Does asymmetric dimethylarginine (ADMA) plasma concentration predict esophageal varices in patients with cirrhosis?

BACKGROUND: In previous studies elevated Asymmetric NG, NG - dimethylarginine (ADMA) plasma levels, an endogenous nitric oxide synthase inhibitor, correlated with the severity of hepatic venous pressure gradient measurement, both in peripheral and in hepatic veins. The aim of this study was to explore whether elevated ADMA plasma levels were able to predict the presence of esophageal varices (EV) and/or large EV in patients with cirrhosis. METHODS: 74 cirrhotic patients who had undergone elective upper gastrointestinal endoscopy in order to assess the presence of portal hypertension and predictors of EV and/or large EV. ADMA levels were assayed by an ELISA test (Immundiagnostik AG, Germany). RESULTS: 53 patients had EV (26/53 had large EV). Univariate analysis of low hemoglobin (p = 0.045), PT-INR (p = 0.003), albumin (p = 0.024), bilirubin (p = 0.036), Child-Pugh score (p = 0.026), and ascites (p = 0.036) predicted the presence of EV. Multivariate analysis predicted EV for only PT-INR. The presence of large EV was predicted with univariate analysis of ADMA plasma levels (p = 0.013), low hemoglobin (p < 0.001), PT-INR (p = 0.001), albumin (p = 0.001), bilirubin (p = 0.026), Child-Pugh score (p < 0.001), ascites (p = 0.004). Sensitivity, specificity, predictive positive and negative values of ADMA plasma level > 0.5 micromol/L(-1) in predicting large EV were 0.69 (95% CI 0.53 - 0.82), 0.51 (95% CI 0.40 - 0.62), 0.43 (95% CI 0.31 - 0.56), 0.76 (95% CI 0.62 - 0.86), while the area under the ROC curve was 0.65 (95% CI 0.51 - 0.79). CONCLUSIONS: ADMA plasma levels were increased in cirrhotics with more advanced liver failure but did not prove to be a useful clinical tool for predicting the presence of esophageal varices or large esophageal varices.

DPEJ placement in cases of PEG insertion failure.

BACKGROUND AND STUDY AIMS: PEG placement is routinely used for enteral feeding; in some cases PEG is not feasible or indicated due to technical difficulties, such as gastric herniation, organ interposition, or presence of gastroparesis. In these cases, surgical gastrostomy or jejunostomy are possible alternatives; more recently, direct percutaneous jejunostomy (DPEJ) has been proposed to avoid surgical intervention. The aim of the study was to evaluate the necessity, technical feasibility and outcome of DPEJ in a group of patients consecutively proposed for PEG placement. PATIENTS AND METHODS: In each patient proposed for PEG placement, an upper gastrointestinal endoscopy was performed, and then a pull traction removal gastrostomy tube (18-20 F) was inserted. When PEG was not feasible or contraindicated, a variable stiffness pediatric videocolonscope was used to reach the jejunum: then DPEJ was performed with the same technique and materials as PEG. In both groups enteral feeding was started 24h after the endoscopic procedure, using an enteral feeding pump and the same nutritional schedules. RESULTS: In a 1-year period 90 patients were proposed for PEG placement; PEG could not be performed for technical reasons in 8 (gastric herniation in 1; organ interposition in 7) and gastroparesis in 1. In one patient both PEG and DPEJ were not feasible for organ interposition. The duration of the endoscopic procedure was slightly longer in DPEJ (mean 20 min versus 15 min). No complications related to the endoscopic procedure were observed in both DPEJ and PEG patients. No nutritional complication were observed in the DPEJ group. CONCLUSION: In our experience, PEG was not feasible or contraindicated in about 10% of patients proposed for. In these patients, DPEJ was placed: the procedure resulted to be feasible and safe with the use of a pediatric videocolonscope to easily reach the jejunum. The insertion of DPEJ did not change the nutritional management of enteral feeding. However, long-term effects or complications remain to be evaluated in larger studies.

Hepatitis C virus infection in type II essential mixed cryoglobulinemias.

The possible relationship between essential mixed cryoglobulinemias (EMCs) and hepatitis C virus (HCV) has been investigated in eight patients with type II EMCs and biochemical signs of liver damage, whose serum tested positive in the ELISA for anti-HCV. Sera were tested using the 2nd generation RIBA assay, while serum HCV-RNA was measured semiquantitatively by a RT-PCR in whole serum, cryoprecipitates and supernatants. In all patients a percutaneous liver biopsy and a bone marrow biopsy were performed. At liver biopsy, chronic active hepatitis and/or cirrhosis were present in 6 patients; in the remaining two, a lymphoplasmacytoid infiltration of elements positive for kappa light chains was found. In all patients a bone marrow biopsy showed a paratrabecular infiltration of monoclonal lymphoplasmacytoid elements similar to those found in the liver of the two patients described above. Antibodies against structural and non-structural HCV proteins were detectable in the serum of all patients. HCV-RNA was amplified from the whole sera, cryoprecipitates and supernatants: significantly higher concentrations were found in cryoprecipitates than in supernatants. Our results confirm the high prevalence of HCV infection and ongoing viral replication in patients with type II EMC and suggest the possible implication of HCV in EMC pathogenesis.

Bone marrow findings further support the hypothesis that essential mixed cryoglobulinemia type II is characterized by a monoclonal B-cell proliferation.

One-hundred-sixteen consecutive bone-marrow biopsies were taken from 76 patients with essential mixed cryoglobulinemia type II (type II cryo), whose median follow-up was 97 months. Fifty-four out of fifty-six subjects who underwent ELISA and RIBA tests for HCV, were found to be positive. At conventional light microscopic examination, 64/76 patients showed discrete lymphoid infiltrates consisting of small elements with plasmacytoid differentiation and with frequent paratrabecular location. Thirty-nine biopsies were studied by immunohistochemistry that revealed the B-cell nature of the infiltrates (CD20+, CD45RA+, CD79 alpha+, CD3-, CD45RO-), with demonstrable monotypic Ig light-chain restriction in 22 cases. It is worthy of note that the lymphoid elements usually appeared protected against apoptosis, because of the strong expression of the bcl-2 oncogene product, and provided with a very low proliferative capacity, the Ki-67 index being lower that 3%. The latter findings are in keeping with the indolent behaviour of the clonal lymphoid population observed in type II cryo and allow some speculation as to the need for environmental stimuli for its maintenance as well as further mutagenic events for its eventual transformation into an overt lymphoma.

Lymphoproliferation in type II mixed cryoglobulinemia.

OBJECTIVE: The role of the hepatitis C virus (HCV) in the etiology of type II mixed cryoglobulinemia (MC) has been well established, but the pathogenetical relationships among the virus, the immune system, the natural history of MC, and lymphoproliferation in the bone marrow and liver need to be further elucidated. METHODS: Eighty-two patients with HCV positive type II MC and 20 subjects with chronic hepatitis C without MC were studied: bone marrow and liver specimens were examined by routine histology and immunohistochemistry, particularly focusing on parameters related to disease behaviour, such as the expression of the bcl-2 oncogene product and the proliferation-associated Ki67 antigen. RESULTS: In most MC patients there were lymphoid infiltrates within the bone marrow showing a monomorphic cytology, frequent immunoglobulin light chain monotypic restriction, expression of the anti-apoptotic bcl-2 oncogene product, and a low proliferative capacity (Ki-67 < 3%). On the other hand, in all non-cryoglobulinemic patients a bone marrow picture of reactive lymphoplasmacytosis was found. In both MC and chronic hepatitis patients, the liver biopsy showed portal infiltrates consisting of T-cells, associated with a significant B-cell component; the latter was particularly abundant in MC, where it was frequently arranged in pseudo-follicles. The B-cell component expressed the bcl-2 oncogene product and CD5 antigen, thus suggesting that the immune system is actively involved in the production of liver damage both in MC and non-cryoglobulinemic patients. It is worth noting that in MC patients (but not in the non-cryoglobulinemic patients) these CD5+/bcl-2+ B-cells frequently also exhibited a monotypic restriction bearing an IgM kappa. CONCLUSION: Our findings in these liver and bone marrow studies further support the role of a lymphoproliferative disorder in the pathology of type II MC: the B cells involved accumulate due to the inhibition of apoptosis, and their low proliferative index justifies the indolent course of the disease. HCV probably interacts with these B-cells, facilitating their clonal expansion.

A pilot study on the effectiveness of cyclosporine in type II mixed cryoglobulinemia.

OBJECTIVE: To evaluate the effect of cyclosporine in the treatment of type II mixed cryoglobulinemia, after the failure of more conventional therapies. METHODS: Two patients with type II mixed cryoglobulinemia associated with chronic HCV infection, purpura, liver disease, and sensitive/motor neuropathy were treated with cyclosporine (2.5 mg/Kg/b.w.), after their failure to respond to treatment with corticosteroid, immunosuppressive drugs, interferon, and plasmapheresis. RESULTS: In both patients an improvement in the clinical manifestations (purpura and peripheral neuropathy), laboratory results (serum transaminases and cryocrit), and liver histology was seen, as well as the disappearance of bone marrow B-cell lymphoproliferation. CONCLUSION: Cyclosporine may be useful in the treatment of type II mixed cryoglobulinemia with prominent autoimmune clinical manifestations, although further studies are needed to better define the selection of patients.

Reliability of immunoassays for anti-HCV antibodies (ELISA and RIBA II) in patients with essential mixed cryoglobulinemia (EMC).

The recent reports of a very high frequency of signs of hepatitis C virus (HCV) infection among patients with essential mixed cryoglobulins (EMC) suggest new hypotheses for the pathogenesis of this disease. However, most of these studies have been seriously criticized. The serologic test designed for detection of anti-HCV antibodies (ELISA, RIBA I and II) may yield a significant rate of false-positive results when performed on cryoglobulinemic sera, and the detection of the HCV genome by PCR is still heavily conditioned by practical problems. Indirect, but possibly more reliable, evidence of HCV infection in cryoglobulinemic patients might come from the demonstration of anti-HCV antibodies by a conventional technique (ELISA or RIBA) in the purified polyclonal non-rheumatoid immunoglobulinemic fraction excreted in the urine by glomerular filtration. Fifty-two patients whose serum had tested positive for HCV antibodies (by ELISA and RIBA) on multiple occasions were enrolled in this study. They were diagnosed as having either EMC or HCV chronic hepatitis without cryoglobulinemia at least one year ago. The urine samples of these patients were tested for anti-HCV antibodies by ELISA and RIBA. In patients with chronic C hepatitis the antibodies most frequently found in the serum were anti-C33c and anti-C22-3. The results of the RIBA were substantially confirmed by ELISA, with a positive test in the urine of 30 of 32 seropositive patients. Similar results were obtained in patients with EMC II. We conclude that the specificity of the RIBA and ELISA tests for HCV antibodies in patients with EMC appears to be as high as in HCV+ patients without serum cryoglobulins. EMC patients have a high incidence of HCV infection and active chronic liver disease.

A laboratory and thrombokinetic study of HCV-associated thrombocytopenia: a direct role of HCV in bone marrow exhaustion?

OBJECTIVE: In order to investigate HCV associated thrombocytopenia, 6 patients suffering from this disease, in the absence of splenomegaly and other common causes of peripheral platelet destruction, underwent laboratory and scintigraphic tests. RESULTS: Thrombokinetic studies revealed a significant, nearly linear, delayed splenic accumulation with normal or low-normal values for the average platelet life span, low-normal recovery, and depressed platelet production. Megakariopoiesis was normal or slightly increased. HCV infection of the megakariocytes was found in two patients. Autoantibodies and liver disease were also investigated. CONCLUSIONS: A role of immunological mechanisms in HCV associated thrombocytopenia appears to be ruled out. The authors conclude that tests for HCV infection should be included in the evaluation of thrombocytopenia in adults and a possible direct involvement of HCV cannot be excluded.

HCV genotypes in bone marrow and peripheral blood mononuclear cells of patients with mixed cryoglobulinemia.

OBJECTIVE: The association of the hepatitis C virus (HCV) with the cryoglobulinemic syndrome is well known, but its pathogenetic mechanism still remains to be clarified. HCV-RNA has been found in the peripheral blood mononuclear cells (PBMC) of infected subjects. We investigated the presence of the HCV genome in bone marrow cells (BMC), and the distribution of different HCV genotypes in individuals with mixed cryoglobulinemia (MC) and in noncryoglobulinemic controls. METHODS: 15 anti-HCV positive subjects with MC, 7 non-cryoglobulinemic patients with type C chronic active hepatitis (CAH) and 2 anti-HCV negative controls were studied. HCV-RNA was detected by nested PCR of the highly conserved 5'-NCR sequence. HCV typing was carried out by means of the hybridization of the same amplified region with specific probes. RESULTS: HCV-RNA was present in the PBMC of a large proportion of the MC patients and controls without any significant differences. On the contrary, HCV-RNA was present in the bone marrow cells of all the patients with MC and in 43% of the CAH controls. The HCV 1b and 2a genotypes seem to be the most prevalent among MC patients. Nevertheless, the patients with type II MC had a very high prevalence of the 2a genotype (77%). CONCLUSION: The results suggest that the presence of HCV-RNA in bone marrow cells may be correlated to the pathogenetic mechanism of MC. Other studies are needed to confirm the frequent association of HCV genotype 2 with MC.

Treatment with interferon-alpha2b of naive non-cirrhotic patients with chronic hepatitis C according to viraemia and genotype. Results of a randomized multicentre study. The North West Italian Hepatological Group.

OBJECTIVE: To establish whether tailoring the dosage of interferon (IFN)-alpha2b in non-cirrhotic naive patients with chronic hepatitis C according to hepatitis C virus (HCV) genotype and viraemic level improves the rate of sustained response (normal alanine aminotransferase values and HCV-RNA negativity 6 months after the end of therapy). PATIENTS: A total of 538 consecutively collected HCV-positive patients with non-cirrhotic chronic hepatitis who had not been previously treated. METHODS: Quantitative viraemia and genotype were determined in each patient by a core laboratory. The patients were randomized to: Group 1, 86 patients with genotype non-1 and viraemia < 1,000,000 HCV genome equivalents/ml (GenEq/ml) treated with 3 Million Units (MU) IFN three times weekly (t.i.w.) for 1 year; Group 2, 42 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 3 MU IFN t.i.w. for 1 year; Group 3, 46 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 5 MU IFN t.i.w. for 1 year; Group 4, 85 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 5, 88 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN t.i.w. for 1 year; Group 6, 94 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 7, 97 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN daily for 2 months followed by 5 MU t.i.w. for a further 10 months. RESULTS: According to an intention-to-treat analysis, a sustained virological response (negative HCV-RNA by polymerase chain reaction 6 months after the end of therapy) was observed in 42% of Group 1 patients, in 21% of Group 2 patients versus 24% of Group 3 patients [P = not significant (NS)], in 28% of Group 4 patients versus 35% of Group 5 patients (P = NS), and in 8.5% of Group 6 patients versus 12% of Group 7 patients (P = NS). CONCLUSIONS: Even though a trend towards a therapeutic improvement is observed, the adoption of more aggressive IFN protocols, such as induction therapy, does not appear to significantly improve the rate of sustained response in patients with chronic hepatitis C associated with HCV genotype 1 and highly viraemic levels compared with standard therapy. Moreover, patients with only one unfavourable predictive factor (genotype 1 or high viraemia) do not gain major therapeutic benefits when treated with high doses of IFN.

Hepatotoxicity of hydroxy-methyl-glutaryl-coenzyme A reductase inhibitors.

The first clinical studies on hydroxy-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors reported a low incidence of liver toxicity. The personal observation of a case of simvastatin-induced acute cholestatic hepatitis prompted us to evaluate the true incidence of hepatic side effects of these drugs in a large Italian population. One hundred patients taking simvastatin and ninety patients treated with pravastatin were followed-up six months with periodical evaluation of serum lipid levels and liver function test. In 5% of simvastatin-treated patients and 4.5% of pravastatin-treated patients significant liver toxicity was observed, which required drug discontinuation. The mechanism of liver damage was direct, idiosyncratic, but immunological features of drug toxicity could be hypothesized in one patient.

[Anti-GOR antibodies in type II mixed cryoglobulinemia associated with hepatitis C virus infection]. / Anticorpi anti-GOR nella crioglobulinemia mista tipo II associata a infezione da virus dell' epatite C.

The frequent association of chronic hepatitic C virus (HCV) infection and type II mixed cryoglobulinemia is considered to be one of the possible signs of interaction between the virus and the immune system. This could also be the case for the appearance of anti-GOR antibodies in serum, as they react with both viral and host antigens. We studied a group of patients with chronic hepatitis C infection and a group with type II mixed cryoglobulinemia associated with HCV infection to ascertain if anti-GOR or other non-organ specific autoantibodies were present in the serum. We found no significant difference between the two groups in presence, prevalence or titer of anti-GOR or other autoantibodies. Moreover, the expression of anti-GOR does not seem to influence the severity of liver damage. Our data support the hypothesis that anti-GOR antibodies are a simple expression of molecular mimicry between viral and human epitopes.

Acute cholestatic hepatitis during simvastatin administration.

Simvastatin, recently introduced in clinical practice for pharmacological treatment of hypercholesterolemia, has been found to cause minor and reversible elevations of serum transaminases. We report a case of acute cholestatic hepatitis during simvastatin therapy. Clinical, biochemical, immunological, and histological findings were consistent with a simvastatin-induced liver damage through an immunological-mediated mechanism. This case suggests a careful monitoring of liver function tests during simvastatin therapy, and caution in continuing simvastatin administration when elevations of serum transaminases take place.

[A sustained response in chronic hepatitis C treated with interferon]. / La risposta sostenuta nella epatite cronica C trattata con interferone.

We analyzed 27 subjects with long-term response, from a group of 110 interferon treated patients with biopsy-proven chronic hepatitis and serum anti-HCV antibodies. The following variables were assessed as potential predictors: sex, age, ALT level before the therapy was started, liver structure, type of interferon, total amount of interferon. Total amount of administered interferon statistically correlated with long-term response by univariate analysis. Nevertheless upon stepwise logistic multivariate analysis none of them was independently predictive of long-term response. Additional studies would be needed in order to develop a model capable of predicting from pre-treatment features which patients are likely to have long-term response.

Probiotics: from research to consumer.

Intestinal microflora has metabolic, trophic and protective functions, and can be modified in pathological conditions and by the exogenous administration of probiotics. Probiotics are defined as living microorganisms which resist gastric, bile, and pancreatic secretions, attach to epithelial cells and colonize the human intestine. In the last twenty years research has been focused on the identification of the role of planktonic flora and adhesive bacteria in health and disease, and on the requisite of bacterial strains to become probiotic product which can be marketed. Probiotics can be commercialized either as nutritional supplements, pharmaceuticals or foods, but the marketing as a pharmaceutical product requires significant time, complex and costly research, and the demonstration of a well-defined therapeutic target. This review examines the sequential steps of research which, from the identification of a possible probiotic strain, lead to its production and marketing, summarizing the whole process existing behind its development, through its growth in laboratory, the studies performed to test its resistance to human secretions and stability, microencapsulation technologies, and safety tests.

Hepatic lymphoid aggregates in chronic hepatitis C and mixed cryoglobulinemia.

We have examined the clinical (virological and immunological), histological and immunohistochemical features of liver lymphoid nodules in hepatitis C virus-positive (HCV+)/mixed cryoglobulinemia (type II and III) and chronic hepatitis C. The clinical features of liver disease were found to be similar in all patients. In all these groups, liver lymphoid nodules were observed to a similar extent, being more frequent in earlier phases of liver disease and less in more advanced stages. These data were confirmed by studies in serial biopsy samples taken from individual patients with type II mixed cryoglobulinemia; the loss of lymphoid nodules with progression to more advanced histological stages of disease in these patients was accompanied by a decrease of the serum levels of cryoglobulins (although not statistically significant). By immunohistochemical analysis, the liver lymphoid nodules contained predominantly B cells with a CD5+/bcl2+/Ki67- phenotype, which were always polyclonal in type III mixed cryoglobulinemia and chronic hepatitis C, and monoclonal in type II mixed cryoglobulinemia. These immunological features were consistent with an active role of the immune system in HCV-associated liver necro-inflammation. Only in type II mixed cryoglobulinemia was there a clonal restriction of B cells. The immunological profile (autoantibodies) and viral genotypes were examined in some patients, but no significant correlation with clinical and immunohistochemical findings was found; however, the prevalence of genotype 2a was significantly higher in type II mixed cryoglobulinemia than in type III and chronic hepatitis without cryoglobulinemia.

Sorbitol clearance: a parameter reflecting liver plasma flow in the rat.

According to the clearance concepts, the functional liver plasma flow may be directly measured from the plasma kinetics of any substance whose hepatic intrinsic clearance largely exceeds liver perfusion. The present study was designed to ascertain the requirements for the reliability of D-sorbitol plasma clearance in evaluating changes of liver perfusion in the male Wistar rat. The plasma disappearance curve of D-sorbitol (3 mg/100 g b.w. by bolus i.v. injection) followed a first order kinetics and fitted a two-compartment model. Very similar estimates of D-sorbitol plasma clearance were obtained by applying the area under the curve method to data obtained by the trapezoidal rule and by compartmental analysis. D-sorbitol hepatic extraction was almost complete in controls and in rats submitted to porta-caval shunt and hepatic artery ligation, while significantly decreased after partial hepatectomy. Renal output never exceeded 10% of the administered amount. No in-vivo diffusion into red cells was observed. In controls, the functional liver plasma flow, as measured by D-sorbitol clearance was 2.83 +/- 0.68 ml/min/100 g (mean +/- SD). Significantly lower values were found in rats submitted to porta-caval shunt (1.19 +/- 0.38), hepatic artery ligation (2.06 +/- 0.53), and partial hepatectomy (1.03 +/- 0.44).

Hepatic clearance of D-sorbitol. Noninvasive test for evaluating functional liver plasma flow.

The hepatic clearance of D-sorbitol, a natural polyol which is metabolized by the liver, was studied in normal and cirrhotic subjects after bolus intravenous injection (2 g) and during constant infusion (54 mg/min) with the aim of providing a noninvasive and simple measure of functional liver plasma flow. The high hepatic extraction of D-sorbitol and the dose-independence of its clearance pointed to a flow-dependent clearance regimen. The renal excretion was taken into account when computing the hepatic clearance. Day-to-day reproducibility of the test was good. No significant difference was found when the hepatic clearance was measured by bolus injection or constant infusion methods. As measured by the bolus injection method, the mean (+/- SD) hepatic clearance in the normal subjects (911 +/- 137 ml/min) was significantly greater (P less than 0.001) than that of the cirrhotics (456 +/- 181 ml/min).