Evaluation of Histological and non-Invasive Methods for the Detection of Liver Fibrosis: The Values of Histological and Digital Morphometric Analysis, Liver Stiffness Measurement and APRI Score.

Prognosis and treatment of liver diseases mainly depend on the precise evaluation of the fibrosis. Comparisons were made between the results of Metavir fibrosis scores and digital morphometric analyses (DMA), liver stiffness (LS) values and aminotransferase-platelet ratio (APRI) scores, respectively. Liver biopsy specimens stained with Sirius red and analysed by morphometry, LS and APRI measurements were taken from 96 patients with chronic liver diseases (56 cases of viral hepatitis, 22 cases of autoimmune- and 18 of mixed origin). The strongest correlation was observed between Metavir score and DMA (r = 0.75 p < 0.05), followed in decreasing order by LS and Metavir (r = 0.61), LS and DMA (r = 0.47) LS and APRI (r = 0.35) and Metavir and APRI (r = 0.24), respectively. DMA is a helpful additional tool for the histopathological evaluation of fibrosis, even when the sample size is small and especially in case of advanced fibrosis. The non-invasive methods showed good correlation with the histopathological methods; LS proved to be more accurate than APRI. The stronger correlation between LS values and Metavir scores, as well as the results of DMA in case of appropriate sample size were remarkable.

miR-122 negatively correlates with liver fibrosis as detected by histology and FibroScan.

AIM: To investigate whether expression of selected miRNAs obtained from fibrotic liver biopsies correlate with fibrosis stage. METHODS: Altogether, 52 patients were enrolled in the study representing various etiologic backgrounds of fibrosis: 24 cases with chronic hepatitis infections (types B, C), 19 with autoimmune liver diseases (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, overlapping syndrome cases), and 9 of mixed etiology (alcoholic and nonalcoholic steatosis, cryptogenic cases). Severity of fibrosis was determined by both histologic staging using the METAVIR scoring system and noninvasive transient elastography. Following RNA isolation, expression levels of miR-21, miR-122, miR-214, miR-221, miR-222, and miR-224 were determined using TaqMan MicroRNA Assays applying miR-140 as the reference. Selection of miRNAs was based on their characteristic up- or downregulation observed in hepatocellular carcinoma. Relative expression of miRNAs was correlated with fibrosis stage and liver stiffness (LS) value measured by transient elastography, as well as with serum alanine aminotransferase (ALT) level. RESULTS: The expression of individual miRNAs showed deregulated patterns in stages F1-F4 as compared with stage F0, but only the reduced level of miR-122 in stage F4 was statistically significant (P < 0.04). When analyzing miRNA expression in relation to fibrosis, levels of miR-122 and miR-221 showed negative correlations with fibrosis stage, and miR-122 was found to correlate negatively and miR-224 positively with LS values (all P < 0.05). ALT levels displayed a positive correlation with miR-21 (P < 0.04). Negative correlations were observed in the fibrosis samples of mixed etiology between miR-122 and fibrosis stage and LS values (P < 0.05), and in the samples of chronic viral hepatitis, between miR-221 and fibrosis stage (P < 0.01), whereas miR-21 showed positive correlation with ALT values in the samples of autoimmune liver diseases (P < 0.03). The results also revealed a strong correlation between fibrosis stage and LS values (P < 0.01) when etiology of fibrosis was not taken into account. CONCLUSION: Reduced expression of miR-122 in advanced fibrosis and its correlation with fibrosis stage and LS values seem to be characteristic of hepatic fibrosis of various etiologies.

[The pathology of hepatitis C]. / A hepatitis C patológiája.

The hepatitis C virus is an RNA virus, which belongs to the genus Hepaciviruses of the family Flaviviridae. Chronic hepatitis, cirrhosis, and ultimately even liver cancer may develop in over 80% of infected cases. The histological features of hepatitis C and hepatitis caused by other hepatotropic viruses show many similarities, however, certain specific histological characteristics are observable. Accordingly, intense lymphocytic infiltration around the periportal areas, steatosis and biliary alterations are frequent findings. Further characteristics of hepatitis C include liver cell destruction (apoptosis, necrosis), periportal inflammation and fibrosis, the degrees of which can be determined by means of the histology activity index. Our knowledge on the hepatitis C virus genome and the mechanism of replication of the virus have established the use of modern, direct-acting antivirals in the treatment of chronic hepatitis C.

[New era in the treatment of chronic hepatitis C - novel direct acting antivirals]. / Korszakváltás a krónikus C-vírus hepatitis terápiájában - új direkt ható antivirális szerek.

Chronic hepatitis C, without treatment, can cause liver cirrhosis, liver failure and liver cancer. The availability of new oral direct acting antivirals, such as the protease inhibitors simeprevir, asunaprevir and paritaprevir, the NS5A inhibitors daclatasvir, ledipasvir, and ombitasvir, the polymerase inhibitors Sofosbuvir and dasabuvir have resulted an enormous progress in the treatment of chronic hepatitis C, leading to >90% sustained viral response rates. Even the hard-to-treat or previously treatment ineligible patients can be cured with the combination of these drugs. Furthermore the treatment duration is much shorter, and the side effects are minimal. Today, treatment of all hepatitis C virus infected patients is recommended, and the best choices are the interferon-free options. Eradication of hepatitis C virus has become realistic, however, appropriate screening programs are mandatory to achieve this goal.

Elevated miR-33a and miR-224 in steatotic chronic hepatitis C liver biopsies.

AIM: To assess the expression of selected microRNAs (miRNA) in hepatitis C, steatotic hepatitis C, noninfected steatotic and normal liver tissues. METHODS: The relative expression levels of miR-21, miR-33a, miR-96, miR-122, miR-125b, miR-221 and miR-224 were determined in 76 RNA samples isolated from 18 non-steatotic and 28 steatotic chronic hepatitis C (CHC and CHC-Steatosis, respectively) cases, 18 non-infected, steatotic liver biopsies of metabolic origin (Steatosis) and 12 normal formalin-fixed paraffin-embedded liver tissues using TaqMan MicroRNA Assays. All CHC biopsy samples were obtained prior to initiating therapy. Patients' serum biochemical values, which included glucose, triglyceride, cholesterol, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl-transferase (GGT), alkaline phosphatase (AP), were obtained and correlated with relative miRNA expression. RESULTS: When compared with control non-infected liver samples, miR-122 and miR-221 levels were reduced in CHC-Steatosis (P < 0.03) and in CHC, CHC-Steatosis and Steatosis (P < 0.01). Alternatively, the expression of miR-33a and miR-224 were elevated in CHC-Steatosis and Steatosis in comparison to control tissue (P < 0.01). The levels of miR-33a and miR-224 in CHC-Steatosis (P < 0.02) and miR-224 in Steatosis (P < 0.001) were increased in comparison to CHC samples. By contrast, the expression of miR-21 did not differ statistically between diseased and normal liver samples. Levels of miR-33a correlated negatively with serum AST and AP levels in Steatosis as well as with necroinflammatory grade in CHC, whereas miR-21 correlated positively with AST in Steatosis and displayed negative correlation with triglyceride level in CHC-Steatosis. In contrast, miRNA levels were not correlated with ALT, GGT, cholesterol levels or fibrosis stage. CONCLUSION: Differences in miRNA expression were observed between CHC and steatotic CHC, CHC and steatotic liver, but not between steatotic CHC and steatotic liver of metabolic origin.

[The role and possibilities of natural interferon treatment in chronic hepatitis C: experience with natural interferon treatment for patients barred from combined antiviral therapy because of the STOP rule]. / A természetes interferon helye és lehetôségei a krónikus C-hepatitis kezelésében: a stopszabály miatt a kombinált antivirális terápiából kizárt betegek kezelésével szerzett tapasztalataink.

UNLABELLED: The first choice, and the most efficient therapy for chronic hepatitis C is the pegylated interferon + ribavirin treatment. The introduction and application of the STOP rule (pegylated interferon + ribavirin treatment should be stopped in cases without sufficient virological answer for the therapy at the 12th or 24th week of the treatment) is motivated by the very high cost of this treatment. AIMS: The greatest problem of the application of the STOP rule is that these patients are not coming in for the proven advantages of one-year interferon treatment (arrest or decrease the inflammation, decrease or prevent the progression to liver cirrhosis, decrease probability or prevent the development of hepatocellular carcinoma), which were observed almost in virologically slow-, partial-, or non-responder patients who received one-year interferon therapy. Based on these data, the official Hungarian treatment protocol allows and recommends the continuation of the antiviral treatment by natural interferon for patients whose pegylated interferon + ribavirin treatment should have been stopped because of the STOP rule. PATIENTS AND METHODS: 15 patients whose pegylated interferon + ribavirin treatment should have been stopped because of the STOP rule (8 men, 7 women, age: 35-63, mean: 48.8 years, HCV genotype: 1b, HAI mean: 6.7, SD: +/-5.03; stage: mean: 1.75 SD: +/-0.9) treatment was continued with natural IFN for further 16-36 (mean 23.7) weeks. The total treatment duration was 48-52 weeks. The duration of follow-up was at least 6 months. CONTROL GROUP: 18 patients whose pegylated interferon + ribavirin treatment should have been stopped because of the STOP rule (7 men, 11 women, age: 32-63, mean: 48.7 years, HCV genotype: 1b, HAI mean: 10.1, SD: +/-4.8; stage mean: 2.0 SD: +/-0.6). The duration of follow-up was at least 6 months. RESULTS: There is no significant difference between the two groups. The ALT level significantly decreased (73.4 U/l SD: +/-25.5 versus 45.9 U/l SD: +/- 22.1) due to pegylated interferon + ribavirin treatment, and remained at this level during the natural interferon treatment and the follow up (45.7 U/l SD: +/-15.1, and 49.3 U/l SD: +/-19.4 U/l; p < 0.001). The difference is significant. The ALT level decreased (108.5 U/l SD: +/-69.8 versus 86.0 U/l SD: +/-82.8) due to pegylated interferon + ribavirin treatment, but increased after the cessation of the therapy (99.7 U/l SD: +/-60.9) in the control group. The biochemical response (significant reduction of ALT level) which was detected during the pegylated interferon + ribavirin treatment remained permanent during the continuation and after the cessation of the therapy in the natural interferon treated group, while relapse occurred in every case in the control group. The viral load increased at least 1 log 10 after cessation of the therapy in pegylated interferon + ribavirin treatment non-responder patients. The natural interferon treatment was able to control the viral replication (prevent the increasing of the viral load), but after the termination of natural interferon dosage, similar elevation of viral load was observed. The subjective side effects of natural interferon treatment were rarely and milder. Leucopenia and thrombopenia occurs rarely and was milder than that during the pegylated interferon + ribavirin therapy. CONCLUSIONS: The patients have no difficulty in the application of natural interferon; probably the positive psychic effect of the fact that they have not been barred from treatment compensated the technical hardness (three injections weekly). A wide range of the application of this therapeutic possibility, and further studies with larger number of patients are suggested.

[Side effect of pegylated-interferon treatment in chronic C hepatitis: agranulocytosis]. / Pegylált interferonkezelés mellékhatása krónikus C-hepatitisben: agranulocytosis.

Chronic C hepatitis is a global health problem. Its treatment is still unresolved. Pegylated interferon means substantive breakthrough in therapy. The longer effect, the lasting, steady therapeutic blood level are the pharmacokinetic advances. There is no significant difference in the side effects of pegylated interferon and standard interferon. The most frequent side effects leading to dose reduction or cessation of the treatment are depression and hematologic disorders. Neutropenia is induced more frequently by pegylated interferon, than by the standard form according to the literature. Combined antiviral treatment (pegylated interferon alpha-2a and ribavirin) of a 54 years old woman, who suffered from posttransfusion chronic hepatitis C was started. The dose of the pegylated interferon alpha-2a and ribavirin was reduced at the 8th week due to leucopenia and mild anemia. Fever, cough, sore throat and weakness occurred. Agranulocytosis was detected which was accounted as a side effect of pegylated interferon treatment. Antibiotic, antimycotic therapy and filgastrim was given. Leukocyte number increased, fever stopped after 10 days of therapy. The patient returned 17 days later. She had been having high fever, weakness, sore throat for 4 days. Ciprofloxacin was given by GP before her registration because of the suspicion of urinary infection, then she took sulfamethoxazol + trimethoprim without medical advise. Agranulocytosis was detected again, Staphylococcus sepsis developed. No sign of hematologic disease was found in the bone marrow. Agranulocytosis was considered aftermath of sulfamethoxazol + trimethoprim. Antibiotics, antimycotic and antiviral treatment, and filgastrim were given, sepsis healed, leukocyte number became normal. 274 patients suffering from chronic hepatitis C were treated by standard interferon, and 43 were treated by pegylated interferon. Rapid and significant decrease of leukocyte count was observed in the patients treated by pegylated interferon in the first 4 weeks of the treatment then it remained stable. Cessation of the treatment or dose-reduction was not necessary due to neutropenia among patients treated by standard interferon, while dose reduction was reasonable in two more cases in addition to this one, treated by pegylated interferon. The authors stress the importance of the exact follow-up of patients according to the protocol, which renders the early recognition of side effects, the prevention of complications, and their early and adequate treatment possible. Thus, pegylated interferon--inspite of its marked side effects and more serious suppressive effect on bone marrow--is the most effective drug for the treatment of chronic hepatitis C.