Influence of HCV and HIV on Development of Cryoglobulinemia

Abstract

Cryoglobulinemic syndrome refers to a systemic inflammatory process that involves small and medium-sized vessels accompanied by multi-organ damage. The aim of the present study was to determine the incidence of cryoglobulinemia among patients infected with human immunodeficiency virus (HIV), hepatitis C virus (HCV) and HCV/HIV co-infection, as well as evaluation of cryoglobulinemia type. The association was evaluated between cryoglobulinemia and clinical symptoms, selected biochemical measures of liver and kidney function, virologic measures, as well as histopathological changes in the liver. One hundred and forty-one patients were enrolled (59 HCV mono-infected, 48 HIV mono-infected, and 34 HCV/HIV co-infected). Cryoglobulinemia was nearly five times less frequent among HIV mono-infected patients (10%) than HCV mono-infected (53%) and HCV/HIV co-infected patients (59%). Cryoglobulinemia was more frequent in patients infected with genotype 1 HCV than genotype 3 (63% vs. 46%, p=0.12). There was a lower incidence of cryoglobulinemia in HIV mono-infected patients treated with antiretroviral drugs (p=0.04). Cryoglobulinemia correlated with ALT activity (p=0.01) and HIV viral load (p<0.001). Symptoms were significantly more frequent among cryoglobulinemic patients than those without cryoglobulinemia (38% vs. 9%, p<0.001). The most common symptoms related to cryoglobulinemia, regardless of cryoglobulinemia type, were fatigue (38%), arthralgia (20%), polineuropathy (18%), and skin lesions (14%). In conclusion, HCV mono-infection and HCV/HIV co-infection, regardless of HCV genotype, are potent stimulators of cryoglobulinemia, with its symptomatic form occurring in about 40% of cases. Effective antiretroviral therapy seems to be protective against cryoglobulinemia development in HIV mono-infected patients.

Introduction

Both hepatitis C virus (HCV) and human immunodeficiency virus (HIV) demonstrate lymphotropism to B-cells. Infection with these viruses can lead to B-cell metabolic activation and production of abnormal immunoglobulines. Anti-apoptotic activity may result in oncogenic effects such as development of lymphomas and chronic lymphocytic leukemia. Cryoglobulines are composed of light and heavy chains. Their solubility is dependent on the concentration as well as the chemical structure and steric conformation, which is conditioned by the temperature, pH, ion balance, and the surface charge. A decrease in temperature leads to steric conformation change, nonpolar surface exposure, worsening solubility, and, ultimately, cryoprecipitation (13). Mixed cryoglobulinemia (MC) include type 2 (a and b) and 3 cryoglobulinemia, and generally result from chronic viral infections.

Cryoglobulines are a part of immune complexes, which may be deposited in the small and medium-sized vessels resulting in inflammation. Thrombosis of the skin arterioles and capillaries leads to focal ischemia and necrosis. Other signs of MC are fatigue, polineuropathy, arthralgia, and sicca syndrome. The consequence of the accumulation of cryoglobulinemic complexes in renal glomerules may be membranoproliferative or less commonly mezangial glomerulonephritis (28).

The aim of the present study was to determine the incidence of cryoglobulinemia among patients infected with HIV, HCV, and HCV/HIV co-infection in respect to the type of cryoglobulinemia. The association was evaluated between cryoglobulinemia and sex, age, HIV and HCV viral load, HCV genotype, CD4+, CD3+, and CD8+ lymphocyte count, selected biochemical measures of liver and kidney function, histopathological changes in the liver, and efficacy of antiretroviral treatment. The prevalence of cryoglobulinemia symptoms was also determined.

Patients and Methods

One hundred and forty-one patients were enrolled of whom 59 were HCV mono-infected, 48 HIV mono-infected, and 34 HCV/HIV co-infected (Table 1). Patients with HBV infection, autoimmune diseases, decompensated liver cirrhosis, or a history of alcohol or drug abuse were excluded.

Table 1.

Clinical Characteristic of Studied Patients

	HCV/HIV (n=34)	HIV (n=48)	HCV (n=59)
Clinical measures
• Gender, n/%
Males	28/82	30/62.5	41/69
Females	6/18	18/37.5	18/31
• Age, years, average (range)	34.6 (23.0–49.0)	43.4 (21.0–66.0)	39.5 (19.0–67.0)
• Weight, kg, average (range)	73.7 (46.0–100.0)	72.2 (43.0–106.0)	76.8 (49.0–119.0)
Biochemical measures, median (range)
• creatinine, mg/dL	0.7 (0.5–0.8)	0.7 (0.6–1.0)	0.8 (0.6–1.1)
• GFR, mL/min/1.73 m²	134.5 (95.0–181.0)	125.7 (76.1–166.8)	118.0 (60.0–183.0)
• MDRD, mL/min/1.73 m²	158.0 (108.0–193.0)	129.0 (86.0–156.0)	125.0 (85.0–154.0)
• ALT, IU/L	54.5 (23.0–149.0)	23.5 (13.0–50.0)	81.0 (47.0–187.0)
Lymphocytes, cells/mm,³ average (range)
• CD3	1214 (189–2,596)	1,305 (213–3,039)	nd
• CD4	392 (16–1,015)	417 (30–1,101)
• CD8	812 (143–1,865)	870 (142–2,500)
• CD4/CD8	0.5 (0.05–1.6)	0.64 (0.1–2.3)
Liver biopsy, n/%	^*		^**
Inflammatory activity
Periportal:
• 1	—		3/5
• 2	9/90		25/43
• 3	1/10		26/45
• 4	—		4/7
Intralobular:
• 1	4/40		8/14
• 2	5/50	nd	42/72
• 3	1/10		8/14
Stage of fibrosis:
• 1	9/90		41/71
• 2	1/10		13/22
• 3	—		3/5
• 4	—		1/2
Virological measures
• HCV genotype, n/%
1 (a and b)	12/35	—	36/61
3 a	13/38	—	22/37
4	9/27	—	1/2
• HIV-RNA, copies/mL, median (range)	110 (102–16,600)	102 (95–1,855)	—
• HCV-RNA, IU/mL, median (range)	592 (28–4,763,157)	—	33,421 (225–1,876,315)
Antiretroviral therapy, n/%	31/91	42/87	na

Liver biopsy was performed in 10 patients.

Liver biopsy was performed in 58 patients.

ALT, alanine transaminase; GFR, glomerular filtration rate; HCV, hepatitis C virus; HIV, human immunodeficiency virus; MDRD, modification of diet in renal disease; na, not applicable; nd, not done.

HCV infection was diagnosed based on the presence of serum anti-HCV antibodies among suspected individuals and then demonstration of HCV-RNA in the serum with determination of the viral genotype using real-time polymerase chain reaction (RT-PCR) (Syngen Biotech), with a detection limit of 12 HCV-RNA IU/mL. A liver biopsy was performed in 68 HCV-infected patients, and the results were evaluated according to the Scheuer scale. All HCV-infected patients were treatment naïve.

HIV infection was diagnosed based on double detection of anti-HIV antibodies in the serum using enzyme-linked immunosorbent assay (ELISA; Abbott) and confirmed by Western blot assay (Cambridge Biotech Corp.). HIV-RNA load was determined using RT-PCR (Cobas Amplicor HIS 1.5; Ultra Sensitive). Seventy-three HIV-infected patients were treated with antiretroviral drugs (ARV) according to current recommendations.

Flow cytometry (FACScan cytometer; Becton Dickinson) was used for specific lymphocyte subpopulation counts.

To detect cryoglobulines, the blood samples were centrifuged at 5,000 rpm at 37°C, and the obtained serum was divided into two tubes that were left for 7 days at 4°C. In the case of precipitate appearance, one of the tubes was incubated at 37°C and then cooled in order to check the reversibility of the process, which confirmed the presence of cryoglobulinemia. The type of cryoglobulinemia was determined with electrophoresis and immunofixation on cryogel (Hydragel IF K20–PN 3220 Maxi-Kit). Different types of heavy and light chains of immunoglobulines were determined using specific antisera: anti-gamma, anti-mu, anti-alpha, anti-kappa, and anti-lambda. The type of cryoglobulinemia was determined based on a modified Brouet scale, taking into account the existence of mono-, olygo-, or polyclonal antibodies. The presence of symptoms related to cryoglobulinemia was evaluated based on medical examination and review of medical history and files of particular patients.

Renal function was assessed based on serum creatinine concentration as well as glomerular filtration rate (GFR) and modification of diet in renal disease (MDRD). Urine was also tested for the presence of protein.

The control group comprised 16 healthy individuals who were age and sex matched. The study was approved by the Bioethical Committee at the the Medical University of Białystok and was in accordance with the Helsinki Declaration of 1975. All patients provided signed informed consent.

Statistical analysis was performed with Statistica v10.0 using the Mann–Whitney U-test, analysis of variance, and the chi-square test. A p-value of<0.05 was considered statistically significant.

Results

There were no cryoglobulines detected in the sera of healthy individuals. Cryoglobulines were detected in 53% of patients infected with HCV and in almost the same proportion (59%) of HCV/HIV co-infected patients (p=0.56).They were significantly less frequent in HIV mono-infected patients (10%, p<0.001; Tables 2 and 3). Across the study group, the incidence of cryoglobulinemia was similar among males (40%) and females (38%).

Table 2.

The Incidence of Cryoglobulinemia, Heavy and Light Chains, and Types of Cryoglobulinemia

	HCV (n=59)	HIV (n=48)	HCV/HIV (n=34)
Cryoglobulinemia, n/%	31/53	5/10	20/59
		^*
		^**
Heavy chains, %
• Gamma	94	100	100
• Alfa	29	20	45
• Mu	42	0	15
Light chains, %
• Kappa	100	20	100
• Lambda	61	100	55
Type of cryoglobulinemia, n/%
• 2a	18/58	1/20	11/55
• 2b	1/3	—	1/5
• 3	12/39	4/80	8/40

p<0.001 (statistical difference between the HCV mono-infected and HIV mono-infected groups).

p<0.001 (statistical difference between the HCV/HIV co-infected and HIV mono-infected groups).

Table 3.

Clinical Characteristic of Patients with Cryoglobulinemia

	HCV/HIV (n=20)	HIV (n=5)	HCV (n=31)
Clinical measures
• Gender, n/%
Males	16/80	2/40	22/71
Females	4/20	3/60	9/29
• Age, years, average (range)	34.0 (26.0–47.0)	30.8 (22.0–42.0)	41.0 (19.0–67.0)
• Weight, kg, average (range)	74.0 (46.0–100.0)	71.4 (53.0–83.0)	78.0 (51.0–119.0)
Biochemical measures, median (range)
• Creatinine, mg/dL	0.67 (0.5–1.0)	0.7 (0.5–0.9)	0.8 (0.6–1.0)
• GFR, mL/min/1.73 m²	133.5 (95.5–175.0)	112.0 (104.0–168.9)	116.0 (85.0–142.0)
• MDRD, mL/min/1.73 m²	160.5 (109.0–200.0)	128.0 (118.0–175.0)	112.0 (81.0–176.0)
• ALT, IU/L	53.5 (22.5–119.0)	19.0 (10.0–27.0)	74.0 (50.0–170.0)
Lymphocytes, cells/mm,³ average (range)
• CD3	1104 (189–2,596)	1,471 (1,061–3,039)
• CD4	331 (16–1,015)	397 (229–1,101)	nd
• CD8	714 (143–1,865)	1092 (794–1,955)
• CD4/CD8	0.4 (0.05–2.0)	0.4 (0.3–0.6)
Liver biopsy, n/%	^***		^*
Inflammatory activity
Periportal:
• 1	—		1/3
• 2	5/83		13/43
• 3	1/17		14/47
• 4	—		2/7
Intralobular:
• 1	2/33		2/7
• 2	3/50	nd	25/83
• 3	1/17		3/10
Stage of fibrosis:
• 1	5/83		21/70
• 2	1/17		7/23
• 3	—		2/7
• 4	—		—
Virological measures
• HCV genotype, n/%
1 (a and b)	9/45	—	21/68
3 a	7/35	—	9/29
4	4/20	—	1/3
• HIV-RNA, copies/mL, median (range)	2,716 (102–21,100)	219 (102–24,200)	—
• HCV-RNA, IU/mL, median (range)	587 (28–2,263,158)^**	–	33,421 (172–1,840,789)
Antiretroviral therapy, n/%	18/90	3/60	na

6 patients; ^**5 patients.

***

In one patient, liver biopsy was contraindicated.

Type 2a and 3 cryoglobulinemia were the most prevalent and detected in similar frequency (53% and 43% respectively). Only two cases of type 2b cryoglobulinemia were confirmed. No case of type 1 cryoglobulinemia was observed. The prevalence of particular types of cryoglobulinemia was comparable between HCV mono-infected and HCV/HIV co-infected patients. In HIV mono-infected patients, type 3 cryoglobulinemia was predominant, but compared to the HCV mono-infected and HCV/HIV co-infected groups, the difference was not statistically significant.

As for the frequency of the particular chains making up the cryoprecipitate, the gamma chains were predominant (96%) among heavy chains, while the kappa were the most frequent among light chains (93%). In patients with HCV mono-infection, heavy mu chains were observed significantly more often than in the HCV/HIV co-infected group (p=0.038). In contrast, in the HIV mono-infected group, heavy mu chains were not detected at all. Kappa light chains were significantly more prevalent in the HCV mono- and co-infected groups compared to the HIV mono-infected group (p<0.001; Table 2).

The distribution of HCV genotypes among cryoglobulinemic patients was similar to the general population in this region. Genotype 1 was demonstrated in 59% (30), genotype3 in 31% (16), and genotype 4 in 10% (5) of HCV-infected patients. Cryoglobulinemia tended to be more prevalent in patients infected with genotype 1 HCV than in patients infected with genotype 3 (63% vs. 46%). However, the difference was not statistically significant (p=0.12). The distribution of the most common types of cryoglobulinemia (2a and 3) in patients with genotype 1 and 3 HCV was similar (Table 4).

Table 4.

Prevalence of Cryoglobulinemia and Its Types Depending on the HCV Genotype (1 or 3)

	Genotype 1 (n=48)	Genotype 3 (n=35)	p
Cryoglobulinemia, n/%	30/63	16/46	ns (p=0.13)
Type 2a	17/57	9/56
Type 2b	0/0	2/13
Type 3	13/43	5/31

There were no association between cryoglobulinemia and body weight, HCV viremia, CD3+, CD4+, and CD8+ cell count, and renal function markers: serum creatinine, GFR, and MDRD. Patients with cryoglobulinemia demonstrated significantly higher ALT activity (p=0.01) and HIV viral load (p=0.0005; Table 5). In the HIV mono-infected group, cryoglobulinemia was more common among younger patients (p=0.01), which was not observed in the HCV- and HCV/HIV-infected groups. In patients with HIV mono-infection, there was a trend towards the occurrence of cryoglobulinemia in patients with a higher CD8+ count (p=0.06), which was not the case in HCV/HIV co-infected patients. Analysis of selected clinical, biochemical, and virological parameters and type of cryoglobulinemia revealed an association with the degree of renal impairment expressed as MDRD (p=0.04) in HCV mono-infected patients.

Table 5.

Relationships Between Selected Clinical, Biochemical, and Virological Parameters and the Presence of Cryoglobulinemia in the Whole Study Group

	Patients with cryoglobulinemia (n=56)	Patients without cryoglobulinemia (n=85)	p
Clinical measures, average (range)
• Age, years	37.7 (19.0–67.0)	41.0 (20.0–66.0)	ns
• Weight, kg	76.1 (46.0–119.0)	73.0 (43.0–106.0)	ns
Biochemical measures, median (range)
• Creatinine, mg/dL	0.8 (0.5–1.0)	0.7 (0.6–1.0)	ns
• GFR, mL/min/1.73 m²	119.0 (89.0–162.0)	123.0 (89.0–167.0)	ns
• MDRD, mL/min/1.73 m²	137.5 (83.0–185.0)	132.0 (86.0–170.0)	ns
• ALT, IU/L	65.5 (22.0–168.0)	43.0 (18.0–132.0)	0.01
Lymphocytes, cells/mm,³ average (range) ^*
• CD3	1,274 (577–2,112)	1,210 (689–1,915)	ns
• CD4	342 (98–978)	378 (173–723)	ns
• CD8	812 (449–1,513)	716 (318–1,451)	ns
Virological measures
• HIV-RNA, copies/mL, median (range)	231 (102–21,400)	102 (102–2,620)	0.0005
• HCV-RNA, IU/mL, median (range)	28,421 (118–2,047,368)	12,053 (199–2,060,526)	ns

Applies to HIV infected and HCV/HIV co-infected patients.

ns, no statistical difference.

There was lower incidence of cryoglobulinemia in HIV mono-infected patients on antiretroviral treatment (p=0.04). In HCV/HIV co-infected patients, such a relationship was not found.

The prevalence of cryoglobulinemia did not reveal significant differences related to severity of the periportal or intralobular inflammation and fibrosis stage (Table 3). Among patients with cryoglobulinemia grade 2 or higher, periportal inflammation was observed in 97%, intralobular inflammation in 89%, and fibrosis in 28% (Table 3).

Clinical symptoms related to cryoglobulinemia were confirmed in 12 HCV mono-infected (20%), 7 HIV mono-infected (15%), and in 10 HCV/HIV co-infected (29%) patients, but the differences between these groups were not statistically significant. It was shown that patients with cryoglobulinemia had clinical symptoms significantly more often compared to patients without cryoglobulinemia (38% vs. 9%, p<0.001). Cryoglobulinemia was associated significantly more often with polineuropathy (p=0.01), arthralgia (p=0.001), skin lesions (p=0.006), and fatigue (p<0.001) in comparison to patients without cryoglobulines (Table 6). Among patients with cryoglobulinemia, the most common symptom was fatigue (38%) followed by arthralgia (20%), polineuropathy (18%), skin lesions (14%), and proteinuria (7%). The incidence of the symptoms was similar regardless of the type of cryoglobulinemia. In patients with cryoglobulinemia, proteinuria was more common than in patients without cryoglobulines, but the difference was not statistically significant (p=0.06). In all HCV mono-infected and HCV/HIV co-infected patients, regardless of cryoglobulinemia, statistically significant relationships between proteinuria and MDRD (p=0.004) as well as between proteinuria and serum creatinine (p=0.02) were shown.

Table 6.

Association Between Cryoglobulinemia and Clinical Signs

Clinical signs and symptoms, n/%	Patients with cryoglobulinemia, 21/38	Patients without cryoglobulinemia, 8/9	p
Fatigue	21/38	8/9	0.00005
Arthralgia	11/20	1/1	0.0001
Polineuropathy	10/18	4/5	0.01
Skin lesions	8/14	2/2	0.006
Proteinuria	4/7	1/1	ns

Discussion

Immunological disturbances associated with HCV and/or HIV infection are the subject of numerous studies because of the possible consequences, such as the development of MC and even malignant transformation (13).

In the present study, cryoglobulines were detected in 40% of all patients. HCV mono-infected and HCV/HIV co-infected patients were significantly more likely to have MC in comparison to HIV mono-infected patients. According to the available data, MC is detected in more than 60% of patients with chronic hepatitis C (2,31). Based on available reports, the incidence of MC in mono-infected HIV patients is very diverse. One of the first studies indicated a higher incidence of MC in HIV mono-infected patients compared to HCV mono-infected patients (7,9). However, further reports indicated that HIV infection is not so important in the development of MC, and the results of subsequently published studies show a high rate of MC in HCV/HIV co-infected patients (1,4,8,10,27,32).

Among the evaluated patients, types 2a and 3 cryoglobulinemia were dominating. Only two cases of type 2b MC were found. These results are consistent with previously published studies, according to which type 2 cryoglobulinemia constitutes 50–60% cases of all MC and type 3 30–40% (31). Type 2b is considered a transitional stage between type 3 and 2a cryoglobulinemia, and indicates that MC is a dynamic process (33).

In the present study, the prevalence of MC did not reveal significant differences related to the severity of the periportal or intralobular inflammation and fibrosis stage, whereas, according to Kayali et al., MC is considered an independent factor associated with advanced liver fibrosis (16). Similarly, the association between MC and severity of fibrosis and hepatic steatosis in patients with chronic hepatitis C was also described by Saadoun et al. (29). Other findings associated with MC in this study were increased levels of inflammatory cytokines as well as increased numbers of LDL receptors observed in the peripheral blood and liver of patients with cryoglobulinemia. This contributed to the enhanced accumulation of lipids in the liver and acceleration of steatosis compared to those without cryoglobulinemia (19,30). However, the results of these studies have been negated after publication of the 10-year prospective study on the prevalence of cirrhosis, including 343 patients with MC, which did not demonstrated any association between MC and progression of fibrosis (34).

Detailed genetic analysis of B-cells showed a low to moderate level of somatic hypermutation of genes encoding the heavy and light chains of immunoglobulines, which is likely to rise due to chronic antigenic stimulation (6). In the course of MC, all types of heavy chains were observed, most commonly mu and gamma chains (33). In the present study, among the heavy chains, gamma chains predominated (96%), while light kappa chains were the most common (93%). However, in HCV mono-infected patients, mu heavy chains were observed statistically significantly more often compared to HCV/HIV co-infected patients (p=0.038). Significantly more prevalent were kappa light chains in HCV mono-infected and HCV/HIV co-infected patients compared to HIV mono-infected patients (p<0.001).

Regarding association between MC type and HCV genotype, the largest group of patients with cryoglobulinemia were those infected with genotype 1 HCV (59%), followed by 31% infected with genotype 3 and 10% with genotype 4. The distribution of the most common types of cryoglobulinemia (2a and 3) in patients with genotype 1 and 3 HCV was similar. Zignego et al. (36) showed that in patients with cryoglobulinemia, genotype 2a was significantly more frequent compared to patients without MC. Other studies have pointed to a higher percentage of MC in patients infected with genotype 1 HCV (18). Antonescu et al. (3) showed that infection with genotype 1b was frequently associated with mono- and oligoclonal MC, while genotype 3 infection often accompanied type 3 MC. Thus, the relationship between cryoglobulinemia and HCV genotypes is largely conditioned by its geographical diversity, as well as other genetic and environmental factors.

Saadoun et al. (29) revealed a higher incidence of MC in females. This was possibly related to the effects of estradiol and testosterone on type Th1 and Th2 response (12). In the present study, no statistically significant relationship between MC and sex was found.

Immune complexes formed in the course of MC include autoantigens—IgG polyclonal antibody (anti-HCV) attached to autoantibodies with RF-activity and HCV core protein. It has also been shown that large cryocomplexes, accumulated in the walls of small blood vessels, contain more HCV-RNA than its serum concentration. It may lead to an underestimation of actual HCV viral load. A reduced number of HCV-RNA copies in patients with MC was demonstrated in the study by Carmack et al. (5). However, in the present study as well as in a study carried out by Scotto et al. (32), this relationship was not confirmed.

In the current study, there was no association between MC and CD3+, CD4+, or CD8+ cell counts in HIV mono-infected and HCV/HIV co-infected patients. Similar results have also been obtained in previous studies (9,10,32). However, in the present study, in patients with HIV mono-infection, there was a trend towards MC existence in patients with a higher CD8 cell count (p=0.06). This association was not seen in HCV/HIV co-infected patients. However, the study by Aaron et al. (1) showed that MC was observed in HCV/HIV co-infected patients with a CD4+ count of >200 cells/mm³ but not among those with a CD4+ count of <200 cells/mm³. This observation suggests the importance of the interaction between the T-dependent cellular response and B-cell activation. There are also reports on MC presence in HCV/HIV co-infected patients during the immune reconstruction phase (1,23). Moreover, the significant reduction of CD4+ cells was associated with an increased proportion of immature/transitional forms of B-cells (12). The lack of a relationship between the occurrence of MC and the number of CD4+ cells in any studies, including the present data, may be due to the high CD4+ count among enrolled patients (417 cells/mm³ was the average in the present study).

In the current study, there was a statistically significant association between MC and elevated HIV viremia (p=0.0005). In one of the first studies on the prevalence of MC in HIV-infected patients, a correlation with high viral load was also shown, although subsequent investigators did not observe such a relationship (9,10,32). However, Malaspina et al. (12) demonstrated the critical role of HIV viral load in B-cell stimulation.

Among HIV mono-infected patients on ARV therapy, a lower incidence of MC was found. In patients with HCV/HIV co-infection, such a relationship was not shown. The study by Kosmas et al. (17) showed that of 11 HIV mono-infected patients with MC, during an average 6.5 years of follow-up after the introduction of ARV therapy, cryoglobulines disappeared in eight patients. It has been demonstrated in numerous studies that many pathological processes associated with the stimulation of B-cells are inhibited as a result of effective ARV therapy with the reduction in the HIV viral load (15,25,26). This included reducing the number of B-cells, inhibition of differentiation toward plasma cells, and a decrease in the number of spontaneously secreted gamma globulines (24).

According to the available literature, symptomatic MC is rare and affects <30% of patients (21). The most common MC symptoms are fatigue, arthralgia, and purpura. In the present study, these clinical signs were observed significantly more frequently in patients with cryoglobulinemia than in patients without cryoglobulinemia (p<0.001). In patients with type 2a and 3 MC, symptoms occurred with comparable frequency. Cryoglobulinemia was significantly more often associated with polineuropathy, arthralgia, skin lesions, and fatigue in comparison to patients without cryoglobulines. There were no correlations between the presence of MC symptoms and HCV genotypes. In the study by Ramos-Casals et al. (27), MC symptoms occurred more frequently in patients infected with HCV genotype 1, whereas HCV mono-infected patients demonstrated symptoms more often than HCV/HIV co-infected patients. According to current data, fatigue affects >50% of MC patients, which was also confirmed in the present study (28). Similar to the present results, other studies have also indicated frequent arthralgia (11,28). It is recognized that the symptoms of peripheral neuropathy are probably the second most common symptoms in the course of MC, after the Ferri and Meltzer triad (14,22,35). In the present study, these symptoms were reported by 18% of patients. Regarding renal involvement, proteinuria tended to be found more often among MC patients than in patients without cryoglobulinemia, but the difference was not significant. The literature confirms renal involvement in MC in approximately 20% of patients (33). Moreover, an increased concentration of cistatin C as one of the most sensitive early indicators of renal damage was found in MC patients (18).

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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