Deciphering the Mechanisms Involved in Microbial Translocation Across the Spectrum of HCV Associated Liver Fibrosis

Hepatitis C (HCV) is a leading cause of cirrhosis worldwide. Most complications associated
with cirrhosis are driven by an altered portal circulation and the development of portal
hypertension. Bacterial translocation (BT) from the gut to the systemic circulation is
considered a pivotal mechanism contributing to the development of life-threatening
complications in end stage cirrhosis. Recent evidence suggests that the liver and systemic
circulation may be exposed to gut derived microbial products at earlier stages of liver
disease. This early exposure may trigger hepatic inflammation, modify immune host response
and accelerate hepatic fibrogenesis; which, in turn, impairs portal inflow, alters the portal
circulation, and leads to development of portal hypertension. The mechanisms resulting in
systemic exposure to gut derived microbial products, and the subsequent host response to BT
has not been studied in patients with early liver disease nor fully compensated cirrhosis.

We therefore intend to enroll 30 chronic HCV patients with either cirrhosis (20) or minimal
liver fibrosis (10). Study participants will undergo extensive evaluation with portal vein
sampling and pressure measurements, dual cholate clearances, liver biopsy, serologic,
immunologic, fecal microbiome and imaging studies. This will be followed by an optional
second percutaneous liver biopsy and portal vein sampling 9-15 months after HCV treatment.
The treatment protocol is a separate independent protocol, 15-DK- 0143 utilizing Sofosbuvir
and GS-5816. The goals of our study are to characterize the extent of BT in early stages of
cirrhotic and non-cirrhotic liver disease, explore the mechanisms contributing to its
occurrence and identify potential serological, immunological and hemodynamic biomarkers
associated with chronic infection. This, in turn, can aid in establishing a possible link
between BT, subsequent host responses and severity of liver disease.

- INCLUSION CRITERIA:

1. All age greater than 18 male or female

2. Capacity to provide written informed consent

3. Evidence of HCV RNA in 2 serum samples at least 6 months apart.

4. All HCV genotypes

5. Liver biopsy in the last 2 years prior to enrollment showing Ishak fibrosis score
of either 0-1 or 5-6. An alternative to liver biopsy will be a Fibroscan study
performed in the 6 months prior to study enrollment showing a score of either kPa
<7 or above 13.

6. Child-Pugh score less than or equal to 6

7. Prior to each liver biopsy and portal vein cannulation procedure, blood will be
drawn for CBC, PT/INR & acute care panel.

EXCLUSION CRITERIA:

1. Pregnant women or females at child bearing age not taking measures to prevent
pregnancy during the period of study

2. Patients currently on treatment for hepatitis C

3. Clinical, serologic or histopathologic evidence supporting other etiologies of chronic
liver disease besides HCV

4. Current or past clinical evidence of decompensated liver disease (e.g. ascites,
bleeding esophageal varices, spontaneous bacterial peritonitis, encephalopathy etc.)

5. Cross sectional liver imaging study from the past 6 months showing a focal lesion
suspicious of hepatocellular carcinoma and/or alpha-fetoprotein level greater than 200
ng/mL.

6. Patients with active bacterial, viral or fungal, systemic or localized infection.

7. Antibiotic treatment 30 days prior to study enrollment

8. History of chronic inflammatory diseases of the bowel (Crohn s disease, Ulcerative
colitis and celiac disease)

9. History of congestive heart failure of moderate to severe degree.

10. History of non-cirrhotic portal hypertension or portal vein thrombosis

11. Patients with severe allergic reactions to iodine contrast, which cannot be controlled
by premedication with antihistamines and steroids.

12. EXCLUSION CRITERIA FOR MRI:

12.1 Subjects with contraindication to MRI scanning. These contraindications include
but are not limited to the following devices or conditions:

a. Implanted cardiac pacemaker or defibrillator

b. Cochlear Implants

c. Ocular foreign body (e.g. metal shavings)

d. Embedded shrapnel fragments

e. Central nervous system aneurysm clips

f. Implanted neural stimulator

g. Medical infusion pumps

h. Any implanted device that is incompatible with MRI.

12.2 Unsatisfactory performance status as judged by the referring physician such that
the subject could not tolerate an MRI scan. Examples of medical conditions that would
not be accepted would include unstable angina and dyspnea at rest.

12.3 Subjects requiring sedation for MRI studies.

12.4 Subjects with a condition precluding entry into the scanner (e.g. morbid obesity,
claustrophobia, etc.).

12.5 Pregnant or lactating women.

12.6 Subjects with severe back-pain or motion disorders who will be unable to tolerate
supine positioning within the MRI scanner and hold still for the duration of the
examination.

12.7 For Gadolinium based and SPIO MRI Use:

a. History of severe allergic reaction to these contrast agents despite the use
of premeditation with an anti-histaminic and cortisone.

b. eGFR < 60 ml/min/1.73m^2

13. Absolute neutrophil count below 1000/mm^3, Hemoglobin level below 10.0 g/dl or
platelet count lower than 70,000/mm^3.

14. INR greater than or equal to 1.5, PTT greater than or equal to 1.3 times control
and/or any known history of disease associated with increased bleeding diathesis.

15. Serum creatinine greater than or equal to 2.0 mg/dl unless the measured creatinine
clearance is greater than 60 mL/min