|Year : 2017 | Volume
| Issue : 3 | Page : 715-720
Assessment of serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis
Moemena S El-Hamouly1, Naglaa S.M. El-Abd1, Ahmed R El-Gazzarah1, Amira M. F. Shehata MD 2
1 Department of Tropical Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical and Chemical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||04-Apr-2017|
|Date of Acceptance||23-Apr-2017|
|Date of Web Publication||15-Nov-2017|
Amira M. F. Shehata
Tala, Menoufia, 32611
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis and to explore its potential relations with liver cirrhosis progression and insulin resistance (IR).
Hepatitis C virus infection is a serious clinical condition that usually progresses to liver cirrhosis. Betatrophin is a newly discovered hormone that has been considered as important regulator of pancreatic β-cell proliferation.
Patients and methods
We analyzed 70 patients who were diagnosed with chronic hepatitis C-related liver cirrhosis. Patients were assorted into three groups according to Child–Pugh score. In addition, a control group was included and consisted of 20 healthy volunteers. Serum betatrophin and IR were evaluated for all patients and controls.
Patients with cirrhosis showed significantly higher circulating betatrophin levels in comparison with healthy controls (P < 0.001). Additionally, positive correlation was observed between betatrophin concentration and the progression of liver cirrhosis as assessed by Child–Pugh score (r = 0.66; P < 0.001). Furthermore, a significantly higher IR was demonstrated in patients with cirrhosis than in controls (P < 0.001). Significantly positive association between betatrophin levels and homeostatic model assessment of insulin resistance was found (r = 0.96; P < 0.001).
Serum betatrophin was significantly increased in patients with chronic hepatitis C-related liver cirrhosis and its level positively associated with liver cirrhosis severity and IR.
Keywords: betatrophin, hepatitis C, insulin resistance, liver cirrhosis
|How to cite this article:|
El-Hamouly MS, El-Abd NS, El-Gazzarah AR, Shehata AM. Assessment of serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis. Menoufia Med J 2017;30:715-20
|How to cite this URL:|
El-Hamouly MS, El-Abd NS, El-Gazzarah AR, Shehata AM. Assessment of serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis. Menoufia Med J [serial online] 2017 [cited 2019 Nov 19];30:715-20. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/715/218259
| Introduction|| |
Hepatitis C virus (HCV) infection is a remarkable health issue globally. HCV infection is extremely prevalent, with estimated 130–150 million persons chronically infected around the world as stated by the WHO . HCV causes persistent infection that usually proceeds to liver fibrosis and ultimately induces ~400-fold increase in the hazard of hepatocellular carcinoma development .
In Egypt, chronic HCV infection predominates; in 2015, the Egyptian Demographic Health Survey estimated that HCV antibodies and HCV ribonucleic acid prevalence is 14.7 and 9.8%, respectively, among the 15–59 years age group .
Insulin resistance (IR) is a state in which normal insulin concentrations fail to fulfill normal metabolic functions, or higher insulin concentrations are required for normal metabolic functions .
Chronic HCV infection is an important factor toward the evolution of impairment of insulin sensitivity . Furthermore, IR as assessed by homeostatic model assessment of insulin resistance (HOMA-IR) was reported to develop early during HCV infection course, and increased HOMA-IR was linked with more progressive cirrhosis .
Betatrophin, also named as lipasin, is a recently identified hormone secreted mainly by the liver and to some extent by adipose tissue and is implicated in the homeostasis of glucose and lipid .
Betatrophin was initially discovered in 2004 as a tumor-associated antigen in the serum of patients diagnosed with hepatocellular carcinoma. However, few subsequent studies were interested on further description of this new protein following its identification. In 2012, important correlation between betatrophin and serum triglyceride concentration was discovered .
The aim of this study was to evaluate serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis and to explore its potential relations with liver cirrhosis progression and IR.
| Patients and Methods|| |
A total of 70 patients (43 males and 27 females, with their ages 57.2 ± 11.6 years) with chronic hepatitis C-related liver cirrhosis who did not match specified exclusion criteria were selected from the Tropical Medicine Department, Menoufia University Hospital, and enrolled in this study between March 2016 and November 2016. HCV infection was diagnosed if patients were seropositive for anti-HCV antibodies, and confirmation was made by HCV ribonucleic acid assessment. Liver cirrhosis was diagnosed by clinical presentation, biochemical tests, and ultrasonographic findings. The progression of cirrhosis was assessed by Child–Pugh  and Model for End-Stage Liver Disease (MELD) scores .
HOMA was used for estimation of IR, as calculated by the equation described by Matthews et al. : HOMA-IR equals fasting glucose (mg/dl) multiplied by fasting insulin (μIU/ml) and the result divided by 405.
Patients who matched with the following criteria were excluded for the study: pregnancy, any proof of active infection (e.g., fever or leukocytosis), known history of type 2 or type 1 diabetes mellitus, hyperthyroidism, Cushing's disease; and administration of drugs known to influence lipid or glucose metabolism.
The control group included 20 healthy sex-matched and aged-matched subjects (12 male and eight female, with mean age of 56.0 ± 10.8 years).
Patients and controls were divided into four groups: group I consisted of 20 patients with Child–Pugh's class A liver cirrhosis, group II consisted of 25 patients with Child–Pugh's class B liver cirrhosis, group III consisted of 25 patients with Child–Pugh's class C liver cirrhosis, and group IV included 20 healthy persons as controls. History taking, clinical check, and particular laboratory tests were done for evaluation of patients and controls.
This study protocol was reviewed and approved by the ethical committee of the Faculty of Medicine, Menoufia University, and signed informed consent forms were obtained from all participants.
Venous blood samples were withdrawn by sterile venipuncture in the morning after 8 h of overnight fasting. Complete blood count, prothrombin time, international normalized ratio (INR), liver function tests, kidney function tests, plasma level of glucose, and serum insulin concentration were measured for all patients and controls. In addition, serum samples for betatrophin analysis were isolated after centrifugation at 3200 rpm for 20 min and kept at −20°C until analysis.
Complete blood count was performed using Sysmex XN-10 Analyzer (Sysmex, Kobe, Japan). Prothrombin time was measured by STA Compact Coagulometer (Diagnostica Stago, Asnieres, France). Plasma glucose and liver and renal function tests were assessed using automated automated AU480 Analyzer (Beckman Coulter Inc., Brea, California, USA).
Serum insulin was analyzed by electrochemiluminescence immunoassay (Cobas, Roche Diagnostics, Germany). Serum betatrophin was measured by specific enzyme-linked immunosorbent assay kit (Glory Science Co. Ltd, Texas, USA) as described by the manufacturer.
Statistical analysis was done by statistical package for the social sciences (SPSS, version 17; SPSS Inc., Chicago, Illinois, USA). Data were described as mean ± SD for continuous quantitative variables and as number for qualitative variables. χ2 or Fisher's exact tests were applied to compare categorical data. Analysis of variance and Kruskal–Wallis tests were used for comparing multiple groups of normally and abnormally distributed quantitative data, respectively. In comparison of two groups with abnormally distributed quantitative variables, Mann–Whitney U-test was used. Spearman's correlation test was used to examine possible correlations between variables. P value of less than 0.05 was considered statistically significant.
| Results|| |
The current study included 70 patients diagnosed with liver cirrhosis on top of chronic HCV infection and 20 healthy controls. No statistically significant difference was found between the patients and controls regarding age and sex distribution (P = 0.79 and 0.65, respectively). A statistically significant difference between the studied groups was observed with respect to the laboratory results of aspartate aminotransferase, alanine aminotransferase, albumin, total bilirubin, prothrombin concentration, INR, platelets count, creatinine, blood urea nitrogen, and sodium (P < 0.001) [Table 1].
|Table 1: Demographics and laboratory characteristics among the studied groups|
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In the studied groups, serum betatrophin concentrations in Child class A patients were in the range of 7–25 ng/ml (median: 14.5), in class B patients were in the range of 30–122.5 ng/ml (median: 50), in class C patients were in the range of 47.5–300 ng/ml (median: 75.5), and in healthy controls were in the range of 3.5–6.5 ng/ml (median: 5) [Figure 1].
Serum betatrophin concentrations in Child class A patients (13.95 ± 5.88 ng/ml) were significantly lower than those in class B patients (60.6 ± 25.69 ng/ml) (P < 0.001), and betatrophin concentrations in class B patients were significantly lower than those in class C patients (103.12 ± 70.16 ng/ml) (P = 0.007) [Table 2].
|Table 2: Fasting blood sugar, insulin, homeostatic model assessment of insulin resistance, and betatrophin levels among the studied groups|
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A statistically significant difference was observed in fasting blood sugar and insulin concentrations between patients with cirrhosis and healthy controls (mean: 100.87; range: 77–124 vs. mean: 82.6; range: 75–90, P < 0.001; and mean: 13.28; range: 3.2–47.5 vs. mean: 3.73; range: 2.2–5, P < 0.001, respectively) [Table 2].
IR was significantly higher in patients with cirrhosis than in healthy subject (mean: 3.5; range: 0.6–14.5 vs. mean: 0.76; range: 0.4–1.1; P < 0.001). In addition; IR was significantly higher in Child class C patients (mean: 5.52; range: 2.2–14.5) compared with those with Child class B (mean: 3.24; range: 1.3–7.8) (P = 0.004), and IR was significantly higher in Child class B patients compared with those with Child class A (mean: 1.44; range: 0.6–1.7) (P < 0.001) [Table 2].
Furthermore, there was positive correlation between betatrophin concentrations and the progression of cirrhosis as assessed by Child classification (r = 0.66; P < 0.001) [Figure 2] and [Table 3]) and by MELD score (r = 0.84; P < 0.001) [Figure 3] and [Table 3]).
|Figure 2: Correlation between betatrophin level and severity of cirrhosis according to Child–Pugh classification.|
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|Table 3: Correlations between serum betatrophin levels in patients and various biochemical parameters|
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|Figure 3: Correlation between betatrophin level and severity of cirrhosis according to Model for End-Stage Liver Disease score.|
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In patients with cirrhosis, positive correlations between serum betatrophin concentrations and bilirubin levels (r = 0.42; P < 0.001), INR (r = 0.59; P < 0.001), serum creatinine (r = 0.51; P < 0.001), and blood urea nitrogen (r = 0.41; P < 0.001) were found, whereas serum betatrophin levels showed inverse correlations with prothrombin concentration (r=−0.64; P < 0.001), platelets count (r=−0.66; P < 0.001), and serum albumin levels (r=−0.69; P < 0.001) [Table 3].
Correlation analysis showed a significant correlation between betatrophin concentrations and IR as estimated by HOMA-IR (r = 0.96; P < 0.001) [Table 3] and [Figure 4]).
|Figure 4: Correlation between serum betatrophin level and insulin resistance.|
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| Discussion|| |
Betatrophin was described as a novel hormone that is predominately expressed in the liver and adipose tissue. Yi et al.  have reported that betatrophin enhances pancreatic β-cell proliferation and improves glucose tolerance in a mouse model of IR. However, subsequent experimental researches in mice challenged the initial results about the betatrophin role in control of pancreatic β-cell functions ,.
Until now, information about betatrophin functions in humans is still conflicting and controversial, and most studies have focused on evaluating the role betatrophin in diabetes ,, obesity ,, or dyslipidemia ,.
Our study demonstrated a significant elevation in serum betatrophin concentrations of patients with chronic hepatitis C-related liver cirrhosis compared with healthy controls. In addition, there was a positive association between betatrophin concentrations and the progression of cirrhosis as assessed by Child classification and by MELD score.
Moreover, serum betatrophin levels showed positive association with bilirubin levels whereas serum betatrophin levels were found to be inversely associated with albumin and prothrombin concentration. These results matched with the results demonstrated by Arias-Loste et al. .
The present study confirmed that IR was significantly increased in patients with chronic hepatitis C-related cirrhosis in comparison with healthy controls. Moreover, IR was significantly elevated in Child score C patients compared with those with Child score B patients whose IR was significantly higher compared with those with Child score A. These findings were consistent with the results reported by Arias-Loste et al. , except for that patients with Child score A liver cirrhosis were not included in their study.
Strong evidence that IR develops not only with patients experiencing chronic HCV infection but also in the early stage of HCV infection has been documented in many studies ,,. A study conducted on 260 patients with various stages of fibrosis on top of HCV infection showed significant IR even in patients with only stage 0 or 1 of liver fibrosis. Despite the findings that IR was demonstrated even in patients with minimal or no fibrosis, more advanced fibrosis was associated with increased HOMA-IR . Other studies confirmed these findings and showed a correlation between the severity of liver fibrosis and IR ,.
The concept that HCV has a direct effect on insulin sensitivity that is not caused by steatosis induced by the virus is confirmed by a transgenic mice model which showed expression of the HCV core protein in the liver. IR was discovered as early as 1 month of age whereas liver steatosis developed after 3 months of age .
A study done by Aytug et al.  examined liver biopsies taken from patients who experienced HCV infection and at the same time did not experience obesity or diabetes. Their study results not only proved the presence of IR induced by HCV infection but also showed a specific deterioration of insulin-stimulated insulin receptor substrate-1/phosphatidylinositol-3 kinase signaling track in patients with HCV, a track that is involved in the various metabolic effects of insulin.
The present study proved a positive correlation between betatrophin concentrations and IR as assessed by HOMA, and these findings were in accordance with Chen et al.  who investigated serum betatrophin levels among persons with diverse glucose tolerance conditions and found a positive correlation between betatrophin levels and IR.
Similarly, Calan et al.  stated that patients experiencing polycystic ovary syndrome had increased betatrophin concentrations that positively associated with IR.
However, a study by Tuhan et al.  demonstrated a negative correlation between serum betatrophin levels and HOMA-IR in children and adolescents experiencing obesity. Moreover, Barja-Fernández et al.  found that plasma betatrophin level correlated negatively with HOMA in a study included women with normal weight, anorexia nervosa, obesity, and morbid obesity. These conflicting results between different studies may be explained by the different racial groups, the design, sample size of each study, or the use of different technical ways for analysis.
In summary, the current study showed that serum betatrophin concentration was significantly elevated in patients with chronic hepatitis C-related liver cirrhosis, and its level positively correlated with liver cirrhosis progression. Elevated serum betatrophin level in patients with chronic hepatitis C-related liver cirrhosis might be interpreted as a compensatory response against IR, which was established to be strongly associated with HCV infection.
| Conclusion|| |
Our data elucidated that serum betatrophin concentrations were significantly elevated in patients with chronic hepatitis C-related liver cirrhosis. Furthermore, positive correlation between betatrophin levels and both liver cirrhosis progression and IR was proved.
Betatrophin may serve as a biomarker of progression of liver cirrhosis and IR in patients with chronic hepatitis C.
Future studies on betatrophin metabolism and regulation are necessary to clarify its actual role in liver cirrhosis and glucose homeostasis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hanafy SM, Shehata OH, Farahat NM. Expression of apoptotic markers BCL-2 and Bax in chronic hepatitis C virus patients. Clin Biochem 2010; 43
Bugianesi E, McCullough AJ, Marchesini G. Insulin resistance: a metabolic pathway to chronic liver disease. Hepatology. 2005; 42
Dai CY, Yeh ML, Huang CF, Hou CH, Hsieh MY, Huang JF, et al.
Chronic hepatitis C infection is associated with insulin resistance and lipid profiles. J Gastroenterol Hepatol 2015; 30
Dai C. Insulin resistance and anti-hepatitis C virus therapy. Adv Digest Med 2016; 3
Calan M, Yilmaz O, Kume T, Unal Kocabas G, Yesil Senses P, Senses YM, et al.
Elevated circulating levels of betatrophin are associated with polycystic ovary syndrome. Endocrine 2016; 53
Tseng YH, Yeh YH, Chen WJ, Lin KH. Emerging regulation and function of betatrophin. Int J Mol Sci 2014; 15
Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973; 60
Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985; 28
Yi P, Park JS, Melton DA. Betatrophin: a hormone that controls pancreatic beta cell proliferation. Cell 2013; 153
Gusarova V, Alexa CA, Na E, Stevis PE, Xin Y, Bonner-Weir S, et al.
Angptl8/betatrophin does not control pancreatic beta cell expansion. Cell 2014; 159
Cox AR, Lam CJ, Bonnyman CW, Chavez J, Rios JS, Kushner JA. Angiopoietin-like protein 8 (angptl8)/betatrophin overexpression does not increase beta cell proliferation in mice. Diabetologia 2015; 58
Fu Z, Berhane F, Fite A, Seyoum B, Abou-Samra AB, Zhang R. Elevated circulating lipasin/betatrophin in human type 2 diabetes and obesity. Sci Rep 2014; 4
Gómez-Ambrosi J, Pascual E, Catalán V, Rodríguez A, Ramírez B, Silva C, et al.
Circulating betatrophin concentrations are decreased in human obesity and type 2 diabetes. J Clin Endocrinol Metab 2014; 99
Guo K, Lu J, Yu H, Zhao F, Pan P, Zhang L, et al.
Serum betatrophin concentrations are significantly increased in overweight but not in obese or type 2 diabetic individuals. Obesity (Silver Spring) 2015; 23
Tuhan H, Abacı A, Anık A, Çatlı G, Küme T, Çalan ÖG, et al.
Circulating betatrophin concentration is negatively correlated with insulin resistance in obese children and adolescents. Diabetes Res Clin Pract 2016; 114
Fenzl A, Itariu BK, Kosi L, Fritzer-Szekeres M, Kautzky-Willer A, Stulnig TM, et al.
circulating betatrophin correlates with atherogenic lipid profiles but not with glucose and insulin levels in insulin-resistant individuals. Diabetologia 2014; 57
Gómez-Ambrosi J, Pascual-Corrales E, Catalán V, Rodríguez A, Ramírez B, Romero S, et al.
Altered concentrations in dyslipidemia evidence a role for ANGPTL8/betatrophin in lipid metabolism in humans. J Clin Endocrinol Metab 2016; 101
Arias- Loste MT, García-Unzueta M, Llerena S, Iruzubieta P, Puente A, Cabezas J, et al.
Plasma betatrophin levels in patients with liver cirrhosis. World J Gastroenterol 2015; 21
Hui JM, Sud A, Farrell GC, Bandara P, Byth K, Kench JG, et al.
Insulin resistance is associated with chronic hepatitis C virus infection and fibrosis progression [corrected]. Gastroenterology 2003; 125
Petit JM, Bour JB, Galland-Jos C, Minello A, Verges B, Guiguet M, et al.
Risk factors for diabetes mellitus and early insulin resistance in chronic hepatitis C. J Hepatol 2001; 35
Sougleri M, Labropoulou-Karatza C, Paraskevopoulou P, Fragopanagou H, Alexandrides T. Chronic hepatitis C virus infection without cirrhosis induces insulin resistance in patients with alpha-thalassaemia major. Eur J Gastroenterol Hepatol 2001; 13
Hickman IJ, Powell EE, Prins JB, Clouston AD, Ash S, Purdie DM, et al.
In overweight patients with chronic hepatitis C, circulating insulin is associated with hepatic fibrosis: implications for therapy. J Hepatol 2003; 39
Shintani Y, Fujie H, Miyoshi H, Tsutsumi T, Tsukamoto K, Kimura S, et al.
Hepatitis C virus infection and diabetes: direct involvement of the virus in the development of insulin resistance. Gastroenterology 2004; 126
Aytug S, Reich D, Sapiro LE, Bernstein D, Begum N. Impaired IRS-1/PI3-kinase signaling in patients with HCV: a mechanism for increased prevalence of type 2 diabetes. Hepatology 2003; 38
Chen X, Lu P, He W, Zhang J, Liu L, Yang Y, et al.
Circulating betatrophin levels are increased in patients with type 2 diabetes and associated with insulin resistance. J Clin Endocrinol Metab 2015; 100
Barja-Fernández S, Folgueira C, Seoane LM, Casanueva FF, Dieguez C, Castelao C, et al.
Circulating betatrophin levels are increased in anorexia and decreased in morbidly obese women. J Clin Endocrinol Metab 2015; 100
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]