Japanese-style intensive medical care improves prognosis for acute liver failure and the perioperative management of liver transplantation.

The Japanese style of intensive medical care for acute liver failure has yielded high survival rates. The care system comprises artificial liver support (ALS) together with treatment for the underlying disease. Plasma exchange in combination with high-volume hemodiafiltration using an high performance membrane has become the standard ALS system. It is safe, efficiently removing more low and middle molecular weight toxic substances than other methods because of the large volumes of buffer (more than 200 L per session), resulting in recovery from coma in patients with severe fulminant hepatitis, a status comparable with the ahepatic state. This ALS is therefore an effective tool to sustain patients with fulminant hepatitis in a favorable condition until liver function recovers or liver transplantation becomes available. The accompanying treatment for underlying disease serves to limit the liver destruction that hampers regeneration. The treatment has remarkably improved the prognosis for patients with subacute types of fulminant hepatitis, which generally carry a less favorable prognosis than the acute type. This treatment system thus provides more time for physicians to assess the indications for liver transplantation as well as giving the patient a greater chance of undergoing transplantation.

Liver support systems as perioperative care in liver transplantation-historical perspective and recent progress in Japan.

A meta-analysis of the efficacy of artificial liver support (ALS) systems for fulminant hepatic failure (FHF) by the Cochrane Hepato-Biliary Group suggested that all ALS systems previously developed are ineffective for FHF. This supports the view that the only treatment of choice for FHF is immediate liver transplantation. Plasma exchange, in combination with high-volume hemodiafiltration or high-flow continuous hemodiafiltration using large pore membranes, which was excluded from the Cochrane meta-analysis because of the lack of randomized control trials, has become a standard ALS system in Japan. This system is safe, and it efficiently removes more low and middle molecular weight toxic substances than other methods by using a large volume of buffers (more than 200 L per session), resulting in recovery from coma in patients with severe FHF comparable to an ahepatic state. These artificial liver support systems are effective tools for sustaining patients with FHF in a favorable condition until liver function recovers or liver transplantation becomes available.

Efficacy of interferon Beta combined with cyclosporine induction and intensified therapy for retreatment of chronic hepatitis C.

OBJECTIVE: Hepatitis C virus (HCV) infection is a major burden after liver transplantation. There is no effective treatment for these patients, therefore management is challenging. Cyclophilins are essential host factors for HCV replication. We have reported herein the efficacy of divided administration of interferon (IFN) beta plus cyclosporine for chronic hepatitis C patients who failed pegylated (Peg)-IFN or IFN combined ribavirin treatment. PATIENTS AND METHODS: We prospectively enrolled 59 patients (median age, 63 years) with genotype 1b who failed to respond to the combinations of IFN plus ribavirin or Peg-IFN plus ribavirin. Our treatment involved induction, intensified, and maintenance therapies. The induction therapy prescribed intravenous 1 MU IFN beta every 4 hours for the first 3 days, 1.5 MU IFN beta every 6 hours for the next 4 days, and then 2 MU IFN beta every 8 hours for 3 weeks. The intensified therapy was the induction therapy shortened to 2 weeks. The maintenance therapy involved Peg-IFN alpha 2b and ribavirin. Cyclosporine was given 4 times daily during the induction and intensified therapies. Ribavirin was given twice daily during the maintenance phase. RESULTS: The end treatment and sustained virological response rates in the present study were 73% (43/59) and 59% (35/59), respectively. The relapse rate was 19% (8/43). Sixteen percent of patients (3/19) were nonresponders. All adverse effects were reversible. The treatment protocol was well tolerated. CONCLUSION: Our protocol should be effective for patients who have failed previous combination therapies.

Artificial liver support system using large buffer volumes removes significant glutamine and is an ideal bridge to liver transplantation.

BACKGROUND: Fulminant hepatitis is an intractable disease of varying etiology. Artificial liver support (ALS) is used to control serious symptoms of fulminant hepatitis, such as brain edema, which may induce postoperative neurological deficits. PATIENTS AND METHODS: ALS was evaluated in 12 patients with fulminant hepatitis who had been placed on an ALS system comprising plasma exchange and online hemodiafiltration. Six of 12 patients fell into an ahepatic state, the absolute indication for liver transplantation. The effects of ALS were evaluated on the basis of improvements in clinical symptoms, removal of glutamine (Gln), and brain computed tomography. RESULTS: All 12 patients regained consciousness with ALS and 5 survived; 7 died despite recovering from hepatic coma. The ALS systems sustained patients in an ahepatic state for more than 2 weeks. The median estimated plasma equivalent volume of removed Gln was 17.9 L (range, 6.7-64.3 L). There was a significant relationship between total buffer volume and the plasma equivalent volume of removed Gln. CONCLUSION: Plasma exchange combined with hemodiafiltration using large buffer volumes is a promising and effective bridging method to liver transplantation.

Intracellular-diced dsRNA has enhanced efficacy for silencing HCV RNA and overcomes variation in the viral genotype.

RNA interference (RNAi) can be used to inhibit viral replication in mammalian cells and therefore could be a powerful new antiviral therapy. Small interfering RNA (siRNA) may be effective for RNAi, but there are some technical problems that must be solved in each case, for example, predicting the effective siRNA target site and targeting heterogeneous sequences in a virus population. We show here that diced siRNA generated from long double-stranded RNA (dsRNA) is highly effective for inducing RNAi in HuH-7 cells harboring hepatitis C virus (HCV) replicons and can overcome variations in the HCV genotype. However, in mammalian cells, long dsRNA induced an interferon response and caused cell death. Here we describe an improvement of this method, U6 promoter-driven expression of long hairpin-RNA with multiple point mutations in the sense strand. This can efficiently silence HCV RNA replication and HCV protein expression without triggering the interferon response or cell death normally caused by dsRNA. In conclusion, intracellular-diced dsRNA efficiently induces RNAi, and, despite the high rate of mutation in HCV, it should be a feasible therapeutic strategy for silencing HCV RNA.

Interferon combined with cyclosporine treatment as an effective countermeasure against hepatitis C virus recurrence in liver transplant patients with end-stage hepatitis C virus related disease.

Hepatitis C virus (HCV) is the most common cause of end-stage liver disease in transplant recipients. Progression of recurrent HCV infection is accelerated. Cyclosporine is not only an immunosuppressive drug, but also an anti-HCV drug. We reported here the beneficial effect of combined interferon and cyclosporine treatment for chronic hepatitis C. We recommend this protocol for established HCV-related graft disease.

[Overview of hepatitis C virus from its discovery to now].

Hepatitis C was first recognized as a form of viral hepatitis that was distinct from disease caused by hepatitis A virus and hepatitis B virus. The etiologic agent of hepatitis C was proposed to be a small, enveloped virus based on demonstrations of its transmissibility to chimpanzees, electron microscopic studies, and sensitive to chloroform. Successful molecular cloning of viral genome in the late 1980's led to the development of assay for serological diagnosis of HCV and it is currently estimated that at least 170 million people are chronically infected with the hepatitis C virus. HCV evades host antiviral defenses by mechanisms that remain to be identified and establishes a persistent infection in a majority of patients. Persistent infection of HCV is a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. Therefore development of antiviral treatment for HCV is an urgent worldwide health problem. Although much has been learned about HCV genome organization, polyprotein processing, protein function and structure, many key questions remain to be answered. Major efforts of Japanese investigators should now be directed at establishing cellular system and animal models appropriate for dissecting the various steps in HCV replication cycle and strategies for blocking them.

[IFN combined cyclosporin A therapy].

Current therapy of chronic hepatitis C with a 6 months course of alpha interferon shows limited effectiveness for patients with chronic hepatitis C. In particular more effective therapy is needed to treat patients who have high serum level of group 1-HCV RNA. We previously reported that a combination of interferon and cyclosporin A was more effective than interferon monotherapy. We also examined whether CsA has an antiviral effect on HCV using cultured human hepatocyte cell line. Propagation of HCV seems to be inhibited by CsA in a dose dependent manner. Further study is needed to clarify the action of cyclosporin A.

The presence of a newly identified infectious agent (SEN virus) in patients with liver diseases and in blood donors in Japan.

The existence of the newly discovered SEN virus (SENV) was investigated in 379 Japanese patients with liver diseases and in 277 blood donors, to determine whether SENV is associated with non-A-E hepatitis. SENV DNA was detected by seminested polymerase chain reaction, with primers directed to 2 SENV strains: SENV-H and SENV-D. SENV was detected in 7 (32%) of 22 patients with fulminant hepatitis, in 15 (17%) of 86 patients with acute hepatitis, in 38 (27%) of 139 patients with chronic hepatitis, in 29 (31%) of 93 patients with liver cirrhosis, in 5 (33%) of 15 patients with autoimmune hepatitis, in 11 (46%) of 24 patients with primary biliary cirrhosis, and in 27 blood donors (10%). Infection occurred more frequently in patients with liver diseases than in blood donors; however, there were no significant differences in SENV-positive rates between patients with non-A-C hepatitis and those with acute or chronic hepatitis due to known hepatitis virus or nonviral liver disease. This study did not suggest SENV as a possible causative agent of non-A-C hepatitis.

Microwave coagulation therapy for hepatocellular carcinoma.

The efficacy and safety of microwave coagulation therapy (MCT) in patients with hepatocellular carcinoma (HCC) and impaired hepatic reserve were studied. Preoperative background factors, postoperative results, and prognostic factors were compared in 51 patients who underwent hepatic resection (HR group) and 38 patients who underwent microwave coagulation therapy (MCT group). Before surgery, measures of hepatic function, including level of albumin (P = 0.0072), prothrombin time (P<0.0001), hepaplastin test (P = 0.0088), and the radioactivity of technetium-99m galactosyl-human serum albumin 15 min in the liver after injection divided by that in both liver and heart (P <0.0001) were significantly lower in the MCT group than in the HR group. The indocyanine green dye retention rate at 15 min was significantly greater (P<0.0001) in the MCT group than in the HR group, and a significant difference was noted in Child-Pugh grade between the groups (P<0.0001). Operative time (P = 0.0014) and blood loss during surgery (P = 0.0005) were significantly lower in the MCT group than in the HR group. In contrast, no significant differences were recognized between the groups in the changes in postoperative liver function, or in the rates of morbidity, mortality, local recurrence, and survival. Moreover, the type of treatment (HR or MCT) was not a prognostic factor. The results indicate that MCT can be used safely as an alternative to hepatic resection in patients with poor liver function without reducing the efficacy of local control.

TT virus infection in patients with fulminant hepatic failure.

OBJECTIVE: A new DNA virus, which has been designated the TT virus, was discovered in 1997. It is not clear whether TT virus is a cause of any of the types of hepatitis. We conducted a case-control study to test the hypothesis that the presence of TT virus is a necessary condition for the development of fulminant hepatic failure in people who have non-A, -B, or -C hepatitis. METHODS: We studied 55 patients with fulminant hepatic failure [28 men, 27 women, mean (+/- SD) age, 47 +/- 15 yr], 32 patients with acute hepatitis (18 men, 14 women, mean age, 38 +/- 15 yr), and 200 healthy subjects (106 men, 94 women, mean age, 42 +/- 14 yr). TT virus DNA was detected in sera by a nested polymerase chain reaction using a primer set for genotype 1. RESULTS: TT virus was more frequently detected in patients with fulminant hepatic failure [in 33 of 55 (60%); 95% confidence interval (CI), 47-73%] than in those with acute hepatitis [in 8 of 32 (25%); 95% CI, 10-40%; p = 0.0016] or in healthy subjects [in 50 of 200 (25%); 95% CI, 19-31%; p < 0.0001]. TT virus was detected at a significantly higher rate in non-A, -B, or -C fulminant hepatic failure [in 18 of 22 (82%); 95% CI, 66-98%] than in fulminant hepatic failure of A, B, or C type [45%, 28-62%, 15/33; p = 0.007] or in non-A, -B, or -C acute hepatitis [24%, 3-44%, 4/17; p = 0.0003]. The logistic regression analysis selected TT virus (p = 0.0009), age (p = 0.0116), and etiology (p = 0.0309) as independent variables associated with fulminant hepatic failure (coefficient of determination, 0.2335). CONCLUSIONS: TT virus comparatively plays a role in the pathogenesis of non-A, -B, or -C fulminant hepatic failure.

Quantitation of hepatitis B virus genomic DNA by real-time detection PCR.

Quantitation of hepatitis B virus (HBV) DNA in serum is a useful method for the monitoring of HBV replication. We attempted to develop a quantitative assay system for HBV DNA that is more sensitive, accurate, and reproducible than existing systems. We detected HBV DNA by real-time detection PCR (RTD-PCR) based on Taq Man chemistry. The efficacy of this assay was evaluated by quantitatively measuring sequential levels of synthetic DNA and DNA in clinical serum samples. The detection limit of this system was as few as 10 DNA copies/reaction. A linear standard curve was obtained between 10(1) and 10(8) DNA copies/reaction. The coefficient of variation for both intra- and interexperimental variability indicated remarkable reproducibility. This system detected HBV DNA in 100% of chronic hepatitis B patients tested and never detected HBV DNA in healthy volunteers who were negative for HBV markers. These observations suggest that RTD-PCR is an excellent candidate for a standard HBV quantification method.

[Reversible posterior leukoencephalopathy in a patient receiving cyclosporin therapy].

We reported a case of reversible posterior leukoencephalopathy syndrome (RPLS) that occurred during cyclosporin A (CyA) therapy for fulminant hepatitis. A 22-year-old man was given an intravenous drip of interferon-beta, metylprednisolone sodium succinate and CyA, and also received plasma exchange and hemodiafiltration. On the 7th day of the intravenous CyA therapy, in which its dose had been increased from 60 mg/day to 84 mg/day, he became somnolent and had headache, double vision, hallucination and then a generalized tonic-clonic seizure. The blood CyA concentration increased to a level as high as 455 ng/ml. Brain computed tomography (CT) scan without contrast medium revealed symmetric low-density areas in the bilateral occipital white matter and partly in the cortex. T2-weighted magnetic resonance imaging (MRI) showed an increased signal intensity, and single-photon emission CT using 99 mTc showed a hypoperfusion of cerebral blood flow in those areas. After CyA administration was changed to 100 mg/day orally to decrease its uptake in the blood, his consciousness and vision recovered within 4 weeks. Then abnormalities in MRI findings completely disappeared. On the basis of the clinical course and time-sequential change of serum CyA level in this patient, he was diagnosed as having RPLS caused by CyA therapy. Recently, the number of cases of RPLS has increased in the Western countries. However, there are few reports of RPLS after CyA therapy in Japan. From this case, we emphasize that careful following up the patient's neurological findings during CyA therapy is very important and that a cranial MRI is an essential tool for the diagnosis of RPLS.

Possible association between serum GB virus C RNA level and disease activity in fulminant hepatitis type G.

BACKGROUND/AIMS: Whether GB virus C causes serious liver diseases remains controversial. The aim of the present study was to determine whether there is an etiological relationship between GB virus C and fulminant hepatitis. METHODS: The level of GB virus C RNA in the sera of three patients with fulminant hepatitis was quantitatively determined using the newly developed real-time detection polymerase chain reaction method, which is based on Taq Man chemistry. The NS 3 region of the viral genome isolated from the sera was sequenced at several time points to confirm whether the same virus was responsible for fulminant hepatitis during the patients' clinical courses. RESULTS: The sensitivity of the PCR was comparable to that of nested PCR and a linear relationship between RNA copy number and threshold cycle was observed for 10(1) and 10(6) RNA copies/ml (r = 0.99). The serum level of GB virus C RNA closely paralleled that of ALT in all patients. Sequence analysis of the NS3 region isolated from the patients' sera revealed that the same GB virus C strain infected the patients during their entire clinical courses, despite plasma exchange therapy. CONCLUSIONS: These observations suggest that GB virus C may be etiologically associated with fulminant hepatic failure, and is not merely an inactive bystander introduced by therapeutic plasma exchange.