Association between Serum β2-Microglobulin Level and Infectious Mortality in Hemodialysis Patients

Background and objectives: Secondary analysis of the Hemodialysis Study showed that serum β₂-microglobulin levels predicted all-cause mortality and that high-flux dialysis was associated with decreased cardiac deaths in hemodialysis patients. This study examined the association of serum β₂-microglobulin levels and dialyzer β₂-microglobulin kinetics with the two most common causes of deaths: Cardiac and infectious diseases.Cox regression analyses were performed to relate cardiac or infectious deaths to cumulative mean follow-up predialysis serum β₂-microglobulin levels while controlling for baseline demographics, comorbidity, residual kidney function, and dialysis-related variables.Results: The cohort of 1813 patients experienced 180 infectious deaths and 315 cardiac deaths. The adjusted hazard ratio for infectious death was 1.21 (95% confidence interval 1.07 to 1.37) per 10-mg/L increase in β₂-microglobulin. This association was independent of the prestudy years on dialysis. In contrast, the association between serum β₂-microglobulin level and cardiac death was not statistically significant. In similar regression models, higher cumulative mean Kt/V of β₂-microglobulin was not significantly associated with either infectious or cardiac mortality in the full cohort but exhibited trends suggesting an association with lower infectious mortality (relative risk 0.93; 95% confidence interval 0.86 to 1.01, for each 0.1-U increase in β₂-microglobulin Kt/V) and lower cardiac mortality (relative risk 0.93; 95% confidence interval 0.87 to 1.00) in the subgroup with >3.7 prestudy years of dialysis.Conclusions: These results generally support the notion that middle molecules are associated with systemic toxicity and that their accumulation predisposes dialysis patients to infectious deaths, independent of the duration of maintenance dialysis.The Hemodialysis (HEMO) Study was a randomized clinical trial designed to examine the impact of two treatment parameters on clinical outcomes of maintenance hemodialysis patients. These parameters were the dialysis dosage based on the clearance of urea (molecular weight [MW] 60 Da) and membrane porosity or flux based on the clearance of β₂-microglobulin (β₂M; MW 11,800 Da) (1). The primary analysis of the HEMO Study did not show a statistically significant reduction in the rate of the primary outcome, all-cause mortality, or any of the predefined secondary outcomes associated with high flux. In secondary analyses, however, a 20% decrease in cardiac death (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.65 to 0.99) was observed for the high-flux group compared with the low-flux group. In the subgroup of patients who had been on dialysis for >3.7 yr (the mean for the entire cohort) before enrollment in the HEMO Study, high flux was associated with lower all-cause mortality (HR 0.68; 95% CI 0.53 to 0.86), cardiac deaths (HR 0.63; 95% CI 0.43 to 0.92) (1,2), and cerebrovascular events (3).Although these are results of secondary analyses and must be interpreted cautiously because of the multiple hypotheses that were tested (4), they are consistent with the notion that high-flux dialysis may have certain beneficial effects. In the HEMO Study, membrane flux was defined by the clearance of β₂M, taken as a surrogate for the clearance of middle molecules. As a result of the higher clearance, the cumulative mean predialysis serum β₂M level during follow-up in the high-flux arm was statistically significantly lower than that in the low-flux arms (33.6 versus 41.5 mg/L) (5). Further secondary analysis of the data showed that predialysis serum β₂M levels predicted all-cause mortality in the HEMO Study cohort, with an 11% increase in mortality for each 10-mg/L increase in β₂M level, even after adjustment for years on dialysis and residual kidney function (5). The specific causes of death that account for this increased mortality have not been determined.In addition to a number of other middle molecules, in vitro studies have identified proteins from the circulating plasma of maintenance dialysis patients, with homology or MW similar to β₂M, that have neutrophil-inhibitory effects (6,7). The accumulation of these proteins leads to higher serum β₂M concentrations and may predispose the patients to infectious complications. Furthermore, because randomization to high flux was associated with a decrease in cardiac deaths in the HEMO Study and an even greater reduction in patients who were on dialysis for >3.7 yr before the study (1,2), it would be reasonable to hypothesize that serum β₂M levels are also predictive of cardiac death, especially in the long-term dialysis subgroup. In this report, we examined the association of serum β₂M levels and dialyzer β₂M kinetics with cause-specific mortality in the HEMO cohort, focusing on cardiac and infectious deaths.     

Serum β2-microglobulin in systemic sclerosis

Summary The role of ₂ microglobulin (₂-m) in Systemic Sclerosis (SS) has been evaluated. Twenty-four female patients have been examined: 15 of them were affected by acrosclerosis (Group 1) and 9 of them by diffuse sclerosis (Group 2). 46.6% of Group 1 and 44.4% of Group 2 had values significantly higher than normal controls. (P<0.01 and P< 0.005 respectively). The authors deal with the validity of the use of B2-m as index of inflammatory activity of the disease.     

Can Serum ST2 Levels Be Used as a Marker of Fibrosis in Chronic Hepatitis B Infection?

Interleukin 33 (IL-33) is a cytokine belonging to the IL-1 superfamily. Soluble ST2 (sST2) binds to IL-33 and by functioning as trap receptor inhibits signal sending to Th2 via transmembrane ST2. Because Th2-type cytokines play an important role in fibrosis, the aim of this study is to determine whether sST2 can be used as a marker of fibrosis in chronic hepatitis B (CHB) patients or not.The study included 19 healthy controls, 54 patients with CHB, and 14 patients with cirrhosis because of CHB. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4) scores also calculated, and correlations between liver biopsies, sST2 levels, and these scores were analyzed in CHB and cirrhosis patients.The sST2 levels in patients with CHB were significantly higher than those in the control group subjects (median: 1133 pg/mL vs 762.5 pg/mL, respectively [P = 0.035]). In CHB patients, the METAVIR fibrosis score (stages from 0 to 4) showed a moderate correlation with serum sST2 level (r = 0.396, P = 0.004) and a weak correlation with FIB-4 score (r = 0.359, P = 0.008), but no correlation with APRI score (r = 0.253, P = 0.06). The under the curve value of serum sST2 was 0.68, and its prediction of significant fibrosis (METAVIR score ≥2) in values >674 pg/mL had a sensitivity of 91.7% and specificity of 40% (P = 0.009). According to multiple logistic regression analysis, only METAVIR fibrosis stage was found to be an independent predictor of serum sST2 elevation in CHB patients (P = 0.04).The sST2 level can be used for differentiating significant fibrosis from mild fibrosis in CHB patients. However, the efficacy of this marker should be verified by larger studies in the future.     

Activation of Tumor Necrosis Factor-α System in Chronic Hepatitis C Virus Infection

Tumor necrosis factor- (TNF-)plays a central role in the host's immunomodulatoryresponse to infective agents. To evaluate theTNF- system in patients with chronic hepatitis Cvirus (HCV) infection, plasma, serum, and peripheral bloodmononuclear cells (PBMC) were prospectively collectedfrom 53 patients and 33 healthy control subjects.Circulating TNF- and TNF receptors were assayed by their respective enzyme immunoassays. Inaddition, TNF- mRNA was quantitated in PBMC usinga branched DNA assay, and production of TNF- byPBMC with and without lipopolysaccharide was also assessed. Patients with chronic HCV infectionhad a higher level of circulating TNF- comparedto healthy control subjects (9.62 ± 6.01 vs 3.66± 1.23 pg/ml, P < 0.001). They also had highercirculating levels of TNF receptors compared to control(CD120a: 3323 ± 1267, pg/ml, N = 49 vs 1855± 422 pg/ml, N = 33, P < 0.001; CD120b: 1290± 650 pg/ml, N = 51, vs 863 ± 207 pg/ml,N = 33, P < 0.001). Plasma TNF- level correlated with circulatingCD120a (r = 0.52, N = 49, P < 0.001) and weakly withCD120b (r = 0.32, N = 51, P = 0.02). Plasma TNF-also correlated with markers of hepatocellular injury, including ALT (r = 0.34, N = 53, P = 0.01) and-GST (r = 0.31, N = 43, P = 0.042), but not withserum HCV RNA levels. There was no difference in theTNF- mRNA levels in PBMC between patients with chronic HCV infection (1.4 ± 1.9units/106 cells, N = 8) and healthy control subjects(2.1 ± 1.4 units/106 cells, N = 8, P = NS). Therewas also no difference in the spontaneous production ofTNF- by PBMC (1 × 10⁶ cells/ml)between patients with chronic HCV infection (14.2± 36.5 pg/ml, N = 11) and healthy subjects (11.9± 14.0 pg/ml, N = 14, P = NS). However, patientswith chronic HCV infection produced more TNF- upon stimulation withlipopolysaccharide compared to healthy control subjects(1278 ± 693 pg/ml, N = 11, vs 629 ± 689pg/ml, N = 14, P < 0.05). These data indicate thatthe TNF- system is activated in patients with chronicHCV infection.     

Hepatitis C in patients with β-thalassemia major. A single-centre experience

Chronic hepatitis C (CHC) and iron overload are the main causes of liver disease in β-thalassemia major (βTM). There is limited data regarding the course of CHC in this population. All patients (n?=?144) from the thalassemia centre of the University Hospital of Patras were evaluated (January 1981 to June 2012). Patients were classified into group A (n?=?57), which consisted of patients with CHC, who either had received antiviral treatment (n?=?49) or not (n?=?8), and group B which included 87 patients without CHC. Nineteen patients died during follow-up (median: 257.5 months (1–355)). Survival rates were 84.2 % and 88.5 % for group A and B, respectively. The causes of death were heart failure (63.2 %), accident (10.5 %), sepsis (5.3 %), liver failure (5.3 %), hepatocellular carcinoma (HCC) (5.3 %), non-Hodgkin lymphoma (5.3 %) and multiorgan failure (5.3 %). There were no differences in total survival between the two groups (p?=?0.524). In the multivariate analysis, survival was neither correlated with CHC (p?=?ns), nor with anti-HCV treatment (p?=?ns), whereas independent negative predictors were presence of heart failure (p?<?0.001), presence of malignancy other than HCC (p?=?0.001) and non-adherence to chelation treatment (p?=?0.013). Predictive factors for the development of cirrhosis were: CHC (p?<?0.001), age?>?35 years (p?=?0.007), siderosis grade 3/4 (p?=?0.029) and splenectomy (p?=?0.001); however, multivariately, only siderosis grade 3/4 was found to be significant (p?=?0.049). In this study, survival of patients with βTM was mainly associated with heart failure, presence of malignancy other than HCC and non-adherence to chelation treatment, rather than with liver disease. Multicentre studies need to be designed to define more accurately the indications of antiviral treatment in this population.     

Study of Non–organ-specific Antibodies in Children with Genotype 4 Chronic Hepatitis C

Background/Aim:

Adult studies established a relationship between hepatitis C virus (HCV) infection and the presence of non–organ-specific antibodies (NOSAs). Most studies were carried out on genotypes 1 and 2. Only a few studies addressed that issue in pediatrics. No studies have been carried out on autoimmunity and genotype 4 in children. We aim to investigate NOSAs in 80 Egyptian children with chronic HCV infection along with studying the underlying genotype of HCV, and correlating autoimmunity with the epidemiological, clinical, biochemical, and virological features.

Materials and Methods:

HCV-RNA was assayed by the polymerase chain reaction and viral genotypes were determined. NOSAs were measured and liver biopsies were taken for histopathological examination.

Results:

Genotype4 was the only detected genotype in the included 80 patients. Anti-smooth muscle antibodies (ASMA) were the only detected antibodies in 32 (40%) patients, always with V specificity (vessels only) at titers ranging from 1:20 and 1:160. Anti-nuclear antibodies (ANA) and liver–kidney microsomal antibodies-1 (LKMA-1) were not detected in any of our patients. Epidemiologic and clinical features did not significantly differ between autoantibody-positive and -negative patients. Among biochemical features, significantly high levels of total bilirubin, albumin, immunoglobulins, alkaline phosphatase, and gamma-glutamyl transpeptidase were found in the antibody-positive group.

Conclusion:

Genotype 4 HCV is the prevailing genotype in Egyptian children with chronic HCV infection. A consistent proportion of these children with chronic HCV infection circulate non–organ-specific autoantibodies. The prevalence of ASMA and the absence of ANA and LKMA-1 might be related to the unique situation in Egypt with unique prevalence of genotype 4. More studies are warranted on larger pediatric population to validate these findings.     

Pegylated Interferon α-2b, Ribavirin and Amantadine for Chronic Hepatitis C

In an attempt to improve the efficacy of antiviral therapy for chronic hepatitis C, a three-drug combination of pegylated interferon -2b, ribavirin, and amantadine has been suggested. Despite the initial enthusiasm, the role of amantadine in the treatment of chronic hepatitis C remains controversial. In a multi-center, open-label clinical trial, the potential efficacy and safety of this triple combination regimen were assessed. In this open-label pilot study, two separate patient populations with chronic hepatitis C and viremia were enrolled: treatment-naive and those who had failed a previous course of treatment. Patients were started on pegylated interferon -2b at a dose of 1.5 g/kg weekly with ribavirin, 1000–1200 mg/day, and amantadine, 200 mg/day, for 4 weeks, followed by pegylated interferon -2b, 0.5 g/kg weekly, ribavirin, 1000–1200 mg/day, and amantadine, 200 mg/day, for another 20 weeks. Patients with undetectable HCV RNA at week 24 continued this regimen for a total of 48 weeks and were followed for another 24 weeks. Patients with undetectable virus (< 50 IU/mL) after 24 weeks of follow-up were considered to have SVR. Health-related quality of life and safety data were also collected. Sixty-nine treatment-naive and 99 nonresponder patients with chronic hepatitis C were enrolled in the study. Of all patients enrolled, 74% were male, aged 47.27 ± 5.76 years; their body mass index (BMI) was 28.87 ± 5.05 kg/m², 79.4% were white, 85% had HCV genotypes 1 and 4, and 36% had cirrhosis. Their baseline HCV RNA was 689,242 ± 698,030 IU/mL, with a baseline ALT of 107.25 ± 79.08. Of the entire cohort, 35 (21%) discontinued early due to side effects or loss to follow-up. Significant anemia (hemoglobin, < 10 g/dL) occurred in 11% (19/168), while severe anemia (hemoglobin, < 8.5 g/dL) occurred in 0.6% (1/168). In the treatment-naive group, sustained virologic response (SVR) was 34.3%, versus 19.4% for the group who had previously failed to respond to a course of treatment (P = 0.01). For both groups combined, virologic response after 24 weeks of therapy was 40.5%, with an end-of-treatment virologic response of 35.7% and a SVR of 26.2%. Patients with genotypes 1 and 4 had lower response rates than those with genotypes 2 and 3 (SVR, 21 vs. 46%; P = 0.001). Patients with advanced fibrosis (Metavir stages 3 and 4) tended to have lower response rates than those with minimal or mild fibrosis (Metavir stages 0–2) (SVR, 10 vs. 30%; P = 0.08). African-American patients with HCV had lower response rates than Caucasians or other ethnic groups (SVR, 4 vs. 29 vs. 20%; P = 0.04). Age, gender, and BMI did not affect SVR. The addition of amantadine to pegylated interferon -2b and ribavirin does not seem to increase the efficacy of this antiviral regimen.     

Novel Biomarker Candidates to Predict Hepatic Fibrosis in Hepatitis C Identified by Serum Proteomics

Background  

Liver biopsy remains the gold standard to assess hepatic fibrosis. It is desirable to predict hepatic fibrosis without the need for invasive liver biopsy. Proteomic techniques allow unbiased assessment of proteins and might be useful to identify proteins related to hepatic fibrosis.     

Endogenous Interferon-α Concentration and Outcome of Interferon Treatment in Patients with Chronic Hepatitis C

To verify its value with regard to the outcomeof therapy in chronic hepatitis C, seruminterferon- (IFN) was measured by ELISA in 70patients (43 male, 27 female) with chronic hepatitis C,treated with IFN 9 MU/week subcutaneously for up to oneyear. Serum IFN was detectable in 49/70 patients, 16 ofwhom had IFN values >125 pg/ml. Only 1/22 patientswho maintained a sustained response six months after the end of treatment had pretreatment serum IFN> 125 pg/ml, in comparison to 15/48 patients who didnot respond or who relapsed ( 6.1, P < 0.02). Atmultivariate analysis the predictive value of serum IFN was independent of age, sex, presence ofcirrhosis, infection by genotype 1b (improvement 7.1, P < 0.01). In patients with chronic hepatitis C,measurement of serum IFN at baseline might be useful for the selection of patients with higherprobability of long-term response.     

Extracorporeal Photopheresis Alone and with Interferon-α2a in Chronic Hepatitis C Patients Who Failed Previous Interferon Therapy

Extracorporeal photopheresis (ECP) is approvedfor treatment of cutaneous, T-cell lymphoma. Evidencesuggests that ECP can induce an immune response againsttumor antigens expressed by malignant T lymphocytes. We theorized that if HCV-infected PBMCs expressviral antigens, ECP could demonstrate antiviral activityby eliciting an immune response against these antigens.Fifteen cirrhotic patients with genotype-1 HCV, who had previously relapsed or notresponded to interferon- (IFN-) therapywere stratified by their HCV RNA titer into one of threetreatment groups: (1) ECP alone, (2) ECP + 3 MIUIFN-_2a subcutaneously three times a week and (3) ECP+ 6 MIU IFN-_2a subcutaneously threetimes a week. All patients received treatment for 24weeks. Group 1 had no significant decrease in HCV RNA.Two patients in group 2 had undetectable HCV RNA at the endof treatment. One patient in group 3 had undetectableHCV RNA at the end of treatment. However, HCV RNA wasdetected in all three patients during follow-up. ECP alone or with IFN- was welltolerated. ECP alone demonstrated no clear antiviralactivity. The combination of ECP and IFN-resulted in an end-of-treatment response (ETR) in threeof 10 patients. All responders had elimination of serum HCV RNAby three months, although no patient had a sustainedresponse. More intensive therapy for a longer durationmay result in sustained responses. A multicenter trial is now underway.     

Diagnostic Value of Serum Level of Soluble Tumor Necrosis Factor Receptor IIα in Egyptian Patients With Chronic Hepatitis C Virus Infection and Hepatocellular Carcinoma

Background:

The prognosis of hepatocellular carcinoma (HCC) is unfavorable and needs serum markers that could detect it early to start therapy at a potentially curable phase.

Objectives:

The aim of this study was to determine the value of serum soluble tumor necrosis factor (TNF) receptor-IIα (sTNFR-IIα) in diagnosis of HCC in patients with chronic hepatitis C virus (HCV) infection.

Patients and Methods:

The study was performed on 110 subjects who were classified into five groups. Group I included 20 patients with chronic noncirrhotic HCV infection and persistently normal transaminases for ≥6 months. Group II included 20 patients with chronic noncirrhotic HCV infection and elevated transaminases. Group III included 20 patients with Chronic HCV infection and liver cirrhosis. Group IV included 20 patients with chronic HCV infection with liver cirrhosis and HCC. Group V included 30 healthy age and sex-matched controls. Medical history was taken from all participants and they underwent clinical examination and abdominal ultrasonography. in addition, the following laboratory tests were requested: liver function tests, complete blood count, HBsAg, anti-HCVAb, HCV-RNA by qualitative PCR, and serum levels of α-fetoprotein (AFP) and sTNFR-IIα.

Results:

The serum level of sTNFR-IIα was significantly higher in patients with HCC in comparison to the other groups. A positive correlation was found between the serum levels of sTNFR-IIα and AST and ALT in patients of group-II. Diagnosis of HCC among patients with HCV infection and cirrhosis could be ascertained when sTNFR-IIα is assessed at a cutoff value of ≥ 250 pg/mL.

Conclusions:

Serum sTNFR-IIα could be used as a potential serum marker in diagnosing HCC among patients with HCV infection.     

l-Carnitine Treatment Reduces Steatosis in Patients with Chronic Hepatitis C Treated with α-Interferon and Ribavirin

Background Hepatic steatosis is a common presentation in patients with chronic hepatitis C. Interferon α exerts both antiviral and immunomodulating actions, and influences on lipid metabolism. The aim of our study was to test whether l-carnitine reduces steatosis in patients treated with interferon and ribavirin. Patients and methods A total of 70 patients were randomly assigned to receive either leucocyte IFN alpha at a dose of 3 MIU thrice a week plus 1,000 mg ribavirin per day for 12 months (group A) or IFN alpha and ribavirin at the same dose plus 2 g carnitine per day (group B). Results Comparison of the two treatments showed significant differences between the mean values of the following parameters at the end of the treatment: ALT −68 vs −95 IU/ml (P < 0.05), total cholesterol 0.08 vs −0.91 mmol/l (P < 0.05) and triglycerides +0.25 vs −20 mmol/l (P < 0.05); and at the follow-up: AST −35 vs −65 IU/ml (P < 0.05) and ALT −55 vs −84 IU/ml (P < 0.05). All values were lower in group B (IFN + Ribavirin + Carnitine) than in group A (IFN plus Ribavirin). When comparing those patients treated with IFN + ribavirin with those treated with IFN plus ribavirin plus carnitine, the response at the end of the treatment was 48% vs 56%, and the sustained response 39% vs 46%, respectively. Conclusions Combined treatment with l-carnitine, ribavirin and IFN alpha resulted in greater antihyperlipidaemic effects and than with ribavirin and IFN alpha alone. The results of this study suggest that l-carnitine may have a role among the reduction of steatosis strategies in patients with hepatitis C treated with IFN alpha and ribavirin.     

Are There Still Difficult-to-Treat Patients with Chronic Hepatitis C in the Era of Direct-Acting Antivirals?

Difficult-to-treat populations with chronic hepatitis C (CHC), in the era of interferon treatment, included patients with liver cirrhosis, kidney impairment, treatment-experienced individuals, and those coinfected with the human immunodeficiency virus. The current study aimed to determine whether, in the era of direct-acting antivirals (DAA), there are still patients that are difficult-to-treat. The study included all consecutive patients chronically infected with hepatitis C virus (HCV) who started interferon-free therapy between July 2015 and December 2020 in the Department of Infectious Diseases in Kielce. The analyzed real-world population consisted of 963 patients, and most of them were infected with genotype 1 (87.6%) with the predominance of subtype 1b and were treatment-naïve (78.8%). Liver cirrhosis was determined in 207 individuals (21.5%), of whom 82.6% were compensated. The overall sustained virologic response, after exclusion of non-virologic failures, was achieved in 98.4%. The univariable analysis demonstrated the significantly lower response rates in males, patients with liver cirrhosis, decompensation of hepatic function at baseline, documented esophageal varices, concomitant diabetes, body mass index ≥25, and previous ineffective antiviral treatment. Despite an overall very high effectiveness, some unfavorable factors, including male gender, genotype 3 infection, liver cirrhosis, and treatment experience, significantly reduce the chances for a virologic response were identified.