|Year : 2017 | Volume
| Issue : 2 | Page : 59-65
Serum interleukin-6 concentration and association with response to hepatitis C virus therapy for chronic hepatitis C patients
Fatma M Abd El Salam1, Naglaa E El Toukhy1, Amal A Mohamed2, Hend A Nekola3
1 Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Biochemistry and Molecular Biology, National Hepatology and Tropical Medicine Research Institute, Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Hepatology, Gastroenterology and Infectious Diseases, Shebein El-Kom Teaching Hospital, Shebein El-Kom, Egypt
|Date of Submission||30-Jan-2017|
|Date of Acceptance||20-Feb-2017|
|Date of Web Publication||20-Nov-2017|
Hend A Nekola
Department of Hepatology, Gastroenterology and Infectious Diseases, Shebein El-Kom Teaching Hospital, Shebein El-Kom, 13133
Source of Support: None, Conflict of Interest: None
Background Egypt has the highest prevalence of hepatitis C virus (HCV) in the world. Interleukin 6 (IL-6) is a pleiotropic cytokine that is elevated in chronic hepatitis C patients. IL-6 was suggested by several studies to play a major role in response to HCV therapy.
Aim The aim of this work was to assess the possible role of IL-6 in the response status of patients with HCV during treatment. Moreover, we attempted to use IL-6 as a predictive factor for response in patients with chronic HCV.
Patients and methods Serum concentrations of IL-6 were measured before and after treatment using a commercially available Quantikine enzyme-linked immunosorbent assay in 57 patients with chronic hepatitis C treated with sofosbuvir and simeprevir for 3 months.
Results The mean values of IL-6 level in responders and nonresponders were 272.96 and 230.5 pg/ml, respectively. IL-6 levels decreased significantly after treatment in the sustained virological response group. The best cutoff point for IL-6 was 233 pg/ml with a sensitivity of 70%, a specificity of 75%, a positive predictive value of 97.2%, and a negative predictive value of 16.7%.
Conclusion Virological response during HCV therapy was associated with a decrease in IL-6 level.
Keywords: hepatitis C virus therapy, hepatitis C virus, interleukin-6, sustained virological response
|How to cite this article:|
Abd El Salam FM, El Toukhy NE, Mohamed AA, Nekola HA. Serum interleukin-6 concentration and association with response to hepatitis C virus therapy for chronic hepatitis C patients. Benha Med J 2017;34:59-65
|How to cite this URL:|
Abd El Salam FM, El Toukhy NE, Mohamed AA, Nekola HA. Serum interleukin-6 concentration and association with response to hepatitis C virus therapy for chronic hepatitis C patients. Benha Med J [serial online] 2017 [cited 2018 Oct 18];34:59-65. Available from: http://www.bmfj.eg.net/text.asp?2017/34/2/59/218819
| Introduction|| |
Hepatitis C virus (HCV) is a leading cause of chronic liver diseases, cirrhosis, and hepatocellular carcinoma . Egypt has possibly the highest HCV prevalence in the world, 10–20% of the general population .
The decision to treat patients with chronic hepatitis C depends on multiple parameters, including a precise assessment of the severity of liver disease and of its foreseeable outcome, the presence of absolute or relative contraindication to therapy, and the patients willing to be treated .
Interleukin-6 (IL-6) is a pleiotropic cytokine that plays a role in the acute phase response . IL-6 is released from various cells in response to systematic or local infection, tissue injury, and inflammation .
As for the liver, IL-6 is produced mainly by kupffer cells  and induces the production of the acute phase proteins, C-reactive protein and haptoglobin .
Previous studies reported that serum IL-6 levels were increased, compared with healthy individuals, in patients with some liver diseases, such as chronic viral hepatitis due to HCV infection .
Previous results suggest that baseline levels of IL-6, as well as their decrease during treatment, are correlated to outcomes of HCV therapy in male patients. Further analyses of IL-6 may provide new strategies for difficult-to-treat Chronic hepatitis C (CHC) patients and prevention of hepatocarcinogenesis .
The aim of this work was to assess the possible role of IL-6 in the response status of patients with HCV during treatment. Moreover, we try to use IL-6 as a predictive factor for response in patients with chronic HCV.
| Patients and methods|| |
This case–control study is a prospective one. It consisted of 57 patients with chronic hepatitis C to be treated with sofosbuvir (SOF) (400 mg once per day) and simeprevir (SIM) (150 mg once per day) for 3 months. They were divided as follows:
- Group 1 (nonresponders, N=4), which included patients with positive HCV RNA after 12 weeks of treatment (the end of treatment).
- Group 2 (responders, N=53), which included patients with negative HCV RNA after 12 weeks of treatment (the end of treatment).
Group 2 was further divided according to sustained virological response (SVR).
- Group 3 (SVR, N=50) included patients with negative HCV RNA after 12 weeks of cessation of treatment.
- Group 4 (the control group, N=26) included healthy individuals.
According to the national committee for control of viral hepatitis, chronic HCV patient’s candidate for combination therapy with SOF and SIM for 3 months and who fulfilled the following inclusion criteria were included: age from 18 to 70 years, HCV RNA positivity, any BMI, treatment-naive or treatment experienced, and all fibrosis stages. Assessment of fibrosis is no more necessary. Performing liver biopsy or transient elastography (fibroscan) is not a prerequisite; however, collection of such data is encouraged if available at the time of presentation. Exclusion criteria were as follows: direct serum bilirubin greater than 2 mg/dl, serum albumin less than 2.8 g/dl, international normalization ratio (INR) greater than or equal to 1.7, platelet count less than 50 000/mm3, ascites or history of ascites, hepatic encephalopathy or history of hepatic encephalopathy, hepatocellular carcinoma, except 4 weeks after intervention aiming at cure with no evidence of activity on dynamic imaging (computed tomography or MRI), and serum creatinine greater than 2.5 mg/dl. If creatinine is between 1.5 and 2.5 mg/dl, glomerular filtration rate should be calculated and should exceed 30 ml/min with favorable nephrological consultation, extrahepatic malignancy except after 2 years of disease-free interval, and pregnancy or inability to use effective contraception.
Laboratory and molecular investigations
The following laboratory and molecular investigations were carried out: complete blood picture, fasting blood sugar, liver function tests (serum bilirubin ‘total and direct’, serum albumin, and prothrombin time and INR), assessment of markers of liver injury − alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase − and assessment of viral markers [including hepatitis B surface antigen and hepatitis C antibody using enzyme-linked immunosorbent assay (ELISA)].
HCV PCR was performed before treatment, after 4 weeks, 12 weeks from the beginning of treatment, and 3 months after the end of treatment. Kidney function tests including serum creatinine level, serum α-fetoprotein using ELISA, and measurement of IL-6 levels before and after treatment using commercially available Quantikine ELISA Kit (R & D System-Biotechne Brand).
All data were collected, tabulated, and statistically analyzed using STATA/SE, version 11.2 for Windows (STATA Corporation, College Station, Texas, USA). Continuous data were expressed as the mean±SD and range, and categorical data were expressed as number and percentage. The Student t-test was used to compare two groups of normally distributed data. However, the Mann–Whitney test (U) was used to compare two groups of nonparametric data. The Wilcoxon signed-rank test (z) was used to compare paired nonparametric data. Percent of categorical variables was compared using Fisher’s exact test.
Pearson correlation coefficient (r) and Spearman correlation coefficient (ρ) were used to test for the correlation between estimated parameters.
Receiver operating characteristics (ROC) analysis was carried out to evaluate the diagnostic performance of IL-6 levels for response among patients. The best cutoff point and the corresponding sensitivity and specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) were estimated.
After the calculation of each of the test statistics, the corresponding distribution tables were consulted to obtain the P-value. Statistical significance was accepted at P-value less than 0.05 (significant). A P-value less than 0.001 was considered highly significant, whereas a P-value greater than 0.05 was considered nonsignificant.
| Results|| |
This study was conducted on 57 patients with chronic hepatitis C and 26 healthy people (the control group) attending outpatients clinic Shebien El-Kom Teaching Hospital from October 2015 to December 2015. From these cases, 53 (92.9%) patients were diagnosed as responders to treatment with SOF and SIM and four (7.02%) patients were nonresponders to treatment. After 3 months of the end of treatment, 50 (87,72%) responding patients developed SVR and the other three patients were missed.
[Table 1] shows the demographic and laboratory data for patients who developed SVR and nonresponders. The mean age in the SVR group was younger than that for nonresponders, and the response to treatment tends to be greater in male than in female patients. Hemoglobin was significantly higher in patients with SVR than in nonresponders. The platelet count was significantly higher in nonresponders than in patients with SVR. ALT, total bilirubin (T. bil.), and INR were significantly higher in nonresponders than in patients with SVR.
|Table 1 Demographic and laboratory data between patients with sustained virological response and nonresponders|
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Baseline IL-6 levels were significantly high in patients than in the control group ([Table 2] and [Figure 1]).
|Table 2 Variations in baseline interleukin-6 between patients and controls|
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IL-6 levels before treatment were significantly higher in patients with SVR than in nonresponders, and, after treatment, IL-6 levels were significantly higher in nonresponders than in patients with SVR ([Table 3] and [Figure 2]).
|Table 3 Interleukin-6 levels between sustained virological response and nonresponders before and after therapy|
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|Figure 2 Comparison between levels of IL-6 in patients groups (groups 1 & 3) before and after treatment|
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There was no significant difference in IL-6 levels after treatment in the nonresponder group, and IL-6 levels decreased significantly after treatment in the SVR group ([Table 4] and [Figure 3]).
|Table 4 Interleukin-6 levels in the same groups before and after therapy|
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|Figure 3 Intra-group comparison of levels of IL-6, before & after treatment|
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There was a negative correlation between IL-6 and platelets, white blood cells, alanine transaminase, and INR and a positive correlation with age, glucose, hemoglobin, AST, T. bil., albumin, creatinine, α-fetoprotein, thyroid-stimulating hormone, and viral load, although nonsignificant ([Table 5]).
|Table 5 Correlations between interleukin-6 at baseline and other parameters|
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ROC for IL-6 for the prediction of response shows that the best cutoff point for IL-6 was 233 pg/ml with a sensitivity of 70%, a specificity of 75%, a PPV of 97.2%, and NPV of 16.7%, and the AUC was 0.6604 ([Table 6] and [Figure 4]).
|Table 6 Receiver operating characteristics for interleukin-6 for prediction of response (sustained virological response)|
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|Figure 4 ROC for IL-6 for prediction of sustained virological response (SVR)|
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| Discussion|| |
Egypt is enduring a large HCV disease burden and is likely to be the most affected nation worldwide by this infection .
There are a series of viral, host, and treatment characteristics that influence the likelihood of HCV treatment success and are useful when assessing the benefits and risks of therapy .
The introduction of direct-acting antiviral agents, in particular SOF, has revolutionized the treatment for chronic HCV. With SOF-based regimens, higher cure rates and shorter duration of treatment have been achieved. In early 2014, SIM plus SOF, the first highly effective interferon (IFN)-sparing HCV treatment regimen, entered the clinical practice in the USA for the treatment of patients with HCV genotype 1 infection .
SMV is active against genotypes 1, 2, 4, 5, and 6. It is administered as a once-daily tablet orally and has demonstrated a favorable safety profile and limited drug–drug interactions .
SIM/SOF combination therapy was more effective, better tolerated, and associated with significantly fewer adverse events, compared with pegylated IFN-based regimens .
HCV infection can increase IL-6 production by altering the innate immune response by upregulating toll-like receptors (TLR4 and TLR2) in B cells, which will likely lead to an increased inflammatory response. The increased TLR4 and TLR2 expression is a result of increased transcription of the TLR4 and TLR2 genes and is mediated by the viral NS5A and core proteins, respectively .
This work aimed to study the association between IL-6 levels and response to SOF and SIM in chronic hepatitis C virus patients.
To achieve this goal, this study was conducted on 57 patients with chronic hepatitis C and 26 healthy people (the control group) attending Shebien El-Kom Teaching Hospital for treatment with SOF 400 mg once a day and SIM 150 mg once a day for 3 months from October 2015 to December 2015.
In this study, PCR was performed for 57 patients with chronic HCV after 12 weeks of treatment with SOF and SIM. Fifty-three (92.98%) patients developed response, and four (7.02%) patients did not develop response. After 3 months of the end of treatment, 50 (87.72%) responding patients developed SVR and the other three patients were missed.
El-Khayat et al.  reported that the overall SVR rate was 95.7% (558 of 583 patients). In total, SVR12 in naive patients with mild fibrosis score (F1 and F2) was achieved in 98.9% (94/95) of patients for F1 and in 98.1% (105/107) for F2, whereas naive patients with severe fibrosis (F3 and F4) achieved an SVR of 97.7% (86/88) for F3 and an SVR of 80.8% (42/52) for F4. SVR in patients with previous IFN treatment was achieved in 100% (45/45) of patients with F1 and in 98.7% (74/75) of patients with F2. However, SVR12 was achieved in 94.7% (72/76) of experienced patients with F3 and in 88.9% (40/45) with F4.
In this study, baseline IL-6 levels were significantly higher in the patient than in the control group. This finding is in agreement with the result of El-Serafi et al.  and Afzal et al. , who reported that IL-6 levels were significantly higher in patients than in controls.
In this study, responders who achieved SVR had significantly higher baseline IL-6 levels compared with those who did not before treatment and significantly lower levels after treatment.
These findings are in agreement with the results of El-Serafi et al. , who reported that CHC patients who achieved early virological response (EVR) had significantly higher IL-6 levels compared with those who did not, and IL-6 level greater than 2.15 pg/ml was significantly associated with EVR and could be considered as an independent predictor of EVR.
Moreover, this finding is in agreement with the results of Faisal et al.  and Nattermann et al. , who reported that a higher level of IL-6 is significantly associated with SVR compared with a lower level. In contrast, Cotler et al.  reported that there was no significant difference in basal IL-6 levels between the groups of responders and nonresponders to IFN therapy.
A possible explanation of this finding is that IL-6 level could modulate the response to treatment through the activation of STAT3 by means of phosphorylation in hepatic stellate cells and by promoting their survival and proliferation. Furthermore, IFN-α activates STAT3, followed by the induction of a wide variety of antiviral and proapoptotic genes that may contribute to the antiviral and antitumor activities of IFN-α in human livers .
STAT3 expression and activation are reduced in HCV-infected livers. The HCV core protein has been shown to prevent phosphorylation of STAT3, which has been associated with resistance of HCV to IFN therapy. IL-6 can overcome HCV core-induced inhibition of STAT3 activation and phosphorylation .
Studies by Mohamed et al.  and Guzmán-Fulgencio et al.  showed a significantly higher level of serum IL-6 in nonresponders compared with responders after pegylated-IFN-α and RBV therapy. They attributed this correlation to the fact that IL-6 promotes the suppressor of cytokine signaling 3 (SOCS3) expressions, which suppresses the JAK-STAT pathway and inhibits the formation of IFN-stimulated gene . Therefore, suppression of IFN-stimulated gene through the activation of IL-6/SOCS3 signal results in resistance to IFN therapy.
In this study, there was a negative correlation between IL-6 and platelets, white blood cells, alanine transaminase, and INR and a positive correlation with age, glucose, hemoglobin, AST, T. bil., albumin, creatinine, α-fetoprotein, thyroid-stimulating hormone, and viral load, although nonsignificant.
Mohamed et al.  reported that there was a negative correlation between the serum levels of IL-6 and AST and also between serum levels of TNFRI and ALT and may indicate that the level of both markers reflect liver injury despite low levels of liver enzymes.
In this study, ROC for IL-6 for the prediction of response show that the best cutoff point for IL-6 was 233 pg/ml with a sensitivity of 70%, a specificity of 75%, a PPV of 97.2%, and NPV of 16.7%, and the AUC was 0.6604.
El-Serafi et al.  reported that IL-6 level greater than 2.15 pg/ml was significantly associated with response and could be considered as an independent predictor of response.
| Conclusion|| |
Virological response during HCV therapy was associated with a decrease in IL-6 levels.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen SL, Morgan TR. The natural history of hepatitis c virus infection. Int J Med Sci 2006; 3:47–52.
El-Zayadi A, Abaza H, Shawky S. Prevalence and epidemiological features of hepatocellular carcinoma in Egypt. A single centre experience. Hepatol Res 2001; 19:170–179.
Chevaliez S, Pawlotosky JM. Hepatitis C virus serologic and virologic tests and clinical diagnosis of HCV related liver disease. Int J Med Sci 2006; 3:35–44.
Heinrich PC, Castell JV, Andus T. Interleukin-6 and the acute phase response. J Biochem 1990; 265:621–636.
Sehgal PB. Interleukin-6: a regulator of plasma protein gene expression in hepatic and non hepatic tissue. Mol Biol Med 1990; 7:117–130.
Oyanagi Y, Takahashi T, Matsui S. Enhanced expression of interleukin-6 in chronic hepatitis C. Liver 1999; 19:464–472.
Ueyama M, Nakagawa M, Sakamoto N, Onozuka L, Funaoka Y, Watanabe T et al.
Serum interleukin-6 levels correlate with resistance to treatment of chronic hepatitis C infection with pegylated-interferon-α2b plus ribavirin. Antivir Ther 2011; 16:1081–1091.
Mohamoud YA, Mumtaz GR, Riome S. The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis. BMC Infect Dis 2013; 13:288.
Brock J, Gluud LL, Gluud C. Meta-analysis: ribavirin plus interferon vs. interferon monotherapy for chronic hepatitis C. Aliment Pharmacol Ther 2010; 32:840–850.
Lawitz E, Sulkowski MS, Ghalib R. Simeprevir plus sofosbuvir, with or without ribavirin, to treat chronic infection with hepatitis C virus genotype 1 in non responders to pegylated interferon and ribavirin and treatment-naive patients: the COSMOS randomized study. Lancet 2014; 384:1756–1765.
Abdel-Ghaffar TY, Sira MM. Hepatitis C genotype 4: the past, present, and future. World J Hepatol 2015; 28:2792–2810.
Hézode C, Fontaine H, Dorival C. Effectiveness of telaprevir or boceprevir in treatment-experienced patients with HCV genotype 1 infection and cirrhosis. Gastroenterology 2014; 147:132–142.
Feldman G, Nischallk HD, Nattermann J, Banas B, Berg T, Teschendorf C. Induction of interleukin-6 by hepatitis c virus core protein in hepatitis C associated mixed cryoglobulinemia and b-cell non Hodgkin’s lymphoma. Clin Cancer Res 2006; 12:4491–4498.
El-Khayat HR, Fouad YM, Maher M. Efficacy and safety of sofosbuvir plus simeprevir therapy in Egyptian patients with chronic hepatitis C: a real-world experience. Gut 2006; 0:1–5.
El-Serafi TI, Awad MM, Tag-Eldeen LA, El-Serafi AT, Husin M. Effect of interleukin-6 and insulin resistance on early virological response of Egyptian chronic hepatitis C patients to combined pegylated interferon plus ribavirin therapy. Egypt Liver J 2013; 3:21–27.
Afzal N, Abbas S, Ahmed A, Arif M, Javeed K. Effect of hepatitis C virus on C reactive protein and interleukin-6 in hemodialysis patients. Iran J Kidney Dis 2011; 5:182–186.
Faisal A, Zytoon AA, Gad Allah A, Dawood A. Predictors of early virological response of viral hepatitis c to combination therapy with pegylated interferon plus ribavirin. Am J Clin Med Res 2013; 4:54–60.
Nattermann J, Vogel M, Berg T. Effect of the interleukin-6 C174G gene polymorphism on treatment of acute and chronic hepatitis C in human immunodeficiency virus coinfected patients. Hepatology 2007; 46:1016–1025.
Cotler K, Rajender R, Maccon J, Wolf DL, Milton W, Wolf DL, Milton W. An analysis of acute changes in interleukin-6 level after treatment of hepatitis C with consensus interferon. J Interferon Cytokine Res 2001; 21:1011–1019.
Gao B. Cytokines, STATs, and liver disease. Cell Mol Immunol 2005; 2:92–100.
Larrea E, Aldabo R, Molano E, Fernandez-Rodrigues CM, Ametzazurra A, Civeira MB. Altered expression and activation of signal transducers and activators of transcription (STATs) in hepatic C virus infection. Gut 2006; 55:1188–1196.
Mohamed AA, Afifi EA, El-Awady RR, Aboelsayed SM, El-Halawany F, Saleh M et al.
Correlation between serum levels of TNFR and IL6 with treatment response to pegylated interferon and ribavirin therapy in chronic hepatitis C Egyptian patients. Virol J Curr Res 2015; 1:6–10.
Guzmán-Fulgencio M, Luis Jiménez J, Berenguer J, Fernández-Rodríguez A, López JC, Cosín J et al.
Plasma IL-6 and IL-9 predict the failure of interferon-a plus ribavirin therapy in HIV/HCV-coinfected patients. J Antimicrob Chemother 2012; 67:1238–1245.
Gale M, Foy E. Evasion of intracellular host defense by hepatitis C virus. Nature 2005; 436:939–945.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]