopsy. Chi-square, t-tests and logistic regression (LR) were performed with Statview.

 

Results:   

657 patients were categorized into 5 groups: 23 American-Indian, 147 Hispanic, 123 African-American, 146 Asian, and 218 Caucasian. Median age of AA (54 years) and Asian (53), Caucasian (52) was higher than either Hispanic (50) or American-Indian, (49) (p<0.05). Percentage of males varied from 45% to 56% (NS). BMI was significantly lower in Asians. American-Indian, and Hispanic had the highest percentage of alcohol abuse (74 and 54%) higher than African American (41%), Caucasian (11%) and Asian  (11%) (p <0.0001). Favourable genotypes were less frequent in Asian  and African American (table). A liver biopsy was performed in 52% American-Indian, 57% Asian, 60% Hispanic, African American (51%) and 66% Caucasian. 26% were found to have cirrhosis either histologic or clinical (LC): 14% had clinical only, 6% had histologic only and 6% had both. Hispanic and C patients were more likely to have LC vs. African American or  Asian (table). Histologically, Hispanic had significantly higher hepatic fibrosis score vs. Asian. LR analysis showed that female sex had lower OR (OR=0.34, 95% CI 0.2-0.7, p<0.001) and Asian and African American race had lower risk for LC (OR 0.4 and 0.3 respectively p= 0.03). Genotypes were not independently associated with LC.

 

Conclusion:

In our cohort,  the severity of hepatitis C varied by race.  Using expanded criteria for the definition of cirrhosis (histological plus clinical) more significant race differences emerged.  Caucasian and Hispanic patients were more likely to have cirrhosis to histologic criteria significantly underestimate the prevalence of cirrhosis.

 

 

23 American

Indian

218

Caucasian

147 H

Hispanic

123

African

American

146

Asian

Median BMI
(range)
cirrhosis

33

27 #

30

28

24 ¶

Genotypes 2,3

37%

26%

25%

7%

18%

Fibrosis Median

3 (0-4)

2 (0-4)

2.5(0-4)§

2.25(0-4)

2 (0-4)

Histologic cirrhosis

3 (13%)

31 (14%)##

30 (20%)‡

7 (6%)

8 (6%)

Clinical/histo (LC)

6 (26%)

75 (34%)

50 (35%)†

15 (12%)

25 (17%)

HCC

1 (4%)

0%

4 (3%)

5 (4%)

9 (6%)

# p<0.01 vs. H; ¶ p<0.0001 vs. all others p<0.005 v. AmInd,C,H; § p=0.01 v. As ## p<0.05 vs. AA, As; ‡ p<0.01 vs. AA, As p<0.0005 vs. AA, As; † p < 0.001 vs. AA, As


#218. HCV genotype determination targeting the 5’ noncoding region yields frequent erroneous subtyping in HCV genotype 1 infection.

S. Chevaliez; R. Brillet; M. Bouvier-Alias; C. Vandervenet; F. Darthuy; J. Remire; G. Dameron; J. Pawlotsky

 

Introduction:

 

HCV genotype determination is mandated to tailor pegylated interferon-ribavirin therapy to the individual patient. HCV genotyping is based on sequencing or reverse hybridization methods that analyze the sequence of the 5’ noncoding region (5’NCR) of HCV genome. However, erroneous subtyping has been reported, especially within HCV genotype 1, due to naturally occurring nucleotide polymorphisms in the 5’NCR. The current development of specific inhibitors with variable antiviral potencies against the subtypes of HCV genotype 1 will make it necessary that genotyping assays accurately discriminate among the subtypes of genotype 1, especially subtypes 1a and 1b, in clinical practice.

 

Objective:   

To determine the frequency of erroneous HCV genotype 1 subtype determination with methods based on the analysis of the 5’NCR.

 

Methods:

167 patients infected with HCV genotype 1 included in a multicenter therapeutical trial were studied. The HCV genotype and subtype were determined in all of them by the reference method, i.e. direct sequence analysis of the NS5B region, followed by phylogenetic analysis. This result was compared to that obtained with an assay determining the sequence of the 5’NCR after PCR amplification (Trugene HCV 5’NC Genotyping Kit, Bayer Healthcare).

 

Results: 

Based on NS5B sequence analysis, 72 patients (43%) were infected with subtype 1a, 89 (53%) with subtype 1b, 4 with subtype 1d, one with subtype 1e and one with subtype 1l. Among the 167 patients, 13 (7.8%) were classified as genotype 1 of unknown subtype with the 5’NCR sequencing assay, including 7 patients with HCV subtype 1a in the NS5B assay, 4 with subtype 1b, and 2 with other subtypes. In addition, the subtype was erroneous in 18 patients (10.8%) with the 5’NCR assay, including 12 with subtype 1a in the NS5B assay who were classified as 1b, two with subtype 1b who were classified as 1a, and 4 with other subtypes who were classified as 1b in 3 cases and 1a in one case.

 

Conclusion:

HCV genotype determination based on the analysis of the 5’NCR does not allow correct determination of HCV genotype 1 subtype in approximately 20% of cases, with an erroneous result in approximately half of them. Erroneous subtype assignment may have deleterious consequences on future therapeutical choices. Therefore, HCV genotype determination should be based on methods that do not rely on the 5’NCR only in order to accurately identify the HCV subtype in clinical practice.

 


#219. A simple and economical score can often displace other invasive or costly methods to evaluate liver fibrosis in chronic hepatitis C virus infection.

A. Vallet-Pichard; V. Mallet; B. Nalpas; V. D'halluin-Venier; H. Fontaine; S. Pol

 

Background:

The accurate evaluation of liver fibrosis in chronic hepatitis C is necessary. Liver biopsy is limited by its invasive nature, its cost, its intra- and inter-observer variability and by sampling errors; the FibroTest (Biopredictive SAS, Paris, France), the most evaluated non-invasive marker of liver fibrosis with an area under the receiving operator curve (AUROC) of 0.85 for the diagnosis of extensive fibrosis, is also limited by its availability, the standardisation of the assays, its cost and a 25% rate of inaccurate results.

 

Aim:

1.     to validate a simple, inexpensive, non-invasive test, denominated FIB-4, which combines standard biochemical values (platelets, ALT, AST) and age, in a series of 1084 liver biopsies performed in 995 patients with chronic hepatitis C virus (HCV) mono-infection;

2.     to compare the results of 784 FIB-4 and FibroTest performed the same day in a series of 595 HCV mono-infected patients. The files of the discordant patients were retrospectively reviewed by two independent investigators. A reference liver biopsy was available in all discordant patients (performed 2.8±1.8 years around the FibroTest).

 

Results:

1.     The FIB-4 enabled the correct identification of patients with severe (F3-F4) fibrosis with an AUROC of 0.84 (95% CI 0.81-0.87). A FIB-4 score ≤ 1.45 had a negative predictive value of 93.7% and a FIB-4 score > 4 had a positive predictive value of 66%. The FIB-4 efficiently identified cirrhosis with an AUROC of 0.89 (95% CI 0.86-0.93).

2.     The FIB-4 was strongly correlated to the FibroTest for a score ≤ 1.45 or > 4 (kappa 0.371, p<0.01). From the 444 cases with a FIB-4 ≤ 1.45, 409 (92.1%) were in agreement with the Fibrotest (F0-F1-F2, score<0.58). The 35 discordant cases were imputed to a FibroTest failure in 23 cases because of a low haptoglobin level (n=7), Gilbert disease (n=7), data capture failure (n=1) or remained unexplained (n=8). Twelve cases were interpreted as a FIB-4 failure because of very young age or unexplained thrombocytosis.

Twenty nine cases had a FIB-4 > 4; 24 (82.7%) of them had concordant results with the FibroTest (F3-F4) and 5 (17.3%) had discordant results (F0-F1-F2). Between 1.45 and 4 (39% of total cases), the FIB-4 was not correlated to the FibroTest.

 

Conclusion:

FIB-4 is a simple and inexpensive method for assessing liver fibrosis. A FIB-4 value ≤ 1.45 or > 4 (60.3% of the cases) is concordant with the FibroTest in 92.1% and 82.7%, respectively. In these ranges, FIB-4 could replace advantageously expensive and/or invasive methods to assess liver fibrosis.

 


#220. Impact of Human Immunodeficiency Virus (HIV) Infection on Hepatitis C Virus (HCV) Persistence Among Illicit Drug Users.

J. Grebely; J. D. Raffa; C. Lai; M. Krajden; B. Conway; M. W. Tyndall.

 

Objective:

To determine the role of HIV infection on the rate and characteristics of virologic clearance in HCV-infected individuals.

 

Methods:

The CHASE Project is a cohort study of an inner city population. The cohort data was linked with a longitudinal (1992-2005) database at the BC Centre for Disease Control containing HCV antibody, HIV antibody and HCV PCR assay results. Retrospective analysis revealed individuals with persistent HCV infection and HCV clearance.

 

Results:

We identified 762 HCV viremic subjects at baseline, with 179/762 (23.5%) spontaneously clearing viremia. HCV clearance was associated with female sex (Adjusted OR 1.61; 1.10-2.35, p=0.01) and Aboriginal ethnicity (AOR 2.94; 2.00-4.34, p<0.001) and inversely associated with illicit drug use (AOR 0.54; 0.29-1.00, p=0.05) and HIV infection (AOR 0.58; 0.38-0.88, p=0.01). Of 218 HIV infected subjects, 48/51 (94%) in whom we could establish the order of HCV and HIV infection were infected with HCV prior to becoming HIV-infected. Subjects infected with HCV first were infected a median of 2.4 years [0.2-10 years] before acquiring HIV. Individuals with HCV clearance and persistence had similar nadir CD4 counts (132 cells/mm3 vs. 137 cells/mm3, p=0.84) and overall median CD4 count (299 cells/mm3 vs. 324 cells/mm3, p=0.47) respectively. HCV clearance was 4/46 (8.7%), 5/25 (20.0%), 15/55 (27.3%), 3/33 (9.1%) in subjects with a nadir CD4 count of <50, >50-100, >100-200, >200, respectively. Median HIV viral load was also similar between groups (12,050 copies/mL vs. 10,070 copies/mL, p=0.72).

 

Conclusions:

·        HCV clearance occurred more often in aboriginals, females, and those without illicit drug use

·        Given that HCV infection and cleareance  occurs before HIV in IDUs, HIV infection increases the persistence of HCV in IDUs rather than decreasing viral clearance

·        Occurrence of HCV viremia was five-fold in those previously uninfected with HCV as compared to those with HCV cleareance

·        Previous infection with natural clearance may be protective with respect to re-infection

·        HIV coinfection may be associated with a risk of HCV reoccurrence either through a recrudescence of existing infection or via an increased susceptibility towards HCV re-infection

 


#221. A Single Tube Multiplex Research Assay to Assess the Risk of Cirrhosis in Subjects with Chronic Hepatitis C.

M. L. Shiffman; R. C. Cheung; S. Friedman; S. Chang; J. J. Catanese; D. Lew; O. T. Abar; C. L. Sigua ; C. D. Santini ; T. M. Vess; D. U. Leong; R. Venkatesh; T. L. Wright; T. J. Layden; N. Bzowej; T. J. White; J. J. Sninsky; H. Huang

 

Background and Aims:

Clinical risk factors such as gender, age at infection, alcohol consumption and obesity are insufficient predictors of cirrhosis risk. Furthermore, accurate estimates of alcohol intake and age at infection are difficult to obtain and subject to recall bias. We have recently demonstrated that host genetics can accurately predict cirrhosis risk in subjects with chronic hepatitis C (CHC) by identifying and confirming a signature of 7 single nucleotide polymorphisms (SNPs). The aim of the present study was to develop a simple and robust research assay which can simultaneously genotype all 7 SNPs and identify gender in a single reaction tube.

 

Methods:

1,468 CHC samples were collected from 5 US centers. The genomic DNA was extracted from frozen whole blood using Gentra AUTOPURE LS® Extraction or QIAGEN QIAamp Maxi Kit, and quantified using a fluorescent PicoGreen® dye assay. The genotypes of the 7 SNPs and gender of all 1,468 DNAs were first determined by Allele Specific PCR (ASP), a previously validated method which served as the “gold standard”. Subsequently, a single tube multiplex PCR-Oligonucleotide Ligation research assay (PCR-OLA) was established. First, 3ng of genomic DNA was used as a template to generate eight distinct PCR amplicons (one for each SNP plus gender). The amplicons were then genotyped by OLA and the ligation products were hybridized to Zip-coded Luminex® beads, and analyzed on a Luminex® 100TM (Iannone et al, Cytometry, 2000, 39:131-40). Finally, genotypes were determined using generic research software.

 

Results:

The multiplex PCR-OLA procedure takes <7 hours, with <1.5 hours hands-on time. A total of 11,744 genotype calls were determined on 1,468 CHC samples. We obtained valid genotype calls for 1468 (100%) and 1461 (99.52%) samples, using ASP and multiplex PCR-OLA, respectively. The genotyping concordance rate between the two platforms ranged from 99.86% to 100% for the 7 SNPs, with an overall concordance rate of 99.91%. For gender determination, we observed 100% concordance between ASP and clinical information, 99.79% concordance between multiplex PCR-OLA and clinical information.

 

Conclusions:

We have developed a simple and robust multiplex PCR-OLA research assay which accurately detects the 7 SNPs for assessing the risk of cirrhosis in CHC patients. It requires minimal DNA input and can be readily automated. This research assay accurately identified those subjects at high risk to develop bridging fibrosis/cirrhosis, and with further studies, may become a useful tool for the management of patients with CHC.

 


#222. Increased risk of hepatocellular carcinoma among patients with hepatitis C cirrhosis and diabetes mellitus.

B. J. Veldt; W. Chen; E. Heathcote; H. Wedemeyer; J. Reichen; W. Hofmann; R. J. de Knegt; S. Zeuzem; M. P. Manns; B. E. Hansen; S. W. Schalm; H. L. Janssen

 

Introduction:

For patients with hepatitis C cirrhosis the risk for development of hepatocellular carcinoma is about 2-10% per year. Recent studies suggest that the presence of diabetes mellitus increases the risk of developing hepatocellular carcinoma.

 

Aim:

The aim of this study is to quantify the risk of hepatocellular carcinoma among patients with both diabetes mellitus and chronic hepatitis C in a large cohort of patients with advanced fibrosis.

 

Results:

We included 541 patients of whom 85 (16%) had diabetes mellitus. The mean age at inclusion was 49 years. There were no differences in body mass index between patients with or without diabetes mellitus (27 vs 26 kg/m2, NS). The prevalence of diabetes mellitus was 10.5% among patients with an Ishak fibrosis score of 4, 12.5% for Ishak 5 and 19.1% for Ishak 6. Multiple regression analysis showed that only cirrhosis (Ishak score 6) was independently associated with diabetes mellitus (p=0.028). During a mean follow-up of 3.3 years, 11 patients (13%) with diabetes mellitus developed hepatocellular carcinoma versus 27 patients (5.9%) without diabetes mellitus. The 5-year occurrence of hepatocellular carcinoma was 18.6% (6.8-30.4) and 5.3% (2.3-8.3) for patients with and without diabetes mellitus (p=0.026). Multivariate Cox regression analysis of patients with Ishak 6 cirrhosis showed that diabetes mellitus was independently associated with the development of hepatocellular carcinoma.

 

Conclusion:

The 5-year occurrence of hepatocellular carcinoma is 18.6% among patients with hepatitis C advanced fibrosis and diabetes mellitus. This is three times as high as in a comparable population without diabetes mellitus.


#223. Direct serological markers of liver fibrogenesis improve the diagnostic accuracy of indirect markers for liver fibrosis in chronic hepatitis C patients.

O. Nuñez; M. Martin; R. Lorente; M. Senosiain; A. Matilla; E. Salinero; M. Catalina; M. Salcedo; M. Muñoz; G. Clemente

 

Introduction/Aim:

The objective was to develop a model to detect liver fibrosis in hepatitis C patients with clinical and analytical parameters used in clinical practice. The second aim was to evaluate if the addiction of direct markers of liver fibrogenesis could improve the diagnostic accuracy.

 

Methods:

A predictive model of liver fibrosis with clinical and analytical parameters was constructed in a cohort of 143 patients, and validated in a second cohort of 169 patients, both from one center. All individual scores were calculated using variables independently associated with significant fibrosis in liver biopsy (grade 3 to 6) evaluated by Ishak score system. In patients from validation cohort, frozen sera had been collected in the time of percutaneous liver biopsy and direct markers of liver fibrogenesis (TIMP-1, MMP-2, MMP-9, Hialuronic acid, VCAM-1 and ICAM-1) were measured by ELISA. Receiver operating characteristic analysis was done and area under the curve (AUC) calculated to assess the diagnostic accuracy of the model in both cohorts. In the validation cohort a fibrosis prediction model was calculated to evaluate if the addiction of direct markers of liver fibrogenesis could improve the accuracy of previous validated model.

 

Results:

Fasting glucose levels > 108 mg/dl, alcohol ingestion > 40 gr/day and age was included in the first model. The AUC in the estimation and validation cohort was 0.726 (CI 95%, 0.623-0.828) and 0.773 (CI 95%, 0.697-0.848), respectively. Hyaluronic acid, ICAM-1 and VCAM-1 values were added to the model. The AUC in the fibrosis prediction model calculated with liver fibrogenesis markers was 0.922 (CI 95%, 0.880-0.965). High scores were associated with significant liver fibrosis. The cutoff score of 0 had a high accuracy to detect significant liver fibrosis with a predictive positive value of 81.4%, and a specificity of 93.1%, and a cutoff score of –1.5 had a predictive negative value of 96.6% to predict patients with no significant fibrosis. Using these cutoffs, 72.5% of patients would be correctly classified.

 

Conclusion:

Clinical and direct markers of liver fibrogenesis can accurately predict liver fibrosis and may be helpful in the management of patients with chronic hepatitis C.

 


#224. Reproducibility of blood scores of liver fibrosis.

P. Calès; P. Veillon; E. Mathieu; C. Ternisien; A. Chevailler; A. Godon; Y. Gallois; Y. Tourmen; F. Joubaud; I. Hubert-Fouchard; F. Oberti; S. Réaud; F. Mauriat; F. Lunel

 

Introduction/Aim:

The main aim was to evaluate the interlaboratory reproducibility of Fibrometer and its composite variables. The secondary aims were to compare the reproducibility of several commonly used test among which the Fibrotest and APRI, and several factors influencing the preanalytical reproducibility of such scores.

 

Methods and results:

527 patients were included into 7 studies; the interlaboratory studies are presented here. Study #1: Interlaboratory reproducibility with 2 different samples (20 patients, 2 laboratories for each patient). We calculated the relative variation - Δ(%) - between both laboratories for Fibrometer and its composite variables; the largest variation was observed with hyaluronate. However, in forward multiple regression, the Fibrometer Δ was predicted at 1rst step by prothrombin index (PI) Δ (p<10-3) , 2nd step: ASAT Δ (p<10-3), 3rd step: time interval Δ(p=0.003)with aR2=0.41. Study #2: Interlaboratory reproducibility with identical samples and dosages at day 1 (33 patients, 12 laboratories). The agreement (ric) of Fibrometer was 0.91 with crude variables and 0.94 with standardized variables for limits (hyaluronate and PI). Study #6: Interlaboratory reproducibility with identical samples and dosages at day 0 (20 patients, 10 laboratories). The agreement (ric) was: Fibrometer: 0.963, Fibrotest: 0.984, APRI: 0.949. In the 10 laboratories the correlation (rs) between liver stiffness (Fibroscan) and Fibrometer varied from 0.55 to 0.73. However, using multiple linear regression including 11 Fibrometers (from 10 laboratories plus their mean value) the liver stiffness was predicted by the Fibrometer of one laboratory (p=0.001) plus that of another laboratory (p=0.03) with aR2: 0.60. In the 10 laboratories the correlation (rs) between liver stiffness and Fibrotest varied from 0.58 to 0.68 and for APRI from 0.22 to 0.40. The correlation between blood score and liver stiffness was slightly higher for Fibrometer (rs: 0.66) than for Fibrotest (rs: 0.63) but much higher than for APRI (rs: 0.25) in the reference laboratory. Using multiple linear regression including Fibrometers, Fibrotests and APRI scores of all laboratories, the liver stiffness was predicted only by Fibrometer. Study #7: Variability according to time (383 patients, 1 laboratory). Fibrometer, measured in only 2 instances in 22 patients, had a fair agreement but 2 patients had a dramatic change therefore the agreement was excellent in the 20 others.

 

Conclusions:

several preanalytical characteristics can influence reproducibility of blood markers of liver fibrosis. When these factors are controlled, agreement of blood scores among laboratories is excellent.

 


#225. EVALUATION OF AN AUTOMATED, HIGHLY SENSITIVE, REAL TIME PCR BASED ASSAY (COBAS AMPLIPREP / COBAS TAQMAN) FOR QUANTIFICATION OF HCV RNA.

C. Sarrazin; A. Wohnsland; B. Gärtner; S. Traver; G. Colucci; S. Zeuzem; A. Valsamakis

 

Introduction:

Diagnosis of hepatitis C virus (HCV) infection and management of therapy is based on qualitative and quantitative measurement of HCV-RNA. A new, automated real-time RT-PCR based assay (COBAS AmpliprepTM / COBAS TaqManTM, Roche Diagnostics, Pleasanton, USA) was designed for linear quantification and highly sensitive detection of HCV-RNA.

 

Aim:

In the present study, performance characteristics of the COBAS AmpliprepTM / COBAS TaqManTM assay (CAP/CTM), were evaluated in a multicenter study and compared with standard RT-PCR-based COBAS Amplicor Monitor 2.0 (CAM).

 

Results:

When tested on multiple replicates of a standard panel and clinical samples, respectively, the CAP/CTM showed a lower detection limit of 7.4 IU/ml (95% CI 6.2-10.6) and a high analytical specificity of 99%. HCV RNA quantification in the assay was linear between ≈30 and 1.4x107 IU/ml, with a correlation coefficient between expected and observed results of >0.99. Analyses of the mean intra- and inter-assay imprecision within the linear range of quantification showed a coefficient of variation of 3% and 3%, respectively. HCV genotypes 1a/b, 2b, 3a, 4, 5 and 6 were equally quantified by the CAP/CTM and CAM assay with mean deviations ranging from -0.29 log10 to 0.23 log10 IU/ml, while a significant under-quantification of HCV genotypes 3a and 4 (-0.59 log10 and -1.03 log10 IU/ml, respectively) was observed by the HPS/CTM assay. Direct comparison of the CAP/CTM with the CAM test, showed a high concordance with a correlation coefficient of 0.96.

 

Conclusion:

The CAP/CTM assay is a reliable and robust assay for highly sensitive detection as well as quantification of HCV RNA within a broad linear dynamic range.


#226. The AST to Platelet Ratio Index Does Not Accurately Predict Significant Fibrosis in HCV/HIV Coinfected Patients with Low CD4 T Cell Counts.

A. Singal; L. V. Thomassen; D. R. Gretch; M. C. Shuhart

 

Background:

Several noninvasive models of liver fibrosis have been proposed in patients with hepatitis C (HCV) infection. We evaluated the performance of the AST to platelet ratio index (APRI) in patients coinfected with HCV and HIV.

 

Methods:

111 HCV/HIV coinfected patients who underwent liver biopsy at Harborview Medical Center between July 2000 and May 2005 were identified by database review. 111 HCV monoinfected patients matched for age, gender, and liver disease stage were randomly selected. Exclusion criteria included inadequate biopsy sample, HBV infection and drug hepatotoxicity. Fibrosis was staged using the Batts Ludwig system (0-4). The APRI cut-off values of 0.5 and 1.5 were used to predict the absence or presence of significant fibrosis, respectively. Areas under the ROC curves (AUC) were compared using a modification of the Wilcoxon rank-sum test.

 

Results:

There was no difference between the HCV and the HCV/HIV groups with respect to demographic or clinical data (not shown). 24 patients (22%) in each group had significant fibrosis (stage 3 or 4). The AUC for predicting significant fibrosis was higher in the HCV group than in the HCV/HIV group (p=.098) (table). The AUC was lower in patients with CD4 counts <300 cells/uL when compared to those with higher CD4 counts, but the difference was not statistically signficant (p=.29). However, the AUC was significantly lower in patients with CD4 counts <300 than in the HCV monoinfected patients (p=.048). Nearly half of the monoinfected and coinfected patients with CD4 count ≥300, but fewer than one-third of those with low CD4 counts, were correctly classified. We explored reasons for the decreased accuracy of the APRI in patients with low CD4 counts, and found that AST did not predict stage in these patients (p=.9). This did not appear to be driven by other mechanisms for increased AST (e.g. HAART) in this subgroup.

 

Conclusion:

In HCV monoinfected patients, the APRI performed well in predicting significant fibrosis using the Batts-Ludwig scoring system, with accuracy similar to that previously reported (AUC .80 and 51% correctly classified). The model did not perform as well in the HCV/HIV coinfected patients; however, its accuracy in those with higher CD4 counts approached that in the HCV group. While the model was significantly less accurate in coinfected patients with low CD4 counts, the mechanisms behind this difference remain to be elucidated.

 

 

AUC (95% CI)

Correctly Classified (%)

HCV

.88 (.81-.96)

53/111 (48)

HCV/HIV

.79 (.70-.88)

45/111 (41)

CD4 <300

.72 (.57-.87)

14/46 (30)

CD4 ≥300

.82 (.70-.95)

31/65 (48)

 


#227. THE NATURAL HISTORY OF PATIENTS WHO SPONTANEOUSLY CLEAR HCV

R. M. Mc Loughlin; D. D. Houlihan; D. Manning; J. E. Hegarty; J. P. Crowe.

 

Introduction:

Hepatitis C is a major public health burden worldwide. 20-45% of infected individuals appear to clear the virus on initial contact and become PCR negative. Some studies suggest that these individuals who are serum negative for HCV still harbour HCV in polymorphonuclear cells, although there are no long-term data on the natural history of individuals who spontaneously clear HCV.

 

Aim:

To review the long-term PCR status of a cohort of patients who were infected with a HCV-contaminated batch of anti-D immunoglobulin in 1977/78, and cleared the virus spontaneously.

 

Method: 

Information was obtained from a prospectively maintained database. Only those exposed to the contaminated anti-D batch in 1977/78, with a positive antibody result (ELISA, RIBA) for HCV were included.

 

Results: 

110 individuals were PCR negative.  Their mean age at diagnosis of HCV was 46 years (range 35-63 years), their mean age at exposure to HCV was 28 years (range 17-45 years). Their alcohol intake ranged from 0-42 units/week, mean 3.35 units, but 29 (26%) consumed no alcohol and a further 32 (24%) consumed < 12 units/week.

At initial assessment 45% complained of fatigue, 33% of arthralgia, 4% depression, 7% of RUQ pain. Transaminase activity revealed a mean AST of 24.53 and a mean ALT of 24.47. Liver histology was available in 22 (21%) and showed normal (10) to mild (12) activity.

 

These patients have since been followed up for a mean of 8.8 years (range 4-11 years). Over that observation period the symptom profile has not changed significantly but two patients have died from unrelated illness, one from colorectal cancer and a second from lymphoma. All patients have remained PCR negative for HCV on repeat testing.

 

Conclusion:

This study shows that 110 females who spontaneously cleared the HCV genotype 1 infection contracted in 1977 have remained PCR negative over a mean follow-up interval of 8.8 years since diagnosis, 37.8 years since exposure. These results strongly imply that individuals achieving spontaneous HCV clearance maintain that status in the long-term.

 


#228. Association between liver fibrosis and insulin sensitivity in chronic hepatitis C patients.

N. Taura; K. Nakao; K. Hamasaki; T. Ichikawa; H. Yatsuhashi; H. Ishibashi; K. Eguchi

 

Introduction:

Several clinical studies have suggested a possible link between chronic hepatitis caused by hepatitis C virus (HCV) and the development of diabetes mellitus. We investigated the association between liver fibrosis and glucose intolerance in HCV-infected patients by measuring insulin sensitivity and β-cell function.

 

Method:  

A total of 83 chronic HCV-infected patients were recruited into this study. We evaluated insulin sensitivity and β-cell function of all patients in a fasting state (homeostasis model assessment of insulin resistance (HOMA-R) and homeostasis model assessment of β-cell function (HOMA-β) and after an oral load of 75g glucose (whole-body insulin sensitivity index (WBISI) and Δ-insulin/Δ-glucose 30).

 

Results:  

In a multivariate analysis, severe fibrosis was the only independent factor associated with insulin resistance. There were significant differences in both HOMA-R (p = 0.0063) and WBISI (p = 0.0159) between patients with mild fibrosis (n=34) and those with severe fibrosis (n=49). Although HOMA-β was increased significantly in the subjects with severe fibrosis compared with those with mild fibrosis (p = 0.0169), Δ-insulin/Δ-glucose 30 showed no significant difference in stage of liver fibrosis, suggesting an uncertain association between liver fibrosis and β-cell function.

 

Conclusion:  

Our findings suggest that the development of liver fibrosis is associated with insulin resistance in HCV-infected patients.

 

 


#229. HCV infection is associated with progressive insulin resistance in liver transplant recipients.

A. Delgado; Y. S. Liu; S. H. Jordan; S. Agrawal; Z. Hui; C. Deborah; R. T. Chung

 

Background and Aim:

An association between hepatitis C virus (HCV) infection and insulin resistance has been recently noted. However, causality has not been established. We sought to evaluate whether HCV induces insulin resistance by prospectively analyzing a cohort of liver transplant (LT) recipients.

 

Methods:

Thirty-four adults (14 HCV(+) and 20 HCV(-)) who underwent consecutive LT at our institution between 2002 and 2003 were followed longitudinally during the first year post-LT. Patient characteristics and medical history were reviewed. Anthropometric and laboratory measurements were obtained at 1,3,6,9, and 12 months post-LT. Insulin resistance (IR) was estimated using the homeostasis model assessment (HOMA). Possible confounders were considered. Repeated measure analyses were done to compare IR between HCV(+) and HCV(-) groups. Cox regression models were used to determine the timing of elevations of HOMA IR relative to HCV RNA levels.

 

Results:

There were no differences between HCV(+) and HCV(-) groups with respect to age, gender, ethnicity, body mass index (BMI), family history of diabetes, and total lifetime alcohol consumption at transplantation, or anthropometric and chemistry laboratory tests obtained at month 1 of the study. Five HCV(+) subjects underwent liver biopsies for elevated ALT during the course of the study, and fibrosis scores were 1 or less in all but one patient. None of the other subjects had clinical indications for biopsy. There was a trend towards lower prednisone use in the HCV(+) group, and there was no difference in use of tacrolimus between the two groups. Eleven HCV(+) subjects were treated with peginterferon (PEG IFN) and ribavirin at some point during the study, but use of PEG IFN or ribavirin did not correlate with HOMA IR. We found higher fasting insulin levels in HCV(+) subjects over time (p=0.007). HOMA-IR was 87% greater in HCV(+) than HCV(-) subjects during the first year post transplantation when controlling for BMI. Furthermore, subjects with high mean HCV RNA levels reached high HOMA-IR levels significantly sooner than subjects with lower HCV RNA levels (p=0.03).

 

Conclusion:

There is significantly greater IR in the HCV(+) group during the first year post-LT, despite comparable baseline insulin levels between the two groups of interest. This cannot be explained by differences in BMI, medications used, alcohol consumption, or degree of fibrosis. Furthermore, subjects with higher HCV RNA levels reach elevated HOMA-IR sooner than those with lower HCV RNA levels. These findings strongly suggest that HCV induces the development of IR.

 


#230. All cause and liver related mortality in a large cohort of HCV infected individuals in the UK.

K. Neal; S. Ratib; B. J. Thomson; S. Ryder; W. L. Irving

 

Introduction:

This study set out to determine the all cause mortality and frequency of liver related death in a large cohort of HCV infected individuals in the UK.

Aim:

The Trent HCV cohort study was established in 1991 with the aim of describing the natural history of chronic HCV (CHC) infection. Over 2500 patients are currently enrolled, with a mean length of follow-up of >5 years. CHC patients attending each of 7 sentinel clinics are invited to enlist for the study with informed consent. Patient-derived data are stored in a centralised, anonymised database.

 

Patients within the cohort are registered with the National Health Service Central Register. Death certificates and cancer registrations from Trent study patients are forwarded to the Trent HCV Study Group. Relevant data from all CHC patients within the cohort of Caucasian (n=1700) and Indian sub-continent (n=79) ethnic backgrounds were downloaded from the central database and compared.

 

Results:

Of 228 cohort deaths, 87 were “liver related”, 51 were related to injecting drug use, and 73 were “unrelated medical”. Factors associated with all cause and liver-related mortality were increased age and male gender. Standardised mortality ratios were 6.4 (95%CI 4.6-10.3) and 2.1 (1.5-3.5) for males and females respectively. Compared with CHC in Caucasians, CHC in patients of Indian ethnicity was more likely to occur in females, in individuals with no clear history of risk factors, and to present at an older age with more severe liver disease.

 

Conclusion:

5 year survival in our cohort is lower than that reported in the literature. Mortality in HCV-infected patients in our study is markedly increased compared to an age-matched population and is more likely to be liver-related. CHC in different ethnic groups appears to have very different characteristics from that in Caucasian patients.

 


#231. Optimization of the diagnosis of cirrhosis comparing clinical, biochemical and radiological features with liver stiffness by FibroScan.

R. Farnan; F. Heitor; I. Nasser; M. Curry; N. Afdhal

 

Introduction:

The diagnosis of cirrhosis is one of the most important diagnoses since it triggers screening for both HCC and varices and can affect patient clinical outcomes. The diagnosis of cirrhosis on clinical features can be variable although many experts believe they can easily diagnose cirrhosis.

 

Aims:  

To compare the diagnosis of cirrhosis by readily available clinical, biochemical and radiological tests with liver stiffness measured by FibroScan in patients with biopsy proven cirrhosis.

 

Methods/Patients:

171 patients (73% M, mean age 52 years) with biopsy proven compensated cirrhosis (80% post necrotic HCV/HBV) were studied. Sixty three patients (37%) had portal hypertension as defined by varices. Clinical parameters were hepatomegaly, splenomegaly by exam and ultrasound (US), stigmata of CLD, liver nodularity on US, platelet count, AST/ALT ratio, APRI and FibroScan. Individual predictive values for cirrhosis were evaluated plus a composite score involving either low platelets (<130,00), AST/ALT >1, or APRI >1 or 2 of the clinical features outlined above. A liver stiffness of > 13kPa was taken as cirrhosis based on previous data in over 500 patients from our site.

 

Results:  

Clinical findings showed either hepatomegaly or splenomegaly in 38%, stigmata in 32% and US nodularity in 13%. Thrombocytopenia was seen in 47% but the diagnostic accuracy was increased to 61% by using APRI. Liver stiffness was a mean of 28kPa with 73% having a stiffness > 13kPa. Liver stiffness could not be measured in 15 patients (9%) and was <13kPa in 31patients (18%). However, in all but 7 patients, liver stiffness was > 8.5kPa which is the cutoff for significant fibrosis. In the 31 patients with non-diagnostic stiffness, 10 met the criteria for cirrhosis by APRI. 8 of the 15 patients in whom FibroScan failed met the cirrhosis criteria by platelets or APRI.

 

Summary:

Clinical diagnosis of cirrhosis is relatively ineffective and < 50%. Platelet count and APRI are simple biochemical parameters but liver stiffness is the best diagnostic test. Combining liver stiffness with APRI and platelet count was diagnostic for cirrhosis in 84% of patients.

 

Conclusion:

Strategies for the diagnosis of cirrhosis non-invasively can be optimized using simple office based tests such as FibroScan and APRI.

 


#232. TRANSIENT ELASTOGRAPHY IN CHRONIC HEPATITIS C - COMPARISON BETWEEN DIFFERENT NONINVASIVE METHODS FOR LIVER FIBROSIS ASSESSMENT.

C. Baldaia; F. Serejo; R. Marinho; A. Costa; J. Velosa; M. C. Moura

 

Background:

Liver fibrosis evaluation has been a major clinical concern in chronic hepatitis C. Recently it became possible to measure liver stiffness as a non-invasive method for fibrosis assessment.

 

Aims:

To evaluate de performance of simple and feasible scores and liver stiffness in liver fibrosis assessment in a reference outpatient clinic.

 

Patients and Methods:

All patients underwent liver biopsy, routine laboratory tests allowing the calculation of AAR (AST/ALT), APRI, Forns Index, HOMA-IR, GGT score and transient elastography using Fibroscan ® (Echosense). GGT score (GGT-ULN)x5+ (AST-ULN) is a marker previously described in our patients (Raimundo et al. J. Hepatology, 1992;16:S52). Fibrosis was scored semi-quantitatively as described by Scheuer. Statistical analysis was performed by SPSS version 12.

 

Results:

105 patients were included. Mean age 43.8±11.8, 78 (74.3%) males. The fibrosis stage was F0/1 - 20 (19%), F2- 54 (51.4%), F3-12 (11.4%), F4-19 (18.1%). The mean: biopsy length-19.28±8.24 mm(6-41), number portal spaces 9.99±3.3, liver stiffness-9.12±0.77 kPa (2-40.3), APRI-0.9±0.97, AAR-0.89±0.88, Forns index-7.54±1.81, GGT score 9.34±9.73, HOMA-IR- 1.07±1.76.

 

The correlation (Spearman`s, 2 sided) between fibrosis stage and: liver stiffness (+0.73), APRI (+4.54), or Forns index(+0.47) is positive and significant. Also positive, although non significant with AAR, HOMA-IR and GGT score and is negative and significant with platelets (-0.3).

 

Area under the ROC (95% CI) for fibrosis ≥3 was 0.92±0.52 for Fibroscan, compared with 0.82±0.096 for APRI, 0.76±0.6 for Forns index and 0.77±0.09 for GGT score, 0.4±0.16 for HOMA-IR and 0.38±0.16 for AAR.

Diagnostic accuracies for predicting fibrosis ≥F3 using different cut – off (some previously described) are compared in the table.

 

Conclusions:

Transient elastography had the best diagnostic performance, in comparison with scores based on routine laboratory tests, for liver fibrosis assessment in this group of chronic hepatitis C patients.

 

Test

AAR

APRI

Forns Index

Score GGT

Fibroscan

Cut-off

≥1

≥0.5

≥1.28

≥6.77

≥4.22

≥6.9

≥10

≥8.29

8.74

Sensitivity

15%

86%

43%

38%

92%

38%

38%

90.3%

84%

Specificity

67%

63%

95%

97%

51%

98%

73%

97.3%

97.3%

Negative predictive value

72%

71.4%

79%

80%

94%

80%

77%

96%

93.5%

Positive predictive value

12%

51%

80%

83%

43%

91%

33%

93.3%

93%

LRpositive

0.45

2.35

9

12.5

1.86

25

1.38

33.41

31.03

LR negative

1.26

0.22

0.6

0.64

0.15

0.63

0.86

0.10

0.17

 

 


#233. Ultracentrifugation of serum samples allows detection of HCV-RNA in patients with occult HCV infection

J. M. Lopez-Alcorocho; J. Bartolome; I. Castillo; E. Rodriguez-Inigo; M. Pardo; V. Carreño

 

Introduction:

 

Occult HCV infection has been described in patients with abnormal liver function tests of unknown origin.1 Patients with occult HCV infection are anti-HCV and serum HCV-RNA negative but all have HCV-RNA in the liver and 70% of them have HCV-RNA in their peripheral blood mononuclear cells (PBMC).1 As HCV replicates in the liver cells of these patients it could be that the amount of serum HCV-RNA is under the detection limit of the most sensitive techniques, including real-time PCR. Thus, to prove this hypothesis, we have improved the method for HCV-RNA detection. One-hundred and six patients with occult HCV infection were included in this study. All of them were anti-HCV and serum. HCV-RNA negative by real-time PCR (sensitivity: 3.2 copies/reaction). All patients had HCV-RNA in the liver biopsy and 69 (65%) were HCV-RNA positive in PBMC. In all patients, other causes of liver disease were excluded. To improve the sensitivity of HCV-RNA detection (up to 8 times), 2 ml of serum were ultracentrifugated over a 20% sucrose cushion for 16 hours at 100,000×g to concentrate HCV particles. Total RNA was isolated from the pellet and HCV-RNA detection was performed by strand-specific real time PCR. To discard cross-contamination among samples, the HCV core region was amplified by real-time PCR from 10 randomly selected patients with HCV-RNA in their concentrated sera. PCR products were cloned and 4 clones from each sample were sequenced.

 

Results:

Out of the 106 patients, 62 (59%) had detectable serum HCV-RNA after ultracentrifugation with a mean load of 79.3±6.3 copies/ml. Phylogenetic analysis showed that the clones segregated separately, indicating that no cross-contamination occurred. Antigenomic HCV-RNA was found in the liver of 56/62 (90%) patients with detectable serum HCV-RNA after ultracentrifugation vs. 27/44 (61%) negative patients (p<0.001). Median load of antigenomic HCV-RNA strand was higher in patients who resulted serum HCV-RNA positive after ultracentrifugation (4.5×104; range: 7.9×102–1.0×106) than in those patients who were negative (2.3×104; range: 4.0×102–2.2×105), but without statistical significance. Out of the 62 patients with occult HCV infection and serum HCV-RNA after ultracentrifugation, 38 (61%) had also HCV-RNA in PBMC, that was similar to the percentage of serum HCV-RNA negative patients who had HCV-RNA in PBMC (31/44: 71%). ALT and GGTP levels and histological liver lesion (necroinflammatory activity and fibrosis) did not differ between both groups.

 

Conclusion:

In conclusion, HCV-RNA can be detected in the serum of patients with occult HCV infection after concentrating circulating viral particles by ultracentrifugation.

 

1J Infect Dis 2004; 189:7-14

 


#234. A screening test for thrombosis risk factors as a new biological marker of liver fibrosis in patients with chronic hepatitis C virus (HCV) infection.

A. Poujol-Robert; V. Eschwege; R. Poupon; A. Robert

 

Background and aim:

The progression of fibrosis in HCV infection is a dynamic process in which genes and environmental factors interact. Recently, a “clotting process” has been found to be associated in this progression. Studies have shown that defects in the protein C anticoagulant pathway are frequently observed in extensive fibrosis and early stage of cirrhosis. A global test, named ACV test is used in laboratory workup for thrombosis risk factors to screen for defects in the protein C pathway*. It is highly sensitive to protein C deficiency, elevated factor VIII level and presence of factor V Leiden and less sensitive to protein S deficiency. The aim of the study was to evaluate whether this test could represent a marker of fibrosis in HCV infection.

 

Patients and methods:

We studied 34 consecutive patients referred for HCV infection with a F3 (n=9) or F4 (n=25) fibrosis METAVIR score and with prothrombin time upper or equal to 80% ([F3-F4] patients) and 34 consecutive patients with an F1 (n=21) or F2 (n=13) fibrosis score and PT upper or equal to 80% ([F1-F2] patients). The ACV test, the plasmatic levels of protein C, protein S and factor VIII and the presence of the factor V Leiden were determined for each patient. The ACV was performed on plasma using 2 activated partial thromboplastin times, 1 in the absence and 1 in the presence of an activator of endogenous protein C and expressed as a ratio.

 

Results:

The ACV obtained in the [F3-F4] patients (median 0.67, range 0.39-0.98) were lower (P<0.0001) than those obtained in the [F1-F2] patients (median 1.01, range 0.45-1.69). In comparison the PT were not different between the 2 fibrosis groups (median 93%, range 80%-104% vs. median 90%, range 80-101%). When the levels of protein C, protein S and factor VIII and the presence of the factor V Leiden were tested in a stepwise linear regression, 55% of the variation in ACV appeared to be explained by factor VIII level (P <0.001), protein C level (P<0.0001) and the presence of factor V Leiden (P=0.003).

 

The area under ROC curve of ACV to differentiate [F1-F2] patients and [F3-F4] patients was 0.88 (95% CI 0.80-0.96). Using a cutoff value of 0.99, the sensitivity, specificity, negative and positive predictive values of ACV for [F3-F4] diagnosis were 100%, 56%, 100%, 69% respectively.

 

Conclusion :

This study showed that ACV, a screening test for thrombosis risk factors, is a very sensitive marker of extensive fibrosis in patients with HCV infection and normal PT. Training and validation sets are required to assess the performance of this test for exclusion of extensive fibrosis.

 

*Thromb Haemostas 1996;75:562-566; Am J Clin Path 1999;112, 233-237.

 


#235. Accurate Identification of Liver Fibrosis by a Continuous 13C Methacetin Breath Test in Patients with Chronic HCV Infection and Normal or Near-Normal Liver Enzymes.

G. Lalazar; T. Hershcovici; O. Pappo; T. Hajjaj; E. Zigmond; M. Shubi; H. Ohana; N. Hemed; M. Margalit

 

Background:

Up to 40% of patients with HCV infection and normal or near-normal serum ALT (≤ x2 ULN) have significant liver disease. Currently, many of these patients undergo a liver biopsy to guide therapeutic decisions. The BreathID® continuous online 13C methacetin breath test reflects hepatic microsomal function (CYP1A2), and was shown to be in correlation with hepatic fibrosis.

 

Aim:

To assess the role of the BreathID® 13C methacetin breath test for identification of liver fibrosis in patients with a normal or near-normal serum ALT level.

 

Methods:

98 treatment-naïve subjects (age range 19-76) with HCV infection and a normal or near-normal serum ALT level, who had undergone a liver biopsy within 9 months, and 46 healthy controls (age range 19-81) underwent a 13C methacetin breath test following oral ingestion of 75mg methacetin. We examined the correlation between PDR (percentage dose recovered), PDRpeak, and CPDR10, 30 and 60 (cumulative PDR 10, 30 and 60 minutes after ingestion of methacetin, respectively) and Metavir score, age and body mass index (BMI). Breath test parameters were compared between two Metavir groups: Metavir score ≤2 and Metavir score >2. Statistical analysis was performed without exclusion of indeterminate cases.

 

Results:

A statistically significant difference between the two Metavir groups was observed for all breath test parameters. Compared to control PDRpeak, an abnormal PDRpeak value was obtained in 41% of chronic HCV patients with normal or near-normal ALT. Interestingly, PDRpeak values were often elevated in patients with low fibrosis compared to controls. Combining data derived from PDRpeak and CPDR10, the methacetin breath test identified patients with severe fibrosis (Metavir>2, n=26) with area under the curve (AUC) 0.9 in ROC analysis (0.825-0.975 95% CI), a positive predictive value (PPV) of 89% and a negative predictive value of 80%. There was no correlation between age or BMI and the methacetin breath score for patients with the same histological score.

 

Conclusions:

These results suggest that the continuous BreathID® 13C methacetin breath is an accurate tool for identification of liver fibrosis in patients with chronic HCV infection and normal or near-normal ALT levels. As such, it may prove to be a powerful, noninvasive alternative to liver biopsy in the management of this patient population.

 


#236. Accurate quantification and sensitive detection of hepatitis C virus RNA using a single automated assay in the clinical setting

J. Méritet; C. Le Pendeven; A. Krivine; J. Nicolas; P. Lebon; A. R. Rosenberg

 

Background.

Quantitative measurements of HCV RNA are becoming increasingly important in the therapeutic management of patients with hepatitis C. However, the lower limit of detection (LLD) of quantitative assays commercially available to date (≥600 IU/mL) is too high to assess achievement of sustained virologic response, hence requiring the use of a qualitative assay with an LLD ≤50 IU/mL. Thus, there is a clinical need for rapid molecular techniques capable of combining the performance of qualitative and quantitative HCV RNA assays into a single assay.

 

Aim.

Here we have assessed the performance in the clinical setting of the Abbott m2000TM RealTime HCV system, a new automated platform for sample preparation (m2000sp) and real-time PCR assay (m2000rt) with a reported linear dynamic range of 12 to 108 IU/mL.

 

Methods.

Clinical samples (80 sera and 25 plasmas) found positive with the Bayer bDNA quantitative assay VERSANTTM HCV RNA 3.0 (LLD=615 IU/mL) were tested with the Abbott assay. All HCV genotypes were represented, across a wide range of HCV RNA values. In addition, Bayer bDNA-negative sera from 59 treated patients were tested with the Abbott assay and with the two commercially available HCV RNA qualitative assays, i.e., Roche Cobas HCV AMPLICORTM v2.0 test (LLD≈50 IU/mL; the most widely used qualitative assay), and Bayer VERSANTTM HCV RNA Qualitative (TMA) assay (LLD≈10 IU/mL; the most sensitive assay). Finally, 50 HCV-seronegative samples were tested with the Abbott assay.

 

Results.

For bDNA-positive specimens, the concordance between the results of the two assays was 100%, and the HCV RNA values correlated very well (r2=0.96), regardless of whether serum or plasma was used. The mean inter-assay difference was only 0.07 log IU/mL, and no significant discrepancy was found among genotypes. For bDNA-negative sera, the HCV RNA values measured by the Abbott assay correlated well with the ranges expected from the results of the qualitative assays. All sera positive with the Roche assay could be quantified with the Abbott assay. All sera positive with the TMA assay were also detected with the Abbott assay, with some results being expressed as ‘detected, <12 IU/mL’. Such Abbott software statement should be considered with caution, however, because the same statement was also given, albeit not reproducibly, for 3 of 50 seronegative samples.

 

Conclusion:

In this study, HCV RNA was quantified accurately for all patients positive with the most widely used qualitative assay, suggesting that the automated Abbott m2000TM RealTime HCV assay can be used as a single molecular test for the clinical management of hepatitis C.

 


#237. Increased Anti-ARFP Antibody Positivity is Associated with End-Stage Liver Disease.

J. L. Walewski; J. A. Gutierrez; A. Klepper; A. D. Branch .

Introduction:

Indirect ELISAs are used to assess anti-HCV antibody status and immune responses to specific viral proteins. Antibody levels can reflect disease state or treatment responses (Nishizono, 1993; Baumert, 2000). In order to test for a possible association between anti-ARFP antibody positivity and disease state, we have developed a novel, specific and sensitive indirect ELISA for anti-ARFP antibodies in patient serum.

 

Methods:

Serum samples were collected under MSSM IRB approved consent. Stocks were made in 50% glycerol, 1% BSA, 1X Phosphate-buffered Saline/Tween 20 (PBS-T). 1a consensus 70 mer peptides (Amino aa 1-70 and Mid aa 40-109) and core 2 (18 mer plus cysteine) were synthesized by 21st Century Biochemicals (Hopkinton, MA). Peptides at [10µg/ml] were individually incubated and covalently linked to Amino-Immobilizer 96 well plates (NUNC) in 1X PBS. Plates were then blocked with 2% BSA/PBS-T (Promega), and the serum samples were tested at a 1:2000 final dilution in 2% BSA/PBS-T. HRP conjugated goat-antihuman IgG (H+L, Jackson labs) was used as the secondary antibody, at a 1:10,000 final dilution in 2% BSA/ 1X PBS-T. TMB substrate reaction was stopped with 8.5% o-phosphoric acid. ODs were measured at λ 450, with λ 650 subtraction for background. All samples were measured in duplicate, these values were averaged and BSA/blocker background values were subtracted for each sample. The threshold for positivity for each peptide was defined as the mean plus three standard deviations of 11 controls (5 healthy serum donors and 6 end-stage liver disease [ESLD] patients [non-HCV]). 28 Genotype 1a HCV positive samples were divided into two groups; 1)HCV ESLD (with ascities, N= 12), and 2) HCV chronics, no cirrhosis (CNC, N=16).

 

Results:

All of the negative controls (healthy and ESLD without HCV) were negative for core, 1a Amino ARFP and 1a Mid ARFP peptides. There was no difference in anti-core positivity between the HCV ESLD and HCV CNC (11/12, 91.6% vs 14/16, 88%). However, HCV ESLD patients (5/12, 42%) had significantly higher positivity to the ARFP peptides than the HCV CNC patients (1/16, 6%). This difference was statistically significant, p=0.036 by Fisher’s Exact test.

 

Conclusions:

While HCV ESLD or HCV CNC patient sera were equally positive to core peptides in our indirect ELISA, positivity to the ARFP peptides was significantly different between the two groups (ESLD; 42% and CNC; 6%). These results indicate that expression of the ARFP by HCV may vary by disease state, and that the detection of antibodies to this protein may provide clinically useful information to further evaluate patient status.

 

(Supported by NIDA016156 and DDK066939)

 


#238. Diagnostic accuracy of blood tests of liver fibrosis for severe fibrosis and cirrhosis in patients with chronic viral hepatitis .

P. Calès; P. Halfon; Y. Bacq; F. Oberti; M. Rousselet; S. Michalak; Y. Gallois; M. Bréchot; A. de Muret; C. Degott; V. Paradis; F. Lunel .

 

Introduction:

Blood tests of liver fibrosis have usually as main diagnostic target clinically significant fibrosis (CSF). From a clinical point of view or in screening perspective, it is important to know the diagnostic accuracy (DA) of those tests for severe fibrosis (SF) or cirrhosis (F4).

 

Methods:

The DA of the following tests was evaluated: FibroMeter (FM), Fibrotest (FT), Hepascore (HS) and APRI in 1000 patients from 3 populations of chronic viral hepatitis: exploratory initial (EI, n=383), internal validation (n=261), external independent validation (EIV, n=356). Liver fibrosis was evaluated by 2 independent pathologists before reaching a consensus according to Metavir staging and with the area of fibrosis.

 

Results:

We present here only the results dealing with FM an FT in EI and EIV populations. a) Diagnostic accuracy: AUROC were for F4: EI population: FM: 0.941±0.016 vs FT: 0.907±0.021 (p=0.258); EIV population: FM: 0.942±0.022 vs FT: 0.858±0.039 (p=0.086); for SF: EI population: FM: 0.927±0.016 vs FT: 0.885±0.025 (p=0.107); EIV population: FM: 0.844±0.030 vs FT: 0.812±0.029 (p=0.331). b) The rate of misclassified patients based on liver biopsy, with a test cut-off at 0.5, was for F4: EI population: FM: 0%, FT: 4.7% (p: NA); EIV population: FM: 0%, FT: 15.4% (p: NA); for SF: EI population: FM: 3.4%, FT: 12.5% (p=0.02); EIV population: FM: 11.8%, FT: 27.8% (p=0.06). c) A test cut-off fixed at 0.37 could decrease the rate of misclassified patients for F4: EI population: FM: 0%, FT: 2.3% (p: NA); EIV population: FM: 0%, FT: 0%; for SF: EI population: FM: 0%, FT: 9.7% (p: NA); EIV population: FM: 5.9%, FT: 14.8% (p=0.22). d) The inclusion of composite variables of FM in a regression model showed the following AUROC in EI population: for SF: 0.942±0.012 vs 0.935±0.014 (p=0.274) in original FM; F4: 0.950±0.013 vs 0.947±0.013 (p=0.642) in original FM. e) The table 1 compares the DA (%) of FM for CSF and FM for the area of fibrosis as a function of diagnostic target by discriminant analysis. The FM for the area of fibrosis becames as accurate as FM for CSF only by SF target.

 

Conclusions:

The diagnostic accuracy of blood tests (FM and FT) is very high for the diagnostic of F4 and comparable to Fibroscan. It is also high for the diagnostic of SF. In both cases, the diagnostic accuracy of FM is superior to that of FT in 2 independent populations. The rate of misclassified patients is significantly higher for FT than for FM. The FM of area of fibrosis is as accurate as the FM of CSF for the diagnostic of SF or F4.

 

Table 1

 

FibroMeter

F (0 to 4)

F (≥ F1)

CSF (≥ F2)

SF (≥ F3)

F4

Metavir F

61.1

66.0

82.1

85.3

88.2

Area

54.3

53.3

75.5

83.2

92.9

 

 

 

 

 


#239. Meta-analysis of blood scores for liver fibrosis in chronic hepatitis C.

P. Calès; P. Halfon; Y. Bacq; V. Leroy; M. Rousselet; M. Bourliere; A. de Muret; N. Sturm; Y. Gallois; G. Penaranda; M. Bréchot; C. Trocme .

 

Introduction:

Blood scores of liver fibrosis are alternative tools to liver biopsy or imaging. The aims of this meta-analysis with individual data were to evaluate the diagnostic accuracy, the center effect (reproducibility) of scores and to compare them.

 

Methods:

The populations from 4 independent centers (dosages, liver interpretation) included 300, 217, 159, and 149 patients with chronic hepatitis C, i.e. 825 patients. Blood scores included Fibrotest (FT), FibroMeter (FM), Hepascore (HS) and APRI.

 

Results:

The global characteristics were the following: 44±12 yr, males: 59.5%, Metavir stages: F0: 4.8%, F1: 46.7%, F2: 25.0%, F3: 12.5%, F4: 11.0%. The 4 populations were significantly different for: age, sex, Metavir score and prevalence of clinically significant fibrosis (≥F2), severe fibrosis (≥F3), and cirrhosis (F4). AUROC are listed in the table 1.

 

FM AUROC for ≥F2 was superior to that of FT (p=0.049), APRI (p=0.001) and HS (p<10-3). AUROC were different according to center, e.g. for FM from 0.773±0.042 to 0.883±0.026. The score profile significantly varied as shown by the comparison of disagreement rate between blood score and liver biopsy (misclassified patients) as a function of Metavir stage: this rate was significantly superior for FM vs FT in F1 (22.9 vs 14.7%, p<10-3) but significantly inferior for FM vs FT in F2 (40.8 vs 62.8%, p<10-3), F3 (13.3 vs 27.6%, p=0.003) and F4 (1.3 vs 9.0%, p=0.07). This disagreement rate blood vs liver significantly varied according to center, e.g. for ≥F2 and FM from 18.3 to 28.6% (ANOVA, p=0.02). By logistic regression, the center had an independent role for this disagreement. Likewise, the disagreement rate between blood scores significantly varied according to center, e.g. for ≥F2, FT vs FM from 16.9 to 26.3% (ANOVA, p=0.05). By contrast, Metavir stage, but not center, had an independent role for this disagreement.

 

Conclusion:

This meta-analysis with individual data validates the published data of accuracy for blood scores of liver fibrosis (except for HS) and shows significant differences between blood scores for global accuracy and even more as a function of Metavir stage which explains a population effect.

 

Table 1

 

≥F2

≥F3

F4

FibroMeter

0.831±0.014

0.887±0.014

0.923±0.013

Fibrotest

0.803±0.016

0.853±0.016

0.892±0.015

APRI

0.784±0.017

0.836±0.017

0.874±0.019

Hepascore

0.775±0.017

0.834±0.017

0.886±0.019

 


#240. High rate of spontaneous viral clearance in patients with iatrogenic acute hepatitis C

A. Licata; V. Calvaruso; D. Ferraro; V. Di Marco; P. L. Almasio; A. Craxì .

Background & Aim:

Changes in the pattern of primary exposure to HCV have caused a shift in the clinical spectrum of acute hepatitis C. Among non-drug users, most Western patients acquire their infection through hospitalization or medical procedures and appear to evolve less often into chronicity after a symptomatic illness (1).

 

Patients and Methods:

Between January 2003 and September 2005, we consecutively observed 15 patients with acute hepatitis C. Initial assessment included HCV-RNA quantitation (Amplicor Monitor®, Roche) and genotyping. Quantitative HCV RNA was retested every 4 weeks.

 

Results:

Seven of 15 patients were males, and the mean age was 57.2 years (range 5 – 83). All subjects had an iatrogenic exposure (endoscopy, surgery, other invasive procedures) as the only risk factor. None was HIV or HBV coinfected, or had a history of liver disease, and significant alcohol consumption and use of illicit i.v. drugs were excluded. All patients had an ALT peak > 20 u.n.l. and a documented seroconversion (anti-HCV negative to positive). Ten were symptomatic, as defined by the presence of bilirubin ≥ 3 mg/dl and/or severe asthenia. Eleven patients (73.3%) cleared spontaneously HCV within 24 weeks of observation (mean time: 11.6 weeks): 8 were symptomatic. Four patients (two on chemotherapy for cancer) did not clear HCV infection within the first 24 weeks after presentation. Mean HCV-RNA at baseline was 477,497 UI/ml in subjects undergoing spontaneous HCV clearance and 1,280,265 UI/ml in those evolving to chronicity. Two of the 4 non-clearers were not treated due to old age or comorbidity, and one refused treatment, while one, infected by HCV 1b, was successfully treated with PEG-IFN and Ribavirin.

 

Conclusions:

Chronic evolution of an acute, mostly symptomatic HCV infection in Western patients with iatrogenic exposure is relatively infrequent. Absence of cofactors, small size of the inoculum and selection bias toward symptomatic acute disease might have affected the low rate of chronicity. Since patients may still clear HCV between 12 and 24 weeks after clinical onset, a 6 months “wait and see” strategy before starting IFN is based on reason.

 

1. Micallef et al, J Viral Hepat. 2006;13:34.

 


#241. Hepatitis C Testing, Infection, and Treatment Rates in Bipolar Patients With and Without Co-morbid Substance Use Disorders.

A. M. Matthews; M. S. Huckans; A. D. Blackwell; P. Hauser .

 

Objective:

To determine and compare the hepatitis C (HCV), screening, testing, and antiviral treatment rates among

1) Bipolar Group (BD group) – history of BD but no SUD

2) Substance Use Disorders Group (SUD group) – history of SUD but no BD

3) Co-occurring Disorders Group (DD group) – history of both BD and SUD

4) Control Group (CON group) – no history of either BD or SUD.

Our hypothesis is that testing rates and HCV prevalence will be higher in the BD, SUD, and DD groups than controls, but that treatment rates will be the same or less for the three diagnostic groups than those in the control group.

 

Methods:

Using a medical record database, information was retrospectively collected on 325,410 patients seen between 1998 and 2004 within facilities and clinics of the VISN 20 of the Northwest Veterans Healthcare Administration. We then compared HCV testing, prevalence, and treatment rates among the four groups: BD, SUD, DD, and CON. Incidence rates, odds ratios, and relative risks were determined and compared among groups.

 

Results:

The following percentages of patients within the total sample met criteria for each risk group:

1.     BD group:  1.5% (n=5025)

2.     SUD group:  11.7% (n=37,970)

3.     DD group:  1.5% (n=4,724)

4.     CON group:  85.3% (n=277,690)

 

Within the total sample, 40% (n=130,021) of patients received testing for HCV.  Relative to Controls, those with BD only, SUD only, or DD were significantly more likely to receive HCV Testing. Compared to controls, those in the BD group, SIUD group and DD group had increased testing rates relative to the CON group.

 

Of all the patients tested for HCV within the total sample, 10.4% (n=13,531) tested positive.  Within each group, 7.1% (n=214) of the BD group, 26.4% (n=6922) of the SUD group, 29.6% (n=1142) of the DD group, and 5.4% (n=5253) of the CON group testing positive for HCV.  These risk groups had a 1.31 fold, 4.86 fold, and 5.46 fold increase in the risk of HCV infection respectively. 

 

Of all patients who tested positive for HCV, 6.7% (n=903) received at least one prescription for IFN.  Relative to Controls, the likelihood that a patient would receive IFN therapy was much less if the had a history of substance disorder. Patients in the BD group or the DD group were statistically as likely to receive IFN as Control, although there is a trend for the DD group to be less likely than controls to receive treatment. 

 

Discussion:

·        Overall prevalence of HCV in VISN 20 was higher than in previous national samples.  10.1% in our VISN 20 sample as compared to 5.4% in the study by Dominitz.  This may reflect a selection bias of who was tested.

·        Testing rates were significantly higher in the BD, SUD, and DD groups than controls.  We would expect this as these groups likely have more risk factors for HCV.

·        HCV prevalence was higher in the BD, SUD, and DD groups than controls.  In particular the SUD and DD groups were much more likely to test positive.  This increased risk for HCV is likely related to drug use behaviors.  This suggests that bipolar patients, particularly if they have co-morbid SUD, should be routinely screened and tested for HCV.

·        Treatment rates were the same or less for the three diagnostic groups than those in the control group.  In particular, those in the DD group also received interferon at a rate that was not statistically different that those in the control group, although there was a trend toward the DD group being less likely to receive treatment.  This suggests recent interventions by the VA to increase screening, testing and treatment of HCV in veterans may be having an effect.

 


#242. Ascites in HCV: A Previously Untapped Source of Antibodies.

J. A. Gutierrez; A. L. Klepper; J. L. Walewski; V. Khaitova; D. M. Jefferson; T. D. Schiano; A. D. Branch.

Introduction:

Analysis of ascitic fluid may shed light on HCV pathogenesis. This compartment is reported to contain a distinctive subpopulation of HCV RNA (Yeh et al., 1996) and it is a potential source of novel reagents and biological materials, including anti-HCV antibodies (Ab), HCV RNA, infected cells, and growth factors. In this study, we compared anti-core HCV Ab levels in sera and ascites and showed that reagent-grade anti-core Ab can be purified from ascites.

 

Methods:  

Patients undergoing therapeutic large volume paracentesis were enrolled under an IRB approved protocol. The group included 29 HCV patients (1 HCV/HIV and 1 post-LT) and 12 controls (3 HBV and 9 EtOH). Serum (when available) and ascites were collected. ELISAs were used to detect anti-HCV core Ab in sera (dilution 1:16,000) and ascites (dilution 1:3,200) using Maleimide plates (Pierce) coupled to core peptide 2 (H77 amino acids 8-25). Anti-Core 2 Ab immunopurification was performed with Sulfolink kits (Pierce). Eluted IgG was tested for activity against core peptide 2 and core peptide 5 (H77 amino acids 29-46). JMP Software was used for analysis.

 

Results:

HCV patients and controls were similar in age, the percentage of males, liver function tests, and ascites cell counts. Immunoglobulins were present in the ascites of all patients. The ratio of IgG in ascites to serum was about 1:5 in HCV patients. Notably, 79% of HCV patients had anti-core 2 Ab in their ascites, while none of the controls had anti-core 2 Ab (see table). Among HCV patients a significant linear relationship was observed between the levels of anti-core Ab in the serum and ascites (R2=0.66, p<0.0001). Anti-core 2 Ab were immunopurified from one patient’s ascites, using either protein-A purified IgG or total ascitic fluid as starting material. A nearly quantitative yield of anti-core 2 antibodies was obtained. This material was specific for the core 2 peptide and did not react with other regions of the core protein.

 

Conclusions:

Ascitic fluid is a rich source of high affinity, reagent grade anti-HCV antibodies. Affinity purification yields antibody preparations with narrow specificities that will be useful in immunohistochemistry, diagnostics and therapy.

 

(Supported by NIDA016156, DDK066939, and DK-34928)

 

 

HCV

CONTROLS

p value*

Serum Anti-core Ab

19/24 (79%)

0

<0.0001

Ascites Anti-core Ab

23/29 (79%)

0

<0.0001

Serum IgG(mg/dl)

2190

1430

0.0134

Ascites IgG(mg/dl)

550

240

0.0167

Serum IgM(mg/dl)

178

200

0.5

Ascites IgM(mg/dl)

24

19.5

0.58

Median IgG/IgM Values Shown; *Wilcoxon Rank Sum Analysis.

 


#243. Diffusion-weighted MR imaging for the diagnosis of liver fibrosis in patients with chronic hepatitis C.

M. Lewin; A. Poujol-Robert; P. Boëlle; D. Wendum; E. Lasnier; C. Hoeffel; L. Arrivé; J. Tubiana; R. Poupon.

 

Background/Aims:  

Liver biopsy remains the gold standard for assessing presence and severity of fibrosis but has several limitations due to sampling and observer errors. Several non-invasive methods have been developed to assess the degree of liver fibrosis. Recently, diffusion-weighted MR imaging (DWMRI) has been reported as a promising technique to evaluate cirrhosis. The aim of this study was to determine the performance of DWMRI for the diagnosis of liver fibrosis in patients with chronic hepatitis C virus (HCV) infection and to compare its accuracy with other noninvasive methods [Fibrotest, APRI and Forns tests, serum hyaluronate concentration and transient elastography] .

 

Methods:  

We prospectively included patients with chronic HCV infection who had DWMRI, biological tests, elastography and then liver histological evaluation. Fibrosis was graded using the METAVIR score. DWMRI was performed on a 1.5 T magnet using EPI sequences with respiratory trigger, phased-array coils and four b-values : 0, 200, 400, and 800 sec/mm2. Hepatic apparent diffusion coefficient (ADC values) were calculated in the right liver on ADC maps.

 

Results:  

54 asymptomatic patients were included. The histological fibrosis score were : F0, n=1 ; F1, n=30 ; F2, n=8 ; F3, n=5 and F4, n=10. Patients with moderate-severe fibrosis (F2-3-4) had hepatic ADC values lower than those of patients without or with mild fibrosis (F0-1) (mean 1.19 ± 0.11 vs 1.30 ± 0.12 cm2/sec). The area under the receiving operator characteristic (AUROC) curve for stages F3-4 were 0.92 (± 0.04) for MRI, 0.92 (± 0.04) for elastography, 0.79 (± 0.08) for fibrotest, 0.87 (± 0.06) for APRI, 0.86 (± 0.06) for Forns, and 0.87 (± 0.06) for hyaluronate. For an ADC cut-off level of 1.28 for stage F3-4, sensitivity, specificity, positive predictive value and negative predictive value were 100%, 56%, 72%, and 94% respectively. The AUROC curve for stages F2-3-4 were 0.79 (± 0.07) for MRI, 0.87 (± 0.05) for elastography, 0.68 (± 0.09) for fibrotest, 0.81 (± 0.06) for APRI, 0.72 (± 0.08) for Forns, and 0.77 (± 0.06) for hyaluronate. The AUROC of the combinaison between ADC and elastography was 0.88 (± 0.05) for stage F2-3-4.

 

Conclusion:  

In this preliminary study, the performance of DWMRI is better or at least similar to that of others noninvasive tests for the presence of significant liver fibrosis. This study highlights the interest of Diffusion-weighted MR imaging to be used as an adjunct to routine imaging to assess the degree of liver fibrosis in patients with HCV infection.

 


#244. NATURAL COURSE AND INCIDENCE OF NON ORGAN-SPECIFIC AUTOANTIBODIES (NOSA) AND HCV INFECTION IN THE GENERAL POPULATION: A NESTED CASE-CONTROL STUDY OF THE DIONYSOS COHORT.

M. Guidi; L. Miglioli; A. Granito; L. S. Crocè; P. Muratori; F. Masutti; L. Muratori; A. Castiglione; M. Lenzi; F. B. Bianchi; G. Bedogni; C. Tiribelli; S. Bellentani.

 

Introduction/Aim:

This study aims to explore the natural course and the crude incidence of non-organ specific autoantibodies (NOSA), and the presence and severity of chronic liver disease (CLD) in the HCV infected subjects of the Dionysos cohort.

 

Methods:

After a median period of 8.5 years from the first (1992) screening, 122 (69 M and 53 F) out of the 161 HCVRNA positive subjects (HCV+) were screened (compliance = 76%), and paired-matched for sex and age with 122 normal subjects of the same cohort (controls=C). Sera were tested for the presence of non-organ specific autoantibodies (NOSA) (anti-nuclear antibody-ANA, anti-smooth muscle antibody-SMA and and anti-liver/kidney microsomes type 1-LKM1) by indirect immunofluorescence (IFL) at a 1:40 serum dilution. The annual crude mortality rate of the entire cohort was also registered.

 

Results:

24/122 patients (20%) were treated with one or more courses of IFN and only 4 (all genotype non-1) are long-term responders. Antiviral treatment was not associated with variation in the autoantibody profile. The overall prevalence (P) of NOSA reactivity (NOSA+) was almost identical at the time of the first and the second screening (P=18.4% vs 18.7%). As expected, the P of NOSA+ was significantly higher in HCV RNA+ than in C subjects (P= 23% vs 14%, p<0.05). The risk of liver-related mortality among the HCVRNA+ subjects was 2X higher when NOSA+ was present (OR= 2.1, range 1-5.8, p<0.05). During the 8.5 yrs of follow up, 79% of the controls and 76% of the HCV+ subjects did not change the state of NOSA reactivity, while the remaining 24% either cleared NOSA or became NOSA+. The annual overall NOSA clearance rate was of 7.5% (7.3% in C and 7.7% in HCVRNA+). Also similar was the annual NOSA+ crude incidence rate between C (1.7% ) and HCV+ subjects (1.8%). ANA and SMA positivity were cleared in 66 and 69% of the cases, respectively, with no significant differences between C and HCVRNA+ subjects.

 

Conclusions:

From these data we conclude that, in the general population, the P of NOSA is higher in HCV infected patients than in controls, and that NOSA positivity affects the natural course and mortality of patients with HCV-related CLD, but not controls. To our knowledge, this is the first study demonstrating a rather high fluctuation of NOSA reactivity in the general population, without differences between controls and HCV infected people.

 


#245. Hepatitis C Anti D: Progression with age?

F. Donnellan; G. Cullen; P. McCormick; J. E. Hegarty.

 

Background:

In Ireland in 1994 it was established that anti-D immune globulin administered to women during 1977 and 1978 for Rhesus isoimmunisation was contaminated with Hepatitis C (HCV) from a single infected donor. It has been shown that at the time of diagnosis 17 years on from the time of infection the overall rate of serious liver disease was low.

 

Aim:

To assess progression of liver disease in this unique group of patients over a 10 year period following diagnosis.

 

Methods:

Using a retrospective chart review and serial liver biopsies we looked at rates of progression of liver disease, requirement for liver transplantation and mortality over a 10 year period from 1994 to 2004.

 

The grade of inflammation and stage of fibrosis were assessed on serial liver biopsies. Inflammation was graded as being absent (0), mild (1), moderate (2) or severe (3. Fibrosis was staged as follows: 0 indicated no fibrosis, 1 periportal or portal fibrosis, 2 portal–portal bridging, 3 portal–central bridging with or without early nodule formation, and 4 probable or definite cirrhosis.

 

Results:

196 women attend our service with past or current HCV infection, 103(53%) of which were found to be HCV PCR positive. 99(96%) of these underwent liver biopsies between 1994 and 2004. The study identified 69 females (67%) who underwent at least 2 biopsies during the course of their disease. Mean interval between first and last biopsy was 6.1 years (range 1-10).

 

The median age at time of infection was 29 years (range 24-33 yrs); while the median age at first biopsy was 45 years and at most recent biopsy was 51 years.

 

There was no significant change in inflammation between first biopsy (mean inflammation score 1.2 [SEM 0.06]) and last biopsy (1.2[0.06]) (p=0.44). In contrast mean fibrosis score increased from 0.5 (SEM 0.1) to 1.0 (0.2) between first and last biopsy (p<0.05).

 

3% of our total PCR positive anti D population underwent liver transplantation while 4% died from HCV related complications.

 

Conclusion:

These results highlight that in our particular subset of patients, HCV infection secondary to contaminated anti-D immune globulin is a progressive disease leading to significant morbidity and mortality.

 


#247. Detection of low amounts of HCV-RNA in the serum of sustained virological responders after antiviral therapy.

P. Fytili; C. Wang; S. Schaffer; S. Schulz; M. P. Manns; H. Wedemeye .

 

Background:

As new, more sensitive methods for the detection and quantification of the hepatitis C virus are becoming available, a careful clinical interpretation of the results is needed.

 

Methods:

In order to evaluate a new commercial HCV quantification assay with a low detection limit (Abbott m2000 real-time PCR system), we performed serial logarithmic dilutions of serum from genotypes 1-6 starting from a 106 virus load.

 

Consequently we tested sera of 50 patients with chronic hepatitis C infection after treatment with PEG-IFNa + Ribavirin between 2001 and 2004. All patients had a Sustained Virological Response (HCV-RNA negative by Cobas AmplicorTM six months after therapy end). Sera at least 6 months after the end of treatment, stored at -20°C, were re-tested with the Abbott HCV RealTime PCR.

 

Results:

The method was stable providing a linear decline of the virus load of the dilutions in all genotypes until the area of 12 IU/ml.

 

From the 50 patients that were examined, 9 had detectable but not quantifiable HCV-RNA (<12 IU/ml) and two had a viral load <100 IU/ml. Interestingly, the one of these two patients had a persisting light increase of the liver enzymes since a successful antiviral treatment five years ago and has always tested RNA negative with the conventional methods until today.

 

Conclusion:

The meaning of the detection of low viral load in patients after antiviral therapy for chronic hepatitis C with the new highly sensitive methods is controversial. It may be associated with a mild course of liver inflammation in single cases, but in most patients it does not show to have a clinical implication. Bigger and longer-term studies of patient cohorts after treatment should evaluate the meaning of low persisting viraemia.

 

Our data are in line with the abstract presented by Maylin et al (LB9, AASDL 2006) showing that SVR is associated with HCV eradication.

 


#248. In HIV/HCV-Coinfected Patients, the Duration of Highly Active Antiretroviral Therapy (HAART) Does Not Predict Fibrosis Progression Rate or Fibrosis Stage.

M. D. Hernandez; L. Logush-Pinto; M. Rodriguez-Torres; C. F. Rios-Bedoya; J. F. Rodriguez-Orengo; A. Fernandez-Carbia; F. Paronetto; N. Brau.

 

Introduction:  

In HIV/HCV-coinfected patients, we have shown that the liver fibrosis progression rate (FPR) is slower in patients with completely suppressed HIV RNA levels than in subjects with uncontrolled viremia with a significant linear correlation between HIV viral load and FPR). Likewise, the stage of fibrosis is less advanced in patients with undetectable plasma HIV RNA (Bräu et al., J Hepatol, Jan-2006). Here, we investigated if either FPR or fibrosis stage are correlated with the duration of HAART.

 

Methods:

A total of 161 HIV/HCV-coinfected patients with data on Ishak fibrosis scoring, HIV RNA, and duration of HAART were retrospectively analyzed, 55 with undetectable HIV RNA level (<50 copies/mL) and 106 with any detectable HIV viral load (50+ copies/mL). FPR and Ishak fibrosis score were compared between the groups using Student t-test and the their correlation with duration of HAART was calculated using linear regression analysis. Independent factors predicting FPR and fibrosis stage were determined using multi-variable linear regression analysis.

 

Results:

The median HIV viral load was <400 copies/mL (IQR, <400, 1,094), and 34.2% of patients had an HIV viral of <50 copies/mL. The median CD4+ cell count was 360 cells /mm3 (Interquartile Range [IQR], 220, 552), and 18.0% had a CD4+ cell count of <200/mm3. The median duration of HAART was 3.2 years (IQR, 1.2, 4.3), and the duration was longer in patients with HIV RNA <50 copies/mL (3.9 years) than in patients with uncontrolled HIV viremia at 50+ copies/mL (2.6 years, p<0.001). The FPR was slower in patients with HIV RNA <50 copies/mL (0.100 Ishak fibrosis units per year) than in subjects with any detectable HIV RNA (0.143 IshFU/yr, p=0.004). -- Duration of HAART was not correlated with FPR (r=0.055, p=0.49), neither in patients with HIV RNA <50 copies/mL (r=0.029, p=0.83) nor in subjects with 50+ copies/mL (r=0.002, p=0.98). Duration of HAART was not correlated with Ishak fibrosis stage either (r=0.007, p=0.93), which applied again to patients with and without detectable plasma HIV RNA. FPR was independently predicted by Ishak necroinflammation score and age at HCV infection (p<0.001 each, r-square=0.439 for model) and fibrosis stage by Ishak necroinflammation score (p<0.001, r-square=0.504 for model).

 

Conclusion:

Duration of HAART is not associated with fibrosis progression rate or fibrosis stage. Future prospective studies should focus on correlating time of undetectable plasma HIV RNA with FPR and fibrosis stage.

 


#249. European liver fibrosis (ELF) markers accurately distinguish fibrosis severity in Chronic Hepatitis C (CHC); an external validation study in a population-based cohort.

J. Parkes; S. R. Bialek; B. P. Bell; N. A. Terrault; A. Zaman; A. N. Sofair; M. Manos; I. Guha; R. Cross; S. Harris; P. J. Roderick; W. M. Rosenberg.

 

Introduction:

Liver biopsy is the reference method for assessing liver fibrosis. However it is costly, has associated risk,and is subject to sampling and interpretation errors. The search for accurate non-invasive markers of liver fibrosis has led to the development of a panel of sensitive serum assays(ELF),measuring fibrosis matrix components, developed in conjunction with Bayer Healthcare, which have previously been shown to be accurate in assessing liver fibrosis in a range of chronic liver disorders[1].The ELF panel was derived in a training set(n=400) and validated in an internal cohort (same study population but separate from training set)(n=521).Here we present the external validation (in an independent population) of the performance of the ELF markers in a cohort of patients with CHC.

 

Methods:

Subjects were 85 treatment naïve patients with CHC within a population based cohort of patients with newly diagnosed chronic liver disease seen during 1999-2001 by all gastroenterologists in a defined geographic area (three US counties). All biopsies were staged for fibrosis using the METAVIR system. TIMP-1, PIINP, and HA were measured in baseline samples, all of which were anonymous to the investigators. Serum for fibrosis markers was taken within 6 months of the biopsy. Fibrosis scores were derived using the published ELF algorithm. The Area Under the Curve (AUC) for Receiver Operator Characteristic Curves was measured for distinguishing between different degrees of severity of fibrosis.

 

Results:

Median age was 43 years (25-72),and 11% (F0),34% (F1),34%(F2),11%(F3),11%(F4) formed the validation cohort. Results from the internal validation in the original cause specific study cohort (column 3) –are compared to the external validation study (column 2). See Table. Conclusion: We confirm the excellent diagnostic performance of the ELF markers in detecting moderate to severe fibrosis (F3 or 4) which may have clinical utility in a population-based cohort of patients with newly diagnosed CHC.

 

References: [1] Rosenberg WM, Voelker M, Thiel R, Becka M, Burt A, Schuppan D et al. Serum markers detect the presence of liver fibrosis: a cohort study. Gastroenterology 2004;127:1704-13.

 

Histology (METAVIR

AUC (95% CI)
CHC Validation Cohort
n=85 (external validation*)

AUC (95% CI)
CHC Original Study Cohort[1]
n=261(CHC internal validation**)

F0 vs F1-4

0.70 (0.51, 0.89

0.73 (0.65, 0.81)

F0,1 vs 2-4

0.74 (0.63, 0.84)

0.74 (0.68,0.81)

F0-2 vs 3,4

0.84 (0.74, 0.94)

0.79 (0.73, 0.86)

F0-3 vs 4

0.90 (0.81, 0.98)

0.83 (0.73, 0.93)

 

*External validation =panel validated in independent population from that in which panel was derived **Internal validation= panel validated in patients recruited in same study population as those in whom the panel was derived.


#250. FIBROSpect II and Image Analysis in the Evaluation of Chronic Hepatitis C.

N. Snyder; G. Sood; O. Tarcin; L. Vergara; G. Hillman; S. Xiao; D. Lau; J. Petersen.

 

Background:

The liver biopsy is the gold standard for assessing hepatic fibrosis in patients with chronic hepatitis C. However, other methods of assessing hepatic fibrosis have been sought. Serum fibrosis markers have been proposed, particularly to separate mild from significant fibrosis. Among the tests available is the FIBROSpect II (FSII), a commercially available panel which is calculated from measurements of hyaluronic acid, tissue inhibitor of metalloproteinases, and alpha 2 macroglobulin. Image analysis has been proposed as a more quantitative method to determine the extent of fibrosis on the liver biopsy.

 

Aims:

We wanted to evaluate the accuracy of the FSII in chronic HCV, and see how well it correlated with individual stages of the disease. In addition, we wanted to utilize image analysis in the assessment of the stage of fibrosis and see whether the FSII correlated better with it or traditional staging.

 

Methods:

We prospectively collected serum on 85 patients undergoing pretreatment liver biopsies. Patients were excluded if they had received anti-viral therapy in the last year, were co-infected with HIV or HBV, or had an organ transplant or hepatocellular carcinoma. Blood was drawn on the day of biopsy,and the FS II was subsequently performed at Prometheus Laboratories. Prometheus was blinded to the patient’s clinical status. The liver biopsies were read blindly by one pathologist and staged using the Batts Ludwig criteria (F0-F4). All liver biopsies had a length > 1.5 cm. Image analysis was performed blindly using institutionally developed software.

 

Results:

85 patients were studied. The distribution by stage was: F0:17.6%, F1:30.6%, F2: 20.0%, F3:14.1%, F4: 17.6%. The clinical sensitivity of the FS II separating mild (F0-F1) from significant (F2-F4) fibrosis was 80.4% with a specificity of 84.6%.The results of image analysis by stage were F0: 4.4%(1.7), F1: 7.3% (2.6), F3: 12.2%(4.0), F4 : 14.9%(3.7). The results of FSII were F0: 30.3(18.0), F1: 44.0 (22.7), F2: 71.5(21.7), F3: 75.8(22.9), F4: 87.7(14.1). The R2 for Image Analysis versus Stage (F) by pathologist was 0.510, the R2 for FS II versus Image Analysis was 0.432, and the R2 for FS II versus Stage was 0.485.All patients with an image analysis of >12% had a FSII of >58 as did 26/27 patients with F3 or F4.

 

Conclusion:

This study shows similar correlations of the FSII with pathologist staging and Image Analysis. Both the FSII and Image Analysis demonstrate significant overlap at F2-F4, suggesting that actual differences in fibrosis at these stages may be smaller than assumed. A FSII < 60 makes advanced fibrosis by staging or image analysis unlikely.

 


#251. GB virus C viraemia and HCV/HIV co-infection: Significant association with lower incidence of liver disease & liver related mortality.

M. Berzsenyi; S. Bowden; K. Watson; A. Mijch; H. Kelly; R. Hammond; S. Crowe; S. Roberts.

 

Background and Aims:

GB virus C (GBV-C), also known as hepatitis G virus, is a member of the Flaviviridae and is closely related to hepatitis C virus (HCV). GBV-C infection has been reported in some studies to improve morbidity and mortality for patients with human immunodeficiency virus (HIV) infection with slower progression to acquired immunodeficiency syndrome (AIDS). However, GBV-C is known to have no effect on liver disease in chronic HCV mono-infection. The aim of the study was to investigate the relationship between GBV-C viraemia and liver disease in HCV/HIV co-infected patients.

 

Methods:

158 well characterized HCV/HIV co-infected patients were recruited from January 1996 to October 2005. Two serum specimens at least 18 months apart were collected from all patients. Total RNA was extracted from serum and active GBV-C infection or viraemia was determined by reverse transcription polymerase chain reaction (PCR). A screening PCR was performed using primers to the NS5B gene and positives were then confirmed by PCR to the E2 gene. Gene sequencing was then undertaken with comparison of sequence homologies. Using previously established methods, systematic review was undertaken of patient records looking for features of liver related morbidity and mortality as close as possible to the time of the patient’s follow-up sample.

 

Results:

57 (36%) patients had GBV-C viraemia with 32 (20%) having persistent viraemia and 25 (16%) transient viraemia (RNA positive in one sample). There was no difference in CD4 count, HIV viral load or number of cases of AIDS between the GBV-C RNA positive or negative populations. Overall 34 (21%) patients had features of advanced liver disease with 20 (12%) having compensated cirrhosis and 14 (9%) having decompensated cirrhosis. GBV-C viraemia was significantly associated with a lower incidence of cirrhosis in univariate (P=0.001) and multivariate analysis (P=0.009, HR 0.25, 95% Cl 0.086-0.78). In univariate analysis, GBV-C was associated with a reduction in decompensated cirrhosis (P=0.02). Viraemic patients were less likely to die from liver-related disease (P=0.004) with no significant effect on overall survival (P=0.2).

Conclusions: In this well characterised HCV/HIV co-infected population, GBV-C viraemia was associated with a significant reduction in the severity of HCV-related liver disease and liver-related death but had no significant effect on overall patient survival.

 


#252. A multicenter Belgian review of patients infected by HCV genotype 4.

M. Nkuize; J. Delwaide; P. Langlet; N. Bourgeois; M. Adler; C. de Galocsy; P. Michielsen; C. Assene.

 

Background and Aims:

It is well established that the prevalence of HCV genotype 4 (HCV4) is high in Central Africa and in the Middle East where the sustained virological response (SVR) on peginterferon/ribavirine is reported to be 72 %. However, few data are available regarding patients infected by HCV4 living in Europe. The specific aims of this study were to compare two groups of patients: Black Africans (BA) and Non-Africans (NA) (European and Arab) residing in Belgium, with respect to demographic features, treatment regimen , compliance, SVR and reason for no treatment.

 

Methods:

7 Belgian centers participated in this study. HCV4 patients were identified. A detailed review of each patient’s chart was performed. Serum HCV RNA levels were measured by an Amplicor quantitative assay. Liver biopsies were evaluated according to the METAVIR classification. Patients were treated with either interferon alone or associated with ribavirine ± amantadine or by pegylated interferon (alpha 2a: 180µg/week or alpha 2b: 1.5µg/kg per week) and ribavirine according to body weight ± amantadine (PegR).

 

Results:

A total of 287 BA (65% women) and 129 NA (60% men) with HCV4 were selected. The mean age at inclusion was 48,22 years ± 12,28 for BA vs 41,62 ± 13,48 for NA (95%CI: 3,72 – 9,41), mean age at treatment was respectively 50,85 years ± 11,89 for BA and 42,23 ± 13,48 for NA (95%CI: 5,18-12,05)respectively. The BMI in BA and NA were 27,35 ± 4,47 and 24,48 ± 4,27 (95%CI: 1,65-4,08) respectively. No significant differences were found for infectious status for HBV and HIV, HCV viral load, dyslipidemia, ALT, histology and dose reduction. In contrast, comorbidities as alcohol consumption in 29.6% of BA vs 50.6% of NA (p=0.001), hypertension in 23% of BA and 4,7% of NA (p=0,004), impaired glucose metabolism in 19,5% of BA and 7% of NA (p=0,001) were observed. One hundred sixty two patients were not treated; the main reasons were normal ALT and /or absence of fibrosis in 80 patients (77.5% BA vs 22.5% NA) (p=0,003). One hundred sixty five patients were treated by PegR: 119 were BA vs 46 of NA. SVR was achieved in 71% of NA patients but in only 26 % of BA (p=0,001). The compliance was similar.

 

Conclusion:

1.     Compared to NA, BA residing in Belgium and suffering from HCV4 were older at inclusion and at time of treatment, are slightly overweighted, have impaired glucose metabolism, hypertension and less alcoholic intake.

2.     BA have a lower SVR compare to NA. This may be due to genetic differences in response to IFN therapy, comorbidities or different patient’s characteristics.

  1. Absence of fibrosis and/or normal ALT are the main reasons for no treatment in both groups.

 


#253. Association Between Intranasal Drug Use and Hepatitis C Virus Infection: A Multicenter Study of 3,871 Patients.

S. Dhalla; A. Aytaman; C. T. Tenner; N. B. Shukla; G. A. Villanueva; G. Punla; C. Patterson; J. Comas; E. J. Bini.

 

Background:

Although injection drug use and blood transfusions prior to 1992 are well-accepted risk factors for hepatitis C virus (HCV) infection, the evidence for intranasal drug use as a risk factor for HCV is conflicting. Furthermore, many prior studies that have evaluated intranasal drug use as a risk factor for HCV infection were potentially confounded by injection drug use. The aim of this study was to determine the association between intranasal drug use and HCV infection in a large population of patients without traditional risk factors for HCV infection.

 

Methods:

Patients with chronic HCV infection (HCV RNA positive) and controls (HCV antibody negative) completed a detailed questionnaire at the time of their scheduled visit to the outpatient primary care or GI clinic at 3 study sites. Data collected included patient demographics and information on HCV risk factors.

 

Results:

A total of 3,871 patients were enrolled, including 1,930 with chronic HCV infection and 1,941 HCV negative controls. There were no differences in the mean age (55.2 ± 9.0 vs. 55.6 ± 11.3 years, p = 0.34) or proportion who were male (80.3% vs. 81.4%, p = 0.39) between HCV-infected patients and controls. However, HCV positive patients were more likely to be racial/ethnic minorities (56.5% vs. 78.5%, p < 0.001). As expected, injection drug use (65.9% vs. 17.8%, p < 0.001), blood transfusions prior to 1992 (22.3% vs. 11.1%, p < 0.001), and intranasal use of cocaine or heroin (61.8% vs. 22.6%, p < 0.001) were more common in HCV-infected patients than in control subjects. Patients with HCV infection were significantly more likely to have a history of intranasal drug use (OR = 5.5; 95% CI, 4.8 – 6.4) and this remained significant after adjustment for age, sex, and race/ethnicity (OR = 5.8; 95% CI, 5.0 – 6.8). After excluding all patients with a history of ever injecting drugs and those who have had a blood transfusion prior to 1992, a total of 1,886 subjects were remaining for analysis (465 HCV positive and 1,421 controls). Among these 1,886 patients without traditional risk factors for HCV infection, we found that HCV positive patients were still significantly more likely to have a history of intranasal drug use (OR = 1.9; 95% CI, 1.5 – 2.4) and this remained statistically significant after adjustment for age, sex, and race/ethnicity (OR = 2.0; 95% CI, 1.6 – 2.5).

 

Conclusions:

·        Intranasal use of cocaine or heroin is associated with HCV infection, even among those without traditional HCV risk factors such as injection drug use and blood transfusions.

·        All patients who have used intranasal drugs should be offered HCV testing, even if they have never injected drugs.

 


#254. A Survey of Primary Care Residents Regarding Knowledge of Hepatitis C.

J. L. Yozviak; E. Vasiliadis; S. R. Kimmel; S. J. Templer; M. Hoffman-Terry.

 

Background:

The hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States. Prior studies have shown that primary care residents are poorly trained in the diagnosis, treatment, and chronic management of HCV. We conducted this survey to assess HCV-related knowledge among our primary care residents in the fields of internal medicine (IM), family practice (FP), and obstetrics-gynecology (OBGYN).

 

Methods:

A 21-item questionnaire measuring core awareness and knowledge of HCV was distributed to IM, FP, and OBGYN residents for baseline measurement prior to a two-part HCV educational session. Six primary constructs were addressed: self-perceived role in caring for patients with possible HCV, screening and diagnosis, barriers to specialist referral, counseling and management, treatment, and contraindications to treating HCV. Constructs were reported as either group percentages of items appropriately selected or as means of participants’ averaged score for questions within that construct. Multiple response questions were scored as number appropriately selected by the participant divided by total number of appropriate items for that question.

 

Results:

83.33% (N=62) returned questionnaires. Residents perceived their primary role to be screening (98.4%) and diagnosis (96.8%) of HCV rather than provision of antiviral therapy (12.9%). All other construct scores were below 70% regardless of specialty or post-graduate year (PGY). Only 50% appropriately selected ELISA/RIBA as the diagnostic test of choice and 37.1% genotype (GT) 1 as the most common in the U.S. 45.2% identified pegylated interferon-alfa and ribavirin as the treatment of choice. Few correctly identified the SVR rate of combination therapy in GT 1 (30.6%) and GT 2 & 3 (9.7% & 11.3%). More would test for exposure to HIV (98.4%) and HBV (92.1%) than HAV (56.5%), and few knew the correct HAV vaccination schedule (16.1%). Most (53.2%) could not correctly identify the rate of vertical transmission from an HCV-infected mother as <10%, and few (30.6%) were aware of current breastfeeding recommendations. No significant differences were noted between specialties or PGY groups.

 

Conclusions:

We identified many aspects of HCV knowledge that are lacking among our primary care residents, particularly involving diagnostic tests, HAV vaccination recommendations, counseling, and antiviral therapy. Underestimating the efficacy of HCV treatment may represent a significant barrier to diagnosis and treatment. Future research is planned to distribute a follow-up survey 1 to 3 months after an educational intervention for each of the residency groups.

 


#255. Intrafamilial and household clustering of hepatitis C virus in rural Egypt: a phylogenetic and matrix correlation tests analysis.

C. Feray; M. El-Daly; V. Thiers; S. El-Kafrawy; A. Fontanet; C. Rekacewicz; F. Rimlinger; M. K. Mohamed; M. Abedl-Hamid.

 

Background:

Hepatitis C virus is highly prevalent in Egypt due to the past spread of HCV through massive antischistosomal campaigns. HCV prevalence remains high and HCV is still spreading in this population through unknown routes.

 

Methods:

In a village located in a village of Nile delta, 139/273 plasma HCV RNA positive subjects were selected on the basis that another relative or household member was also HCV RNA positive. We calculated pairwise genetic distances (NS5B and E1 regions) between HCV strains infecting 133/139 subjects living in 54 different houses. 78 of them had at least one infected relative (spouse, parent, sibling).

 

Results:

Phylogenetic analysis showed genotype 4a in 105 and a new type 4 subtype in 20 patients. Apparent familial or house clustering was suggested for strains belonging to genotype 4a as well as to the new type 4 subtype. Correlation matrix methods were based on Mantel’s test for univariate and multivariate analysis. Mean distances between strains infecting relatives (parents or siblings) or infecting subjects living in the same house were smaller than for subjects who did not share these relations (0.06±0.06. vs 0.15±0.1, p<0.0001 and 0.08±0.08 vs 0.15 ; p<0.0001). Multivariate analysis showed that house and family were independent variables. Backward regression performed on all 133 cases showed that sibling or household were the main independent variables predicting a short genetic distance between strains. The same analysis performed on 105 subjects infected by genotype 4a also showed that both mother-child and father-child were independent and significant variables. No correlation was found with spouse, gender or age variables.

 

Conclusion:

Our findings demonstrate that the intra familial transmission particularly between sibs is important in the particular setting of HCV infection in rural Egypt.  These findings based on the sequence analysis of the HCV strains infecting 133 subjects, largely confirm the largest study based on the starting population of 4022 anti-HCV positive and anti-HCV negative subjects (Plancouline, submitted).  We also strongly confirm a recent study (Mohamed, 2005) which show that to be the relative or the spouse of an infected subject increased the risk of infection.

 

In the present study, we show that the spouses were not infected by similar strains meaning that each member of a couple are not infected by each other or by the same source.  More importantly we evidenced that an household transmission existed and was independent of the familial relationship.   The mean distance between the strains infecting households was larger than the mean distances between strains infecting the same family suggesting that the transmission first occurred in the house then spread within families.

Our approach on the issue of viral transmission through correlations between distance matrix has never been used before.  Applied to a relatively small number of subjects we could clearly show the non-sexual intrafamilial and household transmission of HCV in rural Egypt.  The precise routes of contamination within households and families remain to be established then targeted for prevention strategies.

 


#256. Hepatitis B Virus Coinfection Among American Patients With Chronic Hepatitis C Virus Infection: A Prospective Analysis of Prevalence and Viral Interactions.

P. V. Perumalswami; E. J. Bini.

 

Background & Aims:

HBV-HCV coinfection is common worldwide (10% - 30%) due to shared routes of transmission. However, little is known about HBV-HCV coinfection in the U.S. The aims of this study were to determine the prevalence of HBV infection among Americans with chronic HCV infection and to evaluate HBV-HCV viral interactions.

 

Methods:

We prospectively identified patients with chronic HCV infection (HCV PCR positive) who were seen in the outpatient clinics at our medical center. All subjects were interviewed by a research assistant who obtained detailed demographic and clinical data. HBV testing (HBsAg, HBsAb, and HBcAb) was performed in all subjects, and those with a positive HBsAg test had HBeAg, HBeAb, and HBV DNA testing.

 

Results:

The mean age of the 1,257 patients with chronic HCV infection was 53.4 ± 10.1 years, 93.3% were male, and the subjects were racially diverse (324 whites, 513 blacks, 278 Hispanics, 50 Asians, and 92 from other racial/ethnic groups). Current or prior injection use was common (66.5%), and 78.8% were infected with HCV genotype 1. Of the 1,257 subjects with HCV, 5.7% (95% CI, 4.4% - 7.0) were coinfected with HBV (HBsAg+). The prevalence of HBV coinfection was slightly higher in men (6.0% vs. 2.4%, p = 0.23) and differed significantly according to age (6.3% in <50, 3.9% in 50 – 59, and 8.3% in those ≥70 years old, p = 0.03). There were also significant differences in the prevalence of HBV coinfection according to race (3.1% in whites, 6.2% in blacks, 3.2% in Hispanics, 32.0% in Asians, and 5.0% in others; p < 0.001). A history of injection drug use was more common in HBV-HCV coinfected patients (93.1% vs. 64.9%, p < 0.001). Of the 72 HBsAg+ patients, 53 (73.6%) were HBeAg+ and 67 (93.1%) had detectable HBV DNA. Patients coinfected with HBV and HCV had significantly lower median HCV RNA levels (1.3 vs. 4.6 x 106 copies/ml, p < 0.001) and were less likely to have HCV RNA levels ≥ 5 x 106 copies/ml (11.1% vs. 45.5%, p < 0.001) than those who had HCV monoinfection. Additionally, all 5 HBV coinfected patients who had undetectable HBV DNA levels had very high HCV RNA levels (≥5 x 106 copies/ml). Liver biopsy results in 25 HBV-HCV and 643 HCV-infected patients showed that stage 3 or 4 fibrosis was significantly more common in those with HBV-HCV (84.0% vs. 29.9%, p < 0.001).

 

Conclusions:

·        Among American patients with chronic HCV infection, we found that HBV coinfection was not uncommon (5.7%)

·        The prevalence of coinfection differed according to age and race, and was associated with more severe liver disease.

·        In addition there were substantial viral interactions between HBV and HCV, and HBV appears to have a suppressive effect on HCV viral replication.

 


#257. PREVALENCE OF CELIAC DISEASE IN CHRONIC HEPATITIS C : FINAL RESULTS OF A FRENCH MULTICENTRIC PROSPECTIVE SURVEY.

T. Thevenot; J. Denis; V. Jouannaud; C. Renou; J. Crouzet; H. Lababie; N. Abdelli; E. Nguyen-Khac; P. Dumouchel; S. Bresson-Hadni; M. Chousterman; J. Cadranel; F. Angh.

 

Introduction:

Recently, Fine et al. (1) have reported a prevalence of 1.2% of celiac disease (CD) in patients with chronic hepatitis C (CHC), establishing an epidemiological link between these two diseases. However, other small studies did not find this possible relationship. Here, we report the final results of a French multicentric prospective study.

 

Methods:

Between June, 2003 and November, 2005, every HCV-positive patient had been tested for antiendomysial IgA antibodies (AEA) and antigliadin IgA and IgG antibodies (AGA). Patients with positive AEA and\or AGA were invited to undergo gastroscopy with distal duodenal biopsies.

 

Results:

613 consecutive patients coming from 8 centers were analysed : 59% were male, the mean age was 52 ± 14 years, 60%, 10%, 21%, 8% and 1% were genotypes 1, 2, 3, 4 and 5 respectively, and 49% had a severe fibrosis (F3-F4 in METAVIR score). The presence of at least one CD-antibody was significantly associated with severe fibrosis (p=0.026). Near 54% received antiviral therapy for CHC that was associated with diarrhea (4 % vs 0.35 % in non-treated patients, p=0.002). However, diarrhea was not explained by the existence of a silent CD. Among the 613 HCV-positive patients, CD was not detected. Isolated AEA IgA, AGA IgA and AGA IgG were respectively of 0.16 % (n=1), 6.41 % (n=37) and 3.76 % (n=21). No Significant link was found between autoimmune disorders (type 1 diabetes mellitus, thyroid disorders,…) and CD-antibodies.

 

Conclusions and discussion:

In this large series of HCV-positive patients tested for CD-antibodies, the prevalence of CD was 0% and diarrhea under antiviral treatment was not explained by the presence of a latent CD. Although a type 2 error cannot be ruled out, our French multicentric study suggests that the prevalence of CD in CHC is rare, contrary to the prevalence of AGA IgA and IgG.

 

1) Fine KD et al. Am J Gastroenterol 2001;1:138-45.

 


#258. Treatment of hepatitis C (HCV) in prison settings is cost-effective: mathematical modeling of epidemiology, disease outcomes and cost-effectiveness.

K. Watson; D. Watson; P. Scuffham; S. Bell; P. Desmond; E. Tuck; T. Lightfoot; M. Pruscino; D. Greene; H. McNeill; J. Richmond; M. Karvelas.

 

Introduction:

Prisoners in almost all jurisdictions around the world have a high prevalence of HCV. Despite this, relatively few prisoners receive anti-viral treatment. Many prisoners rotate through settings where there are high rates of unsafe injecting, in networks both outside and inside prison. Thus there is potential for transmission of HCV, particularly in settings where individuals from a high prevalence population contact uninfected individuals (eg after release from custody).

 

Methods/Results:

We have developed a compartmental mathematical model of the epidemiology, natural history and health economic outcomes of HCV. We have used this model to test intervention strategies for HCV both in and out of prison. Prison is an opportunity to treat under close supervision this highly endemic population. Using the software "ithink" (Stella) we can simultaneously alter inputs such as duration of treatment, cost of drug, cure rate, and re-infection rate, and therefore we could model many scenarios. Treatment of prisoners is generally more expensive than treatment through a hospital liver clinic, (approximately USD $3000 more expensive, depending upon protocol). This cost is sensitive to whether or not liver biopsy is part of protocol, and to how much nursing and psychiatric support is provided. However treatment in prison is more effective in health economic terms (USD $1541 per Quality Adjusted Life Year Saved (QALY) in clinic setting, vs USD $1272 per QALY in prison). In disease outcome terms, treatment in prison would prevent a significantly higher number of cases of liver failure and hepatocellular carcinoma. In epidemiologic terms treatment in prison would result in an overall reduction in population prevalence sooner than treatment outside prison. Sensitivity analyses indicate that changes in major parameters do not affect the overall

 

Conclusions:

That it is most economic to treat those people with the potent combination of high prevalence and high transmission potential.

 

Example of costs (in $US) per QALYs in a 25 y.o patient with stage 0/1 disease over 75 years

 

Costs of illness

Costs of treatment
(with biopsy)

QALYS

GAINED

Cost PER QALY 

Clinic

12952

16779

1.85

2068

Prison

12952

20479

4.44

1649

 

Regardless of whether liver biopsy is part of protocol, it is more cost-effective to treat HCV in a prison population than in a community setting, under a wide range of scenarios.

 


#260. Costs and effectiveness of different follow-up schedules for occupational HCV infection detection.

S. Deuffic-Burban; D. Abiteboul; E. Bouvet; Y. Yazdanpanah.

 

Background:  

Infection with hepatitis C virus (HCV) is an important occupational hazard for health care workers (HCWs). In France and the United States, 6000 and 22,000 HCWs are estimated to be occupationally exposed to HCV each year through percutaneous exposures, respectively. Different follow-up schedules for occupational HCV detection have been recommended in different countries. While French guidelines are based on anti-HCV antibody and alanine transaminase (ALT) monitoring, European guidelines recommend ALT monitoring solely, and, US guidelines recommend HCV-RNA testing for HCWs wishing to be reassured earlier.

 

Aim:

To evaluate direct medical costs associated with different follow-up strategies after occupational exposure to HCV and to determine for each strategy the mean time to HCV infection diagnosis. METHODS: Three follow-up strategies were evaluated: S1, anti-HCV antibody and ALT activity at months 1, 3, and 6 after HCV exposure and HCV-RNA testing to confirm anti-HCV antibody positive results and/or ALT elevation (French recommendations); S2, ALT activity monthly during the first 4 months after HCV exposure, anti-HCV antibody at month 6, and HCV-RNA testing to confirm ALT elevation or anti-HCV antibody positive results (European recommendations); S3, HCV-RNA testing at month 1 after HCV exposure (adapted US recommendations). HCWs trajectory after each follow-up strategy was modelled using decision trees. The risk of HCV transmission after HCV occupational exposure was estimated at 0.5%. Time to HCV anti-HCV antibody or HCV RNA positivity and ALT elevation was estimated from the medical literature. Costs were from French databases: anti-HCV antibody=18.90 euros; ALT = 6.75 euros; HCV-RNA = 54 euros; an outpatient visit= 40 euros.

 

Results: 

Direct medical costs of follow-up for 6000 HCV occupational exposures occurring in France were estimated at 706,184 euros with S1, 520,034 euros with S2 and 566,820 euros with S3. Time to HCV infection diagnosis was estimated at 2.2, 2.0 and 1.0 months with S1, S2, and S3 respectively.

 

Conclusion:  

The follow-up strategy based on anti-HCV antibody and ALT monitoring is the most expensive strategy and is associated with the longer delay to HCV infection diagnosis. The follow-up strategy based on HCV-RNA test is more expensive than the follow-up strategy based on ALT monitoring but leads to a shorter delay to HCV infection diagnosis A cost-effectiveness analysis is ongoing to estimate additional costs per QALY gained when comparing these strategies taking into account different exposure scenarios with different risk of HCV transmission.

 


#261. The detection rate of hepatitis C is increased by screening for HCV in risk groups by general practitioners.

P. Munda; A. Zach; K. Loeschenberger; K. Staufer; P. Ferenci.

 

Background:

The prevalence of hepatitis C in Austria is estimated about 1% of the general population. So far only around 20000 infected patients have been identified (0.25% of the Austrian population). Especially in rural areas diagnosis is often missed or delayed.

 

Aim:

To assess the impact of screening for HCV antibodies by general practitioners (GPs) in risk groups in different regions all over Austria.

 

Methods:

We asked 117 GPs from all over Austria to screen all patients for HCV antibodies, who had either elevated liver enzymes or one of the following risk factors: blood transfusion before 1990, intravenous drug abuse, piercing/tattooing, family member with hepatitis C. They filled in a questionnaire stating age and reason for screening/risk factor and results of HCV testing. Data were collected from each physician for between 2 and 6 months.

 

Results:

In total 804 patients were tested by the 117 GPs (329 from urban areas, 475 from rural areas). Overall 28% of all patients were tested positive for HCV antibodies. Subgroup analysis shows in the group of patients from urban areas (n=329) 122 (37%) were positive for HCV-AB, whereas in the rural population (n=475) only 105 (22%) tested positive. Of the 48 patients tested because of drug abuse 29 (60%) had positive HCV-AB, of the 85 tested for piercing/ tattooing 51 (60%) were positive. The patients with history of blood transfusion before 1990 showed a high probability of positive HCV antibodies (49%), whereas only 99 of the 538 (19%) of subjects with elevated liver enzymes, but without risk exposure to acquire hepatitis C had positive antibodies. Family testing showed 9% (1 of 11) of HCV-AB positive patients, pre-OP 22% (2 of 9) were HCV-AB positive. In patients tested for other reasons 24% (6 of 25) were HCV-AB positive.

Of the 227 Anti-HCV positive patients, PCR data were available in 60 (26%). 45 (75%) were PCR positive. 15 of them (25%) were PCR neg. This rate is consistent with epidemiological data. Only 7% of the PCR positive patients did not receive therapy.

 

Conclusion:

·        Testing for hepatitis C by GPs in risk groups and patients with elevated liver enzymes increases the detection rate of chronic hepatitis C allowing referral for treatment for a potentially curable disease.

·         Prevalence in rural areas was lower than in the urban population, but still far above the overall prevalence in the Austrian population.

·        It is therefore advisable to increase the awareness of general practitioners and family doctors about the disease and its treatment by continuous education.

 


#262. Narcotic Analgesics and Progression of Fibrosis in Patients With Chronic Hepatitis C.

C. Vallejos; T. Bordin-Wosk; L. Pockros; P. J. Pockros.

 

Background:  

Narcotic analgesics are commonly prescribed drugs. Frequently their use is seen in patients with chronic hepatitis C (CHC) infection. Despite in vitro data showing that morphine enhances hepatitis C virus (HCV) replication in human hepatic cells, the effects of narcotics on HCV disease progression remains uncertain.

 

Aim:

The aim of this study was to evaluate the potential effects of chronic narcotic analgesic use on the progression of hepatic fibrosis in patients with CHC infection.

 

Methods:  

Using the Scripps Clinic electronic medical records and a hepatitis C patient registry, we identified CHC patients who had been seen at our institution and had undergone a liver biopsy between 1990 and 2005. Their charts were reviewed for the presence of chronic narcotic analgesic use defined as use > 2 months, and known risk factors for progression of hepatic fibrosis including male gender, age >40, obesity, diabetes, alcohol abuse, HIV/HBV coinfection, and organ transplantation. All biopsy reports were also reviewed and fibrosis scores were standardized using the Batts & Ludwig scoring system (stage 1-4).

 

Results:  

A total of 1147 patients were identified. Chronic narcotic analgesic use was noted in 69 and the remainder 1078 patients had to evidence for chronic use.

 

Univariate analysis using 2x2 Chi =Square test of independence suggests chronic narcotic analgesic use correlates with higher BMI (p=0.02), obesity as defined by BMI>30 (p=0.01), history of alcohol abuse (p=0.0006), and advanced fibrosis as defined by stage 3-4 fibrosis (p=0.02) but not with age, gender, or diabetes.

 

Multivariate analysis using logistic regression associated age >40 (OR=1.85(95% CI 1.04-202)), and diabetes (OR=2.43(95%CI 1.41-4.14)) as predictors of advanced fibrosis but not chronic analgesic use.

 

Conclusion:  

In this large retrospective review, chronic narcotic analgesic use was seen more frequently in chronic hepatitis C patients who were obese and reported present or past excessive alcohol use but it did not have an independent association with advanced fibrosis scores.

 


#265. Effect of ethnicity on class II HLA associations with HCV clearance and virus-specific CD4 T cell response.

R. Harris; D. E. Kaplan; M. Kamoun; K. Chang.

Aim:

The virological and clinical outcome of HCV infection has been associated with various host factors including ethnicity and HLA type. HCV is also cleared with a broadly sustained class II-restricted CD4 T cell response. This study was performed to identify class II HLA alleles associated with HCV clearance and HCV-specific CD4 T cell responsiveness, using established cohorts of HCV-seropositive Caucasian and African American patients with defined virological and immunological characteristics.

 

Methods:

HCV-seropositive subjects with chronic viremia (Chronic, n=72) and spontaneous resolution (Resolved, n=24) were enrolled under an IRB-approved protocol. Peripheral blood mononuclear cells were examined for CD4 proliferative T cell responses to recombinant HCV core, NS3/4 and NS5 antigens in addition to control SOD and phytohematogglutinin (PHA). Frequencies of class II HLA DRB and DQB alleles were compared between Resolved and Chronic groups by PCR and sequence-specific probe hybridization, differentiating between Caucasian and African Americans. HLA alleles were also examined in the context of HCV-specific CD4 T cell responsiveness. Statistical analysis was conducted using SPSS version 14.0.1 (SPSS Inc., Chicago, IL).

 

Results:

Among all subjects, HCV clearance was associated with the presence of HLA DQB1*03 as previously reported (Alric et al, Gastro 1997; 113) while HLA DRB1*03 was negatively associated with a multi-specific CD4 responsiveness to two or more HCV antigens. However, there was a marked ethnic difference in HLA associations with HCV clearance and CD4 T cell response. For example, HCV clearance was significantly associated with the presence of HLA DRB1*11 (p=0.019), DRB3*02 (p=0.006) and DQB1*03 (p=0.014) among Caucasian but not African Americans. Consistent with the role of virus-specific CD4 T cells in HCV clearance, a multi-specific HCV-specific CD4 T cell responsiveness was also associated with DRB1*11 (p=0.013) and DRB3*02 (p=0.024) alleles among Caucasian Americans although the significance was lost for DQB1*03. By contrast, African American patients displayed only a negative association between DQB1*02 and CD4 T cell response to HCV core.

 

Conclusion:

We identified several class II HLA alleles that are associated with HCV clearance as well as HCV-specific CD4 T cell response. However, there was a sharp ethnic difference in these HLA associations, suggesting an ethnic difference in HLA restriction elements as well as viral target sequence for virus-specific CD4 T cell responses in HCV clearance. Further studies are needed to understand the basis for our findings and to design epitope-based vaccine useful for diverse ethnic groups.

 


#266. Chronic hepatitis C and outcome of renal transplantation.

E. Ridruejo; C. Díaz; A. Cusumano; M. Dávalos Michel; G. Soler Pujol; L. Jost; A. Vilches; O. G. Mandó.

 

Background:

Chronic viral hepatitis B and C are a common problem in renal transplant patients. There is no uniform agreement regarding their influence on graft outcome and survival of renal transplant patients. The aim of the study was to evaluate the influence of chronic viral hepatitis on the outcome of renal transplantation.

 

Methods:

We retrospectively evaluated the influence of antiHBc, antiHCV and HBsAg positive status; gender; age over 49 years at the time of transplantation; pre and postransplantation ALT elevation; acute rejection; type of graft; number of transplants; and maintenance and induction immunosuppression treatment both graft and patient survival in the population transplanted in our center between 1991 and 2004. All these variables were subjected to a univariate and multivariate data analysis, using the Cox proportional hazard model and the hazard ratio (HR) associated with patient survival and graft survival with their corresponding 95% confidence intervals (CI) and p values. Cumulative patient and graft survival rates were calculated using the Kaplan Meier method and the comparisons were performed using the log rank method.

 

Results:

The univariate analysis showed that antiHCV and antiHBc positive status, triple immunosuppressive therapy and one or more episodes of acute rejection were associated with diminished graft survival; and being over the age of 49 at the time of transplantation, antiHCV positive status, cadaveric donor, kidney-pancreas transplantation and triple immunosuppressive therapy were associated with diminished patient survival. In the multivariate analysis the same variables than in the univariate analysis were associated with diminished patient survival; and antiHCV positive status, triple immunosuppressive therapy and one or more episodes of acute rejection were associated with diminished graft survival(Table). Cumulative patient survival at 13 years was 83% in antiHCV negative and 68% in antiHCV positive (p=0.0286), and cumulative graft survival was 75% in antiHCV negative and 56% in antiHCV positive (p=0.0002).

Conclusion: AntiHCV positive status was associated with an increased risk of graft failure and death.

 

Outcome

Variable

HR

P Value

CI 95%

Graft survival

AntiHCV +

1.97

0.009

1.18-3.29

 

AntiHBc +

1.05

0.823

0.63-1.75

 

Rejection

2.04

0.002

1.29-3.22

 

Maintenance Immunosuppression

12.70

<0.001

4.59-35.10

Patient Survival

Age

3.53

<0.001

1.98-6.28

 

AntiHCV +

1.66

0.049

1.01-2.77

 

Type of graft

0.38

0.019

0.17-0.85

 

Type of transplant

0.09

<0.001

0.03-0.24

 

Maintenance Immunosuppression

2.69

0.002

1.45-5.01

 


#267. Patients with chronic HBV infection are less well informed than patients with HCV infection about their disease and in particular about their viral load.

C. Niederau; C. Fischer; A. Kautz.

 

Background:

Recently, we have shown that German patients with hepatitis C are well informed about their disease (German J Gastro 2006;44:305-17). Since the focus of interest has been on HCV little is known about the knowledge of HBV-infected subjects; knowledge about infection risks is, however, even more important for HBV infected patients than for those infected with HCV.

 

Methods:

The present study prospectively analyzed questionnaires about the information status of HBV-infected patients; the study included a SF12 quality-of-life analysis. Results were compared with a recent survey in HCV infected patients. Overall 1500 questionnaires were distributed by clinics, practioneers, patient support groups and internet; 255 (HBV) and 714 (HCV) questionnaires were sent back and analyzed.

 

Results:

See table. HBV-infected patients were younger (52 vs. 46 yrs), more likely to be male (62 vs. 44%) and to come from abroad (30 vs. 9%). Only 1 and 4% of HBV- and HCV-infected subjects, respectively, considered public information about hepatitis as good or very good; 73 and 77%, however, as bad or very bad. Quality-of-life (SF12) was better in HBV- than in HCV-infected subjects (p<0,001; data not shown), but was not associated with patients' information status.

 

Conclusions:

In both HBV- and HCV-infected subjects there are some information deficits concerning the infection mode (e.g. >10% stated dentists as a major source of infection); the deficits are more pronounced in HBV-infected subjects (11% of answers related to dirty bathrooms, bad food and shaking hands). German subjects with HBV and HCV infection are in general well informed about their own infection; however, HBV-infected subjects are less well informed in particular about their viral load, although this data is more important in HBV than in HCV infection. This lack of information likely reflects a lack of attention payed to HBV-DNA levels by the patients’ physician.

 

Supported by HepNet and Gilead Sciences, Germany

 

 

HBV

HVC

p by χ2

in detail informed about

% patients

% patients

 

HBV-DNA/HCV-RNA

55

85

<0,001

HBe Ag / HCV Genotype

31

75

<0,001

ALT

73

84

0,01

inflammation grade

78

85

0,05

fibrosis stage

79

87

0,05

stated as major infection risk

% answers

% answers

 

sex, drugs, blood products

54

56

n.s.

surgery

13

17

n.s.

birth from infected mother

12

9

0,05

dentist

11

15

0,01

dirty bathroom

4

1

0,001

kisses

4

1

0,001

bad food

2

0

0,01

shaking hands

1

0

 

 


#268. MORTALITY RELATED TO HEPATITIS C AND HEPATITIS B IN FRANCE: ROLE OF HIV COINFECTION.

T. Asselah; F. Pequignot; J. Zarski; N. Ganne; P. Hillon; E. Delarocque-Astagneau; D. Antona; M. Bovet; M. Mechain; J. Desenclos; P. Marcellin; E. Jougla.

 

Background and Aim:

Coinfection with HCV and HIV is common as both viruses are transmitted by parenteral routes, i.e., injection drug use and blood transfusion. Coinfection with HBV and HIV is also common. With the availability of HAART, the mortality rate associated with HIV has decline. The role of HIV coinfection in deaths related to HCV and HBV in France is still unknown

 

Methods and Patients:

This study was based on all death certificates (531 072) in France in 2001. Among them, 34 839 mentioned either HBV, HCV, hepatitis, liver disease, complication of cirrhosis, bacterial infection, HIV or transplantation. From these, 999 were randomly selected. A subsequent questionnaire (epidemiological, clinical and virological information) was sent to the physicians who reported the deaths. 78.5% forms adequately completed were returned and independently analyzed by a panel of hepatologists which determined if deaths were related to HCV or HBV.

 

Results:

The estimated annual number of deaths associated with HCV and HBV were 3618 and1507, respectively. The estimated number of deaths attributable to HCV and HBV were 2646 and 1324 respectively (4.5 and 2.2 deaths per 100 000 habitants).

The estimated number of deaths in case of HIV coinfection, was 534 associated to HCV and 234 associated to HBV (15% of deaths associated to HCV or HBV). Among patients with chronic HCV hepatitis and HIV coinfection: the source of contamination was drug use in 79% of cases, 81 % were under treatment for HIV; 67% had never received treatment for hepatitis. 17% had presented a gastrointestinal bleeding, 30% encephalopathy, 34% ascites, and 2% a hepato-cellular carcinoma.

The mean age of death was younger in case of HIV coinfection than in absence of HIV coinfection (41 versus 70 years).

 

Conclusion:

  • The study confirms the marked association between HIV and HCV-HBV related mortality in France, since about 15% of those who died with HCV or HBV infection were also infected with HIV.
  • A major concern reported in this study is that HCV patients with HIV coinfection had a mean age at death younger than patients without HIV coinfection. A majority of these patients did not received a treatment for chronic hepatitis.
  • These figures emphasize the importance of HCV-HBV infection in HIV patients as a major public health issue and underline the need for ongoing efficient public health program including screening, management and counseling for HCV and HBV infected individuals.

 

 


#269. High Prevalence of HIV and HCV Infection Among Women Who Are Non-Injection Drug Users.

E. Ross; R. F. Raicht; F. Dominelli; E. J. Bini.

 

Background:

Injection drug use is the strongest risk factor for HIV and HCV infection. However, little is known about the epidemiology of HIV and HCV infection among non-injection drug users, especially among women. The aims of this study were to evaluate the prevalence of HIV, HCV, and coinfection with HIV-HCV among an ethnically diverse cohort of women substance abusers.

 

Methods:

We reviewed the medical records of all patients admitted over a 1-year period to a residential substance abuse treatment facility in New York City. A standardized comprehensive medical, psychiatric, and substance use evaluation, as well as HIV and HCV testing, was performed on all subjects at the time of admission.

 

Results:

A total of 709 subjects were admitted for substance abuse treatment (219 women & 490 men). The mean age was similar among women and men (31.8 ± 9.7 vs 33.0 ± 13.3 years, p = 0.16), although race differed between the 2 groups (p = 0.008), with a higher frequency of blacks (63.9% vs 52.7%) and a lower frequency of Hispanics (23.7% vs 36.7%) among women. Women were less likely to be referred from the criminal justice system (51.1% vs 61.1%, p = 0.01) and were less likely to be in jail within the past 30 days (26.9% vs 40.2%, p = 0.001), although the frequency was high in both groups. Although cocaine was the major substance of abuse in both men and women (47.5% vs 29.2%), there were significant differences in the major substance that was abused between the 2 groups (p = 0.001). Injection drug use was uncommon, with 6.8% of women and 10.2% of men reporting that they have ever injected drugs (p = 0.15). There were no significant differences in the prevalence of HIV (10.0% vs 8.8%, p = 0.59), HCV (13.7% vs 16.3%, p = 0.37), or HIV-HCV coinfection (4.1% vs 6.3%, p = 0.24) between women and men. Among the 219 women, the prevalence of HIV (9.3% vs 20.0%, p = 0.18), HCV (8.8% vs 80.0%, p < 0.001), and HIV-HCV coinfection (2.9% vs 20.0%, p = 0.02) was lower in non-injection drug users than in those who have ever injected drugs. The prevalence of HIV among women was highest in those that self-reported their race as other (12.5%), whereas HCV was most common in Hispanics (17.3%). In the 204 women who have never injected drugs, the prevalence of HCV infection was higher among subjects who used intranasal cocaine/ heroin than in those than never snorted drugs (15.8% vs 4.7%, p = 0.007).

 

Conclusions:

Among patients admitted to a residential substance abuse treatment facility, women had a similar frequency of HIV, HCV, and HIV-HCV coinfection as men. HIV and HCV testing should be offered to all women and men substance abusers, even if they have never injected drugs.