Background Systemic sclerosis is an autoimmune disease characterized by multisystem affection that could involve the gastrointestinal tract in the form of gastric antral vascular ectasia (GAVE) that might cause iron-deficiency anemia. Objective Evaluation of the outcome and the experience of management of iron deficiency anemia resulting from GAVE in patients with scleroderma using cyclophosphamide therapy compared with argon plasma coagulation (APC). Patients and methods This study was conducted over a 2-year period from February 2015 to February 2017. Scleroderma patients with GAVE and iron deficiency anemia were treated with cyclophosphamide (group I) others with APC application to areas with mucosal vascular lesions (group II). Results In total, 14 scleroderma patients with iron deficiency anemia resulting from associated GAVE were enrolled into two groups: group I included seven patients who were treated with cyclophosphamide infusion and group II were exposed to APC in sessions. Patients were followed up at 3 and 6 months; the endpoint was a complete response with improved anemia [hemoglobin (HB) and blood indices], and it was achieved in both groups as we found in group I patients there was a highly significant improvement (P<0.001) in HB, 3 and 6 months after therapy and in group II patients there was a highly significant improvement (P<0.001) in iron level 3 and 6 months, HB 6 months after. On comparing both groups it was clear that there was a significant improvement in group I as regards HB and ferritin levels 3 and 6 months after treatment when compared with group II, and highly significant increase in serum iron level 6 months after treatment in group I when compared with group II. Conclusion We found that cyclophosphamide and APC are highly efficacious and safe in controlling anemia resulting from scleroderma-associated GAVE. Also, cyclophosphamide is more efficient than APC in improving in those patients.

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Background Genetic-based studies are being carried out worldwide to identify the susceptibility genes for diabetic nephropathy (DN), which represents a major health problem in all diabetics. Aim To study the association between genotypes of insulin-like growth factor-1 (IGF-1) and DN among Egyptian patients with type 2 diabetes and if there is any possible relation between these polymorphisms and different variables. Patients and methods A total of 26 diabetics without nephropathy (group 1) and 26 with nephropathy (group 2), with an average age of 52.7±6.1 years, and 25 age-matched and sex-matched healthy participants (control group) were included. Two tagging single nucleotide polymorphisms were assessed in IGF-1 gene: rs6214 and rs10860860. Genotypic distribution was tested for Hardy–Weinberg equilibrium. The genotype was evaluated using the χ² tests. Fasting blood glucose, glycated hemoglobin, uric acid, lipid profile, serum creatinine, and urine albumin–creatinine ratio were assessed. Results The distribution of IGF-1 gene polymorphisms reflects a significant association with DN, where the frequency of variant genotype GG in polymorphism rs6214 was found to be significantly higher in diabetics with nephropathy than other groups [odds ratio (OR)=20.57; 95% confidence interval, 2.25–74; P=0.001). Moreover, the frequency of variant AA in polymorphism rs10860860 was also found to be significantly higher in diabetics with nephropathy (OR=7.37; 95% confidence interval, 1.87–30.07; P=0.001). However, GA and AT alleles were found to be associated with ORs less than 1 in diabetics with nephropathy when compared with other groups (P=0.002 and 0.007, respectively), which means that it could be significantly protective against DN. where they found to be significantly higher in diabetics with genotype GG than those with genotype GA (P=0.13, 0.11 respectively). Conclusion The variants of IGF-1 rs6214 and rs10860860 could entail a risk of DN in Egyptians with type 2 diabetes mellitus. It means that the type of IGF-1 gene polymorphism is responsible for the susceptibility of DN more than its serum level.

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Background Diabetic nephropathy (DN) is the most common cause of end-stage renal disease. Microalbuminuria is the most popular method for detecting the early signs of DN. However, pathological changes occur before the onset of microalbuminuria. So, there is a need for another biomarkers that might provide a sensitive and fast means for identification of the progression of DN. Pentraxin 3 (PTX3) is an acute-phase glycoprotein and a soluble receptor acting as an opsonin. PTX3 protein is expressed in vascular endothelial cells and macrophages. Thereby, its levels may reflect more directly the inflammatory status of the vasculature. Aim Evaluation of the levels of serum and urinary PTX3 in type 2 diabetes mellitus (T2DM) patients and its relation to DN. Patients and methods Group A: 20 healthy volunteers (control group). Group B: 20 patients with normoalbuminuric T2DM. Group C: 20 patients with microalbuminuric T2DM. Group D: 20 patients with macroalbuminuric T2DM. Also all the participants divided into two subgroups: Group 1: 40 participants with no nephropathy (controls and normoalbuminuric patients). Group 2: 40 patients with nephropathy (microalbuminuric and macroalbuminuric patients). Results There was no significant difference among all studied groups with respect to age, sex, lipid profile, urinary PTX3, C-reactive protein, and liver function test. Whereas BMI, hemoglobin level, HBA1C, fasting blood sugar, postprandial blood sugar, serum creatinine, estimated glomerular filtration rate, and 24 h urinary albumin excretion; showed high significant difference among all studied groups. Serum albumin and total protein levels were highly significantly decreased in macroalbumiuric group as a result of proteinuria compared to the other three groups Serum PTX3 showed high significant difference between nephropathic (micro and macroalbuminuric) group and non nephropathic group (control and normoalbuminuric). There were highly significant positive correlations between serum PTX3 and (fasting blood sugar, postprandial blood sugar, HBA1C, and 24 h urinary albumin) significant positive correlation with serum creatinine, whereas there were highly significant negative correlations between serum PTX3 and serum total protein and serum albumin. Conclusion Serum PTX3 increased progressively with DN and may be a serum biomarker for early diagnosis of DN. Whereas urinary PTX3 has no relation to DN.

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Background Spontaneous bacterial peritonitis (SBP) is a serious infection of ascitic fluid in cirrhotic patients. High mortality associated with the delay in diagnosis and treatment. There is a need for an accurate and a rapid method for SBP diagnosis. Objectives We aimed to evaluate ascitic fluid calprotectin as a diagnostic marker for SBP. Patients and methods Forty four cirrhotic patients were divided into two groups, non-SBP group: 22 patients with cirrhotic ascites without evidence of SBP and SBP group: 22 patients with cirrhotic ascites and SBP diagnosed by positive ascitic fluid bacterial culture and an increase in polymorphonuclear leukocytes (PMNLs) count in ascites (≥250 cells/mm³). Ascitic fluid calprotectin levels were measured using enzyme-linked immunosorbent assay. Results There was a significant increase of ascitic fluid calprotectin, total leukocytic count, PMNLs, lactate dehydrogenase, and total protein in SBP group when compared to non-SBP group. There were significant positive correlations between white blood cell, ascitic fluid total leukocytic count, PMNLs, total protein, and model for end-stage liver disease score values and ascitic fluid calprotectin among SBP group. Ascitic fluid calprotectin with cutoff value 620 ng/ml, showed a sensitivity of 90.91% and a specificity of 95.45%, in diagnosis of SBP with positive predictive value 95.2% and negative predictive value 91.3%. Conclusion Ascitic fluid calprotectin may be valuable in rapid diagnosis of SBP.

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Background Irisin is a newly discovered myokin secreted by myocytes responsible for transmission of signals from muscles to other body tissues. Irisin improves systemic metabolism by increasing the energy expenditure. Owing to numerous similarities in action between irisin and thyroid hormones it seems imperative to explore these substances’ potential mutual influence on the body. Objective To estimate serum irisin concentration in patients with hypothyroid and hyperthyroid diseases, and to detect the relation of serum irisin in patients with thyroid disorders with creatine kinase (CK), a serum marker of muscle damage. Patients and methods The study comprised 30 hyperthyroid patients (group 1), 30 hypothyroid patients (group 2), and 30 normal persons (group 3). Irisin was measured using enzyme-linked immunosorbent assay. Thyroid-stimulating hormone, triiodothyronine, and free thyroxine levels were measured using chemiluminescent microparticle immunoassay technology. Results Irisin hormone level significantly decreased in hypothyroid patients in comparison with hyperthyroid patients. Irisin hormone level increased in hyperthyroid patients in comparison with normal persons, whereas it decreased in hypothyroid patients in comparison with normal persons. CK level significantly decreased in hyperthyroid patients in comparison with hypothyroid patients. CK level significantly increased in hypothyroid patients in comparison with normal persons, whereas it significantly decreased in hyperthyroid patients in comparison with normal persons. Conclusion Obtained results suggest the influence of thermometabolic state on irisin level.

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The liver distortion that occurs in cirrhosis results in increased resistance to portal blood flow and hence in portal hypertension which is one of the most common and serious complications of liver cirrhosis.Red cell distribution width (RDW) is routinely performed as part of a complete blood cell counts. Elevated RDW values were also shown to be associated with increased risk of mortality in the general population. However, to our knowledge, the role of RDW values predicting LCF and portal hypertension in LC has not been well-defined. The present study was designed to investigate the role of RDW as anon invasive predicting index for LCF and portal hypertension in cirrhotic patient which will improve the diagnostic efficiency and provide useful information with other serum markers for the detection of LCF in LC. We found significantly good correlation between Child–Pugh and RDW values which can ultimately be used to predict the survival of patients with LC. There was also good correlation between RDW and those receiving ?-blockers, so it may be used as an indicator for patient compliance, but there was no significant correlation with the grade of encephalopathy and portal hypertension.

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Background Hepatocellular carcinoma (HCC) is the commonest primary liver neoplasm that usually develop in the background of cirrhosis. Hepatitis C virus is endemic in Egypt and is the major cause of cirrhosis. Studying the characteristics of patients with HCC may help in clarifying the schedule for screening of high-risk patients for an early detection of HCC. Patients and methods The 492 patients attending the hepatology and HCC clinics in Specialized Medical Hospital, Mansoura University for follow up of liver cirrhois and HCC were subjected to full history, physical examination, laboratory profile, and imaging studies needed for the diagnosis. Data were collected and analyzed. According to the radiological results, patients were divided into three groups (fibrosis, cirrhosis, and HCC) and compared. Results The study included 336 males and 156 females. Patients with HCC were mainly males with a mean age of 58 years. A statistically significant difference between HCC group and the other groups with respect to hemoglobin level, white blood cells count, platelet count, aspartate aminotransferase, alanine aminotransferase, albumen level, serum bilirubin, international normalized ratio, and α-fetoprotein (AFP) was found. The sensitivity and specificity of AFP in differentiating HCC cases are 81.1 and 71.9%, respectively. Logistic regression for prediction of HCC showed that males with age greater than 58 years, hypoalbuminaemia, and AFP greater than 11.2 ng/dl have a 76.3% positive predicted value. Conclusion Cirrhotic patients with age greater than 58 years, males, hypoalbuminaemia, and AFP greater than 11.2 ng/dl are at a higher risk to develop HCC more than other patients and should be monitored at close quarters with better contrast-enhanced technique either contrast-enhanced ultrasound or computed tomography scan.

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Introduction Lead is a toxic heavy metal with hematotoxic, neurotoxic, and nephrotoxic effects even at low concentration. Presence of heavy metals like lead in the blood and blood products while donating blood can cause adverse effects to the recipients. Methodology In this study, we have selected 130 volunteers from the donors list obtained from Yenepoya hospital and also from in and around Mangalore. Questionnaires was given to the volunteers to get information on smoking, passive smoking at home or at the work place, duration of smoking, occupation and health status. Whole blood samples were subjected to Atomic Absorption Spectrometer (AAS) and results were obtained. Results Lead content in smokers were found to be 2–3 times higher compared to non-smokers but were in below toxic range (~5 ppm). Conclusion There are no present protocol to screen for heavy metals like lead in the blood banks. Our findings implicate the need to screen for heavy metals while transfusing blood to elderly people, neonates and infants and avoid transfusion of blood and blood products if the lead levels are in toxic range.

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Background Plasma glucose variability may confer a risk for development of chronic diabetic complications. Glycosylated hemoglobin (HbA1c) reflects average glucose level but not glucose variability, which is measured by mean amplitude of glycemic excursions (MAGEs) and continuous glucose monitoring (CGM). Aim To study glucose variability using CGM/MAGE compared with sugar profiles and to assess their value as a therapy guide in patients with diabetic nephropathy on hemodialysis. Patients and methods Group 1 included 50 patients with type 2 diabetes mellitus (T2DM) without diabetic nephropathy. Group 2 included 50 patients with T2DM with diabetic nephropathy. Group 3 included 50 patients with T2DM with diabetic nephropathy on hemodialysis. Measurements of fasting blood glucose, postprandial blood glucose, HbA1c, and glucose variability by MAGE and CGM were done. Results CGM showed significant blood glucose variability (amplitude>130 mg/dl in 40 patients=80% using CGM and in 45 patients=90% using MAGE) in dialysis group (group 3) in comparison with glucose variability in nondialysis groups (group 1+group 2) (amplitude>130 mg/dl in 20 patients=20% using either CGM or MAGE). Group 1 showed significant correlations between either CGM or MAGE and all sugar profiles. Group 2 showed significant correlations between CGM and MAGE with either fasting or postprandial blood glucose but not with HbA1c, whereas group 3 showed nonsignificant correlations between either CGM or MAGE and any of sugar profiles. Conclusion CGM/MAGE have high specificity and sensitivity to measure variability of sugar levels, especially in patients with diabetic nephropathy on hemodialysis or not, in which HbA1c may not be a reliable tool.

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Background and aims Minimal hepatic encephalopathy (MHE) may impair driving performance and adversely disturbs quality of life. Most drivers with chronic liver disease are not routinely screened for MHE and stay untreated due to the deficiency of standardization of normal values, simple tools, and skills to carry out tests. This study evaluated the usefulness of psychometric tests and critical flicker frequency (CFF) to diagnose MHE among screened drivers with chronic liver disease in Assiut, a city in Upper Egypt. Patients and methods A total of 100 drivers with chronic liver disease were screened for MHE. Routine investigations were carried out for all. Psychometric tests including number connection tests A, symbol digits test and CFF testing were applied for them. mini mental state examination questionnaires and Beck’s inventory were carried out for those diagnosed as having MHE. Results MHE was found among 40%, with 20 (50%) in Child’s A, 11 (27.5%) in Child’s B, and nine (22.5%) in Child’s C cirrhosis (P=0.027), and 45% of those with MHE had bad driving history. Twelve (12%) patients had abnormal psychometric tests. The sensitivity and specificity of receiver operating characteristic curves for CFF in the diagnosis of MHE was 100%, with a cutoff of less than or equal to 38.5 Hz, and the area under the curve was 1.00 (95% confidence interval, 0.964–1.00) (P<0.0001). There was significant reverse correlation between CFF and Child–Pugh score (r=−0.271, P=0.030). Conclusion Our data revealed a high prevalence of MHE (40%) among drivers with liver cirrhosis. The CFF test is a simple, accurate, and reliable test for diagnosis of MHE, with no age or literacy requirement. Therefore, we suggest to include the CFF test in screening of drivers with chronic liver disease for early discovery and proper management.

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Background Ischemia-modified albumin (IMA) is a novel marker of tissue ischemia and oxidative stress. Aim We assessed the level of IMA concentration in type 2 diabetes mellitus (T2DM) patients with diabetic nephropathy and its correlation with glycemia level, duration of diabetes, dyslipidemia, serum creatinine, and urinary albumin/creatinine ratio. Patients and methods This study included 91 patients who were divided into three groups: group A (33) included T2DM patients without nephropathy; group B (29) included T2DM patients with nephropathy; and group C (29) included healthy as control. Blood samples were analyzed manually for plasma IMA by spectrophotometric cobalt (II)-albumin-binding assay. Results Serum levels of IMA were significantly higher in group B in comparison to group A with a P value less than 0.001 and group C with a P value less than 0.0001. IMA positively correlated with blood pressure, duration of diabetes, fasting blood glucose, postprandial blood glucose, glycated hemoglobin, cholesterol, low-density lipoprotein, triglycerides, serum creatinine, and albumin/creatinine ratio, all with a P value less than 0.0001 and also with BMI (P<0.003). IMA was a significant discriminator for diabetic nephropathy (P<0.001) with 100% specificity and 100% sensitivity. Conclusion IMA could serve as an indicator of glycemic control and a sensitive marker of diabetic nephropathy.

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Background and Aim One of the most common complications of spontaneous bacterial peritonitis (SBP) is renal injury. The aim of the study was to detect the frequency of AKI as a problem in end stage liver disease patients with SBP, evaluate the role of acute kidney injury network criteria (AKIN) as a prognostic factor for kidney insult in cirrhotic patients complicated by SBP and lastly. Settings and Design A single center, observational, prospective study. Patients and methods The study was conducted on 150 cirrhotic patients complicated by SBP who were admitted in hepatology unit, Mansoura Specialized Medical Hospital, Mansoura University. After that, all patients were followed up for three months duration. Statistical analysis used Data analysis was performed using SPSS version 16.0 (SPSS, Inc, USA). Chi-square test (crosstabs) was used to compare the distribution of different clinical finding according to AKI stage. Results The obtained results were showed a significant change in the number of patients among the three groups at the end of the study versus at admission indicating progressive deterioration of kidney functions. Moreover, the mortality was high (70.42%), most of them were AKIN stage 2 and 3. There was a significant increase of hospital acquired complication especially (hepatic encephalopathy, ICU admission) more commonly in advanced AKIN stages (stage 3). Conclusion AKI, as defined by AKIN diagnostic criteria, is associated with a high mortality rate in cirrhotic patients presented with SBP, especially patients with advanced liver disease (Child B and C, high MELD score) in a stage-dependent pattern.

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Background Hepatitis C virus (HCV) infection is a major health problem in Egypt. It is often complicated by liver cirrhosis and portal hypertension, resulting in gastroesophageal varices, gastropathy, and colopathy. However, there is still lack of data with respect to the prevalence and clinical relevance of colopathy in this kind of liver disease. The aim of this study was to determine the prevalence of colopathic lesions in HCV-related cirrhotic patients, and to study their associations with the severity of liver disease and manifestations of portal hypertension Patients and methods This cross-sectional study included 60 patients with liver cirrhosis who were submitted to thorough clinical, laboratory, and ultrasonographic examinations. In addition, both upper and lower gastrointestinal endoscopy were performed to detect portal hypertensive complications including colopathic lesions. According to their severity, colopathic lesions were graded into three grades. Patients with higher colopathic grading (grade 2 and 3) were compared with the remaining participants with respect to the severity of the liver disease and other manifestations of portal hypertension. Results The prevalence of colopathy in cirrhotic patients with underlying HCV etiology was 91%. Patients with higher grades of colopathy were characterized by more severe liver disease. Moreover, they had increased frequency of both esophageal and gastric varices, and prior sclerotherapy or band ligation, as well as more collaterals and gastropathy, and higher grades of esophageal varices. Conclusion Colopathic lesions are frequent in patients with HCV-induced cirrhosis. Getting endoscopic treatment for varices is a risk factor for developing higher grades of colopathy. The latter could be considered as a marker of a worse prognosis in patients with HCV cirrhosis.

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Background Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) as autoimmune diseases arise owing to failure of immunological self-tolerance. One of the mechanisms employed to control these potentially damaging cells are regulatory T cells (Tregs). The importance of Tregs is underscored by the overwhelming inflammation and autoimmunity that result from their absence. Forkhead box p3 (FoxP3) is an important regulator of Treg function, and the expression of FoxP3 correlates with the expression of other Treg-associated markers such as CD25 and CTLA-4. Aim To investigate the frequency of FoxP3⁺ CD4⁺ CD25^+high cells (Tregs) in peripheral blood from patients with SLE and those with RA. Patients and methods A total of 25 patients with SLE (15 patients with active SLE and 10 patients with inactive SLE), 25 patients with RA (15 patients with active RA and 10 patients with inactive RA), and 10 age-matched and sex-matched healthy controls were enrolled in the study. Patients underwent clinical and laboratory assessment. The frequency of Tregs was determined by flow cytometry. Results The distribution of FoxP3⁺ CD4⁺ CD25^+high cells (Tregs) revealed a highly significant decrease in the frequency of Treg in patients with SLE compared with healthy controls. Moreover, patients with active SLE showed significantly lower Tregs percent when compared with inactive group. Moreover, the distribution of FoxP3⁺ CD4⁺ CD25^+high cells (Tregs) revealed a high significantly decrease in the frequency of Treg in patients with RA compared with healthy controls. Conclusion CD4⁺ CD25⁺ FoxP3 Tregs (as a percent of total CD4 cells) were significantly lower in patients with SLE and those with RA when compared with healthy controls.

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Context Chronic kidney disease (CKD) including hemodialysis (HD) is considered an inflammatory state leading to hepcidin upregulation, which affects iron homeostasis. Aims The aim was to assess the serum level of hepcidin in CKD including HD patients and its correlation with markers of iron status. Settings and design The study was conducted in Zagazig University hospital. Participants and methods A prospective, case–control, comparative study was conducted on 66 participants, who were divided into control group, comprising 22 healthy participants; HD group, comprising 22 patients; and CKD group, comprising 22 patients from stages 2 to 4. All participants were evaluated for serum creatinine, complete blood count, estimated glomerular filtration rate by MDRD4 equation, serum iron, total iron-binding capacity, serum ferritin, transferrin saturation, C-reactive protein, and serum hepcidin level. Statistical analysis The study was analyzed using SPSS version 20. Description of the qualitative variables was done by frequency and percentage. Description of the quantitative variables was in the form of mean and SD. χ²-Test, Student’s t-test, analysis of variance (F-test), and correlation analysis were used for analyzing the data. Results Serum level of hepcidin was increase by increase stages of CKD, and more increase in regular HD patients. There was high statistically significant positive correlation of hepcidin level with serum ferritin (P<0.001), serum iron (P<0.05) in CKD and negative correlation with Hb, eGFR (P<0.001), and it was not correlated with total iron binding capacity (TIBC) (P<0.48). Conclusion Serum hepcidin levels are a good biomarker for iron status in patients with HD and CKD. In addition, determination of hepcidin together with markers associated with iron metabolism improves the identification of patients with iron deficiency.

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Introduction and aim Neuropsychiatric complications that develop after living donor liver transplantation (LT) are frequently encountered, though not adequately estimated among Egyptian recipients. We aimed to estimate the frequency of neuropsychiatric manifestations and neurocognitive functional changes after living donor LT. Patients and methods A prospective observational cohort study was conducted to evaluate 30 adult patients with end-stage liver disease preoperatively in a single Egyptian Transplant Center from November 2012 till January 2014. Relevant preoperative, intraoperative, and postoperative data were recorded and recollected and at 3 and 6 months of follow-up. The assessment included neurologic evaluation, Child–Turcotte–Pugh score, model of end-stage liver disease score, clinical hepatic encephalopathy staging scale, West Haven criteria, and International Society for Hepatic Encephalopathy and Nitrogen Metabolism score for semiquantitative assessment of encephalopathy. Results Hepatitis C virus was the main etiology for liver disease in 27 (90%) patients. Overt hepatic encephalopathy was seen in 26.6%, whereas covert hepatic encephalopathy occurred in 43.3%. Postoperatively, 76.7% of the patients demonstrated neuropsychiatric manifestations, with 50% of them showing mainly early major events, namely, encephalopathy. Late minor manifestation rates were 50%. Early cyclosporine administration and cold ischemia time longer than 40 min were significant predictors of occurrence of early neurologic events postoperatively (P=0.031 and 0.025, respectively). Both risk factors were associated with earlier and higher rates of neurologic complications. Conclusion Patients of living donor LT are at increased risk of developing early postoperative major neurologic sequelae, which become of less clinical significance later on. The patients’ cognitive functions improve with time after transplant.

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Introduction and aim of the work Patients infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) are at increased risk of renal disease. This study compares factors associated with proteinuria and doubling of serum creatinine level in patients who were infected with HCV or HBV alone with those who were coinfected with HCV and HBV. Materials and methods The study was performed on 1243 patients who were diagnosed with HBV and/or HCV at the Cairo University Hospitals. All the included subjects underwent urine analysis for proteinuria and serum creatinine level. Clinical characteristics were recorded at baseline and at last follow-up. Results Of 1243 patients, 293 (23.6%) patients had proteinuria. Subset analysis of the patients with proteinuria showed that 10.6% were HBV infected, 63.8% were HCV infected, and the remaining 25.6% were coinfected with both HBV and HCV. Overall, coinfection with both viruses (P=0.01), lower serum albumin (P=0.001), hypertension (P=0.01), and diabetes (P=0.001) were associated with an increase in risk of proteinuria. Coinfection (P=0.001), presence of HBV (P=0.001), and increasing HCV RNA level in patients with HCV and in coinfected patients (P=0.05) was associated with doubling of serum creatinine level. Conclusion The patients coinfected with HBV and HCV are at greater risk of clinically significant proteinuria and loss of renal function owing to complex virological profile. Progressive loss of renal function in that population is associated with markers of viral activity such as proteinuria and increasing HCV RNA levels among HCV-infected patients.

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