Changes in serum levels of autotaxin with direct-acting antiviral therapy in patients with chronic

20 Pages·2017·10.36 MB·English

RESEARCHARTICLE
Changes in serum levels of autotaxin with
direct-acting antiviral therapy in patients with
chronic hepatitis C
TomooYamazaki1☯,SatoruJoshita1,2☯,TakejiUmemura1,2*,YokoUsami3,
AyumiSugiura1,NaoyukiFujimori1,TakefumiKimura1,AkihiroMatsumoto1,
KojiIgarashi4,MasaoOta1,EijiTanaka1
1 DepartmentofMedicine,DivisionofHepatologyandGastroenterology,ShinshuUniversitySchoolof
Medicine,Matsumoto,Japan,2 ResearchCenterforNextGenerationMedicine,ShinshuUniversity,
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Matsumoto,Japan,3 DepartmentofLaboratoryMedicine,ShinshuUniversityHospital,Matsumoto,Japan,
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4 BioscienceDivision,TOSOHCorporation,Ayase,Japan
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a1111111111 ☯Theseauthorscontributedequallytothiswork.
a1111111111 *[email protected]
Abstract
OPENACCESS Sustainedvirologicalresponse(SVR)rateshaveincreasedremarkablysincetheintroduc-
Citation:YamazakiT,JoshitaS,UmemuraT, tionofdirect-actingantiviralagents(DAAs)forchronichepatitisC.Autotaxin(ATX)isa
UsamiY,SugiuraA,FujimoriN,etal.(2018) secretedenzymeconvertinglysophosphatidylcholinetolysophosphatidicacidandanewly
Changesinserumlevelsofautotaxinwithdirect-
establishedbiomarkerforliverfibrosis.Interferon-freeDAAregimensforchronichepatitisC
actingantiviraltherapyinpatientswithchronic
hepatitisC.PLoSONE13(4):e0195632.https:// couldimproveliverstiffnessinSVRpatientsaccordingtoseveralnon-invasiveevaluation
doi.org/10.1371/journal.pone.0195632 methods,buttheclinicalresponseandsignificanceofATXinthiscontexthavenotyetbeen
Editor:TatsuoKanda,NihonUniversitySchoolof defined.WethereforeinvestigatedsequentialserumATXlevelsatbaseline,4weeksafter
Medicine,JAPAN thestartoftreatment,and24weeksaftertreatmentin159hepatitisCvirus(HCV)-infected
Received:January17,2018 patientswhoreceivedDAAtherapy.Othernon-invasivefibrosismarkers(aspartateamino-
transferase-to-plateletratioandFIB-4index)wereexaminedaswell.BaselinemedianATX
Accepted:March25,2018
levelswerecomparablebetweenthe144patientswhoachievedaSVRandthe15whodid
Published:April4,2018
not(1.54vs.1.62mg/L),butmedianATXlevelsbecamesignificantlydecreasedduringand
Copyright:©2018Yamazakietal.Thisisanopen afterDAAtherapyintheSVRgrouponly(from1.54to1.40and1.31mg/L,respectively;P<
accessarticledistributedunderthetermsofthe
0.001).ATXwassignificantlydecreasedbetweenbaselineand4weeksoftreatmentin
CreativeCommonsAttributionLicense,which
permitsunrestricteduse,distribution,and overall,male,andfemaleSVRpatients(allP<0.001).Insubjectswithlownecroinflamma-
reproductioninanymedium,providedtheoriginal toryactivityintheliver(i.e.,alanineaminotransferase<30U/L),ATXlevelsweresignifi-
authorandsourcearecredited.
cantlyreducedfrombaselineto4weeksoftreatmentandremainedlow(P<0.001)in
DataAvailabilityStatement:Allrelevantdataare patientswithaSVR.Thus,interferon-freeDAAtherapywasassociatedwithasignificant
withinthepaper.
decreaseinserumATXlevelsinpatientsachievingaSVR,suggestingearlyregressionof
Funding:KojiIgarashiisanemployeeofTOSOH liverfibrosisinadditiontoinflammationtreatment.
Corporation.Theotherauthorsdeclarethatthey
havenothingtodiscloseregardingfundingfrom
industriesorconflictsofinterestwithrespectto
thismanuscript.Thefunderprovidedsupportin
theformofasalaryforKojiIgarashi,butdidnot Introduction
haveanyadditionalroleinthestudydesign,data
PersistenthepatitisCvirus(HCV)infectiondevelopsintochronichepatitisandleadstocir-
collectionandanalysis,decisiontopublish,or
preparationofthemanuscript.Thespecificroleof rhosisandhepatocellularcarcinoma(HCC)[1,2].SuccessfulHCVeradication,definedasa
PLOSONE|https://doi.org/10.1371/journal.pone.0195632 April4,2018 1/20
ChangesinATXwithDAAtherapyinchronichepatitisC
KojiIgarashiisarticulatedinthe“author sustainedvirologicalresponse(SVR),isthereforeconsideredimportantindecreasingtheinci-
contributions’section. denceofHCC[3].Severalnewinterferon(IFN)-freedirect-actingantiviralagent(DAA)regi-
Competinginterests:KojiIgarashiisanemployee menshavebeenapprovedforchronichepatitisCinJapan[4–6]andhaveachievedSVRrates
ofTOSOHCorporation.Thisdoesnotalterour of90–100%,shortertreatmentperiods,andlowerratesofadverseeffects.Moreover,accumu-
adherencetoPLOSONEpoliciesonsharingdata latingevidencehasindicatedthatIFN-freeDAAtherapyimprovesliverfibrosisaccordingto
andmaterials.Theotherauthorshavedeclaredthat
severalnon-invasiveevaluationmethods[7–12].
nocompetinginterestsexist.
Autotaxin(ATX)playsanimportantroleinconvertinglysophosphatidylcholinetothebio-
activephospholipidlysophosphatidicacid(LPA)[13]involvedinphysiologicalroles[14,15].
AsATXisrapidlytakenupbyliversinusoidalendothelialcells[16],reducedclearanceofATX
bythedamagedorfibroticlivermayexplaintheelevatedserumATXlevelsfoundinpatients
withliverfibrosis[17].SerumATXlevelsinwomenarealsosignificantlyhigherthaninmen
[18,19]forstillunclearreasons,soitisrecommendedthatATXbeassessedbygender.Serum
ATXiscorrelatedwithliverfibrosisandrepresentsanewnon-invasiveindicatorofhepatic
status[18–23].AlthoughchangesinATXhavebeenstudiedinsmallcohortsofHCV-infected
patientsreceivingIFN-freeDAAtherapy[24],itsabilitytoreflectfibrosisimprovement
remainsunknown.ThisstudythereforeassessedthesequentialchangesinserumATXlevels
forevaluatingliverfibrosisinpatientswithchronichepatitisCbefore,during,andafterIFN-
freeDAAtherapy.
Materialsandmethods
Subjects
Between2014and2016,atotalof159patientswithchronichepatitisCwhoreceivedIFN-free
DAAtherapy(daclatasvirandasunaprevir[n=61],sofosbuvir/ledipasvir[n=54],orsofosbu-
virandribavirin[n=44])wereenrolledinthisstudy.ThediagnosisofchronichepatitisCwas
basedonthepresenceofserumHCVantibodiesanddetectableviralRNA,asreportedprevi-
ously[25].AllpatientswerenegativeforhepatitisBsurfaceantigenandantibodiestothe
humanimmunodeficiencyvirus.Othercausesofchronicliverdiseasewereexcluded.Serum
levelsofHCVRNAweremeasuredwiththeCOBASTaqManHCVTest(RocheDiagnostic
Systems,Tokyo,Japan).HCVgenotypesweredeterminedasdescribedelsewhere[26].No
patienthadahistoryofordevelopeddecompensatedcirrhosisorHCC.Cut-offvalues(mg/L)
forATXlevelsforeachfibrosisstageweredeterminedpreviously[22]asF1=0.8,F2=1.1,
F3=1.3,andF4=1.7formalesandF1=0.9,F2=1.7,F3=1.8,andF4=2.0forfemales.Cir-
rhosiswasobservedin20%(14/70)ofmalesand40%(36/89)offemalesbasedonATXlevels
ofgreaterthan1.7and2.0mg/L,respectively.Thestudywasconductedaccordingtothe
guidelinesoftheDeclarationofHelsinkiandwasapprovedbytheethicscommitteeofShinshu
UniversitySchoolofMedicine(approvalnumber:3244).Writteninformedconsentwas
obtainedfromallsubjects.
IFN-freeDAAtherapy
A24-weekregimenofdaclatasvirandasunaprevir[4]ora12-weekcourseofledipasvirand
sofosbuvir[6]wasadministeredtopatientswithHCVgenotype1.InpatientswithHCVgeno-
type2,a12-weekregimenofsofosbuvirandribavirinwasgiven[5].ASVRwasdefinedas
undetectableserumHCVRNAat24weeksaftercompletingtherapy.Thepresenceofknown
resistance-associatedvariantsinHCV-NS5Aatbaselinewastestedingenotype1bpatients,
whowereallfoundtocarrythewild-typeNS5Aregion(i.e.,absenceofleucineatresidue31
andtyrosineatresidue93).Regardless,thesesubjectsweretreatedwithdaclatasvirandasuna-
previrtherapysinceSVRrateswerereportedlylowerinpatientsharboringsuchresistance-
associatedvariants[4].NopatienthaltedIFN-freeDAAtherapyduetoadverseevents.Forall
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ChangesinATXwithDAAtherapyinchronichepatitisC
patients,serumsampleswereobtainedjustbeforetreatment(baseline),at4weeksoftreat-
ment,andat24weeksaftertreatment.Allcollectedsampleswereimmediatelystoredat-20˚C
untiltesting.
DetectionofATX
WemeasuredATXlevelsbyaspecifictwo-siteenzymeimmunoassayusingthecommercial
automatedimmunoassayanalyzerAIA-system(TosohCo.,Tokyo,Japan)forserumsamples
obtainedbeforethestartoftreatment,at4weeksafterthestartoftreatment,andat24weeks
aftertreatmentcompletion.TheAIA-systemincludesautomated10-microliterspecimendis-
pensation,incubationofthereactioncup,abound/freewashingprocedure,4-methylumbelli-
ferylphosphatesubstratedispensation,fluorometricdetection,andaresultreport.The
antigen-antibodyreactiontimeis10minandthefirstresultisreportedwithin20min.The
throughputoftheAIA-2000systemis200samples/h[27].Theassaywasconductedaccording
totheoptimizedprotocolsusedinpreviousstudies[22,23].
Liverfibrosisindices
Weexamined2additionalsurrogatebloodindicesofliverfibrosis(FIB-4indexandaspartate
aminotransferase[AST]/plateletratio[APRI])beforetreatment,at4weeksoftreatment,and
at24weeksaftertreatment.FIB-4indexandAPRIwererespectivelycalculatedas:age(years)
×AST(U/L)/plateletcount(109/L)×alanineaminotransferase(ALT)(U/L)1/2[28]and(AST/
upperlimitofnormalAST[U/L])×(100/plateletcount[109/L])[29].
Statisticalanalysis
Continuousvariablesareexpressedasthemedianandinterquartilerange.TheFriedmanand
Wilcoxonsigned-ranktestswereusedtoanalyzedifferencesamongcontinuousvariablesat
indicatedtimepoints.Thesignificanceofassociationswasevaluatedbyχ2analysisorFisher’s
exacttest.APvalueoflessthan0.05wasconsideredstatisticallysignificant.Association
strengthwasestimatedbycalculatingtheoddsratioand95%confidenceinterval.
Results
Thecohort’scharacteristicsaresummarizedinTable1.Ofthe159subjects,70(44%)were
male.Median(interquartilerange)agewas69(62–76)yearsandmedianATXlevelwas1.54
(1.13–2.02)mg/L.SincemedianATXlevelswerehigherinwomenthaninmen(1.81vs.1.33
mg/L;P<0.001),weanalyzedourbaselineclinicalcharacteristicsaccordingtogender.Male
patientshadsignificantlyhigherbodymassindex,serumcreatinine,andhemoglobinvalues.
Atotalof144patientsachievedaSVRandtheremaining15sufferedarelapse.Wedetected
nosignificantdifferencesbetweenpatientswithandwithoutaSVRinrelationtoclinicalback-
ground(Table2).BaselineserumATXlevelsdidnotdifferbetweentheSVRandnon-SVR
groups(1.54vs.1.62mg/L;P=0.967),norwereremarkabledifferencesseenforFIB-4index
orAPRI.Amongthe70maleand89femalepatientswithchronichepatitisC,64(91%)and80
(90%),respectively,achievedaSVR.Comparisonsofbaselineclinicalcharacteristicsforeach
genderrevealednosignificantdifferencesaccordingtoSVRstatus(Tables3and4).Baseline
serumATXlevelswerealsosimilarintheSVRandnon-SVRgroups(male:1.33vs.1.35mg/L;
P=0.976,female:1.79vs.1.95mg/L;P=0.908,respectively).FIB-4indexandAPRIdidnot
differbetweentheSVRandnon-SVRgroupsbygender.
Wenextcomparedpre-treatmentserumATXlevelswiththoseat4weeksaftertheinitia-
tionoftherapyand24weeksafteritscompletion.HCVRNAandALTlevelsweresignificantly
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ChangesinATXwithDAAtherapyinchronichepatitisC
Table1. Baselinecharacteristicsof159patientswithchronichepatitisC.
All(n=159) Male(n=70) Female(n=89) Pvalue
Age(years) 69(62–76) 68(61–73) 72(65–76) 0.072
Bodymassindex(kg/m2) 21.5(20.1–23.4) 22.3(20.7–24.2) 21.0(19.3–22.9) 0.005
Treatmentregimen 0.980
Daclatasvir+asunaprevir 61 26 35
Ledipasvir+sofosbuvir 54 25 29
Sofosbuvir+ribavirin 44 19 25
Genotype(1/2) 115/44 51/19 64/25 0.895
HCVRNA(logIU/mL) 6.1(5.7–6.6) 6.1(5.8–6.6) 6.1(5.7–6.4) 0.595
Alanineaminotransferase(U/L) 39(24–61) 44(27–70) 34(23–57) 0.106
Creatinine(mg/dL) 0.73(0.63–0.85) 0.85(0.78–0.97) 0.66(0.58–0.73) <0.001
Albumin(g/dL) 4.1(3.8–4.3) 4.1(3.9–4.4) 4.0(3.8–4.3) 0.207
Hemoglobin(g/dL) 13.8(12.7–15.1) 15.1(13.3–15.7) 13.2(12.6–14.0) <0.001
Platelets(×104/mm3) 15.3(10.9–19.8) 14.4(10.6–18.2) 15.4(11.3–19.7) 0.198
α-fetoprotein(ng/mL) 4.7(2.8–7.5) 4.5(2.4–9.3) 4.8(3.2–7.3) 0.672
FIB-4index 3.36(1.88–4.88) 3.30(2.09–4.80) 3.37(1.77–5.01) 0.695
APRI 1.06(0.63–1.80 1.15(0.77–2.03) 1.03(0.55–1.72) 0.146
Autotaxin(mg/L) 1.54(1.13–2.02) 1.33(0.95–1.61) 1.81(1.30–2.41) <0.001
Valuesareexpressedasthemedian(interquartilerange).
https://doi.org/10.1371/journal.pone.0195632.t001
decreasedoverall(P<0.001,Friedmantest)(Fig1Aand1B).MedianATXbecamesignifi-
cantlydecreasedinthe144patientswhoachievedaSVR(1.54[1.14–2.02],1.40[1.08–1.79],
and1.31[1.05–1.63]mg/L,respectively;P<0.001)(Fig1C).Thereweresignificantdifferences
Table2. Baselinecharacteristicsof144patientswithaSVRand15without.
SVR(n=144) Non-SVR(n=15) Pvalue
Age(years) 69(62–76) 69(64–75) 0.915
Male/female 64/80 6/9 0.741
Bodymassindex(kg/m2) 21.5(20.1–23.4) 20.3(19.3–22.5) 0.264
Treatmentregimen 0.112
Daclatasvir+asunaprevir 53 8
Ledipasvir+sofosbuvir 50 4
Sofosbuvir+ribavirin 41 3
Genotype(1/2) 103/41 12/3 0.485
HCVRNA(logIU/mL) 6.1(5.8–6.6) 6.0(5.6–6.5) 0.726
Alanineaminotransferase(U/L) 39(24–63) 34(25–60) 0.888
Creatinine(mg/dL) 0.73(0.63–0.85) 0.68(0.63–0.82) 0.493
Albumin(g/dL) 4.1(3.8–4.3) 4.0(3.8–4.4) 0.821
Hemoglobin(g/dL) 13.8(12.8–15.1) 13.2(12.1–14.0) 0.216
Platelets(×104/mm3) 15.5(11.2–19.8) 10.0(6.3–17.7) 0.120
α-fetoprotein(ng/mL) 4.6(2.7–7.3) 6.3(4.3–12.2) 0.131
FIB-4index 3.22(1.89–4.79) 3.91(1.70–6.28) 0.374
APRI 1.05(0.63–1.78) 1.23(0.57–2.04) 0.511
Autotaxin(mg/L) 1.54(1.14–2.02) 1.62(1.07–2.06) 0.967
Valuesareexpressedasthemedian(interquartilerange).
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ChangesinATXwithDAAtherapyinchronichepatitisC
Table3. Baselinecharacteristicsof64malepatientswithaSVRand6without.
SVR(n=64) Non-SVR(n=6) Pvalue
Age(years) 67(57–73) 70(67–82) 0.210
Bodymassindex(kg/m2) 22.3(20.8–24.5) 21.0(20.0–22.0) 0.332
Treatmentregimen 0.884
Daclatasvir+asunaprevir 23 3
Ledipasvir+sofosbuvir 23 2
Sofosbuvir+ribavirin 18 1
Genotype(1/2) 46/18 5/1 0.546
HCVRNA(logIU/mL) 6.1(5.8–6.7) 6.0(5.2–6.5) 0.417
Alanineaminotransferase(U/L) 44(27–71) 31(26–48) 0.260
Creatinine(mg/dL) 0.85(0.79–0.97) 0.64(0.64–0.99) 0.416
Albumin(g/dL) 4.2(3.9–4.4) 4.0(3.9–4.1) 0.554
Hemoglobin(g/dL) 15.2(13.7–15.7) 12.3(12.0–12.5) 0.067
Platelets(×104/mm3) 14.7(10.9–19.6) 8.2(6.3–10.0) 0.093
α-fetoprotein(ng/mL) 4.5(2.4–9.2) 6.3(4.7–10.8) 0.444
FIB-4index 3.06(2.01–4.66) 4.43(3.91–4.93) 0.288
APRI 1.10(0.77–2.06) 1.35(0.80–1.76) 0.976
Autotaxin(mg/L) 1.33(0.97–1.60) 1.35(0.88–1.69) 0.976
Valuesareexpressedasthemedian(interquartilerange).
https://doi.org/10.1371/journal.pone.0195632.t003
betweenbaselineand4weeksoftreatment(P<0.001)andbetween4weeksoftreatmentand
24weeksaftertreatment(P<0.001).FIB-4indexandAPRIweresignificantlydecreasedover-
all(P<0.001,Friedmantest)(Fig1Dand1E).Inthe15patientswithoutaSVR,HCVRNA
andALTlevelsdecreasedfrombaselineto4weeksoftreatment(P<0.01)andthenincreased
Table4. Baselinecharacteristicsof80femalepatientswithaSVRand9without.
SVR(n=80) Non-SVR(n=9) Pvalue
Age(years) 72(65–77) 68(56–75) 0.297
Bodymassindex(kg/m2) 21.0(19.3–22.9) 20.3(18.0–23.0) 0.549
Treatmentregimen 0.835
Daclatasvir+asunaprevir 30 5
Ledipasvir+sofosbuvir 27 2
Sofosbuvir+ribavirin 23 2
Genotype(1/2) 57/23 7/2 0.680
HCVRNA(logIU/mL) 6.1(5.8–6.4) 6.3(5.6–6.8) 0.799
Alanineaminotransferase(U/L) 33(22–57) 49(21–81) 0.518
Creatinine(mg/dL) 0.66(0.58–0.73) 0.71(0.57–0.78) 0.714
Albumin(g/dL) 4.0(3.8–4.3) 4.0(3.8–4.4) 0.875
Hemoglobin(g/dL) 13.2(12.6–13.9) 13.7(12.7–14.4) 0.496
Platelets(×104/mm3) 15.8(11.6–19.8) 13.7(6.5–20.5) 0.395
α-fetoprotein(ng/mL) 4.6(3.2–7.2) 6.6(4.8–11.4) 0.149
FIB-4index 3.34(1.77–4.95) 3.82(1.61–8.23) 0.653
APRI 0.97(0.54–1.72) 1.09(0.55–3.73) 0.376
Autotaxin(mg/L) 1.79(1.31–2.38) 1.95(1.19–2.79) 0.908
Valuesareexpressedasthemedian(interquartilerange).
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ChangesinATXwithDAAtherapyinchronichepatitisC
Fig1. Changesinserumlevelsof(A)HCVRNA,(B)ALT,(C)ATX,(D)FIB-4index,and(E)APRIbefore,during,andafter
IFN-DAAtherapyin144patientswithaSVR.Boxesrepresenttheinterquartilerangeofthedata.Thelineacrosstheboxesindicatesthe
medianvalue.Hashmarksdepictthenearestvaluewithin1.5timestheinterquartilerange.Opencirclesindicateoutliers.PT:post-
treatment.(cid:3)(cid:3)(cid:3),P<0.001.
https://doi.org/10.1371/journal.pone.0195632.g001
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ChangesinATXwithDAAtherapyinchronichepatitisC
to24weeksaftertreatment(P<0.01)(Fig2Aand2B).SerumATXlevelsdecreasedgradually,
butnotsignificantly(1.62[1.07–2.06],1.58[0.95–2.07],and1.28[1.04–2.18],respectively;
P=0.058)(Fig2C).ChangesinFIB-4indexandAPRIweresimilartothoseforALT(Fig2D
and2E).
WeexaminedserialHCVRNA,ALT,ATX,FIB-4index,andAPRIchangesbefore,during,
andafterIFN-freeDAAtherapyaccordingtogender(Figs3–6).Inmaleandfemalepatients
withaSVR,HCVRNAandALTlevelsweresignificantlydecreasedoverall(Fig3Aand3B,
Fig4Aand4B).ATXlevelsbecamesignificantlydecreasedinthe64malepatients(1.33[0.96–
1.60],1.21[0.88–1.53],and1.07[0.87–1.31],respectively;P<0.001,Friedmantest)(Fig3C)
and80femalepatients(1.79[1.31–2.38],1.55[1.20–2.06],and1.53[1.24–1.81],respectively;
P<0.001)(Fig4C)achievingaSVR.Inparticular,ATXsignificantlydecreasedfrombaseline
to4weeksoftreatmentinbothgenders(male:P<0.001,female:P<0.001).FIB-4indexand
APRIdecreasedsignificantlyoverallandfrombaselineto4weeksoftreatment(Fig3Dand
3E,Fig4Dand4E).Incontrast,HCVRNAandALTlevelsdecreasedfrombaselineto4weeks
oftreatmentandthenincreasedto24weekspost-treatmentinmaleandfemalepatientswho
experiencedarelapse(Fig5Aand5B,Fig6Aand6B).ATXlevelsinpatientswithoutaSVR
didnotchangesignificantlyduringoraftertherapyinmale(1.35[0.86–1.69],1.13[0.88–1.41],
and1.11[0.93–1.56],respectively;P=0.135)(Fig5C)orfemale(1.95[1.19–2.79],2.02[1.58–
2.14],and1.83[1.15–2.48],respectively;P=0.368)(Fig6C)subjects.FIB-4indexandAPRI
decreasedsignificantlyfrombaselineto4weeksoftreatmentandthenincreasedto24weeks
post-treatmentinfemales(Fig6Dand6E).
Lastly,weanalyzedthechangesinserumATXofpatientswithALT<30U/LsinceATX
hasbeencorrelatedwithnecroinflammatoryactivityintheliver.Theclinicalcharacteristicsof
54patientswithALT<30U/LaresummarizedinTable5.Among48SVRpatients,serum
HCVRNAandALTlevelsweredecreasedsignificantlyoverall(Fig7Aand7B).SerumATX
becamesignificantlydecreasedoverthestudyperiodinthe48patientswithaSVR(P=0.002,
Friedmantest)(Fig7C),asdidoverallFIB-4indexandAPRI(Fig7Dand7E).Inthe6patients
withoutaSVR,serumHCVRNAandALTlevelsdecreasedfrombaselinetoweek4andthen
increasedto24weekspost-treatment(Fig8Aand8B).SerumATX(P=0.472),FIB-4index,
andAPRIwereunchangedoverall(Fig8C–8E).TheserialchangesinHCVRNA,ALT,ATX,
FIB-4index,andAPRIwererespectivelyanalyzedforrepresentativepatientswithALT<30
U/LandthepresenceorabsenceofaSVR(Fig9Aand9B).Therewasageneralconcordance
betweenALTandviremialevels.Fibrosismarkersalsocorrelatedwitheachotherinboth
patients.
Discussion
ThepresentstudyexaminedtheserumATXlevelsof159patientswithchronichepatitisCfor
associationswithtreatmentoutcomeofIFN-freeDAAtherapy.SerumATXlevelswerehigher
infemalethaninmalepatients,inagreementwithourpreviousstudies[22].Baselineserum
ATXlevelswerecomparablebetweenpatientswithandwithoutaSVR,butonlythoseachiev-
ingaSVRexhibitedsignificantlydecreasedATXlevelsduringandafterIFN-freeDAAtherapy
inoverall,male,female,andlowALTgroups.
Althoughliverbiopsyisthegoldstandardforassessingthedegreeofliverfibrosis,simple
andreliablenon-invasivemethodsareneededtomoreeasilyestimatediseaseandtreatment
status.AftercommencingIFN-freeDAAtherapy,theregressionofliverfibrosisinpatients
withaSVRhasbeendemonstratedbyseveralnon-invasivetechniques,suchasserumhyal-
uronicacid,typeIVcollagen,andWisteriafloribundaagglutinin-positiveMac-2-bindingpro-
tein[7],aswellasbytransientelastography[8–11],liverandacousticradiationforceimpulse
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ChangesinATXwithDAAtherapyinchronichepatitisC
Fig2. Changesinserumlevelsof(A)HCVRNA,(B)ALT,(C)ATX,(D)FIB-4index,and(E)APRIbefore,during,andafter
IFN-DAAtherapyin15patientswithoutaSVR.PT:post-treatment.(cid:3),P<0.05;(cid:3)(cid:3),P<0.01;(cid:3)(cid:3)(cid:3),P<0.001.
https://doi.org/10.1371/journal.pone.0195632.g002
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ChangesinATXwithDAAtherapyinchronichepatitisC
Fig3. Changesinserumlevelsof(A)HCVRNA,(B)ALT,(C)ATX,(D)FIB-4index,and(E)APRIbefore,during,andafter
IFN-DAAtherapyin64malepatientswithaSVR.PT:post-treatment.(cid:3)(cid:3),P<0.01;(cid:3)(cid:3)(cid:3),P<0.001.
https://doi.org/10.1371/journal.pone.0195632.g003
PLOSONE|https://doi.org/10.1371/journal.pone.0195632 April4,2018 9/20
ChangesinATXwithDAAtherapyinchronichepatitisC
Fig4. Changesinserumlevelsof(A)HCVRNA,(B)ALT,(C)ATX,(D)FIB-4index,and(E)APRIbefore,during,andafter
IFN-DAAtherapyin80femalepatientswithaSVR.PT:post-treatment.(cid:3)(cid:3),P<0.01;(cid:3)(cid:3)(cid:3),P<0.001.
https://doi.org/10.1371/journal.pone.0195632.g004
PLOSONE|https://doi.org/10.1371/journal.pone.0195632 April4,2018 10/20