COMPARATIVE STUDY OF FIB-4 INDEX AND TRANSIENT ELASTOGRAPHY AMONG PATIENTS WITH CHRONIC HEPATITIS C VIRUS INFECTION IN GEORGIA.

Liver biopsy remains the reference standard for fibrosis staging. However, it has several limitations, which have led to the development of non-invasive methods. We evaluated liver fibrosis severity among HCV infected patients by comparing transient elastography (TE) and FIB-4 index. Retrospective study was conducted. Clinical data for 750 patients were obtained. The mean age of the study population was 51 years; 595 (79.3%) were male and 155 (20.7%) were female. TE and tests on biological samples were performed within one-week timeframe. Additional analyses of prothrombin index, albumin concentration, splenomegaly on abdominal ultrasound and esophageal varices on upper gastrointestinal endoscopy were performed among selected patients. Comparable results were observed among 534 patients (71.2%). FIB-4<1.45 had a negative predictive value of 89% to exclude significant fibrosis and FIB-4>3.25 had a positive predictive value of 100 % to confirm the existence of significant fibrosis. Inconclusive FIB-4 score was obtained in 170 (22.7%) patients. Of them 127 (74.7%) had significant fibrosis (F3-F4) by TE. Discordant results (FIB-4 <1.45 and Liver Stiffness Measurement (LSM) >9.5 kpa) were observed in 46 (6.1%) of patients. Low prothrombin index, low albumin concentration, splenomegaly and esophageal varices were significantly (p<0.001) correlated with TE results. Discrepancy showing high FIB-4 score and low LSM was not observed in our cohort. There was a good correlation between TE and FIB-4 score. FIB-4 could rapidly replace expensive methods to assess liver fibrosis severity in some scenarios. However, our study demonstrated superiority of TE. LSM correlated better with indirect markers of significant fibrosis.

Discrepancy between HCV structural and non structural genes in Georgian genotype two patients.

Correct identification of hepatitis C genotypes is an important diagnostic tool, which guarantees further selection of adequate treatment regimen and correct duration. Ideal approach for accurate genotyping is amplification of both structural and non structural parts of HCV genome. As different methods, which use either one or another region for HCV genotyping sometimes lead to indeterminate genotype and subtype results. Therefore, it is of importance to compare HCV genotyping results based on two different genomic regions. As part of this study, remnant 108 specimens, with previous history of successful genotype identification by 5'UTR/core Versant HCV genotyping kit, were retrospectively analyzed. "In house" HCV real time PCR based method that amplifies parts of NS5B region was used for this purpose. Based on our data, genotyping calls were concordant between genotype one and genotype three specimens group in both regions. However, discrepancy was evident among genotype 2 group. Of 25 specimens originally typed as genotype 2 in structural region, only 7 was confirmed in non structural region, remaining 18 specimens were typed as 1b. Therefore, the discordance rate between structural and non structural regions for genotyping call among genotype two was 72%. Our data showed highly discordant structural and non structural genome for genotype two identification in our specimens. We propose that this phenomenon might be due to the recombination event between genotype two and genotype one. Possible circulation of this strain in Georgia stresses the need for detailed sequencing and phylogenetic analyses of these specimens in both structural and non structural parts of HCV genome.

Occurrence of occult HCV infection among Hiv infected patients in Georgia.

Occult hepatitis C (OCI) infection has been known as detectable HCV-RNA in the liver or peripheral blood mononuclear cells (PBMCs) in the absence of detectable serum or plasma HCV-RNA. OCI has been detected among different patients groups worldwide, it has been found not only in chronic hepatitis patients of unknown origin, but also among several groups at risk for HCV infection (hemodialysis patients or family members of patients with occult HCV). This occult infection has been reported also in healthy populations without evidence of liver disease. Prevalence of occult Hepatitis C virus has not been investigated in Georgian population, where a rate of HCV infection is highest (6.7%) among Eastern European Countries. The aim of this study was to investigate the occurrence of occult HCV infection among HIV infected individuals in Georgia. As a pilot study, we have selected three groups of HIV infected patients for analyses: Group 1- HIV infected patients without evidence of liver disease (n=98), group 2- HIV infected patients with cryptogenic liver disease (n=34) and group 3- HIV/HBV co infected patients (n=29). HCV RNA was tested in PBMCs samples by real-time polymerase chain reaction. HCV genotyping was performed by Line-probe assay based on reverse-hybridization technology. Liver fibrosis was evaluated by transient elastography (FibroScan®). HCV-RNA was detected in PBMCs specimens among 2 (2%) subjects from group 1, 4 (12%) subjects from group 2, and 9 (31%) subjects from group 3. HCV genotypes were determined for 14 of 15 OCI subjects resulting following genotype distribution: 6 (46%) - 1b, 3 (23%) - 2a/2c and 5 (38%) - 3a. One samples failed to be genotyped due to extremely low HCV viral load. Our data revealed the occurrence of occult HCV infection in HIV infected patients. No single HCV genotype was predominant in the present study. Liver fibrosis was found more frequently and the fibrosis score was significantly higher in OCI patients versus negative ones, suggesting that undiagnosed OCI might impact on the liver damage. The study demonstrated that testing only for HCV antibody fails to identify the true prevalence of HCV co-infection among HIV infected patients. We propose that in the absence of liver biopsy specimens, analysis of PBMC sample for HCV-RNA would be informative for detection of occult HCV.

Assessment of liver fibrosis and cirrhosis by transient elastography among patients with chronic HBV and HCV infection in Georgia.

The aim of the study was to evaluate liver fibrosis (LF) and cirrhosis using Transient elastography (TE) using Fibroscan in patients with chronic HBV and HCV infection. The device evaluates LF by measurement of liver stiffness (LS). 525 patients with chronic HCV infection and 105 patients with chronic HBV infection were included in the study. These patients were investigated at the Georgian-French joint hepatology clinic "Hepa" from November 2007, till November 2008. Among investigated HBV infected 105 patients 65 (61.9%) had no fibrosis (LS<5.5 kpa), 23 (21.9%) had mild fibrosis (LS-5.5-8.0 kpa), 9 (8.6%) had severe fibrosis (LS-8.0-14.0 kpa) and 8 (7.6%) had liver cirrhosis (LS>14.0 kpa). Among investigated HCV infected 525 patients 200 (38.1%) had no fibrosis (LS<5.5 kpa), 139 (26.5%) patients had mild fibrosis (LS-5.5-8.0 kpa), 87 (16.5%) patients had severe fibrosis (LS-8.0-14.0 kpa) and 99 (18.9%) patients had liver cirrhosis. It is concluded that transient elastography (TE) using Fibroscan is simple, non-invasive, reliable and easily reproducible method for assessing liver fibrosis and cirrhosis in patients with chronic HBV and HCV infection. TE is characterized with an excellent accuracy. TE results are well correlated with the clinical signs as well as with the results of laboratory and instrumental investigations. Fibrosis stages by Metavir measured using Fibroscan well corresponds with the liver biopsy results. Considering the high prevalence of fibrosis and cirrhosis among patients with chronic HBV and HCV infection, TE is a very valuable method for detecting early stages of fibrosis allowing to avoid the progression of liver damage, as well as end-stage liver disease. TE is easy to perform and therefore allows regular follow-up of the course of LF.

Acute/recent HCV infection. Clinical course, viral replication kunetic and disease outcome.

The aim of the study was to reveal and investigate acute/recent HCV infection at the very early stage in seronegative blood donors and seronegative Injecting Drug Users (IDUs) and to assess clinical laboratory variants of infection, viral replication kinetic, disease outcome, host and viral characteristics. Two groups of patients were included in this study. The first group consisted of ELISA negative 7000 blood donors; the second group included 3000 Injecting Drug Users (IDUs). All patients were investigated on HCV RNA by qualitative PCR using mini pool method. A pool of 6 was applied for blood donors' and a pool of 5 for IDUs. PCR negative pools were excluded from the study, while PCR positives were examined on individual samples. Anti-HCV was detected by ELISA and RIBA. Detection HCV RNA was performed by Real time PCR technique using COBAS TaqMan Test. HCV genotyping--by INNO-Lipa. HLA typing--by Sequence Specific Primer Amplification (SSP). 16 patients with acute/recent HCV were revealed: 7 from blood donors, 9 from IDUs. Among them: 4 were symptomatics and 12 asymptomatics. Out of 4 symptomatics 3 were with jaundice. Among 12 asymptomatics: 8 had elevated ALT; 2 neither elevated ALT nor symptoms but developed anti-HCV; 2 were with normal ALT and without further anti-HCV seroconversion. Among 16 subjects: 9 had genotype -1b, 1--genotype 1a, 3--genotype 2a/2c and 3--genotype 3a. Out of 16 cases 4 cleared the virus; 12 developed chronic infection. Spontaneous clearance (recovery from the disease) was observed in 2 out of 4 symptomatic patients and only in 2 patients out of 12 asymptomatics. In all patients viremia increased rapidly and reached a peak by week 4. Viral titer was remarkably stable for the next three weeks, followed by two or three fold decrease by week 9. After week 10 the viremia rapidly decreased: 4 or 5 logs by week 12 and it became either undetectable by weeks 16-18 (viral clearance), or virus was not eliminated and viral titer persisted in all follow up period (chronic infection). HLA DRB1 1101, DQB1 0301 and DRB1 1301/DQA1 0103 alleles were associated with clearance of HCV whereas DRB1 0301 was associated with chronic infection. Prevalence of HCV among seronegative blood donors was 0.1% and among IDUs 0.3%. Among acute/recent HCV infected patients rate of chronicity was 75% (50% in symptomatics and 83% in asymptomatics). Rate of recovery was 50% in symptomatic patients and about 16% in asymptomatics. Acute/recent HCV infection might have following clinical laboratory forms: symptomatic disease with or without jaundice, asymptomatic with or without elevated ALT, but with further anti-HCV seroconversion. It remains unclear whether enigmatic form of disease--acute/recent HCV infection without further seroconversion exists or not.

Fibroscan and FibroTest/FibroMax to assess liver fibrosis/cirrhosis in patients with chronic HBV and HCV infection in Georgia.

Although, liver biopsy is the gold standard in assessment of the degree of liver damage, the method has some limitations. For this reason, assessment of liver damage using non-invasive methods is currently an important topic in hepatology. The aim of the study was to evaluate liver fibrosis/cirrhosis using Transient Elastography and FibroTest/FibroMax in patients with chronic HCV and HBV infection in Georgia and to compare Fibroscan and FibroTest/FibroMax results. 252 patients were included in the study, among them 185 with chronic HCV infection and 67 with chronic HBV infection. These patients were investigated at the Georgian-French Joint Hepatology Clinic "Hepa", from December 2007 to November 2008. In patients with chronic HCV or HBV infection Fibroscan and Fibrotest/FibroMax results were correlated in 127 (68.6%) and 45 (67.2%) cases, respectively. Discordance in one degree of fibrosis stage was found in 36 (19.5%) patients with chronic HCV infection and in 14 (20.9%) patients with chronic HBV infection. Discordance in more then one degree of fibrosis stage was found in 22 (11.9%) and 8 (11.9%) cases. In patients with Fibroscan and Fibrotest/FibroMax concordant results liver biopsy might be avoided. Fibroscan and Fibrotest/Max appear to be very valuable methods for detecting early stages of fibrosis among patients with chronic HCV and HBV infection, allowing to avoid the progression of liver damage, as well as end-stage liver disease. These methods are easy to perform and therefore allows regular follow-up of the course of LF.

Ifn/Rbv treatment induced anemia and its correction with epoetin alpha in patients with hepatitis C.

The aim of the 18 months follow up study was to assess the frequency of anemia during IFN/RBV therapy in patients with chronic hepatitis C; to manage anemia either with recombinant human erythropoietin (rHuEPO)--epoetin alpha or with RBV dose reduction and to compare the rate of SVR in patients with RBV dose reduction and with administration of epoetin alpha. Study enrolled 61 patients with chronic active hepatitis C aged 33-61 years. All patients had HCV genotype 1b. Out of them 41 were male and 20 female. Anemia (Hb <10 or >2 g/dL Hgb drop from baseline) developed in 41 patients out of 61 (67,21%) during the therapy. These 41 patients were randomized into two groups: 21 patients who received 40 000 IU epoetin alpha weekly (I group) and 20 patients in whom for managing anemia we used standard of care (SOC) or RBV dose reductions from 1000/1200 to 800/600 mg (II group). In all 21 patients of the I group the Hb level normalized without reduction of RBV dose. In this group of patients SVR at 6 months after completion of full course of treatment was achieved in 17 (66%) patients. Improvement of quality of life (QOL) was observed in all 21 patients. Out of 20 patients of II group with standard of care (SOC) 5 patients developed symptomatic anemia with fatigue and dyspnoea; RBV was stopped temporarily. In 15 patients RBV dose was reduced from 1200 mg to 600 mg for correction of anemia. In this group of patients SVR at 6 months after treatment completion was achieved in 7 (25%) patients. Lower RBV doses yield a lower treatment response in patients with HCV genotype 1. In anemic HCV-infected patients on RBV/PEG-IFN therapy, EPO maintains RBV dose and significantly improves anemia and QOL. EPO has the potential to improve adherence rate, which may in turn improve SVR.

Hiv prevalence among high risk behavior group persons with herpes zoster infection.

The aim of the two year (2003-2005) study was to study the HIV prevalence among high risk behavior groups of persons with Herpes Zoster infection. For this purpose we have investigated the high risk group patients: 1257 prisoners (1st group), 1543 IDUs (2nd group) and 1350 persons including: homosexuals, persons with history of frequent unprotected sex and persons with hepatitis B and C (3rd group). We revealed the persons with current or previous history of Herpes Zoster, and studied HIV prevalence among them. Besides, we have studied the immune status of revealed HIV positive persons, relationship between disease (Herpes Zoster) severity and CD4 count. Herpes Zoster infection was diagnosed based on clinical symptoms, anamnesis and by detection of VZV specific IgM and IgG by ELISA. HIV infection was diagnosed by ELISA method and was confirmed by Western Blot. CD4 count was detected by immunophenotyping technique and was analyzed using a FACSCalibur flow cytometer. The total prevalence of HIV infection among high risk behavior group persons with Herpes Zoster infection was 18,9% (31 HIV cases out of 164). The disease (Herpes Zoster) severity and duration was associated with decreased rate of cellular immunity, CD4 count. Herpes Zoster has a positive predictive value for HIV infection, predominantly recurrent Herpes Zoster. Herpes Zoster should be recognized as a marker condition indicating the necessity of screening for HIV, especially in Georgia, the region where the problem of IDU exists.

Peculiarities of herpes zoster in immunocompetent and immunocompromised hosts.

The aim of five years (2000-2005) study was to investigate the peculiarities of Herpes Zoster in immunocompromised and immunocompetent patients. For this purpose we have investigated the clinical course of Herpes Zoster, disease duration, complications of disease, as in acute phase as well as postherpetic neuralgia in 74 HIV positive (1st group) and 74 HIV negative (2nd group) groups of patients. In both group of patients we have studied the prevalence of the following complications: 1. Acute complications of Herpes Zoster: a) Neurological: motor neuropathy, cranial neuritis, meningoencephalitis, transverse myelitis. b) Ophthalmic: keratitis, iritis, retinitis, visual impairment c) Cutaneous: bacterial superinfection, scarring, disfigurement. d) Visceral: pneumonitis, hepatitis. e) Multidermatomal. 2. The complications of after resolution of infection: a) Postherpetic neuralgia and various duration of pain associated with postherpetic neuralgia such as : < month, 1-6 months, 6-12 months and >1 year durations. b) Recurrent herpes zoster. Herpes Zoster infection was diagnosed based on clinical symptoms and by detection of VZV specific IgM and IgG by ELISA. HIV infection was diagnosed by ELISA method and was confirmed by Western Blot. We found that Herpes Zoster may develop as in HIV positive as well as HIV negative population. Study showed that severe cases of disease (Herpes Zoster), long duration and rate of complications are much higher in HIV/AIDS than in HIV negative group patients. Rate of hospitalization is also higher in HIV/AIDS patients with Herpes Zoster than in HIV negative patients with Herpes Zoster. Frequency of recurrent Herpes Zoster is much higher in HIV/AIDS patients than in HIV negative patients. The postherpetic neuralgia is very frequent complication for both group (HIV positive and HIV negative) Herpes Zoster patients, but its duration longer in HIV/AIDS patients in comparison HIV negative group. There were no significant difference in disease severity, duration and complications among male and female patients.