Ultrastructure of liver progenitor/oval cells in children with nonalcoholic steatohepatitis.

PURPOSE: Very interesting reports have appeared lately on the role of liver progenitor/oval cells in the morphogenesis and development of nonalcoholic steatohepatits (NASH) in adult patients and experimental animals. However, no literature data concerning pediatric patients have been available. Therefore, the purpose of the study was to evaluate the ultrastructure of the population of liver progenitor/oval cells in the biopsy material from children with previously clinocopathologically diagnosed NASH. MATERIAL/METHODS: Electron-microscopic examinations were conducted on fresh tissue samples collected from 10 children with NASH (aged 2-14 years), which were fixed with a solution of 2% paraformaldehyde and 2.5% glutaraldehyde in 0.1 M cacodylate buffer. RESULTS: Ultrastructural examinations of the liver progenitor/oval cells in children with NASH show a quite prominent number of these cells, especially their two types, hepatic progenitor cells (HPCs) and intermediate hepatocyte-like cells (IHCs), with intermediate bile-like cells being the least frequent. They were found to occur single or in clusters of two, seldom of three, and frequently in the areas of advanced liver fibrosis or close to them. Many times, these cells were accompanied by hepatocytes showing a varying degree of death, to total cell disintegration. Interesting was the presence of activated nonparenchymal liver cells, i.e. Kupffer cells/macrophages and hepatic stellate cells, frequently found to adhere to the hepatic oval cells. CONCLUSIONS: The current study suggests a marked involvement of the population of liver progenitor/oval cells, mainly HPCs and IHCs, in the development of nonalcoholic steatohepatitis in pediatric patients, especially in fibrosis progression.

Extrahepatic manifestations associated with chronic hepatitis C infections in Poland.

PURPOSE: To assess the prevalence and predictive factors of extrahepatic manifestation (EM) in patients with chronic hepatitis C (CHC) infection in Poland. MATERIAL AND METHODS: 340 consecutive patients (mean age: 42 years) with untreated CHC were studied between 2000 and 2006. The HCV infection was defined by positive serology and serum HCV RNA. The inflammation grade and fibrosis stage were assessed according to Ishak. Demographic, laboratory and liver biopsy data were collected. The patients with liver cirrhosis, concomitant HBV or HIV infection, autoimmune liver diseases and alcohol abusers were excluded from the analysis. RESULTS: 210 patients with CHC (61.7%) presented at least 1 extrahepatic manifestation, including mixed cryoglobulinemia (37.1%), thrombocytopenia (27.6%), thyroid autoimmunity (16.2%), dermatological disorders (4.1%) and type 2 diabetes (4.1%). Other EM such as the sicca syndrome, nephropathy, polyneuropathy and B-cell lymphoma were observed in single cases. In multivariate analysis lower platelet count was found as a predictive factor of EM in patients with CHC. CONCLUSIONS: The majority of patients with CHC, living in Poland, have EM, of which cryoglobulinemia, thrombocytopenia, thyroid autoimmunity, dermatological disorders and type 2 diabetes are most common. Through the multivariate analysis the lower platelet predicts extrahepatic manifestations associated with chronic hepatitis C.

Tumor necrosis factor alpha and its soluble receptors in obese children with NAFLD.

PURPOSE: To evaluate the serum levels of tumor necrosis factor (TNF) alpha and its soluble receptors in obese children with non-alcoholic fatty liver disease (NAFLD). MATERIAL/METHODS: Fasting serum levels of TNFalpha and its receptors were determined in 45 consecutive obese children with suspected liver disease and 20 lean controls. The degree of liver steatosis was graded in ultrasound according to Saverymuttu. 1H-MR spectroscopy was performed with 1.5T scanner with PRESS sequence. RESULTS: A fatty liver was confrmed in 32 children by ultrasonography (group I); 16 of them also had increased ALT activity (group Ia - NAFLD). Serum concentrations of TNFalpha and its receptors were significantly higher in obese children with NAFLD compared to controls. Significant correlation was found between ultrasonographic grade of liver steatosis and TNFalpha level but serum level of this adipokine was not significantly different in children with advanced liver steatosis (grade 2-3, n=13) compared to patients with mild steatosis (grade 1, n=19). The ability of TNFalpha and its receptors (R1, R2) to differentiate children with advanced liver steatosis from those with mild steatosis was insignificant. However, the ability of serum TNFalpha to differentiate obese children with liver steatosis from those without steatosis was significant (AUC=0.7448, p=0.0291). CONCLUSION: Although TNFalpha does not predict advanced liver steatosis, it may be suitable serum marker in predicting liver steatosis in obese children.

Serum concentration of adiponectin, leptin and resistin in obese children with non-alcoholic fatty liver disease.

PURPOSE: Obesity, insulin resistance and dyslipidemia are the most significant risk factors of non-alcoholic fatty liver disease (NAFLD) but the role of adipokines in patomechanism of this disease is not clear. The aim of the study was to evaluate the serum levels of leptin, adiponectin and resistin in obese children with NAFLD. MATERIAL/METHODS: The fasting serum levels of adipokines were determined in 44 consecutive obese children with suspected liver disease and in 24 lean controls. The degree of the ultrasound liver steatosis was graded according to Saverymuttu. RESULTS: The fatty liver was confirmed in 33 children by ultrasonography (16 of them also showed an increased ALT activity). The serum leptin level was significantly higher and adiponectin level was lower in the obese children with NAFLD when compared to controls. Only adiponectin correlated with homeostasis model assessment of insulin resistance (HOMA-IR). Significant negative correlations were found between the ultrasonographic grades of liver steatosis and adiponectin and resistin levels. Serum adiponectin and resistin levels were lower in children with an advanced liver steatosis (grade 3, n=10) compared to patients with a mild steatosis (grade 1-2, n=23). The ability of serum adiponectin and resistin to differentiate children with an advanced liver steatosis from those with mild steatosis was significant. CONCLUSIONS: These data suggest a role of both adiponectin and resistin in the pathogenesis of NAFLD in obese children and confirm the association between adiponectin and insulin resistance. Adiponectin and resistin may be suitable serum markers in predicting an advanced liver steatosis in children with NAFLD.

Matrix metalloproteinases and their tissue inhibitors in children with chronic hepatitis B treated with lamivudine.

PURPOSE: To evaluate if measurements of MMP-2, MMP-9, TIMP-1 and TIMP-2 have clinical applicability as markers of liver fibrosis and to assess the effect of long-term lamivudine treatment on liver fibrosis in children with chronic hepatitis B (chB). MATERIAL AND METHODS: The observation was carried out on 41 children with biopsy proven chB (HBe/+/, HBVDNA/+/) who were nonresponders to previous IFNalpha therapy. Lamivudine was administered in the group of 29 children (3 mg/kg/day, maximum 100 mg/daily). The serum concentration of examined markers was measured with ELISA before and after 24 months of therapy. ROC analysis was used to calculate the power of the assays to detect advanced liver fibrosis (score >2 according to Batts & Ludwig). RESULTS: Serum TIMP-1 and TIMP-2 levels were significantly higher and MMP-9 lower in children with chB compared to controls. There was a significant positive correlation between serum MMP-2 and negative correlation between MMP-9 level and the stage of liver fibrosis. The ability of serum MMP-9 to differentiate children with mild fibrosis from those with advanced fibrosis was significant (AUC = 0.75; p = 0.03). Other serum markers did not allow a useful prediction. 2-year lamivudine treatment did not improve histological fibrosis but it caused significant decrease of serum TIMP-2 (p = 0.01) and increase of MMP-9 level (p = 0.00005). CONCLUSIONS: MMP-9 is a better serum fibrosis marker than MMP-2, TIMP-1 and TIMP-2 to diagnose children with advanced liver fibrosis. The significant decrease of TIMP-2 and increase of MMP-9 level during therapy suggest antifibrotic effect of lamivudine in children with chB.

Serum level of YKL-40 does not predict advanced liver fibrosis in children with chronic hepatitis B.

PURPOSE: The aim of the study was to evaluate the serum concentration of YKL-40 (human cartilage glycoprotein-39) in the assessment of fibrosis stage in children compared to biopsy and prior to antiviral treatment for chronic hepatitis B. MATERIAL AND METHODS: We determined serum level of YKL-40 (METRA, EIA kit, Quidel Corporation, San Diego, USA) after an overnight fast in 63 children (age range 4-17 years, mean 10 years) with biopsy-verified chronic HBeAg-positive hepatitis B. Fibrosis stage and inflammation grade were assessed in a blinded fashion according to Ishak et al. We defined advanced liver fibrosis as a score >2. Receiver operating characteristics (ROC) analysis was used to calculate the power of the assay to detect advanced liver fibrosis (AccuROC, Canada). RESULTS: Serum concentration of YKL-40 was significantly higher in patients with chronic hepatitis B compared to controls (n=16) (38.5 +/- 19.2 vs 27.9 +/- 8.75 ng/mL; p = 0.032). The ability of serum YKL-40 to differentiate children with advanced liver fibrosis (n=31; 49.2%) from those with mild fibrosis was not significant (AUC = 0.387 +/- 0.072, p = 0.12). This marker was not a good predictor of histologic inflammation either. CONCLUSION: Serum level of YKL-40 does not predict advanced liver fibrosis in children with chronic hepatitis B.

[The assessment of nutritional status in children with chronic hepatitis B treated with interferon alpha]. / Ocena stanu odzywienia dzieci z przewleklym zapaleniem watroby typu B podczas terapii interferonem alpha.

The aim of the study was an evaluation of nutrition status in children with chronic hepatitis B during IFN-alpha therapy. Observation was carried out in a group of 40 children in the age range of 1-14 years with clinically, diagnosed chronic hepatitis B. Respectful of age 2 subgroups were distinguished. I: 27 children up to 4 years old, II: 13 children in the age range of 4-14 years. The nutritional status was evaluated by anthropometric measurement (body mass, body length/height). Moreover Cole index was estimated at the beginning and completion of the treatment and in the time of the highest weight loss. None of the examined children has body mass deficiency before IFN-alpha treatment: Cole index was in normal range as well. Lack of appetite, connected with IFN-alpha administration, was observed in 42.5 children during therapy. Weight loss was observed in 65% of the examined children especially in the first 2 months of therapy. Return to the initial body mass value was observed within 3 months after IFN-alpha completion in 77% children; but in 2 children only 12 months after IFN-alpha therapy termination. 12 months after IFN-alpha completion Cole index lower than initial was observed in 42.5% of the examined children in spite of return of body mass to initial values. There was no observed unfavourable influence of IFN treatment on body height. 20-weeks IFN-alpha therapy in children with chronic hepatitis B often causes lack of appetite, which may lead to reversible disturbances in nutritional status. Correct dietetic proceeding is necessary to decrease the frequency and intensity of disturbances in nutritional status in this group of children.

[The methods of estimation and monitoring liver fibrosis in patients with chronic viral hepatitis]. / Metody oceny i monitorowania wlóknienia watroby u chorych na przewlekle wirusowe zapalenie watroby.

Liver fibrosis may be defined as increased deposition of extracellular matrix components which is a result of the dynamic imbalance between synthesis and degradation of connective tissue. This pathological process is caused by chronic liver injury e.g. chronic infection of hepatotropic viruses, alcohol intake and autoaggressive liver diseases. Author presents methods' review of estimation liver fibrosis in patients with chronic hepatitis with special reference to the role of serum liver fibrosis markers.

[Thyroid function in children with diagnosed chronic hepatitis B treated with interferon alpha]. / Funkcja tarczycy u dzieci z rozpoznanym przewleklym zapaleniem watroby typu B leczonych IFN-alpha.

The aim of the study is to estimate thyroid function during interferon alpha therapy in children with chronic hepatitis B. 31 children aged 4-16 years were included in the study. Thyroid function was monitored by estimation of thyroid hormones (FT3, FT4, TSH) and antithyroid antibodies (TPO, ATG) concentration before and after therapy completion. In all children normal thyroid hormones and ATG concentration were found before and after therapy completion. Presence of TPO before IFN treatment in blood serum of 2 girls (6.45%) and in 4 children (12.9%) after IFN therapy were found. Clinical features of thyroid dysfunction were not observed in this group of children during IFN therapy.

Current knowledge on treatment of chronic hepatitis B in children.

So far the treatment of chronic hepatitis B has been based on the use of numerous agents, particularly interferon alpha which proved the most effective. Attempts are made to introduce new therapeutic methods (antiviral agents--nucleoside analogues, immunotherapy--anti HBV vaccine, gene therapy) in order to obtain higher percentage of patients with durable inhibition of HBV replication than it is observed after treatment with interferon alpha. The current work has been devoted to the presentation of the experiences with interferon alpha, lamivudine and anti HBV vaccine used in subjects with chronic type B hepatitis, with special reference to paediatric patients.

Application of ursodeoxycholic acid (UDCA) in the therapy of liver and biliary duct diseases in children.

The paper discusses the experience accumulated so far in the field of application of ursodeoxycholic acid (UDCA) in selected disorders of the liver and biliary ducts in the developmental age population. In the aforementioned diseases, chronic administration of UDCA is safe, reduces the clinical symptoms, improves the biochemical parameters, and even the histopathologic picture of the affected organ. Such a therapy should be instituted in order to improve the quality of life, reduce the incidence of complications and postpone the transplantation of the liver till the time the child is older.

Is TT virus (transfusion transmitted virus) a novel hepatotropic agent causing hepatitis?

The author presents the review of world literature regarding the infections with TT virus (Transfusion Transmitted Virus) that was discovered in Japan in 1997.

Blind liver biopsy in children--diagnostic significance and complications in authors' own material.

The purpose of the study is the analysis of liver biopsy performed in patients hospitalized at 3rd Department of Pediatric Diseases of Medical University in Bialystok in 1993-1998 with particular regard to the assessment of indications and the incidence of complications connected with the procedure. The procedure was conducted on the group of 250 patients aged 1-17 years with the use of Menghini needles. The indications for diagnostic liver puncture included chronic infection with HBV (228 children), chronic infection with HCV (6 children), chronic hypertransaminasemia (13 children), hepatomegaly (2 children) and hyperbilirubinemia (1 child). Complications were observed in 3 patients (1.2%). Blind liver biopsy is an important diagnostic tool in pediatric hepatology but possible occurrence of life-threatening complications suggests that it be used with caution. The paper was presented as a part of hepatological session of XXVI Congress of Polish Pediatricians in Mikolajki on 6-9th June 1999.

The role of free oxygen radicals in children with chronic viral hepatitis B.

Lipid peroxidation of polyunsaturated fatty acids, being important components of cellular membranes, caused by free oxygen radicals is considered to be one of the main causes of hepatocyte injury. The aim of this study is to estimate the malondialdehyde (MDA) level in the red blood cells of children with chronic viral hepatitis B. The decrease of MDA concentration along with the clinical and serological improvement in children with chronic hepatitis B was observed. We also noticed a correlation of MDA with HBeAg-anti HBe seroconversion and obliteration of HBV DNA polimerase activity.