1. Francesco NEGRO

2. Steatosis and Chronic Hepatitis C: liaisons dangéreuses? Francesco Negro Unité de Viropathologie Centre Médical Universitaire Genève Paris, January 22, 2007 Paris, January 22, 2007

3. Prevalence of Steatosis in Chronic Hepatitis C Steatosis occurs in:  ~50% of chronic hepatitis C patients (overall considered) HOURIGAN et al, Hepatology 1999;29:1215 LEANDRO et al, Gastroenterology 2006;130:1636  ~40% of chronic hepatitis C patients without known factors of fatty liver (overweight, alcohol drinking, drugs, hyperlipidemia) RUBBIA-BRANDT et al, J Hepatol 2000;33:106  ~20% of chronic hepatitis B patients CZAJA et al, J Hepatol 1998;29:198 THOMOPOULOS et al, Eur J Gastroenterol Hepatol 2006;18:233

4.  Occurrence and severity of steatosis is associated with genotype 3 MIHM et al, 1997; RUBBIA-BRANDT et al, 2000; ADINOLFI et al, 2001 KUMAR 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

5. Severity of steatosis and HCV genotype The HCV-MAID study (n = 3,068) P = <0.001 LEANDRO et al, Gastroenterology 2006;130:1636-1642

6. Steatosis score and HCV RNA levels 70 immunocompetent chronic hepatitis C cases RUBBIA-BRANDT et al, J Hepatol 2000;33:106-115

7. 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

8. 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

9. HCV core protein transgenic mouse MTP intracytoplasmic TG storage STEATOSIS HCV core protein VLDL assembly impaired VLDL secretion TG Apo B PERLEMUTER et al, FASEB J 2002;16:185

10. Intrahepatic MTP mRNA levels are inversely correlated with steatosis scores MIRANDOLA et al, Gastroenterology 2006;130:1661-9 steatosis score Intrahepatic MTP mRNA levels P = 0.0017

11. 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

12. Insulin resistance causes liver steatosis BROWNING & HORTON, J Clin Invest 2004;114:147

13. Risk factors for steatosis in 44 non-3a, alcohol abstinent chronic hepatitis C patients MUZZI et al, J Hepatol 2005;42:41-46 30% 20% 18% 32%

14. 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?)

15. Steatosis as a factor of liver disease progression

16. Natural History of HCV Liver Disease ~70%2 – 30% / 20 yrs2 - 4% / yr Liver failure (2 – 5% / yr)

17. Factors associated with an accelerated fibrosis progression in chronic hepatitis C Age at infection Sex HIV Coinfection HBV Coinfection Immunosuppression Liver disease activity Overweight Alcohol abuse Steatosis Smoking Iron overload Insulin resistance

18. 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

19. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% no steatosissteatosisno steatosissteatosis no progressionprogressed 1progressed 2 or more type non-3type 3 Steatosis accelerates fibrosis progression in genotype 3 chronic hepatitis C WESTIN et al, J Hepatol 2002;37:837

20. The HCV MAID Study Predictors of fibrosis in 3,068 patients All pts. HCV genotypeBMI 1234<2525-30>30 n3068169456366914214811287300 Activity5.334.354.5211.14.116.494.90NS Male gender1.921.79NS 1.91 NS Steatosis1.661.72NS 1.61NS Age1.04 NS1.05NS1.021.051.08 DiabetesNS4.52NS Alcohol abuseNS 1.69NS LEANDRO et al, Gastroenterology 2006

21.  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, 2005 MUZZI et al, 2005; LEANDRO et al, 2006 Fibrogenesis in Chronic Hepatitis C: Steatosis or Insulin Resistance?

22. 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

23. Insulin resistance and activation of hepatic stellate cells Production of CTGF hyperglycemia hyperinsulinemia PARADIS et al, Hepatology 2001;34:738-744

24. 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 F0F1-F2F3-F4F

25. Omental macrophages are associated with liver necroinflammation CANCELLO et al, Diabetes 2006;55:1554-1561 Intrahepatic necroinflammation P<0.05

26. The Metabolic Syndrome EGIR 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)

27. Factors associated with an accelerated fibrosis progression in chronic hepatitis C Age at infection Sex HIV Coinfection HBV Coinfection Immunosuppression Liver disease activity Overweight Alcohol abuse Steatosis Smoking Iron overload Insulin resistance Metabolic syndrome

28. Steatosis as a factor of poor response to interferon- 

29. Steatosis at baseline and SVR POYNARD et al, Hepatology 2003;38:75-85 P=0.33 P<0.001 (n = 134)(n = 746)(n = 900)

30. Steatosis and SVR in HCV genotype 2 and 3 patients ZEUZEM et al, J Hepatol 2004;40:993-999 % SVR severity of steatosis

31. In HCV patients with virally-induced steatosis: high serum HCV RNA high steatosis score

32. Insulin resistance decreases SVR in chronic hepatitis C ROMERO-GOMEZ et al, Gastroenterology 2005;128:636-641

33. HCV genotype 1, intrahepatic SOCS-3 and response to IFN-  therapy WALSH et al, Gut 2006

34. 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

35. 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 degradation of IRS-1 by members of the SOCS family

36. binding to IRS-1 causes its proteasomal degradation interference with the insulin signaling binding to Janus kinase inhibits Tyr-phosphorylation of STAT1 interference with the IFN-  signaling  SOCS-n HCV

37. Steatosis and Chronic Hepatitis C: liaisons dangéreuses? Fibrosis progression Resistance to IFN-  Viral steatosis Unlikely Due to higher level of HCV replication Metabolic steatosis Yes, mediated by IR

38. Increasing insulin sensitivity in chronic hepatitis C patients Increase physical activity Reduce body weight Insulin sensitizers ?? –Metformin –Thiazolidindiones (pioglitazone, rosiglitazone…)

39. But the best solution is ……