Appearance of cross linked proteins in human atheroma and rat pre-fibrotic liver detected by a new monoclonal antibody.

A new monoclonal antibody against malondialdehyde (MDA)-treated low density lipoprotein (LDL) was raised using homogenate of human atheroma as immunogen. This antibody, DLH2, was obtained by selecting the clones which did not react to native LDL but did react to copper-induced oxidized LDL (OxLDL). DLH2 showed a greater reactivity to MDA-LDL than to OxLDL. When LDL was treated with various aldehyde containing reagents, treatment of LDL with glutaraldehyde or MDA greatly increased the reactivity to the antibody, while LDL treated with 2,4-hexadienal or 4-hydroxynonenal was not reactive. Among many proteins tested, high density lipoprotein, bovine serum albumin and hemoglobin showed significant reactivity to DLH2 after they were treated with MDA or glutaraldehyde. When low density and high density lipoproteins treated with MDA were subjected to immunoblot analysis, newly formed products larger than the original apolipoproteins were detected with the antibody, suggesting that this antibody recognizes aggregated proteins with divalent short chain cross linkers. The antigenic materials were shown by immunohistochemical analysis to be present in foamy macrophages in human atheromatous lesions. DLH2 antigen did not colocalize either with apolipoprotein B. Furthermore, we found a massive accumulation of the antigenic material in Kupffer cells in the liver of rats treated with alcohol and carbonyl iron, a model of hepatic fibrosis due to oxidative stress. These results suggest the presence of cross linked proteins in damaged tissues.

Prostaglandin F2 alpha and indomethacin in hepatogenic pulmonary angiodysplasia. Effects on pulmonary hemodynamics and gas exchange.

We treated a 68-year-old man with cirrhosis of the liver associated with moderate hypoxemia. Contrast-enhanced echocardiography revealed late opacification of the left ventricle, and pulmonary perfusion imaging with 99mTc macroaggregated albumin showed evidence of a significant uptake in both lungs and in the liver, spleen, and kidneys. Right cardiac catheterization revealed pulmonary hypotension, low pulmonary vascular resistance, and high cardiac output. We administered prostaglandin F2 alpha intravenously (0.2 microgram/kg/min for 30 minutes) and indomethacin orally (75 mg/day for three days). There was some degree of resolution of the hypoxemia and increases in both pulmonary arterial pressure and pulmonary vascular resistance. These findings suggest that the pathophysiology of hepatogenic pulmonary angiodysplasia is a reversible intrapulmonary vascular dilatation. These conditions can to some extent be modulated by vasoactive substances such as prostaglandins or other eicosanoids.

Effects of indomethacin on hepatogenic pulmonary angiodysplasia.

A patient had liver cirrhosis associated with marked hypoxemia. With administration of indomethacin (75 mg/day for six days), PaO2 was elevated up to 50 mm Hg from 44 mm Hg. At that time, dynamic pulmonary perfusion imaging revealed a plateau time course curve of MAA uptake in the lungs, as compared with findings obtained during the state of severe hypoxemia without indomethacin. These observations suggest that part of hepatogenic pulmonary angiodysplasia is a functional vasodilatation that is presumably modulated by vasoactive substances, such as prostaglandins and/or other eicosanoids.

Increased expression of proliferating cell nuclear antigen in autoimmune hepatitis in a patient with raised serum concentration of CA19-9.

A 52 year old woman had autoimmune hepatitis and an increased concentration of serum carbohydrate antigen 19-9 (CA19-9). The origin of the raised CA19-9 was studied using immunohistochemistry. Liver biopsy section showed chronic active hepatitis with large numbers of proliferated bile ductules. Immunohistochemical analysis revealed that the proliferated bile ductule cells were positive for proliferating cell nuclear antigen (PCNA) and for CA19-9. It is speculated that the raised serum CA19-9 concentration was derived from proliferated bile ductule cells and these cells, which are positive for PCNA, may be able to produce high concentrations of CA19-9.

Co-localisation of insulin-like growth factor II and the proliferation marker MIB1 in hepatocellular carcinoma cells.

AIM: To assess the effect of insulin-like growth factor II (IGF-II) on proliferation of hepatocellular carcinoma (HCC) cells. METHODS: Expression of IGF-II mRNA and protein was detected in 10 archival HCC specimens using in situ hybridisation and immunohistochemistry, respectively. Expression of the Ki-67 antigen, a proliferation marker, was determined immunohistochemically on the same sections. RESULTS: Increased expression of IGF-II mRNA and protein was detected in five of the 10 HCCs in cells located at the periphery of tumour nests. The pattern of localisation of IGF-II was almost identical with that of Ki-67 antigen. CONCLUSIONS: Most of the Ki-67 antigen positive cells co-expressed IGF-II, suggesting that IGF-II may act as an autocrine or paracrine growth factor, and may play an important role in the development of HCC.

Eosinophilic enteritis observed during alpha-interferon therapy for chronic hepatitis C.

We report a patient with chronic hepatitis C who developed eosinophilic enteritis while being treated with recombinant interferon alpha-2b. He had no history of either allergic disorders or recurring episodes of abdominal cramps, nausea, or diarrhea. He also had had a normal eosinophil count prior to the interferon treatment. After a 12-week course of interferon alpha-2b, he began to complain of severe abdominal pain, diarrhea, and abdominal fullness. His peripheral eosinophil count increased to 45% (absolute count, of 7,610/microl). Abdominal ultrasonography and computed tomography revealed diffuse thickness of the intestinal wall with gross ascites that contained numerous eosinophils. An upper gastrointestinal barium study with small bowel follow-through showed an edematous mucosal layer of the jejunum and ileum. There was a spectacular relief of the patient's subjective symptoms after the administration of prednisolone. Follow-up studies revealed resolution of the ascites and the mucosal layer edema and normalization of the peripheral eosinophil count. Prednisolone was tapered off, but the eosinophilic enteritis did not recur. As there had been no evident exposure to common causative factors for eosinophilic enteritis, we suggest that interferon alpha-2b could thus have played a role in the triggering of the eosinophilic enteritis.

Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices.

Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report a 65-year-old woman who presented with hematemesis and melena. She was admitted to our department because of prolonged shock, despite having received transfusion of a large volume of blood. Upper gastrointestinal endoscopy revealed nodular varices with active bleeding in the second portion of the duodenum. Endoscopic injection sclerotherapy (EIS) was performed using a tissue adhesive agent, alpha-cyanoacrylate monomer, with only temporary benefit. However, anemia continued to progress after the procedure. Therefore, we combined transileocolic vein obliteration (TIO) with balloon-occluded retrograde transvenous obliteration (B-RIO), using 5% ethanolamine oleate with iopamidol to obliterate the varices. Complete hemostasis was achieved without complications. Neither recurrence of varices nor further bleeding has occurred for over 3 years. We conclude that combined TIO and B-RTO, which can obstruct both the feeding and the draining vessels of duodenal varices to retain the sclerosing agent completely in the varices, is a safe and effective hemostatic measure for ruptured duodenal varices, when EIS has failed to accomplish complete hemostasis.

Increased expression of transforming growth factor-alpha in a patient with recurrent hepatocellular carcinoma following partial hepatectomy.

A 45-year-old woman with chronic hepatitis B underwent partial hepatectomy for hepatocellular carcinoma (HCC). However, the HCC recurred 2 months after surgery and rapid progression of the disease resulted in her death. Immunohistochemistry showed that transforming growth factor-alpha (TGFalpha) was barely expressed in the liver specimens obtained at hepatic resection, whereas autopsy specimens were strongly stained with anti-TGFalpha antibody in the cytoplasm of both non-tumourous and tumourous liver cells. A higher level of Ki67 expression, a proliferating marker, was observed in the recurrent HCC, similar to that of TGFalpha. Thus, we speculate that the partial hepatectomy increased the level of TGFalpha leading to recurrence and progression of HCC through an autocrine/paracrine mechanism.

The natural history and prognostic factors in patients with cirrhosis and gastric fundal varices without prior bleeding.

Objectives and methods: The prognostic factors have not yet been fully evaluated in patients with cirrhosis and gastric fundal varices (FV). We investigated the natural history of 145 patients with cirrhosis and FV with no history of bleeding. Various possible prognostic factors, which include clinical, biochemical, and endoscopical variables, were analyzed using Cox's proportional hazard model. Results: Among the 145 patients with cirrhosis and FV, there were 76 patients in class A, 45 in class B and 24 class C according to Child's classification. Sixty-five patients had concomitant hepatocellular carcinoma at the time of enrollment. Seventy deaths and 34 episodes of the hemorrhage from FV occurred during the mean follow-up period of 26.4 months. The cumulative survival rates at 1, 3, and 5 years were 75, 53 and 34%, respectively. The cause of death was related to gastrointestinal hemorrhage in 18 patients (15 deaths were related to FV hemorrhage), hepatic failure in 22, hepatocellular carcinoma in 22, and other causes in eight patients. In patients with small-, medium-, and large-sized FV, the deaths related to FV hemorrhage were 4, 21 and 54%, respectively. Overall, the death related to FV hemorrhage was 21%. A multiple regression analysis using Cox's model showed hemorrhage from FV, the presence of hepatocellular carcinoma and poor Child's status were all highly significant prognostic factors. Conclusion: The natural history of the patients with cirrhosis and FV was adversely modified by the hemorrhage from FV, concomitant hepatocellular carcinoma and poor hepatic functional reserve. Since the number of deaths related to FV hemorrhage was great in patients with large-sized FV, it is important to identify high-risk large FV and its prophylactic obliteration. Further studies are needed to elucidate the efficacy of prophylactic obliteration of large-sized FV.

Recurrent intracranial hemorrhagic episodes in hepatopulmonary syndrome.

A 57-year-old woman with hepatopulmonary syndrome was treated for eight years. Severe hypoxemia continued and her erythrocytosis was slowly progressive. Two episodes of intracranial hemorrhagic attack had occurred during the follow-up period and the patient died due to multiple organ failure after the second intracranial hemorrhage. Her autopsy findings confirmed not only established liver cirrhosis associated with intracranial hemorrhage but also the marked dilatation of pulmonary capillaries in both lungs. These findings suggest that secondary erythrocytosis in hepatopulmonary syndrome can be contributed to fatal intracranial vascular accidents. The containment of erythrocytosis should be considered in these patients.

The effects of chronic endoscopic variceal sclerotherapy on systemic and splanchnic hemodynamics in patients with cirrhosis.

The aim of this study was to determine whether endoscopic variceal sclerotherapy affects systemic or splanchnic hemodynamics. We measured hemodynamic parameters before and after the first course of sclerotherapy in 35 patients with cirrhosis. Following sclerotherapy, there was a significant decrease in cardiac index and a significant increase in systemic vascular resistance. Changes in hepatic venous pressure gradient varied from patient to patient with no statistically significant change in the group overall. However, all 20 patients with a decline in the hepatic venous pressure gradient had a concomitant decrease in cardiac index and/or a large extravariceal shunt. The multivariate analysis disclosed that the decrease in cardiac index was a statistically significant contributor for the decline in hepatic venous pressure gradient. We conclude that the obliteration of esophageal varices by sclerotherapy significantly reverses the hyperdynamic circulatory state in patients with cirrhosis. Spontaneous changes in systemic hemodynamics and the interaction with hepatic hemodynamics must be taken into account when evaluating hepatic hemodynamics in patients undergoing variceal sclerotherapy.

Reversibility of pulmonary telangiectasia in liver cirrhosis evidenced by serial dynamic pulmonary perfusion imaging.

Pulmonary perfusion imaging with Tc-99m MAA revealed significant uptake in the lungs, brain, spleen, and both kidneys of a 48-year-old woman with liver cirrhosis and pulmonary telangiectasia associated with marked hypoxemia and cyanosis. Dynamic pulmonary perfusion imaging revealed a gradual reduction after peak uptake in both lungs. Several weeks after albumin replacement, the hypoxia and dyspnea disappeared with no change in hepatocellular function. At that time, dynamic pulmonary perfusion imaging revealed a plateau-like time-activity curve of uptake in the lungs, as compared with the findings obtained during the state of severe hypoxemia. These observations suggest that pulmonary telangiectasia in a patient with liver cirrhosis may be due to functional vasodilatation. Serial dynamic pulmonary perfusion imaging indicates the passage of the MAA particles through the widened lumen of the pulmonary alveolar capillaries.

Detection of pulmonary telangiectasia using dynamic pulmonary perfusion imaging in patients with liver cirrhosis.

Two cases of liver cirrhosis associated with marked hypoxemia are presented. Chest radiographs and cardiopulmonary function showed no abnormalities, except for the low diffusion capacity of carbon monoxide and slight elevation of the shunt ratio (20 and 6.2%, respectively), as estimated under conditions of 100% oxygen inhalation. Pulmonary perfusion imaging with Tc-99m macroaggregated albumin (MAA) revealed a significant radioisotope uptake in the lungs, brain, spleen, and both kidneys. Shunt ratios, estimated by the quantitative radionuclide method, were 60 and 68%, respectively. Dynamic pulmonary perfusion imaging revealed a gradual reduction in uptake in all areas of both lungs. The discrepancy of the shunt ratio between the two methods results from an abnormal dilatation of alveolar capillaries. The gradual reduction of radioactivity in areas of the lungs is caused by the passage of MAA particles through widened pulmonary capillaries.

Prediction of portal vein invasion by hepatocellular carcinoma: a correlations between portal vein tumor thrombus and biochemical tests.

Hepatocellular carcinoma patients were categorized into three grades according to the extent of portal vein invasion by the tumor. Correlations between the extent of portal vein invasion and values of alpha-fetoprotein (AFP), and various biochemical tests were examined. The extent of portal vein invasion by the tumor significantly correlated with the values of glutamic oxaloacetic transaminase (GOT), glutamic oxaloacetic transaminase: glutamic pyrubic transaminase (GOT:GPT), lactic dehydrogenase (LDH), alkaline phosphatase, leucinaminopeptidase (LAP), gamma-glutamic transpeptidase (gamma-GTP) and log10AFP. Results of the multivariate logistic regression analysis showed the values of LAP, LDH, log10AFP and GOT:GPT to be statistically significant independent indicators of portal vein invasion by hepatocellular carcinoma. The calculated probability for portal vein tumor thrombus, which was derived from the results of a step wise multivariate logistic regression procedure, revealed high accuracy and specificity for predictability. To design effective therapy and to predict the prognosis, it would be beneficial to obtain additional information from this calculated probability in patients with hepatocellular carcinoma.

Differential effects between tauroursodeoxycholic and taurochenodeoxycholic acids in hepatic fibrosis: an assessment by primary cultured Ito and Kupffer cells from the rat liver.

The pathogenesis of hepatic fibrosis in cholestasis is still unknown, except for endotoxaemia. There is a possibility that the elevation of serum bile acids in cholestasis may play an important role in hepatic fibrogenesis due to a reaction to perisinusoidal cells, such as Ito or Kupffer cells. To assess the effects of bile acids, we investigated the cell proliferation and collagen formation of primary cultured Ito cells that were incubated with a Kupffer cell conditioned medium (KCCM) treated with either taurochenodeoxycholic acid (TCDCA) or tauroursodeoxycholic acid (TUDCA) in short-term (8 h) or long-term (48 h) cultures. KCCM treated with TCDCA (100 mumol/L) but not with TUDCA increased cell proliferation of Ito cells in short-term cultures and also partially elevated collagen formation by Ito cells in long-term cultures. The release of tumour necrosis factor-alpha (TNF alpha) from Kupffer cells was increased by TCDCA in short-term cultures, but not in long-term cultures. The release of transforming growth factor-beta 1 (TGF beta 1) from Kupffer cells was increased by TCDCA in long-term cultures, but not in the short-term cultures. TUDCA showed no significant effect on the release of TNF alpha and TGF beta 1 from Kupffer cells. TUDCA or TCDCA itself showed no direct effect on the cell proliferation and collagen formation of Ito cells. In conclusion, these findings are thus considered to show the potentially important role of TCDCA on the development of hepatic fibrosis in the early phase of cholestasis without endotoxaemia.

Unresponsiveness of peripheral T cells induced by apoptotic bodies derived from autologous T cells.

Several reports described the dose-dependent effect of Staphylococcus aureus enterotoxin B (SEB) regarding both levels of apoptosis and anergy of T cells. We investigated here whether T-cell apoptosis induced with SEB causes unresponsiveness of naive T cells. Apoptotic bodies were isolated from human T cells stimulated with antigen-presenting cells (APCs) and SEB by the continuous density gradient centrifugation method. When naive T cells were stimulated with APCs and SEB in the presence of apoptotic bodies, their proliferation was dose dependently suppressed and their TCRs were less downregulated than those of T cells stimulated without apoptotic bodies. Furthermore, those T cells were predisposed not to respond to restimulation with fresh APCs and SEB in the absence of apoptotic bodies. These results, taken together with the observation of tight binding of apoptotic bodies to APCs, imply that T cells stimulated in the presence of apoptotic bodies may undergo unresponsiveness due to interruption of contact with APCs.

Putative hemochromatosis gene mutations and alcoholic liver disease with iron overload in Japan.

It is well known that alcoholic liver disease is associated with iron overload. To study the role of hemochromatosis gene mutations on the pathogenesis of alcoholic liver disease (ALD), we have analyzed C282Y and H63D mutations on the chromosomes obtained from 95 Japanese alcoholics. Patients were divided in two groups [i.e., 64 alcoholic patients with liver damage (group I) and 31 alcoholics without liver damage (group II)]. In group I, biochemical examinations showed that serum levels of iron and ferritin were significantly high, and unsaturated iron binding capacity levels were low, compared with those of group II. An analysis by means of allele-specific polymerase chain reaction demonstrated that C282Y mutation was not observed in both groups I and II. H63D mutation was observed in only two heterozygotes of group I and in one heterozygote of group II. Results could not indicate the relationship between ALD and these mutations. We speculate that other causes of iron overload may exist in ALD with iron overload.