Hepatitis G virus infection in the elderly.

BACKGROUND AND AIMS: At least 10% of post-transfusion and community-acquired hepatitis cases are not accounted for by the A to E viruses. Hepatitis G virus (HGV), a novel agent belonging to the Flaviviridae and distantly related to HCV has recently been identified. The epidemiology and clinical significance of this infection in the geriatric setting is still little known. Aim of the investigation was to assess the prevalence and clinical significance of HGV infection in the geriatric setting. PATIENTS: 105 unselected consecutive patients (mean age 73.4 years). METHODS: HGV-RNA was detected by a single-tube reverse-transcription heminested polymerase chain reaction with primers from the 5' untranslated region of the virus. Anti-HGV antibodies were detected with a commercial anti-E2 immunometric assay. RESULTS: 3/105 patients (2.9%) were viraemic, without a history or clinical evidence of hepatitis. Anti-HGV antibodies were detected in 25 patients (23.8%), 40% of whom had associated anti-HCV antibodies. The presence of HGV-RNA and anti-HGV antibodies was mutually exclusive. CONCLUSIONS: HGV infection is highly prevalent in our population and the cumulative risk of exposure is proportional to age. In most cases, HGV infection is self-limiting and clinically irrelevant. Immunity against E2 or other associated uncharacterized viral epitopes appears to be protective.

High prevalence of the His63Asp HFE mutation in Italian patients with porphyria cutanea tarda.

Sporadic porphyria cutanea tarda (PCT) is caused by a reduced activity of uroporphyrinogen decarboxylase (URO-D) in the liver. Mild to moderate iron overload is common in PCT, as iron is one of the factors which trigger the clinical manifestations of the disease through the inactivation of URO-D. A role for genetic hemochromatosis in the development of iron overload in sporadic PCT has been hypothesized in the past. The aim of this work was to investigate whether mutations of HFE, which is a candidate gene for hemochromatosis, play the role of genetic susceptibility factors for PCT in Italian patients, who have a high prevalence of acquired triggering factors, such as hepatitis C virus (HCV) chronic infection and alcohol. We determined HFE genotypes of 68 male patients with PCT. Our data do not confirm an association of PCT with the Cys282Tyr HFE mutation, strongly associated with hemochromatosis in Northern European countries. A second mutation of HFE, His63Asp, however, had a significantly increased frequency as it was present in half of the patients. Surprisingly, the presence of the His63Asp mutation was not related to the iron status of patients, suggesting that a subtle abnormality of iron metabolism induced by this mutation could escape detection by the standard parameters of iron status. In PCT patients with liver disease, the presence of the mutation could contribute to the inactivation of URO-D, either directly or through a synergistic action with other factors that cause liver damage.

Presence of fetal DNA in maternal plasma and serum.

BACKGROUND: The potential use of plasma and serum for molecular diagnosis has generated interest. Tumour DNA has been found in 'the plasma and serum of cancer patients, and molecular analysis has been done on this material. We investigated the equivalent condition in pregnancy-that is, whether fetal DNA is present in maternal plasma and serum. METHODS: We used a rapid-boiling method to extract DNA from plasma and serum. DNA from plasma, serum, and nucleated blood cells from 43 pregnant women underwent a sensitive Y-PCR assay to detect circulating male fetal DNA from women bearing male fetuses. FINDINGS: Fetus-derived Y sequences were detected in 24 (80%) of the 30 maternal plasma samples, and in 21 (70%) of the 30 maternal serum samples, from women bearing male fetuses. These results were obtained with only 10 microL of the samples. When DNA from nucleated blood cells extracted from a similar volume of blood was used, only five (17%) of the 30 samples gave a positive Y signal. None of the 13 women bearing female fetuses, and none of the ten non-pregnant control women, had positive results for plasma, serum or nucleated blood cells. INTERPRETATION: Our finding of circulating fetal DNA in maternal plasma may have implications for non-invasive prenatal diagnosis, and for improving our understanding of the fetomaternal relationship.

Prevalence and clinical significance of hepatitis G virus infection in adult beta-thalassaemia major patients.

The risk of polytransfused patients for hepatitis C virus (HCV) infection is likely to extend to another recently identified member of the Flaviviridae, hepatitis G virus (HGV). We investigated the prevalence of HGV in 40 adult Italian patients with transfusion-dependent thalassaemia and evaluated the clinical significance of HGV infection. HGV-RNA was detected in 9/40 patients (22.5%). HGV infection was significantly associated with HCV viraemia (P = 0.0012), with all patients positive for HGV being also viraemic for HCV. Overall, the clinical picture of patients with HCV/HGV co-infection was not different from that of patients with isolated HCV. However, patients co-infected with both viruses had lower values of alanine-transferase (P = 0.035) and a lower titre of HCV viraemia (P = 0.042) in the absence of other evident factors which could influence the clinical expression of HCV infection. In conclusion, HGV is highly prevalent among Italian polytransfused patients. No evidence of a clinically significant pathogenic role for HGV in liver disease could be found in these patients. In a subset of cases a possible interference of HGV with HCV infection was observed.

Diffusion of HCV through peritoneal membrane in HCV positive patients treated with continuous ambulatory peritoneal dialysis.

PURPOSE OF THE STUDY: We evaluated the presence of HCV in the peritoneal effluents of viraemic patients treated with continuous ambulatory peritoneal dialysis (CAPD) to evaluate the risk of transmitting the infection with this procedure. PROCEDURE: Fifteen of 81 CAPD patients (18.5%) had anti-HCV antibodies and eight were viraemic. At the beginning of CAPD two of the viraemic patients had ascites with a clinical picture of chronic active hepatitis and cirrhosis. Peritoneal dialysates were collected after an overnight exchange with 1.36% glucose and after a 4-h exchange with 3.86% glucose. Fluids from the overnight exchange were spun to obtain a cellular pellet and the supernatant 100-fold concentrated. RESULTS: No viral genome could be detected in unconcentrated samples and in cellular pellets, while HCV-RNA at low titre was detected in concentrated dialysates from the two patients with active liver disease. CONCLUSIONS: Our findings confirm that HCV may be present in the CAPD effluent of some patients; however, the titre of virus in the effluent was extremely low, at the limit of detection of the PCR assay. Peritoneal fluids originating from patients with HCV associated severe liver disease may be a potential source of infection.

Hepatitis G virus infection in hemodialysis patients.

The increased risk of hemodialysis patients for infections sustained by hepatitis viruses is likely to extend to a newly discovered parenterally transmitted virus, HGBV-C/HGV, able to cause acute and chronic hepatitis. The aim of this study was to assess the prevalence and clinical relevance of this infection in Italian hemodialysis patients. Nineteen of 100 patients (19%) on maintenance hemodialysis were viremic for HGBV-C/HGV, and all of them were infected with a HGV-like genotype. Eight of these patients were coinfected by hepatitis B or hepatitis C viruses. A clinical picture of chronic hepatitis was not appreciable in patients with isolated HGV infection and the presence of HGV did not appear to modify the clinical course of hepatitis B and hepatitis C infections.

High prevalence of hepatitis C virus type 1b in Italian patients with Porphyria cutanea tarda.

BACKGROUND: A strong association between sporadic porphyria cutanea tarda and chronic hepatitis C virus infection was recently described in Italy, France and Spain. AIMS: To explore whether hepatitis C virus genotype plays a role in porphyria cutanea tarda complicating chronic hepatitis C. PATIENTS: Forty-seven hepatitis C virus-positive porphyria cutanea tarda patients and a control group of 45 patients of similar age with hepatitis C virus-associated chronic liver disease. METHODS: Comparison of frequency of hepatitis C virus genotypes in the two groups and in relation to the age of patients, hepatic histopathology and with the presence of other factors potentially able to trigger porphyria cutanea tarda. RESULTS: A single genotype, hepatitis C virus 1b, was found to be present in nearly 90% of porphyria cutanea tarda-associated chronic liver disease, significantly exceeding the frequency of the same genotype in the control group (p = 0.0001). The presence of hepatitis C virus 1b was not related to the age of patients or disease severity as evaluated by hepatic histopathology. CONCLUSIONS: Hepatitis C virus-associated chronic hepatitis found in the majority of Italian patients with porphyria cutanea tarda is usually sustained by hepatitis C virus genotype 1b. This viral strain might have a direct pathogenic role in inducing porphyria cutanea tarda or could increase the susceptibility of patients of other triggering factors such as iron overload or alcohol abuse.

Iron stores, response to alpha-interferon therapy, and effects of iron depletion in chronic hepatitis C.

We studied 81 patients with chronic hepatitis C to investigate the relationship between iron and alpha-interferon response. Sixty-one patients (group A) were given alpha-interferon irrespective of iron status, whereas 20 (group B) with iron overload, were iron depleted before alpha-interferon therapy. In group A, 21 patients responded to alpha-interferon and 40 were non-responders. Increased iron indices were significantly more frequent in non-responders than responders. Multivariate analysis showed that among the independent variables evaluated, only gamma-GT and liver iron concentration predicted therapy outcome. After phlebotomy treatment, serum alanine aminotransferase fell significantly both in patients of group B (196 +/- 122 IU/l vs 82 +/- 37 IU/l, p < 10(-6)) and in 12 non-responders of group A (198 +/- 89 IU/l vs 107 +/- 81 IU/l, p < 10(-6)). In 16 iron depleted patients, eight from each group, subsequent treatment with alpha-interferon produced a response in only one patient. These results suggest that increased liver iron is a negative prognostic factor for alpha-interferon response in chronic hepatitis C. Iron depletion had a beneficial effect on serum alanine aminotransferase in all the patients treated, but did not improve the response to alpha-interferon.

Hepatitis C virus genotypes and reinfection of the graft during long-term follow-up in 35 liver transplant recipients.

To understand the clinical outcome of hepatitis C virus (HCV) recurrence, data from 35 liver transplant recipients who survived more than 6 months were reviewed. The presence of HCV-RNA was evaluated and genotyping was performed. On the basis of alanine aminotransferase (ALT) levels, patients were sorted into four groups. In 20 patients, a chronic elevation in ALT was found; HCV-RNA detection was positive in 17/17 and the following genotypes were found in 15 of them: 1b in ten patients, 2a in four patients, and 3a in one patient. In 11 patients, ALT levels remained normal throughout follow-up; in nine of them HCV-RNA was positive; HCV genotyping was available in eight patients and identified type 1b in two, type 2a in five, and type 3a in another patient. In two patients, ALT fluctuated above and below the upper limits of normality; type 1b HCV-RNA was found in one of them. In two patients, after an initial period of normality, ALT levels showed an abrupt rise; HCV-RNA was positive and type 1b was identified in both patients. Eight patients developed HCV-related deep jaundice and three of them spontaneously recovered. Progressive hepatic injury occurred in eight patients, six with chronic ALT elevation and two showing a late ALT elevation; genotype 1b was present in seven patients while in one, genotype 3a was found; sub-acute graft failure developed in five of them, leading to death in two and retransplantation in the others; the other three patients are alive with recurrent overt cirrhosis. The 1, 3, and 5 year actuarial survivals were 89%, 79%, and 63% respectively. The 1, 3, and 5 year actuarial risks of progressive graft damage were 6%, 7%, and 15%, respectively. In conclusion, HCV reinfection causes a slow decrease in the long-term patients' survival. Persistent elevation of ALT is more frequently observed in patients with genotype 1b infection.

High prevalence of a rare hepatitis C virus in patients treated in the same hemodialysis unit: evidence for nosocomial transmission of HCV.

Hepatitis C virus (HCV) is a major cause of hepatitis among patients treated with maintenance hemodialysis. Blood transfusion appears to be the primary risk factor, but nosocomial transmission of HCV in the dialytic environment has been hypothesized. We addressed this issue by analyzing the individual variation of genomic sequences of HCV in 28 patients on chronic hemodialysis (HD) from the same department and 25 environmentally unrelated patients with HCV-related liver disease. Genome variations of HCV were studied by single strand conformation polymorphism (SSCP) analysis of polymerase chain reaction products obtained from the 5'-untranslated region of the viral genome and by sequence analysis. Six different SSCP patterns were identified in HD patients versus 16 in control patients. Among HD patients the three more frequent SSCP patterns accounted for 85% of observations, while in the control group each pattern was found in 4 to 12% of patients. The ability of SSCP to discriminate sequence variation was proven by sequence analysis which confirmed identity/diversity of sequences selected by SSCP. Moreover, sequence analysis permitted a recognition of the most frequent genome observed in HD patients as a type 4 HCV, which is considered to be rare in the Italian population. The relative homogeneity of HCV variants in HD patients treated in the same HD and the high prevalence in this unit of a rare viral variant support the possibility of a nosocomial transmission of HCV in the dialytic environment.

Single-tube reverse transcription and heminested polymerase chain reaction of hepatitis C virus RNA to detect viremia in serologically negative hemodialysis patients.

Detection of hepatitis C virus genome is the only method currently available for detecting viremia in infected individuals. We describe a substantial simplification of current methods for viral RNA reverse transcription and polymerase chain reaction amplification, which allows cDNA synthesis and nested amplification in a single tube; this is achieved through compartmentalization of the reagents for the two reactions with a wax barrier. This procedure retains a high sensitivity: analysis of serum samples from hemodialysis patients, a high-risk group for hepatitis C virus infection, confirmed the presence of the virus in 88% of antibody-positive patients and detected viremia in patients without serological or biochemical evidence of hepatitis C virus infection.