A phase I/II study of recombinant human interleukin-12 in patients with chronic hepatitis C.

Interleukin-12 (IL-12) plays a central role in mounting an effective cellular immune response directed towards elimination of intracellular pathogens. The present open-label, multicenter, dose-escalation phase I/II study was designed to assess tolerability, pharmacokinetics, pharmacodynamics, and efficacy of subcutaneously administered recombinant human interleukin-12 (rHuIL-12) in the treatment of chronic hepatitis C. Sixty patients (42 men, 18 women, aged 24-60) were treated with 0.03 microgram/kg (n = 16), 0.1 microgram/kg (n = 14), 0.25 microgram/kg (n = 15), or 0.5 microgram/kg rHuIL-12 (n = 15) for 10 consecutive weeks. rHuIL-12 was generally well tolerated, with 2 patients (3.3%) being withdrawn from treatment for adverse events. Treatment was associated with temporary decreases in neutrophils and lymphocyte counts and with elevations in serum transaminases and bilirubin. Serum IL-12 levels observed were higher at 0.5 microgram/kg compared with 0.25 microgram/kg doses, suggesting a dose-related increase in systemic exposure of IL-12. Measurable levels of interferon gamma (IFN-gamma) were also observed at the highest dose of 0.5 microgram/kg. At the end of treatment hepatitis C virus (HCV) RNA was detectable in all patients. A more than 50% decrease in pretreatment HCV RNA levels was observed in 3 of 16 patients of the 0.03-microgram/kg dose group, in 3 of 14 of the 0.10-microgram/kg dose group, in 6 of 15 of the 0.25-microgram/kg dose group, and in 8 of 15 patients of the 0.5-microgram/kg dose group. Although in several cases serum alanine transaminase (ALT) levels decreased either during or after treatment, ALT normalization was observed in only 4 patients at the end of treatment and in 5 patients at the end of follow-up. Significant anti-rHuIL-12 antibody titers were not detectable in any patient. In conclusion, antiviral activity of rHuIL-12 in patients with chronic hepatitis C does not appear advantageous in comparison with other currently available treatments.

Effect of fluoroquinolone on the enhanced nitric oxide-induced peripheral vasodilation seen in cirrhosis.

BACKGROUND: In patients with cirrhosis, portosystemic shunts allow intestinal bacteria and endotoxin to enter the systemic circulation. Endotoxemia may induce increased synthesis of nitric oxide, thereby contributing to arterial vasodilation. OBJECTIVE: To test the hypothesis that the antibiotic norfloxacin blocks the effects of nitric oxide. DESIGN: Placebo-controlled, double-blind, crossover study. SETTING: Alfred Hospital, Melbourne, Australia. PATIENTS: 9 patients with alcohol-related cirrhosis and 10 healthy controls. INTERVENTION: Norfloxacin, 400 mg twice daily, for 4 weeks. MEASUREMENTS: Peripheral blood flow was measured by using forearm venous occlusion plethysmography. RESULTS: Basal forearm blood flow was higher in patients with cirrhosis than in controls (3.69 +/- 0.27 mL/100 mL per minute and 2.47 +/- 0.40 mL/100 mL per minute; P = 0.014) but returned toward normal after norfloxacin was given (2.64 +/- 0.31 mL/100 mL of tissue per minute in patients with cirrhosis). Responses to NG-monomethyl-L-arginine were greater in patients with cirrhosis but returned to normal after norfloxacin was given. CONCLUSION: Bacterial endotoxemia in patients with cirrhosis induces increased synthesis of nitric oxide that can be corrected with norfloxacin.

Efficacy and tolerance of a 6-month treatment course of daily interferon-alpha 2a for chronic hepatitis C with cirrhosis. The Australian Hepatitis C Study Group.

Response to interferon-alpha (IFN-alpha) treatment in hepatitis C is poorer when cirrhosis is present. In the third Australian multicentre hepatitis C trial, Aushep-3, we examined the efficacy and tolerability of an intensive 24-week course of interferon-alpha 2a in Child-Pugh grade A patients with chronic hepatitis C and cirrhosis. This was an open uncontrolled trial of 4.5 million units (MU) of IFN-alpha 2a daily for 24 weeks; follow-up was 48 weeks. Chronic hepatitis C and cirrhosis were confirmed histologically. HCV RNA was determined in serum by reverse transcriptase polymerase chain reaction (PCR), and viral genotyping was by line-probe assay. Treatment response was defined as a reduction of alanine aminotransferase (ALT) to less than 1.5 times the upper limit of normal (and by at least 50% of pretreatment values) at weeks 20 and 24. Sustained response was defined as normal serum ALT after treatment from trial week 28 until week 48. Among the 56 patients, a treatment response occurred in 18 (32% by intention-to-treat; 42% of those who completed treatment) and eight (14%) had a sustained response. At 24 weeks, HCV RNA was not detectable in 12 of 17 treatment responders, and remained negative at 48 weeks in six of eight sustained responders. Treatment response by genotype occurred in 75% of patients with HCV type 2, in 38% with HCV type 3a and in 12% with HCV genotype 1. Sustained response occurred in only one (4%) patient with HCV genotype 1 but in five (20%) with genotypes 2 or 3a. Among 13 patients withdrawn, nine were for adverse effects, most often haematological; 10 others underwent dose reduction for adverse effects. It is concluded that a sustained biochemical and viral response to treatment with IFN-alpha 2a can be obtained in some patients with hepatitis C and cirrhosis, particularly those with genotypes 2 or 3a. Therefore, patients with cirrhosis should be considered for interferon treatment on an individual basis. Genotyping may improve case selection, but vigilance is required for haematological complications.

Management of haematemesis and melaena.

Upper gastrointestinal bleeding remains a common medical emergency with high morbidity and mortality. High risk patients are best managed in specialised units. Endoscopy is the procedure of choice for diagnosis and haemostatic therapy of peptic ulcers, reducing deaths and the probability of rebleeding, as well as the need for surgery; for acute variceal bleeding, pharmacotherapy followed by endoscopic ligation is recommended.

Treatment of cirrhotic hepatitis C virus patients with daily doses of interferon-alpha 2a.

In patients with hepatitis C who have cirrhosis the rate of sustained response following interferon therapy is less than half that of patients without cirrhosis. It has been suggested, however, that a higher dose regime in patients with cirrhosis may improve response. The results of a recent Australian study of cirrhotic patients who were given an intense interferon programme of 4.5 MIU daily for 24 weeks were compared with previous studies of patients with hepatitis C. In the Australian study, 14% of patients had a sustained response at 6 months after end of therapy. Of 11 studies of interferon response in chronic hepatitis C comparison of pretreatment variables showed considerable differences. Identification of predictors of response by univariate and multivariate analysis regularly indicated the importance of age and fibrosis. Analysis of six studies with either a poor (5% or less) or a reasonable (14-19%) sustained response rate to interferon in patients with cirrhosis suggested that a higher dose or longer duration of therapy was associated with better results. The experience of the Australian study, where 14% of patients had a sustained biochemical response to interferon and side-effects were reasonably tolerated with careful monitoring, suggests that future studies in cirrhosis should be carried out exploring higher doses and longer durations of therapy.

Chronic hepatitis C: effect of alcohol on hepatitic activity and viral titre.

BACKGROUND/AIMS: Alcohol and the hepatitis C virus have been postulated to interact to adversely affect the natural history of patients with chronic liver disease. The aim of this study was to examine the effect of alcohol on hepatitic activity and serum HCV RNA levels in patients with chronic hepatitis C. METHODS: Forty-five consecutive patients with chronic hepatitis C were classified according to alcohol intake over the 3-month period preceding study entry: group 1 (n = 23), > 10 g alcohol/day; group 2 (n = 22), < or = 10 g alcohol/day. Hepatitic activity and alcohol intake were assessed at study entry and, following moderation of alcohol intake, after a mean follow-up period of 4.4 +/- 0.2 months. RESULTS: Hepatitic activity was significantly greater in the patients who consumed > 10 g of alcohol/day. Moderation of alcohol consumption in patients consuming > 10 g/day resulted in a significant decrease in both disease activity (p = 0.0002) and viral RNA titre (p = 0.018); there was no change over the study period in patients with a consistently low alcohol intake. CONCLUSION: The results support the hypotheses that, in patients with chronic hepatitis C, alcohol aggravates hepatic injury, increases viral load and adversely affects the natural history of the associated liver disease.

Chronic hepatitis C and interferon alfa therapy: predictors of long term response.

OBJECTIVE: To identify independent patient, disease and viral characteristics that predict a sustained biochemical or viral response to interferon alfa therapy in patients with chronic hepatitis C. DESIGN: Comparison of interferon responders and non-responders by univariate and multivariate analysis. SETTING: The hepatitis clinic of the Alfred Hospital, Melbourne (a tertiary referral hospital), between July 1989 and June 1994. SUBJECTS: All patients with chronic hepatitis C who were treated with interferon alfa (IFN-alpha; 3 million IU, three times a week or more) for at least 12 weeks. OUTCOME MEASURES: Patient demographic and epidemiologic characteristics, pretreatment serum alanine aminotransferase (ALT) and 2-gamma-glutamyl transpeptidase (GGT) levels, histological grading of hepatic steatosis, necroinflammatory activity and fibrosis, serum hepatitis C virus (HCV) RNA titres and genotype and post-treatment serum ALT levels and presence of HCV RNA. RESULTS: Of 58 patients, 13 (22%) had a sustained (six months or longer) biochemical response to IFN-alpha therapy, including 12 (21%) with a sustained viral response. Univariate analysis showed that young patients with a normal serum GGT level, grade 0-1 steatosis and fibrosis, low viral titre and infection with genotypes 3a and 2a were more likely to have a sustained response. Infection with genotypes other than 1a and 1b was the only independent variable associated with both a sustained biochemical and viral response. After adjusting for genotype, a hepatic fibrosis grade of 0-1 was also independently associated with viral response. This logistic regression model accurately predicted the virological response in 80% of cases. CONCLUSION: In Australian patients with chronic hepatitis C, a sustained viral response to IFN-alpha therapy is most likely in those infected with a genotype other than 1a or 1b and with minimal hepatic fibrosis.

A comparison of Doppler flowmetry with conventional assessment of acute changes in hepatic blood flow.

The validity and clinical relevance of Doppler flowmetry in measuring changes in regional blood flow are uncertain. In the present study we compared changes induced ketanserin in regional splanchnic blood flow as measured by Doppler flowmetry with changes in conventionally measured systemic and in hepatic haemodynamic indices estimated pharmacokinetically using indocyanine green. Fourteen patients with alcoholic cirrhosis and portal hypertension were evaluated. On multivariate analyses, significant associations were noted for only three indices: changes in estimated hepatic blood flow were predicted jointly by changes in flow in the main and right portal veins and hepatic artery (R2 = 0.80); changes in intrahepatic shunting (indocyanine green extraction) were predicted by changes in flow in the main and right portal veins (R2 = 0.55); and changes in sinusoidal perfusion (indocyanine green clearance) were significantly predicted by changes in main portal vein flow alone (R2 = 0.76). These data support the validity of Doppler flowmetry in quantifying change in regional blood flow, but highlight the limitations in its clinical application and interpretation. The association of changes in main portal vein flow with changes in sinusoidal perfusion has clinical potential but requires confirmation using other modulating drugs.

Immunolocalisation of interferon-alpha in hepatitis C patients and its correlation with response to interferon-alpha therapy.

Localised interferon-alpha production was investigated in hepatitis C patients entered into a trial of interferon-alpha-2a therapy. Antibodies capable of reacting specifically with interferon-alpha-2, interferon-alpha-4 or with all interferon-alpha subtypes were used as immunohistochemical and immunofluorescence probes to study interferon-alpha production in liver biopsy tissue, and peripheral blood mononuclear cells prior to and after stimulation with Sendai virus. Measurement of cytoplasmic interferon-alpha, specifically interferon-alpha-2 and interferon-alpha-4, in peripheral blood mononuclear cells isolated from the hepatitis C patients and of total interferon-alpha secreted into culture supernatants by these cells showed interferon-alpha production similar to that of peripheral blood mononuclear cells isolated from normal individuals. Interferon-alpha-positive cells were observed in the infiltrating mononuclear cells of the liver biopsy tissue obtained from 8 of the 14 patients. Lymphocytes, fibroblasts, Kupffer cells, polymorphonuclear cells and monocytes stained positive for interferon-alpha, and specifically interferon-alpha-4, in all of the eight patients. The cytoplasm of hepatocytes also stained weakly positive in three of these patients. Interferon-alpha positive cells showed a good correlation with the degree of histological damage observed in the liver biopsies but not with presence of antibodies towards hepatitis C virus or levels of serum alanine aminotransferase measured prior to interferon-alpha-2a therapy. Interestingly, response to therapy seemed linked to local interferon-alpha production status. Those patients who responded best to therapy displayed no or only low levels of interferon-alpha positive cells in liver biopsy tissue. Thus patients with a lower activation of their endogenous interferon-alpha system may benefit from administration of exogenous interferon-alpha.

Detection of interferon-alpha expression by PCR in patients with chronic hepatitis C and hepatitis non-A, non-B.

The polymerase chain reaction (PCR) was used to examine expression of interferon-alpha (IFN A) genes in general and the expression of messenger RNA (mRNA) encoding the subtypes IFN-alpha-2 and IFN-alpha-4 in blood and liver biopsy samples from patients with chronic hepatitis C or hepatitis non-A, non-B (HC/HNANB) infection entered into a trial of IFN-alpha-2a therapy. Peripheral blood mononuclear cells (PBMC) from healthy controls and HC/HNANB infected patients were studied for their capacity to produce transcripts encoding IFN-alpha after stimulation with Sendai virus. Expression at the level of mRNA for IFN A and the subtypes IFN A2 and A4 was detected in both controls and HC/HNANB infected patients PBMC and no significant difference was seen in expression of IFN A transcripts or level of total IFN-alpha secreted into culture supernatants between controls and patients. Interferon A, and specifically IFN A2 and IFN A4 transcripts were detected in a high proportion of liver biopsies from patients with HC/HNANB infection. The presence of IFN A mRNA (and specifically IFN A2 and IFN A4) showed no correlation to histological improvement nor response to therapy. The use of PCR to detect those IFN A genes that are not expressed, thereby identifying subtypes that may be lacking, could be the key to the choice of IFN-alpha subtypes that are used for effective therapy.

Change in serum hyaluronan: a simple index of short-term drug-induced changes in hepatic sinusoidal perfusion.

BACKGROUND: Hyaluronan is an endogenous polysaccharide whose clearance from the plasma is predominantly by liver sinusoidal cells and is sinusoidal flow dependent. This study was designed to determine if a change in serum hyaluronan might reliably reflect short-term drug-induced changes in sinusoidal perfusion. METHODS: Hemodynamic changes following an oral dose of ketanserin were compared with changes in serum hyaluronan levels in 12 patients with alcoholic liver disease and portal hypertension. Indices determined comprised heart rate, mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance, hepatic venous pressure gradient (HVPG), indocyanine green (ICG) clearance and extraction, and total hepatic blood flow. Measurements were made in a basal state 1 hour after ketanserin ingestion and expressed as a ratio of values post- to pre-ketanserin administration. RESULTS: Ketanserin had variable effects comprising both increases and decreases in all indices. On univariate and multivariate analysis, changes in serum hyaluronan concentration (1.05 +/- 0.13, mean +/- SD) significantly correlated with only one index: changes in ICG clearance (0.93 +/- 0.17, r = -0.65, P = 0.02). CONCLUSIONS: Changes in serum hyaluronan levels reflect short-term drug-induced changes in sinusoidal perfusion in patients with alcoholic liver disease and portal hypertension. Serial measurement of serum hyaluronan levels may offer a simple method of screening vasoactive drugs for their short-term effects on sinusoidal perfusion.

Hemodynamic and liver function predictors of serum hyaluronan in alcoholic liver disease.

To define hepatic predictors of serum hyaluronan in patients with chronic liver disease, 62 patients with alcoholic liver disease were evaluated. In group 1, 30 patients had concurrent assessment of serum hyaluronan, liver function tests, Pugh grade and hemodynamic indices. A second, overlapping group of 42 patients (group 2) also had antipyrine clearance measured but without hemodynamic assessment. All but six patients had elevated serum hyaluronan levels. In both groups, serum hyaluronan levels differed between Pugh grades and, in each group, was significantly greater in Pugh grade C compared with those in Pugh grade A (p less than 0.05, Kruskal-Wallis test). When analyzed by correlation, serum hyaluronan was significantly associated with several indices in group 1, but on multivariate linear regression only three statistically independent predictors of serum hyaluronan were identified: serum albumin (p = 0.008), indocyanine green clearance (p = 0.024) and indocyanine green extraction (p = 0.036). The overall R2 for these correlates was 65%. In the second group, antipyrine clearance was not significantly associated with serum hyaluronan (r = 0.29, p = 0.06), but other associations were similar to the first group. On multivariate analysis, only serum albumin predicted serum hyaluronan (p less than 0.001; R2 = 43%). In conclusion, indices of hepatocyte synthetic function, sinusoidal blood flow and degree of intrahepatic shunting are independent predictors of serum hyaluronan in alcoholic liver disease. These data show the unique nature of serum hyaluronan and suggest its potential application to the assessment of acute hemodynamic changes in patients with liver disease.

Coagulopathy during ascites reinfusion: prevention by antiplatelet therapy.

The development of disseminated intravascular coagulation (DIC) during a controlled IV infusion of concentrated ascitic fluid was studied in a group of patients with cirrhosis and refractory ascites. Nine studies were performed on patients who had not received prophylactic antiplatelet therapy. All developed laboratory evidence of DIC. The total collagen infused, estimated by ascitic hydroxyproline concentration, correlated significantly with both the prolongation of the partial thromboplastin time with kaolin (r = 0.8628; P less than 0.005) and the decrease in platelet count (r = 0.5674; P less than 0.05). The changes in the coagulation profile were reversible on ceasing the infusion, returning to baseline levels within 12 hours. There were no changes in the coagulation profiles of four patients studied 48 hours after beginning antiplatelet therapy with aspirin and dipyridamole. It is concluded that the infusion of concentrated ascitic fluid into a peripheral vein of patients with cirrhosis results in DIC, the severity of which correlates with the amount of collagen infused and which is completely prevented by inhibiting collagen-induced platelet aggregation. The results support the hypothesis that the DIC that complicates ascites infusion into the systemic circulation is largely related to ascitic fluid collagen.

Pathophysiology of ascites formation.

Ascites formation in patients with cirrhosis of the liver is dependent on local factors that preferentially localize any fluid retention to the peritoneal space and systemic factors that favor renal retention of salt and water. The local factors are largely related to adaptive changes in the hepatic sinusoids and mesenteric capillaries in response to an increase in hydrostatic pressure. The systemic factors reflect the disturbance in volume homeostasis evident in patients with cirrhosis and are largely explained by the neurohumoral consequences of a decreased peripheral vascular resistance.

Augmentin-induced jaundice.

OBJECTIVE: To alert clinicians to the hepatotoxic potential of Augmentin (amoxycillin and clavulanic acid), a widely prescribed antibiotic, in susceptible patients, and to point out that the hepatic illness may be delayed but serious and protracted. DESIGN AND SETTING: Case reports of patients with Augmentin-induced jaundice referred to the gastroenterology departments in three major teaching hospitals, and a review of cases reported to the Australian Adverse Drug Reactions Advisory Committee (ADRAC). PATIENTS: Eight patients with nine episodes of Augmentin-induced jaundice personally treated by the authors from March 1988 to February 1990 are described. A further 19 patients reported to ADRAC from May 1987 to November 1989 are discussed. All patient histories were carefully reviewed to ensure that there was a temporal relationship between the course of Augmentin and the onset of the hepatitic illness and that other causes of jaundice were reasonably excluded. RESULTS: Jaundice developed in some of these patients several weeks after drug treatment was completed. The illness may be protracted over many weeks. As yet, there has been no case of progressive disease leading to the liver failure. CONCLUSIONS: The data suggest that a hypersensitivity reaction to clavulanic acid is the likely cause of the jaundice. Therefore, Augmentin, although an important antibiotic, should be reserved for severe infections for which amoxycillin is unsuitable.