Antiviral Treatment of Egyptian Patients with Advanced Cirrhosis due to HCV genotype 4; using PegIntron and ribavirin.

Effect on Glutathione

Shendy Mohammed shendy*, Naema I.El-Ashry,** Alaa Awad Taha*, Moetaz Sery Siam*Department of tropical medicine, Gastroenterology and Hepatology* and department of Clinical Chemistry**, Theodor Bilharz Research Institute.

Abstract:

Little data until now are available regarding the effect of therapy in Egyptian patients with advanced cirrhosis due to HCV genotype 4, the predominant type. The aim of this work is to assess the therapeutic effect of combination therapy with pegylated interferon alfa-2b and ribavirin in Egyptian patients with advanced cirrhosis due to HCV. Patients and methods: 29 patients of advanced cirrhosis due to HCV genotype 4 were included in the study. All are of Child-Pugh grade B but without any contraindications to both drugs. They were given treatment and followed by clinical, biochemical, hematological and virological evaluation. Results: One male patient died from brain stem hemorrhage due to care accident after 8 weeks of treatment. Four patients were withdrawn due to severe side effects of therapy within first 2 months (one due to severe thrombocytopenia, another one due to severe neutropenia and recurrent chest infection, severe Rheumatoid factor positive polyarthritis in one and thyrotxicosis in the fourth). Treatment is continued in other all patients for the recommended period of time (24 patients). The virus titer was not significantly reduced after 12 weeks in 8 patients who were considered non-responders and therapy was stopped. Viral response was detected in the remaining 16 cases (initial responders) who continued treatment for 48 weeks. They all showed biochemical and virological response at end of treatment (end of treatment responders). Sustained response was evaluated after 6 months of the end of treatment. Four patients showed virological relapse and sustained response was present in 12 cases (41.38 % of intention to treat patients, 50 % of the protocol treatment patients). The only predictive response in these cases was the original viral load which was significantly less in sustained response cases in comparison to the non-responsive and relapsing cases. Reduced Glutathione in liver biopsy was significantly reduced after treatment in those with sustained response (P = 0.002) and in all patients taken together (P < 0.001). There is significant reduction in the HAI score (histological activity) after treatment in sustained response category and total patients (P =0.001) but not in other categories or in the fibrosis grade (P >0.05). Conclusion: it is concluded from this study that patients with advanced cirrhosis but with no contraindication to combination therapy can be managed in the same way as earlier cases with pegylated IFN and ribavirin showing nearly similar responses, anti-oxidant effect and tolerability.

IntroductionThere are real concerns about patients with cirrhosis after HCV infection and their outcome

because the survival rate after 5 years in patients with decompensated liver disease (Child-Pugh C) is very poor (only 50%) (Padilla, 2002).

Although clearance of HCV from serum and liver is the main therapeutic target in chronic hepatitis C, delay in progression of fibrosis may represent a secondary therapeutic target that could be particularly important in patients with advanced fibrosis who fail to achieve SVR. Several indirect data suggest that interferon (IFN-α) may have antifibrotic effects. Significant improvements in liver histology have been observed not only in patients with sustained virological response (SVR) (Marcellin et al., 1997 and Camma et al., 1998) but in all patients who achieve sustained biochemical response (SBR) regardless of virologic response as well (Bruno et al., 1998 and Mathurin et al., 1998). Moreover, improvements in both the necroinflammatory activity and the extent of fibrosis have been observed at 6-12 months after the end of therapy in patients with partial virologic response, which are usually included among the nonresponders (Shiffman el al., 1999).

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Besides its potential beneficial effect on liver histology, IFN-α therapy may also be associated with reduction of hepatocellular carcinoma (HCC) incidence ((Lau et al., 1998 and Shiratori et al., 2000). In a meta-analysis including studies with patients with HCV cirrhosis, 6-12 months of IFN-α therapy was found to be associated with almost negligible risk of HCC for patients with a sustained response (<1% in 4 years) and significantly lower risk of HCC in patients without sustained response (9%) when compared with untreated patients (21.5%) (Papatheodoridis et al., 2001).

A trial was done to overcome the poor tolerability in patients with advanced chronic hepatitis and decompensated liver disease, who were awaiting for liver transplantation, using an accelerating regimen of interferon alfa-2b plus ribavirin. The regimen involved initiating therapy at a lower dose of interferon alfa-2b of 1.5 MU 3 times per week plus ribavirin 600 mg per day, with a stepwise incremental change in the doses to achieve the standard regimen of 3 MU of interferon alfa-2b 3 times per week plus ribavirin 1000-1200 mg per day. Sustained virologic responses were obtained in 17% (Everson et al., 2000).

Interferon-based maintenance therapies have been proposed for several years for the prevention of hepatic decompensation and the development of hepatocellular carcinoma in nonresponder patients with cirrhosis (Poynard et al, 1999 and Shiffman 2003). Although this concept is supported by results from several retrospective studies, we still lack data from controlled prospective trials. The HALT-C (pegylated interferon alfa-2a) and EPIC-3 (pegylated interferon alfa-2b) trials are ongoing.

Upon the introduction of the long acting PEG-IFN, a marked improvement was observed, such that 30% of patients with bridging fibrosis or cirrhosis achieved SVR with PEG IFN alpha 2a monotherapy alone (Heathcote et al., 2000)). Combination of ribavirin with PEG-IFN has improved the chance of SVR to just over 40% (Manns et al, 2001 and Fried et al., 2002). However, this figure still remains less than may be achieved in individuals without background cirrhosis (Wright TL, 2002 and Mauss et al, 2004).

Thus, therapy with pegylated interferon and ribavirin is clearly indicated for patients with compensated cirrhosis as long as the white cell and platelet counts allow the reduction induced by the therapy (Padilla, 2002). The results from two recent studies supported treatment of HCV infection in the setting of decompensated cirrhosis if patients are selected carefully (Fontana et al., 2004 and Lim and Imperial, 2005).

In Egypt, no data until now are available regarding the effect of therapy in our patients with advanced cirrhosis due to HCV, particularly genotype 4, the predominant type.

Hepatitis C infection causes a state of chronic oxidative stress and increased reactive oxygen species (ROS) production which may contribute to fibrosis and carcinogenesis in the liver. This in turn leads to oxidation of the glutathione pool, reduction in NADPH content and inhibition of electron transport. This was believed to be due to direct interaction of core protein with mitochondria in hepatocytes (Moriya et al. 2001, Okuda et al. 2002, Wen et al. 2004, Otani et al. 2005, and Masaaki et al. 2005) (45-49).

The aim of this work is to assess the therapeutic effect of combination therapy including effect on reduced glutathione concentration in liver biopsy in Egyptian patients with advanced cirrhosis due to HCV.

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Materials and methods:

In this study, 29 patients with advanced cirrhosis due to HCV genotype 4 were enrolled to enter the study. They were 19 males and 10 females. All patients were subjected to history taking and clinical examination with special stress on the stigmata of chronic liver disease, abdominal ultrasonography, and upper endoscopy. Liver biopsy was not mandatory because of fear of complications in such advanced cases and the clinical diagnosis of cirrhosis. Liver biopsy was done only for those without contraindications before and after treatment. Blood samples from all patients were collected after an overnight fast into plain and anticoagulated tubes and transferred immediately to the lab, and subjected to complete blood picture, Serum ALT, AST, bilirubin, alkaline phosphatase, albumin, globulins and prothrombin time and concentration. Thyroid functions and antibodies and autoimmune markers were done only in clinically suspicious cases. Urea, creatinine, blood sugar, ECG, chest X ray and when indicated cardiac enzymes were done for all patients. Liver biopsy was done whenever possible and no contraindication, to determine the level of reduced glutathione content and histopathology before and after treatment in liver tissues. Upper endoscopy and abdominal ultrasound evaluation of liver, spleen and portal hypertension were done before and after end of treatment in all patients. Markers for hepatitis B and C viruses were performed by enzyme immunoassay (EIA) according to the manufacturer’s instructions. The following markers were performed: Hepatitis B surface antigen (HBsAg) by Murex version 3, Murex-Biotech Ltd. UKHepatitis B core total antibody (anti-HBc total) by ETI-AB-Corek-2 DiaSorin s.r.l., Italy.Hepatitis C antibody (anti-HCV) by Murex anti HCV version 4 Murex-Biotech Ltd UKHCV RNA was extracted using acid guanidinium thiocyanate-phenol chloroform single step method (Chomczynski and Sacchi.1987). HCV-RNA was detected by qualitative nested RT-PCR using two sets of primers within the 5’ non-coding region. Amplification products were analyzed using 2% agarose gel electrophoresis (Van Doorn et al., 1994). Quantitative PCR was done by using Light Cycler (Roche) real time and on line quantification using fluorescein dye with external standard of 4 dilution positive control for calibration curve. Viral load was estimated as follows:

<10,000 copies /ml: weak viraemia10,000-100,000 copies /ml: mild viraemia 100,000- 1,000,000 copies /ml: moderate viraemia> 1,000,000 copies /ml: high viraemia

Genotyping of HCV was done using amplified products of specific primers from the 5-UTR region in a reverse transcription polymerase chain reaction (Roche Diagnostics, Switzerland) followed by a reverse hybridization technique (Innolipa HCV II [Innogenetics, Belgium])

Determination of Glutathione Content— Freshly isolated liver tissue samples (50–75 mg) and mitochondrial samples (2 mg) were sonicated using a Branson Sonifer 450 (VWR Scientific Products, West Chester PA) for 15 s at power setting 3 in ice-cold 5% trichloroacetic acid and centrifuged at 3000 x g at 4 °C for 10 min. The concentration of reduced GSH was measured by the thioester method using the GSH-400 kit (Oxis International Inc., Portland, OR). Total glutathione content of samples was measured by the glutathione reductase-DTNB recycling assay using a commercial kit (GSH-412, Oxis International). (Anderson, 1989 and Masaaki et al. 2005) (49,50). Isolation of Mitochondria—Liver mitochondria were isolated by a modification of the method of Johnson and Hardy (Johonson, and Lardy,1967). In brief, liver (400 mg) was minced on ice and transferred (10% w/v) to isolation buffer (250 mM sucrose, 10 mM HEPES, 0.5 mM EGTA, 0.1% BSA, pH 7.4). The sample was gently homogenized by 3–4 strokes with a Dounce homogenizer and loose fitting pestle. The homogenate was centrifuged at 500 x g for 5 min at 4 °C. The supernatant fraction was retained, whereas the pellet was washed with isolation buffer and centrifuged again. The combined supernatant fractions were centrifuged at 7800 x g for 10 min at 4 °C to obtain a crude mitochondria pellet. The mitochondria pellet was resuspended in isolation buffer (without EGTA and BSA) and centrifuged again at 7800 x g for 10 min. An

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aliquot was removed for determination of protein concentration by the Bio-Rad assay kit, using bovine serum albumin as the standard.

Inclusion criteria:Patients with liver cirrhosis due to HCV genotype 4 with detectable virus RNA in serum and elevated liver enzymes.Negative HBsAg and anti-HB core antibodies. No evidences of hepatosplenic schistosomiasis (clinically and by ultrasound).No history of severe upper gastrointestinal bleeding due to portal hypertension complications. CBC and prothrombin time are compatible with interferon and ribavirin treatment (Hemoglobin level ≥ 12 g/dl in women and ≥ 13 g/dL in men, White blood cell count ≥ 1500/mm3, Platelet count ≥ 100,000/mm3) No contraindications for interferon therapy such as uncontrolled ascites, or severe, persistent encephalopathy, ischemic heart disease, autoimmune diseases, persistent infection, uncontrolled diabetes mellitus, severe neuropsychiatric disorders, pregnancy or inability to practice contraception, debilitating medical conditions, particularly a history of pulmonary disease, history of cardiovascular disease, coagulation disordersAge between 18-65 yearsPatients give informed consent to continue medication and follow up.

Treatment of selected cases was done using peginterferon-alfa 2b (pegIntron) 1.5 μg/kg of body weight subcutaneous once weekly and ribavirin 800-1200 mg/ day according body weight in two divided doses (800 mg in those <65 kg, 1000 mg in those of 65-85 kg, 1200 mg for those > 85 kg).

Dose adjustment was done during treatment according biochemical and hematological parameters as advised by the manufacturer as follows:

- reduction of pegIntron to half the dose if neutrophil count was reduced to less than 750/μl ( or total WBC is less than 1500/μl) or platelet count is less than 50,000/μl, and

- for ribavirin, it is reduced to 600 mg /day if hemoglobin is reduced to < 10 gm/dl or indirect bilirubin > 5 mg/dl

- both PegIntron and ribavirin are discontinued if neutrophil count is less than 500//μl (or total WBC is less than 750/μl), or direct bilirubin is more than 2.5 times the upper limit of normal or indirect bilirubin > 4 mg/dl (for more than 4 weeks), or if serum creatinine is increased to >2mg/dl or the ALT or AST level is doubled or increased 10 times the upper limit of normal.

- Treatment is discontinued also if no reduction of HCV RNA level by 2 logs after 12 weeks and considered not responding not responding to treatment (Poynard T et al., 2005)

The following precautions were followed to overcome the common side effects of medications:a) Acetaminophen or ibuprofen was taken one hour before injection, b) Patient was encouraged to drink 24 ounces of water before injection to combat dehydration c) Enough rest (6 to 10 hours each night) was allowed.d) Light exercise in daily routine to reduce muscle loss (Muscle loss can cause increased fatigue).e) Balanced diet and daily requirements of vitamins supplementations f) Relaxation and stress management were added with avoiding stressful situations if possible.g) Eating small frequent meals, even when not hungry and healthy snacks throughoutthe day. Taking a 5-10 minute walk before meals to increase appetite and decrease nausea.

Liver function tests and CBC, are repeated after 2 weeks, one month, 3 months, 6 months and at end of treatment. Viral RNA was quantified before treatment, 12 weeks, 24 weeks and at end of treatment (48 weeks) and after 6 months of end of treatment (to detect sustained virologic response).

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Patients were grouped in a retrograde manner according treatment complications and response into four categories:Category I: (12 patients) with sustained response to therapy for 6 months after the end of treatment Category II: (8 patients) not responding to treatment with persistent viremia at 12 weeks of treatmentCategory III: (4 patients) showing relapse of viremia after 6 months of end of treatmentCategory IV: (5 patients) prematurely withdrawn from the study due to severe adverse reactions, due to accidental events or lost follow up.

Statistical AnalysisResults are expressed as absolute values and mean ± SD. Statistical analysis of the data was carried

out using the ANOVA test. For correlation studies, the Pearson correlation coefficient was used. A p -value of < 0.05 was considered significant. Statistical analysis was performed using the SPSS 12 for window statistical Package.

Results:

This study included 29 patients. They were 19 males and 10 females. All had liver cirrhosis of Child’s B grade. One male patient died from brain stem hemorrhage due to care accident after 8 weeks of treatment. Four patients were withdrawn due to severe side effects of therapy within first 2 months. One (a female) was withdrawn due to severe thrombocytopenia. Another one (male) was due to severe neutropenia and recurrent chest infection. The other two (who are females) were due to severe autoimmune manifestations, in the form of severe rheumatoid factor positive polyarthritis in one and thyrotxicosis in the other. Treatment was continued in other all patients for the recommended period of time (24 patients). After 12 weeks (3 months), treatment was stopped in 8 patients due to persistent viremia.

The mean age of the patients was 49.92 ± 5.67 and no significant differences in the mean ages between different response categories. The treatment was tolerated by most patients despite frequent complaints of flue-like symptoms (such as myalgia, fever, headache, giddiness, malaise, anorexia, hypersomnia), mild hair loss in 10 patients, mild degrees of irritability and depression in 9 patients (feelings of deep and constant sadness, hopelessness, crying, changes in mood, loss of interest in things, trouble concentrating), skin rash and itching in 6 patients, mild thyroiditis in 2 patients (both are females) without clinical hypo-,hyperthyroidism and development of diabetes mellitus in 2 cases (tables 3 & 4).

Ascites was found before treatment (at any time during follow up) in 18/29 (62.4 %) patients, but was controlled in all of them before enrollment. However, some cases, reappear during treatment but were all controlled by balanced diet with sufficient protein intake, diuretics and salt restriction. In all, diuretics can be withdrawn again after control of ascites (tables 3 & 4). There was history of small (<3 cm) HCC in one patient proved by liver biopsy and alpha fetoprotein and was treated successfully by radiofrequency ablation 6 months before enrollment in the study.

History of hepatic encephalopathy of mild grades; I-II, (in the form of personalities changes, sleep rhythm disturbances, emotional and behavioral changes, some drowsiness, and flapping tremors); were detected during pretreatment period in 16/29 (55.2 %). These manifestations were all transient for few days and were responding to simple measures of mild protein restriction and disaccharides. Similar attacks reappeared during treatment in 4 cases with similar response to treatment. Mild attacks also developed in 2 new cases including one case of non-variceal (from congestive gastropathy) upper gastrointestinal tract bleeding which was mild and responds to conservative treatment

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No cases of hepatocellular carcinoma have been developed in patients during the period of treatment and the 6 months of follow up period (tables 3 & 4).

Viral response to therapy after 12 weeks was evaluated as disappearance or a two log reduction of

the virus. In such cases, therapy is continued for a total of 48 weeks. This was observed in 16 cases. In 8 cases, the virus titer was not reduced to such extent. Therefore therapy was stopped in these 8 patients and considered not responding to therapy. Evaluation of viral response was performed after 6 months of end of treatment. Sustained response was observed in 12 cases, while relapse was detected in 4 cases. The end of treatment response was observed in 66.67% of cases who were able to continue medicines for 12 weeks, while sustained response was observed in 50% of such cases (protocol treatment patients) and in 41.38 % of intention to treat patients. The only predictive response in these cases was the original viral load which was significantly less in sustained response cases in comparison to the non-responsive and relapsing cases.

The biochemical response at end of treatment (as defined by normalization of ALT) was observed in patients responding to therapy including relapsing patients (with very minimal elevation, 2-5 units above normal, still detected in 2 patients in each group). In relapsing patients, elevation of liver enzymes recurred in all cases after 6 months after being normalized during the whole course of treatment.

There were mild but significant reduction in the three blood elements; which is more pronounced in haemoglobin level and least pronounced in platelet count; after treatment in all patients. However, except for the female patient withdrawn from treatment due to thrombocytopenia, none of all other patients reached a level to stop or reduce the doses of any of both drugs.

The liver span in the midline (left lobe) was found to be significantly longer in patients with sustained response than those not responding to treatment (table2). It was found also to be negatively correlated with congestive gastropathy, oesophageal varices, short axis of spleen, presence of ascites and encephalopathy. Liver span in mid-clavicular line was significantly increased and long axis of spleen was significantly decreased after treatment in patients showing sustained response. Ascites was significantly less in patients showing sustained response than those not responding to therapy.

Reduced Glutathione was found to be significantly reduced after treatment only in those with sustained response (P = 0.002) and in all patients taken together (P < 0.001)( table 17). There is significant reduction in the HAI score (histological activity) after treatment in sustained response category and total patients (P =0.001) but not in other categories or in the fibrosis grade (P >0.05) (table18).

Discussion

In all published trials the greater the degree of hepatic fibrosis the lower the response to antiviral therapy. When standard IFN monotherapy was used, there was a negligible response seen in patients with cirrhosis (Schalm et al., 1999), but upon the introduction of the long acting PEG-IFN, a marked improvement was observed, such that 30% of patients with bridging fibrosis or cirrhosis achieved SVR with PEG IFN alpha 2a monotherapy alone (Heathcote et al., 2000)). Combination of ribavirin with PEG-IFN has improved the chance of SVR to just over 40% (Manns et al, 2001 and Fried et al., 2002). However, this figure still remains less than may be achieved in individuals without background cirrhosis (Wright TL, 2002 and Mauss et al, 2004). The results from two recent studies supported treatment of HCV infection in the setting of decompensated cirrhosis if patients are selected carefully (Fontana et al., 2004 and Lim and Imperial, 2005).

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Most of the previous studies included patients with genotypes 1, 2 & 3. Few studies were performed including patients with genotype 4 which is predominant in Egypt. It constitutes about 91- 94 % of cases of HCV ( Ray et al., 2000 and El-zayadi et. al., 1999).

Treatment trials in patients with genotype 4 passed in three stages. The first stage was in the early era of the use of standard interferon monotherapy. Two studies in France demonstrated very low sustained response rate of 10-11% in comparison to 35% in genotype 3 (Remy et al., 1998 and Zylberberg et al., 2000). Then, the addition of ribavirin to interferon has slightly improved the sustained response rate to the range of 5-42% with the average response around 20% (El-faleh et al., 1998 and 2000; El-Zayadi et al., 1999 and Sheha and Salem 2002). Lastly, the introduction of the long acting pegylated interferon in preliminary studies, has placed genotype 4 midway between type 1 on one side and types 2 & 3 on the other side as regards the sustained response rate to new combination therapy. In these studies, the sustained response rate ranged between 40 to 69% vs. 16 to 39 % for the standard combination therapy using usual interferon (Diago et al., 2002; Shobokshi et al., 2002 and 2003; Hasan et al., 2003; Thakeb et al., 2003; and Esmat et al., 2003). In all of these studies, patients with as early as possible active disease with mild fibrosis were selected to avoid side effects and improve the sustained response rate as has been concluded from the previous experiences with usual interferon. No studies until now have included patients with advanced fibrosis or cirrhosis.

The improvement in liver histology and the reduced rate of complications including hepatocellular carcinoma in old studies of patients with sustained response and to a lesser extent in partial responders or even in non-responders to the combination therapy (Lau et al., 1998; Shiratori et al., 2000; Heathcote, 2003 and Everson et al., 2004), might push as to make such new therapy with pegylated interferon available to as much of the at-risk population as possible.

In this study, advanced cases of liver cirrhosis were selected. Twenty nine patient of Child-Pugh grade B underwent treatment with long acting pegylated interferon and ribavirin. Unfortunately, five cases had been withdrawn due to side effects or accidental death. The other 24 cases continued under the trial for the first 12 weeks when re-evaluation of viral response was done. They were tolerant to the therapy with the side effects neither more nor severer than usual particularly if usual precautions were taken to manage such effects. Reappearance or development of new ascites, encephalopathy, or bleeding occurred in an expected rate; even less; and were easily managed and controlled. Also, hepatocellular carcinoma didn’t develop in any of the patients during the period of follow up despite being advanced. This might add another evidence of the protective effect of therapy against HCC in patients with sustained response and even relapsing or partial responders if given in late advanced cases.

The tolerability to combination therapy in these advanced patients might allow us to add these cases to our treatment protocols of HCV and give good news to some patients who feel hopeless about their cure.

Secondly, the mean age of this group of patients was higher than in previous studies. This again will open the way for somewhat older ages to take their chances of treatment whenever no general medical illness or contraindication to therapy exists.

Despite the encouraging observations in this study, it was not a controlled study, the number of patients is somewhat small and liver biopsy was not obtained before and after treatment in most cases. Liver biopsy was not feasible and might be serious in these advanced patients. Our study opinion, is that biopsies are not essential and it was not expected to have significant histological changes within

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the treatment period in such advanced cases. Also it is not essential neither for diagnosis nor staging of patients with clear clinical, biochemical, ultrasonographic and endoscopic manifestations of cirrhosis in addition to the virological diagnosis.

The concept of the three month trial for viral response was applied in this study and found reasonable. Non-responding cases can be withdrawn to avoid the cost and side effects of medicines. Those who didn’t respond (8 patients) were similar to those responding in all parameters except the pretreatment viral load. Thus, high viral load was found to be the only predicting factor for failure of treatment in such patients. This is logic and accepted because the other known predicting factors are not working in this group of patients such as age (mostly old), duration of illness (probably long in all), degree of fibrosis (marked in all cases, mostly cirrhotic).

Viral response to therapy after 12 weeks was observed in 16 cases in which therapy is continued for a total of 48 weeks. It was not detected in 8 cases in which therapy was stopped and considered not responding to therapy. The evaluation of patients responding to treatment 6 month later showed sustained response in 12 cases, while relapse was detected in 4 cases. At the end of treatment response was observed in 66.67% of cases who were able to continue medicines for 12 weeks, while sustained response was observed in 50% of such cases (protocol treatment patients) and in 41.38 % of intention to treat patients. These findings are similar to findings observed in compensated cirrhosis in which the sustained response rate ranged from 26% (low dose ribavirin: 800 mg/day) to 37% (standard dose ribavirin: 1000-1200 mg/day) in genotype 1 and from 69% to 75% in genotypes 2/3 with overall response rate of 36 to 45% (Marcellin P et al., 2004).

Virological response was associated with biochemical response in all patients even in relapsing patients in this study. This means that the biochemical response follows virological response even if transient. Therefore, these patients get benefit from treatment whatsoever and it was assumed that even those not responding at week 12 could be given maintenance doses for longer time to get such benefits.

The presence of significantly larger left lobe of liver (span in midline) in patients with sustained response may indicate that higher liver volume and regeneration is a good sign in these patients. This also can be understood from the increased liver span in mid-calvicular line and decreased size of spleen after treatment in the same category of patients.

The recent AASLD Practice Guideline on Diagnosis, Management, and Treatment of Hepatitis C (2005) dealt with the topic of antiviral therapy in patients with decompensated cirrhosis. In their recommendations, Strader et al. suggest that antiviral therapy might be initiated at low dose in hepatitis C virus (HCV) infected patients with mild degrees of hepatic compromise, preferably in patients who have been accepted as candidates for liver transplantation. Studies are ongoing using standard IFN daily (3MU/day) and ribavirin (800mg/day) when the expected time for liver transplantation was around 4 months. The rational is to produce virological response by the week 12 when the patients approach transplantation aiming at reducing the infection of the graft. After a median treatment duration of 12 weeks, 9 (30%) of 30 patients achieved on-treatment virological response, which persisted in 6 (20%) after transplantation (Forns et al., 2004).

The effect of therapy on the manifestations of portal hypertension (PH) in our patients was subtle and not significant but because this is not a controlled study, we can’t evaluate such effect properly. However, no remarkable complications aroused during treatment and follow up period. Studies are ongoing to explore the effect of maintenance therapy with pegylated interferon on portal hypertension and its complication (COPILOT Study). The initial 2 years of follow up demonstrated that the survival of these patients with PH was superior compared to the colchicine arm. IFN-treated subjects had a

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lower incidence of variceal bleeding. In addition, the development of PH at 2 years of follow-up was lower in the group of IFN-treated individuals (12/95, 12%) than in the colchicine group (24/92, 28%) (p= 0.025). In a subgroup of patients who underwent measurements of hepatic venous pressure gradient (HVPG), a reduction of 41% in their HVPG values was observed after 24 weeks of therapy with pegylated IFN-a-2b (Curry M. et al., 2005). If this is confirmed in more studies and longer follow up, maintenance therapy with small dose of pegylated IFN 0.5 μg/kg/week may be advised in this critical group of patients. Also, if patients are selected carefully, treatment of HCV infection in the setting of decompensated cirrhosis is possible (Lim and Imperial 2005 and Annicchiarico et al., 2005)). This suggestion is now becoming a reality as has been observed in this study.

It was found that hepatitis C infection causes a state of chronic oxidative stress due to production of reactive oxygen species. This may contribute to fibrosis and carcinogenesis in the liver. In this study, reduced glutathione was estimated in liver biopsy in those for whom liver biopsy was done. Significant reduction in the reduced Glutathione after treatment was found only in those with sustained response (P = 0.002) and in all patients taken together (P < 0.001) but not in other categories because of the lower number of cases that did not reach statistical significance. The reduction of reduced glutathione in all patients after treatment can explain some of the beneficial effect of antiviral treatment particularly IFN despite absence of virological response in some patients. This reduction is due to reduction in the oxidative stress in the liver after treatment. Numerous studies have shown that oxidative stress is present in chronic hepatitis C to a greater degree than in other inflammatory liver diseases (Barbaro et al., 1999 and Valgimigli et al., 2002) and a prospective study showed improvement in liver injury in chronic hepatitis C with antioxidant treatment (Houglum et al., 1997). It was found that HCV core protein expression caused an increase in mitochondrial ROS production, an oxidation of the mitochondrial glutathione pool, inhibition of electron transport, and an increase in ROS production by mitochondrial electron transport complex (Masaaki et al. 2005). Low glutathione levels are found in people with cataracts, HIV infection, chronic HCV, and cirrhosis. People with cirrhosis of the liver may have difficulty in synthesising glutathione. This may explain why glutathione levels are 30% below normal in people with cirrhosis (white et al., 1994 and Burgunder and Lauterberg 1987).

Levels of the most important form of glutathione (reduced glutathione) are significantly below normal in people who have alcoholic hepatitis or hepatitis C. Studies have shown that people with hepatitis C who had the lowest glutathione levels also had the highest viral loads and more evidence of liver damage. Glutathione has been shown to have direct antiviral effects (Loguercio et al., 1999 and Barbaro et al., 1996). Although no research has been done with the hepatitis C virus (HCV), glutathione has been shown to inhibit HIV in the test tube. Although this research does not prove that raising glutathione levels leads to lower viral loads, it does indicate that optimal levels of glutathione may be an important factor in controlling HCV infection (Staal et al., 1992).

Also significant reduction in the HAI score (histological activity) after treatment was found in in sustained response category and total patients but was insignificant in those with non-response or in the fibrosis grade. However, there was some reduction in the fibrosis score and HAI activity in all these patients whether showing sustained response or not. However, the small number of cases for whom biopsy was performed did not allow having any conclusion regarding the effect of treatment on the liver pathology as shown by histopathological examination.

Conclusion:As patients with cirrhosis due to hepatitis C have a high chance of dying from progressive liver

disease they have much to gain from successful antiviral therapy. The highest sustained virological response in patients with cirrhosis has been achieved using pegylated interferon alfa plus ribavirin.

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Patients who do not achieve sustained virologic response can still show clinical, biochemical and probably histological improvement with lesser chance to develop HCC. They also had less oxidative stress which can explain many beneficial effects apart from antiviral response. Thus, it is concluded from this study that patients with advanced cirrhosis but with no contraindication to combination therapy can be managed in the same way as earlier cases with pegylated IFN and ribavirin. Longer controlled studies and follow up may direct the light to the long term benefits and survival in such patients.

Table 1: Number, sex, age and grade of liver disease in all patient categories.

Parameter Total patients Patients with Sustained R

Patients not responding

Patients with relapse

Patients withdrawn early due side effects

Numbers % of ITT % of PT

2924/29 (82.76%)24/24 (100%)

1212/29 (41.38%) 12/24 (50.00%)

88/29 (27.59%)8/24 (33.33%)

44/29 (13.79%)4/24 (16.67%)

55/29(17.24%)5/24 (20.83%)

Males 19 10 5 2 2Females 10 2 3 2 3Mean age 50.17 ± 5.51 49.67± 6.59 49.88 ± 5.11 50.75 ± 4.99 51.40 ± 5.03Grade of liver cirrh.

B B B B B

ITT: intention to treat. PT: Protocol treatment.No differences in mean of age and grade of liver disease between all category groups

Table 2: Ultrasonographic findings of liver, PV and collaterals in different patient categories (means) before and after treatment.

10.33 .29 9.14 .36 9.80 .63 10.40 .30 9.94 .20

5.88 .22 4.84 .12 4.83 .19 5.30 .24 5.34 .14

14.00 .30 13.69 .34 13.63 .38 14.00 .63 13.86 .19

1.75 .25 2.25 .25 2.25 .25 1.80 .37 1.97 .14

10.55 .31 9.29 .29 9.68 .60 10.34 .33 10.04 .20

5.78 .18 4.91 .15 5.25 .13 5.36 .25 5.40 .11

13.83 .23 13.25 .37 13.50 .29 14.00 .45 13.66 .16

1.75 .22 2.63 .18 2.50 .29 2.00 .45 2.14 .15

liver /MCL/before ttt

liver/ML/before ttt

PV diam/before ttt

collaterals/before ttt

liver/MCL/after ttt

liver/ML/after ttt

PV/after ttt

collaterals/after ttt

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

Mean SE

total patients

response categories

*The span of the liver in midline is significantly longer in sustained response category than in none response category (p =0.005)*The span of the liver in MCL is significantly increased after treatment in responding patients only (P=0.05) not in other groups or total patient evaluation.

Table 3: Ultrasonographic findings of spleen and splenic vein in different patient categories (means) before and after treatment.

10

16.15 .43 17.74 .73 17.08 .55 17.26 .71 16.91 .32

5.79 .28 7.20 .27 7.00 .29 6.84 .14 6.53 .18

10.42 .47 11.63 .71 10.50 .65 10.50 .71 10.78 .31

15.43 .39 17.27 .53 15.98 .41 15.60 .61 16.04 .28

6.05 .25 7.18 .18 6.98 .23 6.78 .12 6.61 .15

10.67 .47 11.50 .63 11.25 .48 10.40 .68 10.93 .29

axis of spleen/before ttt

width of spleen/before ttt

SV/before ttt

spleen/longaxis/after

spleen/shortaxis/after

SV/after

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

Mean SE

total patients

response categories

*The long axis of spleen is significantly decreased after treatment in sustained responders (P=0.03) and total patient (P=0.0001) evaluation but not in other patient categories. *Also the short axis is decreased significantly after treatment in sustained responders only (P=0.01).

Table 4: Clinical data (OV, gastropathy, collaterals, ascites, and HE) of patient categories

3 3

3 2 1 2 8

5 5 2 3 15

1 1 1 3

2 2

7 3 2 4 16

3 5 2 1 11

6 1 2 9

3 4 3 2 12

3 3 1 1 8

6 1 2 2 11

6 7 2 3 18

7 2 2 2 13

5 6 2 3 16

none

grade I

grade II

grade III

OV

none

mild

severe

cong. gastropathy

none

one site

two sites

collaterals

absent

controlled

ascites grade

none

mild

enceph grade

sustainedresponse non-response relapse

withdrawndue to side

effects total patients

response categories

11

*There are more significant ascites in none-response cases than SR cases (P=0.002)**Two-tailed partial correlation according response category classification showed significant correlation between each of:

1- Grade of oesophageal varices and each of age (P< 0.05), grade of PH gastropathy (P=0.002), long axis (P=0.049) and short axis of spleen (P=0.002) and negatively with span of liver in midline (P=0.046)

2- Grade of gastropathy and short axis of spleen (P=0.04) and negatively with liver span in midline (P=0.033)

3- Portal vein diameter and grade of congestive gastropathy (P=0.002)4- Length of short axis of spleen and OV, gastropathy, negatively with liver span in midline

(P=0.004), absence of ascites (P=0.004), absence of encephalopathy (P=0.034) and collaterals (P=0.002).

Table 5: complications reappearing or newly developed in all patients during treatment.Parameter Sustained

Response Patients not responding

Relapsing Patients

withdrawn early due side effects

Total pts after ttt

Total pts before ttt

Bleeding Upper GIT: Others :

02

1 (mild ,non-variceal)

101

03

17

15

Oesoph. Varices None; Grade I Grade II Grade III:

4341

2420

0130

0112

69103

38153

Cong. Gastrop None Mild Severe

372

026

031

013

31312

21611

Encephalopathy Recurrence New

01

20

10

10

5(17.24%)41

16(55.17%)

HCC 0 0 1 0 0 1

There is one small HCC in one patients of relapse category treated successfully by radiofrequency

Table 6: complications appearing in all patients during treatment.Parameter Patients with

Sustained R Patients not responding

Patients with relapse

withdrawn early due side effects

Total patients

Flue-like symptoms 12 8 4 5 29 (100%)Ascites: Reappearance New

11

31

10

10

(27.59%)62

Depression (mild) 3 3 1 2 9(31.03%)

Hair loss 5 2 2 1 10(34.48%)

Thyroiditis (clinical): Thyroid antibodies

13

11

01

1:(with hyperthyroidism)

2

3 (10.34%)7(24.14%)

Development of DM 1 0 1 0 2(6.9%)

Skin rash/itching 2 1 2 1 6(20.7 %)

12

Table 7: ALT levels before, during and after treatment in all patient categories (mean and standard error)

93.58 6.94 90.25 9.19 127.50 12 114.40 12.4 100.93 5.10

56.17 4.13 98.25 6.14 61.00 3.5 61.60 5.12 69.38 4.21

44.67 3.12 90.75 5.11 45.75 2.7 52.60 7.35 58.90 4.35

36.50 1.43 84.88 4.12 39.00 1.6 . . 53.04 4.93

36.83 1.27 . . 38.00 1.8 . . 37.13 1.03

34.75 1.21 . . 70.25 6.1 . . 43.63 4.29

ALT/before treatment (ttt)

ALT/after one month of ttt

ALT after 3 months of ttt

ALT/after 6 month of ttt

ALT/ at end of ttt

ALT/ 6 month after end of ttt

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

Mean SE

total patients

response categories

*ALT was significantly lowered in sustained R cases after one month of treatment than in non-response cases.

Table 8: AST levels (U/dL) before, during and after treatment in all patient categories (mean and standard error)

113.75 7.55 127.75 6.92 149.75 12 130.40 6.28 125.45 4.57

67.92 4.52 72.00 4.71 72.25 4.87 59.40 5.31 68.17 2.57

52.58 3.85 71.25 4.86 57.50 1.32 61.60 9.42 59.97 2.89

55.00 3.98 71.00 4.22 53.75 3.79 . . 60.13 2.91

54.67 4.02 . . 50.00 1.83 . . 53.50 3.05

51.67 2.55 . . 88.00 7.63 . . 572.06 513

AST/before ttt

AST/after one month of ttt

AST/ after 3 months of ttt

AST/ after 6 months of ttt

AST/at end of ttt

AST/after 6 months of end of ttt

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

Mean SE

total patientsresponse categories

Figure 1: Biochemical response in all patients.

0

20

40

60

80

100

120

140

1 2 3 4 5 6treatment months

AL

T (

U/d

l)

SR NR Relapse Intolerant

13

Figure 2: Biochemical response in all patients (AST)

0

20

40

60

80

100

120

140

160

before 1m 3m 6m 12m 6m later

Month of treatment

AS

TSR NR relapse intolerant

Table 9: Bilirubin levels(mg/dL) before, during and after treatment in all patient categories (mean and standard error)

2.68 .96 3.75 .93 3.48 .77 3.08 .48 3.16 .94

4.08 1.04 5.13 1.16 4.60 1.01 3.98 .30 4.42 1.05

2.28 .73 4.99 .75 4.80 .57 3.90 .37 3.65 1.39

1.70 .47 4.16 .60 2.53 .43 . . 2.66 1.23

1.73 .36 . . 1.73 .22 . . 1.73 .32

1.69 .33 . . 2.85 .51 . . 1.98 .63

BIL/before treatment (ttt)

BIL/after one month of ttt

BIL/after 3 months of ttt

BIL/after 6 month of ttt

BIL/ at end of ttt

BIL/ 6 month after end of ttt

Mean SD

sustainedresponse

Mean SD

non-response

Mean SD

relapse

Mean SD

withdrawndue to side

effects

Mean SD

total patients

Response categories

*Bilirubin before treatment is significantly less in SR cases than relapse cases (P= 0.024)

Table 10: Albumin levels(g/dL) before, during and after treatment in all patient categories (mean and standard error)

14

2.98 .52 2.66 .22 2.78 .28 3.02 .38 2.87 .41

3.23 .58 2.95 .36 2.85 .45 3.08 .19 3.08 .46

3.42 .46 2.96 .14 2.88 .43 3.10 .20 3.16 .41

3.57 .36 2.93 .21 3.25 .44 . . 3.30 .43

3.68 .53 . . 3.20 .50 . . 3.56 .55

3.63 .48 . . 3.18 .40 . . 3.51 .50

Albumin/before treatment (ttt)

Alb/after one month of ttt

Alb/after 3 months of ttt

Alb/after 6 month of ttt

Alb/ at end of ttt

Alb/ 6 month after end of ttt

Mean SD

sustainedresponse

Mean SD

non-response

Mean SD

relapse

Mean SD

withdrawn dueto side effects

Mean SD

total patients

response categories

Table 11: Globulins levels(g/dL) before, during and after treatment in all patient categories (mean and standard error)

5.36 .55 5.26 .27 5.25 .31 4.92 .13 5.24 .42

5.03 .46 5.24 .40 4.90 .41 5.08 .40 5.08 .42

4.38 .69 5.10 .28 4.88 .28 4.78 1.04 4.72 .68

4.59 .56 4.95 .31 4.55 .48 . . 4.70 .49

4.56 .83 . . 4.45 .33 . . 4.53 .72

4.52 .57 . . 4.78 .48 . . 4.59 .54

Globulin before treatment (ttt)

Glob/after one month of ttt

Glob/after 3 months of ttt

Glob/ after 6 months of ttt

glob/ at end of ttt

glob/ 6 month after end of ttt

Mean SD

sustainedresponse

Mean SD

non-response

Mean SD

relapse

Mean SD

withdrawndue to side

effects

Mean SD

total patients

response categories

*From the third month of treatment improvement of all parameters of liver function was significantly better in SR cases than non-response cases (P< 0.01).

Table 12: PT prolongation(seconds) before, during and after treatment in all patient (mean & SE).

3.08 .79 3.49 .44 3.28 .51 2.84 .32 3.18 .62

2.64 .64 4.10 .52 3.20 .37 2.92 .31 3.17 .80

2.21 .66 4.13 .43 3.03 .17 2.40 .38 2.88 .96

1.83 .46 4.04 .45 1.68 .24 . . 2.54 1.16

1.70 .28 . . 2.08 .22 . . 1.79 .31

1.44 .39 . . 2.13 .30 . . 1.61 .47

PT/before treatment (ttt)

PT/after one month of ttt

PT/after 3 months of ttt

PT/after 6 month of ttt

PT/ at end of ttt

PT/ 6 month after end of ttt

Mean SD

sustainedresponse

Mean SD

non-response

Mean SD

relapse

Mean SD

withdrawn dueto side effects

Mean SD

total patients

response categories

Table 13: Haemoglobin levels (g/dl) before, during and after treatment

15

14.22 .25 14.23 .26 14.40 .50 14.16 .34

12.74 .34 12.79 .22 12.85 .29 13.36 .28

12.76 .24 12.78 .25 13.38 .40 13.02 .19

12.75 .25 12.85 .20 13.38 .27 12.90 .23

HB before ttt

HB, 2-4weeks

HB, 24 weeks

HB, after ttt

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

response categories

Figure 3: Haemoglobin levels (g/dl) before, during and after treatment

Hb levels before and during treatment

0

2

4

6

8

10

12

14

16

18

1 2 3 4time

Hb

level

(g/d

l)

Sr NR Relapse Intolerant

Table 14: Platelet count (thousands/mm3) before, during and after treatment

130.42 6.51 119.75 6.96 129.00 16.1 108.40 7.09

131.58 5.23 113.88 7.06 130.75 13.9 105.20 6.34

124.92 4.83 111.38 5.65 125.25 13.7 92.60 11.74

130.17 4.89 112.00 5.71 108.50 11.1 89.40 9.45

Platelets,before ttt

Platelet, 2-4 weeks

Platelets,24 weeks

Platelets,after ttt

Mean SE

sustainedresponse

Mean SE

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

response categories

Table 15: Leukocytic count (thousands/mm3) before, during and after treatment

16

5.63 .36 5.04 .38 5.10 .24 6.16 .49

5.10 .25 5.26 .19 4.70 .55 4.86 .35

3.99 .16 3.98 .25 3.75 .14 4.18 .24

3.93 .15 3.76 .18 3.68 .11 4.06 .19

WBCs, before ttt

WBCs, 2-4 weeks

WBCs, 24 weeks

WBCs, after ttt

Mean SE

sustainedresponse

Mean Se

non-response

Mean SE

relapse

Mean SE

withdrawn dueto side effects

response categories

*There are mild but significant decrease in the three blood elements; which is more pronounced in Hb level and least pronounced in platelet count; after treatment in all patients.

Table 16: Viral levels(copies/ml) before, during and after treatment in all patient categories (mean and standard error)

528333.33 462435.91 2416875 1024098.69 2107500 932313.43 1543621 1120856.57

20000.00 27879.61 1508750 704707.39 82500.00 117862.91 526666.67 810584.42

6666.67 16143.30 1975625 751643.14 12500.00 25000.00 663958.33 1034308.19

.00 .00 . . 162500.0 325000.00 40625.00 162500.00

.00 .00 . . 545000.0 676880.10 136250.00 388636.51

viremia/before ttt

viremia/3 mon

viremia/6mon

viemia /end

viremia/6m.later

Mean SD

sustained response

Mean SD

non-response

Mean SD

relapse

Mean SD

total patients

response categories

*There is significant correlation between levels of viremia before treatment and levels at end of treatment and 6 months later on in all patients.

Table 17: Reduced Glutathione concentration in liver biopsy (nmol/mg protein of liver tissue).

6 1.78 .24

6 1.38 .32

4 2.03 .18

4 2.00 .17

5 1.83 .26

5 . .

2 1.88 .11

2 . .

17 1.87 .23

17 1.63 .41

GTH before Treatment

GTH after treatment

Sustained response

GTH before Treatment

GTH after treatment

Non-response

GTH before Treatment

GTH after treatment

Relapse

GTH before Treatment

GTH after treatment

Withdrwan due to sideeffects

Group

GTH before Treatment

GTH after treatment

Group Total

Count Mean Std Deviation

count: number of patients for whom liver biopsy was done in each category.It was found that there is significant reduction in the reduced Glutathione after treatment only in those with sustained response (P = 0.002) and in all patients taken together (P < 0.001)

Table 18: Results of Liver biopsy in patients without contraindications.

17

14.5000 12.3333 3.3333 3.3333

1.04881 1.03280 .51640 .51640

14.7500 14.0000 3.5000 3.5000

1.50000 1.82574 .57735 .57735

15.4000 3.6000

1.34164 .54772

14.5000 3.5000

.70711 .70711

14.8235 13.0000 3.4706 3.4000

1.18508 1.56347 .51450 .51640

Mean

Std. Deviation

Mean

Std. Deviation

Mean

Std. Deviation

Mean

Std. Deviation

Mean

Std. Deviation

GroupSustained response

Non-response

Relapse

Withdrwan due toside effects

Total

Histolog.activity before

treatment

Histolog.activity after

treatment

Grade offibrosisbefore

treatment

Grade offibrosis after

treatment

There is significant reduction in the HAI score (histological activity) after treatment in sustained response category and total patients (P =0.001) but not in other categories or in the fibrosis grade (P >0.05)

Figure 4: Viral load in responding patients

RS ni tnemtaert gnirud aimeriv

0

000002

000004

000006

000008

0000001

0000021

0000041

0000061

1 2 3 4

tnemtaert fo shtnoM

reti

t la

riv

Figure 5: viral levels in non-responding patients.

18

viral loads in nonresponding patients

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

5000000

1 2 3

time of measurement

vir

al

loa

d

Figure 6: Viral load in relapsing patients

viremia during treatment in relapsing patients

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

1 2 3 4 5

Months of treatment

vir

al

tite

r

Figure 7: Viral load in all 24 patients continuing treatment

19

viremia in all patients

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

5000000

1 2 3 4 5

time of treatment

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49. Masaaki Korenaga, Ting Wang, Yanchun Li, Lori A. Showalter, Tehsheng Chan, Jiaren Sun, and Steven A. Weinman (2005): Hepatitis C Virus Core Protein Inhibits Mitochondrial Electron Transport and Increases Reactive Oxygen Species (ROS) Production. J. Biol. Chem., Vol. 280, Issue 45, 37481-37488

50. Anderson, M. E. (1989) in Glutathione: Chemical, Biochemical and Medical Aspects. Part A (Dolphin, D., Poulson, R., and Avramovic, O., eds) pp. 339–365, John Wiley and Sons, New York

51. Barbaro, G., Di Lorenzo, G., Asti, A., Ribersani, M., Belloni, G., Grisorio, B., Filice, G., and Barbarini, G. (1999): Am. J. Gastroenterol. 94, 2198–2205

52. Valgimigli, M., Valgimigli, L., Trere, D., Gaiani, S., Pedulli, G. F., Gramantieri, L., and Bolondi, L. (2002) Free Radic. Res. 36, 939–948

53. Houglum, K., Venkataramani, A., Lyche, K., and Chojkier, M. (1997) Gastroenterology 113, 1069–1073

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blood levels in patients with and without chronic liver disease. Alcohol Clin Exp Res. 1999;23(11):1780-1784.

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نتيجة المتقدم الكبدى بالتليف المصابين المصريين المرضى عالجاإلصابة

الوراثى بالفيروس النوع ج باستخدام ٤الكبدى وذلكالريبافيرين مع المفعول طويل االنترفيرون

. معهد الهضمى والجهاز والكبد األمراضالمتوطنة قسم شندىشريف محمد شندىبلهارسلألبحاث تيودور

المصريين المرضى عالج نتائج عن األن حتى كافية معلومات يوجد ال أنه حيثالوراثى النوع ج الكبدى الفيروس عن الناتج المتقدم الكبدى بالتليف المصابين

طويل االنترفيرون باستخدام العالج تقيم هو البحث من الهدف كان ولذلك الرابع . علي البحث تم وقد المرضى هؤالء فى معا والريبافيرين مريض ۲٩المفعول

النوع من مصنفين " بجميعهم لديهم " موانع يوجد وال بوف اتشيلد تقسيم حسب. . بالفحوصالالزمة العالج تحت متابعتهم تم وقد األدوية هذه الستخدام

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شهور ثالث قبل البحث من خرجوا مرضى خمسة هناك أن البحث نتيجة وكانتالبيضاء الدم كرات و الدموية الصفائح نقص مثل شديدة مضاعفات لظهور

( مريض ( وفاة و الدرقية الغدة وظائف وزيادة الروماتيد موجب المفاصل والتهابات . ثالث حتى بالعالج استمروا فقد المرضى باقى أما سيارة حادث أثر دماغى بنزيف

وعدم للعالج استجابتهم لعدم وذلك مرضى ثمانية فى العالج أوقف حين شهورمستجيبي غير واعتبروا الدم فى الفيروس مستوى . نانخفاض عشر والستة للعالج

حتى استمر الذي للعالج مبدئيا استجابوا فقد الباقون واعتبروا ٤٨المرضى أسبوع . انتكاسة حدث العالج إيقاف من أشهر ستة بعد و نهايته عند للعالج مستاجبين

الفيروسفى فى 4بظهور التام الشفاء واستمر الذين 12مرضى و الباقين مريضو % ٨٣,٤١يمثلون المرضى جميع .%٥٠من بالعالج استمروا الذين المرضى من

الدم الفيروسفى مستوى هو التامة االستجابة على الدال الوحيد العامل وكان . استجابتهم استمرت الذين فى أقل كان حيث العالج قبل

كان وكذلك احصائية داللة ذو انخفاضا المختزل الجلوتاثيون تركيز انخفض وقدفقط الدائمة االستجابة ذي المرضى فى الكبد عينات فى النسيجى التحسن

المرضى باقى وليسفى

عندهم ليس والذين المتقدم التليف ذوي المرضى أن البحث هذا من يستنتجفى تستخدم والتى بنفساألدوية عالجهم الممكن من األدوية هذه الستخدام موانع

. تقريبا العالج وتحمل االستجابة بنفسدرجة المبكرة الحاالت

Abnormal methionine metabolism occurs in animals fed ethanol and in end-stage cirrhotic patients. Expected consequences of these abnormalities include reduced hepatic S-adenosylmethionine and glutathione (GSH) levels, impaired transmethylation, and reduced homocysteine catabolism, resulting in the often-observed hyperhomocystinemia in cirrhotic patients. decreased hepatic methionine, S-adenosylmethionine, cysteine, and GSH levels. It may be important to replenish these thiols in patients hospitalized with alcoholic hepatitis

Lee TD; Sadda MR; Mendler MH; Bottiglieri T; Kanel G; Mato JM; Lu SC (2004): Abnormal hepatic methionine and glutathione metabolism in patients with alcoholic hepatitis.Alcohol Clin Exp Res.; 28(1):173-81

Chronic HCV infection is associated with excess oxidative stress within the liver (6,7,8). HCV protein expression caused an increase in mitochondrial ROS production, an oxidation of the mitochondrial glutathione pool, inhibition of electron transport, and an increase in ROS production by mitochondrial electron transport complex

Masaaki Korenaga, Ting Wang Yanchun Li, Lori A. Showalter, Tehsheng Chan, Jiaren Sun and Steven A. Weinman (2005): Hepatitis C Virus Core Protein Inhibits Mitochondrial Electron Transport and Increases Reactive Oxygen Species (ROS) Production. J. Biol. Chem., Vol. 280, Issue 45, 37481-37488, November 11, 2005

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Hepatitis C virus (HCV) infection is associated with increased lipoperoxidation, which may lead to interference with mitochondrial function with possible depletion of mitochondrial DNA (mtDNA). An increased production of free radicals in patients with genotype 1b may influence the evolution of the liver disease by enhancement of the cytopathic effect of HCV.

6. Barbaro, G., Di Lorenzo, G., Asti, A., Ribersani, M., Belloni, G., Grisorio, B., Filice, G., and Barbarini, G. (1999): Hepatocellular mitochondrial alterations in patients with chronic hepatitis C: ultrastructural and biochemical findings .Am. J. Gastroenterol. 94, 2198–2205

7. Valgimigli, M., Valgimigli, L., Trere, D., Gaiani, S., Pedulli, G. F., Gramantieri, L., and Bolondi, L. (2002): Oxidative stress EPR measurement in human liver by radical-probe technique. Correlation with etiology, histology and cell proliferation. Free Radic. Res. 36, 939–948

Oxidative stress mediates activation and stimulates collagen production of cultured hepatic stellate (Ito) cells.

enhanced oxidative stress initiates a fibrogenesis cascade in the liver of patients with chronic hepatitis C.

8. Houglum, K., Venkataramani, A., Lyche, K., and Chojkier, M. (1997): A pilot study of the effects of d-alpha-tocopherol on hepatic stellate cell activation in chronic hepatitis C. Gastroenterology 113, 1069–1073

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