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Insulin resistance, hepatic steatosis and hepatitis C: A complex relationship with relevant clinical implications
Marco Arrese
,
Corresponding author
marrese@med.puc.cl

Correspondence and reprint request:
, Arnoldo Riquelme*, Alejandro Soza*
* School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Relationships between metabolic and viral factors and hepatic steatosis in the setting of chronic hepatitis C&#46; Insulin resistance is the major determinant of steatosis and in turn is aggravated by several genotype-independent mechanisms probably related to the presence of viral proteins in the hepatocyte and due to the inflammatory response linked to viral infection&#46; Several specific steatogenic mechanisms operate in genotype 3 infection&#46; Alcohol consumption can also contribute to steatosis development&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="p0050" class="elsevierStylePara elsevierViewall">Insulin resistance &#40;IR&#41; is a complex pathophysiological condition where higher-than-normal concentrations of insulin are needed to maintain a normal glycemia and adequate glucose utilization in insulin target tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IR is of global importance since is closely linked to an epidemic condition such as obesity and it precedes and predicts the development of type 2 diabetes mellitus &#40;T2DM&#41;&#46; IR is also considered the main underlying cause of the so-called metabolic syndrome&#44; a cluster of metabolic abnormalities that are associated to increased cardiovascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the field of liver diseases&#44; IR has reached significant notoriety as it promotes hepatic steatosis and for being considered the major underlying defect of non-alcoholic fatty liver disease &#40;NAFLD&#41;&#44; the most common liver disease in the West&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0055" class="elsevierStylePara elsevierViewall">IR is frequently found in patients with chronic hepatitis C &#40;CHC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Estimations from different sources indicate that roughly 50&#37; of patients with CHC exhibit some evidence of insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This association is more frequent than that expected or predicted by chance and may have impact in the natural history of the disease as well as on treatment outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In addition&#44; recent research had disclosed the existence of a complex relationship between the hepatitis C virus &#40;HCV&#41; infection and insulin resistance where viral-induced and host&#8217;s metabolic abnormalities seem to act in a mutually reinforcing manner&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This review summarizes recent information on the intricacies and links between hepatitis C viral infection and IR&#46; For a more detailed review of the topic the reader is referred to recent in-depth and state-of-the art papers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Epidemiological Aspects</span><p id="p0060" class="elsevierStylePara elsevierViewall">As mentioned before&#44; the association of IR and CHC occurs more often than predicted by chance with figures ranging between 30 to 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This was first noted in 2003 by Hui&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> that compared values of fasting C peptide&#44; serum insulin and homeos-tatic model assessment &#40;HOMA-IR&#41; in HCV infected patients and healthy volunteers showing that patients with HCV infection exhibit significantly higher levels of C peptide&#44; fasting serum insulin and HOMA-IR compared with matched controls&#46; High frequency of IR in HCV-infected patients has been confirmed by several studies with some differences related to the way that IR is assessed&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> HOMA-IR is the most commonly used tool which has a reasonable but not perfect correlation with the gold standard tool which is the 2-step hyperinsulinemic-euglycemic clamp&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="p0065" class="elsevierStylePara elsevierViewall">IR is also likely responsible of the increased prevalence and incidence of T2DM in patients with CHC&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The reported prevalence of T2DM in non-cirrhotic patients with CHC is between 7 to 21&#37; which is higher than that observed in other forms of chronic hepatitis or in the general population&#46; Moreover&#44; a prospective study showed that patients with HCV infection and a high-risk profile for developing T2DM developed the disease 11 times more frequently than those without HCV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In line with these findings&#44; a meta-analysis of 34 studies performed by White et al&#46; and concluded that a significant DM risk in HCV-infected cases exists in comparison to non-infected controls in both retrospective and prospective studies&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">Since IR is closely linked to hepatic steatosis is also of interest to analyze the frequency of this finding in patients with HCV infection&#46; Of note&#44; the prevalence of hepatic steatosis is also significantly increased in HCV-infected patients compared with patients with other hepatopathies reaching figures nearer to 50&#37; and ranging from 40&#37; to 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Even though hepatic steatosis is a very prevalent condition in the general population&#44; this figure is higher than that expected by chance&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Interestingly&#44; a consistent finding among published studies is that steatosis has a close relationship with viral genotype&#46; Infection with genotype 3 HCV is more strongly related to steatosis than infection by non-3 genotypes&#44; exhibiting figures of prevalence of steatosis of 70-80&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Moreover&#44; in genotype 3 HCV-infected patients steatosis correlates with viral load&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This suggests that&#44; in the case of this genotype&#44; viral-specific mechanisms promotes fat deposition in the liver cell&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> On the other hand&#44; a weaker correlation with viral load and higher values of IR parameters such as HOMA-IR index indicates that&#44; in the setting of infection with non-3 genotypes of HCV&#44; occurrence of steatosis is more closely linked to basal metabolic abnormalities and IR&#46; The latter may indeed be aggravated by viral infection&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Thus&#44; current evidence suggests that while HCV-associated hepatic steatosis is mainly virus-induced in genotype-3 infected patients&#44; host-factors &#40;mainly IR&#41; play a major role in steatosis in non-3 genotypes&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pathogenetic Considerations</span><p id="p0075" class="elsevierStylePara elsevierViewall">The relationship between IR and HCV infection is complex and bidirectional &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46; On one side IR&#44; through promotion of steatosis&#44; hepatic inflammation and a pro-fibrogenic state&#44; might increase the chance of aggravating disease activity or determine disease progression&#46; On the other&#44; HCV infection itself may&#44; through several mechanisms&#44; induce a worsening of the insulin resistant state&#44; promoting T2DM and hepatic derangements linked to lipotoxicity thus increasing liver injury&#46; A brief summary of the potential mechanisms at play in this setting is provided below&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">IR and HCV</span><p id="p0080" class="elsevierStylePara elsevierViewall">IR is a complex condition which exact cause is not yet clear&#46; It involves a disturbed action in insulin-sensitive organs such as the liver&#44; muscle and adipose tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Insulin effects are elicited after binding of insulin to its receptor that is linked to a complex signaling pathway that involves sequential activation of the insulin receptor substrates &#40;IRS&#41;&#44; phosphatidyli-nositol-3-kinase &#40;PI3K&#41;&#44; Akt and protein kinase C&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This cascade of events has been well characterized at the molecular level and essentially results in promotion of cellular storage of excess glucose as glycogen&#44; suppression of gluconeogenesis and&#44; in muscle and adipose tissue&#44; stimulation of glucose uptake after translocation of the glucose transporter GLUT4 to the plasma membrane&#46; IR results from defects at any level of the insulin receptor-related signaling pathway&#46; Details of these defects are beyond the scope of this review and can be found elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> It is of interest however&#44; to point out that HCV infection seems to be able of either directly induce or worsening a pre-existent IR&#46; Compelling evidence of the latter comes from experiments involving transgenic mice showing direct effects of HCV core protein in modulating insulin signaling&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> This effect is probably related to disturbed insulin signaling due changes in expression or activity of IRS-1&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Several other viral-related mechanisms such as increased HCV-core induction of the molecule suppressor of cytokine signaling 3 &#40;SOCS-3&#41;&#44; leading to proteasomal degradation of IRS-1 and IRS-2 have been described <span class="elsevierStyleItalic">in vitro</span><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> but its importance in the clinical setting are unknown&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">Other important aspect of the relation between IR and HCV infection is the role of hepatic and systemic inflammation&#46; It has been suggested that increased levels of pro-inflammatory cytokines such as interleu-kin &#40;IL&#41;-1&#44; tumor necrosis factor &#40;TNF-&#945;&#41;&#44; IL-6 and leptin&#44; and reduced levels of adiponectin may directly contribute to the occurrence of HCV-related IR&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Although there is <span class="elsevierStyleItalic">in vitro</span> evidence in support of this view &#40;i&#46;e&#46; TNF-&#945; interferes with insulin signaling in the liver by inducing serine phosphorylation of IRS-1 and hypophosphorylation of IRS-2&#41;&#44; a direct proof of this has been difficult in the clinical setting due to the presence of many confounders&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Steatosis and HCV</span><p id="p0090" class="elsevierStylePara elsevierViewall">fat accumulation in the liver cell &#40;steatosis&#41; can occur by many mechanisms&#46; The commonest causes are linked to alcohol consumption and metabolic de-rangements&#44; mainly IR&#44; seen in overweight and obese people with IR and&#47;or diabetes&#46; The latter condition &#40;which is termed NAFLD&#41; encompasses a pathological spectrum from simple steatosis to an inflammatory form of the disease termed nonalcoholic steatohepatitis &#40;NASH&#41;&#46; While simple steatosis has a benign clinical course NASH patients are deemed at high-risk for developing more advanced fi-brosis&#44; cirrhosis and hepatocellular carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="p0095" class="elsevierStylePara elsevierViewall">NAFLD pathogenesis may involve a two-step process&#46; The first and obligatory phase&#44; is the development of IR that has a central role in triglyceride accumulation in liver cells&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In the setting of IR&#44; uninhibited lipolysis occurs in adipose tissue determining a fatty acid overflow to the liver&#46; After their uptake by hepatocytes&#44; fatty acids are utilized for triglyceride synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In addition&#44; compensatory hyperinsulinemia present in IR contributes to stimulate <span class="elsevierStyleItalic">de novo</span> lipogenesis in the liver cell contributing to steatosis&#46; The second step&#44; which occurs only in a proportion of NAFLD subjects&#44; is hepatic inflammation and triggering of local fibrogenesis&#46; The underlying mechanisms that determine that some individuals with simple steatosis evolve toward NASH remain unknown&#46; However&#44; inflammatory events occurring in the adipose tissue are key initial events in promotion IR through adipokine imbalance and fatty acid-induced oxidative stress are considered among the main culprits&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="p0100" class="elsevierStylePara elsevierViewall">Being both common entities in the general population&#44; NAFLD and HCV infection can clearly coexist&#46; Since HCV infection may aggravate IR&#44; which is the main cause of NAFLD&#44; it is difficult to quanti-tate the contribution of each condition in a given patient&#46; Some authors have proposed that NAFLD or NASH can be diagnosed on histological basis in the setting of concomitant HCV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> However&#44; this is controversial and difficult due to lack of information on cut-offs for the degree of steatosis and the fact that some histological findings can be present in both conditions&#46; In spite of that&#44; it has been estimated that 10&#37; of patients with HCV display features of NASH&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> As mentioned before&#44; the close association of steatosis with HCV genotype 3 infection suggests that direct viral-related steatoge-nic mechanisms are at play in this setting&#46; In the case of non-3 genotypes&#44; pre-existing IR drives stea-tosis development and worsening of IR due to HCV infection can either increase the degree of steatosis or determine progression to NASH&#46; Some of the proposed specific mechanisms involved in the pathoge-nesis of steatosis in the context of HCV infection are shown in <a class="elsevierStyleCrossRef" href="#t0005">table 1</a>&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Implications</span><p id="p0105" class="elsevierStylePara elsevierViewall">The clinical implications of the presence of IR and steatosis in patients with CHC have become evident in many studies that consistently showed that these co-factors are related to both a poorer response to antiviral therapy and disease progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Current data on the topic is summarized below&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">The negative impact of IR on achieving sustained viral response &#40;SVR&#44; defined as undetectable HCV RNA 24 weeks after completing treatment&#41; after standard antiviral therapy &#40;Pegylated interferon plus ribavirin&#41; in patients with CHC has been demonstrated in several studies&#46; Romero-G&#243;mez&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44; <a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> showed marked differences in the rates of SVR in HCV infected patients with and without IR&#44; assessed by HOMA-IR&#46; In this study&#44; 23 of 70 &#40;32&#46;8&#37;&#41; patients with genotype 1 CHC and IR &#40;HOMA-IR &#62; 2&#41; achieved a SVR vs&#46; 26 of 43 &#40;60&#46;5&#37;&#41; genotype 1 CHC patients without IR&#46; These results has been confirmed by other authors &#40;34-37&#41; and extended to non-1 genotypes&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Thus&#44; since IR is an independent predictor of treatment response&#44; HOMA-IR could help to predict treatment outcome in a given patient&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">IR has been also associated to fibrosis in CHC pa-tients&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> However&#44; it is its main consequence stea-tosis&#44; the feature that has been found more consistently associated to disease progression in patients with CHC&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Studies including paired biopsies provide stronger evidence in this regard&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> More recently&#44; these results were confirmed by analysis of data from the HALT-C Trial cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In this study involving more than 1000 patients&#44; hepatic stea-tosis was a strong and independent predictor of fibrosis not related to other laboratory markers for liver disease severity&#46; A number of mechanisms can account for the profibrogenic effects of IR and steatosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="p0120" class="elsevierStylePara elsevierViewall">Another important clinical implication of IR in CHC is the strong relationship of IR and T2DM development&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Cross-sectional and longitudinal stu-dies support the notion that HCV infection determines an excess in the risk of developing T2DM&#44; particularly in those with known risk fac-tors&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> More recently the relationships between HCV infection&#44; T2DM and hepatocellular carcinoma have gained significant attention given the rise of liver cancer in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Interestingly&#44; it has been shown that IR is somewhat modified by treatment and that the incidence of T2DM in patients achieving SVR is significantly lower than that seen in non-responders&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Perpectives for Clinical Management</span><p id="p0125" class="elsevierStylePara elsevierViewall">Available data on the complex relationship between IR and CHC offers some opportunities for clinical intervention&#46; This includes active management of body weight and specific pharmacological treatment of IR and&#47;or hepatic steatosis&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">Although it has been shown that weight reduction may have impact on both liver histology and biochemistry in patients with CHC&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> interventions aiming to modify body weight before treatment have not been formally tested in large-scale trials&#46; Thus&#44; we do not known if patients that lose weight and introduce lifestyle changes have a different natural history that those that do not follow these general recommendations&#46; However&#44; analysis of outcomes in the HALT-C trial provides strong evidence about the benefits of weight loss in overweight or obese patients with CHC&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In this study&#44; patients that lost more than 5&#37; of the baseline weight showed significant decrease in both hepatic steatosis and inflammation&#46; As for the potential impact of weight loss on the response to antiviral treatment&#44; no large prospective studies have been conducted&#46; Only a small study reported by Tarantino&#44; <span class="elsevierStyleItalic">et al&#46;</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> showed that a strict low calorie diet for three months&#44; aiming to achieve a 10&#37; reduction in body mass index before starting treatment&#44; indeed determined higher rates of response to peginterferon plus riba-virin therapy&#46; It is therefore appropriate to specifically counsel those CHC patients who are overweight or obese aiming to lose at least 5&#37; of their basal weight in order to potentially improve the response to antiviral therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Joint work of hepatologists with a multidisciplinary obesity management-team could increase chances of a successful response in this setting&#46;</p><p id="p0135" class="elsevierStylePara elsevierViewall">Management of IR with insulin sensitizing agents aiming to increase the chances of responding to treatment is another recently explored possibility&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> However&#44; available data is limited in this regard&#46; The INSPIRED-HCV study<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> considered administration of pioglitazone to HCV infected patients that did not respond to standard treatment&#46; This trial was prematurely terminated due to lack of efficacy&#46; However&#44; the dose of pioglitazone &#40;15mg&#47;d&#41; and the difficult-to-treat patients included in the trial limit the interpretation of results&#46; Other attempts of improving treatment response with pioglitazone have been reported&#46; One study published only in abstract form showed that in genotype-1 patients naive to treatment 30 mg&#47;d of pioglitazone showed a significantly increased occurrence of a rapid virological response&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> Unfortunately&#44; SVR were not reported&#46; In other preliminary study&#44; Conjeevaram et al&#46; showed that although pioglitazone treatment led to a significant reduction in IR and reversal of hepatic steatosis in HCV genotype-1 patients with IR&#44; SVR was similar in treated and non-treated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Another recent study from Egypt involving HCV infected genotype 4 patients showed positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> More recently&#44; an interesting case-report suggest that sequential&#44; rather than concomitant&#44; administration of pioglitazone with antiviral therapy could be more effective in achieving response to treat-ment&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Finally&#44; the addition of metformin to standard antiviral treatment was studied in a prospective&#44; multicentered&#44; randomized&#44; double-blinded&#44; placebo-controlled trial in 19 Spanish hospi-tals&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Although there was a trend to achieve a higher SVR in metformin treated patients the study failed to show a statistically significant difference between arms&#46; Clearly&#44; additional studies on the role of adding insulin sensitizing agents to standard antiviral treatment are warranted&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Acknowledgement</span><p id="p0140" class="elsevierStylePara elsevierViewall">This work was partially supported by grants from the Fondo Nacional De Ciencia y Tecnolog&#237;a de Chile &#40;Fondecyt &#35;1080170 to MA and &#35;1080323 to A&#46;S&#46;&#41;&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">This article is based in a oral presentation in a meeting of the Latinamerican Association for the Study of the Liver &#40;ALEH&#41;&#44; held in Canc&#250;n&#44; M&#233;xico on March 18-19&#44; 2009&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Abbreviations&#58; Used in This Paper&#58;</span><p id="p0150" class="elsevierStylePara elsevierViewall">IR&#58; Insulin resistance&#59; HCV&#58; hepatitis C virus&#59; T2DM&#58; type 2 diabetes mellitus&#59; NAFLD&#58; non-alcoholic fatty liver disease&#59; CHC&#59; chronic hepatitis C&#59; HOMA-IR&#58; homeostatic model assessment&#59; IRS&#58; insulin receptor substrates&#59; IL&#58; interleukin&#59; TNF&#58; tumor necrosis factor&#59; NASH&#58; Nonalcoholic steatohepatitis&#59; SVR&#58; sustained viral response&#46;</p></span></span>"
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        "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Insulin resistance &#40;IR&#41; is a common pathophysiological condition where higher-than-normal concentrations of insulin are needed to maintain a normal glycemia and adequate glucose utilization in insulin target tissues&#46; A high proportion &#40;50-80&#37;&#41; of patients chronically infected with the hepatitis C virus &#40;HCV&#41; exhibit evidence of IR&#46; Basic and clinical studies have disclosed a complex bidirectional relationship between IR and HCV infection that has important clinical implications&#46; HCV infection may promote IR through direct viral-dependent mechanisms or due to activation of the inflammatory response resulting in increased production of Tumor Necrosis Factor-&#945; and other cytokine-related molecules&#46; These abnormalities may act synergistically with pre-existing metabolic risk factors and result in the development of hepatic steatosis and type 2 diabetes mellitus &#40;T2DM&#41; which are frequently found in the setting of HCV infection&#46; Moreover&#44; in addition to underlying metabolic abnormalities leading to its development hepatic steatosis also exhibit genotype-specific pathogenic mechanisms&#46; A number of studies have shown that hepatic steatosis is associated to fibrosis progression in patients with HCV and that IR has a negative impact on the response rates to interferon-a-based therapy&#46; Thus&#44; modification of these factors through life-style changes or pharmacological agents may represent an undervalued specific target of therapy aiming to improve sustained virolo-gical response rates and reduce HCV related-morbidity and mortality&#46;</p></span>"
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          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Relationships between metabolic and viral factors and hepatic steatosis in the setting of chronic hepatitis C&#46; Insulin resistance is the major determinant of steatosis and in turn is aggravated by several genotype-independent mechanisms probably related to the presence of viral proteins in the hepatocyte and due to the inflammatory response linked to viral infection&#46; Several specific steatogenic mechanisms operate in genotype 3 infection&#46; Alcohol consumption can also contribute to steatosis development&#46;</p>"
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                            0 => "Reaven GM"
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                      "titulo" => "Current concepts in the pathogenesis of nonalcoholic fatty liver disease&#46;"
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Article information
ISSN: 16652681
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos