Source: Dissertation Abstracts International, Volume: 68-11, Section: B, page: 7281. Adviser: Lu-Yu Hwang. Includes bibliographical references.

published_or_final_version / Medicine / Doctoral / Doctor of Philosophy

Autoimmune hepatitis (AIH) was identified as an entity by the Swedish professor Jan Waldenström in the 1950s. It was then denoted lupoid hepatitis, characterized by liver inflammation and most often affecting young women. During the years the diagnosis has become more defined (as the non A non B hepatitis has been identified as Hepatitis C) and now can be safely separated from other diseases with liver inflammation. Studies of epidemiological data and long term prognosis have been scarce in the literature. Within a collaboration between the university hospitals in Sweden, we collected what we believe is the largest cohort in the world of patients with AIH. Data from the medical records of 473 individuals was, after AIH-score calculations where the diagnosis was confirmed, collected in a data base, in which most of the analysis was done. Data from the Swedish national registers of cancer, death cause, and birth register was searched for these patients as well as controls. The aim of the thesis was to explore epidemiological and clinical outcome of AIH.The onset of AIH may be at any age, but the incidence seems to increase after 50 years of age; 75% are females, the overall incidence (0.85/ 100,000 inhabitants and year) and prevalence (11/100,000 inhabitants) are figures that are within the range of another but smaller Scandinavian study. Approximately 30 % had cirrhosis already at diagnosis and 87% displayed at some time positive auto-antibodies indicating AIH (Smooth muscle ab and or antinuclear ab).  Indications of future risk for liver transplantation or death is an advanced AIH at diagnosis with liver cirrhosis, decompensated liver disease, elevated PK INR as well as age. Acute hepatitis-like onset seems to carry a lower risk for later liver transplantation or death. Current Swedish national therapy traditions with immune suppression seem to be well tolerated. Five and ten years overall life expectancy does not differ from controls. Thirty-five women gave birth to 63 children, for 3 after liver transplantation of the mother. Thirteen of the women had liver cirrhosis. Current pharmacological treatment seems to be safe both for the patient and the foetus. Thirty percent of the patients experienced flair after delivery. It has been supposed that there is an overrisk for hepatocellular cancer (HCC) associated with AIH. Our figures are the first in the world to be presented that confirms a twenty-three fold overrisk (95% Confidence Interval 7.5-54.3) for hepatobiliar cancer. We found as well an overrisk of non-Hodgkin lymphomas of 13.09 (95% CI 4.2-30.6).Conclusion:  Our epidemiological results confirm that AIH is a fairly uncommon disease, and that many already at time of diagnosis have an advanced disease with liver cirrhosis. There is a clear overrisk for HCC and lymphoma. For those women with AIH who become pregnant the prognosis for the child as well as for the mother is good, even for those women who already have compensated cirrhosis. There is a risk for relapse after delivery. The overall survival for AIH patients with current therapy is good.

Generally Hepatitis C Virus tropism is limited to hepatocytes. This limited tropism is a result of the receptors HCV requires for cellular entry and other host cellular factors including, uniquely, a liver specific miRNA, miR-122. The relationship between HCV and miR-122 is interesting, as commonly, miRNA are associated with suppression of function, but in the case of HCV, miR-122 actively promotes HCV proliferation. In-depth studies have demonstrated that miR-122 along with the RNA induced silencing complex (RISC) protein Argonaute 2 (Ago2) binds directly to two seed sequences separated by 8-9 nucleotides on HCV 5’UTR. Binding to the 5’UTR results in an increase in viral replication and translation. The method by which miR-122 promotes HCV translation and replication is not fully understood but evidence suggests that part of the function of miR-122 is to stabilize the HCV genome and protect it from exonuclease degradation by Xrn1, but other mechanisms remain to be identified. The reliance of HCV on miR-122 is best exemplified by the fact that removal of miR-122 by a miR-122 antagonist drastically impedes HCV viral titers in Chimpanzees and humans with no indication of escape mutants. The observation that HCV augmentation of the HCV life cycle by miR-122 requires Ago2 suggests that other components downstream in the miRNA suppression pathway may also be part of the mechanism of action. Our studies focused specifically on the processing body (p-body) associated DEAD-box helicase DDX6. DDX6 is essential for p-body assembly, required for robust miRNA suppression activity and elevated in HCV associated hepatocellular carcinomas. As such we hypothesized that DDX6 and p-bodies were directly or in-directly associated with the mechanism of action of miR-122. Knocking down DDX6 with siRNA indicated that DDX6 augments both HCV replication and translation. To examine whether DDX6 augmentation of HCV replication was related to the effects of miR-122 on the HCV life cycle, HCV replication and translation were assessed in the presence or absence of miR-122 when DDX6 was knocked down. Our data indicated that HCV replication and translation were augmented equally by miR-122 whether DDX6 was present or not. Our data also demonstrated that HCV replication and translation that was occurring independent of miR-122 was also still affected by DDX6 knockdown. Taken together our observations strongly suggest that the role DDX6 has on HCV is independent of HCV and miR-122’s relationship. In order to better understand miR-122’s relationship with HCV, we hypothesized that targeting the miR-122 binding region with siRNA would inhibit HCV replication initially, but that over the course of several rounds of treatment with the same siRNA, HCV would mutate to escape the siRNA, producing escape mutants that replicate without a dependency on miR-122. These escape mutants could be evaluated on how they replicate without using miR-122, shedding light on miR-122 and HCV’s relationship. Conversely if no escape mutants arose the siRNA could be further studied as a potential therapeutic for HCV. siRNA designed to target the miR-122 binding region inhibited HCV replication, confirming that the designed siRNAs could access the miR-122 binding region and function as an siRNA. Interestingly, when the siRNAs were used against a replication competent HCV RNA having a single nucleotide mutation in the first miR-122 binding site, instead of abolishing siRNA knockdown, two of the siRNA showed enhanced inhibition activity. The target sequences of these siRNAs spanned both miR-122 binding sites and we speculate that their inhibitory activity was due to competition for miR-122 binding to site 2. This observation indicates that siRNA targeting the miR-122 binding region have dual activity, by siRNA induced cleavage, and as a competitive inhibitor of miR-122 binding. Selection for viral escape mutants of the miR-122-binding site targeting siRNAs revealed viral RNAs having mutations within the miR-122 binding sites, in the surrounding region, and to other areas within the HCV IRES. The mutant viruses will be used to assess the influence of miR-122 binding site mutations on HCV replicative fitness, and to determine if the virus can evolve to replicate independent from augmentation by miR-122.

H λοίμωξη που προκαλείται απο τον ιό της ηπατίτιδας C HCV είναι μείζον πρόβλημα για την δημόσια υγεία όπως επίσης και η κύρια αιτία της χρόνιας ηπατικής νόσου και ηπατοκυτταρικού καρκινώματος, με περίπου 180 εκατομμύρια μολυσμένα άτομα σε όλο τον κόσμο. Ο HCV είναι ένας RNA ιός θετικής πολικότητας που ανήκει στο γένος Hepacivirus της οικογένειας των Flaviviridae. Έξι γονότυποι ( 1-6 ) είναι γνωστοί, καθένας από τους οποίους μπορεί να υποδιαιρεθεί περαιτέρω σε αρκετές υποτύπους. Το γονιδίωμα του HCV αποτελείται από ένα μεγάλο ανοικτό πλαίσιο ανάγνωσης (ORF), πλαισιωμένο από ιδιαίτερα δομημένες 5 'και 3' αμετάφραστες περιοχές (UTRs). Και οι δύο περιοχές UTRs είναι συντηρημένες και έχουν τον έλεγχο της ιογενούς μετάφρασης και αναπαραγωγής. Το 5' UTR του HCV περιέχει μια περιοχή IRES απο την οποία γινεται η έναρξη της cap ανεξάρτητης μετάφρασης του ιικού RNA. Η HCV IRES εξαρτώμενη μετάφραση του ORF παράγει μια ενιαία πρόδρομη πολυπρωτεΐνη που μεσω μετα-μεταφραστικής τροποποίησης από κυτταρικές και ιικές πρωτεάσες, οδηγεί στην ωρίμανση δομικών και μη δομικών πρωτεϊνών. Αρκετές μελέτες έχουν δείξει ότι διαφορετικές κυτταρικές ή ιικές πρωτεΐνες μπορούν να ρυθμίσουν την ενεργότητα του HCV IRES. Στόχος της παρούσας μελέτης ήταν η κατανόηση της ρύθμισης της HCV IRES εξαρτώμενης μετάφρασης. Πρώτον, προσπαθήσαμε να ορίσουμε το ρόλο των ιικών πρωτεϊνών στην HCV IRES εξαρτώμενη μετάφραση που παραμένει αμφιλεγόμενος. Σαφώς, οι μελέτες μας έδειξαν ότι η HCV NS5A ρυθμίζει αρνητικά την ενεργότητα του IRES με κύτταρο-εξαρτώμενο τρόπο. Επιπρόσθετα, υπάρχουν ισχυρές ενδείξεις ότι η ενεργοποιημένη PKR ρυθμίζει θετικά την ενεργότητα του IRES ενώ η καταστολή της έκφρασης της ενδογενούς PKR έχει το αντίθετο αποτέλεσμα. Επιπλέον, καταλήξαμε στο συμπέρασμα ότι η NS5A μεσολαβεί ανασταλτικά στην IRES-εξαρτώμενη μετάφραση και συνδέεται με την αδρανοποίηση της PKR. Τέλος στην παρούσα εργασία ερευνήσαμε τη ρύθμιση της ενεργότητας του HCV IRES σε συνθήκες χαμηλού οξυγόνου, δεδομένου ότι υποξικές περιοχές εντοπίζονται στον ηπατοκυτταρικό καρκίνο (HCC) και συνδέονται με την ύπαρξη ενός εναλλακτικού προφίλ κυτταρικής μετάφρασης Τα αποτελέσματά μας δείχνουν ότι η HCV IRES-εξαρτώμενη μετάφραση ρυθμίζεται αρνητικά σε υποξικές συνθήκες και μάλιστα με κύτταρο-εξαρτώμενο τρόπο. / HCV infection is a major public health problem and a leading cause of chronic liver disease and hepatocellular carcinoma, with approximately 180 million infected individuals worldwide. HCV is a positive sense RNA virus that belongs to the genus hepacivirus of the Flaviviridae family. Six major HCV genotypes (1–6) are known, each of which can be further subdivided into several subtypes (1a, 1b, 2a, etc). The HCV genome consists of a large open reading frame (ORF), flanked by highly structured 5’ and 3’ untranslated regions (UTRs). Both UTRs are conserved and control viral translation and replication. The HCV 5'-UTR contains an IRES that initiates cap-independent translation of the viral RNA. IRES-mediated translation of the HCV ORF yields a single polyprotein precursor that is co- and post-translationally processed by cellular and viral proteases, giving rise to mature structural and non structural proteins. Several studies have suggested that different cellular non canonical proteins or viral proteins can regulate the HCV IRES activity. The aim of this study was to understand the regulation of the HCV IRES dependent translation. Firstly, we tried to delineate the role of the viral proteins on HCV IRES dependent translation that still remains controversial. Clearly our studies demonstrated that HCV NS5A down-regulates IRES activity in a cell-type dependent manner. Additionally, we provide strong evidence that activated PKR up-regulates the IRES activity while silencing of endogenous PKR had the opposite effect. In addition, we concluded that the NS5A-mediated inhibitory effect on IRES-dependent translation was linked with the PKR inactivation. Moreover, as it is already reported that localised hypoxic areas are continuously present in HCC due to its high proliferation rate leading to an altered translation pattern, we investigated modulation of HCV IRES activity under low oxygen settings. Our results provided preliminary evidence that HCV-IRES-dependent translation is negatively regulated by low oxygen levels or under hypoxia-mimicking conditions in cell-specific manner.

Μελετήθηκαν επιδηµιολογικές, κλινικές, βιοχηµικές, ιολογικές και ανοσολογικές παράµετροι σε ασθενείς αιµοκαθαιρόµενους για χρόνια νεφρική ανεπάρκεια µε HCV λοίµωξη και συγκρίθηκαν µε τις αντίστοιχες παραµέτρους HCV µολυνθέντων ασθενών µε φυσιολογική νεφρική λειτουργία. 1) Η µελέτη µας έδειξε ότι οι αιµοκαθαιρόµενοι ασθενείς µε HCV λοίµωξη είχαν σηµαντικά µικρότερες τιµές αµινοτρανσφερασών από αυτούς που είχαν φυσιολογική νεφρική λειτουργία. Από αυτό συµπεραίνεται ότι στους αιµοκαθαιρόµενους, για να εκτιµηθούν οι αµινοτρανσφεράσες σαν βιοχηµικοί δείκτες της ηπατίτιδας C θα πρέπει να διορθώνονται όσον αφορά την υποαµινοτρανσφερασαιµία των αιµοδιυλιζοµένων. 2) Οι αιµοδιυλιζόµενοι είχαν χαµηλότερο ιικό φορτίο από τους ασθενείς µε φυσιολογική νεφρική λειτουργία, σε αντίθεση µε άλλους ανοσοκατεσταλµένους ασθενείς που παρουσιάζουν υψηλότερο ιικό φορτίο από τους ανοσοϊκανούς µε HCV λοίµωξη. Με το χαµηλότερο ιικό φορτίο πιθανώς συσχετίζεται ο µικρότερος βαθµός νεκροφλεγµονώδους δραστηριότητας που ανευρέθη στην βιοψία του ήπατος αυτών των ασθενών. 3) Η συχνότητα κρυοσφαιριναιµίας των αιµοκαθαιροµένων ασθενών δεν διέφερε από αυτών µε φυσιολογική νεφρική λειτουργία, αλλά οι αιµοκαθαιρόµενοι παρουσίαζαν µικρότερες τιµές κρυοκρίτη και κανείς εξ αυτών δεν εµφάνισε κλινικό σύνδροµο κρυοσφαιριναιµίας. Επίσης η συχνότητα ανευρέσεως θετικού ρευµατοειδούς παράγοντος ήταν µικρότερη ενώ τα επίπεδα του C4 κλάσµατος του συµπληρώµατος ήταν υψηλότερα στους αιµοκαθαιρόµενους ασθενείς. Αυτά τα ευρήµατα υποδηλώνουν σχετική ανεπάρκεια του µηχανισµού δηµιουργίας αυτοαντισωµάτων και ανοσοσυµπλεγµάτων στους αιµοκαθαιρόµενους ασθενείς. 4) Οι αιµοδιυλιζόµενοι ασθενείς µε HCV λοίµωξη παρουσίαζαν ξηρά κερατοεπιπεφυκίτιδα σε παρόµοιο ποσοστό µε τους HCV ασθενείς µε φυσιολογική νεφρική λειτουργία, αλλά η ανοσολογική αντίδραση των δακρυικών αδένων έναντι του ιού της ηπατίτιδας C ήταν µάλλον µικρότερη. Η ξηρά κερατοεπιπεφυκίτιδα στους ασθενείς µε HCV λοίµωξη έδειξε να συνδυάζεται µε µεγάλη ηλικία και µεγαλύτερο στάδιο ηπατικής ίνωσης. 5) Τέλος, οι αιµοκαθαιρόµενοι ασθενείς ανευρέθησαν να έχουν µικρότερο βαθµό νεκροφλεγµονώδους δραστηριότητας και ίνωσης από τους ασθενείς µε φυσιολογική νεφρική λειτουργία και πιθανώς µάλιστα ηπιώτερη νόσο όσον αφορά όλες τις παραµέτρους αυτής. / We studied epidemiological, clinical, biochemical, virological and immunological characteristics of HCV infected patients on chronic hemodialysis for end stage renal failure and we compared them to those of otherwise normal patients with chronic HCV infection. 1) Our study showed that the mean values of aminotransferases were significantly lower in hemodialysis patients compared to patients with normal renal function. Our data suggest that in patients undergoing hemodialysis aminotransferases levels should be interpreted, for evaluation of hepatitis C activity, after correction for hypoaminotransferasemia of the hemodialysis population. 2) HCV viral load was found significantly lower in patients on maintenance hemodialysis than in the group with normal renal function. This contrasts with the high HCV viral load that is usually found in other immunocompromised patients. The lower grading of necroinflammatory activity, which was found in liver biopsy samples of hemodialysis patients, is possibly related to the lower viral load in these patients. 3) Prevalence of cryoglobulinemia in HCV-infected hemodialysis patients was not different from that of patients with normal renal function, but hemodialysis patients had lower cryocrit values and none of them presented a cryoglobulinemic syndrome. Rheumatoid factor positivity rate was also lower in hemodialysis group, while complement C4 levels were higher in these patients. These findings denote less efficient mechanism of creating autoantibodies and immune complexes in this population. 4) Patients on hemodialysis infected with HCV have a similar percentage of keratoconjunctivitis sicca with normal renal function HCV patients. Nevertheless hepatitis C virus appears to incite lower immunologic response to lacrimal glands in uremic as opposed to otherwise normal patients. Keratoconjunctivitis sicca in patients with chronic HCV infection was associated with older age and higher staging score of fibrosis in liver biopsy. 5) Finally, hemodialysis patients were found to have lower grading and staging score than those with normal renal function and possibly less severe disease from every aspect.

H παρούσα μελέτη είχε σαν στόχο την μελέτη και τον προσδιορισμό των αιμοδυναμικών αλλαγών που συμβαίνουν στο ηπατικό παρέγχυμα με τη βοήθεια της απλής (Gray Scale Ultrasonography, GSU) και της έγχρωμης Doppler υπερηχοτομογραφίας (Color Doppler, CDU), στην διάρκεια της χρόνιας ηπατικής νόσου. Ο απώτερος σκοπός ήταν ο διαχωρισμός της χρόνιας νόσου του ήπατος από την αρχόμενη καλά αντιρροπούμενη κίρρωση σε ομάδα ασθενών με ένα καλά τεκμηριωμένο ιστολογικό profil. Για τον λόγο αυτό, έγινε προσπάθεια να απομονωθούν εκείνες οι GSU και CDU παράμετροι που με μεγάλη ακρίβεια διαχώριζαν τους ασθενείς με τη χρόνια ηπατίτιδα από αυτούς που έπασχαν από καλά αντιρροπούμενη κίρρωση αρχικού σταδίου (CIR). / To assess the value of gray scale (GS) and colour Doppler ultrasonography (CDU) in differentiating the progression of chronic viral hepatitis (CVH) and compensated liver cirrhosis (CIR).

HIV is known to affect the epidemiology, transmission, pathogenesis and natural history of HCV infection whilst studies on the effects of HCV on HIV have shown conflicting results and are confounded by the influence of intravenous drug use and anti-retroviral therapy. This study was conducted in KwaZulu-Natal Province in South Africa where HIV is predominantly a sexually transmitted infection. Intravenous drug use is rare in this region and the study population was naive to anti-retroviral therapy. For this study, specimens from selected sentinel sites submitted to a central laboratory for routine HIV testing were screened for anti-HCV IgG antibodies. HIV positive HCV-positive patients were compared to HIV-positive HCV-negative patients in a subgroup of patients within this cohort in order to determine if HCV sero-prevalence was associated with clinical outcomes in a linked anonymous retrospective chart survey. The prevalence of HCV was 6.4% and that of HIV, 40.2%. There was a significantly higher prevalence of HCV among HIV infected patients as compared to HIV negative patients (13.4% vs. 1.73% respectively). HCV-HIV co-infected patients had significantly increased mortality (8.3 vs. 21%). A significant association was found between HCV serostatus and abnormal urea and creatinine levels. Hepatitis B surface antigen seropo-sitivity was not found to be a confounding factor. This study has found that hepatitis C co-infection is more common in HIV positive individuals and is associated with an increased mortality and renal morbidity. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2008.

Background: Approximately 170 million persons are infected with the hepatitis C viral infection (HCV), globally. Of this number, 3.2 – 4 million persons in the U. S. are infected with HCV. Although previous research has indicated a decrease in the rates of Hepatitis C in the U.S. approximately 12,000 deaths occur annually from those who suffer from chronic liver disease, as a result of being chronic carriers of HCV. Being a recipient of blood transfusions prior to 1992, intravenous drug users (IDUs), or persons with multiple sex partners are associated with increased risk for HCV infection. IDUs constitute the largest cohort for those infected with HCV. Due to the few clinical manifestations HIV and HCV share and HIV patients living longer due to Highly Active Antiretroviral Therapy (HAART), Many individuals infected with HIV are discovering co-morbidities with HCV. Methods: Secondary Data from the State Electronic Notifiable Disease Surveillance System (SENDSS) were used to analyze all confirmed cases of hepatitis C in the state of Georgia for the year 2009. All subjects in this analysis were confirmed as Hepatitis C infected. Descriptive frequencies for all categorical data were tested and analyzed, which included: gender, race, geographic region, disease status, age distribution, risk factor data such as injection drug use, blood transfusion prior to 1992, long term hemodialysis, accidental needle stick, tattoo, sexual contacts, and incarceration. Binary logistic regression for univariate and multivariate analysis was used to test the associations between geographic region of all HCV cases and their demographic characteristics. Results: Descriptive analysis of the prevalence of HCV cases in Georgia in 2009 reveal higher rates of HCV in rural regions (GOA) of the state among White males of non-Hispanic origin. In this same region, these cases were more likely to report risk factors involving injection drug use, blood transfusions prior to 1992, incarceration, or tattoos. Prevalence of most cases of HCV in Georgia for the year 2009 are seen in those age 20 – 30 and those 40 – 60. A higher number of those reporting intravenous drug use in metropolitan Atlanta (MSA) are Black of non-Hispanic origin. Bivariate logistic regression reveals that White Non-Hispanics living in rural areas of Georgia (GOA) have a 3.48 higher odds of being infected with Hepatitis C than Black Non-Hispanics (OR = 3.48, p < 0.001, CI 2.54 – 4.77). Conclusion: Resources for prevention of Hepatitis C should be directed to marginalized communities within Georgia regions outside of the Atlanta Metropolitan Statistical Area. The primary focus of prevention should also be tailored to new initiates of intravenous drug use and those 20 – 30 and 40 – 60 years of age. Further knowledge and understanding of behaviors that put individuals at risk for acquiring Hepatitis C, such as intravenous drug use, in rural Georgia may warrant interventions tailored to benefit these communities from acquiring or spreading Hepatitis C.

No description available.