Liver fibrosis in young Egyptian beta-thalassemia major patients: relation to hepatitis C virus and compliance with chelation

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1 ORIGINAL ARTICLE Jnury-Februry, Vol. 12 No.1, 213: Liver fibrosis in young Egyptin bet-thlssemi mjor ptients: reltion to heptitis C virus nd complince with cheltion Mohsen S. Ellfy,* Gml Esmt,** Rnd M. Mtter,* Heshm E. Abdel Aziz,* Wlid A. Mssoud*** ABSTRACT * Deprtment of Peditric Hemtology, Ain Shms University, Ciro 11566, Egypt. ** Deprtment of Tropicl Medicine, Ciro University, Ciro 12613, Egypt. *** Reserch Deprtment, Ntionl Center for Exmintions nd Eductionl Evlution (NCEEE), Ciro 111, Egypt. Bckground. The min cuses of liver fibrosis in trnsfusion-dependent thlssemi mjor re heptitis C virus (HCV) infection nd heptic iron overlod. The study imed to ssess liver fibrosis in Egyptin dolescents nd young dult poly-trnsfused bet thlssemi ptients infected with HCV using liver FibroScn in reltion to iron overlod nd Liver iron concentrtion (LIC). Mteril nd methods. Fifty-one regulrly trnsfused bet thlssemi ptients bove 12 yers old were subjected to mesurement of serum lnine trnsminse (ALT), serum ferritin (SF), HCV (ntibody nd RNA), LIC ssessed by heptic R2* nd trnsient elstogrphy (TE) (FibroScn). FibroTest nd liver biopsy were done to 25 ptients. Results. Eighty two% of studied thlssemi ptients were HCV ntibody positive; 21(49%) of them were viremic (HCV RNA positive); medin LIC ws 12 mg/gm dry weight. There were strong positive correltion between the degree of liver stiffness nd Ishk fibrosis score ssessed in liver biopsy specimens (P =.2) nd between FibroScn nd FibroTest results (P <.1). Ptients with HCV viremi showed significntly higher ALT, γ-glutmyl trnspeptidse (GGT), SF, LIC nd incresed liver stiffness compred to ptients with no viremi (P =.1,.1,.12,.6 nd.1) respectively. Liver cirrhosis (TE vlues > 12.5kP) ws encountered in 23.5% nd vrible degrees of liver fibrosis (TE vlues > kp) in 35% of studied thlssemic ptients. Conclusion. Young bet thlssemi ptients with ctive heptitis C infection my hve heptic cirrhosis or fibrosis t young ge when ccompnied with heptic siderosis. Non invsive Liver FibroScn nd Fibro- Test were relible methods to ssess liver fibrosis in young thlssemic-ptients. Key words. Iron overlod. Liver iron concentrtion. Cirrhosis. FibroScn. FibroTest. INTRODUCTION Correspondence nd reprint request: Mohsen S. Ellfy, MD, PhD, Professor of Peditrics. 2 syed Zkri Khlil Street, Morb 1153, Msken Sherton Heliopolis, Ciro, Egypt. Tel.: Fx: E-mil: ellfym@hotmil.com Mnuscript received: Jun 3, 212. Mnuscript ccepted: Jul 3, 212. Worldwide, no ptients get more red cell products thn those with thlssemi mjor. The life-long need for trnsfusion renders ptients vulnerble to trnsfusion-trnsmitted virl infections. Heptitis C virus infection hs emerged s the mjor risk in the lst decdes. 1 Heptitis virus C infection is the min risk fctor for liver fibrosis in trnsfusion-dependent thlssemics. Excess liver iron is now clerly recognized s cofctor for the development of dvnced fibrosis nd cirrhosis in ptients with HCV infection. 2-4 In dults, the non-invsive ssessment of fibrosis in chronic heptitis, especilly of virl etiology, is more nd more ccepted, prtilly replcing liver biopsy in some countries. Guidelines from Frnce recommend tht the first-line test for untreted ptients with HCV chronic heptitis, with no comorbidities, should be non invsive procedure (either FibroTest or FibroScn ). 5 The vst mjority of studies ssessing trnsient elstogrphy (TE) s compred to liver biopsy were performed in ptients with HCV chronic heptitis. 6-9 In bet-thlssemi ptients (especilly HCV infected ones) t higher risk of liver biopsy relted complictions s compred to other chroniclly HCV-infected ptients, the vilbility of noninvsive method to mesure heptic fibrosis is crucil. 1 However, FibroScn; medicl device bsed on TE nd FibroTest; were not extensively investigted in young bet thlssemi ptients infected with HCV.

2 Liver fibrosis in bet-thlssemi mjor ptients., 213; 12 (1): The purpose of this study ws to ssess liver fibrosis sttus in young polytrnsfused bet thlssemi ptients infected with HCV using both FibroScn nd FibroTest in reltion to iron overlod nd liver iron concentrtion (LIC). MATERIAL AND METHODS This cross sectionl study included fifty one regulrly trnsfused bet thlssemi ptients (26 mles nd 25 femles with ge rnge yers from Thlssemi Center, Ain Shms University during the period from Mrch 29 to Mrch 21. Written informed consent ws obtined from dult ptients, ptients prents or their legl gurdins fter pprovl of the study by the Locl Ethicl Committee, Ain Shms University. The study protocol conformed to the ethicl guidelines of Declrtion of Helsinki Inclusion criteri Bet thlssemi mjor ptients ged 12 yers, poly-trnsfused > 1 trnsfusion, with liver siderosis; LIC > 2 mg Fe/g liver dry weight [dw], HCV ntibody positive ptients hve hd their infection for t lest 1 yers s recorded from their files. All ptients received iron cheltion therpy either in the form of subcutneous infusion of desferoxmine (Desferl; Sigm, Sint Louis, Missouri, US) with dose of 4 mg/kg for 5 dys/week. Alterntively, orl cheltion therpy Deferiprone (Ferriprox ; Apo- Phrm, Toronto, Cnd) ws dministered t 75 mg/kg/d for 7 dys/week. Complince defined s the extent to which ptients tke medictions s prescribed by their helth cre providers; ws ssessed by the following questions: How mny doses were missed per dy during the preceding 4 weeks, nd Wht is the mount of mediction remining? At ech clinic visit, the old vils were brought nd the remining tblets were counted. Exclusion criteri Non pplicbility conditions of FT: dibetes mellitus, ptients with ALT > 1 times ULN (Upper Limit of Norml), serum bilirubin > 5 mg /dl. Thlssemic ptients were ctegorized on the bsis of risk to develop liver fibrosis i.e. both LIC vlues nd HCV viremi into 3 subgroups: Group I. Ptients with both HCV-RNA positivity nd LIC > 14 mg/gm dw. Group II. Ptients with either HCV-RNA positivity or LIC > 14 mg/gm dw, nd Group III. Ptients with negtive viremi with LIC < 14 mg/gm dw. Blood smples were tken 4 weeks from lst blood trnsfusion; Complete blood count ws performed using coulter B66 (Mimi, Florid, USA), Liver function tests including AST, ALT using Synchron CX9 utonlyzer (Bre, Cliforni, USA), serum ferritin on Immulite instrument (Dignostic products corportion West 96 St. Los Angeles, USA), heptitis B surfce ntigen, humn immunodeficiency virus ntibody using ELISA technique (R & D system, USA) nd HCV ntibody using ELISA technique (R & D system, USA) nd HCV RNA by polymerse chin rection (Amplicor HCV; Roche Moleculr Systems, Bsel, Switzerlnd) were done to ll ptients ccording to mnufcturer s instructions. Trnsfusionl iron intke ws clculted in mg/kg/dy. 11 FibroTest (Biopredictive, Frnce, [FT]): this test consists of n lgorithm of five fibrosis mrkers (lf2-mcroglobulin, polipoprotein A1, hptoglobin, GGT, bilirubin) It hs been evluted in 25 ptients suitble for FT who performed lso liver biopsy. Gmm-glutmyltrnspeptidse (GGT), totl bilirubin, polipoprotein A1, nd hptoglobin were mesured with Cobs Integr 4 nlyzer (Roche, Indinpolis, Indin, USA) nd Roche Dignostics regents (Roche, USA). Alph2-mcroglobulin ws ssyed with Cobs Integr 4 Turbidimetry with Dko utility chnnel regents (Glostrup, Denmrk). All tests were performed by personnel blinded to ll ptients dt, including biopsy results. Liver iron concentrtion (LIC) ws ssessed by Mgnetic resonnce imging (MRI) mesurements of the proton trnsverse relxtion prmeter R2 using 5 mm xil slices. R2 scns were performed using FerriScn technology (Resonnce Helth). 14 Results re expressed s mg/gm liver dry weight. Liver histology nd quntifiction of liver fibrosis Liver biopsy ws performed in 25 ptients with chronic HCV heptitis who ccepted to do the biopsy within one month from TE by senior opertors using the Menghini technique with 1.6-mm-dimeter needle (Hepfix, Brun, Melsungen, Germny). All biopsy specimens were nlyzed by the sme

3 56 Ellfy M, et l., 213; 12 (1): trined pthologist blinded to the results of non-invsive methods. Fibrosis ws scored by Ishk clssifiction. 15 None of the ptients experienced biopsy complictions. 12 mg/gm liver dw. Ishk fibrosis score ws 6 in 4 ptients, 5 in 3 ptients, 4 in 4 ptients, 3 in 4 ptients nd 2 in 1 ptients. Men stiffness vlue ws 1.75 ± 1.41 kp (medin 6.8, rnge kp). Trnsient elstogrphy (TE) A 5, 3,712 All ptients were exmined by TE (FibroScn ; Echosens, Pris, Frnce). The procedures were performed by the sme investigtor who ws blind to clinicl, serologicl, nd histologicl dt. Detils of the technicl bckground nd exmintion procedure hve been previously described. 16 The results were expressed in kilopscls (kp). The medin vlue ws considered representtive of the elstic modulus of the liver. Only procedures with t lest 1 successful cquisitions nd success rte of t lest 6% with interqurtile rnge (IQR) of ll vlidted mesurements less thn 3% of the medin vlue were considered relible. Twenty five ptients who hd the liver biopsy nd FT were retested fter 2 weeks to verify the results. Cirrhosis ws defined ccording to the published cut-offs in ptient with heptitis C: 12.5 kp. 17 The cut-off vlue of TE 6 kp for dignosing F 1 (18) ws used to exclude heptic fibrosis with smller vlues. No liver stiffness mesurement filure ws observed in the present study. Serum ferritin (ng/ml) B LIC (mg/gm) 4, 3, 2, 1, ,598 1,626 TE > 12.5 kp TE: kp TE < 6 kp TE vlues Sttisticl nlysis 1 Anlysis of dt ws performed by using SPSS (version 15). Comprison between 2 groups of ptients ws mde using Student s t-test for prmetric mesures nd Wilcoxon signed-rnk test (Z vlue) for non prmetric mesures. Spermn s rnk correltion coefficient ws used to correlte between two quntittive vribles. P vlue <.5 ws considered the cut-off vlue for significnce. RESULTS Fifty-one consecutive ptients (26 mles nd 25 femles; men ge ± 3.11 yers); 25 with suitble liver biopsy entered the study. All bet thlssemi mjor ptients were trnsfusion-dependent: they trnsfused pcked red cells every dys with pretrsfusionl Hb levels from 7.4 to 9.4 g/dl. Medin BMI ws 19.5 (rnge kg/m 2 ). Eighty-two percent of thlssemi ptients were HCV ntibody positive; 21 of them (49%) were viremic (HCV RNA positive), 4% were heptitis B surfce ntigen positive nd none of them ws humn immunodeficiency virus positive. Medin LIC ws C Percent of cses TE > 12.5 kp TE: kp TE < 6 kp TE vlues TE > 12.5 kp TE: kp TE < 6 kp TE vlues RNA positive RNA negtive Figure 1. Serum ferritin (A), LIC (B) nd RNA positive cses (C) mong bet thlssemi mjor ptients with different TE vlues.

4 Liver fibrosis in bet-thlssemi mjor ptients., 213; 12 (1): Tble 1. Demogrphic nd biochemicl mrkers of HCV viremic vs. non viremic Bet Thlssemi mjor ptients. HCV Viremi Non viremic HCV P Age (yers) 16.67±3.45 (N = 21) 15.53±.39 (N = 3) n.s. T I (mg/kg ).45±.1 (N = 21).38±.8 (N = 3) n.s. ALT (IU/L) ±49.16 (N = 21) 53.6± (N = 3).1* AST (IU/L) 95.5±49.31 (N = 21) 38.± 2.45 (N = 3).1* GGT (IU/L) 48.83±19.47 (N = 12) 23.46± 8.24 (N = 13).1* S.F. (ng/ml) 381±1329 (N = 21) 263± 1317 (N = 3).12* LIC (mg/gm liver dw) 2.86±15.27 (N = 21) 1.43± 6.21 (N = 3).6* FT.71±.21 (N = 12).54±.22 (N = 13) n.s. TE (kp) 15.95±13.77 (N = 21) 7.11± 4.79 (N = 3).1* *Significnt. TI: trnsfused iron. ALT: lnine minotrnsferse. AST: sprtte minotrnsferse. GGT: γ-glutmyl trnspeptidse. SF: serum ferritin. LIC: liver iron concentrtion. dw: dry weight. FT: FibroTest. TE: trnsient elstogrphy. kp: kilopscl. Tble 2. Risk of liver fibrosis in reltion to HCV RNA positivity nd LIC in Bet Thlssemi mjor ptients. (Risk ) Liver fibrosis (HCV RNA & LIC vlues) Group I (N = 9) Group II (N = 16) Group III (N = 26) P1 P2 TI (mg/kg).5 ±.12 (N = 9).43±.8 (N=16).38±.8 (N = 26) n.s..47* Complince with cheltor.11 ±.33 (N = 9).31±.48 (N=16).73±.45 (N = 26) n.s..3* FT.81 ±.22 (N = 6).68±.2 (N=7).47±.13 (N = 12).4*.2* TE (kp) ±13.23 (N = 9) 9.46±5.27 (N=16) 5.51± 2.28 (N = 26).1*.1* Group I: HCV RNA +ve & LIC 14. Group II: HCV RNA +ve & LIC < 14 OR HCV RNA -ve & LIC 14. Group III: HCV RNA -ve & LIC < 14. *Significnt, P1: comprison between column 1 nd column 2 p vlues. P2: comprison between column 2 nd column 3 p vlues. RNA: ribonucleic cid. LIC: liver iron concentrtion. TI: trnsfused iron. FT: FibroTest. TE: trnsient elstogrphy. Using FibroScn; liver cirrhosis (TE vlues > 12.5 kp) ws encountered in 23.5% nd vrible degrees of liver fibrosis (TE vlues > kp) in 35% of studied thlssemic ptients. There ws strong positive correltion between degree of liver stiffness nd Ishk fibrosis score detected by liver biopsy (r =.4, P =.2). All ptients with liver cirrhosis (TE vlues > 12.5 kp) were HCV ntibody positive nd showed highest HCV RNA positivity (Figure 1). Ptients with HCV viremi showed significntly higher ALT, GGT, SF, LIC nd incresed liver stiffness compred to ptients with no viremi (P =.1,.1,.12,.6 nd.1) respectively (Tble 1). Non viremic HCV ntibody positive ptients showed significntly higher LIC (12.1 ± 6.56 vs ± 2.79 mg/gm liver dry weight, P =.6) nd incresed liver stiffness (8.26 ± 5.3 vs ± kp, P =.6) compred to HCV ntibody negtive ptients. Highest serum ferritin (SF), LIC nd RNA positivity were observed mong bet thlssemi mjor ptients with TE vlues in the cirrhotic rnge (bove 12.5kP) (Figure 1). Lowest liver stiffness, fibrotest results nd best complince with cheltion therpy were obtined in thlssemic ptients with negtive viremi nd LIC less thn 14 mg/gm dw wheres highest TE vlues, worst complince with cheltion nd highest fibrotest results were shown in ptients with both HCV- RNA positivity nd LIC bove 14 mg/gm dw followed by ptients with either HCV-RNA positivity or LIC bove 14 mg/gm dw (Tble 2). Detils of complince of ech subgroup were shown in figure 2, where % of the ptients complint with Deferoxmine hd LIC below 14 mg/gm dw nd negtive viremi. Most of the non-complint ptients to Deferoxmine were HCV RNA positive with LIC bove 14 mg/gm dw nd 83% of the ptients complint with Deferiprone hd LIC below 14 mg/gm dw nd negtive viremi. Reltion between complince with cheltors nd TE vlues showed tht most non complint ptients with Deferoxmine hd TE more thn 12.5 kp wheres most complint ptients with Deferiprone hd TE less thn 6 kp (Figure 3). Strong positive correltions were shown between TE vlues nd both SF levels nd LIC (Figure 4), between TE vlues nd fibrotest (r =.935, p <.1) nd lso between SF levels nd LIC (r =.538, P <.1).

5 58 Ellfy M, et l., 213; 12 (1): Percent of cses Non complint Complint Non complint Complint Deferoxmine Deferiprone Percent of cses Non complint Complint Non complint Complint Deferoxmine Deferiprone RNA pos & LIC 14 RNA pos & LIC < 14 or RNA neg & LIC 14 RNA neg & LIC < 14 Figure 2. Risk of Liver fibrosis/cirrhosis (RNA Positivity nd LIC) in bet thlssemi mjor ptients ccording to complince with iron cheltion therpy. TE > 12.5 kp TE: kp TE < 6 kpa Figure 3. Complince with iron cheltion therpy mong bet thlssemi mjor ptients with different TE vlues. A 5, B 6 4, 5 S Ferritin 3, 2, LIC , Fibroscn Figure 4. Correltion between Fibro Scn nd both serum Ferritin (A) (r =.555**, P <.1) nd LIC (B) (r =.929, P <.1) Fibroscn DISCUSSION The present study reveled tht 82% of thlssemi ptients were HCV ntibody positive; 21(49%) of them were viremic (HCV RNA positive). Previous studies on the prevlence of heptitis C in Egyptin thlssemic children reported tht 44% 19 to 75.6% 2 hd heptitis C ntibodies. HCV-PCR ws positive in 64% of studied Egyptin ptients. 21 While in Itlin multicenter study; 22 nti-hcv ntibodies were found in 91% of thlssemic ptients nd 72% of them were viremic. A high percentge of fibrosis/cirrhosis ws encountered in the studied young bet thlssemi mjor ptients. The development nd the severity of liver fibrosis were strongly relted to the presence of chronic HCV infection nd to the extent of liver iron overlod. Ptients with liver cirrhosis (TE vlues > 12.5kP) hd multiple risk fctors; ll were HCV ntibody positive; hd high LIC ( 14 mg/gm) nd SF levels bove 2,5 ng/ml. Severl studies reported similr dt. Ptients with HCV viremi showed higher TE vlues nd incresed fibrosis. However; two non viremic ptients showed TE

6 Liver fibrosis in bet-thlssemi mjor ptients., 213; 12 (1): vlues in the cirrhotic rnge nd some non viremic ptients hd fibrosis; this might be explined by the undetectble persistent low level of HCV viremi for long durtion with high liver iron due to poor complince with cheltion therpy. This observtion is in concordnce with previous study 27 who reported fibrosis by liver biopsy in non viremic HCV ntibody-positive ptients suggesting tht HCV my persist in the liver in the mjority of HCV RNA-negtive cses. Liver iron concentrtion is relted to trnsfusionl iron intke, type nd complince with cheltion therpy. In trnsfusion-dependent thlssemi mjor, heptic iron overlod is one of the mjor problems for the progression of the liver disese nd is due to regulr trnsfusion regimen tht leds to iron overlod. 28 Previous studies suggested the role of iron loding s fctor in fibrosis progression in heptitis C. 22,29-31 The positive correltions observed between TE vlues nd both SF levels nd LIC in our study re in greement with Frquelli, et l., 1 who reported tht in thlssemi mjor ptients with higher ferritin levels, TE incresed progressively; viremic ptients with higher ferritin levels showed higher increse of TE s compred with non viremic ones suggesting possible synergistic effect of iron overlod nd ongoing HCV on heptic fibrosis. In this study; serum ferritin (SF) levels were ssessed s potentil surrogte mrker for LIC nd showed positive correltion with LIC. There re controversies on the reltion between SF nd heptic fibrosis. Dt on strong correltion between SF nd the degree of heptic fibrosis ws observed in thlssemi mjor ptients not infected with HCV; however, SF levels lone were not sufficient to ssess the degree of fibrosis in HCV positive thlssemi mjor ptients. 32 Menwhile; others found no correltion between TE vlues nd the degree of iron overlod in bet-thlssemi mjor ptients The positive correltion between Fibrotest results nd TE vlues in studied thlssemic ptients ws in concordnce with previous studies in other heptic disorders In ptients with FibroScn nd Fibrotest concordnt results liver biopsy might be voided. FibroScn nd Fibrotest pper to be vluble methods for detecting erly stges of fibrosis mong ptients with chronic HCV infection, llowing voiding the progression of liver dmge. 36 Combintions of two modlities of non-invsive methods cn relibly differentite between miniml nd significnt fibrosis, nd the- reby void liver biopsy in significnt percentge of ptients. 37 In the current study, cirrhosis ws reveled by FibroScn nd confirmed by biopsy in young thlssemics s erly s 12 yers old. The reltively long durtion of infection nd poor complince with cheltion my explin this observtion. TE vlues incresed proportionlly ccording to the Ishk stge. This goes in greement with previous reports. 1,33-34 Highest TE vlues observed in ptients with both HCV-RNA positivity nd high LIC (> 14 mg/gm dw) my confirm tht thlssemic ptients with ctive HCV repliction nd severe iron overlod develop severe fibrosis or cirrhosis more frequently. Their concomitnt presence results in striking increse in risk for liver fibrosis progression. 38 Difference in complince with cheltors in our ptient subgroups my help explin these findings. Moreover, strong correltion between TE nd fibrosis stge detected by liver biopsy my denote tht high LIC did not ffect the usefulness of TE. Liver Iron, in ssocition with HCV viremi, my led to n incresed rte of fibrosis detected by TE, but further studies re required on wider scle before this cn be determined. FibroScn should be verified on thlssemic ptients of younger ge group s we hd cirrhotic thlssemic ptients who died erly in the second decde of life with liver cell filure. In the current study, most complint ptients with deferoxmine or deferiprone hd the lowest TE vlues wheres most non complint ptients hd higher TE vlues. It is noteworthy tht most complint ptients with deferiprone showed TE vlues within norml rnge. These results cn confirm previous results which demonstrted no evidence of heptic fibrosis induced by deferiprone. Non complince with cheltion in the group with HCV viremi nd high LIC ws mrked. Adherence to dequte cheltion therpy cn prevent the development of liver fibrosis in thlssemics free of HCV-infection nd my reduce the risks of developing severe fibrosis in thlssemics with chronic heptitis C. 42 CONCLUSIONS Liver cirrhosis nd/or fibrosis were commonly encountered in young bet thlssemi ptients with chronic ctive heptitis C infection nd hevy iron overlod. Thlssemic ptients complint with dequte cheltion my hve norml liver

7 6 Ellfy M, et l., 213; 12 (1): stiffness with reduced LIC. Liver FibroScn nd FibroTest were relible methods s surrogte for liver biopsy to ssess fibrosis progression in thlssemic ptients. ABBREVIATIONS HCV: heptitis C virus. LIC: liver iron concentrtion. ALT: lnine minotrnsferse. SF: serum ferritin. RNA: ribonucleic cid. TE: trnsient elstogrphy. FT: FibroTest. GGT: γ-glutmyl trnspeptidse. kp: kilopscl. dw: dry weight. ULN: upper limit of norml. MRI: mgnetic resonnce imging. IQR: inter-qurtile rnge. BMI: body mss index. PCR: polymerse chin rection. AST: sprtte minotrnsferse. TI: trnsfused iron. GRANTS AND FINANCIAL SUPPORT None. REFERENCES 1. Cohen AR, Glnello R, Pennell DJ, Cunninghm MJ, Vichinsky E. Thlssemi. Hemtology Am Soc Hemtol Educ Progrm 24: Fernndez-Rodriguez CM, Gutierrez ML, Serrno PL, Lledó JL, Sntnder C, Fernández TP, Tomás E, et l. Fctors influencing the rte of fibrosis progression in chronic heptitis C. Dig Dis Sci 24; 49: Lin TJ, Lio LY, Lin SY, Lin CL, Chng TA. Influence of iron on the severity of heptic fibrosis in ptients with chronic heptitis C. World J Gstroenterol 26; 12: Guyder D, Thirourd AS, Erdtmnn L, Rkb N, Jcquelinet S, Dnielou H, Perrin M, et l. Liver iron is surrogte mrker of severe fibrosis in chronic heptitis C. J Heptol 27; 46: Fontine H, Petitprez K, Roudot-Thorvl F, Trinchet JC. Guidelines for the dignosis of uncomplicted cirrhosis. Gstroenterol Clin Biol 27; 31: Ziol M, Hndr-Luc A, Kettneh A, Christidis C, Ml F, Kzemi F, de Lédinghen V, et l. Noninvsive ssessment of liver, fibrosis by mesurement of stiffness in ptients with chronic heptitis C. Heptology 25; 41: Spore I, Sirli R, Delenu A, Tudor A, Curescu M, Corninu M, Lzr D. Comprison of the liver stiffness mesurement by trnsient elstogrphy with the liver biopsy. World J Gstroenterol 28; 14: Lupsor M, Bde R, Stefãnescu H, Grigorescu M, Sprchez Z, Serbn A, Brnd H, et l. Anlysis of histopthologicl chnges tht influence liver stiffness in chronic heptitis C. Results from cohort of 324 ptients. J Gstrointestin Liver Dis 28; 17: Blnc PL, Gbbuti A, Mrino N, Mecocci L, Mzzott F. Liver stiffness in chronic heptitis C: will it modify the ssessment of ptients? J Heptol 27; 46(Suppl. 1): S21-S Frquelli M, Cssinerio E, Roghi A, Rigmonti C, Cszz G, Colombo M, Mssironi S, et l. Trnsient elstogrphy in the ssessment of liver fibrosis in dult thlssemi ptients. Am J Hemtol 21; 85: Cohen AR, Glimm E, Porter JB. Effect of trnsfusionl iron intke on response to cheltion therpy in bet-thlssemi mjor. Blood 28; 111: Poynrd T, Imbert-Bismut F, Muntenu M, Messous D, Myers RP, Thbut D, Rtziu V, et l. Overview of the dignostic vlue of biochemicl mrkers of liver fibrosis (FibroTest, HCV FibroSure) nd necrosis (ActiTest) in ptients with chronic heptitis C. Comp Heptol 24; 23: Shheen AA, Wn AF, Myers RP. FibroTest nd FibroScn for the Prediction of Heptitis C-Relted Fibrosis: A Systemtic Review of Dignostic Test Accurcy. Am J Gstroenterol 27; 12: St. Pierre TG, Clrk PR, Chu-nusorn W, Fleming AJ, Jeffrey GP, Olynyk JK, Pootrkul P, et l. Noninvsive mesurement nd imging of liver iron concentrtions using proton mgnetic resonnce. Blood 25; 15: Ishk K, Bptist A, Binchi L, Clle F, De Groote J, Gudt F, Denk H, et l Histologicl grding nd stging of chronic heptitis. J Heptol 1995; 22: Sndrin L, Fourquet B, Hsquenoph JM, Yon S, Fournier C, Ml F, Christidis C, et l. Trnsient elstogrphy: new noninvsive method for ssessment of heptic fibrosis. Ultrsound Med Biol 23; 29: Cster L, Vergniol J, Foucher J, Le Bil B, Chnteloup E, Hser M, Drriet M, et l. Prospective comprison of trnsient elstogrphy, Fibrotest, APRI, nd liver biopsy for the ssessment of fibrosis in chronic heptitis C. Gstroenterology 25; 128: Wng JH, Chngchien CS, Hung CH, Eng HL, Tung WC, Kee KM, Chen CH, et l. FibroScn nd ultrsonogrphy in the prediction of heptic fibrosis in ptients with chronic virl heptitis. J Gstroenterol 29; 44: el-gohry A, Hssn A, Noomn Z, Lvnchy D, Myert C, el-ayt A, Fwz N, et l. High prevlence of heptitis C virus mong urbn nd rurl popultion groups in Egypt. Act Trop 1995; 59: el-nnwy AA, el-azzouni OF, Solimn AT, Amer AE, Demin RS, el-syed HM. Prevlence of heptitis-c ntibody seropositivity in helthy Egyptin children nd four high risk groups. J Trop Peditr 1995; 41: Rgb L, Hell S, Zghloul N, El-Rziky M, Afifi R, Musllm KM, Ther A. Clinic-virologic nlysis of heptitis C infection in trnsfusion-dependent bet-thlssemi mjor children. Int J Lb Hemtol 21; 32: Prti D, Mggioni M, Milni S, Cerino M, Cinciulli P, Coggi G, Forni GL, et l.; Cooley cre Coopertive Group. Clinicl nd histologicl chrcteriztion of liver disese in ptients with trnsfusion-dependent bet-thlssemi. A multicenter study of 117 cses. Hemtologic 24; 89: Li CK, Chik KW, Lm CW, To KF, Yu SC, Lee V, Shing MM, et l. Liver disese in trnsfusion dependent thlssemi mjor. Arch Dis Child 22; 86: Cunninghm MJ, Mcklin EA, Neufeld EJ, Cohen AR. Thlssemi Clinicl Reserch Network. Complictions of β-

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