Hépatites Non A-E_Virus G et TTV.ppt
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Transcript of Hépatites Non A-E_Virus G et TTV.ppt
Hepatites Non A-EVirus G et TTV …
et autres considérations métaboliques
Vlad Ratziu, DU Hépatites Virales 2008Hôpital Pitié Salpêtrière,
Paris, France
Evidence for Additional Hepatitis Agents
Prospective transfusion-associated hepatitis studies : 12%
Acute cases of overt hepatitis : 20%
Fulminant hepatitis : 25%
Chronic liver disease : 20-30%
Hepatitis-associated aplastic anemia : most of them
VHG : GBV-C, 95 % homology
VHG : HCV, 29 % homology
HGV Epidemiology and Diagnosis
HGV transmission: parenteral +++; vertical Risk groups: polytransfused, hemophiliacs,
hemodialysis, patients infected with HIV, HCV, HBV
Diagnosis: ongoing infection : HGVRNA without anti-E2 exposure with viral clearance : anti-E2 Ab
HGV Epidemiology and Diagnosis
HGV prevalence : blood donors 1.5-2.5% chronic NA-NE hepatitis 10-13% cryptogenic cirrhosis 20% HCV infection 18-20% HBV infection 8-10%
Prevalence of Serum HGVRNA in Acute Hepatitis of Viral Origin
non A-E 9 HBV 32* HAV 25 HCV 20
%
* : p<0.05 vs HAV and HCV
Alter M, NEJM 1997
HGV : is it an Hepatotropic Virus ?
Pessoa, Hepatology 1998
HGV : is it an Hepatotropic Virus ?
low level of hepatic HGVRNA compared to HCVRNA
no interaction of hepatic HCVRNA and HGVRNA levels when patients with monoinfection are compared with those infected with both viruses
Pessoa, Hepatology 1998
HGV has no Pathogenic Role on the Course of Acute Hepatitis
No apparent effect on the clinical course of acute disease among the patients with hepatitis A, B or C
No effect on the frequency or severity with which chronic hepatitis C develops
Long-standing HGV viremia but no chronic hepatitis
HGV and Transfusion associated Hepatitis (TAH)
HGV can be transmitted by transfusion +++
Protracted viremia possible (years) but 90% are mild
Prevalence of HGV is not higher in non-A-C transfusion associated hepatitis than in HCV, minor ALT elevation or transfused patients with no hepatitis
HGV milder forms than HCV; HCV-HGV not more severe than HCV
A CAUSAL RELATION BETWEEN HGV AND TAH IS NOT ESTABLISHED
Alter H, NEJM 1997
HGV in End-Stage Liver Disease and Liver Transplantation
HGV infection frequently present in end-stage liver disease (13% in HCV, 22-64% in cryptogenic cirrhosis)
HGV frequently present and/or acquired after liver transplantation
HGV does not influence the clinical outcome after liver transplantation.
Fried, Hepatology 1997Pessoa, Hepatology 1998
Does HGV Impact on the Course of other Viral Infections?
HCV HIV
No Histopathologic Impact of HGV on Chronic Hepatitis C
Patients: Chronic HCV alone in 85 pts Chronic HCV-HGV in 17 pts
No difference in the necroinflammatory grade, fibrosis stage, proportion of cirrhosis, steatosis or bile duct lesions
HGV INFECTION DOES NOT MODIFY THE COURSE OF CHRONIC HCV INFECTION
CONTRIBUTION TO LIVER DISEASE LESS THAN OTHER HEPATOTROPIC VIRUSES
Bralet, Gastroenterology 1997
Improved Survival in HGV-HIV Coinfection
Tillmann, NEJM 2001
Improved Survival in HGV-HIV Coinfection
Improved survival even after development of AIDS and introduction of HAART
Slower progression to AIDS
Beneficial effect independent of age, sex, CD4+, CD8+ cell counts
Inverse correlation HGV viral load- HIV viral load
Under HAART, increase in HGV viral load while decrease in HIV viral load
Tillmann, NEJM 2001
Multicenter AIDS Cohort Study Baltimore, Chicago, Pittsburgh, LA
• Cohorte de patients homosexuels mâles infectés par le VIH et suivis avant 1996
• Recherche du VHG au moment de l’infection, 12 à 18 mois et 5 à 6 ans après la séroconversion VIH RT-PCR : infection en cours antiE2 : infection passée, disparition du virus
Williams, NEJM 2004
L’infection par le GBV-C Améliore la Survie des Patients VIH
GBV-C pos
GBV-C éliminé
GBV-C neg
SURVIE A 10 ANS CD4+
75%
39%
16%
-26/mm3
-70/mm3
-107/mm3
Effet dépendant du taux de CD4 et virémie VIHEffet significatif pls années après primoinfection
VIHWilliams, NEJM 2004
Inhibition of HIV Replication by HGV in PBMC
No effect on the entry of HIV into the cells
No differences in expression of CD4, CXCR4 or CCR5
Xiang, NEJM 2001
Molecular Interactions Between GBV-C and HIV
Establishing Causality for New Viruses
Pathogen present in most cases of the disease Pathogen found preferentially in the target organ Should not be significantly detectable in subjects
without the disease Copy number should decrease or become
undetectable with resolution of the disease Copy number should correlate with disease
severityAlter, Postgraduate Course, AASLD 2000
Chronic Liver Disease - Beyond the Viruses ...
Definition Etiologies
Etiologie de la Cirrhose (n=78) Etude Dionysos (Hepatology 1994)
HCV28 %
HBV 9 %
HBV+ALCOOL 3 %
HEMOCHROMATOSE
1 %
ALCOOL26 %
CBP1 %
HCV+ALCOOL 3%
CRYPTOGENIC24 %
Factors Associated with ALT Levels
SEX BMI
Cholesterol Triglycerides Glycemia Oral contraceptives Smoking Age Physical exercise Medications
Piton, Hepatology 1998Prati, Ann Intern Med 2002
What is a Normal ALT Value ?
“Normal” ALT ranges from 26 UI/l (females, 95th percentile) to 66 UI/l (males BMI > 26 kg/m²)
New definitions of normal ALT (no overweight, lipid, carbohydrate alterations) : 30 UI/l for men 19 UI/l for women Piton, Hepatology 1998
Prati, Ann Intern Med 2002
Clinical Implications of the Different Thresholds for Normal ALT
Blood donors male donors : 4 - 20% female donors : 1.5 - 16%
HCV infection males : 13 - 22 % females : 20 - 45 %
Piton, Hepatology 1998
abnormal ALT
Chronic Liver Disease - Beyond the Viruses ...
Etiologies : Overweight, Diabetes +++ Covert Alcohol Drugs Seronegative autoimmune liver diseases Vascular liver diseases Celiac disease Occult HBV
Impact of Overweight on Chronic Liver Disease
< 25 32 0.3 (0.32-0.33)
25-27 25 1.16 (1.15-1.17)
> 27 45 1.83 (1.81-1.85)
BMI (kg/m2) % Relative Risk (CI 95%)
Dionysos Study, n = 1211 (6917 total)
(Bellentani Hepatology 1994)
Proportion of Patients With Cryptogenic Cirrhosis according to BMI - UNOS Database
0
5
10
15
20
25
30
35
40
> 40 BMI35 - 4030 - 3525 - 30< 25
HCV Alcohol CryptogenicN =19271
%
(Nair, Hepatology 2002)
0
5
10
15
20
25
30
35
40
Obésité et Cirrhose Cryptogénétique
Cirrhose X NASH Cirrhose C CBP
N
Age
Obésité (%)
Femmes (%)
Diabète (%)
70 50 39 33
63(+/- 11) 49(+/-14) 60(+/-7) 54(+/-10)
70 56 36 100
47 64 3 15
53 42 25 15
Caldwell, Hepatology 1999
Normal : 10 %
Steatosis alone : 48 %
Steatohepatitis : 42 %
Liver Histology in Overweight Patients
n = 858 ; 9 studies, 1978 - 2002
Prevalence of NASH/NAFLD
First (or second) cause of chronic liver disease in Western Countries
Prevalence among patients with abnormal LFTs of undetermined etiology (n=673, 5 studies)
steatosis alone : 30%
steatohepatitis : 26%
Hepatic Fibrosis in NASH
None or mild 65
Severe (cirrhosis excepted) 20
Cirrhosis 15
%
n= 572, 9 studies 1980 - 2001
Risk Factors for Severe Fibrosis in NASH
Age > 45-50 yrs
Diabetes
ALT>2N
BMI > 27 kg/m²
HTA
HyperTG
AST/ALT > 1Ratziu, Gastroenterology 2000Ratziu, Gastroenterology 2000
Angulo, Hepatology 1999Angulo, Hepatology 1999
Dixon, Gastroenterology 2001Dixon, Gastroenterology 2001
Abnormal Liver Function Tests
A frequent problem in clinical hepatology
New viruses : less of a problem
NAFLD : more of a problem
Identifying patients at risk of liver disease - that is the problem !
Viral Etiologies of Acute Hepatitis in the US(1985-1986 and 1991-1995)
HAV 48 HBV 34 HCV 15 non A-E 3
%
Alter, NEJM 1997
N=10 533