Evaluation of Lipid Profile in Patients with Hepatitis C Virus Related Liver Cirrhosis‎

Many chronic liver diseases including; fatty liver disease, alcoholism and viral hepatitis can induce liver cirrhosis (LC). Mostly cirrhotic patients remain without specific symptoms until reaching de compensation stage [1].

Clinical evaluation of liver cirrhosis depends mainly on Child–Pugh score. However, the addition of subjective clinical criteria including ascites and hepatic encephalopathy restricted it. Model for end-stage liver disease (MELD) score, originally established to help predicting mortality in cirrhotic patients  who undergo trans-jugular intrahepatic porto-systemic shunt procedures (TIPS). It was a good predictor of short-term mortality in cirrhotic patients. The main advantages of MELD score over the Child-Pugh score are  being dependent on objective and accessible variables (serum creatinine, serum bilirubin, prothrombin time (PT) and international normalized ratio (INR) [2].

Ascites severity, degree of hepatic encephalopathy serum total bilirubin  and serum albumin have been suggested to predict 90-day mortality independent of MELD score.  However, depending on subjective criteria such as severity of hepatic encephalopathy or ascites is considered unwanted [3].

Because liver is responsible for synthesis of lipoprotein  and cholesterol, hepatocytes have important role in regulating the balance between lipid biosynthesis and transport [4].

Lipid metabolism is  disturbed in cirrhosis and glycogen reserves are significantly decreased encouraging lipolysis and malnutrition ^[4]_. Hepatitis C virus (HCV) infection can increase serum level of inflammatory cytokines and disturb endothelial function, therefore alter lipid metabolism [5]_.

This study aimed to evaluate lipid profile in patients with hepatitis C virus induced liver cirrhosis.

SUBJECTS AND METHODS

Study design: Case control study.

Study setting: This study was completed in Tropical Department at Zagazig University hospitals and Al-Ahrar Teaching Hospital in the period from April 2021 to October 2021.

Sample size: This study included 63 patients. They were allocated into 2 groups.

Inclusion criteria:

1-  Patients with HCV related liver cirrhosis diagnosed by clinical, laboratory and imaging modalities or histo-pathologically criteria in some cases.

2-  Control group which was divided into two subgroups:

a- Patients with chronic HCV infection  and didn’t fulfill the criteria of cirrhosis but they had elevated liver enzymes for more than 6 months with HCV markers (Antibodies and PCR).

b-  Healthy control. 

Exclusion criteria:

Age

Process:The following data were reported for all patients after obtaining an informed consent:

1. Medical history taking.
2. Clinical examination:

General examination with attention to liver cell failure manifestations including jaundice, flabbing tremors and edema of the  lower limb.

Local abdominal examination searching for signs of chronic liver disease, liver cell failure and portal hypertension eg (Organomegally and ascites). Ascities could be; mild which could be detected only by ultrasonography, moderate which could be detected by positive bilateral shifting dullness or tense which showed positive transmitted thrill).

1. Abdominal ultrasonography :
2.  Laboratory investigations in form of :

• LFT, HCV Antibody and PCR. 
• Fasting serum lipid profile assessment of Serum total cholesterol , TG ,  HDL, LDL, VLDL.

1. Child-Pugh classification of the patients
2. MELD score calculation
3. Upper GI endoscopy for cirrhotic patients.

PRINCIPLE :

Cholesterol esters resolve in fatty acids and  cholesterol by Cholesterol esterase (CHE).Then cholesterol become oxidized by Cholesterol Oxidase (CHOD)  and release hydrogen peroxide and Cholesterol-3-one. Red dye compound become formed by a reaction between the released hydrogen peroxide and a phenol substitute. The red color intensity is directly proportional to the whole cholesterol in the sample when read at500/520nm

For the enzymatic determination of Triglycerides according to the following reaction:

Triglycerides  + H₂ O Fatty acids + Glycerol

Glycerol +ADP+ATP Glycerol-3-phosphate

Glycerol-3-phosphate + H₂O₂+ O₂ Di hydroxyl acetone phosphate

2 H₂ O₂+ 4-AAP + 4-CHLOROPHENIL  colored compound + H₂O

The intensity of the red color formed is directly proportional to level of triglycerides in the sample

HDL-Cholesterol is formed through precipitation of VLDL lipoproteins and LDL, thus HDL lipoproteins persist in solution. HDL-Cholesterol in supernatant is considered as a sample for assay of cholesterol conferring to the next reaction:

Cholesterol ester  fatty acids + Cholesterol

Cholesterol+O₂ Cholest-4-en-3-ona+H₂O₂

2H₂O₂+4-AAP+p-HBA Colored Comp. +4H₂O

Formed color is assesed at 546 nm and is proportional to concentration of HDL-Cholesterol in sample.

SPECIMEN COLLECTION:

Non hemolyzed fresh serum or plasma.

Statistical Analysis

Statistical analysis was done using SPSS version 24. Quantitative continuous variables were represented as the mean± SD & range, and qualitative variables were represented as absolute frequencies (number) & relative frequencies (percentage).

ANOVA (F) test was used when comparing more than two groups of normally distributed data.

Tukey Post-hoc Least Significant Difference (LSD) test was used to compare between each 2 group separately.

Compared categorical data was done using Chi-square test (χ2test) and fisher exact test.

ROC curve was used.

All tests were two sided. P-value< 0.05 was statistically significant (S), p-value < 0.001 was highly statistically significant (HS), and p-value ≥ 0.05 was statistically insignificant (NS).

RESULTS

Age was distributed as 54.95 ± 2.39, 55.0 ± 2.02        and 55.52 ± 2.71 respectively with no significant difference also There was no statistically significant difference between the studied groups regarding sex distribution Table (1).

There is statistically significant difference between the studied patient groups regarding presence of jaundice, hepatomegaly, splenomegaly, banded OV, ascites, lower limb edema and encephalopathy Table (2).

There is statistically significant difference between the studied groups regarding total cholesterol and HDL cholesterol, TG and VLDL cholesterol., the difference is significant among groups except cholesterol and LDL as the difference is only between HCV and other two groups without significant difference between them Table (3).

The best cutoff of HDL cholesterol in diagnosis of presence of liver cirrhosis is ≤37.71 mg/dL with area under curve 0.745, sensitivity 71.4%, specificity 71.4%, positive predictive value 55.6%, negative predictive value 83.3%m accuracy 71.4% Table (4) & figure (1).

The best cutoff of VLDL cholesterol in diagnosis of presence of liver cirrhosis is ≤21.423 mg/dL with area under curve 0.78, sensitivity 84.5%, specificity 75.0%, positive predictive value 63.3%, negative predictive value 90.2%m accuracy 78.5% Table (5) & figure (2).

This table shows Performance of all of lipid profile in diagnosis of presence of  cirrhosis;≤157.5, ≤152.9, ≤83.2 and ≤30.59 respectively with perfect validity Table (6).  

Table (6): Performance of all of lipid profile in diagnosis of presence of  cirrhosis.

AUC: Area under curve.                     PPV: Positive predictive value.         NPV: Negative predictive value.

**: p≤0.001 is statistically highly significant.  

Significant AUC  with cutoff regard Serum cholesterol, Serum triglycerides, LDL and VLDL ≤157.5, ≤152.9, ≤83.2 and ≤30.59 respectively with perfect validity.