- Open Access
The influence of polymorphic GSTM1 gene on the increased susceptibility of non-viral hepatic cirrhosis: evidence from observational studies
- Ye Gu†1,
- Jing Zhao†1,
- Li Ao1,
- Jianning Ma1,
- Kena Bao1,
- Min Liu2Email author and
- Weiping Huang1Email author
© The Author(s) 2018
Received: 23 February 2018
Accepted: 13 June 2018
Published: 19 June 2018
It is reported that glutathione S-transferase mu (GSTM1) polymorphism is associated with non-viral hepatic cirrhosis (HC). However, some studies showed different views. Therefore, in this paper, a meta-analysis was conducted to get a more comprehensive understanding of GSTM1 polymorphisms in non-viral HC susceptibility. The results showed that GSTM1 null was associated with the increased risk of non-viral HC (OR = 1.337, 95% CI 1.112–1.804, p = 0.005). Subgroup analysis of cirrhosis type revealed that GSTM1 null was a prominent risk factor for alcoholic HC (OR = 1.416, 95% CI 1.112–1.804, p = 0.005). Meanwhile, subgroup analysis of population indicated that the significant differences only existed in Asian population (OR = 1.719, 95% CI 1.212–2.438, p = 0.002). In hospital-based studies, patients with GSTM1 null were more likely in risk of HC (OR = 1.426, 95% CI 1.092–1.863, p = 0.009). Subgroup analysis using genotyping method showed a significant association between GSTM1 null genotype and HC occurrence in the studies employing the multiple PCR genotyping method (OR = 1.559, 95% CI 1.171–2.076, p = 0.002). Based on the results of this analysis, it was concluded that GSTM1 null genotype could increase the susceptibility of non-viral hepatic cirrhosis. In addition, alcohol intake, Asian ethnicity, sample source from hospital and multiple PCR genotyping method may also influence the susceptibility of hepatic cirrhosis.
Hepatic cirrhosis (HC) expresses in dysfunction of liver due to normal liver tissue are gradually replaced by necrotic hepatocytes, which is caused by different etiology . Patients with progressed HC suffer from a series of symptoms including diarrhea, ascites and esophageal variceal rupture bleeding . As a chronic disease, HC brings a heavy burden to both the patients’ families and the society . Cirrhosis affected 2.8 million people’s health and caused 1.3 million deaths in 2015 . HC has become a worldwide public concern.
HC are mainly caused by hepatitis virus infection (hepatitis B, hepatitis C), heavy alcohol consumption and exposure to some chemical substances [5–7]. At present, viral hepatitis has been effectively prevented by health education and vaccine application. However, non-viral hepatic cirrhosis accounts for 51.4% of all cirrhosis, deserving more attention due to multiple influence factors. A number of studies have shown that genetic factors are responsible for the cirrhosis development other than environmental factors [8–10].
Glutathione S-transferase (GST) gene family is involved in the biotransformation phase II of harmful substances and has an important function to protect the cellular [11, 12]. The major GSTs family isoforms can be categorized into α (alpha), μ (mu), θ (theta), and ∏ (pi) classes . Glutathione S-transferase mu (GSTM1) is one of the most widely expressed gene . Null genotype was reported to be the most common variant of GSTM1 among populations . It was reported that individuals with null genotype of the GSTM1 had no ability to detoxicate the xenobiotics . Soto-Quintana et al.  reported that GSTM1 null genotype was related to a group of diseases including cancers and metabolic disorder, which may result in the vulnerability of liver tissue.
A lot of studies were performed to explore the association of GSTM1 gene polymorphism with cirrhosis risk. GSTM1 null genotype has been found to be related with non-viral hepatic cirrhosis in some studies [18–20]. However, several reports showed no significant correlation between GSTM1 null genotype and non-viral hepatic cirrhosis [21–23]. In this paper, a meta-analysis was performed to investigate the association between GSTM1 gene polymorphism and non-viral cirrhosis susceptibility.
Literatures were searched to find all the related articles in Pubmed, Web of Science, Embase databases (ultimate search updated on July 31, 2017) using the keywords “polymorphism”, “cirrhosis”, “chronic liver disease”, “glutathione S-transferase M1 (GSTM1)”. Two independent reviewers screened the relevant articles using standardized screening guide. The eligible articles were enrolled in this meta-analysis according to the inclusion and exclusion criteria.
Inclusion and exclusion criteria
Studies meeting all of the following inclusion criteria are included: (a) included studies must be concentrated on the relationship between glutathione S-transferase M1 and the non-viral hepatic cirrhosis. (b) All enrolled studies must be the case–control studies. (c) Hepatic cirrhosis must be diagnosed on the basis of liver biopsy. (d) Published in English. (e) Studies with enough data to calculate odds ratios and corresponding 95% confidence intervals (ORs, 95% CIs) were included.
Exclusion criteria were as follows: (a) reviews, abstracts, letters, comments, family-based studies and single-case reports were excluded. (b)The articles with insufficient data or overlapped data were excluded.
Quality criteria for eligible studies
Case and control group were both selected from hospital
Control groups were selected from normal residents
Matching of case group and control group
> 3 factors
Two investigators (M. Liu and Y. Gu) extracted data independently. Any disagreement was settled by discussion. The extracted data included name of the first author, year of publication, country, ethnicity, number of cases and controls, genotyping method, control sources and genotype distribution in cases and controls.
This meta-analysis was performed using STATA software (version12.0, STATA Corp, College Station, TX). Crude odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated to assess the strength of association between glutathione S-transferase M1 and the cirrhosis. Pooled ORs were calculated using random-effect model (M–H heterogeneity method) or fixed-effect model (Mantel and Haenszel method). I2 index and p value of the Chi-squared test were used to inspect the heterogeneity among the enrolled literature . If notable heterogeneity existed (p < 0.05 and/or I2 > 50%), the random-effect model was used to estimate Ors , on the contrary, the fixed-effect model was performed . Subgroup analysis was performed on cirrhosis type and population. The Z test and p value of 0.05 were used to judge whether the differences of OR values had statistical significance. Sensitivity analysis was conducted to assess the influence of individual studies. Begg’s test was applied to evaluate the publication bias .
Search strategy and characteristics of eligible articles
Studies characteristics of each article included in the meta-analysis and distribution of genotype frequency of GSTM1 among controls and cirrhotic patients
Sample size (case/control)
GSTM1 active, N (%)
GSTM1 null, N (%)
GSTM1 active, N (%)
GSTM1 null, N (%)
Age, ethnicity, region
Age, gender, ethnicity, drink habits
Age, ethnicity, drink habits
Primary biliary HC
Horizontal starch gel electrophoresis
Results of meta-analysis
Subgroup analysis of the association between GSTM1 polymorphism and non-viral HC-based on cirrhosis type, ethnicity, controlled source and genotyping method
Test for association
Test for heterogeneity
To date, it is the first time to perform meta-analysis to reveal the association between GSTM1 polymorphism and non-viral HC susceptibility. Hepatic cirrhosis is affected by many factors. Among these risk factors, genetic factors have become a research focus now. Many studies showed that GSTs played a crucial role in the etiology of HC. GSTM1 is a common type of GSTs gene. Some researchers reported that GSTM1 polymorphism was associated with the increased risk of non-viral HC. However, other investigations suggested that there was no relationship between GSTM1 polymorphism and non-viral HC. After the combination of these data, results of this meta-analysis revealed that GSTM1 null was a risk factor for susceptibility of HC (OR = 1.337, p = 0.013). In addition, results from subgroup analysis classified by ethnicity indicated that HC risk of Asians with GSTM1 null was increased in (OR = 1.719, p = 0.002). But it was not applicable for non-Asians. Furthermore, subgroup analysis was also conducted on cirrhosis type. In alcoholic hepatic cirrhosis group, the results are consistent with that of all enrolled studies (OR = 1.416, p = 0.005).
Based on the current literature, GSTM1 null is significantly associated with non-viral hepatic cirrhosis risk in Asian population. Interestingly, it was reported that Asian population were more vulnerable to viral hepatic cirrhosis . The popularity of GSTM1 null has been reported to vary with different ethnic populations, 30% of Caucasians while 70% of Asians . The high prevalence of GSTM1 null among Asians may lead to the increased vulnerability to HC. Except for the genetic factors, other factors such as economic and social-cultural factors can also contribute to the development of hepatic cirrhosis. Participants in Khan’s two enrolled studies are Indians. Patients in this region sometimes were reluctant to see the doctor because of economy stresses or lack of education, which interferes the early discovery and treatment of the cirrhosis [30, 31]. This phenomenon can also be observed in the undeveloped area of China, the world’s first ranked incidence and mortality area of HC . It is worthy to notice that the interaction between genetic factors and non-genetic factors may impact the occurrence of non-viral cirrhosis.
Another particular finding of our study was that GSTM1 null could be a significant risk factor for susceptibility of alcoholic HC. Heavy alcohol consumption can promote the formation of reactive oxygen species (ROS) and acetaldehyde, which are both associated with the developing of cirrhosis . However, individual susceptibility to alcoholic cirrhosis varies. Song et al.  reported that only approximately 30% of the heavy alcohol consumers developed to liver cirrhosis, suggesting that genetic factors play an important role. GSTM1 activity was involved in the metabolism of xenobiotics and facilitated to protect the cellular from oxidative reactions . Therefore, individuals with GSTM1 null are more likely found to be in risk of hepatic cell damage triggered by excessive alcohol consumption.
This meta-analysis is rigorous. First, this paper is focused on GSTM1 polymorphism and the risk of non-viral hepatic cirrhosis. Studies were selected from three open classic biomedical databases, Pubmed, Web of Science and Embase database. A thorough search strategy was designed. Language type and the period covered by the publications were also limited strictly. Second, objective quality evaluation, particular inclusion criteria and strict exclusion criteria were established to ensure the reliability of this meta-analysis. Finally, the results were generated through appropriate statistics. Sensitivity analysis and stratification analysis were also performed to control the confounding factors.
However, this meta-analysis has limitations to some extent. The data of this meta-analysis were collected from published literature and it is impossible to eliminate publication bias completely. We can only minimize the effect of publication bias to obtain more reliable results. We studied both alcoholic and non-alcoholic HC in the subgroup analysis. However, most of the studies enrolled participants are the excessive drinker. Thus, it is hard to get an accurate result of the non-alcoholic HC in this work. Further well-designed studies focusing on non-alcoholic population with larger sample sizes and different ethnic population are needed to clarify the present findings.
According to the analysis results of this study, GSTM1 null is associated with the increased risk of non-viral hepatic cirrhosis. Subgroup analysis of cirrhosis type, population, controlled source and detection method also suggest that GSTM1null is a prominent risk factor of hepatic cirrhosis. Thus, GSTM1 polymorphism is related to the pathologies of non-viral hepatic cirrhosis.
ML, YG and WPH were responsible for the conception, design, and acquisition of data, YG and JZ drafting the initial manuscript and revising it critically for important intellectual content. ML, JNM and KNB analyzed and interpreted the data. YG wrote the final draft. All authors read and approved the final manuscript.
This research was supported by the Key Subjects of Jiading District (No. ZD02).
The authors declare that they have no competing interests.
Availability of data and materials
All data and materials are available.
Consent for publication
All participants signed informed consent.
Ethics approval and consent to participate
This research was approved by Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences.
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- Dan L, et al. Harrison’s principles of internal medicine. In: Cirrhosis and its complications, chapt. 308. 18th ed. New York: McGraw-Hill; 2012.Google Scholar
- Lee JS. Albumin for end-stage liver disease. Korean J Intern Med. 2012;27(1):13–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Bajaj JS, Wade JB, Gibson DP, Heuman DM, Thacker LR, Sterling RK, Stravitz RT, Luketic V, Fuchs M, White MB, Bell DE, Gilles H, Morton K, Noble N, Puri P, Sanyal AJ. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol. 2011;106(9):1646–53.View ArticlePubMedPubMed CentralGoogle Scholar
- GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459–544.View ArticleGoogle Scholar
- GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385(9963):117–71.View ArticleGoogle Scholar
- Szabo G, Wands JR, Eken A, Osna NA, Weinman SA, Machida K, Joe Wang H. Alcohol and hepatitis C virus–interactions in immune dysfunctions and liver damage. Alcohol Clin Exp Res. 2010;34(10):1675–86.View ArticlePubMedPubMed CentralGoogle Scholar
- Liu M, Chen L, Zhou R, Wang J. Association between GSTM1 polymorphism and DNA adduct concentration in the occupational workers exposed to PAHs: a meta-analysis. Gene. 2013;519(1):71–6.View ArticlePubMedGoogle Scholar
- Burza MA, Molinaro A, Attilia ML, Rotondo C, Attilia F, Ceccanti M, Ferri F, Maldarelli F, Maffongelli A, De Santis A, Attili AF, Romeo S, Ginanni Corradini S. PNPLA3 I148M (rs738409) genetic variant and age at onset of at-risk alcohol consumption are independent risk factors for alcoholic cirrhosis. Liver Int. 2014;34(4):514–20.View ArticlePubMedGoogle Scholar
- Ibrahim AM, Ahmed HS, Alazizi NM, Mansour MA, Mansour SA. Glutathione S-transferases M1 and T1 gene polymorphisms and the outcome of chronic hepatitis C virus infection in Egyptian patients. Ann Hum Genet. 2016;80(1):32–7.View ArticlePubMedGoogle Scholar
- Joshita S, Umemura T, Nakamura M, Katsuyama Y, Shibata S, Kimura T, Morita S, Komatsu M, Matsumoto A, Yoshizawa K, Ishibashi H, Tanaka E, Ota M. STAT4 gene polymorphisms are associated with susceptibility and ANA status in primary biliary cirrhosis. Dis Markers. 2014;2014:727393.View ArticlePubMedPubMed CentralGoogle Scholar
- Board PG, Menon D. Glutathione transferases, regulators of cellular metabolism and physiology. Biochim Biophys Acta. 2013;1830(5):3267–88.View ArticlePubMedGoogle Scholar
- Jancova P, Anzenbacher P, Anzenbacherova E. Phase II drug metabolizing enzymes. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010;154(2):103–16.View ArticlePubMedGoogle Scholar
- Oliveira C, Lourenço GJ, Sagarra RA, Derchain SF, Segalla JG, Lima CS. Polymorphisms of glutathione S-transferase Mu 1 (GSTM1), Theta 1 (GSTT1), and Pi 1 (GSTP1) genes and epithelial ovarian cancer risk. Dis Markers. 2012;33(3):155–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Bunderson BR, Kim JE, Croasdell A, Mendoza KM, Reed KM, Coulombe RA Jr. Heterologous expression and functional characterization of avian mu-class glutathione S-transferase. Comp Biochem Physiol C Toxicol Pharmacol. 2013;158(2):109–16.View ArticlePubMedGoogle Scholar
- Duggan C, Ballard-Barbash R, Baumgartner RN, Baumgartner KB, Bernstein L, McTiernan A. Associations between null mutations in GSTT1 and GSTM1, the GSTP1 Ile (105) val polymorphism, and mortality in breast cancer survivors. Springerplus. 2013;2:450.View ArticlePubMedPubMed CentralGoogle Scholar
- Wu B, Dong D. Human cytosolic glutathione transferases: structure, function, and drug discovery. Trends Pharmacol Sci. 2012;33(12):656–68.View ArticlePubMedGoogle Scholar
- Soto-Quintana O, Zúñiga-González GM, Ramírez-Patiño R, Ramos-Silva A, Figuera LE, Carrillo-Moreno DI, Gutiérrez-Hurtado IA, Puebla-Pérez AM, Sánchez-Llamas B, Gallegos-Arreola MP. Association of the GSTM1 null polymorphism with breast cancer in a Mexican population. Genet Mol Res. 2015;14(4):13066–75.View ArticlePubMedGoogle Scholar
- Khan AJ, Husain Q, Choudhuri G, Parmar D. Association of polymorphism in alcohol dehydrogenase and interaction with other genetic risk factors with alcoholic liver cirrhosis. Drug Alcohol Depend. 2010;109(1–3):190–7.View ArticlePubMedGoogle Scholar
- Khan AJ, Ruwali M, Choudhuri G, Mathur N, Husain Q, Parmar D. Polymorphism in cytochrome P450 2E1 and interaction with other genetic risk factors and susceptibility to alcoholic liver cirrhosis. Mutat Res. 2009;664(1–2):55–63.View ArticlePubMedGoogle Scholar
- Frenzer A, Butler WJ, Norton ID, Wilson JS, Apte MV, Pirola RC, Ryan P, Roberts-Thomson IC. Polymorphism in alcohol-metabolizing enzymes, glutathione S-transferases and apolipoprotein E and susceptibility to alcohol-induced cirrhosis and chronic pancreatitis. J Gastroenterol Hepatol. 2002;17(2):177–82.View ArticlePubMedGoogle Scholar
- Burim RV, Canalle R, Martinelli Ade L, Takahashi CS. Polymorphisms in glutathione S-transferases GSTM1, GSTT1 and GSTP1 and cytochromes P450 CYP2E1 and CYP1A1 and susceptibility to cirrhosis or pancreatitis in alcoholics. Mutagenesis. 2004;19(4):291–8.View ArticlePubMedGoogle Scholar
- Rodrigo L, Alvarez V, Rodriguez M, Pérez R, Alvarez R, Coto E. N-Acetyltransferase-2, glutathione S-transferase M1, alcohol dehydrogenase, and cytochrome P450IIE1 genotypes in alcoholic liver cirrhosis: a case? Control Study. Scand J Gastroenterol. 1999;34(3):303–7.View ArticlePubMedGoogle Scholar
- Davies MH, Elias E, Acharya S, Cotton W, Faulder GC, Fryer AA, Strange RC. GSTM1 null polymorphism at the glutathione S-transferase Ml locus: phenotype and genotype studies in patients with primary biliary cirrhosis. Gut. 1993;34(4):549–53.View ArticlePubMedPubMed CentralGoogle Scholar
- Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJ. Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. JAMA. 2002;288(6):728–37.View ArticlePubMedGoogle Scholar
- Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.View ArticlePubMedPubMed CentralGoogle Scholar
- DerSimonian R, Laird N. Meta-analysis in clinical trials. Contemp Clin Trials. 2015;45(Pt A):139–45.View ArticlePubMedPubMed CentralGoogle Scholar
- Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22(4):719–48.PubMedGoogle Scholar
- Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.View ArticlePubMedGoogle Scholar
- Baclig MO, Alvarez MR, Lozada XM, Mapua CA, Lozano-Kühne JP, Dimamay MP, Natividad FF, Gopez-Cervantes J, Matias RR. Association of glutathione S-transferase T1 and M1 genotypes with chronic liver diseases among Filipinos. Int J Mol Epidemiol Genet. 2012;3(2):153–9.PubMedPubMed CentralGoogle Scholar
- Vasudevan S, Shalimar, Kavimandan A, Kalra N, Nayak B, Thakur B, Das P, Gupta SD, Panda SK, Acharya SK. Demographic profile, host, disease & viral predictive factors of response in patients with chronic hepatitis C virus infection at a tertiary care hospital in North India. Indian J Med Res. 2016;143(3):331–40.View ArticlePubMedPubMed CentralGoogle Scholar
- Bhattacharyya M, Barman NN, Goswami B. Survey of alcohol-related cirrhosis at a tertiary care center in North East India. Indian J Gastroenterol. 2016;35(3):167–72.View ArticlePubMedGoogle Scholar
- Mokdad AA, Lopez AD, Shahraz S, Lozano R, Mokdad AH, Stanaway J, Murray CJ, Naghavi M. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med. 2014;12:145.View ArticlePubMedPubMed CentralGoogle Scholar
- Galicia-Moreno M, Rosique-Oramas D, Medina-Avila Z, Álvarez-Torres T, Falcón D, Higuera-de la Tijera F, Béjar YL, Cordero-Pérez P, Muñoz-Espinosa L, Pérez-Hernández JL, Kershenobich D, Gutierrez-Reyes G. Behavior of oxidative stress markers in alcoholic liver cirrhosis patient. Oxid Med Cell Longev. 2016;2016:9370565.View ArticlePubMedPubMed CentralGoogle Scholar
- Song DS, Chang UI, Choi S, Jung YD, Han K, Ko SH, Ahn YB, Yang JM. Heavy alcohol consumption with alcoholic liver disease accelerates sarcopenia in elderly Korean males: The Korean National Health and Nutrition Examination Survey 2008–2010. PLoS ONE. 2016;11(9):e0163222.View ArticlePubMedPubMed CentralGoogle Scholar