Francesco NEGRO

Steatosis and Chronic Hepatitis C:

liaisons dangéreuses?

Francesco NegroFrancesco NegroUnité de ViropathologieUnité de Viropathologie

Centre Médical UniversitaireCentre Médical Universitaire

GenèveGenève

Paris, January 22, 2007Paris, January 22, 2007

Occurrence and severity of steatosis is associated with genotype 3

MIHM et al, 1997; RUBBIA-BRANDT et al, 2000; ADINOLFI et al, 2001KUMAR et al, 2002; MONTO et al, 2002; POYNARD et al, 2003

HOFER et al, 2002; WESTIN et al, 2002

The score of steatosis correlates with the level of HCV RNA in serum and liver, but only in patients with genotype 3

RUBBIA-BRANDT et al, 2000; ADINOLFI et al, 2001

Virological response to IFN- is associated with the disappearance of the steatosis, which recurs at the time of virological relapse

RUBBIA-BRANDT et al, 2001; KUMAR et al, 2002; POYNARD et al, 2003

HCV-induced (i.e. viral ) steatosis

Severity of steatosis and HCV genotype

The HCV-MAID study (n = 3,068)

0

10

20

30

40

50

60

1 2 3 4

st 0 st 1 st 2 st 3

P = <0.001

LEANDRO et al, Gastroenterology 2006;130:1636-1642

n Serum HCV RNA

Liver (+) HCV RNA

Liver (-) HCV RNA

All patients 70 0.24 0.26a 0.36b

Only steatotic 28 0.24 0.34 0.49b

Only genotype 1 29 0.45 0.27 0.32

Only genotype 3 24 0.48 0.37 0.64b

a P <0.05 ; b P <0.01

Steatosis score and HCV RNA levels

70 immunocompetent chronic hepatitis C cases

RUBBIA-BRANDT et al, J Hepatol 2000;33:106-115

Expression of liver steatosis in HCV infection

and pattern of response to -interferon

Liver steatosis in a patient with recurrent hepatitis C after LT, before -IFN therapy (1a),at the time of virological response (1b) and on occasion of the biochemical and

virological relapse after the end of treatment (1c)

RUBBIA-BRANDT et al, J Hepatol 2001; 35: 307

Serum lipid profile changes in HCV

In chronic hepatitis C, Apolipoprotein B levels:– are inversely correlated with steatosis score– revert to normal upon response to therapy

HCV type 3a lowers serum cholesterol levels: HCV 1 HCV 3 HCV 4 P 188 ± 36 147 ± 42 172 ± 35 <0.01

Hypocholesterolemia in genotype 3a: – returns to normal in sustained virological responders– is not shared by other HCV genotypes

HOFER et al, Am J Gastroenterol 2002;97:2880

SERFATY et al, J Hepatol 2001;34:428

HCV core protein transgenic mouseHCV core protein transgenic mouse

MTP

intracytoplasmicTG storage

STEATOSIS

HCV coreprotein

VLDLassembly

impairedVLDL secretion

TG Apo B

PERLEMUTER et al, FASEB J 2002;16:185

Intrahepatic MTP mRNA levels are inversely correlated with steatosis

scores

MIRANDOLA et al, Gastroenterology 2006;130:1661-9

steatosis score

Intr

ah

epati

c M

TP m

RN

A levels

P = 0.0017

In most patients with genotype non-3 who do not drink alcohol:

Steatosis occurrence and severity is not (or only partially) modified by antiviral treatment

KUMAR et al, 2002; POYNARD et al, 2003

Steatosis score correlates with body mass index rather than with HCV RNA replication

ADINOLFI et al, 2001

Metabolic steatosis in chronic hepatitis C

Insulin resistance causes liver steatosis

BROWNING & HORTON, J Clin Invest 2004;114:147

Risk factors for steatosis in 44 non-3a, alcohol abstinent chronic hepatitis C

patients

BMI >25

HOMA >2

no risk factors

BMI >25 / HOMA >2

MUZZI et al, J Hepatol 2005;42:41-46

30%20%

18%

32%

Mechanisms of steatosis in hepatitis C

Steatosis in hepatitis C is multifactorial:

viral steatosis:•correlates with viral replication level•responsive to antivirals•likely due to impaired lipoprotein secretion

metabolic steatosis:•mostly unaffected by antivirals•associated with BMI/insulin resistance

other causes (genetic?)

Steatosis as a factorof liver disease

progression

Natural History of HCV Liver DiseaseNatural History of HCV Liver Disease

~70%

2 – 30% / 20 yrs

2 - 4% / yr

Liver failure

(2 – 5% / yr)

Factors associated with an accelerated fibrosis progression

in chronic hepatitis C

Age at infectionSex

HIV CoinfectionHBV Coinfection

ImmunosuppressionLiver disease activity

OverweightAlcohol abuse

SteatosisSmoking

Iron overloadInsulin resistance

Impact of steatosis on liver fibrosis progression in chronic hepatitis C

A retrospective study on repeated liver biopsies

FARTOUX et al, Hepatology 2005;41:82-87

0%10%20%30%40%50%60%70%80%90%

100%

no steatosis steatosis no steatosis steatosis

no progression progressed 1 progressed 2 or more

type non-3 type 3

Steatosis accelerates fibrosis progression

in genotype 3 chronic hepatitis C

WESTIN et al, J Hepatol 2002;37:837

The HCV MAID StudyPredictors of fibrosis in 3,068

patients

All pts.

HCV genotype BMI

1 2 3 4 <25 25-30 >30

n 3068 1694 563 669 142 1481 1287 300

Activity 5.33 4.35 4.52 11.1 4.11 6.49 4.90 NS

Male gender 1.92 1.79 NS NS NS 1.91 1.91 NS

Steatosis 1.66 1.72 NS NS NS 1.61 NS NS

Age 1.04 1.04 NS 1.05 NS 1.02 1.05 1.08

Diabetes NS 4.52 NS NS NS NS NS NS

Alcohol abuse

NS NS NS NS NS NS 1.69 NSLEANDRO et al, Gastroenterology 2006

By MV, the HOMA insulin resistance index (but not steatosis) is a factor independently associated with fibrosis (P<0.001) and its progression rate (P=0.03)

HUI et al, Gastroenterology 2003

Insulin resistance and/or diabetes are associated with severity of fibrosis

RATZIU et al, 2003; HUI et al, 2003; FARTOUX et al, 2005MUZZI et al, 2005; LEANDRO et al, 2006

Fibrogenesis in Chronic Hepatitis C:Fibrogenesis in Chronic Hepatitis C:Steatosis or Insulin Resistance?Steatosis or Insulin Resistance?

Association between diabetes and hepatocellular carcinoma

A systematic review of epidemiologic evidence

• Diabetes significantly associated with HCC:– In 9 of 13 case-control studies (OR 2.5, 95% CI 1.8 - 3.5)– In 7 of 13 cohort studies (risk ratio 2.5, 95% CI 1.9 - 3.2)

• Association independent of alcohol or viral hepatitis (in 10 studies that examined these factors)

EL-SERAG et al, Clin Gastroenterol Hepatol 2006;4:369-380

Insulin resistance and activation of hepatic stellate

cellsProduction of CTGF

hyperglycemia hyperinsulinemia

PARADIS et al, Hepatology 2001;34:738-744

BMI and fibrosis in chronic hepatitis C

The HCV MAID Study (n = 3,068)

r = 0.125

LEANDRO et al, Gastroenterology 2006;130:1636-1642

10

20

30

40

50

0 1 2 3F0 F1-F2 F3-F4F

Omental macrophages are associated with liver necroinflammation

CANCELLO et al, Diabetes 2006;55:1554-1561

Intrahepatic necroinflammation

P<0.05

The Metabolic SyndromeEGIR Definition (1999)

Hyperinsulinemia (top 25% of fast insulin values among the non-diabetic population)

plus two of the following:

1. 6.1 mmol/L fasting glucose (non-diabetic)2. 140/90 arterial pressure (or treatment)3. 2.0 mmol/l triglycerides (or treatment)4. 1.0 mmol/l HDL cholesterol (or treatment)5. Waist circumference 94 (men) or 80 (women)

Factors associated with an accelerated fibrosis progression

in chronic hepatitis C

Age at infectionSex

HIV CoinfectionHBV Coinfection

ImmunosuppressionLiver disease activity

OverweightAlcohol abuse

SteatosisSmoking

Iron overloadInsulin resistance

Metabolic syndrome

Steatosis as a factorof poor response to

interferon-

Steatosis at baseline and SVR

POYNARD et al, Hepatology 2003;38:75-85

0

10

20

30

40

50

60

70

80

90

3 non-3 1, 4, 5, 6

SteatosisNo steatosis

P=0.33

P<0.001

P<0.001

(n = 134) (n = 746)(n = 900)

Steatosis and SVR in HCV genotype 2 and 3 patients

0

20

40

60

80

100

0 <5% 6-32% 33-66% >66%

ZEUZEM et al, J Hepatol 2004;40:993-999

% S

VR

severity of steatosis

In HCV patients with virally-induced steatosis:

high serum HCV RNA

high steatosis score

Insulin resistance decreases SVR in chronic hepatitis C

ROMERO-GOMEZ et al, Gastroenterology 2005;128:636-641

HCV genotype 1, intrahepatic SOCS-3 and response to IFN-

therapy

WALSH et al, Gut 2006

Insulin resistance in HCV infection:

additional, direct role of HCV 1b 3a GFP Huh-7

IRS-1

-Actin

IRS-2

1b 3a GFP Huh-7

SOCS-7

-Actin

PAZIENZA et al, Hepatology 2007

• After SOCS binding to IRS-1, the SOCS box recruits the E3 ligase which is involved in the ubiquitination of the IRS-1 protein

• The complex is then targeted for proteasomal degradation

(adapted from Larsen and Röpke, APMIS 110:833-44, 2002)

IRS-1

Induction of proteasomal degradationof IRS-1 by members of the SOCS family

binding to IRS-1causes its proteasomal

degradation

interferencewith the

insulin signaling

binding to Janus kinaseinhibits Tyr-phosphorylation

of STAT1

interferencewith the

IFN- signaling

SOCS-n

HCV

Steatosis and Chronic Hepatitis C:

liaisons dangéreuses?

Fibrosis progression

Resistance to IFN-

Viral steatosis

UnlikelyDue to higher level of HCV replication

Metabolic steatosis

Yes, mediated by IR

Yes, mediated by

IR

Increasing insulin sensitivity

in chronic hepatitis C patients• Increase physical activity

•Reduce body weight• Insulin sensitizers ??

–Metformin–Thiazolidindiones (pioglitazone, rosiglitazone…)

But the best solution is ……