Association of serum level of growth differentiation factor 15 with liver cirrhosis and hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) and liver cirrhosis are associated with high mortality worldwide. Currently, alpha-fetoprotein (AFP) is used as a standard serum marker for the detection of HCC, but its sensitivity and specificity are unsatisfactory, and optimal diagnostic markers for cirrhosis are lacking. We previously reported that growth differentiation factor 15 (GDF15) was significantly induced in HCV-infected hepatocytes. This study aimed to investigate GDF15 expression and its correlation with hepatitis virus-related liver diseases. A total of 412 patients with various liver diseases were studied. Healthy and Mycobacterium tuberculosis-infected subjects were included as controls. Serum and tissue GDF15 levels were measured. Serum GDF15 levels were significantly increased in patients with HCC (6.66±0.67 ng/mL, p<0.0001) and cirrhosis (6.51±1.47 ng/mL, p<0.0001) compared with healthy controls (0.31±0.01 ng/mL), though the GDF15 levels in HBV and HCV carriers were moderately elevated (1.34±0.19 ng/mL and 2.13±0.53 ng/mL, respectively). Compared with HBV or HCV carriers, GDF15 had a sensitivity of 63.1% and a specificity of 86.6% at the optimal cut-off point of 2.463 ng/mL in patients with liver cirrhosis or HCC. In HCC patients, the area under the receiver operating curve was 0.84 for GDF15 and 0.76 for AFP, but 0.91 for the combined GDF15 and AFP. Serum GDF15 levels did not significantly differ between the high-AFP and low-AFP groups. GDF15 protein expression in HCC was significantly higher than that in the corresponding adjacent paracarcinomatous tissue and normal liver. Using a combination of GDF15 and AFP will improve the sensitivity and specificity of HCC diagnosis. Further research and the clinical implementation of serum GDF15 measurement as a biomarker for HCC and cirrhosis are recommended.

Fig 1. Serum GDF15 is increased in patients with LC or HCC.

(A) Scatter plots show the serum GDF15 levels in healthy (n = 202), LC (n = 88) and HCC (n = 223) patients by ELISA. The black line indicates the mean, for which the value is indicated at the bottom of the scatter plot. ** indicates that P < 0.0001 for both LC and HCC compared with healthy controls. (B) The GDF15 ROC curve is plotted to compare the HCC or LC patients versus HBV or HCV carriers.

Fig 2. Serum GDF15 level alterations in patients with hepatitis virus-related diseases.

Scatter plots show the serum GDF15 levels in healthy subjects and patients with various liver diseases by ELISA. The black line indicates the mean, for which the value is indicated at the bottom of the scatter plot. The P values for HBV carriers vs. HBV cirrhosis, HBV carriers vs. HBV HCC and HCV carriers vs. HCV HCC are indicated.

Fig 3. Serum GDF15 is not related to tuberculosis infection.

Scatter plots showing the serum GDF15 levels in healthy subjects (n = 202) and patients with active tuberculosis (TB, n = 200) or latent TB (n = 200) infection by ELISA. The black line indicates the mean, for which the value is indicated on the top of the scatter plot.

Fig 4. Comparison of serum GDF15 and AFP for the diagnosis of HCC.

(A) Serum GDF15 levels in two HCC groups with AFP ≤20 ng/mL (n = 91) and >20 ng/mL (n = 132), respectively. (B) ROC curves comparing GDF15 (red line), AFP (black line) and combined (green line) for HCC diagnosis versus all other conditions in the cohort, including healthy patients, HBV or HCV carriers and patients with cirrhosis. The area under the ROC curve for GDF15 was significantly different from that for AFP, P<0.001.

Fig 5. GDF15 protein expression in HCC, adjacent paracarcinomatous liver (PCL) and normal liver (NL) tissues.

(A) Normal liver and HCC with different grades of malignancy were prepared for IHC with anti-GDF15 or isotype antibodies, respectively. Representative results are shown. (B) GDF15 protein expression in HCC (T) and PCL (P) lysates was determined by Western blotting. An antibody against β-Actin was used as a loading control. (C) Quantification of Western Blot described in Fig 4B with Image J.