The document discusses a study evaluating insulin, growth hormone, TNF-αR (P55) and IL-1 receptor antagonist (IL-1ra) as biochemical markers for severity of hepatitis C virus (HCV) genotype 4 infection before and after treatment with pegylated interferon α-2a and ribavirin. 54 HCV patients were divided into non-cirrhotic (Group A, n=42) and cirrhotic (Group B, n=12) groups. Treatment resulted in higher sustained virological response rates in non-cirrhotic patients. Insulin levels significantly increased and TNF-αR (P55) decreased in responding non-cirrhotic patients. Insulin and TNF

1. The clinical and the prognostic value of Insulin, Growth Hormone,
TNF-R (P55) and IL-1 receptor antagonist (IL-1ra) in Chronic
Hepatitis due to HCV Genotype 4 before and after combination
therapy with Pegylated Interferon α-2a and Ribavirin.
Nihal M.El Assaly1, Naema El Ashri1, Omnia El Bendary1, Shendy M.Shendy2 , Mervat Al-
Damarawy3, M. Ali Saber 4 and Ehab El Dabaa4
1. Clinical Chemistry Department. Theodor Bilharz Research Institute (TBRI), 2.
Gastroenterology and Hepatology Department (TBRI) 3. ICU department (TBRI). 4.
Biochemistry Department (TBRI).
Journal -Egyptian Medical Journal Of The National Research Center, June 2007; vol. 6 (1):
38 – 45.
35401019.
Abstract
Combined therapy using Interferon alfa (IFN) and Ribavirin (RIB) represents the standard treatment in
patients with chronic hepatitis C. However, the percentage of responders to this regimen is still low, while
its cost and side effects are elevated. Therefore, the possibility to predict patient's response to the above
treatment is of paramount importance. Aim of this work is to evaluate the role of IL-1ra, and TNFaRI
(P55) which are receptors related to inflammatory response and, GH and Insulin which are hormones
metabolized in the liver as biochemical non invasive markers of severity of liver disease due to HCV
infection genotype 4, whether cirrhotic or non-cirrhotic. The effect of interferon alpha 2a and ribavirin
therapy on their levels and whether they could be used as parameters predicting the outcome of interferon
alpha 2a therapy in patients with chronic HCV infection . Methods 54 patients infected by HCV genotype
4 were enrolled in this study. They were classified into two groups according to the liver histology. Group
A of 42 chronic compensated HCV patients with no cirrhosis, Group B of 12 chronic HCV patients with
established cirrhosis and 12 healthy controls. Patients were treated by Pegylated INF α-2a (180 μg for
group A and 130 μg for group B) once weekly & 1200 mg Ribavirin/ day in two doses. Tested parameters
have been done by ELISA method before and after treatment for group A, group B and control group.
Results: end of treatment response (ETR) and sustained virological response (SVR) were 73.817% and
61.91% for group A, and 58.33% and 33.33% for group B respectively. Serum IL-1ra was increased after
treatment but this increase was not significant (P>0.05). There was a significant increase of serum insulin
(P<0.01) of group A after treatment compared to group A before treatment, group B and control group. On
the other hand, serum TNF-aR (P55) showed significant decrease (p <0.05) in group A after treatment
compared to group A before treatment, group B and control group. TNF-aR (P55) showed positive
correlation with sALT and sAST. Also, serum GH level decreased in group A after treatment compared to
the other studied groups; but, this decrease was not statistically significant Conclusion Pegylated INF α-2a
and Ribavirin are effective combination in treatment of chronic HCV genotype 4. Insulin and TNFaR

2. (P55) correlate with HCV infection and could be used as a marker of peg - IFN α-2a and Ribavirin
response while IL-1ra and GH are of no value.
Key words: HCV, HCV patients treated with IFN and ribavirin, cytokines and receptors and hormones.
INTRODUCTION:
Chronic Hepatitis C ( HCV ) is a major public health problem in Egypt. It is caused by genotype 4 in
more than 90 % of the patients.1 Early treatment of HCV will markedly reduce the progression to cirrhosis,
decompensated disease and hepatocellular carcinoma.2
Combined therapy using Interferon alfa (IFNa) and Ribavirin (RIB) represents the standard treatment
in patients with chronic hepatitis C. However, the percentage of responders to this regimen is still low,
while its cost and side effects are elevated. Therefore, the possibility to predict patient's response to the
above treatment is of paramount importance. The viral genotype, the degree of inflammation, fibrosis and
the viral load prior to treatment are considered the strongest predictors of response to antiviral therapy.3
Until recently interferon alfa (INFa) and ribavirin were the combination of choice in treatment of
HCV. Response of Egyptian patients with chronic hepatitis C to standard therapy of interferon and ribavirin
combination is unsatisfactory and only less than 40 % of Egyptian patients had sustained virologic response
(SVR).4,5 Factors that influence response rate to interferon therapy are numerous and include both host and
viral factors.6
Pegylated INF has longer half life than standard INF and can be administered once weekly. So, its
combination with ribavirin resulted in SVR in 82 % of patients with genotype 2 and 3 and 42% of patients
with genotype 1.7 Good response of other genotypes (2 & 3) to Pegylated INF therapy pushed us to study
its efficacy on genotype 4.3
The number of patients with genotype 4 who were enrolled in European studies was too small to be
included in statistical analysis. Also, the response of this genotype 4 to pegylated INF with ribavirin was
not properly studied in the Middle East and north Africa.1
Interleukin-1 (IL-1) is a cytokine that plays an important role in initiating the cascade of events of
immuno-inflammatory responses through co-stimulation of T lymphocytes, B-cell proliferation and
induction of adhesion molecules and stimulation of the production of other inflammatory cytokines. The
role of IL-1 in immuno-inflammatory responses is highlighted by the presence of endogenous regulators
(IL-1 receptor antagonist, soluble receptors type 1 and II, human IL-1 accessory protein) that, when
secreted into the blood stream may serve as endogenous regulators of IL-1 action.8
Hepatitis C virus (HCV) infection is resistant to interferon alpha (IFN-Alpha) in some patients. The
mechanism of this resistance is unknown.7 It was proved that Interleukin-1 receptor antagonist (ILI-Ra) is
induced by IFN-alpha and is a good indicator of IFN activity, and this increase indicates that IFN receptors
are functioning in patients with IFN-resistant hepatitis C and that the lack of response is related to other
virologic or immunologic factors.9

3. Cirrhosis is characterized by high growth hormone (GH) levels which fail to decrease and often
paradoxically increase after administration of glucose or insulin.10,11 The cause of this high GH level
remains uncertain. It may be a decrease in its metabolic clearance rate or diminish in liver growth hormone
receptors.12 Insulin resistance is present in nearly all patients with liver cirrhosis, but its etiology remains
unclear. Recent studies have shown that tumor necrosis factor-a (TNF-a) system is involved in the insulin
resistance of liver cirrhosis, as serum concentrations of TNF-a, and soluble TNF receptors (sTNF-RI and
sTNF-RII) are increased in cirrhotic patients.13 Itoh et al4, proved that the serum levels of sTNFRs
increased in proportion to the severity of liver disease; and, that the levels of sTNFRs revealed significant
correlations with the serum levels of alanine aminotransferase and aspartate aminotransferase.14
It is presumed that resolution of hepatitis C, as evidenced by normalization of liver function tests and
disappearance of hepatitis C virus (HCV) RNA from serum reflects virus eradication.15
In this study our aim is to evaluate the role of IL-1ra, and TNFaRI (P55) which are receptors
related to inflammatory response and, GH and Insulin which are hormones metabolized in the liver as
biochemical non invasive markers of severity of liver disease due to HCV infection genotype 4, whether
cirrhotic or non-cirrhotic. The effect of interferon alpha 2a and ribavirin therapy on their levels and
whether they could be used as parameters predicting the outcome of interferon alpha 2a therapy in patients
with chronic HCV infection
Patients and methods:
This study was conducted on 12 healthy control persons and 54 HCV chronic hepatitis
patients (continue with us till the end of the study out of group of patients) who had positive
anti-HCV (detected by ELISA) and detectable HCV RNA (by RT- PCR amplicor molecular
system, F Hoffmann - La roche Basel Switzerland) in their serum and did not receive antiviral
therapy for HCV before (naïve patients). All chronic hepatitis patients were of genotype 4 as
detected by the Inno Lippa HCV II assay (innogenetics inc., GA, USA). HBsAg was negative
in all patients (done by ELISA). Group A: 42 patients were highly selected from a group of
HCV patients receiving a schedule of antiviral treatment for 1 year treatment. They were
collected according to the following inclusion criteria: Genotype 4, with positive HCV-RNA,
elevated ALT more than two folds the upper limit of normal, and negative autoantibodies
including anti-ANA, anti-AMA, anti-thyroid globulin and anti LKM antibodies. exclusion
criteria: HBsAg positivity (by ELISA), diabetes, cirrhosis (by liver biopsy), disturbed thyroid
function, Hb < 11g/dl, platelets count < 100.000/cumm, and WBCs < 1500/cumm, and their
Group B: 12 patients had the same inclusion and exclusion criteria but had cirrhosis on liver
biopsy.

4. Study design and strategy of treatment:
The study was done over a period of 30 months. The 54 studied Egyptian patients (who
continue till the end) were classified into two groups:
Group A: 42 patients with chronic HCV hepatitis received 180 μg Pegylated INF α-2a
subcutaneously once weekly & 1200 mg Ribavirin/ day in two doses by oral route.
Group B: 12 patients with liver cirrhosis received 130 μg Pegylated INF α-2a once weekly
& 1200 mg Ribavirin/ day in two doses.
Blood samples were collected under aseptic conditions before treatment, after 12 weeks,
after 48 weeks of the combined treatment and 6 months after completion of the treatment
schedule to be assayed for our studied parameters. All subjects were fasting overnight before
sampling. Serum was separated from the other contents and stored at –70° C untill assayed.
The initial response (IR) was defined as the clearance of the virus or reduction of the viral
load by two logs after 12 weeks of treatment. Patients who failed to achieve IR discontinued
treatment Patients who achieved initial response continued treatment for 48 weeks to prevent
relapse. The end of treatment response (ETR) was defined as clearance of the virus at the end
of treatment (48 weeks).
Reassessment of ALT and HCV RNA were done 6 months after stopping therapy. Patients
who had absent HCV after these 6 months were defined to have sustained virological response
(SVR).
The dose of Pegylated INF α-2a was reduced to 130 μg in two patients from group A when
the WBCs count dropped below 1500/cmm and rose again in one of them after improvement of
the count
The dose of Ribavirin was reduced to 600 mg / day in 8 patients when the Hb level dropped
below 10 mg/dl.
I. Clinical evaluation:
- A detailed history and clinical examination was performed for all the patients with special
emphasis on the possible duration of the HCV infection, age and sex.
- Ultrasonography was done by an ultrasound machine Hitachi EUB 515 A, using a convex
linear transducer 3.5 MHz to exclude cirrhotic patients.

5. - Biopsy was done by a Hepafix needle 14 mm in diameter and the biopsy was done according
to the Menghini technique to confirm the diagnosis. All biopsy specimens were immersed in
10% formol and sent for histopathological analysis.
II. Laboratory tests:
The following investigations had been done to all patients at recommended times before, during and
after treatment :-
- Liver function tests (Serum albumin, direct bilirubin, AST and ALT) and CBC were done before and
every 2 weeks after starting treatment using standard laboratory methods.
- Fasting blood sugar was done using standard laboratory method to exclude diabetes.
- Hepatitis marker HCV-RNA by (PCR).
- ANA, AMA, T3, T4, TSH (By ELISA), Anti-thyroid globulin Ab, anti LKM by indirect
immunofluorescence antibody test using (the Binding site LTD, Birmingham, England).
- Serum Insulin by ELISA using (Biosource Europe S.A.)
- Serum growth hormone level by enzyme immune assay method (IBL, Hamburg, Germany, and quorum
Diagnostics Inc., Vancover, British Colombia, Canada respictevely).
- Serum Interleukin I- receptor antagonist by ELISA (Biosource IL-ra Cytoscreen Kit, Europe S.A. Rue
de L' Industrie, 8 B-1400 Nivelles Belgium.)
- Serum TNF a RI by EASIA using Biosource Kit
Statistical analysis:
Medians were compared using the median test. Continuous variables were expressed as
mean ± SD and were compared by using paired t-test or correlated by using simple regression
done by Excel program. Differences were considered significant if P< 0.01.
RESULTS:
This study was conducted on 54 HCV patients, their ages range (20 - 70) all were Egyptian; 41 males
and 13 females. Results were presented as mean ±SD. Table (1) showing the characteristics of the studied
group and the main positive findings of the studied parameters after the combined treatment of pegylated
interferon α 2a and ribavirin.
Table (1): shows characteristics of the 54 HCV genotype 4 patients
Gender: Count %
Male 41 76.00%
Female 13 24.00%
Total 54 100.00%
Age: Total 54 100.00%
From 20 to 39 15 27.78%
From 40 to 54 34 62.96%
From 55 to 70 5 9.26%

6. Non- cirrhotic 42 77.7%
Cirrhotic 12 22.3%
Table 2: Clinical data of Chronic HCV patients:
Clinical Data Non-cirrhotic (n = 42) Cirrhotic (n = 12)
Presenting symptoms: Fatigue:
31
9
Dyspepsia
23
7
Upper abdominal pain
19
8
History of Jaundice
8
6
Bleeding tendency
5
5
Non (accidental)
5
0
Signs:
jaundice
Hepatomegaly
Splenomegaly
Oedema
Ascites
Foetor hepaticus/ palmar erythema
Spider Naevi/ flabbing tremors
15
28
13
0
0
0/0
0/0
6
3
7
3
0
0/3
2/0
Table 3: Endoscopic and ultrasonographic findings in patients with chronic HCV infection:
Clinical Data Non-cirrhotic (n = 42) Cirrhotic (n = 12)
Endoscopic findings:
Oesophageal varices:
1. Grade: 1/2
2. Grade: 3/4
Gastric varices
Congestive gastropathy
1. mild
2. severe
Peptic ulcer
Chronic gastritis
2/1
0/0
0
4
0
2
15
4/3
1/0
2
7
2
1
7
Ultrasonographic findings:
Liver size:
a. Average size
b. Mildly enlarged
c. Markedly enlarged
d. Shrunken
Echopattern:
Long axis of spleen
Collaterals:
23
11
7
1
diffuse
13+/- 1.65
3
3
4
0
5
coarse cirrhotic
16 +/- 3.27
7

7. Gall stones 5 4
Table 4: Liver function tests and viral load in HCV patients before and after treatment.
Clinical Data Non-cirrhotic Gp A (n = 42) Cirrhotic group B (n = 12)
ALT before/after treatment U/L 101.5 ± 8.5 / 39.4 ± 4.93* 76.3 ± 5.92 / 45.43 ± 4.54*
AST before/after treatment U/L 81 ±7.21 / 40.17 ± 4.37* 93 ± 4.62 / 49.94 ±6.73*
Bilirubin before/after treatment (mg/dl) 1.8 ± 0.61 / 1.1 ± 0.23 2.67 ± 0.83 / 1.52 ± 0.63
Serum albumin before/after treatment 3.9 ± 0.23 / 4.05 ± 0.31 3.1 ± 0.41/3.31 ± 0.47
Prothr. time before/after treatment 12.16 ± 1.04/ 11.74 ± 1.01 13.54 ± 1.48 / 12.62 ± 1.36
HCV RNA load > 2 X106 copies/ml 11/7 3/2
HCV RNA load < 2 X106 copies/ml 31/9 9/6
* Significant decrease compared to its level before treatment
Table 5: Histological findings in patients with chronic HCV infection:
Clinical Data Non-cirrhotic Group A (n = 42) Cirrhotic group B (n = 12)
Liver biopsy findings:
Activity:
1. Mild
2. Moderate
3. Severe
Grade:
1. Grade 1
2. Grade 2
3. Grade 3
4. Grade 4
5. Grade 5
(cirrhosis)
27
11
4
32
5
4
1
0
3
7
2
0
0
0
0
12
Patients with initial response (IR) in both cirrhotic and non Cirrhotic groups showed decreased end of
treatment (ETR) response that became 73.817% (31/42 patients) in non cirrhotic and 58.33% (7/12
patients) of the initial responders in cirrhotic. Sustained virological response (SVR) was 26/42 (61.91%)
and 4/12 (33.33%) in both groups. The biochemical response was also initially high then decreased in both
groups. The difference was significant between both groups concerning virological response and the
biochemical response (P <0.05).
Table 6: Virological response (disappearance of HCV RNA in serum)in both groups of chronic
HCV:
Initial response (IR) End of treatment
Response (ETR)
Sustained Virological
response (SVR)
Group A 42/42 31/42 (73.817%) 26/42 (61.91%)

8. Group B 12/12 7/12 (58.33%) 4/12 (33.33%)
Table 7: The mean values of the studied parameters in treatment groups (before and after treatment)
and the reference group.
HCV without
cirrhosis
Before
treatment
HCV without
cirrhosis after
treatment
Cirrhosis
Before
treatment
cirrhosis after
treatment
Referenc
e group
TNF-αR (P55)
mean ± SD 3.91±1.98 1.85 ±0.55**† 7.4 ±2.98**† 6.53 ±2.79** 3.23 ± 0.28
range 1.4 - 9.5 1.3 - 3.9 2.9 - 11.2 2.8 - 11.2 2.9 - 3.7
IL-1 Ra
Mean ±SD 193.4±42.07** 214.7±44.04** 167.08±33.8**† 166.25±44.42**
‡ 133.5±37.7
range 145 - 256 145 - 276 135 - 215 115 - 225 71 - 184
GH
Mean ±SD 7.56±1.33** 4.93±1.45† 23.15±10.9**† 22.34±10.93** 4.57±1.93
range 2.5 - 8.0 2.5 - 7 5.5 - 30.5 5.5 - 30.5 2.0 - 7.0
Insulin
Mean ±SD 26.72±8.27 48.8±16.07**† 51.12±16.8**† 53±19.62** 14.49±5.5
Range 14.5 - 36.5 28 - 70 14.5 - 85 32 - 80 8.5 - 28
** Statistically Significant compared to the reference group.
† Statistically significant compared to the HCV without cirrhosis before treatment
NB: cirrhosis after treatment group show no significant change compared to its level before treatment.
The two HCV groups showed significantly higher basal levels of TNF-αR (P55) before
treatment compared to the reference group and a significant decrease in its level after treatment.
Its level was significantly higher in cirrhotic than non-cirrhotic patients whether before or after
treatment. IL-1ra showed significantly higher levels in the two treatment groups before
treatment compared to the reference group. Its level increased significantly in non-cirrhotic
group after treatment but didn’t show significant changes in cirrhotic patients. There were
higher levels of GH in the two treatment groups before treatment compared to the reference
group which is significant for cirrhotic group but of no significance for non-cirrhotic group and
a significant decrease of GH in non-cirrhotic patients after treatment compared to their level
before treatment. Insulin level was significantly higher in HCV patients than control group and
showed a significant increase in its level after treatment compared to its level before treatment.
The levels of both GH and insulin were significantly higher in cirrhotic than non-cirrhotic
patient.
Discussion:

9. Serum ALT and HCV-RNA by PCR are the standard markers to assess liver disease and to monitor
response to therapy in patients with chronic HCV infection. Other factors as viral load, genotype and
grade of fibrosis are also, used to predict the treatment outcome of such patients (8). In 1995 Martinot et
al., proved that viral genotype is a major predictor of SVR and patients with genotype 4 were considered
as “difficult to treat” by the standard interferon (9).
In this study we tried to estimate the role of IL-1ra, TNF-α R (P55) as a receptors related to
inflammatory response and, GH and insulin as a hormones metabolized in the liver in HCV infection,
cirrhotic and non-cirrhotic. Also to find their significance as non invasive biochemical markers that may
correlate with HCV infection and predict the outcome of pegylated interferon-α 2a with ribavirin therapy
in patients with chronic HCV infection genotype 4.
In our study the growth hormone levels were higher in the two studied groups before therapy
compared to the reference group. This higher level was highly significant in cirrhotic patients
while not significant in patients with early liver disease (non-cirrhotic). Also it was significantly
higher in cirrhotic than non-cirrhotic group. This means that the increases in the level of growth
hormone are related directly to the severity of the disease. After treatment its level decreased
significantly only in non-cirrhotic patients (early liver affection). It did not remarkably change
after treatment in cirrhotic patients (advanced liver disease) where treatment was not able to
correct the abnormal levels. Thus, the increase in its basal level and the return of it to normal
after treatment depends on the severity of liver disease. This was agreed by others who proved that
cirrhosis is characterized by high growth hormone (GH) levels (10, 11). The cause of this high (GH) level
remains uncertain. It may be a decrease in its metabolic clearance rate or diminish in liver growth
hormone receptors (12).
In this study also, insulin level was significantly higher in HCV patients (all are non-diabetic)
compared to control group and showed a significant increase in its level after treatment compared to its
level before treatment. The levels of insulin were significantly higher in cirrhotic than non-cirrhotic
patient. Thus, insulin also rises proportionately with the degree of liver affection, being more elevated in
cirrhotic patients. Treatment with interferon and ribavirin increased insulin levels in such patients more
and more. This was previously reported by others (17). HCV infection changes a subset of hepatic
molecules regulating glucose metabolism. A possible mechanism is that HCV core-induced suppressor of
cytokine signaling (SOCS3) promotes proteosomal degradation of insulin receptor substrates IRS1 and
IRS2 through ubiquitination. In patients with HCV infection there was increase in fasting insulin levels
and that increase was associated with the presence of serum HCV core, the severity of hepatic fibrosis
and a decrease in expression of insulin receptor substrate IRS1 and IRS2, which are central molecules of
the insulin-signaling cascade. BMI, serum levels of AST and TNF-alpha were related with HOMA-IR
(which is a measure of insulin resistance). Hepatic fibrosis and inflammation appear to play key roles in
the increase in insulin resistance and insulin level in patients with chronic HCV infection (18, 19).

10. Previous studies had found that impaired glucose tolerance and iron overload were frequently
demonstrated in hepatitis C virus (HCV)-related liver diseases (20).
Our study revealed a high level of IL-1ra in both groups before and after treatment in HCV patients
compared to the reference group. Its level increased significantly after treatment in patients with earlier
degree of liver affection but didn’t change in cirrhotic patients. In 1999, Gramantieri et., al (21) proved
that the increased level of IL-1Ra may contribute to the pathogenesis and the activity of chronic active
hepatitis C (21). In 2002 Cotler et al (9) proved that Serum IL-1Ra levels increased rapidly in all patients
with hepatitis C after IFN-alpha administration, irrespective of their virologic response (9). IL-1Ra levels
remained elevated at 1 week but were similar to baseline by week 2 of treatment in patients receiving
continuous therapy. The increase in IL-1Ra indicates that IFN receptors are functioning in patients with
IFN-resistant hepatitis C and that the lack of response is related to other virologic, genetic or
immunologic factors (22).
In this study, the two HCV groups showed also significantly higher basal levels of TNF-αRI (P55)
before treatment compared to the reference group and a significant decrease in its level after treatment
mainly at the non cirrhotic group, while its decrease in the cirrhotic group was not significant compared
to the reference group. Its level was significantly higher in cirrhotic than non-cirrhotic patients whether
before or after treatment, as its levels were related directly to the severity of infection. In 1999, Itoh et al
proved that in the sustained responder group, the levels of sTNF-R p55 showed a significant decrease (p <
0.0002.). He also proved that the TNF alpha-R- mediated pathway, is involved in the hepatic
inflammation-fibrosis process in chronic hepatitis C (14). More recent study revealed that hepatitis C
virus (HCV) core protein modulates multiple cellular processes, including those that inhibit tumor
necrosis factor alpha (TNF-alpha)-mediated apoptosis such as TNF-alpha R1 and that this may play
important role in the pathogenesis of HCV liver disease (23). Also, the number of TNF-alpha-producing
cells was found to be increased in the liver and the circulating levels of TNF-alpha were significantly
increased in patients with chronic hepatitis. Soluble TNF receptors, TNF-alphaRI (p55) and -alphaRII
(p75), and IL-10, act as TNF-alpha buffer. Patients with liver cirrhosis (LC) and hepatocellular carcinoma
(HCC) had significantly elevated levels for sTNF-alphaRII compared with the other patient groups and
controls (24). In another study, correlation was found between the two soluble TNFRs (P < 0.0001) and
between the soluble TNFRs and ALT levels (P < 0.003). It was suggested that these sTNF-alphaR closely
correlated with disease progression and may reflect the degree of inflammation in the liver and even may
be related to the development of HCC (25). Other study revealed that treatment with interferon did not
affect serum levels of sTNF-alphaRs and, that the lower levels of soluble TNFR-p75 were present from
day 3 in patients who had significant virus decay at day 30 (26). In one study, it was found that both
tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) TRAIL-R1 and -R2 showed
coefficient correlation with caspase-3 activity, and were strongly associated with apoptosis in human
HCC (27). Thus, it was found that activation of the tumour necrosis factor (TNF)-alpha system has a
pivotal role in the inflammatory process of chronic hepatitis C, and TNF-alpha levels correlate with the

11. degree of inflammation. Also, TNF-alpha is known to cause insulin resistance, with similar defects in the
insulin signalling pathway to those described in HCV infection and HCV patients have significantly high
levels of soluble TNF-alpha receptors particularly in those with diabetes (28).
It is concluded from this study that pegylated INF-α combined with ribavirin therapy is the regimen of
choice in treating chronic HCV infection of genotype 4 especially in non cirrhotic patients for at least 48
weeks. The increase in the basal levels of GH and TNF-αRI (P55) and the reduction of these levels after
treatment depends on the severity of liver disease, thus it can be used successfully as a sensitive, non-invasive
and cheap liver function tests related to both the severity of the disease and to the response to
medical treatment. P55 can be used successfully as a liver function test denoting improvement of
patients by this treatment with or without HCV RNA denoting regression of the viremia and viral
affection of liver cells. P55 and IL-1ra could be also used on selecting the patients to be treated
successfully. GH and Insulin could be used for the follow up.
REFERENCES:
1. Zekry AR, Bahanssy AA and Ramadan AS. Hepatitis c virus genotyping versus serotyping in
Egyptian patients, Infection (2001); Jan-Feb; 2a (1) 24-26.
2. Attia MA, : Prevalence of HBV & HCV in Egypt and Africa. Antivir ther (1998); 3 supplement 3, 1-9.
3. Maiellaro PA; Cozzolongo R; Marino P: Artificial neural networks for the prediction of response to
interferon plus ribavirin treatment in patients with chronic hepatitis C. Curr Pharm Des. (2004);
10(17):2101-9.
4. Mc Hutchinson JG, Gordon SG and Schiff E: INF α-2a alone or in combination with ribavirin as
antiviral treatment of chronic hepatitis C, NEJM (1998); 339 : 1485-92.
5. Poynard T, Marcellin P and Lees S: Randomized trial of INF α-2b plus ribavirin for 48 weeks or 24
weeks versus INF α-2b plus placebo for 48 weeks for treatment of chronic HCV hepatitis., Lancet
(1998); 532:1426-32.
6. El-Zayadi A, Selim O, Haddad S, Simmonds P, Hamdy H, Badran HM and Shawky S: “Combination
treatment of interferon alpha-2b and ribavirin in comparison to interferon monotherapy in treatment of
chronic hepatitis C genotype 4 patients”. Ital J Gastroenterol Hepatol (1999); 31: 472-475.
7. Mannervik B, Awasthi YC and Board PG: Nomenclature for human glutathione-S transferase (letter).
Biochemical journal (1992) ; 282: 305-306.
8. Libra M; Mangano K; Anzaldi M; Quattrocchi C; Donia M; di Marco R; Signorelli S; Scalia G;
Zignego AL; de Re V; Mazzarino MC; Nicoletti F: Analysis of interleukin (IL)-1beta IL-1 receptor

12. antagonist, soluble IL-1 receptor type II and IL-1 accessory protein in HCV-associated
lymphoproliferative disorders. Oncol Rep. (2006); 15(5):1305-8.
9. Cotler SJ., Craft T., Ferris M., Morrisey M., McCone J., Reddy KR., Conrad A., Jensen DM., Albercht
J., Taylor MW. : Induction of IL-Ira in resistant and responsive hepatitis C patients following
treatment with IFN-con1.: J Interferon Cytokine Res (2002); 22 (5): 549-54.
10. Riley WJ, McCann VJ. : Impaired glucose tolerance and growth hormone in chronic liver disease. Gut
(1981); 22:301-5.
11. Shanker TP, Fredi JL, Himmelstein SS: Elevated growth hormone levels and insulin resistance in
patients with cirrhosis of the liver. Am J Med Sci (1986); 291: 248-54.
12. Shmueli E, Srewart K, Alberti KG, Record CO: Growth hormone, insulin like growth factor-1 and
insulin resistance in cirrhosis. Hepatology (1994); 19: 322-8.
13. S.Y. Lin, Y.Y. Wang, and W.H.H. Sheu ::Increased serum soluble tumor necrosis factor receptor
levels are associated with insulin resistance in liver cirrhosis. Metabolism Clin. and Exp. (2004);
53;Issue 7; 922- 926.
14. Itoh Y;Okanoue T; Ohnishi N; Sakamoto M; Nishioji K; Minami M; Murakami Y; Kashima K.
:Serum levels of soluble tumor necrosis factor receptors and effects of interferon therapy in patients
with chronic hepatitis C virus infection. Am J Gastroenterolg (1999): y; 94 (5):1332-40.
15. Pham TN; MacParland SA; Mulrooney PM; Cooksley H; Naoumov NV; Michalak TI: Hepatitis C
virus persistence after spontaneous or treatment-induced resolution of hepatitis C. J Virol 2004
Jun;78(11):5867-74.
16. Martinot-Pegnoux M, Marcellin P and Pouteau M: Pretreatment serum hepatitis C virus RNA levels
and hepatitis C virus genotype are the main and independent prognostic factors of sustained response
to interferon alfatherapy in chronic hepatitis C. Hepatology (1995); 22:1050-6.
17. Mc Hutchinson JG, Gordon SG and Schiff E: INF α-2a alone or in combination with ribavirin as
antiviral treatment of chronic hepatitis C, NEJM; (1998) ; 339 : 1485-92.
18. Maeno T; Okumura A; Ishikawa T; Kato K; Sakakibara F; Sato K; Ayada M; Hotta N; Tagaya T;
Fukuzawa Y; Kakumu S : Mechanisms of increased insulin resistance in non-cirrhotic patients with
chronic hepatitis C virus infection. J.Gastroenterol. Hepatol. (2003) ; 18(12): 1358-63.
19. Kawaguchi T; Yoshida T; Harada M; Hisamoto T; Nagao Y; Ide T; Taniguchi E; Kumemura H;
Hanada S; Maeyama M; Baba S; Koga H; Kumashiro R; Ueno T; Ogata H; Yoshimura A; Sata M :
Hepatitis C virus down-regulates insulin receptor substrates 1 and 2 through up-regulation of
suppressor of cytokine signaling 3. Am.J. Pathol. (2004); 165(5):1499-508.

13. 20. Furutani M; Nakashima T; Sumida Y; Hirohama A; Yoh T; Kakisaka Y; Mitsuyoshi H; Senmaru H;
Okanoue T: Insulin resistance/beta-cell function and serum ferritin level in non-diabetic patients with
hepatitis C virus infection. Liver Intern (2003);23(4):294-9
21. Kwon SY; Kim SS; Kwon OS; Kwon KA; Chung MG; Park DK; Kim YS; Koo YS; Kim YK;
Choi DJ; Kim JH: Prognostic significance of glycaemic control in patients with HBV and HCV-related
cirrhosis and diabetes mellitus. Diabet. Med (2005);22(11):1530-5.
22. Gramantieri L; Casali A; Trere D; Gaiani S; Piscaglia F; Chieco P; Cola B; Bolondi L : Imbalance of
IL-1 beta and IL-1 receptor antagonist mRNA in liver tissue from hepatitis C virus (HCV)-related
chronic hepatitis. Clin Exp Immunol (1999) Mar;115(3):515-20.
23. Saito K; Meyer K; Warner R; Basu A; Ray RB; Ray R : Hepatitis C virus core protein inhibits tumor
necrosis factor alpha-mediated apoptosis by a protective effect involving cellular FLICE inhibitory
protein. J. Virolog. ( 2006); 80;9: 4372-9.
24. Kakumu S; Okumura A; Ishikawa T; Yano M; Enomoto A; Nishimura H; Yoshioka K; Yoshika Y :
Serum levels of IL-10, IL-15 and soluble tumour necrosis factor-alpha (TNF-alpha) receptors in type
C chronic liver disease.Clin.Exp.Immunol. (1997);109(3):458-63.
25. Riordan SM; Skinner NA; Kurtovic J; Locarnini S; McIver CJ; Williams R; Visvanathan K: Toll-like
receptor expression in chronic hepatitis C: correlation with pro-inflammatory cytokine levels and liver
injury.Inflamm. Response (2006); 55(7): 279-85.
26. Torre F; Rossol S; Pelli N; Basso M; Delfino A; Picciotto A: Kinetics of soluble tumour necrosis
factor (TNF)-alpha receptors and cytokines in the early phase of treatment for chronic hepatitis C:
comparison between interferon (IFN)-alpha alone, IFN-alpha plus amantadine or plus ribavirin.
Clin.Ex. Immunol. (2004);136(3):507-12
27. Yano Y; Hayashi Y; Nakaji M; Nagano H; Seo Y; Ninomiya T; Yoon S; Wada A; Hirai M; Kim SR;
Yokozaki H; Kasuga M : Different apoptotic regulation of TRAIL-caspase pathway in HBV- and
HCV-related hepatocellular carcinoma.Int.J. Clin.Med. (2003);11(4):499-504
28. Knobler H; and Schattner A : TNF-{alpha}, chronic hepatitis C and diabetes: a novel triad.
QJM(2005);98 (1): 1-6.
دراسة الهمية الكليكينية لكل من النسسولين وهرمون النمو و مستقبلت عامل التآكل الورمى ألفا و
مضادات مستقبلت النسترلوكين- ١ و دللتها فى تطور مرض اللتهاب الكبدى المزمن ج النوع
الوراثى ٤ وذلك قبل وبعد العلج بالنسترفيرون ألفا ۲ أ والريبافيرين

14. نسهال العسالى* ، نسعيمة العشرى*، أمنية البندارى*، شندى محمد شندى**، ميرفت الدمراوى***،محمد علصصى صصصابر**** و
ايهاب الدباغ****
معهد تيودور بلهارس للبحاث، *قسم الكيمياء الكلينيكية و و قسم الجهاز الهضمى والكبصصد والمصصراض المتوطنصصة و*** قسصصم
الرعاية المركزة و**** قسم الكيمياء الحيوية
ملخص البحث:
ان العلج بالنسترفيرون ألفا ۲ أ والريبافيرين يمثل العلج المتعارف عليه لمرض اللتهاب الكبدى المزمصصن ج ولكصصن نسسصصبة
الستجابة قليلة والعراض الجانسبية والتكلفة عالية ولذلك فان امكانسية البحث عن عوامل نستوقصع مصصن خللهصا اسصتجابة المرضصى
لهذا العلج لهو ذات أهمية غير عادية.
ولذلك كان الهدف من هذا البحث هو تقييم الهمية الكلينيكية والدللة فى تطور المرض لكل مصن مسصتقبلت عامصل التآكصل
الورمى ألفا و مضادات مستقبلت النسترلوكين- ١والمرتبطة بالسيتوكينات المسببة لللتهابات وكذلك النسسولين وهرمون النمصصو
والتى يتم التخلص منها عن طريق الكبد و ذلك فى مرضى اللتهاب الكبدى المزمن ج النوع الوراثى ٤ المتليف والغير متليصصف،
والبحث عن أهمية هذه العوامل كدللت كيميائية غير نسافذة لتقييم مراحل العدوى وتوقع استجابة المرض للعلج.
وقد شملت الدراسة ٥٤ مريضا باللتهاب الكبدى المزمن ج النوع الوراثى ٤ مقسمين ال مجموعتين: الولى وتشمل ٤۲
مريضا حالتهم مستقرة و ل يوجد عندهم تليف كبدى والمجموعة الثانسية وتشمل ١۲ مريضا حالتهم مستقرة أيضا و لكن يوجصصد
عندهم تليف كبدى بالضافة الى ١۲ حالة مقارنسة سليمة. وقد تم علج المرضى بالنسترفيرون ألفا ۲ أ ( ١٨٠ ميكروجرام لكصصل
مريض اسبوعيا فى المجموعة الولى و ١٣٠ ميكروجرام لكل مريض اسبوعيا فصى المجموعصة الثانسيصة ) والريبصافيرين ١۲٠٠
مجم مقسمة على جرعتين يوميا. وقد تمعمل الفحوص اللزمصة لتقييصم المرضصى قبصل وبعصصد العلج شصصاملة تحاليصصل الفيصصروس و
. النسسولين وهرمون النمو و مستقبلت عامل التآكل الورمى ألفا و مضادات مستقبلت النسترلوكين- ١
و قد أظهرت النتائج استجابة فى ٨۲,٧٣ % عنصصد نسهايصة العلج و ٩١,٦١ % اسصتجابة مسصتديمة فصى المجموعصة الولصصى
وفصصى ٣٣,٥٨ % عنصصد نسهايصصة العلج و ٣٣,٣٣ % اسصصتجابة مسصصتديمة فصصى المجموعصصة الثانسيصصة. وقصصد ازداد مسصصتوى مضصصادات
مستقبلت النسترلوكين- ١ بعد العلج فى المجموعتين بدون دللة إحصائية، كما ازداد مستوى النسسولين فى المجموعة الولصصى
زيادة ذو دللة إحصائية عنه قبل العلج وعنه فى المجموعة الثانسية وحالت المقارنسة، وقصصد انسخفصض مسصتوى مسصتقبلت عامصل
التآكل الورمى ألفا انسخفاضا ذو دللة إحصائية عنه قبل العلج وعنه فى المجموعة الثانسية وحصصالت المقارنسصصة والصصذى كصصان أيضصصا
متناسبا تناسبا طرديا مع إنسزيمات الكبد. كما انسخفض مستوى هرمون النمو ولكنه انسخفاضصا غيصصر ذى دللصة إحصصصائية عنصصه قبصل
العلج وعنه فى المجموعة الثانسية وحالت المقارنسة.
يستنتج من هذا البحث أن العلج بالنسترفيرون ألفا ۲ أ والريبافيرين هو علج فعال فصى حصالت اللتهصاب الكبصدى المزمصن ج
النوع الوراثى ٤ و أن مستوى النسسولين و مستقبلت عامل التآكصل الصورمى ألفصا لصه دللصة و مرتبصط بوجصود العصصدوى وتطصوره
. واستجابته للعلج، ول ينطبق ذلك على هرمون النمو و مضادات مستقبلت النسترلوكين- ١