Journal of Hepatology 44 (2006) 679–685

www.elsevier.com/locate/jhep

Viral and metabolic factors influencing alanine aminotransferase

activity in patients with chronic hepatitis C
Daniele Prati1,*, Mitchell L. Shiffman2, Moisés Diago3, Edward Gane4, K. Rajender Reddy5,
Paul Pockros6, Patrizia Farci7, Christopher B. O’Brien8, Pilar Lardelli9, Steven Blotner10,
Stefan Zeuzem11
1
Ospedale A. Manzoni, Lecco and IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan, Italy
2
Virginia Commonwealth University Health System, Richmond, VA, USA
3
Hospital General de Valencia, Valencia, Spain
4
Hospital, Auckland, New Zealand
5
University of Pennsylvania, Philadelphia, PA, USA
6
The Scripps Clinic, La Jolla, CA, USA
7
Università di Cagliari, Cagliari, Italy
8
University of Miami, Miami, FL, USA
9
Roche, Basel, Switzerland
10
Roche, Nutley, NJ, USA
11
Saarland University Hospital, Homburg/Saar, Germany

See Editorial, pages 624–626

Background/Aims: In chronic hepatitis C, disease progression and clinical manifestations are heterogenous. To
clarify the role and interactions of viral and host factors in inducing liver cell injury, we examined the associations of
several virological and metabolic variables with serum alanine aminotransferase levels.
Methods: Patients with chronic hepatitis C enrolled in three phase III clinical trials of peginterferon alfa-2a (40KD)
plus ribavirin (two studies analysing ‘elevated’ and one persistently ‘normal’ alanine aminotransferase) were included.
Results: Multivariate analyses of 2881 patients before treatment and of 1403 patients with a sustained virological
response indicated that gender, viral factors (genotype, HCV RNA titer) and indicators of metabolic syndrome (body
mass index, blood pressure, blood glucose, cholesterol and triglyceride concentration) were associated with alanine
aminotransferase levels. In addition, hepatitis C virus infection influenced serum lipids concentration according to a
genotype-specific effect.
Conclusions: Heterogeneity in alanine aminotransferase levels in patients with chronic hepatitis C partially depends
on the degree of derangement of fat and carbohydrate metabolism. As this is the result of an interaction of chronic
hepatitis C infection with the patient’s individual characteristics, treatment decisions should not be based on alanine
aminotransferase level alone but rather on global evaluation of the patient.
q 2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Keywords: Cholesterol; Triglyceride; Sustained virological response; Ribavirin; Peginterferon alfa-2a (40KD)

Received 23 November 2005; received in revised form 9 January 2006; accepted 12 January 2006; available online 25 January 2006
* Corresponding author. Department of Transfusion Medicine and Hematology, Ospedale Alessandro Manzoni, via dell’Eremo 9/11, Lecco 23900, Italy.
Tel.: C39 339 1022840/341 489872, fax: C39 0341 489871.
E-mail address: d.prati@ospedale.lecco.it (D. Prati).
Abbreviations: ALT, alanine aminotransferase; BMI, body mass index; CHC, chronic hepatitis C; HCV, hepatitis C virus; SVR, sustained virological
response.

0168-8278/$32.00 q 2006 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.jhep.2006.01.004
680 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685

1. Introduction Here, we used a large database of patients with both

Hepatitis C virus (HCV) results in numerous compli-
cations including chronic hepatitis, cirrhosis, end-stage liver
disease and hepatocellular carcinoma [1–3]. However,
disease progression and clinical manifestations of patients
with chronic hepatitis C are heterogenous. The mechanisms
behind this variability remain to be fully elucidated.
Most patients with chronic hepatitis C have elevated
serum alanine aminotransferase (ALT), usually coupled
with liver inflammation. However, 15–46% of patients with
chronic hepatitis C (CHC) have ALT levels within the
‘normal’ laboratory range [3–5] Despite this persistently
normal ALT, some individuals may present with significant
hepatic inflammation and fibrosis or be at risk of progressive
liver damage and have an impaired quality of life [6–13].
The apparent discrepancy between clinical and laboratory
data can perhaps be explained by inappropriate thresholds
for ALT determination [14,15], and is reflected by the
evolving definition of the severity of chronic liver disease,
that is now based on the degree of liver fibrosis progression
more than on the extent of hepatic cytolysis. With these
limitations in mind, measurement of ALT levels during the
course of HCV infection still remains an important guide,
and is in fact a major determinant in current management
algorithms [1].
Previous reports have indicated that metabolic abnorm-
alities including liver steatosis, obesity and diabetes can
worsen the course of CHC [16]. In addition, chronic HCV
infection has a direct steatogenic effect on liver cells, and
may be involved in the development of type 2 diabetes
mellitus [17,18]. However, little is known about the role and
the reciprocal interactions of host and viral factors in
inducing liver cell injury. This information would be very
useful for a better understanding of the pathogenesis and
natural course of CHC, and could improve the use and
interpretation of laboratory indicators in clinical hepatology.
‘normal’ and elevated ALT from the global clinical trial
program for peginterferon alfa-2a (40KD) plus ribavirin in
CHC, to investigate the relationships between ALT level
and several viral and host factors. Data collected before and
after antiviral treatment enabled us to examine, in the same
subjects, the various metabolic patterns in the presence and
in the absence of viral replication.
2. Experimental procedures
2.1. Inclusion criteria
Data were obtained from patients enrolled in three phase III,
randomized, controlled, multinational clinical trials of peginterferon alfa-
2a (40KD) and ribavirin. The main findings and eligibility criteria of
these studies are reported elsewhere [3,19,20]. Allocation and doses of
treatment administered in each of the three studies are shown in Fig. 1.
To take into account the limitations of retrospective studies, this
analysis investigated the relationships between ALT level and several viral
and host factors, with the intention of generating hypotheses that could be
tested prospectively. To overcome some of the drawbacks of retrospective
studies, (e.g. missing data and risk of selection bias), only patients with data
for all demographic and baseline disease characteristics were included in
the analyses.
In Zeuzem et al. ‘normal’ ALT study, patients were required to have
persistently ‘normal’ ALT (using a stringent definition of persistently
‘normal’ ALT): ALT equal to or below the upper limit of normal (ULN, 30
IU/L) confirmed on R3 occasions, R4 weeks apart, with R1 value
obtained during the 42-day screening period and R1 value obtained within
the previous 6–18 months see [13]. Blood samples for laboratory analyses
were collected in the morning after overnight fasting.
SVR in all studies was defined as undetectable HCV RNA by
qualitative PCR (COBAS AMPLICORe HCV Test, v2.0, limit of detection
50 IU/mL), 24 weeks following the end of treatment [13,19,20].
2.2. Statistical analysis—linear regression
Univariate linear regression analysis was carried out between various
patient characteristics at baseline. Stepwise multiple linear regression
analysis was also used to explore the association between possible baseline
metabolic and virological factors and baseline ALT values in the pooled

Zeuzem et al. Hadziyannis et al.

Fried et al.
514 patients randomized 1311 patients randomized
1149 patients randomized
• Peginterferon alfa (40KD) + low-dose • Peginterferon alfa (40KD) +
• Peginterferon alfa (40KD) +
ribavirin 800 mg/day x 24 wks (n = 219) low-
low-dose ribavirin 800 mg/day x 24 wks (n = 214)
ribavirin 1000/1200 mg/day x 48 wks
• Peginterferon alfa (40KD) + low-dose • Peginterferon alfa (40KD) + standard-dose
(n = 465)
ribavirin 800 mg/day x 48 wks (n = 221) ribavirin 1000/1200 mg/day x 24 wks (n = 288)
• Peginterferon alfa (40KD) alone
• Untreated (n = 74) • Peginterferon alfa (40KD) +
x 48 wks (n = 231)
low-dose
low- ribavirin 800 mg/day x 48 wks (n = 365)
• Interferon alfa-2b + ribavirin
• Peginterferon alfa (40KD) + standard-dose
1000/1200 mg/day x 48 wks (n = 453)
ribavirin 1000/1200 mg/day x 48 wks (n = 444)

Protocol violations
Qualifying ALT >30IU/L (n = 10)
Transition to cirrhosis (n = 1)

Not in safety population Not in safety population Not in safety population

(n = 23) (n = 32) (n = 27)

480 patients analyzed 1117 patients analyzed 1284 patients analyzed

Fig. 1. Flow of patients included in the analysis. Patients included in the analysis with either ‘normal’ or elevated ALT from 3 studies [13,19,20].
 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685
patient population with ‘normal’ and elevated ALT. Analyses were also
separated by gender. Logarithms at base 10 (log10) for baseline ALT were
used instead of the original values due to the skewed distribution of ALT (as
seen previously [14]). In the stepwise model building process, a variable
was added to the model if the adjusted F-statistic was significant at the 0.10
level and a variable was deleted from the model if the corresponding
F-statistic was not significant at the 0.05 level.
The following baseline disease and demographic factors were
considered for entry into the model: gender, age, ethnicity (Caucasian vs.
non-Caucasian), body mass index, (BMI), HCV genotype (1 vs. non-1, 2 vs.
non-2, 3 vs. non-3 and 4 vs. non-4), log10 pre-treatment HCV RNA titre,
serum cholesterol, triglyceride and glucose levels and blood pressure at
baseline. Linear regression by geographical region was not investigated as
it was considered that this may be influenced by differences in recruitment
among the studies. Because ALT level is lower in women, in agreement
with previous studies [14,21], factors related to ALT were also analysed
separately for each gender.
To determine whether additional parameters apart from the presence of
HCV infection had any influence on ALT, the same analyses were also
performed in the subset of patients who achieved an SVR. The effects of the
aforementioned factors at the end of follow-up were also analysed.
Laboratory values, blood pressure, body weight and BMI measured at the
end of follow-up were studied. Finally, multiple regression analyses on the
pooled dataset were also performed to investigate the association between
possible prognostic factors and elevated baseline cholesterol and glucose
levels.
2.3. Re-defining the upper limit of the normal range
for serum ALT
A revised definition of the ULN range for serum ALT was estimated
retrospectively. The cut-off value was defined as the 95th percentile of the
final ALT value in patients from the ‘normal’ ALT study who achieved an
SVR. The cut-off was also calculated separately for male and female
patients to avoid gender as a confounding factor. Following stratification,
‘normal’ was broken down into ‘high normal’ and ‘low normal’ using the
new cut-off as the boundary. ALT levels for the three trial populations were
then compared using the newly established cut-offs (i.e. ‘high normal’ vs.
‘low normal’ vs. elevated levels in the Fried and Hadziyannis trials) and the
appropriate statistical analysis (Chi-square test, Kruskal–Wallis test or
F-test).
3. Results
Data from 2881 patients were included in the analyses
(Fig. 1). Of these, 2401 patients had elevated ALT and 480
patients had ‘normal’ ALT. Baseline characteristics of the
two groups are summarized in Table 1. Statistically
significant differences between ‘normal’ and ‘abnormal’
ALT patients were observed in gender and age, ethnicity
and HCV genotype distribution, HCV RNA level, body
weight, BMI, mode of infection, blood lipids and glucose
concentration, and arterial blood pressure. Data at study
entry was available from 2386 patients from the elevated
ALT population and 480 patients from the ‘normal’ ALT
population.
3.1. Pre-treatment factors associated with ALT level
Univariate linear regression analysis confirmed signifi-
cant relationships (P!0.05) between ALT level and several
factors, including gender, genotype, viral load, baseline
plasma glucose and cholesterol levels, and blood pressure.
681
The results of the multiple linear regression analysis of
pooled data from all three studies are reported in Table 2.
The model showed that the predictive factors accounted for
approximately 10% of the variability observed for pre-
treatment ALT (adjusted r2Z0.0922). Within the model,
gender, genotype 2 (vs. non-2), genotype 3 (vs. non-3), low
serum cholesterol and triglyceride concentrations, high
blood glucose level, high HCV RNA and high diastolic
blood pressure all showed a significant association with
ALT level. When the analysis was conducted separately by
gender, similar results were obtained (data not shown).
In light of the clear-cut relationships between ALT level
and metabolic factors, a multivariate analysis was
performed to identify other baseline covariates (in addition
to ALT) independently associated with cholesterol and
glucose levels. In the whole population, serum cholesterol
concentration was directly associated with increasing age,
female gender, Caucasian ethnicity, serum triglyceride
concentration, and diastolic blood pressure, and inversely
associated with blood glucose level, BMI, and HCV
genotype 1 and 3 infection (Table 2). The multiple linear
regression model explained approximately 15% of the
variability observed for cholesterol (adjusted r2Z0.1494).
Similarly, regarding blood glucose concentration, we
observed direct relationships with male gender, increasing
age, increasing BMI, serum triglyceride concentration,
systolic blood pressure, and Caucasian race, and inverse
relationships with serum cholesterol level and infection with
genotype 2 (Table 2). This multiple linear regression model
explained approximately 11% of the variability observed for
glucose (adjusted r2Z0.1108).
We examined the effect of viral suppression on biochemi-
cal parameters other than ALT comparing the difference in
concentration between pre-treatment and end of follow-up
values in patients with and without an SVR. Attainment of
SVR was paralleled by a significant increase of cholester-
olaemia (C0.41G0.87 mmol/L in SVR vs. K0.05G
0.70 mmol/ in non SVR patients; P!0.0001) and triglycer-
idaemia (C0.153G0.921 mmol/L vs-0.007G1.048 mmol;
P!0.0001), while blood glucose concentration remained
unchanged (K0.08G1.25 vs. K0.03G1.65; PZ0.33).
3.2. Factors associated with ALT level in patients
with an SVR
Within the three trials, 1403 patients (172 with ‘normal’
ALT, 1231 with elevated ALT) achieved an SVR.
Univariate analyses identified statistically significant
relationships (P!0.05) between serum ALT and gender,
BMI, serum triglyceride levels and systolic and diastolic
blood pressure at end of follow-up.
Multivariate analysis showed that male gender, BMI, and
serum triglyceride levels, diastolic blood pressure at the end
of follow-up had a direct association with ALT (Table 3). The
analysis conducted separately by gender showed that ALT
682 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685

Table 1
Baseline characteristics of 2881 patients included in the analysis with either ‘normal’ or elevated ALT from 3 studies [13,19,20]

Normal ALT (%30 IU/L) Elevated ALT (O30 IU/L) Total (nZ2881) P-value, normal vs.
(nZ480) (nZ2401) elevated ALT patients
Gender, no. patients (%)
Males 195 (41) 1634 (68) 1829 (64) !0.0001*
Females 285 (59) 767 (32) 1052 (36)
Race, no. patients (%)
Caucasian 410 (85) 2088 (87) 2498 (87) !0.0001*
Black 39 (8) 89 (4) 128 (4)
Oriental 12 (3) 150 (6) 162 (6)
Other 19 (4) 74 (3) 93 (32)
Age, yearsGSD 43.4G9.9 42.4G9.7 42.6G9.8 0.04a
Body weight, kgGSD 73.5G16.4 78.2G16.9 77.4G16.9 !0.0001a
BMI, kg/m2GSD 25.9G5.1 26.4G4.9 26.3G4.9 0.043a
Mode of infection, no. patients (%)
IVDU 150 (32) 846 (35) 996 (35) !0.0001*
Transfusion 111 (23) 430 (18) 541 (19)
Other percutaneous 41 (9) 149 (6) 190 (7)
Other 155 (32) 688 (29) 843 (29)
Unknown 15 (3) 253 (3) 268 (9)
HCV RNA, 106 copies/mlGSD 3.2G3.7 6.0G7.2 5.5G6.8 !0.0001a
Genotype, no. patients (%)
1 327 (68) 1467 (61) 1794 (62) !0.0001*
2 90 (19) 355 (15) 445 (15)
3 40 (8) 489 (20) 529 (18)
4 19 (4) 69 (3) 88 (3)
Other 4 (1) 21 (1) 25 (1)
Biochemical parameters
Glucose BL, mmol/LGSD 5.1G1.2 5.4G1.7 5.3G1.6 0.041a
Cholesterol BL, mmol/LGSD 4.8G0.9 4.5G1.0 4.5G1.0 !0.0001a
Triglyceride BL, mmol/LGSD 1.4G0.9 1.4G1.1 1.4G1.1 nsa
Systolic BP, mmHgGSD 121G15 125G15 124G15 !0.0001a
Diastolic BP, mmHgGSD 76G10 78G10 78G10 !0.0001a

Plus-minus data are presented as meanGstandard deviation (SD); BL, blood level; BP, blood pressure; ns, not significant; *Chi-square tests.
a
Student’s t-test.

was also associated to non-Caucasian race (in males only) 4. Discussion

and to diastolic blood pressure and age (in females only).
3.3. Re-defining the healthy upper threshold for ALT
The healthy upper threshold for ALT was calculated
separately for males and females to avoid gender as a
confounding factor. The cut-off (95th percentile of the end of
follow-up ALT values of patients from the ‘normal’ ALT
study who achieved an SVR) was 25 IU/L in men and 22 IU/L
in women. Patients were then grouped as ‘low normal’ ALT
(classified as %25 IU/L in males and %22 IU/L in females)
or ‘high normal’ ALT (classified as O25 IU/L but %30 IU/L
in males and O22 IU/L but %30 IU/L in females).
As a consequence of applying gender differentiated
thresholds, a higher proportion of patients were observed to
be male in the ‘low normal ALT’ group than in the ‘high
normal’ ALT group (45 vs. 31%). In addition, patients with
‘low normal ALT’ had a significantly lower frequency
of HCV genotype 3, higher frequency of genotype 2, and
lower levels of blood glucose and blood pressure than did
those with ‘high normal’ ALT (P!0.05, data not shown).
A relationship was seen between measures of metabolic
imbalance and ALT levels. In particular, ALT was inversely
associated with serum cholesterol and triglyceride levels.
Multivariate analysis showed that this relationship was
dependent on HCV genotype. In addition, in those patients
who attained an SVR, blood lipid concentrations substan-
tially increased after therapy. These findings suggest that
CHC is the cause of the decrease of circulating lipids.
The association between serum lipids and ALT contrasts
with that typically found in patients with non alcoholic fatty
liver disease [22,23] and in blood donors [14,21], where an
increase in hepatic cytolysis is typically accompanied by
hyperlipidaemia. However, Fartoux et al. have recently
observed that low cholesterol levels are the biochemical
hallmark for hepatic steatosis in CHC patients [24] and
several lines of evidence indicate that HCV constituents are
able to induce derangements of lipoprotein secretion at
different metabolic levels [22,23]. Although this study did
not assess histological steatosis, our data, combined with the
above associations [14,21–24] support the hypothesis that
 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685 683

Table 2
Parameter estimates gained from multivariate linear regression identifying pre-treatment factors associated with (a) ALT level, (b) serum cholesterol
concentration and (c) blood glucose concentration in patients with chronic hepatitis C and either ‘normal’ or elevated ALT from 3 studies [13,19,20]

Variable ALT level (nZ2748) Serum cholesterol (nZ2867) Blood glucose (nZ2867)
2
Overall adjusted r 0.092 0.149 0.114
Gender (females vs. males) K0.123 (P!0.0001) 0.211 (P!0.0001) K0.125 (PZ0.044)
Race (Caucasian vs. non-Caucasian) 0.132 (PZ0.008) 0.132 (PZ0.0005)
Age (per 10-year increment) 0.071(pZ0.0001) 0.234 (P!0.0001)
Genotype 1 vs. non-1 K0.172 (P!0.0001)
Genotype 2 vs. non-2 0.046 (PZ0.004) K0.241 (PZ0.0025)
Genotype 3 vs. non-3 0.087 (PZ!0.0001) K0.689 (P!0.0001)
Log10 ALT (IU/L) K0.354 (P!0.0001) 0.248 (PZ0.009)

Cholesterol concentration (mmol/L) K0.037 (P!0.0001) K0.1197 (PZ0.0001)

Glucose concentration (mmol/L) 0.010 (PZ0.005) K0.045 (P!0.0001)

BMI K0.013 (PZ0.0007) 0.046 (P!0.0001)

Triglyceride concentration (mmol/L) K0.015 (PZ0.013) 0.209 (P!0.0001) 0.265 (P!0.0001)
Systolic BP (10 mm Hg) 0.076 (PZ0.003)
Diastolic BP (10 mm Hg) 0.019 (PZ0.001) 0.046 (PZ0.010)
HCV RNA log10 0.030 (PZ0.0004)

Only factors identified as associated with ALT level, serum cholesterol or blood glucose concentrations are shown.

‘viral steatosis’ is a major factor that influences the
biochemical pattern in CHC patients.
In our study, the metabolic imbalance promoted by the
virus was not just paralleled, but intensified by the presence
of ‘pure’ metabolic disease. In fact, higher ALT activities
were found in the presence of two of the main indicators of
metabolic syndrome, namely increased glucose levels and
blood pressure. Additionally, these two factors were
independently associated with decreased serum cholesterol
concentration. At the clinical level, the consequence of
these associations is exacerbation of hepatocellular injury
when viral and host factors co-exist in the same individual.
One possible mechanism for this relationship is that virus-
induced metabolic imbalance can cause insulin resistance
through a mechanism of lipotoxicity [25,26], and thus
directly increase blood glucose levels and blood pressure.
However, this hypothesis does not completely explain
our findings. We found that HCV clearance after therapy
had no apparent effect on glucose levels. Additionally, the
multivariate model identified the typical profile of non
alcoholic fatty liver disease as the main predictor of
increased ALT, suggesting the independent role of

Table 3
Parameter estimates from multivariate linear regression identifying factors associated with ALT level in patients with SVR included in 3 studies
[13,19,20]

Variable Parameter estimate

Males (nZ874) Females (nZ529) All (nZ1403)
Overall adjusted r2 0.061 0.0231 0.082
Gender (females vs. males) K0.083 (P!0.0001)
Race (Caucasian vs. non-Caucasian) K0.050 (PZ0.020)
Age (per 10-year increment) 0.0200 (PZ0.021)
BMI 0.011 (P!0.0001) 0.004 (PZ0.0004)
Triglycerides concentration (mmol/L) 0.021 (PZ0.002) 0.018 (PZ0.002)
Diastolic BP (per 10 mmHg increase) 0.022 (PZ0.015) 0.019 (PZ0.001)

Only factors identified as associated with ALT level are shown.

684 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685
metabolic steatosis in worsening liver cell damage. There-
fore, the most likely interpretation for our findings is that, as
a result of increased host production and metabolic
impairment triggered by HCV, lipoproteins are progress-
ively ‘trapped’ in liver cells. A similar mechanism of
progressive fat accumulation leading to chronic liver
disease has been described in congenital hypobetalipopro-
teinemia [27,28].
Previous analyses have investigated the influence of
different HCV genotypes on the course of liver disease. The
inconsistent results in these studies may be explained by
substantial differences in genotype distribution which arose
from the studies being conducted in limited geographic
areas [2,3]. In contrast, this present analysis included a large
number of patients enrolled in 19 countries, and so is able to
clarify this issue.
Our data demonstrate that infection with different HCV
genotypes has differential effects on a patient’s hepatic
cytolysis and lipid metabolism, as reflected by specific
biochemical profiles. We found that the decrease of serum
cholesterol concentration was most evident for genotype 3,
intermediate for genotype 1, and not significant for
genotype 2. In addition, both univariate and multivariate
analyses showed that genotype 3 was an important variable
associated with elevated ALT. This was not unexpected,
considering the striking relationship observed between lipid
metabolism and cytolysis, and the well-known steatogenic
effect of genotype 3 [29–31]. We also observed that patients
with ‘normal’ ALT had a slightly higher frequency
of genotype 2 infection than those with ‘abnormal’ ALT
levels. This finding confirms earlier studies, mainly
conducted in Italy, where this genotype is particularly
frequent [1,32,33]. However, this association was not
confirmed with the multivariate analysis, where a direct
relationship between ALT levels and genotype 2 was seen.
The discrepancy between the two models may be
explained by the observation that genotype 2, unlike
genotypes 1 and 3, had no relation with blood cholesterol
and glucose concentrations. Thus, this genotype probably
had a ‘pure’ inflammatory effect (i.e. not significantly
mediated by an impairment of lipid metabolism), which
resulted in lower ALT level at the individual level. Indeed,
to date, virus-induced histological steatosis was more
evident in patients with genotypes 1 and 3, than in patients
with genotype 2 [31], further supporting this interpretation.
The multicentric study design, the large sample size, and
the use of standardised HCV RNA assays also allowed us to
examine the association between ALT level and HCV
viraemia, which have remained inconclusive in studies
conducted to date [2,3,34]. Our analysis revealed a direct
association between ALT and HCV RNA levels. However,
viraemia was unrelated to serum lipid concentration,
suggesting that the two factors induce hepatocellular injury
by separate mechanisms.
Gender was another important variable influencing ALT
level. Based on our data, the higher prevalence of women
previously observed in patients with ‘normal’ ALT levels
can, at least in part, be attributed to a different reactivity of
the two genders to chronic liver disease [21,34–36]. Indeed,
the effect of gender on ALT level was also maintained after
the clearance of HCV viraemia. Furthermore, in women
only, ALT levels tended to increase with age, which
corroborates the hypothesis that hormonal factors play an
important role in determining the course of liver disease
[34,36].
These findings have clinical implications for the manage-
ment of CHC patients. When evaluating a CHC patient in
whom a substantial contribution of metabolic steatosis to
liver injury is suspected, laboratory data should be evaluated
critically, taking into account any reciprocal relationships
between viral and host factors that may be present. As
previously stated, the serum lipid profile on its own is not a
good predictor of metabolic disease. Consequently, clinical
decisions such as the prescription of dietary and lifestyle
modifications prior to antiviral treatment should be based on
other indicators, including gender, blood pressure, body
adiposity and HCV genotype rather than just on cholesterol
and triglyceride concentration. Whatismore, given the high
prevalence of dyslipidaemia in industrialized countries
coupled with an increasing use of lipid-lowering therapies
to reduce cardiovascular risk, the possible benefits and
harms of different therapeutic approaches in CHC patients
need to be carefully explored in prospective studies.
Recently, in the first multinational trial of a pegylated
interferon plus ribavirin in patients with CHC and persistently
‘normal’ ALT levels, treatment with 48 weeks of
peginterferon alfa-2a (40KD) plus ribavirin resulted in a
52% rate of sustained virological response (SVR) [13].
Interestingly, most patients with virological responses
during therapy displayed concomitant decreases in serum
ALT level (despite having persistently ‘normal’ ALT prior
to treatment). These decreases were maintained after the end
of treatment in individuals who attained sustained
responses. This indicates that, despite a biochemical silence,
there is still some degree of cytolysis in patients with
‘normal’ ALT. Therefore, when treating these individuals,
the extent of the reduction in ALT level following viral
clearance may represent the margin of possible benefit.
On the basis of these considerations, we re-calculated the
upper limit of the normal distribution of ALT in patients
who had successfully cleared the virus. In both men and
women, values were approximately 30% lower than the
threshold chosen to identify ‘normality’ in the three clinical
trials from which our data originate [13,19,20]. This figure
is in line with those reported in other studies using different
methodology [14,15], and further confirms the need for a
critical revision of the criteria used for the identification of
the healthy ALT thresholds.
In conclusion, our data demonstrate that the heterogeneity
of ALT levels in patients with CHC depends to some extent
on the degree of derangement of fat and carbohydrate
metabolism. As the interplay between chronic HCV infection
 D. Prati et al. / Journal of Hepatology 44 (2006) 679–685
and the patient’s individual characteristics is complex,
management decisions should not be based on ALT level
alone but rather on global evaluation of the patient.
Acknowledgements
This analysis was supported by Roche, Basel,
Switzerland.
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