Long-term clearance of hepatitis C virus following interferon α-2b or peginterferon α-2b, alone or in combination with ribavirin.

Sustained virologic response (SVR) is the standard measure for evaluating response to therapy in patients with chronic hepatitis C (CHC). The aim of this study was to prospectively assess the durability of SVR in the pivotal studies of peginterferon (PEG-IFN) α-2b or IFN α-2b. We conducted two phase 3b long-term follow-up studies of patients previously treated for CHC in eight prospective randomized studies of IFN α-2b and/or PEG-IFN α-2b. Patients who achieved SVR [undetectable hepatitis C virus (HCV) RNA 24 weeks after completion of treatment] were eligible for inclusion in these follow-up studies. In total, 636 patients with SVR following treatment with IFN α-2b and 366 with SVR following treatment with PEG-IFN α-2b were enrolled. Definite relapse (quantifiable serum HCV RNA with no subsequent undetectable HCV RNA) was reported in six patients treated with IFN α-2b and three patients treated with PEG-IFN α-2b. Based on these relapses, the point estimate for the likelihood of maintaining response after 5 years was 99.2% [95% confidence interval (CI), 98.1-99.7%] for IFN α-2b and 99.4% (95% CI, 97.7-99.9%) for PEG-IFN α-2b. Successful treatment of hepatitis C with PEG-IFN α-2b or IFN α-2b leads to clinical cure of hepatitis C in the vast majority of cases.

Adherence to assigned dosing regimen and sustained virological response among chronic hepatitis C genotype 1 patients treated with boceprevir plus peginterferon alfa-2b/ribavirin.

BACKGROUND: Adherence to therapeutic regimens affects the efficacy of peginterferon alfa (P) and ribavirin (R) therapy in patients with chronic hepatitis C virus genotype 1. AIM: To determine if medication adherence impacts efficacy [sustained virological response (SVR)] with triple therapy that includes boceprevir (BOC) plus P/R. METHODS: Adherence was determined in two Phase 3 clinical studies with BOC: SPRINT-2 (previously untreated patients) and RESPOND-2 (patients who failed previous therapy with P/R). Adherence to the assigned duration of the dosing regimen and adherence to the three times a day (t.d.s.) dosing interval of 7-9 h for BOC were assessed by the recording of data from patients' dosing diaries and by the amount of study drug dispensed and returned. RESULTS: Most patients (63-71%) adhered to ≥80% of their assigned treatment duration and achieved SVR rates of 86-90%. In contrast, patients who adhered to <80% of their assigned treatment duration achieved SVR rates of 8-32% (P < 0.0001), particularly low in patients who failed previous therapy (SVR = 8-15%). Different rates of adherence (<60% to >80%) to the t.d.s. dosing interval (7-9 h) with BOC did not influence the SVR rates (SVR = 60-83%) with the exception of patients who failed previous treatment and adhered to <60% of the t.d.s. dosing interval with BOC (SVR = 48-50%; P = 0.005). CONCLUSIONS: The achievement of an SVR is more dependent on adherence to the assigned duration of treatment than adherence to the t.d.s. dosing interval with boceprevir. Adherence to >60% of t.d.s. dosing with boceprevir is important in patients who failed previous therapy.

Association of a polymorphism in the indoleamine- 2,3-dioxygenase gene and interferon-α-induced depression in patients with chronic hepatitis C.

Interferon (IFN)-α treatment for infectious diseases and cancer is associated with significant depressive symptoms that can limit therapeutic efficacy. Multiple mechanisms have been implicated in IFN-α-induced depression including immune, neuroendocrine and neurotransmitter pathways. To further explore mechanisms of IFN-α-induced depression and establish associated genetic risk factors, single nucleotide polymorphisms in genes encoding proteins previously implicated in IFN-α-induced depression were explored in two self-reported ethnic groups, Caucasians (n=800) and African Americans (n=232), participating in a clinical trial on the impact of three pegylated IFN-α treatment regimens on sustained viral response in patients with chronic hepatitis C. Before treatment, all subjects were free of psychotropic medications and had a score ≤20 on the Center for Epidemiologic Studies Depression Scale (CES-D), which was used to assess depressive symptom severity throughout the study. In Caucasians, a polymorphism (rs9657182) in the promoter region of the gene encoding indoleamine-2,3-dioxygenase (IDO1) was found to be associated with moderate or severe IFN-α-induced depressive symptoms (CES-D>20) at 12 weeks of IFN-α treatment (P=0.0012, P<0.05 corrected). Similar results were obtained for treatment weeks 24, 36 and 48. In subjects homozygous for the risk allele (CC, n=150), the odds ratio for developing moderate or severe depressive symptoms at treatment week 12 was 2.91 (confidence interval: 1.48-5.73) compared with TT homozygotes (n=270). rs9657182 did not predict depression in African Americans, who exhibited a markedly lower frequency of the risk allele at this locus. The findings in Caucasians further support the notion that IDO has an important role in cytokine-induced behavioral changes.

Hemopexin decreases spontaneous chemiluminescence of cold preserved liver after reperfusion.

Hemopexin is a plasma protein with exceptionally high affinity for heme. During liver transplantation heme is released via lysis of transfused blood. This heme may catalyze peroxidative reactions that contribute to "reperfusion" injury of the organ. Using a rat liver model of cold storage and reperfusion we tested the potential anti-oxidant effects of hemopexin. After 3 h of cold storage rat liver was reperfused with warm oxygenated buffer. Spontaneous liver chemiluminescence, which is a parameter of oxyradical production, was measured during reperfusion and expressed as an index of free radical production (IFRP). Chemiluminescence reached a maximum within 5 min of reperfusion and decreased to baseline within 30 min. Addition of hemopexin to the perfusate (5 microM) significantly decreased the IFRP. By contrast, the control proteins albumin and gamma-globulin (10 microM) had a smaller non-significant effect. The data suggest that heme could be complexed by hemopexin during reperfusion, thus inhibiting heme mediated cellular injury.

Efficacy of interferon monotherapy in the treatment of relapsers and nonresponders with chronic hepatitis C infection.

Results of numerous studies have demonstrated similar efficacy profiles for the interferons (IFNs) currently approved for the treatment of chronic hepatitis C virus (HCV) infection. Although it has been suggested that some IFNs are more efficacious in certain patient populations, the current data support an equivalent efficacy and safety profile for these agents. Among patients requiring retreatment, no single study has made a direct comparison of IFN alfa-2b (IFN-alpha 2b) and consensus IFN (CIFN) in patients who have relapsed or have not responded to previous IFN therapy. However, at least 11 studies using IFN-alpha 2b and 1 using CIFN have demonstrated efficacy in the relapsing and nonresponding patient populations. A review of these studies suggests that overall efficacy and tolerability are similar regardless of IFN-alpha subtype. Overall, up to 59% and 83% of relapsed patients retreated with IFN have shown sustained response rates, as measured by negative HCV RNA titer and normalization of alanine aminotransferase (ALT) levels, respectively. Up to 14% and 25% of patients who failed to respond to previous IFN therapy have shown sustained HCV RNA response and normalization of ALT, respectively, after retreatment.

Chemiluminescent measurement of increased free radical formation after ischemia/reperfusion. Mechanisms of free radical formation in the liver.

It has been proposed that xanthine oxidase-derived superoxide mediates reperfusion injury in the liver; however, there is a little direct evidence to support this hypothesis. In this paper we describe a model system to directly and noninvasively measure oxyradical formation and hepatic injury in isolated perfused rat liver. Using this sensitive chemiluminescent technique, we clearly demonstrate the theorized burst in oxygen radical production upon reperfusion of previously ischemic liver, without perturbing the system with chemical luminescence enhancers. This increase in chemiluminescence (CL) upon reperfusion was diminished by the free radical scavengers trolox and ascorbate, as well as N-2-mercaptoproprionyl-glycine (MPG), thereby confirming the oxyradical nature of this signal. Additionally, superoxide dismutase and the xanthine oxidase inhibitor allopurinol, but not catalase, attenuated the reperfusion effect, providing the most direct evidence so far that XOD derived superoxide anion is formed during liver reperfusion. Hepatic injury (AST release) did not appear to relate to increased CL, supporting the notion that the oxyradical flux may serve as a signal for other events leading to tissue injury. Further studies using this sensitive chemiluminescent technique should aid in delineating the detailed mechanism(s) of reperfusion injury.

Hepatic free radical production after cold storage: Kupffer cell-dependent and -independent mechanisms in rats.

BACKGROUND/AIMS: Free radicals are important mediators of reperfusion injury; however, the mechanism(s) of oxyradical production after liver reimplantation are not well understood. A model of cold storage and reperfusion using low-level chemiluminescence to directly measure oxyradical production during reperfusion was developed. METHODS: Rat livers were harvested and stored at 4 degrees C in University of Wisconsin cold-storage solution or Euro-Collins solution for 0-48 hours and then flushed and reperfused with warm oxygenated (37 degrees C) Krebs-Henseleit buffer. Liver chemiluminescence was measured using a sensitive photomultiplier tube, and hepatocellular injury was assessed by measuring aspartate aminotransferase release into the perfusate. RESULTS: Chemiluminescence reached a maximum within 5 minutes of reperfusion and then decreased to a baseline within 30 minutes. There was a marked increase in chemiluminescence after only a short period of storage in University of Wisconsin cold-storage solution. Chemiluminescence decreased with longer periods of storage but steadily increased again after 16 hours of storage. Chemiluminescence after 22 hours of storage, but not after 3 hours of storage, was decreased by pretreatment with the Kupffer cell inactivator gadolinium chloride. CONCLUSIONS: The data suggest two mechanisms of oxyradical production during cold storage and reperfusion of the rat liver. The later phase seems to be Kupffer cell dependent.

Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores.

OBJECTIVES: To determine which clinical characteristics are associated with decreased survival after transjugular intrahepatic portosystemic shunting (TIPS). METHODS: Forty-nine consecutive patients were treated with TIPS; 46 of them had refractory variceal bleeding. Univariate statistics and logistic regression analyses were used to determine the relationship between clinical, biochemical, and hemodynamic variables and 30-day) survival. RESULTS: Shunt insertion was successful in 48 (98.0%) of 49 cases. Median portal-systemic gradient was reduced from 22.5 (range 9-36) [median (5th-95th percentile)] to 12 (range 4-20) mm Hg. Thirty (61.2%) of 49 patients survived more than 30 days; four patients died more than 30 days after TIPS in mean follow-up of 8.4 months. Significant differences (p < 0.05) were found between those who survived more than 30 days and those who did not, with respect to preprocedural prothrombin time, bilirubin, albumin, alanine aminotransferase, and treatment with vasopressin and nitrates, balloon tamponade, or mechanical ventilation. Whereas there were no significant differences between the pre- and post-TIPS portal vein pressures and portal-systemic gradients in survivors and non-survivors, the pre- and post-TIPS hepatic vein pressures were significantly lower in survivors. Survival was inversely proportional to Child-Pugh class (p < 0.01) and to APACHE II score (p < 0.01). The single determinant most closely associated with decreased survival in the month after TIPS was the APACHE II score, a score of 18 stratifying patients into those at low and high risk of mortality [odds ratio 21.7 (CI 3.6-131.7)]. Only 1 (7.7%) of 13 patients with Child-Pugh C cirrhosis and an APACHE II score exceeding 18 survived more than 30 days. CONCLUSIONS: Patients with advanced cirrhosis, especially those with high pre-TIPS APACHE II scores, are at high risk for reduced survival after TIPS, despite adequate portal decompression.

Endotoxin-stimulated nitric oxide production increases injury and reduces rat liver chemiluminescence during reperfusion.

BACKGROUND/AIMS: Nitric oxide has many physiological functions and may play an important role in modulating tissue injury. However, the mechanism of NO action in ischemia/reperfusion injury is completely unknown. This report investigates the role of NO in hepatic reperfusion injury. METHODS: Rat liver was oxygenated for 30 minutes, followed by 30 minutes of ischemia, and then reperfused for 30 minutes. Perfusate was sampled for aspartate aminotransferase content, as an indication of hepatic injury, and for nitrite, an index of NO production. Spontaneous organ chemiluminescence was continuously monitored as a measure of oxyradical production. RESULTS: NO production by the perfused rat liver was induced in vivo by pretreatment with Escherichia coli lipopolysaccharide. This induction led to an increase in hepatic injury during reperfusion that was partially ameliorated by the NO synthase inhibitor NG-monomethyl-L-arginine. Chemiluminescence during reperfusion, a measure of superoxide production in this system, was also decreased in the lipopolysaccharide-treated animals, and this effect was blunted by NG-monomethyl-L-arginine. CONCLUSIONS: These data suggest that NO may combine with superoxide formed during reperfusion to directly cause hepatocellular injury. In vitro work shows that this chemical product is the highly toxic species peroxynitrite.

Evaluation of purine nucleoside phosphorylase release as a measure of hepatic endothelial cell injury.

With emerging data that endothelial cell (EC) injury is the limiting factor in liver preservation and hepatic function, a simple and reliable biochemical technique for monitoring EC injury is needed. Measurement of purine nucleoside phosphorylase (PNP) release into the circulation from perfused liver has been proposed as such a method. However, our experiments with perfused rat liver did not display a clear or direct relationship between PNP release and endothelial cell injury. Therefore, we re-examined the suitability of using PNP as a measure of nonparenchymal injury by measuring its distribution in purified populations of hepatocytes, ECs, and Kupffer cells (KCs) and correlating cell injury and enzyme release in short-term cultures at 37 degrees C of each cell type. Purified cells were incubated (4 x 10(6) cells/mL) in oxygen or nitrogen saturated. Wisconsin solution or Krebs buffer for 6 hours, with cell viability and PNP release assayed every 2 hours. ECs had the lowest specific activity (27 +/- 9 U/mg protein; mean +/- standard error of the mean [SEM]) compared with both hepatocytes (115 +/- 15) and KCs (66 +/- 18). Despite a decrement in EC and KC viability over time in each incubation solution, there was poor correlation between time of incubation and PNP release (r = .01 to .22), and between cell viability and PNP release (r = .01 to .16). In contrast, PNP release from incubated hepatocytes correlated with the length of incubation (r = .57 to .78) as well as cell injury (r = .63 to .77) in all four test solutions.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased oxyradical production during reoxygenation of perfused rat liver. Signal versus injury.

Despite general agreement on the importance of oxyradicals in mediating "reperfusion" injury, the precise event(s) mediated by increased free radical production remain unclear. In this study we describe for the first time a model of unenhanced chemiluminescence of isolated perfused rat liver demonstrating a marked increase in oxyradical production after reoxygenation. Using aspartate aminotransferase and purine nucleoside phosphorylase release as measures of liver injury, there was no direct link between oxyradical production and hepatic injury. However, there was an abrupt increase in neutrophil chemotaxis activity in the perfusate at the time of reoxygenation with a subsequent decrement, following the pattern of oxyradical production. These data suggest that free radical formation during hepatic reperfusion may mediate signal transduction, as opposed to direct cell injury, as a primary mechanism of action.

Rapid conversion to high xanthine oxidase activity in viable Kupffer cells during hypoxia.

It has been widely postulated that the central mechanism of hepatic reperfusion injury involves the conversion, during ischemia, of the enzyme xanthine dehydrogenase (XDH) to its free radical-producing form, xanthine oxidase (XOD). However, this theory has been questioned because (a) XDH to XOD conversion in whole liver occurs very slowly; (b) the cellular distribution of XDH/XOD is unclear; and (c) the direct demonstration of XDH to XOD conversion in viable cells is lacking. In this paper, we address all three issues by measuring XDH to XOD conversion and cell viability in purified populations of hepatic endothelial cells (EC), Kupffer cells (KC), and hepatocytes (HEP). Although XDH/XOD activity on a cellular basis was greater in hepatocytes (0.92 +/- 0.12 mU/10(6) cells) than ECs (0.03 +/- 0.01) or KCs (0.12 +/- 0.04), XDH + XOD specific activity was similar in all three cell types (HEP 1.85 +/- 0.10 U/g protein; EC 1.69 +/- 0.54; KC 2.30 +/- 0.22). Over 150 min of warm (37 degrees C) or 24 h of cold (4 degrees C) hypoxia, percent XOD activity increased slowly in ECs, from 21 +/- 2% (basal) to 39 +/- 3% (warm) and 49 +/- 5% (cold) and in HEPs (29 +/- 2% to 38 +/- 3% and 49 +/- 2%), but converted significantly faster in KCs (28 +/- 3% to 91 +/- 7% and 94 +/- 4%). The dramatic changes in Kupffer cell XOD during cold hypoxia occurred despite only minor changes in cell viability. When hypoxic KCs were reoxygenated after 16 h of cold hypoxia, there was a marked increase in cell death that was significantly blocked by allopurinol. These data suggest that significant conversion to the free radical-producing state occurs within viable KCs, and that Kupffer cell XOD may play an important role in mediating reperfusion injury in the liver.

Evaluation of University of Wisconsin cold-storage solution in warm hypoxic perfusion of rat liver: the addition of fructose reduces injury.

BACKGROUND: University of Wisconsin cold-storage solution (UW solution) has markedly improved organ preservation for liver transplantation. However, the efficacy of this solution in preserving hepatocyte viability during warm ischemia is undefined; hence, the effects of UW solution on warm hypoxic injury in the isolated perfused rat liver were examined. METHODS: Livers were perfused using a modified protocol that included a period of hypoxic perfusion with isosmotic Krebs' solution at the end of each experiment. Hepatic injury was evaluated by aspartate aminotransferase (AST) release into the perfusate and the trypan blue perfusion technique. RESULTS: Although UW solution appeared to decrease hepatic injury during hypoxic perfusion, as reflected by low AST release, perfusion with UW solution led to hepatocyte shrinkage and cessation of bile flow even under oxygenated conditions. UW solution did not protect against warm hypoxic injury, as assessed by AST release into the perfusate (182 +/- 15 U/mL, mean +/- SD) or trypan blue staining of the dead hepatocyte nuclei (56% +/- 5%). However, the addition of fructose to UW solution resulted in a significant decrease in AST release (66 +/- 15 U/mL) and parenchymal cell death (39% +/- 7%). CONCLUSIONS: These data suggest that the addition of fructose or other gluconeogenic substrates may complement the overall hepatoprotective effects of UW solution, particularly during periods of warm hypoxia.

Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt.

Anorectal varices are portal-systemic collaterals commonly found in patients with portal hypertension. Although these varices rarely bleed, when bleeding does occur it may be massive and life threatening. Anorectal varices may be mistaken for hemorrhoids and there is no agreed upon method for their definitive diagnosis. Additionally, there is no standard therapy for bleeding anorectal varices, and when techniques designed for the control of hemorrhoidal bleeding are employed the results can be disastrous. We report here the first use of a transjugular intrahepatic portosystemic shunt (TIPS) for the permanent control of bleeding anorectal varices. Magnetic resonance imaging/magnetic resonance venography (MRI/V) was used as a non-invasive method for the identification of anorectal varices and to confirm the successful decompression of these varices with TIPS placement. MRI/V and TIPS may provide significant advances in the diagnosis and treatment of rectal variceal bleeding.

Hypoxic liver injury and the ameliorating effects of fructose: the "glucose paradox" revisited.

It has been independently postulated that nutritional status is a modulator of the hepatic injury response to hypoxia and that glucose may be a poor substrate for hepatocellular metabolism. This study provides data linking these two concepts within the framework of metabolic zonation of the liver. With the use of a hypoxically perfused isolated rat liver model, cellular injury, as reflected by aspartate aminotransferase (AST) release, was significantly greater in the liver of fasted (mean AST 489 U/g liver at 3 h) than fed (40 U/g) animals. The extent of injury during hypoxia was decreased to a comparable degree in fasted livers perfused with Wisconsin solution (27 U/g) or 20 mM fructose (51 U/g). Perfusion with (11.5 mM) glucose plus insulin provided no hepatoprotection (791 U/g); however, supraphysiological amounts of glucose (100 mM) with (310 U/g) or without (321 U/g) insulin (10 U) or dihydroxyacetone (220 U/g) provided a modest reduction in AST release. Cellular injury measured by trypan blue uptake showed a marked zonal pattern, with upstream regions incurring greater parenchymal and nonparenchymal injury than downstream areas. These data that indicate that exogenous glucose is poorly utilized as an energy substrate by the liver during hypoxia are consistent with data from the fasted-refed rat model, suggesting a "glucose paradox" in the liver. The findings also suggest that low levels of oxygen are an important factor mediating "hypoxic" liver injury.

Enhanced activity of the free radical producing enzyme xanthine oxidase in hypoxic rat liver. Regulation and pathophysiologic significance.

It has been widely proposed that conversion of xanthine dehydrogenase (XDH) to its free radical-producing form, xanthine oxidase (XOD), underlies ischemic/reperfusion injury, although the relationship of this conversion to hypoxia and its physiologic control have not been defined. This study details the time course and control of this enzymatic interconversion. In a functionally intact, isolated perfused rat liver model, mean % XOD activity increased as a function of both the duration (25 to 45% in 3 h) and degree (r = 0.97) of hypoxia. This process was markedly accelerated in ischemic liver by an overnight fast (45 vs. 30% at 2 h), and by imposing a short period of in vivo ischemia (cardiopulmonary arrest 72%). Moreover, only under these conditions was there a significant rise in the XOD activity due to the conformationally altered XDH molecule (XODc, 18%), as well as concomitant morphologic injury. Neither circulating white blood cells nor thrombosis appeared to contribute to the effects of in vivo ischemia on enzyme conversion. Thus, it is apparent that conversion to the free radical-producing state, with high levels of XOD activity and concurrent cellular injury, can be achieved during a relatively short period of hypoxia under certain well-defined physiologic conditions, in a time course consistent with its purported role in modulating reperfusion injury. These data also suggest that the premorbid condition of organ donors (e.g., nutritional status and relative state of hypoxia) is important in achieving optimal organ preservation.

Developmental changes of cerebral phenylalanine uptake from severely elevated blood levels.

Brain phenylalanine concentrations at plasma levels raised to that in phenylketonuric subjects were studied in rats from fetal through postnatal life. Suppression of the hepatic phenylalanine hydroxylase with alpha methylphenylalanine, and injections of age-adjusted doses of phenylalanine on the next day, assured the persistence of the same elevation of plasma levels for at least four hours prior to assay. The net phenylalanine uptake determined under these conditions underwent several-fold decreases between the fourth day and the end of the suckling period, and by about the age of 30 days it was as low as in adulthood. The development of transport properties studied here could contribute to the change with age in the vulnerability of the brain to the same degree of hyperphenylalaninemia and, since the cerebral phenylalanine uptake may decrease to non-damaging levels during childhood, it is pertinent to defining the age at which the rigorous diet of phenylketonurics might be safely relaxed.