Induction of elastin expression in vascular endothelial cells relates to hepatoportal sclerosis in idiopathic portal hypertension: possible link to serum anti-endothelial cell antibodies.

Hepatoportal sclerosis accompanied by dense elastic fibre deposition is generally regarded as the primary lesion in the development of idiopathic portal hypertension (IPH). This study was performed to clarify the mechanism of elastic fibre deposition in the peripheral portal tracts of IPH liver in relation to serum anti-endothelial cell antibodies (AECA). In-vitro experiments were performed using human dermal microvascular endothelial cells (HMVEC) and patients' sera. The presence of serum AECA was assayed by a cell-based enzyme-linked immunosorbent assay (ELISA) using HMVEC. Immunohistochemical analysis of elastin was performed using liver tissue sections of IPH patients. IPH sera contained one or more AECA that could bind to the vascular endothelial cells of the peripheral portal tracts of the liver. When the value of AECA greater than the mean ± 2 standard deviations of healthy controls was regarded as positive, the positive detection rate of either immunoglobulin (Ig)G, IgA or IgM AECA in IPH sera was 30% (10 of 33 cases). IPH sera induced the expression of elastin in HMVEC, which appeared to be associated with the presence of AECA. Apoptosis was also induced in HMVEC by the stimulation with IPH sera. In vivo, elastin expression was observed in the endothelial cells of the peripheral portal tracts of IPH livers in a proportion of cases. The disease pathogenesis of IPH seems to be heterogeneous, and this study elucidated a possible contribution of the induction of elastin expression in the portal vessels to hepatoportal sclerosis of IPH, which might be linked to serum AECA as a causative factor.

Add-on combination therapy with adefovir dipivoxil induces renal impairment in patients with lamivudine-refractory hepatitis B virus.

Combination therapy with adefovir dipivoxil (ADV) and lamivudine (LAM) is recommended for patients infected with LAM-refractory hepatitis B virus (HBV). However, the effects of such therapy on renal function and serum phosphorus levels have not been fully evaluated. Combination therapy with ADV and LAM was given to 37 patients infected with LAM-refractory HBV, including 17 with hepatic cirrhosis. Serum HBV DNA levels decreased to below 2.6 log(10) copies/mL in 23 (62%) of 37 patients at 12 months, 25 (78%) of 32 patients at 24 months, and 16 (84%) of 19 patients at 36 months. Except for one cirrhotic patient, serum alanine aminotransferase levels were below 50 IU/L in all patients during combination therapy. Serum creatinine levels increased in 14 (38%) of 37 patients, and serum phosphate levels decreased to below 2.5 mg/mL in 6 (16%) of 37 patients during combination therapy. Patients who received combination therapy for 36 months or longer had a significantly incidence of elevated serum creatinine levels. Fanconi syndrome occurred in a 57-year-old woman with cirrhosis after ADV was added to LAM. Combination therapy with ADV and LAM can maintain biochemical remission in patients with LAM-refractory HBV. However, the dosing interval of ADV should be adjusted according to renal function and serum phosphate levels in patients receiving long-term treatment.

Somatic mutation of mitochondrial DNA in cancerous and noncancerous liver tissue in individuals with hepatocellular carcinoma.

Unlike other types of cancer, hepatocellular carcinoma (HCC) is usually preceded by chronic inflammation caused by viral infection. The mutation of mitochondrial DNA (mtDNA) in hepatocarcinogenesis associated with viral infection was investigated. Compared with control liver tissue, the frequency of mtDNA mutations was markedly increased in both noncancerous and cancerous liver specimens from individuals with HCC. The accumulation of mtDNA mutations in HCC tissue reflected the degree of malignancy. The frequency of mtDNA mutations in HCC tissue was also greater than that described previously for other types of tumors. These observations suggest that the repeated destruction and regeneration of liver tissue associated with chronic viral hepatitis lead to the accumulation of mtDNA mutations. The genetic instability that results in the high rate of mtDNA mutation in cancerous liver tissue is also consistent with the multicentric hepatocarcinogenesis detected clinically.

Outcomes of dysplastic nodules in human cirrhotic liver: a clinicopathological study.

The number of dysplastic nodules detected clinically has increased since patients with hepatitis virus-associated cirrhosis, who are at increased risk for hepatocellular carcinoma (HCC), began to undergo regular cancer surveillance. Although it is potentially important to determine which type(s) of nodule may be prone to progress to HCC, outcomes of dysplastic nodules have not been fully investigated. This prompted us to examine the outcomes of dysplastic nodules in cirrhotic patients clinicopathologically. We studied 33 dysplastic nodules of <20 mm in maximum diameter, diagnosed by fine needle aspiration biopsy under ultrasonography (US). These nodules were clinically followed, mainly by US examination, for up to 70 months. When the nodules enlarged or exhibited changes on US, they were histologically reexamined by second biopsy. Surprisingly, 15 of the 33 nodules (45.5%) disappeared, 14 nodules (42.4%) remained unchanged, and only 4 nodules (12.1%) progressed to HCC. The latter 4 nodules were all hyperechoic on US and were composed of clear cells with fatty change or small cells with increased nuclear density, and in all 4 patients serum was positive for hepatitis C virus antibody. Univariate analyses revealed that, although not significant, the hyperechoic nodules or nodules with small cell change showed a higher HCC progression rate in comparison with the hypoechoic nodules or the nodules without small cell change. In summary, most of the dysplastic nodules we followed disappeared or remained unchanged, but some progressed to HCC. Hyperechoic nodules in patients with hepatitis C virus-associated cirrhosis, which show small cell change with increased nuclear density, may be prone to progress to HCC.

Diagnosis of chronic liver disease from liver scintiscans by fuzzy reasoning.

UNLABELLED: We investigated the possibility that fuzzy reasoning might be used to standardize diagnosis of liver disease based on scintigraphic results and compared the results with those obtained when scintiscans were scored conventionally. METHODS: Seventy-five patients with chronic liver disease (11 patients had chronic persistent hepatitis, 26 had chronic aggressive hepatitis and 38 had cirrhosis) and 25 controls were studied. Another 75 patients with hepatitis or cirrhosis were examined to test the effectiveness of the membership functions. Liver scintiscans were taken 20 min after the intravenous injection of 111 MBq of 99mTc-phytate. Fuzzy reasoning was used to evaluate the following five items: the ratio of the sizes of the left and right lobes, splenomegaly, radioactivity in the bone marrow, deformity of the liver and distribution of radioactivity in the liver. The degree of conformity to each of the three liver diseases being investigated was substituted into the membership function for the conclusion. The center of gravity for each patient's results was calculated. Conventional scoring was made with three levels for each of the five items examined by fuzzy reasoning. RESULTS: Distinctions between chronic persistent hepatitis and chronic aggressive hepatitis were difficult to assess with fuzzy reasoning and conventional scoring. The diagnostic accuracy was 95% for patients with cirrhosis and 88% for patients with chronic hepatitis with fuzzy reasoning. With conventional scoring the accuracy was 86% for patients with cirrhosis and 75% for patients with chronic hepatitis. When fuzzy reasoning was used to examine the other 75 patients with chronic liver diseases, the accuracy was 93% for patients with cirrhosis and 86% for patients with chronic hepatitis. CONCLUSION: The method is simple and can be used routinely in clinical settings.

Results of surgery for portacaval shunt in a patient with situs inversus diagnosed and evaluated by per rectal portal scintigraphy.

A 70-yr-old man diagnosed with situs inversus was hospitalized because of hepatic encephalopathy. Per rectal portal scintigraphy showed portal hypertension and a region with high radionuclide activity in the right lateral region of the abdomen. In percutaneous transhepatic portograms, a giant portacaval shunt was seen in the region with high radionuclide activity. After the portacaval shunt was obstructed surgically, the hepatic encephalopathy disappeared. In per rectal portal scintigraphy done 2 wk after surgery, the pattern was normal and the region with high radionuclide activity had disappeared.

Portal circulation by technetium-99m pertechnetate per-rectal portal scintigraphy.

Portal circulation in patients with chronic liver diseases was evaluated by [99mTc]pertechnetate per-rectal scintigraphy. Technetium-99m pertechnetate (10 mCi) was instilled into the upper rectum, and serial scintigrams were taken. Radioactivity curves for the liver and heart were then recorded sequentially. Through analysis of these curves, the per-rectal portal shunt index (Sl) was calculated for six healthy subjects and 228 patients, 59 with chronic hepatitis, seven with idiopathic portal hypertension, six with primary biliary cirrhosis, and 156 with cirrhosis. In the healthy subjects, the Sl was 1.9-5.2% (mean 4.1%). In hepatitis, the mean Sl was 7.1%, and in cirrhosis, 52.9%. The Sl was higher in cirrhotic patients with esophageal varices than in those without (p less than 0.001), and in cirrhotic patients with encephalopathy than in those without (p less than 0.01). For some patients with portal hypertension, portal collateral circulation could be depicted, and images of changes in the portal collateral circulation after vascular anastomosis were seen.

Evaluation of fulminant hepatic failure by scintigraphy with technetium-99m-GSA.

UNLABELLED: We evaluated the usefulness of hepatic receptor imaging with 99mTc-diethylenetriaminepentaacetic acid galactosyl human serum albumin (GSA) to establish the diagnosis and prognosis of fulminant hepatic failure (FHF). METHODS: Of the 20 patients, 8 had acute hepatitis and 12 had FHF. Computer acquisition of gamma-camera data started just before the injection of 185 MBq 99mTc-GSA and stopped 20 min later. Time-activity curves for the heart and liver were generated from regions of interest (ROIs) for the whole liver and precordium. A receptor index was calculated by division of the radioactivity of the liver ROI by that of the liver plus heart ROIs 15 min after the injection. An index of blood clearance was calculated by division of the radioactivity of the heart ROI at 15 min by that of the heart ROI 5 min after the injection. RESULTS: The receptor index was less than 0.83 in all patients with FHF, but it was more than 0.83 in all patients with acute hepatitis. The index of blood clearance was more than 0.72 in all patients with FHF but less than 0.72 in all patients with acute hepatitis. All six survivors of FHF had receptor indices of 0.58 or more, but in five of the six patients who later died, the receptor index was 0.58 or less. The index of blood clearance was 0.85 or less in all survivors but 0.85 or more in the same five patients who later died. CONCLUSION: Hepatic receptor imaging with 99mTc-GSA facilitated the evaluation of hepatic function reserve and was useful in establishing the diagnosis and prognosis of FHF.

Clinical usefulness of scintigraphy with 99mTc-galactosyl-human serum albumin for prognosis of cirrhosis of the liver.

UNLABELLED: Scintigraphy with 99mTc-diethylenetriamine pentaacetic acid-galactosyl-human serum albumin (99mTc-GSA) is useful for evaluating hepatic functional reserve. We assessed the clinical usefulness of this technique, including its value in establishing a prognosis, in patients with cirrhosis of the liver. METHODS: Scintigraphy with 99mTc-GSA was performed in 10 healthy subjects, 42 patients with chronic hepatitis and 158 patients with cirrhosis. Computer acquisition of gamma camera data were started just before the injection of 99mTc-GSA. Time-activity curves for the heart and liver were generated from regions of interest (ROIs) for the heart and the entire liver. A receptor index was calculated by dividing the radioactivity of the liver ROI by that of the liver-plus-heart ROI 15 min after the injection. An index of blood clearance was calculated by dividing the radioactivity of the heart ROI at 15 min by that of the heart ROI at 3 min. RESULTS: The median receptor index was lower in patients with cirrhosis than in patients with chronic hepatitis or in healthy subjects, and the median index of blood clearance was higher. The receptor index was significantly lower when a complication (varices, ascites) was present. The index of blood clearance was significantly higher when a complication (varices and ascites) was present. Correlation of the two indices with classic indicators for functional reserve was significant. On the basis of the receptor index, the patients with cirrhosis were divided into two groups of roughly equal size: group A, receptor index over 0.85, and group B, receptor index 0.85 or less. On the basis of the index of blood clearance, the patients with cirrhosis were divided into two groups of roughly equal size: group A, index of blood clearance < 0.70, and group B, index of blood clearance > or = 0.70. The cumulative survival rates were lower in group B than in group A. CONCLUSION: Scintigraphy with 99mTc-GSA is clinically useful, especially in establishing the prognosis of patients with cirrhosis of the liver.

Hepatic distribution of blood flow from the superior or inferior mesenteric vein mapped by portal scintigraphy with iodine-123-iodoamphetamine.

UNLABELLED: We previously reported the clinical meaning of measurements of the relative contributions of the superior and inferior mesenteric veins with [123I]iodoamphetamine after oral (in an enteric capsule) and rectal administration. The same method was used to map blood flow in the liver from both of these veins in 82 subjects, 31 with chronic hepatitis and 51 with cirrhosis. METHODS: Three hours after administration of a capsule containing 22.8 MBq of [123I]iodoamphetamine, data showing hepatic blood flow from the superior mesenteric vein were collected for 10 min. Next, 111 MBq of [123I]iodoamphetamine was administered rectally and data showing hepatic blood flow from the inferior mesenteric vein were collected for 30 min. Shunt indices from the superior and inferior mesenteric veins were calculated from these data. RESULTS: In patients with chronic hepatitis, blood from the superior mesenteric vein flowed into the right lobe or both lobes, but, in some patients with cirrhosis, blood from this vein flowed into the left lobe. In some patients with chronic hepatitis, blood from the inferior mesenteric vein flowed into the left lobe, but, in most patients with cirrhosis, the liver was not visualized during this examination and evaluation was not possible. Of the 53 patients in whom blood flow from both veins could be evaluated, 47 had blood from the two veins mixed to some extent in the liver and 6 had portal streamlining, with blood from the superior mesenteric vein going to the right lobe and blood from the inferior mesenteric vein going to the left lobe. CONCLUSION: These results suggest that blood flow in the superior and inferior mesenteric veins can be found mixed in the liver in most subjects with liver disease.

Course before and after treatment of a patient with Budd-Chiari syndrome monitored by iodine-123-iodoamphetamine scintigraphy per os and per rectum.

A 55-yr-old woman with Budd-Chiari syndrome was treated by percutaneous transluminal angioplasty with a balloon catheter. Before and after treatment, portal scintigraphy was performed by the administration of [123I]iodoamphetamine per os and per rectum. An enteric capsule was used for the oral administration. Before treatment, the portal shunt index via the superior mesenteric vein was 40.5%; two weeks after treatment, it was 50.2%; and five months after treatment, it was 41.2%. Before treatment, the portal shunt index via the inferior mesenteric vein was 86.0%; two weeks after treatment, it was 87.6%; and five months after treatment, it was 21.8%. The treatment improved the portal circulation through the inferior mesenteric vein only, with little effect on the portal circulation through the superior mesenteric vein.

Changes in results of Gallium-67-citrate scanning after interferon therapy for chronic hepatitis C.

UNLABELLED: Gallium-67 scanning is useful for early diagnosis and grading of interstitial lung disease. In a study of the side effects of interferon (IFN) on the lungs of patients with chronic hepatitis C, we performed 67Ga scanning before and after IFN therapy. METHODS: The 66 subjects who underwent at least one scanning, before IFN therapy, were 8 patients with chronic persistent hepatitis (CPH), 21 with chronic aggressive hepatitis 2A (CAH-2A), 25 with chronic aggressive hepatitis 2B (CAH-2B) and 12 with cirrhosis. All had underlying hepatitis C viral infection. Of those patients, 20 were examined again within 1 mo after IFN therapy. Patients received an intravenous injection of 340 MBq 67Ga-citrate and were imaged 72 hr later. ROIs were established for anterior views of the lungs (Lu), liver (Li) and soft tissue of the upper arm as background (B). The counts per unit size of each region of interest were used in calculation of the ratios Lu/B and Li/B. RESULTS: The medians of Lu/B were 2.46 in CPH, 2.56 in CAH-2A, 2.50 in CAH-2B and 2.47 in cirrhosis. These differences were not statistically significant. The medians of Li/B were 6.42 in CPH, 6.14 in CAH-2A, 5.11 in CAH-2B and 4.03 in cirrhosis. The differences between the median Li/B of cirrhotic patients and the medians for patients with CPH, CAH-2A and CAH-2B were significant. After therapy, Lu/B was higher than before in 16 of the 20 patients and lower in the four other patients; the overall rise was significant (Wilcoxon rank-sum test). Li/B was higher than before in 11 of the 20 patients and lower in the nine other patients. CONCLUSION: IFN caused uptake of the radionuclide to increase in most patients. This method showed changes in the accumulation of 67Ga-citrate that could have been missed if the results had been inspected by eye. IFN can cause interstitial lung disease, but unlike other drugs with this side effect, the onset seems to be gradual enough to be detected quantitatively by 67Ga scanning.

Fulminant hepatic failure monitored by technetium-99m-DTPA-galactosyl-human serum albumin scintigraphy.

We describe a 43-yr-old woman with fulminant hepatic failure whose progress was monitored scintigraphically using 99m-Tc-galactosyl-human serum albumin (99mTc-GSA). On admission, the liver was atrophic and the heart was delineated distinctly by scintigraphy with 99m-Tc-GSA. The receptor index, calculated by dividing the radioactivity of the liver region of interest by the radioactivity of the liver plus heart regions of interest at 15 min post-tracer injection, was very low. As the patient's condition improved, the right lobe of the liver enlarged while the left lobe became atrophic; after 4 mo, the left lobe almost completely disappeared. Delineation of the heart gradually became less distinct, and the receptor index slowly increased. Hepatic receptor imaging with 99m-Tc-GSA can define both the hepatic functional reserve and morphological changes of the liver, so it is useful for the diagnosis and follow-up study of fulminant hepatic failure.

Clinical usefulness of conjugated bilirubin levels in patients with acute liver diseases.

We used a specific method to measure conjugated bilirubin levels in patients with acute liver diseases to examine its clinical usefulness. Conjugated and total bilirubin levels were measured in 102 samples obtained from six patients with acute liver diseases (three with fulminant hepatic failure, one with acute severe hepatitis and two with acute hepatitis; see text for criteria). Total and conjugated bilirubin levels were measured with Iatro T (total)-Bil and D (direct)-Bil kits (Iatron Laboratories Tokyo, Japan) and with conventional Nescauto T(total)-Bil and D(direct)-Bil VE kits (Nippor Shoji, Osaka, Japan). The Iatro D-Bil kit measures conjugated bilirubin correctly, while the Nescauto D-Bil VE kit measures some nonconjugated bilirubin and delta bilirubin as well as conjugated bilirubin. Total bilirubin levels determined by the two methods showed good correlation. The conjugated bilirubin level measured with the Iatro D-Bil kit was strongly correlated with the direct bilirubin level measured with the Nescauto D-Bil VE kit, but there was no correlation between the conjugated-to-total bilirubin ratio and the direct-to-total bilirubin ratio. When we examined the changes in bilirubin levels in our patients with respect to outcome, we found that the two patients in whom the ratio of conjugated-to-total bilirubin exceeded 0.3 died, while all four patients in whom the ratio remained below 0.3 survived. The ratio of direct-to-total bilirubin was unrelated to outcome. The conjugated bilirubin level measured with the Iatro kits was therefore considered useful for the diagnosis and follow-up of acute liver diseases.

Calcitriol for bone loss in patients with primary biliary cirrhosis.

Because osteoporosis is a common complication of primary biliary cirrhosis, we evaluated the effects of calcitriol (1alpha, 25-dihydroxyvitamin D3) on bone mineral density in 34 women with primary biliary cirrhosis (stage I disease in 16 patients, stage II in 9, stage III in 4, and stage IV in 5). Patients were assigned randomly to receive calcitriol (0.5mg twice a day) or not. Bone mineral density of the lumbar vertebrae was measured by dual-energy X-ray absorptiometry at least twice during a period of 12-43 months. The mean annual change in bone mineral density was 0.1% in the treatment group and -3.1% in the control group. The median annual change (with 25th and 75th percentiles) in bone mineral density was 0.3% (-0.5%, 1.9%) in the treated group and -3.1% (-4.1%, -2.1%) in the control group. This difference between the two groups was significant (P = 0.0007, Mann-Whitney U-test). Our findings suggest that calcitriol prevents bone loss and may be an effective treatment for osteoporosis in patients with primary biliary cirrhosis.

Longitudinal changes of bone mineral content with age in patients with cirrhosis of the liver.

Bone disorders are associated with cirrhosis. Knowledge of the natural course of bone changes in cirrhosis could help in decision-making about medical treatment. We carried out one measurement of bone mineral density (BMD) in 184 Japanese patients (98 men and 86 women) with cirrhosis by dual-energy X-ray absorptiometry. Differences in BMD values means +/- SD between the 98 cirrhotic men and 283 healthy men of the same age reported in another study were not significant. In the 86 cirrhotic women, BMD tended to show a greater decrease with age than in healthy controls reported elsewhere. Differences in BMD values (means +/- SD) between 622 healthy women reported elsewhere and our patients were not significant for women up to age 60 years, but at 60 years or more, the mean BMD in cirrhotic women (0.692 +/- 0.100) was lower than that in healthy women (0.749 +/- 0.101; P < 0.01). In 61 of the 184 patients (31 men and 30 women), the bone mineral content (BMC) of lumbar vertebrae was measured at least twice, at intervals of 10-72 months. In this longitudinal part of the study, the group mean of estimated annual change for cirrhotic men was -0.4%, close to that of healthy men (-0.2%). This mean in cirrhotic women was -2.8%, significantly different from that of healthy women (-1.1%; P < 0.05). As expected, cirrhotic women were the most likely to lose BMC, and many needed prompt treatment.

Natural course of portal hemodynamics in patients with chronic liver diseases, evaluated by per-rectal portal scintigraphy with Tc-99m pertechnetate.

Portal circulation can be evaluated in a relatively noninvasive way by per-rectal portal scintigraphy. We used this method to evaluate portal hemodynamics in patients with chronic liver diseases and underlying hepatic viral infection; the patients did not need surgery or sclerotherapy, or refused it, so changes in the natural course were identified. A solution of Tc-99m pertechnetate was instilled into the rectum, and serial scintigrams were taken while radioactivity curves for the liver and heart were produced. The per-rectal portal shunt index was calculated from the curves. In a longitudinal study, 70 patients (9 with mild chronic hepatitis, 10 with moderate chronic hepatitis, 7 with severe chronic hepatitis, 22 with cirrhosis but without varices, and 22 with both cirrhosis and varices) were examined at least twice at intervals of 12-102 months (mean, 39 months). The shunt index was higher for more severe disorders, increasing in the order of mild chronic hepatitis, moderate chronic hepatitis, severe chronic hepatitis, cirrhosis without varices, and cirrhosis with varices. The mean annual changes in the mean shunt index were 1.0% in mild chronic hepatitis, 4.4% in moderate chronic hepatitis, 6.1% in severe chronic hepatitis, 10.7% in cirrhosis without varices, and 6.2% in cirrhosis and varices. Cirrhotic patients were arbitrarily divided into two groups of roughly equal size on the basis of the shunt index at the first examination. In those with a shunt index of 30% or more, the mean annual change was 4.7%. The patients with a shunt index of less than 30% had a mean annual change of 11.8%. Changes in the portal hemodynamics were not steady. The shunt index rose gradually as disease advanced from mild to moderate and to severe chronic hepatitis and cirrhosis of the liver, after which the index rose rapidly when varices developed, slowing later.

Prevalence of TT virus in patients with fulminant hepatic failure in Japan.

A novel virus (TT virus) was isolated from patients with posttransfusion hepatitis of unknown etiology. We studied the prevalence of TT virus in 26 patients with fulminant hepatic failure without risk factors, including blood transfusion, and also examined 106 healthy blood donors as controls. We assayed serum TT virus DNA by seminested polymerase chain reactions and also examined the genotypes of this virus. Serum was obtained at admission from patients with fulminant hepatic failure. Serum samples at admission from seven (27%) of the 26 patients were positive for TT virus DNA. There were no differences in clinical findings, duration from onset to coma, or results of laboratory tests in patients with and without TT virus DNA. However, all 7 patients with TT virus died, whereas 9 of the 19 patients without TT virus died. The outcome for patients with fulminant hepatic failure and TT virus was significantly worse than for patients without the virus (P = 0.0227). TT virus was also detected in 29 (27%) of the 106 healthy blood donors. The genotype of the TT virus was mainly 1a in both groups. There were no differences in the rate of positivity and the genotypes of TT virus between patients with fulminant hepatic failure and healthy blood donors. TT virus infection may not cause severe hepatitis, such as fulminant hepatic failure, but it may indicate a poor outcome in such patients.

Osteopenia in primary biliary cirrhosis and cirrhosis of the liver in women, evaluated by dual-energy X-ray absorptiometry.

To study bone involvement in primary biliary cirrhosis (PBC), we used dual-energy X-ray absorptiometry to measure bone mineral density (BMD) in Japanese women with PBC and with cirrhosis of the liver. In both groups, in each decade up to 60 years of age, the mean BMD of the lumbar spine was not significantly different from that in healthy Japanese women; however, in patients aged 60 years or more, the level was significantly lower both in the patients with PBC (P < 0.001) and in those with cirrhosis of the liver (P < 0.01). Patients with PBC were also examined by single-photon absorptiometry. The BMD of the radius in the patients with PBC was less changed than that of the lumbar vertebrae; thus, the bone changes in PBC seem to be greater in spongy than in cortical bone.

Use of immobilized histidine in assay for endotoxin in patients with liver disease.

The Limulus amebocyte lysate (LAL) test has the disadvantage of being influenced by various inhibitors and activators. We have developed a method for the LAL reaction that involves the specific adsorption and isolation of endotoxin using a membrane filter unit and immobilized histidine; in this present study we used the method to measure endotoxin in the plasma of patients with acute or chronic liver disease. The adsorbed endotoxins are separated from LAL-inhibitors or -activators by the membrane filter unit, and their activity is directly assayed with the LAL reagent in a filter cup without any inhibition or activation. The study population consisted of 23 subjects, 3 with fulminant hepatitis and 20 with cirrhosis (9 with esophageal varices and 11 without). All 3 (100%) of the samples of plasma from patients with fulminant hepatitis were positive for endotoxin, as were the samples of 7 (78%) of the 9 patients with cirrhosis and esophageal varices, and 2 (18%) of the 11 patients with cirrhosis but without such varices. The results suggested that this method appears to be useful for assaying the concentration of endotoxin in patients with fulminant hepatitis or cirrhosis of the liver.