sex- or gender-specific medicine in hepatology

Review Article

Sex- or gender-specific medicine in hepatology

Sumiko Nagoshi

Department of Internal Medicine, Saitama Medical University, Saitama, Japan

Sex- or gender-specific medicine is an up-to-date medicalscience in recent medical care. Medical doctors must offerbetter medical care and should understand and elucidate themechanisms underlying the sex or gender differences regard-ing the incidence or etiology, clinical features, and naturalhistory or response to therapies. Sex or gender differencesare frequently seen among liver diseases, such as viral hepa-titis, alcoholic liver disease, non-alcoholic fatty liver disease,autoimmune hepatitis, primary biliary cirrhosis, primary

sclerosing cholangitis and hepatocellular carcinoma. Themechanisms of sex or gender differences, however, are stillunclear. Clinicians and basic scientists are required to coop-eratively contribute to the development of sex- or gender-specific medicine to establish an accurate diagnosis andprophylaxis.

Key words: hepatocellular carcinoma, liver disease, sex- orgender-specific medicine

INTRODUCTION

THE IMPORTANCE OF sex- or gender-specific medi-cine in medical care has been recognized since the

1990s, and a number of studies related to the sex orgender differences have been piled up in the etiology,diagnosis, therapy, and prophylaxis of various diseases,and taken up as special reviews in the fields of cardiacdisease, diabetes, hyperlipidemia, autoimmune disease,osteoporosis, pharmacokinetics, pharmacodynamics,and psychiatric disease. Nevertheless, sex- or gender-specific medicine in hepatology has seldom beenreviewed despite of its progress. Hepatologists areobliged not only to promote sex- or gender-specificmedicine in liver diseases, but also to propagate its clini-cally observed facts to the society.

VIRAL HEPATITIS

THE PREVALENCE OF hepatitis B surface antigen(HBsAg) was reported to be higher in men as com-

pared with women throughout the world.1 An analysis

of 3485648 first-time blood donors in Japan showedpositive HBsAg in blood to be significantly more fre-quent in male donors (0.73%) than in female donors(0.53%), while the antibody to hepatitis C virus (anti-HCV) was equally detected in men (0.48%) and women(0.50%).2 Considering that the main route of chronicinfection with hepatitis B virus (HBV) in Japan is verticaltransmission, which seems to occur equally betweenmen and women, HBV is more likely to be eliminated inwomen than in men. It was also reported that havingHBsAg was significantly more prevalent in men (9.7%)than in women (5.4%) in Okinawa.3 In the follow-upstudy of up to 19 years (mean = 9.2 years) in 946 HBsAgcarriers in Okinawa, clearance of HBsAg was seen morefrequently in women (7.8%) than in men (5.8%).4 Ananalysis of 342407 apparently healthy blood donorsin Japan showed that positive hepatitis B e antigen(HBeAg) was significantly more frequent in male donors(19.1%) as compared with female donors (16.7%), andthat the rate of having the antibody to HBeAg was sig-nificantly less in men (49.6%) than in women (53.1%)among 6342 asymptomatic HBV carriers.5 In contrast, astudy with 3063 Chinese patients who had chronichepatitis B infection showed no sex or gender differencein the spontaneous seroconversion rate of HBeAg to itsantibody.6 The rate of progression to liver cirrhosis in105 HBsAg-positive patients for 1–16 years was 24% inmen and 8% in women.7 However, there are few reportsthat describe the sex or gender differences in the naturalhistory of chronic hepatitis B.

Correspondence: Professor Sumiko Nagoshi, Division ofGastroenterology and Hepatology, Department of Internal Medicine,Saitama Medical University, Saitama, Japan. Email:[email protected] 27 July 2007; revision 5 October; accepted 23 October2007.

Hepatology Research 2008; 38: 219–224 doi: 10.1111/j.1872-034X.2007.00301.x

© 2007 The Japan Society of Hepatology 219

mailto:[email protected]

It is known that 60–80% of adults infected with HCVprogress to chronic hepatitis. In addition, there is areport stated that the rate of HCV clearance was signifi-cantly higher in women (44.6%) than in men (33.7%),based on the data of 4720 residents in Egypt, in whichthe rate of HCV clearance was defined as the rate of thecases showing no HCV RNA in the blood among thepeople with anti-HCV antibody.8 A study conducted infive European countries showed that sex or gender wasidentified as one of the risk factors for HCV transmissionto health care workers after exposure to blood or infec-tious body fluids from anti-HCV antibody-positivesources through percutaneous injuries (odds ratio formales vs females, 3.1).9 In chronic hepatitis C infection,the serum alanine aminotransferase (ALT) level wasreported to be significantly higher in men than inwomen, only when the inflammatory activity was mild(A0–A1), and was significantly higher in youngerpatients than in older patients when the activity wasmore severe (A2–A3).10 Moreover, the progression timefrom HCV infection to liver cirrhosis was longer inwomen than in men,11–14 whereas no sex or gender dif-ferences were seen in some reports.15–17

Recently it was reported in Japan that the sustainedvirological response (SVR) rate to combination therapywith pegylated interferon and ribavirin showed nosex or gender differences in chronic hepatitis C patientsunder 50 years of age, although the SVR rate was signifi-cantly higher in men (51%) than in women (20%) inthose aged over 50 years.18 In contrast, in US patientsbetween the ages of 18 and 70 years given such combi-nation therapy, the SVR rate was significantly higher inwomen than in men.19

These differences may be associated with immuneresponses, which are distinct between men and women,as described later.

ALCOHOLIC LIVER DISEASE

THE INCIDENCE OF alcoholic liver disease increasesin a dose-dependent manner proportionally to the

cumulative alcohol intake. Becker et al. reported thatalcohol-induced liver disease developed more rapidly inwomen than in men.20 The lowest point of weeklyalcohol intake that helps develop liver disease washigher in men (168–324 g) than in women (84–156 g).In the case of heavy drinkers with a weekly consumptionof 336–492 g, the relative risk of developing liver cirrho-sis was 7 in men and 17 in women, and the relative riskfor alcoholic liver disease was 3.7 in men and 7.3 inwomen. The group with weekly consumption of

12–72 g was the group with relative risk 1. As the factorsaffecting the differences in susceptibility to alcoholictoxicity, the age at the time of the regular consumptionof alcohol, the way of drinking (that is, with or withoutmeals), or the nutritional status may differently affectmen and women.

There are several explanations for the mechanismsbehind sex or gender differences in alcoholic liverdisease. If one consumes the same amount of alcoholper body weight, the blood ethanol concentrationwould be higher in women than in men.21 It was alsoreported that alcohol dehydrogenase (ADH), an enzymeinvolved in alcohol metabolism, was expressed at lowerlevels in the stomach in women as compared with men,and that the activity of gastric ADH was correlated withthe gastric first-pass ethanol metabolism, affecting theblood ethanol concentration.21 Baraona et al. stated thatthe sex or gender difference in the first-pass metabolismof ethanol was mainly due to lower gastric ADH activityin women than in men.22

In a study using rats, both the plasma endotoxin leveland the expression of the receptor of the endotoxin(CD14) in Kupffer cells were raised after ethanol inges-tion.23 The addition of estrogen enhanced tumor necrosisfactor-a production in Kupffer cells via elevation of theplasma endotoxin level and hepatic CD14 expression,resulting in increased inflammatory activity in the liver.23

The administration of ethanol increased the hepaticactivity of cytochrome P4502E1 (CYP2E1), a pro-oxidantenzyme, in female rats, and the ethanol-induced CYP2E1activity was significantly reduced after the administrationof anti-estrogen.24 Ethanol feeding also increased theimmuno-detectable CYP2E1 more abundantly in cas-trated micropigs than in non-castrated micropigs.25 Inaddition, there was a significant correlation between thehepatic CYP2E1 level and serum 17-b-estradiol level incastrated micropigs after feeding ethanol.25

NON-ALCOHOLIC FATTY LIVER DISEASE

THE PREVALENCE OF non-alcoholic fatty liverdisease (NAFLD) has been shown to be higher in

men than in women in Asia.26 However, some studiesindicate an age-related trend. The prevalence of fattyliver among 39151 people who visited the Japanesehealth check-up center, was 25–30% in all of the agegroups between 30 and 60 years in men, while theprevalence was 10% or less in the 30–39-year age groupand increased gradually with age in women.27 In womenover the age of 70 years, fatty liver was more prevalent.A high body mass index was assumed to be one feature

220 S. Nagoshi Hepatology Research 2008; 38: 219–224

© 2007 The Japan Society of Hepatology

closely related to the onset of fatty liver, while alcoholintake did not show any clear relation to fatty liver.27

Among 3175 Shanghai adults, the peak prevalence offatty liver in men occurred earlier (40–49 years) than inwomen (over 50 years).28 It was also reported that5–20% of patients with NAFLD progressed to cirrhosis(non-alcoholic steatohepatitis) over a 10-year period.29

Although the sex differences in the degree of fibrosis inpatients with NAFLD were not identical, women tend topredominate among patients with severe fibrosis, ascompared with those with mild fibrosis.30,31

In mice with steatohepatitis induced by methionineand a choline-deficient diet, there were no sex differ-ences in liver injury.32 However, hepatic steatosisbecame evident in aromatase-deficient mice lackingintrinsic estrogen production, but substantially dimin-ished in mice treated with 17-b-estradiol.33 The roles ofestrogen in hepatic lipid metabolism and fibrosisremain to be further investigated.

AUTOIMMUNE LIVER DISEASES

IT IS WELL known that there are sex or gender differ-ences in the immune system. Women have a signifi-

cantly higher number of CD4+ T lymphocytes andhigher CD4+/CD8+ ratio than men.34 It was also recog-nized that the secretions of interferon-g (IFN-g) andinterleukin (IL)-10 were enhanced after the addition ofestrogen to the medium in T-cell clones isolated fromwomen,35 whereas the secretions of IFN-g, IL-4, and IL-5were inhibited by androgen in murine T cells.36 Immuneresponses were enhanced by estrogen at low doses andsuppressed at high concentrations.35 These findingssuggest that estrogen or androgen may modulate theimmune system, resulting in extended sex or genderdifferences in autoimmune liver diseases.

Autoimmune hepatitisAutoimmune hepatitis (AIH) occurs frequently inwomen aged between 10 and 30 years or during latemiddle age.37 Women account for 70–90% of AIHpatients.38,39 Miyake et al. reported that male patientswith AIH showed a lower frequency of reproducibility indiagnosis with the revised scoring system proposed bythe International Autoimmune Hepatitis Group40 and alower serum immunoglobulin G (IgG) level than femalepatients in Japan.41 In addition, the frequency of nor-malization of the serum ALT level within 6 months afterthe beginning of corticosteroid treatment was signifi-cantly lower in men (73%) as compared with women(93%).41 However, there was no sex or gender difference

in age, form of clinical onset, frequency of symptomaticconcurrent autoimmune diseases, and human leukocyteantigen DR (HLA DR) status.41 In the UK, the frequen-cies of concurrent autoimmune diseases and HLA DR4were significantly higher in women than in men, whilethere was no sex or gender difference in the serum IgGlevel and response to corticosteroid treatment.42 Theseregional differences might arise from the fact that theclinical feature of AIH is different between patients withHLA DR3 and those with DR4,43 and that most Japanesepatients with AIH have HLA DR4.44

The severity of AIH was likely to decrease duringpregnancy when estrogen was secreted at high levels,and acute exacerbation could occur after delivery.45 Incontrast, de novo presentation of AIH or its flaring indisease activity was also shown during pregnancy.46

Primary biliary cirrhosisMost patients with primary biliary cirrhosis (PBC) arefemale, usually 40–60 years of age.38 Published data onthe ratios of incidence in women to men ranged from3:1 to 22:1.47 The complication of hepatocellular carci-noma (HCC) in patients with PBC was reported to besignificantly greater in men than in women.48 Age at thetime of diagnosis, male, and history of blood transfu-sion were three independent factors of developing HCCin PBC patients who had negative markers for bothHBV and HCV, and a combination of age, male, andadvanced-stage PBC was associated with patients’ sur-vival.49 It was reported that age at diagnosis of PBC washigher in men (62 years) as compared with women(51 years),50 and that concomitant autoimmune dis-eases were less prevalent in men.48 There was no sero-logical difference between men and women.47

Primary sclerosing cholangitis (PSC)In the Mayo Clinic study of 174 patients with primarysclerosing cholangitis (PSC), two-thirds were men andthe mean age at the time of diagnosis was 39 years.51

In an analysis of 388 Japanese patients with PSC,52

there was male predominance (59%) and two peaks inthe age distribution, with a mean age of 47 years. Thefirst peak was found in the group of PSC patients withinflammatory bowel diseases (IBD), who were mainlyin their teens or twenties; the second peak was in thegroup of 50–60-year-olds, in which there were somepatients with complications of autoimmune pancreatitis(AIP). The percentage of sex or gender distribution didnot differ among the three subgroups; PSC with IBD,PSC with AIP, and PSC without AIP.

Hepatology Research 2008; 38: 219–224 Sex-specific medicine in hepatology 221


HCC

MALE PREDOMINANCE AMONG patients withHCC is observed in high-risk as well as low-risk

areas, regardless of ethnic and geographic diversities.53

At present, the exact reason for such sex or gender dif-ferences is unclear.

According to our investigations, the age at diagnosisof HCC was older in women (70 years) than in men(67 years), and the platelet count was significantly lowerin women (8.8 1 3.9 ¥ 104/mm3: mean 1 SD) than inmen (11.3 1 4.5 ¥ 104/mm3) among 99 patients withpositive HCV RNA (Nagoshi S, 2007, unpublisheddata). This finding suggests that women may developHCC in a more advanced stage of liver fibrosis thanmen. It was reported in Japan that there was no sex orgender difference in the incidence rate of having cirrho-sis in patients with HCC, although women were diag-nosed at a significantly older age than men.54 Incontrast, Cong et al. showed that women with HCCwere younger than men and that only 49% of womenwith HCC had cirrhosis in contrast to 68% among menin China.55 Such discrepancies may be attributed to thedifferences in the prevalence of HBV and HCV infec-tions. The positive rates of having HBsAg in patientswith HCC were 11% in men and 7% in women inJapan,54 and 71% in men and 60% in women inChina.55

It has been reported that female patients with HCCshowed a better survival rate than male patients.54,56,57

Some papers suggest that the better prognosis infemale patients might relate to a high incidence oftumor encapsulation and less invasive tumors,56 lowertumor recurrence rate,57 and the presence of a lowernumber of androgen receptors in HCC.58 Interestinglythe reason for the better prognosis in female patientswith the same risk was reported to be ascribed to morefrequent follow up for the early diagnosis of HCCdevelopment than male patients.54 Also, no significantsex or gender difference in the survival rate wasreported in HCC patients.59

CONCLUSION

SEX- OR GENDER-specific medicine and care are theup-to-date medical issues to be established from the

standpoint of bio-sociology and bio-economics, includ-ing geographic cultures.

The establishment of diagnosis, therapy, and prophy-laxis based on sex or gender differences must be madetowards extended quality of life and happiness.

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sex- or gender-specific medicine in hepatology

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