Baseline serum cholesterol is associated with a response to pegylated interferon alfa-2b and ribavirin therapy for chronic hepatitis C genotype 2.

Background. HCV infection is associated with lipid disorders because this virus utilizes the host lipid metabolism to sustain its life cycle. Several studies have indicated that higher concentrations of serum cholesterol and LDL before treatment are important predictors of higher rates of sustained virological response (SVR). However, most of these studies involved patients infected with HCV genotype 1. Thus, we performed a multi-institutional clinical study to evaluate the impact of lipid profiles on SVR rates in patients with HCV genotype 2. Methods. A total of 100 chronic hepatitis C patients with HCV genotype 2 who received peg-IFN alfa-2b and ribavirin therapy were consecutively enrolled. The significance of age, sex, BMI, AST level, ALT level, WBC, hemoglobin, platelet count, gamma-glutamyltransferase, total cholesterol level (TC), LDL level, HCV RNA, and histological evaluation was examined for SVR using logistic regression analysis. Results. The 100 patients infected with HCV genotype 2 were divided into 2 groups, an SVR group and a non-SVR group. Characteristics of each group were subsequently compared. There was no significant difference in the level of HCV RNA, BMI, platelet, TG, or stage of fibrosis between the groups. However, there were significant differences in the levels of TC and LDL-C. In multivariate logistic regression analysis using baseline characteristics, high TC level was an independent and significant risk factor (relative risk 18.59, P = 0.015) for SVR. Conclusion. Baseline serum total cholesterol levels should be considered when assessing the likelihood of sustained treatment response following the course of peg-IFN and ribavirin therapy in patients with chronic HCV genotype 2 infection.

Evaluation of new prognostic staging systems (SLiDe score) for hepatocellular carcinoma patients who underwent hepatectomy.

BACKGROUND/AIMS: A new prognostic staging system, the SLiDe (S, stage; Li, liver damage; De, des-gamma-carboxy prothrombin) score was recently proposed. We examined 207 HCC patients following hepatic resection to determine the usefulness of this staging system for HCC patients after surgery. METHODOLOGY: Disease-free and overall survival rates were calculated according to the Kaplan-Meier method, and differences between groups were tested for significance using the log-rank test. RESULTS: Regarding disease-free survival, there were no significant differences in survival between SLiDe score 0 vs 1, between score 2 vs 3, and between score 4 vs 5. There were significant differences between 0-1 vs 2-3 (p < 0.01) and between 2-3 vs 4-5 (p < 0.01). Regarding overall survival, there were no significant differences in survival between score 0 vs 1, between score 2 vs 3, and between score 4 vs 5. There were significant differences between 0-1 vs 2-3 (p < 0.05) and between 2-3 vs 4-5 (p < 0.01). CONCLUSIONS: The SLiDe score, a staging system that combines tumor factors, a tumor marker and hepatic function, might be a better predictor of prognosis in HCC patients who have undergone hepatic resection.

Clinical implications of antimitochondrial antibodies in type 1 autoimmune hepatitis: a longitudinal study.

BACKGROUND/AIMS: Autoimmune hepatitis (AIH) is a chronic liver disease characterized by the presence of antinuclear antibodies. However, antimitochondrial antibodies (AMA) and bile duct changes, which are the characteristics of primary biliary cirrhosis (PBC), can be detected in AIH patients. METHODOLOGY: Twenty patients with definite AIH were prospectively followed-up, and the serial changes in AMA profiles were determined. We also examined the correlations between these antibodies and histopathological findings in the liver. RESULTS: Of the 20 patients, 7 (35%) had bile duct injury, and 2 of these 7 patients also showed chronic nonsuppurative destructive cholangitis or ductopenia of interlobular bile ducts histopathologically. Serologically, 7 patients (35%) were positive for AMA at least once by immunoblotting during the follow-up periods. There were no significant differences in biochemical hepatobiliary indices, the presence of bile duct lesions, or the changes in biochemical profiles between AMA-positive and AMA-negative AIH patients during the follow-up periods. CONCLUSIONS: We confirmed that AMA and certain histopathological findings that are characteristics of PBC can be seen in some AIH patients. However, there was no significant correlation between AMA positivity and the histopathological findings in the liver, or biochemical hepatobiliary indices. Thus, the clinical implications of AMA in AIH patients remain unclear.

Intracellular balance of oxidative stress and cytoprotective molecules in damaged interlobular bile ducts in autoimmune hepatitis and primary biliary cirrhosis: In situ detection of 8-hydroxydeoxyguanosine and glutathione-S-transferase-pi.

AIM: Bile duct injury has been thought to be absent in autoimmune hepatitis (AIH), but recent studies have indicated that AIH patients do have bile duct injury. In this study, the intracellular balance of oxidative stress and cytoprotection in biliary epithelial cells was investigated to clarify the pathogenesis of bile duct injury in AIH. METHODS: The intracellular status of oxidative DNA damage caused by oxidative stress and glutathione, an endogenous cytoprotective molecule, were examined in patients with AIH, primary biliary cirrhosis (PBC), and normal controls by immunostaining of 8-hydroxydeoxyguanosine (8-OHdG) and glutathione-S-transferase-pi. RESULTS: Immunohistochemically, 8-OHdG expression was detected as abundantly in the damaged bile ducts of AIH patients as in PBC patients. Moreover, in AIH, 8-OHdG expression was detected in damaged bile ducts more than in undamaged bile ducts. Glutathione-S-transferase-pi expression was relatively preserved in the damaged bile ducts of AIH patients compared to PBC patients, reflecting preservation of intracellular glutathione. CONCLUSIONS: In AIH, oxidative stress and DNA damage may be involved in the pathogenesis of bile duct injury in a manner similar to that found in PBC. However, relatively preserved intracellular glutathione may play a key role in preventing progressive bile duct loss following bile duct injury in AIH.

IgA class antibodies to 2-oxo-acid dehydrogenase complex are not predictive markers of histopathological progression in primary biliary cirrhosis.

Although antimitochondrial antibody (AMA) is the characteristic serological feature of primary biliary cirrhosis (PBC), its pathogenic role remains unclear. In our previous study, we reported a positive correlation between immunoglobulin (Ig) A class anti-2-oxo-acid dehydrogenase complex (2-OADC) and histopathological stage. To determine whether the appearance of IgA class anti-2-OADC by immunoblotting represents an early marker of more aggressive disease or whether it is late finding during the disease course of PBC, we tested not only the entire IgA class but also IgA1, IgA2 and secretory IgA class anti-2-OADC in serial serum samples from 15 patients with PBC. During the median observation period of 51 months, four cases showed histopathological progression (from stage 1 to 2, stage 1 to 3, stage 1 to 4 and stage 2 to 4). There was no statistically significant correlation between the above IgA class anti-2-OADCs and histopathological progression. There was no significant correlation between histopathological stages and IgA2 class anti-2-OADC or secretory IgA class anti-2-OADC by immunoblotting. IgA class anti-2-OADC was more frequent in stages 3-4 than in stages 1-2 (p = 0.0049), but IgA1 class anti-2-OADC was more frequent in stages 1-2 than in stages 3-4 (p = 0.0232). Our present study demonstrated that serum IgA class 2-OADC was not a predictive marker of histopathological progression but was associated with the histopathological stage of PBC. Although the IgA class AMA may have a specific pathogenic role for PBC, the discrepant results between IgA and IgA1 class anti-2-OADC should be further assessed to investigate different functional activities depending on their molecular form.

Comparison of the grade evaluated by "Liver damage" of Liver Cancer Study Group of Japan and Child-Pugh classification in patients with hepatocellular carcinoma.

BACKGROUND: The "Liver damage" classification proposed by the Liver Cancer Study Group of Japan and Child-Pugh classification are both useful classifications for hepatic function. However, the factors responsible for the difference between the two classifications have not been fully investigated. METHODS: The medical records of 594 admissions of 220 patients with hepatocellular carcinoma (HCC) were retrospectively analyzed for encephalopathy, ascites, serum bilirubin and albumin, plasma retention rate (%) at 15min after injection of 0.5mg/kg of indocyanine green (ICG R15), and prothrombin time. RESULTS: Of 594 admissions, ICG R15 was tested in 337 (56.7%). The Child-Pugh classification was evaluated in all 594 admissions, but the "Liver damage" could be evaluated in 510 (85.9%) due to the lack of ICG R15 results. Of the 594 admissions, 372 (62.6%), 162 (27.3%), and 60 (10.1%) were Child-Pugh grade A, B, and C, respectively. Of the 510 admissions, 219 (42.9%), 202 (39.6%), and 89 (17.5%) were "Liver damage" grade A, B, and C, respectively. The grade of "Liver damage" was similar to that of Child-Pugh classification in 369 (72.4%), under-evaluated in 138 (27.1%), and over-evaluated in 3 (0.6%). The Child-Pugh classification was statistically a better classification for predicting outcome than "Liver damage", but the "Liver damage" had better stratification ability than Child-Pugh classification in patients with relatively good liver function. CONCLUSIONS: Although the "Liver damage" could not be evaluated in some cases due to the lack of ICG R15 results, this classification system is useful in the evaluation and prediction of outcome of patients with early-stage liver diseases.

Similar anti-mitochondrial antibody reactivity profiles in familial primary biliary cirrhosis.

AIMS: : Familial accumulation of primary biliary cirrhosis (PBC) has been documented. To examine the importance of genetic factors, we carried out family study of the disease with a particular focus on the reactivity profiles of anti-mitochondrial antibodies (AMA). PATIENTS AND METHODS: : Eighty-five patients with PBC that we experienced in the period of 1982-2003 were investigated, retrospectively. Twelve patients from a total of six families were investigated clinically and immunologically. RESULTS: : Of the 85 patients, 5 (5.9%) were found to have a family history of PBC. The six PBC family relationships consisted of four cases of sisters and two cases of a mother and daughter. HLA haplotypes were identical in two cases and were half-similar in the other cases. AMA titers were almost the same in three families and in five of the six families, sera from individual members within the family showed similar AMA-reactive bands in immunoblotting. CONCLUSION: : The prevalence of PBC is strikingly increased in family members (frequency of 5.9%). Sera from PBC patients of the same family showed the same AMA reactivity profile, suggesting that development of AMA may be greatly influenced by certain underlying genetic factors. Large-scale genomic studies of familial PBC will be critical to identify mechanisms of disease susceptibility.

The sperm mitochondria-specific translocator has a key role in maternal mitochondrial inheritance.

The mechanism of maternal mitochondrial inheritance in animals involves the selective elimination of sperm mitochondria by the elimination factor of the egg and the sperm mitochondria-specific factor. In vitro fertilization using sperm from isogenic mice incorporating heterospecific mitochondrial DNA (mtDNA) showed that the number of PCR positives of sperm mtDNA in two-cell embryos was significantly increased following sperm incubation with anti-tetratricopeptide repeat-containing protein involved in spermatogenesis (tpis) protein, anti-translocator of mitochondrial outer membrane (Tom) 22 and anti-Tom40 antibodies. The treatment of fertilized eggs with EGTA and other endonuclease inhibitors increased the sperm mtDNA levels. We conclude that the elimination factor, which is probably an endonuclease, is selectively received by the tpis protein of the sperm mitochondrial outer membrane within the egg. It is then transported into the sperm mitochondria by Tom22 and Tom40, where it destroys the sperm mtDNA, establishing the maternal inheritance of mtDNA.

Hepatocellular carcinoma in a male patient with early stage (stage I) primary biliary cirrhosis.

The true incidence of hepatocellular carcinoma (HCC) in patients with primary biliary cirrhosis (PBC) remains undetermined due to limited epidemiological studies and some conflicting results. Some studies indicated that in PBC, male gender, cirrhosis, hepatitis C virus (HCV) superinfection, and history of blood transfusion are associated with the development of HCC, and the occurrence of HCC in the early stage of PBC is rare. We present herein a 75-year-old male patient with stage I PBC who developed oropharyngeal squamous cell carcinoma, followed by HCC and duodenal adenocarcinoma without hepatitis B or C virus infection. While it could be argued that the concurrence of HCC and stage I-PBC in our patient was coincidental, patients with early stage PBC should be strictly followed up as cirrhotic patients with PBC by monitoring the serum concentration of tumor markers for HCC and appropriate imaging methods.

Does the diagnosis of primary biliary cirrhosis or autoimmune cholangitis depend on the 'phase' of the disease?

BACKGROUND: It is unclear whether autoimmune cholangitis (AIC) is a separate disease entity or primary biliary cirrhosis (PBC) without antimitochondrial antibodies (AMA) since fluctuation of AMA titres by immunofluorescence (IF) is often observed during the course of PBC. The aim of this study was to determine the serial changes in AMA profiles during the course of initially diagnosed PBC or AIC. METHODS: In this prospective study, 32 patients with PBC or AIC were followed-up for at least 20 months and tested for AMA by IF, enzyme-linked immunosorbent assay (ELISA), and immunoblotting (IB). RESULTS: When positive AMA result was defined as 'AMA by IF positive', 'AMA by IF and/or ELISA positive', and 'AMA by IB positive', the diagnosis of PBC or AIC did not change in 78%, 91%, and 97%, respectively, throughout follow-up. However, the diagnosis changed in one patient, and three patients were diagnosed as AIC throughout follow-up, despite the use of all three assays. CONCLUSIONS: Our results suggested that the diagnosis of PBC and AIC was dependent on the 'phase' of the respective disease in 22% of the patients when negative AMA result was defined as 'AMA by IF negative'. This may result in recommending IB analysis before making the diagnosis of AIC.

Preliminary analysis of a newly proposed prognostic scoring system (SLiDe score) for hepatocellular carcinoma.

BACKGROUND: The long-term prognosis of hepatocellular carcinoma (HCC) remains poor and the prediction of survival is often difficult because of the limited liver function and frequent recurrence of HCC in most patients. Therefore, a prognostic classification of HCC should account for both tumor-related variables and liver function. METHODS: The value of reported prognostic factors for HCC was assessed and a new prognostic classification was established called the 'SLiDe' scoring system (S, stage; Li, liver damage; De, des-gamma-carboxy prothrombin) using 'stage' and 'liver damage' of the recently revised 4th edition of the Japanese staging system edited by the Liver Cancer Study Group of Japan, and the serum level of des-gamma-carboxy prothrombin (DCP) in 177 patients with HCC. RESULTS: Univariate analysis identified Child-Pugh stage, liver damage, tumor morphology, portal vein thrombosis, stage, serum level of alpha-fetoprotein (AFP), serum level of DCP, and initial treatment as significant prognostic factors. Of these, liver damage, stage, and serum level of DCP remained independent predictive factors of survival after multivariate prognostic analysis using the proportional hazards regression model. Therefore, a new prognostic scoring system (SLiDe scoring system) was derived that assigned a linear score (0/1/2/3) to these three covariates. This SLiDe scoring system was statistically a better model for predicting outcome in the present study population than the Cancer of the Liver Italian Program (CLIP) and the Japan Integrated Staging (JIS) scoring systems, as judged by the Akaike Information Criteria. CONCLUSION: The SLiDe scoring system is useful for the assessment of the prognosis of patients with HCC as long as the Japanese staging system is used, although this uses parameters such as the indocyanine green retention test and DCP, which are not examined routinely in every part of the world. Therefore, the proposed classification should be further validated in other large study populations.

Anti-extractable nuclear antigens (ENA) antibodies in patients with chronic hepatitis C before and after treatment with interferon.

A high prevalence of serological markers classically associated with autoimmune hepatitis or other autoimmune diseases has been reported in patients with chronic hepatitis C. However, the prevalence of antibodies to extractable nuclear antigens (anti-ENA) are rarely reported in such patients and the effect of treatment with interferon (IFN) on their prevalence is not known. In the present study, serum samples collected from 44 patients with chronic hepatitis C and 44 patients with non-hepatitis C virus (HCV) infected liver diseases were tested for anti-ENAs (U1 RNP, Sm, Ro/SS-A, La/SS-B and Scl-70) antibodies by enzyme-linked immunosorbent assay (ELISA). In 26 patients with chronic hepatitis C who received IFN treatment, serum samples were also collected just after completion of IFN treatment, and/or at 6-40 months after completion of the treatment, and tested for these antibodies. Sixteen (36%) of 44 sera from patients with chronic hepatitis C were positive for at least one of the above anti-ENA antibodies, whereas only 7 (16%) of 44 sera from patients with non-HCV infected liver diseases were positive for such antibodies (p = 0.0290). There was no significant difference in the prevalence of each of anti-ENA antibody between men and women. Results of anti-ENA antibodies in most IFN-treated patients with chronic hepatitis C did not change after treatment. However, in some cases serum anti-U1 RNP, anti-La/SS-B and anti-Scl-70 became negative or converted to the gray zone after completion of IFN treatment regardless of HCV elimination. Our results showed that the overall prevalence of anti-ENA antibodies was significantly higher in patients with chronic hepatitis C than in those with non-HCV-infected liver diseases. However, the disappearance of anti-ENA antibodies after IFN treatment in patients with chronic hepatitis C may be due to the immunomodulating effects of IFN rather than HCV elimination.

Immune thrombocytopenic purpura in patients with ulcerative colitis.

Extraintestinal manifestations of ulcerative colitis (UC) are well known, but immunologically mediated hematological diseases are relatively rare. We describe two cases of immune thrombocytopenic purpura (ITP) associated with preexisting UC. Our patients had typical symptoms of UC, and endoscopy showed pancolitis. During treatment with 5-aminosalicylic acid and steroids, severe thrombocytopenia was noted. ITP was diagnosed based on a normal to high number of megakaryocytes in the bone marrow, positive autoantibody to platelet membrane antigen, and absence of splenomegaly. Medical treatment, including increased dosage of steroids, failed to control UC and ITP in both patients. In the first patient, the platelet count recovered after colectomy, while the second patient died of a cerebral hemorrhage. We stress that a diagnosis of ITP should be considered for thrombocytopenia in patients with UC, especially those showing extensive and significant colonic inflammation, and that colectomy of UC might resolve resistant ITP.

Correlation between histopathological findings of the liver and IgA class antibodies to 2-oxo-acid dehydrogenase complex in primary biliary cirrhosis.

Although anti-mitochondrial antibody (AMA) is the characteristic serological feature of primary biliary cirrhosis (PBC), its pathogenetic role remains unclear. We tested sera from 72 Japanese patients with histologically confirmed PBC for AMA by indirect immunofluorescence, anti-pyruvate dehydrogenase complex (PDC) by enzyme inhibition assay, immunoglobulin (Ig) G class anti-PDC by ELISA, and IgG, IgM, and IgA class anti-2-oxo-acid dehydrogenase complex (2-OADC) by immunoblotting. Of the 72 sera, 60 (83%), 50 (69%), 42 (58%), and 71 (99%) were positive for AMA by immunofluorescence, enzyme inhibition assay, ELISA, and immunoblotting, respectively. There was no significant correlation between histological stages and AMA by immunofluorescence, PDC inhibitory antibodies by enzyme inhibition assay, IgG class anti-PDC antibodies by ELISA, or IgG and IgM class anti-2-OADC by immunoblotting. IgA class anti-2-OADC by immunoblotting was more frequent in stages 2-4 than in stage 1 (P = 0.0083). Of the IgA class anti-2-OADC, anti-PDC-E2 (74 kDa) and anti-E3BP (52 kDa) were more frequent in stages 2-4 than in stage 1 (P = 0.0253 and 0.0042, respectively). Further examination of histopathological findings in 53 of 72 liver biopsy specimens showed that IgA class anti-PDC-E2 and IgA class anti-E3BP were associated with bile duct loss, and IgA class anti-PDC-E2 was also associated with interface hepatitis and atypical ductular proliferation. IgA is known to be secreted into the bile through biliary epithelial cells, implying that IgA class anti-PDC-E2 and E3BP may have a specific pathogenetic role during their transport into the bile by binding to their target antigen(s) in biliary epithelial cells, and this may be followed by dysfunction and finally destruction of biliary epithelial cells. Our present results suggest that these autoantibodies against 2-OADC detected by immunoblotting may be associated with the pathogenesis and pathologic progression of PBC.

Evaluation of newly developed ELISA using "MESACUP-2 test mitochondrial M2" kit for the diagnosis of primary biliary cirrhosis.

OBJECTIVES: An enzyme-linked immunosorbent assay (ELISA) using MESACUP-2 Test Mitochondria M2 kit (new-M2 ELISA) has recently become commercially available. The aim of this study was to evaluate the clinical utility of this newly developed ELISA for the diagnosis of primary biliary cirrhosis (PBC). DESIGN AND METHODS: We tested the immunoreactivity of sera from 82 Japanese PBC patients to the 2-oxo-acid dehydrogenase complex (2-OADC) enzymes by indirect immunofluorescence, enzyme inhibition assay using commercially available TRACE Enzymatic Mitochondrial Antibody (M2) Assay (EMA) kit, commercial ELISAs using MESACUP Mitochondria M2 kit (old-M2 ELISA) and new-M2 ELISA, and immunoblotting on bovine heart mitochondria. RESULTS: Each test gave the following positive results; antimitochondrial antibodies (AMA) by immunofluorescence in 71 (87%) out of the 82 sera, enzymatic inhibitory antibody to pyruvate dehydrogenase complex (PDC) by EMA in 61 (74%), immunoglobulin (Ig) G class anti-PDC antibody by old-M2 ELISA in 55 (67%), IgG/M/A class anti-E2 subunit of PDC (PDC-E2)/anti-E2 subunit of branched chain oxo-acid dehydrogenase complex (BCOADC-E2)/anti-E2 subunit of 2-oxoglutarate dehydrogenase complex (OGDC-E2) antibodies by new-M2 ELISA in 73 (89%), and IgG, IgM, or IgA class antibodies against at least one of the 2-OADC enzymes by immunoblotting in 82 (100%). Fifty-three of the 82 sera (65%) were all positive by these five assays. Of the 18 sera that were positive by new-M2 ELISA but negative by old-M2 ELISA, 12 were theoretically interpretable. Of the 11 sera that were negative for AMA by immunofluorescence but positive for at least one of anti-2-OADC enzymes by immunoblotting, four (36%) were positive by new-M2 ELISA, whereas only two and one sera were positive by EMA and old-M2 ELISA, respectively. CONCLUSIONS: Our results indicated that the sensitivity of the newly developed new-M2 ELISA was higher than that of EMA and old-M2 ELISA, and comparable with that of immunofluorescence. However, it is still unclear whether the new-M2 ELISA could replace the conventional immunofluorescence testing for routine assay requests because six (7%) sera showed discrepant results between these two assays.

Fatty liver in non-alcoholic non-overweight Japanese adults: incidence and clinical characteristics.

BACKGROUND AND AIMS: Fatty liver is not uncommon in many countries, including Japan, and is mainly caused by alcohol usage and obesity. The aim of this study was to determine the incidence and causative factors of fatty liver in Japanese adults. METHODS: The clinical characteristics of 3432 Japanese adults who visited our hospital between January and December 2000 for thorough medical examinations were recorded including sex, age, body mass index (BMI), percentage body fat measurement using a bipedal bioimpedance instrument, history of alcohol intake, blood pressure, serum levels of aspartate aminotransferase, alanine aminotransferase (ALT), gamma-glutamyl transpeptidase, total cholesterol, triglyceride, uric acid, fasting blood glucose (FBG), and liver status by ultrasonography (USG). RESULTS: Of 3432 participants, 747 (21.8%) were diagnosed as having fatty liver by USG, 1873 (54.6%) were 'daily alcohol drinkers', and 698 (20.3%) were overweight (BMI >or= 25 kg/m2). Fatty liver was more frequent in men and overweight subjects (P < 0.01), whereas there was no significant difference in the proportion of the 'daily alcohol drinker' between fatty liver and non-fatty liver participants. The logistic regression analysis showed that BMI, ALT, and triglyceride were independent predictors of fatty liver in both sexes, and FBG, uric acid, percentage body fat, and total cholesterol were independent predictors of fatty liver only in men. It was noted that 319 (9.3%) were non-alcoholic individuals with fatty liver, and 141 (4.1%) were non-alcoholic and non-overweight individuals with fatty liver. The logistic regression analysis showed that percentage body fat was an independent predictor of fatty liver in non-alcoholic and non-overweight participants in both sexes, although non-significant in women in the whole group. CONCLUSIONS: In our study population, 21.8% had fatty liver diagnosed by USG, 9.3% were non-alcoholic with fatty liver, and 4.1% were non-alcoholic and non-overweight with fatty liver. Our results suggest that central body fat distribution can correlate with the development of fatty liver, and that measurement of percentage body fat is useful to assess the etiology of fatty liver in non-alcoholic and non-overweight participants, particularly women.