|Year : 2017 | Volume
| Issue : 2 | Page : 81-86
Serum lipids in chronic viral hepatitis B patients in Makurdi, Nigeria
Ayu Agbecha1, Chinyere Adanna Usoro2, Maisie Henrietta Etukudo2
1 Department of Chemical Pathology, Federal Medical Centre, Makurdi, Nigeria
2 Department of Medical Laboratory Science, Chemical Pathology Unit, University of Calabar, Calabar, Nigeria
|Date of Web Publication||14-Mar-2017|
Department of Chemical Pathology, Federal Medical Centre, Makurdi
Source of Support: None, Conflict of Interest: None
Background: One of the major causes of liver disease in the world is hepatitis B virus (HBV) infection. The liver as a homeostatic organ plays a pivotal role in maintaining the relative balance of lipid and lipoprotein metabolism in the body. Aim: The study aimed at determining the impact of chronic hepatitis B (CHB) disease on serum lipids and the effect of the stages of this disease on lipid pattern in infected patients. Methodology: The study involved the selection of 70 CHB patients attending clinic at a Tertiary Hospital in Makurdi, Nigeria. After fulfilling the inclusion criteria, 65 anthropometrically matched apparently healthy individuals were selected as control to the CHB group. CHB is defined in the study as persistent infection evidenced by seropositivity for hepatitis B surface antigen without remission for up to 1-year. Results: There was a significantly reduced (P = 0.001) high-density lipoprotein cholesterol (HDL-C) and raised (P = 0.044) low-density lipoprotein cholesterol (LDL-C) in chronic HBV compared to seronegative controls. There was a significantly lowered HDL-C (P = 0.017), very LDL-C (P = 0.005), and triglyceride (P = 0.034) in asymptomatic CHB compared to the matched controls. There was a significantly lowered total cholesterol (P = 0.019) and HDL-C (P = 0.017) in symptomatic CHB compared to the matched controls. Conclusion: Lowered serum lipids are associated with CHB disease and likely to be mediated altered liver metabolism. However, reasons for the low levels of lipids in this viral disease still remains unclear.
Keywords: Cholesterol, chronic hepatitis B, lipids, lipoproteins
|How to cite this article:|
Agbecha A, Usoro CA, Etukudo MH. Serum lipids in chronic viral hepatitis B patients in Makurdi, Nigeria. CHRISMED J Health Res 2017;4:81-6
|How to cite this URL:|
Agbecha A, Usoro CA, Etukudo MH. Serum lipids in chronic viral hepatitis B patients in Makurdi, Nigeria. CHRISMED J Health Res [serial online] 2017 [cited 2017 Oct 17];4:81-6. Available from: http://www.cjhr.org/text.asp?2017/4/2/81/201981
| Introduction|| |
One of the major causes of liver disease in the world is hepatitis B virus (HBV) infection. HBV could cause either acute or chronic viral hepatitis, which may lead to liver cirrhosis or hepatocellular carcinoma subsequently resulting to death. Only few acute HBV infections are symptomatic. Less than ten percent of children and about 50% of adults with acute HBV are reported to have jaundice. Individuals who fail to spontaneously or naturally clear the virus after acute infection become chronic carriers of the viruses. Chronicity to HBV infection has been defined as continuously testing positive to hepatitis B surface antigen (HBsAg) for 6 months or longer., Two billion people in the world are estimated to be infected with HBV, of this number, an estimated 350 million (representing 17.5% of the 2 billion) worldwide are chronically infected with HBV. About 600,000 deaths occur yearly due to the consequences of acute or chronic HBV.
The liver as a homeostatic organ plays a pivotal role in maintaining the relative balance of lipid and lipoprotein metabolism in vivo, modulating both endogenous and exogenous cycles of lipid metabolism. It is involved in the sequestration, remodeling (synthesis or recycling), and redistribution of lipid metabolites including lipoproteins such as low-density lipoproteins (LDLs), high-density lipoproteins (HDLs), and their corresponding apolipoproteins, triglycerides (TGs), and total plasma cholesterol., Thus, the extracellular circulating levels of these metabolites in plasma depend significantly on the functional integrity of the hepatic tissues. Thus, compromising the functional integrity of the hepatic tissue by hepatitis B (HB) could be linked with dyslipidemia.
It has been well documented that chronic liver dysfunction might interfere with lipid metabolism in vivo and could change plasma lipid and lipoprotein patterns. The previous studies also suggest that chronic HBV infection has an inverse association with all lipids.,
Pathophysiologically, there are two main stages of chronic HB (CHB) infection–chronic symptomatic (fulminant CHB infection) and chronic asymptomatic stage with their attendant pathological manifestations. However, most studies of dyslipidemia involving CHB infection have not investigated the bearing of these stages on lipid profile of infected hosts. The aim of this study, therefore, was to assess the impact of chronic viral HB on lipid profile and the effect of the stages of this disease on plasma lipid pattern.
| Methodology|| |
The Institutional Ethical clearance was obtained from the Tertiary Hospital in Makurdi, Nigeria. Seventy chronic viral HB patients attending the hospital and 65 apparently healthy individuals who fulfilled the inclusion aged 18–55 years were selected, respectively, as the test group and the control group. Informed consent was sought from the participants by educating them on the nature of the study. A structured questionnaire was administered to the consented patients, who answered the questions and returned same. The inclusion criteria involved patients who continuously tested positive for HBsAg for up to 1-year during their periodic visit to the clinic, apparently healthy individuals with the desired blood pressure (BP), and anthropometric indices. The exclusion criteria comprised subjects with conditions that predisposes to dyslipidemia.
To obtain host plasma lipoprotein pattern solely based on HBV effect, anthropometric effects on plasma lipids must be eliminated. The study groups were therefore anthropometrically matched for valid comparisons. The lipid profile of chronic hepatitis B virus (CHBV) subjects (n = 70) were compared with anthropometrically matched controls (n = 65). Using a cutoff alanine amino transferase value of greater and <36 U/L, the CHB subjects (n = 70) were subgrouped into symptomatic (n = 14) and asymptomatic (n = 56) CHB, respectively. The plasma lipids of the symptomatic (n = 14) and asymptomatic (n = 56) chronic hepatitis C subjects were statistically compared with that of their anthropometrically matched controls (n = 14 and n = 56, respectively).
Four milliliters of fasting venous blood samples were aseptically collected from the selected subjects and processed into serum samples for the determination of HBsAg, T/HDL/LDL cholesterol, and TGs.
The monolisa HBsAg ultra enzyme-linked immunosorbent assay (ELISA) kit, obtained from Bio-Rad Marnes-la-Coquette France, was used for the assay of HBsAg. Determination of HBsAg was based on the ELISA sandwich principle. Immobilized mouse monoclonal anti-HBs antibodies bind HBsAg in sample. The amount of the antigen bound depends on the amount in sample. A second monoclonal antibody, peroxidase labeled is added to the mixture which binds the available epitopes on the HBsAg. The amount of the second monoclonal antibody bound to the HBsAg is proportional to the amount of HBsAg. On addition of an enzyme substrate, a product is formed which react with the chromogen tetramethylbenzidine to yield a colored solution. The intensity of the solution is proportional to the concentration of the HBsAg present in the sample.
The reagent kit for the determination of cholesterol, HDL-C, and TG was obtained from Randox Laboratories Limited, United Kingdom. TC was determined by the cholesterol esterase method. Free cholesterol is liberated from cholesterol esters by cholesterol esterase. The free cholesterol is oxidized by cholesterol oxidase to yield a ketone and hydrogen peroxide. The hydrogen peroxide is converted into water and oxygen, which is immediately used for the oxidation of para aminophenazone in a phenol solution giving rise to a pink colored solution. The intensity of the colored solution is directly proportional to the concentration of cholesterol in the sample. The HDL-C was determined by the cholesterol esterase method after fractional separation from other lipids. The HDL-C reagent is a mixture of cholesterol esterase, cholesterol oxidase, and catalase. These enzymes eliminate chylomicrons, very LDL-cholesterol (VLDL-C), and LDL-C. HDL-C is released into the supernatant mixture of detergent and serum after centrifugation. The HDL-C fraction extracted is measured the cholesterol esterase method used in cholesterol determination. TGs were determined using the lipase method. Lipase hydrolyses TG into hydrogen peroxide, subsequently acted on by peroxidase to produce water and oxygen. The oxygen is immediately used for the oxidation of para aminophenazone which in the presence of phenol yields a pink-colored quinoneimine dye, whose color intensity is directly proportional to the concentration of TG in the serum. LDL-C and VLDL-C were estimated using the Friedewald equation.
The statistical package IBM SPSS version 21 (IBM Armonk, New York, United States) was used in analyzing the data generated. Descriptive statistics were used in determining the means and standard deviations of the parameters measured. The Student's t-test was used in comparing the means of parameters in CHBV and control groups. A two-tailed P < 0.05 was indicative of statistical significance.
| Results|| |
[Table 1] shows the BP, age, body mass index (BMI), fasting TC., HDL-C, LDL-C, VLDL-C and TG in chronic HBV, and seronegative subjects. There was no significant (P > 0.05) difference between the mean systolic BP, diastolic BP, age, BMI of CHB, and controls. There was a significantly reduced (P = 0.001) HDL-C and raised (P = 0.044) LDL-C in chronic HBV compared to seronegative controls. Whereas no significant difference in mean fasting serum TC, VLDL-C, TG was observed between chronic HBV and seronegative subjects.
|Table 1: Blood pressure, age, body mass index, lipid profile, liver function in chronic hepatitis B virus patients, and controls|
Click here to view
[Table 2] shows the BP, anthropometric parameters, lipid profile of asymptomatic CHB, and controls. There was no significant (P > 0.05) difference between the mean systolic BP, diastolic BP, age, BMI of asymptomatic CHB, and controls. There was a significantly lowered HDL-C (P = 0.017), VLDL-C (P = 0.005), and TG (P = 0.034) in asymptomatic CHB compared to the matched controls whereas no significant (P > 0.05) difference in mean fasting serum TC, LDL-C was observed between asymptomatic CHB and matched subjects.
|Table 2: Blood pressure, age, body mass index, lipid profile, liver function in asymptomatic chronic hepatitis B virus patients (with alanine transaminase value <36 U/L), and controls|
Click here to view
[Table 3] shows the BP, anthropometric parameters, lipid profile of symptomatic CHB, and controls. There was no significant (P > 0.05) difference between the mean systolic BP, diastolic BP, age, BMI of symptomatic CHB, and controls. There was a significantly lowered TC (P = 0.019) and HDL-C (P = 0.017) in symptomatic CHB compared to the matched controls whereas no significant (P > 0.05) difference in mean fasting serum LDL-C, VLDL-C, and TG was observed between symptomatic CHB and matched subjects.
|Table 3: Blood pressure, age, body mass index, lipid profile, liver function in symptomatic chronic hepatitis B virus patients (with alanine transaminase value >36 U/L), and control patients|
Click here to view
| Discussion|| |
HBV is one of the leading causes of liver disease. The liver is the major organ that metabolizes lipids. Several studies have linked the association of liver diseases irrespective of the etiology with dyslipidemia. Various case–controlled studies reported dyslipidemia in CHB disease, however, with differing lipid profile pattern. Based on liver involvement, CHB disease is classified into asymptomatic and symptomatic CHB disease. Besides the overall CHB patients, our study further determined the lipid profile pattern in asymptomatic and symptomatic CHB groups, to establish a lipid profile pattern dependent and independent of the liver. The CHB groups were extensively matched with age, BMI, and BP controls to eliminate false results which could emanate from the already established causes of the metabolic syndrome.
Our study revealed a statistically low HDL-C in the unsubgrouped, asymptomatic, and symptomatic CHB patients compared to their matched controls. TC was found to be low in all the CHB groups compared to their matched controls. However, the low TC was statistical only in the symptomatic CHB group. This result agrees with the study of Su et al., who reported an association between asymptomatic chronic HBV infection and lower serum levels of TC and HDL-C. Low TC level has also been reported in CHB patients compared to controls by other studies.,,,, Hsu et al. reported a lower HDL-C in CHB patients, while Chung et al. reported a lower HDL-C in CHB men compared to controls.
In our study, a statistically low TG level was observed in the asymptomatic CHB subgroup compared with its matched control. No statistical difference was observed in TG levels of ungrouped and symptomatic CHB patients compared with their matched controls. This result is in line with the studies of Choi et al., and Chen et al., who reported that HBsAg positivity was associated with lower prevalence of hypertriglyceridemia., Other studies also reported low TG levels in CHB patients compared to controls.,,,,,,,
We observed a statistically low VLDL-C in the asymptomatic CHB subgroup compared to its matched controls. The ungrouped and symptomatic CHB patients also revealed low VLDL-C when compared with their matched controls, however, not statistical. This observation is in line with the studies of Jarcuška et al., and Janicko et al., who reported lower levels of apolipoprotein B100, which is the principal protein component of LDL and VLDL particles.,
The study reveals a statistically elevated LDL-C level in the ungrouped CHB compared with its matched control. In addition, a nonstatistical elevated LDL-C was observed in the asymptomatic CHB subgroup compared with the matched controls. This agrees with studies by Li et al., and Kwarteng et al., who showed elevated LDL-C in CHB patients compared to controls., Some published studies did not find any difference in the levels of LDL-C in patients with CHB and controls.,, Nevertheless, other studies reported significantly low LDL-C in CHB patients compared to controls.,,,
Most of the studies in literature ascribed dyslipidemia in CHB patients as an outcome of impaired hepatic function. Whether there are nonhepatic causes of yet to be established, lipid profile pattern in CHB disease remains unanswered.
There are four proteins that originate from the HBV genome including polymerase, a surface protein, a core protein, and the HBx protein. Among these proteins, HBx protein has been reported to induce hepatic steatosis and inflammation. The previous reports have demonstrated that HBx proteins induce the expression of lipid synthesis-related genes and inflammation in the liver transgenic mice.,, The consequence of the interaction of HBx protein with host hepatic metabolic genes is to switch hepatic metabolism from fatty acid synthesis and secretion through lipoproteins to increased hepatic lipid synthesis and storage., Thus, the liver becomes more adipogenic sequestering most of the lipids that diffuse into it, creating a steatotic condition in the infected liver.,,, Data from hepatoma cell cultures suggest that hepatocytes infected with HBV have lower concentrations of apolipoprotein mRNA. Kang et al. reported the specific impairment of hepatic secretion of apolipoprotein B by HBx protein and further ascribed low serum TG to the same viral protein. Thus, hepatic steatosis and impairment in the secretion of TGs and apolipoproteins could in part explain the lowered plasma lipids observed in our study.
Other studies have demonstrated nonhepatic causes of dyslipidemia in CHB patients. Neurath and Strick in their study reported the binding of apolipoprotein H to the HBsAg with subsequent lowering of the plasma apolipoprotein. The prolonged surge in proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1, IL-6, and interferon-alpha (IFN-α) has been linked with dyslipidemia in studies following the chronic state of the HBV-infection.,,, Thus, interaction of HBsAg with apolipoprotein H and lipidemic effect of cytokines could have contributed to the observed distortions in the various lipid indices of the HB-infected population. Cytokines such as the TNF-α, IL-1, IL-6, and IFN-α have been reported to increase lipogenesis, decrease clearance of circulating LDLs, and inhibit hepatic lipase activity.,, This probably accounts for the observed increase in the serum LDL levels among the HBV-infected populations in our study.
| Conclusion|| |
Lowered serum lipids are associated with CHB disease and likely to be mediated altered liver metabolism. However, reasons for the low levels of lipids in this viral disease still remains unclear. Therefore, the role of HBV in lipid metabolism should be further explored.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rehermann B, Nascimbeni M. Immunology of hepatitis B virus and hepatitis C virus infection. Nat Rev Immunol 2005;5:215-29.
McMahon BJ. Natural history of chronic hepatitis B. Clin Liver Dis 2010;14:381-96.
Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepatitis C virus infection. Lancet Infect Dis 2005;5:558-67.
World Health Organization. Hepatitis B. The immunological basis for immunization series. Module 22. Geneva, Switzerland: World Health Organization; 2010;1-16.
Mast EE, Margolis HS, Fiore AE, Brink EW, Goldstein ST, Wang SA, et al.
A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of infants, children, and adolescents. MMWR Recomm Rep 2005;54:1-31.
Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2007;45:507-39.
World Health Organization. Hepatitis B: WHO Fact Sheet NO204 Geneva, Switzerland: World Health Organization; 2013. p. 204.
Katsuramaki T, Mizuguchi T, Kawamoto M, Yamaguchi K, Meguro M, Nagayama M, et al.
Assessment of nutritional status and prediction of postoperative liver function from serum apolioprotein A-1 levels with hepatectomy. World J Surg 2006;30:1886-91.
Peterhans E. Reactive oxygen species and nitric oxide in viral diseases. Biol Trace Elem Res 1997;56:107-16.
Miller JP. Dyslipoproteinaemia of liver disease. Baillieres Clin Endocrinol Metab 1990;4:807-32.
Chen JY, Wang JH, Lin CY, Chen PF, Tseng PL, Chen CH, et al.
Lower prevalence of hypercholesterolemia and hyperglyceridemia found in subjects with seropositivity for both hepatitis B and C strains independently. J Gastroenterol Hepatol 2010;25:1763-8.
Liu PT, Hwang AC, Chen JD. Combined effects of hepatitis B virus infection and elevated alanine aminotransferase levels on dyslipidemia. Metabolism 2013;62:220-5.
Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499-502.
Su TC, Lee YT, Cheng TJ, Chien HP, Wang JD. Chronic hepatitis B virus infection and dyslipidemia. J Formos Med Assoc 2004;103:286-91.
Janicko M, Senajová G, Drazilová S, Veselíny E, Fedacko J, Siegfried L, et al.
Association between metabolic syndrome and hepatitis B virus infection in the Roma population in eastern Slovakia: A population-based study. Cent Eur J Public Health 2014;22:S37-42.
Wong VW, Wong GL, Chu WC, Chim AM, Ong A, Yeung DK, et al.
Hepatitis B virus infection and fatty liver in the general population. J Hepatol 2012;56:533-40.
Li WC, Lee YY, Chen IC, Sun C, Chiu FH, Chuang CH. Association between the hepatitis B and C viruses and metabolic diseases in patients stratified by age. Liver Int 2013;33:1194-202.
Jarcuška P, Janicko M, Kružliak P, Novák M, Veselíny E, Fedacko J, et al.
Hepatitis B virus infection in patients with metabolic syndrome: A complicated relationship. Results of a population based study. Eur J Intern Med 2014;25:286-91.
Hsu CS, Liu CH, Wang CC, Tseng TC, Liu CJ, Chen CL, et al.
Impact of hepatitis B virus infection on metabolic profiles and modifying factors. J Viral Hepat 2012;19:e48-57.
Chung TH, Kim MC, Kim CS. Association between hepatitis B surface antigen seropositivity and metabolic syndrome. Korean J Fam Med 2014;35:81-9.
Choi JS, Han KJ, Lee S, Chun SW, Kim DJ, Kim HC, et al.
Serum HBV surface antigen positivity is associated with low prevalence of metabolic syndrome in Korean adult men. J Epidemiol 2015;25:74-9.
Luo B, Wang Y, Wang K. Association of metabolic syndrome and hepatitis B infection in a Chinese population. Clin Chim Acta 2007;380:238-40.
Kwarteng JK, Owusu L, Afihene M, Mica E, Opare-Sem O, Arthur FK. Lowered serum triglyceride levels among chronic hepatitis b-infected patients in Ghana. J Sci Technol 2013;32:1-10.
Wang CC, Hsu CS, Liu CJ, Kao JH, Chen DS. Association of chronic hepatitis B virus infection with insulin resistance and hepatic steatosis. J Gastroenterol Hepatol 2008;23:779-82.
Hajjou M, Norel R, Carver R, Marion P, Cullen J, Rogler LE, et al.
cDNA microarray analysis of HBV transgenic mouse liver identifies genes in lipid biosynthetic and growth control pathways affected by HBV. J Med Virol 2005;77:57-65.
Kim KH, Shin HJ, Kim K, Choi HM, Rhee SH, Moon HB, et al.
Hepatitis B virus X protein induces hepatic steatosis via transcriptional activation of SREBP1 and PPARgamma. Gastroenterology 2007;132:1955-67.
Kim K, Kim KH, Kim HH, Cheong J. Hepatitis B virus X protein induces lipogenic transcription factor SREBP1 and fatty acid synthase through the activation of nuclear receptor LXRalpha. Biochem J 2008;416:219-30.
Shlomai A, Shaul Y. The metabolic activator FOXO1 binds hepatitis B virus DNA and activates its transcription. Biochem Biophys Res Commun 2009;381:544-8.
Altlparmak E, Koklu S, Yalinkilic M, Yuksel O, Cicek B, Kayacetin E, et al.
Viral and host causes of fatty liver in chronic hepatitis B. World J Gastroenterol 2005;11:3056-9.
Thomopoulos KC, Arvaniti V, Tsamantas AC, Dimitropoulou D, Gogos CA, Siagris D, et al.
Prevalence of liver steatosis in patients with chronic hepatitis B: A study of associated factors and of relationship with fibrosis. Eur J Gastroenterol Hepatol 2006;18:233-7.
Tsochatzis E, Papatheodoridis GV, Manesis EK, Chrysanthos N, Kafiri G, Archimandritis AJ. Hepatic steatosis in chronic hepatitis B develops due to host metabolic factors: A comparative approach with genotype 1 chronic hepatitis C. Dig Liver Dis 2007;39:936-42.
Cindoruk M, Karakan T, Unal S. Hepatic steatosis has no impact on the outcome of treatment in patients with chronic hepatitis B infection. J Clin Gastroenterol 2007;41:513-7.
Norton PA, Gong Q, Mehta AS, Lu X, Block TM. Hepatitis B virus-mediated changes of apolipoprotein mRNA abundance in cultured hepatoma cells. J Virol 2003;77:5503-6.
Kang SK, Chung TW, Lee JY, Lee YC, Morton RE, Kim CH. The hepatitis B virus X protein inhibits secretion of apolipoprotein B by enhancing the expression of N-acetylglucosaminyltransferase III. J Biol Chem 2004;279:28106-12.
Neurath AR, Strick N. The putative cell receptors for hepatitis B virus (HBV), annexin V, and apolipoprotein H, bind to lipid components of HBV. Virology 1994;204:475-7.
Argilés JM, Lopez-Soriano FJ, Evans RD, Williamson DH. Interleukin-1 and lipid metabolism in the rat. Biochem J 1989;259:673-8.
Grunfeld C, Dinarello CA, Feingold KR. Tumor necrosis factor-alpha, interleukin-1, and interferon alpha stimulate triglyceride synthesis in HepG2 cells. Metabolism 1991;40:894-8.
Naeem M, Bacon BR, Mistry B, Britton RS, Di Bisceglie AM. Changes in serum lipoprotein profile during interferon therapy in chronic hepatitis C. Am J Gastroenterol 2001;96:2468-72.
Khovidhunkit W, Kim MS, Memon RA, Shigenaga JK, Moser AH, Feingold KR, et al.
Effects of infection and inflammation on lipid and lipoprotein metabolism: Mechanisms and consequences to the host. J Lipid Res 2004;45:1169-96.
Feingold KR, Grunfeld C. Tumor necrosis factor-alpha stimulates hepatic lipogenesis in the rat in vivo
. J Clin Invest 1987;80:184-90.
Feingold KR, Soued M, Serio MK, Moser AH, Dinarello CA, Grunfeld C. Multiple cytokines stimulate hepatic lipid synthesis in vivo
. Endocrinology 1989;125:267-74.
Feingold KR, Staprans I, Memon RA, Moser AH, Shigenaga JK, Doerrler W, et al.
Endotoxin rapidly induces changes in lipid metabolism that produce hypertriglyceridemia: Low doses stimulate hepatic triglyceride production while high doses inhibit clearance. J Lipid Res 1992;33:1765-76.
[Table 1], [Table 2], [Table 3]