Jpn. J. Infect. Dis., 60, 377-381, 2007 Original Article Hepatic Steatosis and Fibrosis in Chronic Hepatitis C in Taiwan Meng-Hsuan Hsieh1, Li-Po Lee2, Ming-Yen Hsieh2, Kun-Bow Tsai3, Jee-Fu Huang4, Nai-Jen Hou4, Shinn-Chern Chen2,5, Zu-Yau Lin2,5, Ming-Yuh Hsieh2,5, Liang-Yen Wang2,5, Chia-Yen Dai1,2,5,6*, Wan-Long Chuang2,5 and Ming-Lung Yu2,5 1Department of Occupational and Environmental Medicine, 3Department of Pathology, and 4Department of Internal Medicine, Kaohsiung Municipal HsiaoKang Hospital; 2Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital; and 5Faculty of Internal Medicine and 6Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (Received May 21, 2007. Accepted September 5, 2007) SUMMARY: Hepatitis C virus (HCV) infection has been associated with hepatic steatosis. However, the role of hepatic steatosis in the pathogenesis of HCV infection remains controversial. In our study, 425 consecutive HCV-viremic patients with biopsy-proven chronic hepatitis C (male, 264; mean age, 49.0 years) were enrolled. Scoring of hepatic steatosis was based on the method described by Kleiner and on histopathology performed using the Knodell and Scheuer systems. HCV RNA level and genotypes were determined at the time of biopsy. Hepatic steatosis was observed in 30.8% of patients, including 113 mild, 16 moderate, and 3 with severe hepatic steatosis. Patients with a body mass index (BMI) <23 kg/m2 had a significantly lower rate (18.9%) of hepatic steatosis (P < 0.001). Hepatic steatosis did not correlate with the hepatic necroinflammatory activity, but was related to hepatic fibrosis (P = 0.035). Hepatic steatosis was also not associated with HCV RNA level, and the distribution was similar between patients with HCV genotype 1 and genotype 2 infection. According to multivariate analysis, BMI is the strongest risk factor associated with hepatic steatosis, followed by hepatic fibrosis and triglyceride level with odds ratios (95% confidence intervals) of 2.51 (1.49-4.23), 2.06 (1.14-3.70), and 1.02 (1.01-1.03), respectively. Hepatic steatosis was associated with being overweight, hepatic fibrosis, and triglyceride level in chronic hepatitis C. (11,12). Given that hepatic steatosis may therefore be an INTRODUCTION important histopathological factor in CHC, the aim of this Hepatic steatosis is a pathological phenomenon whereby study was to establish the prevalence of hepatic steatosis in fat is deposited within hepatocytes. Many factors are known Taiwanese CHC patients and to evaluate whether hepatic to be risks for hepatic steatosis, including diabetes mellitus, steatosis was related to the virological characteristics of HCV hyperlipidaemia, certain drugs, and obesity (1,2). In recent and the histopathological features of liver biopsy. In addition, years, some studies have shown that chronic hepatitis C (CHC) the association between hepatic steatosis and anthropometric is also a risk factor, and indeed hepatic steatosis is associated and biometabolic markers in CHC patients was also explored. with CHC (3,4). Previous studies have shown that 30-70% of liver biopsies from patients with CHC include histological MATERIALS AND METHODS evidence of steatosis (5-7). Recent studies indicate that hepa- titis C virus (HCV) core protein has a direct inhibitory effect Patients: A total of 425 consecutive CHC patients were on the function of microsomal triglyceride transfer proteins enrolled at the Kaohsiung Municipal Hsiao-Kang Hospital related to the secretion of very low density lipoproteins (VLDL) (a regional core hospital) and Kaohsiung Medicine Univer- (8,9). Furthermore, HCV core protein is known to damage the sity Hospital (a medical center) from August 1998 to March mitochondria and therefore create oxidative stress within the 2005. They were all seropositive for antibody to HCV (anti- hepatocytes, a process that disrupts the peroxidation of fats HCV) for more than 6 months, and positive for HCV RNA. within hepatocytes and can lead to hepatic steatosis (5,8). All patients underwent liver biopsies and were proven to have In clinical observations, it remains controversial whether CHC. The patients’ medical histories were taken and their hepatic steatosis influences the progression of fibrosis in the body mass index (BMI) was measured on the date of their liver histopathology of CHC patients. Steatosis has been liver biopsy. Hypertension was determined according to the reported to be independently associated with fibrosis in CHC criteria defined by the National Committee on Prevention, (3,4); however, other studies have documented that steatosis Detection, Evaluation, and Treatment of High Blood Pressure is not associated with the presence of or subsequent progres- (13). Patients with diabetes mellitus were classified accord- sion to fibrosis in a cohort study group (10). Several HCV ing to the diagnostic criteria of the National Diabetes Data hyperendemic townships in southern Taiwan were found to Group (14), or if the patient’s past history mentioned taking have a prevalence of higher than 30% in previous studies oral hypoglycemic agents (OHA) or injecting insulin to con- trol blood sugar. Hyperlipidaemia was defined as the fasting *Corresponding author: Mailing address: Hepatobiliary Division, lipid criterion according to the third report of the National Department of Internal Medicine, Kaohsiung Medical Univer- Cholesterol Education Program (NCEP) Expert Panel on De- sity Hospital, 100 Tzyou 1st Rd, Kaohsiung City 807, Taiwan. tection, Evaluation, and Treatment of High Blood Choles- Tel: +886-7-3121101 ext. 7475, Fax: +886-7-3234553, E-mail: terol in Adults (Adult Treatment Panel III) final report (15). [email protected] Patients were classified as overweight if their BMI was greater 377 than or equal to 23 kg/m2, according to the Asia-Pacific BMI assay kits (Abbott, North Chicago, Ill., USA). HCV RNA was criteria (16). Patients were excluded if they were diagnosed detected using a standardized automated qualitative reverse with coexisting hepatocellular carcinoma, decompensated transcription-polymerase chain reaction (PCR) assay (COBAS cirrhosis or hepatic failure, other hepatic diseases (such as AMPLICOR Hepatitis C Virus Test, version 2.0; Roche, Wilson’s disease or α1-antitrypsin deficiency), biliary system Branchburg, N.J., USA), with a detection limit of 50 IU/mL. disease, pancreatic disease or other severe systemic diseases HCV RNA levels were detected with a branched DNA assay (such as renal failure), or if concurrent hepatitis B or human (Versant HCV RNA 3.0; Bayer, Emeryville, Calif., USA), immunodeficiency virus infection was present. Patients with performed strictly in accordance with the manufacturer’s a history of alcohol consumption exceeding 40 g/day or those instructions. Quantification was limited to 615 IU of HCV diagnosed with alcoholism, intravenous drug abuse, or expo- RNA per ml. HCV genotypes (1a, 1b, 2a, 2b, and 3a) were sure to hepatotoxic drugs were also excluded. determined through amplification of the core region using Liver histopathology: Liver biopsy samples of at least 2 genotype-specific primers (20). All data were collected at the cm in length were taken and stored –4°C in a refrigerator time of the liver biopsies. for 8 h, before being reversed in a freezer under –70°C. Statistical analysis: The statistical tests used were Student’s Biopsy samples were stained with hematoxylin and eosin, t test, the Mann-Whitney test, χ2 square test, and Fisher exact and the results were then reported by one pathologist. The test. All of these tests are two-sided, and the significance degree of hepatic necroinflammatory change was classified levels were set at α = 0.05. Logistic regression analysis was according to the histological activity index (HAI) score performed to determine the factors associated with hepatic system (17), and the fibrosis stage was set according to fibrosis based on the odds ratio and 95% confident intervals the Scheuer scale (18). The extent of hepatic steatosis was for these covariates. The covariates analyzed were age, sex, assessed by light microscopy and graded as none (0-5%), hypertension, diabetes mellitus, hyperlipidaemia, HCV geno- mild (5-33%), moderate (33-66%), and severe (>66%), type, HCV viral load, BMI, and hepatic necroinflammatory according to the area occupied by fatty hepatocytes (19). activity and fibrosis. The procedures were performed using the Laboratory tests: The presence of anti-HCV was tested SPSS 12.0 statistical package (SPSS, Inc., Chicago, Ill., USA). by using third generation enzyme-linked immunosorbent Table 1. Basic demographics and factors associated with steatosis and non-steatosis patients in chronic hepatitis C patients Patient Steatosis1) (–)Steatosis1) (+) Fibrosis2) (–) Fibrosis2) (+) P P No. (%) No. (%) No. (%) No. (%) No. (%) No. of case 425 (100) 293 (68.2) 132 (30.8) 91 (21.4) 334 (78.6) Age (y) (mean ± SD) 49.0 ± 12.2 49.2 ± 12.5 48.4 ± 11.7 0.48 42.5 ± 13.0 50.7 ± 11.4 0.027) Sex Male 264 (62.1) 177 (60.4) 87 (65.9) 0.28 64 (70.3) 200 (59.9) 0.07 Female 161 (37.9) 116 (39.6) 45 (34.1) 27 (29.7) 134 (40.1) Hypertension3) Without 357 (84.0) 250 (85.3) 107 (81.1) 0.27 83 (91.2) 274 (82.0) 0.037) With 68 (16.0) 43 (14.7) 25 (18.9) 8 (8.8) 60 (18.0) Diabetes mellitus4) Without 384 (90.4) 267 (91.1) 117 (88.6) 0.42 85 (93.4) 299 (89.5) 0.27 With 41 (9.6) 26 (8.9) 15 (11.4) 6 (6.6) 35 (10.5) Hyperlipidemia5) Without 407 (95.8) 282 (96.2) 125 (94.7) 0.46 85 (93.4)