Correspondence should be addressed to Bassem Refaat;

Transcription

1 Gstroenterology Reserch nd Prctice, Article ID , 9 pges Reserch Article Serum Activins nd Follisttin during the Tretment of Chronic Heptitis C Genotypes 1 nd 4 nd Their Correltions with Virl Lod nd Liver Enzymes: A Preliminry Report Bssem Reft, 1 Adel Gll El-Shemi, 1,2 Ahmed Mohmed Ashshi, 1 nd Adnn AlZngi 3 1 Lortory Medicine Deprtment, Fculty of Applied Medicl Sciences, Umm Al-Qur University, P.O. Box 767, Al Adeyh, Mkkh, Sudi Ari 2 Deprtment of Phrmcology, Fculty of Medicine, Assiut University, Assiut 6515, Egypt 3 Gstroenterology Deprtment, King Adullh Medicl City, Mkkh 21955, Sudi Ari Correspondence should e ddressed to Bssem Reft; ssem.reft@yhoo.co.uk Received 11 Ferury 214; Revised 21 Ferury 214; Accepted 7 Mrch 214; Pulished 1 April 214 Acdemic Editor: Pul Enck Copyright 214 Bssem Reft et l. This is n open ccess rticle distriuted under the Cretive Commons Attriution License, which permits unrestricted use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. Aims. To mesure the effect of pegylted interferon-α therpy on serum ctivin-a, ctivin-b, nd follisttin nd their correltion with virl lod nd liver firosis in chronic heptitis C (CHC). Methods. This study ws cross-sectionl nd ser were collected from 165 prticipnts clssified into 7 groups: 4 helthy negtive control, 33 tretment nïve ptients s positive control, 19 ptients t week 4, 22 t week 12, nd 19 t week 24 of tretment initition nd 21 responders nd 11 nonresponders t the end of 48-week tretment protocol. Serum cndidte proteins were mesured using ELISA nd liver firosis ws ssessed y AST pltelet rtio index (APRI). Results. CHC significntly incresed ctivins nd decresed follisttin compred to negtive control (P <.5). Activin-A nd follisttin levels returned to the levels of negtive control group t weeks 4, 12, nd 24 following tretment initition nd were significntly different from positive control (P <.5). Both proteins were significntly different etween responders nd nonresponders. Activin-A correlted positively nd significntly with the virl lod nd APRI. Conclusion. CHCmodultes serum ctivin-a nd follisttin nd they pper to e influenced y pegylted interferon-α therpy. Further studies reneeded to explore the role of ctivins in CHC. 1. Introduction Infection with heptitis C virus (HCV) is glol helth prolem nd it infects t lest 17 million people worldwide withnestimtedprevlenceof3to4millionnewlycquired infections per yer [1]. Although future tretment for chronic heptitis C (CHC) is interferon free nd it chieves higher sustined virl response, HCV infection is still currently treted with weekly injection of pegylted interferon-α- (PEG-INF-α-) 2 or -2 plus dily weight-sed dose of rivirin nd the recommended durtion of tretment for genotypes 1 nd 4 is 48 weeks [2, 3]. Furthermore, the cost of the new tretment is estimted to e 6, 1, USD nd therefore PEG-INF-α my still hve role especilly in those ptients living in developing countries nd for whom ccess to the new drugs is not definite [4 8]. IFN-α lters the immune response in ptients with CHC from T helper- (Th-) 2 to Th1 medited pttern to fvour the erdiction of the virus [9 12] nd this is chieved through the modultion of severl cytokines, including IFN- γ, interleukin (IL)-2, IL-6 nd IL-1, tumour necrosis fctor- (TNF-) α, nd trnsforming growth fctor-β (TGF-β) [13 16]. Activins,whichrememersoftheTGF-β fmily, re homodimers of inhiin β-suunits (βa nd βb), nd the different dimeriztion of suunits gives rise to three proteins: ctivin-a (βa-βa), ctivin-b (βb-βb), nd ctivin-ab (βa- βb), nd their iologicl ctions re tightly regulted y their inding protein, follisttin [17]. Activin-A nd follisttin reexpressedytheheptocytendtheyreinvolvedin the regultion of liver regenertion. The expression of these proteins is ltered in vriety of liver pthologies, including

2 2 Gstroenterology Reserch nd Prctice virl heptitis, liver firosis/cirrhosis, nd heptocellulr crcinom [18 22]. Activin-A nd follisttin lso ply n importnt immunoregultory role in the pthogenesis of inflmmtory nd firotic humn diseses [23]. In this concept, ctivin-a cn ct s pro- or nti-inflmmtory gent depending on type of the disese nd the cellulr nd immune contexts nd its ctions re locked y follisttin [24, 25]. Moreover, ctivin- Amyekeyregultorofhumorlimmuneresponsend its secretion is up-regulted in ctivted Th2 clones [26 28]. Little is known out the effect of PEG-INF-α sed therpy for the tretment of CHC on serum concentrtions of ctivins nd follisttin. Therefore, concentrtions of ctivin- A, ctivin-b, nd follisttin in serum smples collected t different times during the tretment protocol for genotypes 1nd4werecompredwiththoseotinedfromhelthy nd tretment nïve ptients with CHC genotypes 1 nd 4. We lso investigted whether serum concentrtions of the cndidte molecules differ etween tretment responder nd nonresponder nd correltion studies were performed etween the cndidte molecules, virl lod, nd liver function prmeters. 2. Ptients nd Methods 2.1. Ethicl Approvl. The study ws pproved y the Institutionl Review Bord nd Ethics Committee of King Adullh Medicl City (IRB 12-28). All smples were collected following otining informed written consent from ll the prticipnts Study Design. The tril ws cross-sectionl nd serum smples were collected from 4 helthy lood donors nd they served s negtive control (NC) group. The NC group consisted of 2 mles nd 2 femles (ge rnge: 3 6 yers).theprticipntsdidnotreportnycurrentcuteor chronic medicl condition, history of hospitlistion, nd no mediction for significnt clinicl disese. Additionlly, lortory results for their hemtologicl, iochemicl, nd metolic prmeters were within norml rnge. Serum smples were lso collected ccording to the inclusion nd exclusion criteri (Tle 1) from 6 different groups of ptients with totl numer of 125 ptients dignosed with CHC nd for whom polymerse chin rection following reverse trnscription ws positive for HCV RNA. The 6 groups were defined ccording to the time of their smple collection: positive control (PC) group included 33 infected ptients who did not strt their tretment protocol. The 4 weeks (4 W) group included 19 ptients t week 4 fter the initition of 48 weeks of tretment protocol with pegylted-interferon-α sed therpy who chieved rpid virl response. The 12 weeks (12 W) group consisted of 22 ptients t week 12 fter the strt of the tretment protocol. The 24 weeks (24 W) group consisted of 19 ptients t week 24 following the initition of tretment. The responder (R) group included smples collected t week 48 from 21 ptients who chieved end of tretment virl response nd who remined negtive fter 6 months from the termintion of the tretment protocol. The non-responder (NR) group included smples collected from nother 11 ptients who were positive for HCV y PCR t the end of 48-week tretment protocol. All treted ptients received PEG-INF-α-2 (Pegsys, Roche, Bsel, Switzerlnd) t dosge of 18 μg perweekin comintion with dily dose of rivirin (Copegus, Roche) sed on the ody weight (1 mg if <75 kg or 12 mg if 75 kg). The results of liver function prmeters nd virl lod t the time of smple collection were performed s prt of the routine lortory follow-up Clcultion of AST/Pltelet Rtio Index (APRI). APRI ws clculted using the following eqution: (AST/upper limitofnorml)/plteletcount( 1 9 /L) 1. The interprettion of the APRI results ws performed ccording to previously pulished studies [29, 3]. Briefly, index.5 indicted norml liver with no or miniml firosis, >.5 nd 1.5 Progressive firotic stges (e.g. Metvir F1-to-F4) nd >1.5 indicted liver cirrhosis. Only smples with 1.2 APRI were included into the study to void collecting smples from ptients with liver cirrhosis Enzyme Linked Immunosorent Assy (ELISA). ELISA ws used for quntittive mesurement of humn ctivin- A (R&D systems, Minnepolis, USA), ctivin-b (Uscn Life Science Inc., Huei, Chin), nd follisttin (R&D systems, Minnepolis, USA). All smples were processed in duplicte nd ccording to the mnufcturer s instructions. The opticl density of the pltes ws mesured within 1 min using plte reder t 45 nm nd correction t 56 nm s recommended y the mnufcturer. As reported y the mnufcturer, the lowest detection limit of ctivin-a y the used kit is 3.7 pg/ml nd the upper limit is 15 pg/ml. The intr-ssy nd interssy precisions ofthekitre4.3%nd5.8%,respectively.thekitcross rects y.2% nd.45% with inhiin-a nd ctivin-ab, respectively. The detection rnge of the ctivin-b kit is pg/ml nd the minimum detectle dose is 6.4 pg/ml. The intr-ssy nd interssy precisions re <1% nd <12%, respectively. Cross-rections with the other ctivin/inhiin isoforms were not detected y the mnufcturer Activin(s)/Follisttin Rtio Index. Activin-A/follisttin rtio index (AFRI), ctivin-b/follisttin rtio index (BFRI), nd ctivins/follisttin rtio index (ASFRI) were clculted s follows, respectively: [ctivin-a/follisttin 1], [ctivin- B/follisttin 1], nd [(ctivin-a + ctivin-b)/follisttin 1] Sttisticl Anlysis. Sttisticlnlysisoftheresultsws performed using SPSS version 16. Cross-tultion followed y Chi squre (χ 2 ) test ws used for frequency nlysis. According to dt normlity, either Student s t-test or Mnn- Whitney U test ws used to compre etween 2 groups. Furthermore, one-wy ANOVA followed y LSD post hoc test or Kruskl-Wllis followed y Dunn s post hoc test ws used to compre etween more thn 2 groups depending on

3 Gstroenterology Reserch nd Prctice 3 Tle 1: Inclusion nd exclusion criteri. Principl inclusion criteri Ptient ge 18 yers. HCV RNA positive No concurrent infection with HBV or HIV Dul therpy using peg-inf-α 2 or 2 with rivirin No mendment/modifiction of tretment protocol Tretment nïve ptients Compensted liver disese (e.g. no liver cirrhosis, filure, or cncer) nd APRI 1.2 Acceptle hemtologicl nd iochemicl indices No or controlled type 2 dietes mellitus nd hypertension Principle exclusion criteri Ptient ge <18 yers. Previous nonresponders/relpse Solid orgn trnsplnt (renl, hert, or liver, etc.) Mono-or triple sed therpy mendment/modifiction of tretment protocol Autoimmune condition (e.g. type 1 DM, rheumtoid rthritis, etc.) History or current thyroid disese Uncontrolled type 2 DM nd HTN Concurrent chronic disese (renl filure, coronry hert disese, etc.) the dt homogeneity. Correltions were determined using Person s test. P vlue <.5 ws considered significnt. 3. Results 3.1. Demogrphic Dt nd Routine Lortory Prmeters. There ws no significnt difference in the men ge, distriution of gender, virl genotype, virl lod t dignosis, nd ALP either etween the 7 study groups or within ech group ccording to gender nd virl genotype (Tle 2). However, serum lumin, AST, ALT, nd APRI were significntly different etween the study groups (Tle 2) Activins nd Follisttin in the Different Study Groups. Overll, ctivin-a, ctivin-b, follisttin, AFRI, BFRI, nd ASFRI showed significnt vrition etween the 7 study groups. CHC with no tretment (PC group) significntly incresed serum concentrtions of ctivin-a (P = ),ctivin-b(p =.3), AFRI( ),BFRI (P =.2), ASFRI(P =.4), nd significntly decresed follisttin (P = ) compred to the NC group (Figure 1). Following the initition of tretment, significnt decrese (P <.5) in the concentrtions of ctivin-a, AFRI, BFRI, nd ASFRI ws oserved t 4 W, 12 W, nd 24 W compred to the PC group nd the levels were similr to the NC (P >.5). Significnt increse in the concentrtions of follisttin (P <.5) ws oserved t 12 W nd 24 W compred to the PC group nd the levels were not different from the NC group (Figure 1). There ws no significnt chnge for ctivin-b following the initition of tretment when compred to the PC group (P >.5) (Figure 1). Furthermore, there ws no significnt chnge etween the 4 W, 12 W, nd 24 W in serum levels of ctivin-a, ctivin-b, AFRI, BFRI, nd ASFRI. The responder group hd serum concentrtions of ctivin-a, AFRI, BFRI, ASFRI, nd follisttin t similr levels seeninthenc,4w,12w,nd24wgroups(p >.5). However, ctivin-a (P = ),AFRI(P =.1), BFRI (P =.2),ndASFRI( ) were significntly decresed nd follisttin significntly incresed (P = ) compredtothepcgroup.therewsnosignificntin ctivin-b levels when compred to the other groups. In the nonresponder group, serum ctivin-a, ctivin-b, nd follisttin were significntly different from ll groups except for the PC group, where no significnt difference ws detected. However, significnt differences were detected for AFRI, BFRI, nd ASFRI when compred to ll groups (Figure 1). Activin-A nd follisttin were significntly higher in mle (331.1 ± 65.5 pg/ml nd ± pg/ml, resp.) compred to femle (256.8 ± 7.1 pg/ml nd ± pg/ml, resp.) prticipnts in the control group (P <.5). However, there ws no significnt difference (P >.5) etween oth genders within ech CHC group (dt not shown) Correltion of Serum Activins nd Follisttin with Liver Enzymes, Alumin, nd Virl Lod. Activin-A significntly correlted positively with the virl lod (r =.716, P = ),AST(r =.374, P =.3), ndapri (r =.528, P = ) nd negtively with lumin (r =.57, P = ) (Tle 3). Significnt positive correltion ws lso oserved etween the virl lod nd AFRI (r =.64, P = ) nd ASFRI (r =.534, P = ) (Figure 2). 4. Discussion This current study is the first to report the effect of PEG- INF-α sed therpy on serum concentrtions of ctivin- A, ctivin-b, AFRI, BFRI, ASFRI, nd follisttin in ptients dignosed with CHC. This is lso the first report to show significnt difference in serum concentrtions of those proteins etween tretment responders nd nonresponders in ptients infected with HCV genotypes 1 nd 4 following PEG-INF- α sed therpy for 48 weeks. Finlly, our results showed significnt correltion for serum ctivin-a with the virl lod nd liver function prmeters.

4 4 Gstroenterology Reserch nd Prctice Tle 2: Demogrphic nd lortory chrcteristics of the ptients ccording to study groups. NC (n =4) PC(n=33) 4W(n=19) 12W(n=22) 24W(n=19) R (n =21) NR(n=11) Age (yers) 39 ± ± ± ± ± ± ± 18.1 Gender Mle 2 (5%) 16 (48.4%) 11 (57.9%) 15 (68.1%) 13 (68.4%) 12 (57.1%) 5 (45.5%) Femle 2 (5%) 17 (51.6%) 8 (42.1%) 7 (31.9%) 6 (31.6%) 9 (42.9%) 6 (55.5%) Genotype G1 ND 14 (42.4%) 1 (52.9%) 1 (47.3%) 1 (55.5%) 11 (52.3%) 3 (27.3%) G4 ND 19 (57.6%) 9 (41.1%) 12 (52.7%) 9 (45.5%) 1 (47.7%) 8 (72.7%) Virllodtdignosis(IU/mL) ND ± ± ± ± ± ± Alumin (g/dl) 4.4 ± ± ± ± ± ± ±.48 ALP (IU/L) 79.4 ± ± ± ± ± ± ± 42.8 ALT (IU/L) 28 ± ± ± ± ± ± ± 18.7 AST (IU/L) 21 ± ± ± ± ± 8.3,c 28 ± 1.7,c 42.4 ± 2.4,e,f APRI.37 ±.7.85 ± ± ± ±.2,.65 ±.21,.72 ±.3 ND = not done, P <.5 compred to NC, P <.5 compred to PC, c P <.5 compred to 4 W, d P <.5 compred to 12 W, e P <.5 compred to 24 W, nd f P <.5 compred to R.

5 Gstroenterology Reserch nd Prctice Men ctivin-a ± SD in the different groups, c, d, e, f Activin-B (pg/ml) Men ctivin-b ± SD in the different groups, c, c, f () () Men follisttin ± SD in the different groups 35 3 Men ctivin-a/follisttin rtio index (AFRI) ± SD in the different groups, c, d, e, f Follisttin (pg/ml) , c, d, e, f AFRI (c) (d) Men ctivin-b/follisttin rtio index (BFRI) ± SD in the different groups,, c, d, e, f 5 4 Men Activins/follisttin rtio index (AsFRI) ± SD in the different groups,, c, d, e, f BFRI AsFRI (e) (f) Figure 1: Men ± SD of serum () ctivin-a, () ctivin-b, (c) follisttin, (d) AFRI, (e) BFRI, nd (f) ASFRI in the different study groups ( P =.5 compred to NC, P <.5 compred to PC, c P <.5 compred to 4 W, d P <.5 compred to 12 W, e P <.5 compred to 24 W, nd f P <.5 compred to R).

6 6 Gstroenterology Reserch nd Prctice 2 2 R =.57 P = R =.716 P = Virl lod (IU/mL) Alumin (g/dl) () () 2 R =.374 P =.3 2 R =.528 P = AST (IU/L) APRI (c) (d) 2 R =.186 P =.36 2 R =.27 P = ALT (IU/L) ALP (IU/L) 3 4 (e) (f) Figure 2: Correltion of serum ctivin-a with () virl lod, () serum lumin, (c) AST, (d) APRI, (e) ALT, nd (f) ALP y Person s correltion test.

7 Gstroenterology Reserch nd Prctice 7 Tle 3: Results of correltion nlysis using Person s test for ctivin-a,ctivin-b,follisttin,afri,bfri,nd ASFRI with virl lod,lumin, liver enzymes, nd APRI. Virl lod t smple collection Alumin ALP ALT AST APRI Activin-A R vlue P vlue Activin-B R vlue P vlue Follisttin R vlue P vlue AFRI R vlue P vlue BFRI R vlue P vlue ASFRI R vlue P vlue P <.1. Our results suggest tht HCV nd/or its ssocited liver firosis modulted serum ctivin-a nd follisttin. Additionlly,othmolecules,utnotctivin-B,couldemodulted through PEG-INF-α sed therpy in CHC ptients. The expressions of ctivin suunits nd follisttin hve een reported in the liver nd ltertion in their expression hseenlinkedwithseverlliverdiseses[18]. Serum ctivin- A significntly increses in liver firosis nd cirrhosis induced y virl nd non-virl fctors [31]. Serum ctivin-a ws linked to virl repliction in chronic heptitis B nd heptitis C [19], nd it correlted significntly with liver dmge ssocited with HCV [2]. Hence, it hs een suggested tht pthologicl ltertion in the heptic expression of ctivin ndfollisttincouldledtoimpiredliverregenertion[32] nd the development of liver firosis, cirrhosis, nd heptocellulr crcinom [33]. Our results correlte nd support the previous findings s there ws significnt decrese in serum follisttin nd significnt increse in serum ctivin-a, ctivin-b, AFRI, BFRI, nd ASFRI in ptients with CHC nd who did not receive tretment compred to helthy controls. APRIhseenproposedspredictorofliverfirosis nd cirrhosis in CHC to replce liver iopsy in sustntil proportion of ptients [34]. Severl studies hve confirmed the high sensitivity nd specificity nd significnt correltion of APRI with oth the stge of liver firosis nd the grde of ctivity [29]. The present study showed significnt positive correltions of serum ctivin-a with liver enzymes nd APRI nd significnt negtive correltion with serum lumin, suggesting tht the oserved increse in ctivin-a nd decrese in follisttin in the PC nd nonresponder groups couldeduetothechcssocitedliverfirosis.therefore, we hypothesize tht serum ctivin-a could e promising serum mrker for the dignosis of liver firosis/cirrhosis ssocited with CHC. However, further studies re required to support our suggestion. The current results lso showed significnt positive correltions for ctivin-a, AFRI nd ASFRI with the virl lod, proposing tht serum ctivin-a nd follisttin could e modulted y HCV through either the ssocited liver dmge or s prt of the host immune response to control the virl infection. Activin-A nd follisttin re elements of oth innte nd humorl immune responses [24, 25] nd oth proteins hve een descried in immune response to severl pthogens including viruses [35]. Activin-A nd follisttin re lso importnt regultors of regultory T-cells [36], nturl killer cells [37], nd dendritic cells [38], which re known to ply n importnt role in controlling CHC infection [1]. Furthermore, ctivin-a hs een shown to promote the production of Th2 cytokines, which promote the development of humorl response nd the susequent development of liver firosis [9, 1]. Hence, we suggest tht the oserved chnges in in serum ctivin-a/follisttin could represent the response y the host to the virl dmge which triggers n inflmmtory response driven y ctivin- A. However, dditionl studies re needed to explore whether ctivin-a nd/or follisttin re involved in the immune response to HCV. PEG-INF-α sed therpy is key component of CHC tretment through the induction of Th1 immune response [39]. INF-α promotes Th1 response through the increse in

8 8 Gstroenterology Reserch nd Prctice the production of severl cytokines y the heptocyte nd immune cells [16]. Additionlly, IFN-α lters the production of immunogloulin, decreses T regultory cell function [4], nd stimultes the production of toll like receptors (TLR) [39]. Gthered dt from pulished reports suggest tht ctivin-a/follisttin might e trget for PEG-INF-α sed therpy for the erdiction of CHC. The expressions of TLR- 2 nd 4 increse significntly following PEG-INF-α sed therpy in ptients with CHC [41] nd they re potent regultors of the relese of ctivin-a [42]. In ddition, PEG- INF-α increses the production of TNF-α [43]nd decreses serum IL-6 nd IL-1 in ptients with CHC [14]. These cytokines hve lso een reported to e regulted y ctivin- A[36]. Moreover, ctivin-a hs een reported to modulte the relese of INF-γ [44], which plys n importnt role in controlling CHC following PEG-INF-α sed therpy [45]. Consequently, the oserved significnt ltertion in ctivin- A nd follisttin fter 4, 12, nd 24 weeks of tretment could e medited y the therpy used. More studies re required to illustrte the kinetics nd source of serum ctivin-a nd follisttin during the course of PEG-INF-α sed therpy. A limittion for our study is tht we dopted crosssectionl design nd performing longitudinl prospective cohort study would revel the true kinetics of serum ctivin-a nd follisttin following PEG-INF-α sed therpy nd their correltion with the virl lod during the course of tretment. Susequently, it would llow etter understnding of the effect(s) of the currently used tretment for CHC nd virl lod on serum ctivins nd follisttin. However, the current study is preliminry report nd we re currently processing future studies with longitudinl design to mesure the clinicl vlue of ctivins nd follisttin in the prediction of tretment outcome in CHC. In conclusion, serum concentrtions of ctivin-a nd follisttin re different etween ptients with nd without HCV nd t the different stges of IFN therpy. Activin- A nd follisttin pper to e influenced y PEG-IFN-α sed therpy nd they seem to correlte with liver dmge ssocited with CHC. Further studies re needed to illustrte the role(s) of ctivin-follisttin xis in CHC nd to explore the effect(s) of PEG-INF-α therpy on the expression of ctivins ndfollisttinytheheptocyte. Conflict of Interests The uthors declre tht there is no conflict of interests regrding the puliction of this pper. Acknowledgment The uthors thnk KACST for the finncil support of the study (12-MED232-1) under the Ntionl Science, Technology nd Innovtion Pln. The study ws funded y Grnt (12-MED232-1) under the Ntionl Science, Technology nd Innovtion Pln from King Adul Aziz City for Sciences nd Technology (KACST), Riydh, KSA. References [1] F. M. Averhoff, N. Glss, nd D. Holtzmn, Glol urden of heptitis C: considertions for helthcre providers in the United Sttes, Clinicl Infectious Diseses, vol. 55, supplement 1, pp. 1 15, 212. [2]M.G.Ghny,D.B.Strder,D.L.Thoms,ndL.B.Seeff, Dignosis, mngement, nd tretment of heptitis C: n updte, Heptology,vol.49,no.4,pp , 29. [3] C.Lee, Dcltsvir:potentilroleinheptitisC, Drug Design, Development nd Therpy,vol.7,pp ,213. [4] C. M. Lnge nd S. Zeuzem, Perspectives nd chllenges of interferon-free therpy for chronic heptitis C, Journl of Heptology,vol.58,pp ,213. [5]Z.M.Younossi,M.E.Singer,H.M.Mir,L.Henry,ndS. Hunt, Impct of interferon free regimens on clinicl nd cost outcomes for chronic heptitis C genotype 1 ptients, Journl of Heptology,vol.6,no.3,pp ,214. [6] K. Chn, M. N. Li, E. J. Groessl et l., Cost effectiveness of direct-cting ntivirl therpy for tretment-nive ptients with chronic HCV genotype 1 infection in the veterns helth dministrtion, Clinicl Gstroenterology nd Heptology, vol. 11, no. 11, pp , 213. [7]S.A.Ferrnte,J.Chhtwl,C.A.Brss,A.C.ElKhoury, F. Poordd, J. P. Bronowicki et l., Boceprevir for previously untreted ptients with chronic heptitis C Genotype 1 infection: US-sed cost-effectiveness modeling study, BMC Infectious Diseses,vol.13,rticle19,213. [8] S.Cure,F.Binic,S.Gvrt,S.Curtis,S.Lee,ndG.Dusheiko, Cost-effectiveness of telprevir in comintion with pegylted interferon lph nd rivirin in previously untreted chronic heptitis C genotype 1 ptients, JournlofMediclEconomics, vol.17,no.1,pp.65 76,214. [9] M.MoserndK.M.Murphy, DendriticcellregultionofTH1- TH2 development, Nture Immunology, vol. 1, no. 3, pp , 2. [1] P.Fllhi,C.Ferri,S.M.Ferrri,A.Corrdo,D.Snsonno,nd A. Antonelli, Cytokines nd HCV-relted disorders, Clinicl nd Developmentl Immunology, vol. 212, Article ID 46817, 1 pges, 212. [11] J. D. Frrr nd K. M. Murphy, Type I interferons nd T helper development, Immunology Tody, vol. 21, no. 1, pp , 2. [12] M. A. Jimenez-Sous, R. Almns, C. de l Fuente et l., Incresed Th1, Th17 nd pro-firotic responses in heptitis C- infected ptients re down-regulted fter 12 weeks of tretment with pegylted interferon plus rivirin, Europen Cytokine Network,vol.21,no.2,pp.84 91,21. [13] E. P. M. Corssmit, J. de Metz, H. P. Suerwein, nd J. A. Romijn, Biologic responses to IFN-α dministrtion in humns, Journl of Interferon nd Cytokine Reserch,vol.2,no.12,pp , 2. [14] M. Ueym, M. Nkgw, N. Skmoto et l., Serum interleukin-6 levels correlte with resistnce to tretment of chronic heptitis C infection with pegylted-interferon-α2 plus rivirin, Antivirl Therpy, vol. 16,no. 7, pp , 211. [15] E. J. Pvon-Cstillero, P. Munoz-de-Rued, R. Lopez-Segur et l., Importnce of IL-1 nd IL-6 during chronic heptitis c genotype-1 tretment nd their reltion with IL28B, Cytokine, vol.61,no.2,pp ,213.

9 Gstroenterology Reserch nd Prctice 9 [16] H. Tilg, New insights into the mechnisms of interferon lf: n immunoregultory nd nti-inflmmtory cytokine, Gstroenterology,vol.112,no.3,pp ,1997. [17]B.A.Reft,A.O.Bhthiq,S.Socknthn,R.L.Stewrt, M.Wells,ndW.L.Ledger, Productionndlocliztionof ctivins nd ctivin type IIA nd IIB receptors y the humn endoslpinx, Reproduction, vol. 128, no. 2,pp , 24. [18] C. Rodgrki-Dr, S. Vejd, N. Erlch et l., The ctivin xis in liver iology nd disese, Muttion Reserch: Reviews in Muttion Reserch,vol.613,no.2-3,pp ,26. [19] S. Ptell, D. J. Phillips, D. M. de Kretser, L. W. Evns, N. P. Groome, nd W. Sievert, Chrcteriztion of serum ctivin-a nd follisttin nd their reltion to virologicl nd histologicl determinnts in chronic virl heptitis, Journl of Heptology, vol. 34, no. 4, pp , 21. [2] M. Y. Elsmmk, G. M. Amin, G. M. Khlil, W. S. Rg, nd M. M. Az, Possile contriution of serum ctivin A nd IGF- 1 in the development of heptocellulr crcinom in Egyptin ptients suffering from comined heptitis C virus infection nd heptic schistosomisis, Clinicl Biochemistry, vol.39,no. 6, pp , 26. [21] M. Grusch, C. Drucker, B. Peter-Vörösmrty et l., Deregultion of the ctivin/follisttin system in heptocrcinogenesis, Journl of Heptology,vol.45,no.5,pp ,26. [22] M. K. Jin, B. Adms-Huet, D. Terekhov et l., interferon Acute nd chronic immune iomrker chnges during interferon/rivirin tretment in HIV/HCV co-infected ptients, Journl of Virl Heptitis,214. [23] S. Werner nd C. Alzheimer, Roles of ctivin in tissue repir, firosis, nd inflmmtory disese, CytokinendGrowthFctor Reviews,vol.17,no.3,pp ,26. [24] K. L. Jones, A. Mnsell, S. Ptell et l., Activin A is criticl component of the inflmmtory response, nd its inding protein, follisttin, reduces mortlity in endotoxemi, Proceedings of the Ntionl Acdemy of Sciences of the United Sttes of Americ, vol. 14, no. 41, pp , 27. [25] D. J. Phillips, D. M. de Kretser, nd M. P. Hedger, Activin nd relted proteins in inflmmtion: not just interested ystnders, CytokinendGrowthFctorReviews, vol. 2, no. 2, pp , 29. [26] K. Ogw, M. Fun, Y. Chen, nd M. Tsujimoto, Activin A functions s Th2 cytokine in the promotion of the lterntive ctivtion of mcrophges, Journl of Immunology, vol. 177, no. 1, pp , 26. [27] K. Ogw, M. Fun, nd M. Tsujimoto, A dul role of ctivin A in regulting immunogloulin production of B cells, Journl of Leukocyte Biology,vol.83,no.6,pp ,28. [28] D. J. Phillips, K. L. Jones, J.-P. Y. Scheerlinck, M. P. Hedger, nd D. M. de Kretser, Evidence for ctivin A nd follisttin involvement in the systemic inflmmtory response, Moleculr nd Cellulr Endocrinology,vol.18,no.1-2,pp ,21. [29] S. A. Foud, S. Esmt, D. Omrn, L. Rshid, nd M. H. Koisi, Noninvsive ssessment of heptic firosis in Egyptin ptients with chronic heptitis C virus infection, World Journl of Gstroenterology, vol. 18, no. 23, pp , 212. [3]F.Guzelulut,M.Sezikli,Z.Akkn-Cetinky,B.Ysr,S. Ozkr, nd A. O. Kurds-Ovunc, AST-pltelet rtio index in the prediction of significnt firosis nd cirrhosis in ptients with chronic heptitis B, The Turkish Journl of Gstroenterology,vol.23,pp ,212. [31] A. Voumvourki, G. Nots, M. Koulentki, M. Georgidou, S. Klironomos, nd E. Kouroumlis, Incresed serum ctivin- A differentites lcoholic from cirrhosis of other etiologies, Europen Journl of Clinicl Investigtion,vol.42,no.8,pp , 212. [32] R. D. Hughes nd L. W. Evns, Activin A nd follisttin in cute liver filure, Europen Journl of Gstroenterology nd Heptology,vol.15,no.2,pp ,23. [33] E. Kreidl, D. Ozturk, T. Metzner, W. Berger, nd M. Grusch, Activins nd follisttins: emerging roles in liver physiology nd cncer, World Journl of Heptology, vol. 1, no. 1, pp , 29. [34] C.-T. Wi, J. K. Greenson, R. J. Fontn et l., A simple noninvsive index cn predict oth significnt firosis nd cirrhosis in ptients with chronic heptitis C, Heptology, vol. 38,no.2,pp ,23. [35] Y. Nishino, R. Ooishi, S. Kurokw et l., Gene expression of the TGF-β fmily in rt rin infected with Born disese virus, Microes nd Infection, vol. 11, no. 8-9, pp , 29. [36] M. Semitekolou, T. Alissfi, M. Aggelkopoulou et l., Activin- A induces regultory T cells tht suppress T helper cell immune responses nd protect from llergic irwy disese, Journl of Experimentl Medicine,vol.26,no.8,pp ,29. [37] N.C.Roson,H.Wei,T.McAlpine,N.Kirkptrick,J.Ceon, nd E. Mrskovsky, Activin-A ttenutes severl humn nturl killer cell functions, Blood, vol.113,no.14,pp , 29. [38] S. Scuter, E. Rioldi, R. Dniele et l., Production nd function of ctivin A in humn dendritic cells, Europen Cytokine Network,vol.19,no.1,pp.6 68,28. [39] M. H. Heim, Interferons nd heptitis C virus, Swiss Medicl Weekly,vol.142,ArticleIDw13586,212. [4] I.Kruse,G.Vlesini,R.Scrivo,ndY.Shoenfeld, Autoimmune spects of cytokine nd nticytokine therpies, Americn Journl of Medicine, vol. 115, no. 5, pp , 23. [41] T. Hmmond, S. Lee, M. W. Wtson et l., Toll-like receptor (TLR) expression on CD4 + nd CD8 + T-cells in ptients chroniclly infected with heptitis C virus, Cellulr Immunology,vol. 264, no. 2, pp , 21. [42] K. L. Jones, D. M. de Kretser, I. J. Clrke, J.-P. Y. Scheerlinck, nd D. J. Phillips, Chrcteristion of the rpid relese of ctivin A following cute lipopolyscchride chllenge in the ewe, Journl of Endocrinology,vol.182,no.1,pp.69 8,24. [43] G. Ahlenstiel, B. Edlich, L. J. Hogdl et l., Erly chnges in nturl killer cell function indicte virologic response to interferon therpy for heptitis C, Gstroenterology, vol. 141, no. 4, pp e2, 211. [44] K.S.Fmulski,B.Sis,L.Billeserger,ndP.F.Hllorn, Interferon-γ nd donor MHC clss I control lterntive mcrophge ctivtion nd ctivin expression in rejecting kidney llogrfts: shift in the Th1-Th2 prdigm, Americn Journl of Trnsplnttion,vol.8,no.3,pp ,28. [45] T. N. Phm, D. M. Lin, P. M. Mulrooney-Cousins et l., Heptitis C virus lod nd expression of unique suset of cellulr genes in circulting lymphoid cells differentite nonresponders from responders to pegylted interferon lphrivirin tretment, Journl of Medicl Virology, vol.85,no.3, pp ,213.

10 MEDIATORS of INFLAMMATION The Scientific World Journl Gstroenterology Reserch nd Prctice Journl of Dietes Reserch Interntionl Journl of Journl of Endocrinology Immunology Reserch Disese Mrkers Sumit your mnuscripts t BioMed Reserch Interntionl PPAR Reserch Journl of Oesity Journl of Ophthlmology Evidence-Bsed Complementry nd Alterntive Medicine Stem Cells Interntionl Journl of Oncology Prkinson s Disese Computtionl nd Mthemticl Methods in Medicine AIDS Behviourl Neurology Reserch nd Tretment Oxidtive Medicine nd Cellulr Longevity