Clinical relevance of anti-interferon antibodies in the serum of chronic hepatitis C patients treated with interferon-alpha.

The development of anti-interferon (anti-IFN) antibodies in the serum of patients undergoing antiviral therapy has been postulated as one possible cause of interpatient variability in response to therapy. We analyzed the relationship between the appearance of anti-IFN antibodies and the loss of response to interferon-alpha (IFN-alpha), as characterized by a breakthrough of serum aminotransferase after a period of complete biochemical remission. The analysis involved clinical trials where neutralizing anti-IFN antibodies were detected by standardized and comparable methods. The results show that a time relationship between breakthrough and anti-IFN antibodies is observed in only a few cases and is independent of the type of IFN-alpha preparation used. Thus, causes of IFN resistance other than anti-IFN antibodies must also be implicated in most breakthrough cases. Another potential is the selection of drug-resistant viral strains. Current ration behavior following the appearance of breakthrough (from whatever cause) in clinical practice advocates changing treatment to a different type of IFN-alpha. The detection of anti-IFN enzyme-linked immunosorbent assay (ELISA) antibodies or IFN neutralizing antibodies does not appear to provide any additional information for decision making.

Urinary D-glucaric acid excretion in the Seveso area, polluted by tetrachloro-dibenzo-p-dioxin (TCDD): five years of experience.

On July 10, 1976, an explosion in a factory in Seveso, Italy, located 30 km north of Milan, producing trichlorophenol caused the release of TCDD-containing compounds in the surrounding area. Since extremely small doses of TCDD have been shown to induce hepatic microsomal enzymes in animals, urinary D-glucaric acid excretion (a measurable index of enzyme induction), has been investigated in Seveso in adults and children 6 to 8 years old, in order to clarify whether levels of environmental exposure to TCDD were sufficient to produce an induction in man. Urine samples were collected from 1976 to 1981. As a control group, people living in Cannero (a nonindustrialized village on lake Magiore), in Busto Arsizio (a small industrial town near Milan) and in Lentate (a noncontaminated zone near Seveso) were chosen. In the first period of collection, children with chloracne (which is considered to be a characteristic manifestation of intoxication with chlorinated products) showed significantly increased levels of D-glucaric acid excretion compared to children without chloracne living in the same zone. As far as chronic exposure is concerned, up to 3 years after the accident both adults and children living in the Seveso area showed a statistically significant enhancement of D-glucaric acid elimination compared to the control groups. This study demonstrates that adults and children living in the polluted zones had an increased activity of hepatic microsomal enzymes for some years, since, although the urinary excretion of D-glucaric acid is only an indirect measure of enzyme activity, studies in man have indicated that it is, however, sensitive and quantitative.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of IgM antibody to hepatitis B core antigen in the diagnosis of hepatitis B exacerbations.

IgM anti-HBc levels were measured by the IMx Core-M Abbott assay in 939 serum samples in order to define a specific and sensitive cut-off value for diagnosis of chronic hepatitis B. The sera used were obtained from 52 chronic HBV patients and 10 HBV carriers with HCV or HDV co-infections and 155 asymptomatic subjects without evidence of liver disease. A Youden index value of 95.4% with 98% sensitivity and 97.4% specificity was obtained for an IMx Index value of 0.204 as cut-off. A one-year follow-up study with monthly tests has shown that quantitative analysis of IgM anti-HBc can serve as a noninvasive tool for monitoring HBV infection, and provides an accurate diagnosis of hepatitis B exacerbations. Significant elevations of IgM anti-HBc levels were associated with hepatitis B exacerbations in 96.2% of the cases but with none of the ALT flare-ups observed in HCV or HDV infected individuals. These results suggest that quantitative analysis of IgM anti-HBc provides the highest degree of confidence in definition of spontaneous and therapy-induced exacerbations or remissions of hepatitis B.

The role of transplantation in small hepatocellular carcinoma complicating cirrhosis of the liver.

Of 176 hepatic transplants performed from 1986 to December 1992, 27 patients had small hepatocellular carcinoma (< or = 5 centimeters) complicating cirrhosis of the liver. All patients were asymptomatic for the hepatic malignancy and the diagnosis was established in each instance preoperatively by means of serial sonographic scans and alpha-fetoprotein levels. Cirrhosis was classified as Child's A in eight instances, as Child's B in 16 and Child C's in three. The cause was alcoholic in three patients, posthepatitic in 21 patients (eight hepatitis B virus [HBV] positive and 13 hepatitis C virus [HCV] positive) and undetermined in three. The in-hospital mortality rate was 11 percent (three of 27). Additionally, five patients died at different intervals after transplantation: only two died of neoplastic recurrence at 12 and 32 months, respectively (7.4 percent rate). Actuarial survival rates were 82 percent at one year and 71 percent at three years, with a mean follow-up period of 32 months (range six to 78 months). Morbidity related to the procedure was a relevant problem: 21 percent of the patients had prompt resumption of normal life while 37 percent required repeated hospitalization and 42 percent required strict control on an outpatient basis. The most frequent problem was HBV or HCV reinfection of the grafted liver, which occurred in 42 percent. Based on this experience, transplantation of the liver has shown an excellent oncologic accuracy for small hepatocellular carcinoma in cirrhosis of the liver, thus representing the most rational surgical procedure for patients with Child's B and Child's C cirrhosis classification. The relevant mortality and morbidity rates, strictly related to this procedure, suggest other options as more appropriate in those with Child A cirrhosis at this time.

gamma-Glutamyl-transpeptidase in diabetics: a case control study.

Several investigators have reported high levels of gamma-glutamyl-transpeptidase (GGT) in the diabetic population. Therefore, we undertook a study to see the prevalence of 'isolated' high GGT in a large population of diabetics without chronic liver disease (CLD), as compared to an age- and sex-matched control group of non-diabetic subjects without CLD, and the role of extrahepatic factors in 'isolated' high GGT, as possible etiopathogenetic causes. We selected 351 diabetics with normal hepatologic screening, without echographic abnormalities of the hepatic parenchyma or the biliary tract. Age, duration and therapy of diabetes, body mass index (BMI), alcohol consumption, glycosylated hemoglobin (HbA1), and the presence of hepatitis B virus (HBV) were studied to see if they are related to high GGT. The control group included 260 age- and sex-matched non-diabetic subjects. We did not find any significant difference between diabetics and the control group in the prevalence of high GGT (mean: 17.5% vs. 23%; women: 16% vs. 14.5%). Multiple regression analysis showed that alcohol consumption plays the major role in the high GGT of both men and women.

Increased urinary D-glucaric acid excretion by children living in an area polluted with tetrachlorodibenzoparadioxin (TCDD).

Extremely small doses of TCDD have been shown to induce hepatic microsomal enzymes in animals. Whether levels of environmental exposure to TCDD were sufficient to produce enzyme induction in man, has been investigated in Seveso, where in July 1976 explosion in a factory spread toxic substances, one of which was TCDD, to the surrounding area. The hepatic microsomal enzyme activity was assessed by estimating urinary d-glucaric acid (UGA) excretion in children 6-8 years old. In 31 children, urine samples were collected between August and December 1976; in 67 other children in February 1979. As a control group 60 children living in Busto Arsizio (a small industrial town near Milan) and 26 living Cannero (a non-industrialized village on Lake Maggiore) were chosen. In the first period of collection, children with chloracne (which is considered to be a characteristic manifestation of intoxication with chlorinated products), showed significantly increased levels of UGA compared with children without chloracne. In 1979, children living in the Seveso area showed a statistically significant enhancement of d-glucaric acid excretion compared to the control groups. In conclusion, this study demonstrates that many children living in the Seveso area have an increased activity of hepatic microsomal enzymes, since, although the urinary excretion of d-glucaric acid is only an indirect measure of enzyme activity, studies in man have indicated that it is both sensitive and quantitative. As far as the cause of this increase is concerned, since it is possible to exclude the influence of alcohol, contraceptives, phenobarbitone or other drugs, it is reasonable to conclude that TCDD, a potent inducer agent, could be responsible for this phenomenon.

Alpha interferon treatment in chronic hepatitis C.

INTRODUCTION: Alpha interferon (alpha IFN) treatment normalizes serum ALT levels in at least half of all patients affected by chronic hepatitis C, but a reactivation of the disease is frequently observed after the end of therapy. Different regimens of alpha IFN therapy have been proposed but the optimal schedule is still controversial. Recently at least 6 different types of HCV have been identified and the HCV genotype has been proposed as an important factor influencing the response to alpha IFN therapy. OBJECTIVE: The aim of this study was to evaluate the efficacy of different regimens of alpha IFN in chronic hepatitis C, and to study the relationship between the response to treatment and HCV genotypes. METHODS: 160 consecutive patients affected by biopsy-proven chronic hepatitis C were randomly treated with different doses of lymphoblastoid alpha IFN [adjusted to the body surface area (m2)] and different durations of therapy, as follows: 2 MU/m2/t.i.w. for 6 or 12 months or 4 MU/m2/t.i.w. for 6 or 12 months. Biochemical and virological responses were studied: ALT levels were monitored monthly during and for at least 6 months after the end of treatment, and serum HCV RNA was assessed before and at the end of therapy, using nested RT-PCR. Biochemical responses were defined in advance as follows: non-response as maintenance of abnormal ALT levels during treatment; complete response as the normalization of ALT by the 4th month and lasting until the end of treatment; sustained response as a complete response lasting for at least 6 months after the end of therapy. The clearance of serum HCV RNA at the end of therapy was considered a virological response. In pre-treatment sera stored at-80 degrees, HCV genotyping was performed according to the method of Okamoto. The Chi square test and multiple stepwise logistic regression were used for the statistical analysis. RESULTS: A sustained biochemical response was significantly more frequent in patients treated for 12 than in patients treated for 6 months, independently of the dosage (45% vs 24% in patients treated with 2 MU/m2/tiw, and 55.5% vs 30% in those treated with 4 MU/m2/tiw). The distribution of HCV genotypes (according to the classification of Okamoto) was 9.8% type I, 45.5% type II, 37.1% type III and 7.6% type V. Both the biochemical and virological responses were significantly correlated to the HCV genotype, being significantly more frequent in patients infected with type III or V (71-60% biochemical and 48-50% virological response, respectively) than in patients with type I or II (15% biochemical and 18-21% virological response, respectively). CONCLUSIONS: 12 months of alpha IFN treatment seemed to be significantly more efficacious than 6 months of therapy, and a significant relationship between the HCV genotype and the biochemical and virological response to alpha IFN was found.

[Influence of diacereine on the gastroduodenal mucosa of ulcer patients in remission and on the diuresis of cirrhosis ascites patients]. / Influenza della diacereina sulla mucosa gastroduodenale degli ulcerosi in fase di remissione e sulla diuresi del cirrotico ascitico.

Diacereine (DAR) is a new anti-arthrosis drug with an unusual action mechanism. Once it was found that, unlike existing FANS, DAR has no effect on prostaglandin synthesis, it was thought interesting to assess its clinical tolerability on two groups of patients. The first was a group of high risk patients with arthrosis or arthritis. The second consisted of patients with a history of duodenal ulcer or cirrhotics in the ascitic phase. In the first group the DAR was given (100 mg per diem per os) for 30 days after oesophagogastroduodenoscopy that was repeated at the end of treatment. DAR treatment of patients with ulcers in the clinical remission phase was reliable in the sense that no recurring ulceration or major endoscopic lesions were observed but the subjective tolerability was not excellent in about half the patients due to the appearance of dyspeptic symptoms that are, however, a notoriously common response to any drug treatment in this kind of case series. In a second group of 5 patients with various types of cirrhosis of the liver, the aim was to assess the effect of DAR treatment on kidney function and ascitic decompensation. The drug was administered orally in doses of 100 mg per diem for 10 days. On the basis of the results observed in this case series only it can be stated that the use of DAR on ascitic cirrhosis patients produces no alterations in kidney function and does not reduce the effectiveness of diuretic treatment. Indeed it may well be that DAR has a positive effect on diuresis, that increased in this series in line with earlier experimental results.

"Breakthrough" during interferon therapy for chronic hepatitis C. Overview on the diagnosis, possible aetiology and recommendations for management.

A relapse of serum aminotransferase levels after complete normalisation during alpha interferon therapy for chronic hepatitis C is diagnosed as Breakthrough. Its prevalence ranges between 14% and 21% of the responders, with no significant differences between the alpha interferons. Hepatitis C virus genotype and interferon dose do not seem to represent predisposing factors. The development of neutralising antibodies to interferon is associated with Breakthrough in about half of the patients; other aetiologic factors such as down-regulation of interferon receptors or development of virus resistance to interferon may be implicated in the remaining cases. The therapeutic switch from recombinant to lymphoblastoid alpha interferon has been demonstrated to be a successful strategy to overcome Breakthrough and to restore a complete response.

Nadolol can prevent the first gastrointestinal bleeding in cirrhotics: a prospective, randomized study.

Propranolol has been reported to prevent the risk of hemorrhage in patients who survived episodes of variceal rupture. Since the first bleeding episode can be lethal, we did a prospective, randomized trial to see whether beta-blockers could also prevent the first hemorrhage. Seventy-nine consecutive cirrhotics with large esophageal varices by endoscopy and who had never bled were randomly allocated to one of the following treatments: placebo; ranitidine (300 mg per day), or nadolol (40 to 120 mg per day)--which is not cardio-selective, reduces portal hypertension and does not interfere with renal flow. Since no significant differences between ranitidine and placebo treatment were observed, the two groups were combined as the control group and compared with the nadolol group. After a mean follow-up of 24 months, only 1 of the 30 patients in the nadolol group had bled, while 11 of the 49 patients in the control group had bled. The percentages of patients who had not bled 1 and 2 years after the inclusion were 100 and 94.4% for the nadolol group and 81.2 and 70.2% for the control group (p less than 0.02), respectively. There were no differences in the mortality rate. In conclusion, nadolol significantly protects against the first gastrointestinal bleeding episode in cirrhotics.

[Effect of acute administration of high doses of ethanol on the canalicular Na+K+ dependent ATPASE in the isolated and perfused rat liver]. / Effetto della somministrazione acuta di alte dosi di etanolo sull'ATP-asi canalicolare Na+K+ dipendente nel fegato isolato e perfuso di ratto.

Na+-K+-ATPase in canaliculi-enriched liver plasma membranes was found to be inhibited by high concentration of ethanol (12 mmoles %ml) both in vitro and in vivo; the decrease of Na+-K+-ATPase, which is considered a major factor in the production of bile-salt independent fraction of canalicular bile flow, may be the cause of the previously observed reduction of bile flow after ethanol administration.

Biochemical and histochemical estimations of liver gamma-glutamyltransferase activity in ethanol-fed rats.

Ethanol-fed rats showed significantly elevated plasma and liver gamma-glutamyltransferase activity, compared with rats fed carbohydrates isocalorically, or with untreated control animals. The activity of gamma-glutamyltransferase in liver was detected by means of both biochemical and histochemical methods. These data suggest that increased plasma gamma-glutamyltransferase activity commonly found in alcoholics can be related, at least in part, to a hepatic enhancement of the activity in the liver.

Antibodies developing against a single recombinant interferon protein may neutralize many other interferon-alpha subtypes.

Three hepatitis C patients out of 15 who received recombinant interferon-alpha 2a (rIFN-alpha 2a) therapy developed high levels of neutralizing antibody coincident with clinical relapse. On analysis, antibodies in their sera were found to also produce some neutralization of lymphoblastoid IFN. Purified lymphoblastoid IFN was separated chromatographically into 10 fractions, each containing one or two IFN-alpha subtypes, and these were used individually to examine the subtype specificity of the neutralizing antibodies in the patients' sera. All three sera neutralized all the subtypes present in the 10 lymphoblastoid IFN fractions. These findings may explain why some patients who develop antibody-mediated resistance to treatment with rIFN-alpha 2 preparations are unable to respond again when treated instead with a human cell derived preparation containing many IFN-alpha subtypes.

Problems in diagnosing viral hepatitis.

The most reliable method of making a specific aetiological diagnosis of chronic viral hepatitis would be to identify virus specific cytotoxic T lymphocytes responsible for the killing of virus infected hepatocytes in each patient's liver. Unfortunately, this can not be proposed for routine diagnosis and surrogate tests are required. The detection of virus markers, and even of the virus itself, does not imply that liver damage is caused by virus infection. Indirect markers of the host's antiviral immunoresponse have to be used to confirm more specifically the diagnosis of viral hepatitis. IgM antibodies against viral antigens implicated in the elimination of the virus seem to be suitable alternative candidates. Significant changes in the serum values of viraemia and aminotransferases occur within a few days, while a significant variation in liver histology takes much longer. Only the kinetics of the highly variable parameters can be used for an appropriate study of the relationship between viraemia, antiviral immunoresponse, and liver cell necrosis. Quantitative and dynamic analyses of hepatitis virus markers seem the most suitable and reliable methods of monitoring the patients eligible for antiviral treatment and identifying the most appropriate time to start this.