Randomized controlled trial of twice-a-day administration of natural interferon beta for chronic hepatitis C.

We conducted a randomized controlled trial to assess the efficacy of twice-a-day administration of natural interferon beta (IFNbeta) as an induction of IFN therapy for chronic hepatitis C. Seventy-one patients with chronic hepatitis C were enrolled into the trial and randomly assigned into three treatment groups. Six million units (MU) of IFNbeta were administered once-a-day for the first 4 weeks, and then thrice weekly for 12 weeks in 20 patients (once-a-day group). Three milion units of IFNbeta were administered twice-a-day for the first 2 weeks, 6 MU once-a-day for the next 2 weeks, and then thrice weekly for 12 weeks in 23 patients (twice-a-day+beta group), or 6 MU of lymphoblastoid IFNalpha were administered thrice weekly for the last 12 weeks instead of IFNbeta in 28 patients (twice-a-day+alpha group). Four patients in once-a-day group (20%), 9 in twice-a-day+beta group (39%), and 12 in twice-a-day+alpha group (43%) obtained sustained response. Sustained response rate in twice-a-day groups was higher than in once-a-day group, although there was no statistical significance. The present study suggested the possible superiority of twice-a-day administration of IFNbeta as an induction therapy to once-a-day administration, but further studies are needed to confirm this regimen.

[Cooperative medical care by physicians of general hospitals and psychiatrists of an alcoholism treatment unit in Mie Prefecture].

Clinical practice of psychiatric liaison with physicians is the first step for an early treatment of alcohol dependence. Screening patients with alcohol dependence in general hospitals, carrying out intervention, and referring them to psychiatric specialists are running smoothly by the cooperation of member of the Mie Association for the Study of Alcohol-related Diseases. This association is being conducted by managers constituted of doctors, nurses, and medical social workers and the meeting is held every 6 months at district general hospitals to achieve three objectives; 1) evoking a sense of responsibility for alcoholic patients in the mind of general hospital staffs, 2) developing a network for psychiatric liaison with physicians to care patients of their alcohol dependence, and 3) keeping up activities of the association. We have already held the regular meeting 12 times, and prepared pamphlets for screening alcohol misuse and for early intervention. A course for learning skills of early intervention in this summer won the favor of participants. Through case conference of alcoholism and full accounts of the experiences given by recovered patients or their families, meeting attendants know patients' distress, families' sorrow, and their delight brought by the recovery, and are motivated to assist patients with alcohol dependence. Thus, "Spirit to Spirit" is a keyword to develop a network of the cooperative medical care for supporting patients with alcohol dependence. Referral of alcoholic patients to psychiatrists and/or psychiatric liaison therapy is promoted by a reliable, faithful, and face to face relationship between physicians and psychiatrists. Physicians' learning the skill for early intervention in alcohol dependence is followed by an increase in referral of patients to psychiatrists, and which suggests the importance of providing teaching and training of medical care for alcohol dependence to medical staffs including doctors of emergency care units, orthopedics, obstetrics, and dentistry. Therefore, systematic tools for screening alcohol dependence in general practice, and for referring patients to psychiatrics after brief intervention are needed to be prepared under the leadership of a learned society. Popularizing the skill of brief intervention in general medical practice is also indispensable for advising alcoholic patients about changing their drinking pattern or abstinence.

Phenotypic expression of natural killer cell associated membrane antigens in patients with chronic liver disease and hepatocellular carcinoma.

The function and phenotypes of peripheral blood natural killer (NK) cells from patients with chronic liver disease and hepatocellular carcinoma (HCC) were examined using a 4 hr 51Cr release NK assay and two-color flow cytometry utilizing anti-Leu-7 and anti-Leu-11 monoclonal antibodies. There was no significant difference between control and patient groups in the percent representation of a total of NK, Leu-7-11+ or Leu-7+11- cells except that the percent representation of Leu-7+11- cells was significantly increased in patients with liver cirrhosis (LC) in comparison with that of chronic active hepatitis (CAH). On the other hand, patients with LC and HCC had lower absolute numbers of a total of NK, Leu-7-11+ and Leu-7+11- cells than did controls or patients with CAH, reflecting the diminished peripheral blood lymphocyte count. Our data indicate that decreased in vitro NK activity in patients with LC and HCC observed in the present study may be due to a functional defect of NK cells.

Natural killer and activated killer activities in chronic liver disease and hepatocellular carcinoma: evidence for a decreased lymphokine-induced activity of effector cells.

Natural killer (NK) and activated killer (AK) cells appear to be important in immunoregulation, elimination of virus-infected cells and resistance to tumours. NK activity against K 562 and AK activity against FL target cells of peripheral blood mononuclear cells (PBMC) from patients with chronic persistent hepatitis (CPH), chronic active hepatitis (CAH), liver cirrhosis (LC) and hepatocellular carcinoma (HCC) were investigated using 51Cr release assay. Spontaneous NK activity of patients with LC (P less than 0.05) and HCC (P less than 0.001) was decreased when compared to that of controls. The sera and PBMC from patients with low NK activity had no inhibitory effect on the NK activity of normal subjects. Indomethacin treatment significantly enhanced the NK activity of controls (P less than 0.05), whereas the drug did not affect that of patients with low NK activity. The percentages of PBMC that reacted with monoclonal antibodies anti-Leu-7 and anti-Leu-11a were similar in controls and patients. However, a Leu-11a+/Leu-7+ ratio, and NK activity of Leu-11+ and Leu-7+ cell-rich populations were significantly decreased in cirrhotic and HCC patients when compared to controls. Interleukin 2 boosted both NK and AK activities of patients, but to a lesser degree in comparison with those of controls when similarly stimulated. gamma-Interferon also significantly augmented NK and AK activities of patients, but the levels of cytotoxicity were lower in HCC patients (P less than 0.05) than those of controls. These findings suggest that the decreased NK and AK activities in chronic liver disease and HCC are due to an altered subpopulation ratio of NK cells and a functional defect of effector cells.

Proliferation and immunoglobulin synthesis of peripheral blood mononuclear cells from patients with chronic liver disease stimulated by Staphylococcus aureus Cowan 1 and interleukin 2.

Proliferation and IgG synthesis of peripheral blood mononuclear cells (PBMC) in response to stimulation with recombinant interleukin 2 (IL-2) and Staphylococcus aureus Cowan 1 (SAC) were evaluated in 32 patients with chronic persistent hepatitis (CPH), chronic active hepatitis (CAH) and liver cirrhosis (LC). Eleven patients had serum HBe antigen, 10 presented with HBe antibody and 11 had non-A, non-B hepatitis. IgG synthesis of PBMC induced with the two stimuli was significantly decreased in patients with CAH and LC when compared with that of controls. However, the generated amounts of IgG were not associated with the HB virus carrier state. B cells and T4+ cells were responsible for the diminished IgG synthesis in patients with CAH and LC when assessed by coculture experiments. On the other hand, proliferative response of PBMC to IL-2 and SAC were similar in controls and patient groups. These findings indicate that IgG production level of PBMC stimulated with IL-2 and SAC can reflect the severity of the underlying disease in chronic hepatitis patients.

Interferon-gamma production by peripheral blood mononuclear cells of patients with chronic liver disease.

We investigated the role of the interferon system in the pathogenesis of chronic liver disease. Interferon-gamma production by peripheral blood mononuclear cells was measured with an ELISA. While concanavalin A-stimulated and recombinant interleukin 2-stimulated production of interferon-gamma in patients with chronic active hepatitis and liver cirrhosis was significantly decreased when compared with that of controls (518 +/- 189 and 729 +/- 195 units per ml, mean +/- S.D.), there was also a lot of overlap. Addition of indomethacin to the cultures partially restored interferon-gamma production in patients with chronic active hepatitis and liver cirrhosis, indicating that suppressor function of monocytes was, in part, responsible for the diminished interferon-gamma production. Serial studies showed that interferon-gamma production rose during acute deterioration of illness, during treatment with interleukin 2 and with the improvement of clinical course. Interferon-gamma production was not different among hepatitis B e antigen or antibody positive, and non-A, non-B patients with chronic active hepatitis and liver cirrhosis. Our findings suggest that diminished interferon-gamma production is associated with disease severity in chronic liver disease, irrespective of the hepatitis B virus carrier state. It would be interesting to compare the efficacy of treatment with interferon-gamma or interferon-gamma inducers such as interleukin 2 in chronic hepatitis B patients with and without decreased in vitro interferon-gamma production.

Long-term carriage of hepatitis C virus with normal aminotransferase after interferon treatment in patients with chronic hepatitis C.

Studies were undertaken to investigate whether interferon therapy could induce hepatitis C virus (HCV) carriage with normal serum alanine aminotransferase (ALT) values using an assay that combined reverse transcription and polymerase chain reaction. The subjects studied were 53 patients with chronic active hepatitis C who received interferon (alpha, 33 cases; beta, 20 cases) therapy. All were seropositive for HCV RNA prior to therapy. In all 22 complete responders, whose ALT levels fell to normal during therapy and for at least 24 weeks after therapy, HCV RNA became persistently negative except in two cases. The two had sustained viremia on treatment and for 1.0-1.5 years of follow-up, although their biochemical tests were normal. In 15 patients with a transient response in whom the disease recurred when interferon was stopped, HCV RNA was undetectable in 80% of the cases at the end of therapy, but the virus reappeared with subsequent elevation of ALT in all patients. However, 3 patients in this group had normal enzyme levels with viremia for 2.1-2.8 years of follow-up after acute deterioration of illness. In 16 patients who did not respond to interferon, HCV RNA was persistently positive during and after therapy. These findings suggest that interferon therapy induces a long-term carrier state of HCV infection with normal ALT levels in some patients.

Changes in serum hepatitis C virus RNA titer and response to interferon therapy in patients with chronic hepatitis C.

Response to interferon (IFN) therapy for chronic hepatitis C has been determined by the alteration of serum alanine aminotransferase (ALT) values. However, eradication of hepatitis C virus (HCV) could be another aim of the therapy. Thus, we serially measured serum HCV RNA levels during therapy and for at least 12 months after cessation of therapy in 65 patients with chronic hepatitis C who received IFN-alpha (49 cases) or -beta (16 cases). The presence of HCV and its amount were measured by the combination of nested and competitive PCR. Twenty-seven patients, who were categorized as complete responders, showed sustained normalization of ALT values for more than six months posttreatment. The viral RNA titers at pretreatment were significantly lower in complete responders (logarithmic copy numbers/ml: 5.4 +/- 1.3, P < 0.001) than in partial and nonresponders. Complete response rate was significantly higher in patients with HCV genotype III (68.4%, P < 0.01) than those with type II (23.6%). Among 27 complete responders, HCV RNA became undetectable in only 13 patients six months after completion of therapy, and 11 still had low levels of viremia; however, none experienced relapse of the disease during follow-up of 12-24 months. Three complete responders showed lasting high-titered viremia, and their ALT values rose again during follow-up. Our data suggest that IFN treatment of chronic hepatitis C is often ineffective in eradicating HCV infection even in responders, and long-term follow-up study is necessary to determine the sustained beneficial effect of IFN.

Recombinant human alpha-interferon therapy for chronic non-A, non-B hepatitis: second report.

Four million units per day of recombinant human alpha-interferon were administered three times weekly for 16 wk to 26 patients with chronic non-A, non-B hepatitis. The efficacy of therapy was assessed by comparing it with the results in the nontreated patients, or with our previous study in which we administered 2 million units per day of interferon. The treatment was discontinued in four patients 8 wk after start of therapy because there was no improvement in serum aminotransferase levels. The remaining 22 patients completed the treatment schedule, and their aminotransferase values showed significant decreases throughout the therapy and during the follow-up period, compared with their baseline levels or the nontreated group. After 3 months of follow-up, normal aminotransferase activities were seen in eight treated patients. In four of these patients, liver histology showed a marked improvement in inflammation and parenchymal cell necrosis. Percent change from pretreatment level of serum 2',5'-oligoadenylate synthetase activity was significantly higher in the aminotransferase-normalized group than in the nonnormalized group during therapy. The present study suggested that a higher dose of alpha-interferon could control the disease activity more effectively in patients with chronic non-A, non-B hepatitis.

Pilot study of recombinant human interleukin 2 for chronic type B hepatitis.

Recombinant human interleukin 2 was administered to 10 patients with chronic type B hepatitis as a part of a pilot study to evaluate its antiviral activity. Patients received 1 to 3 x 10(5) units per day of interleukin 2 for 21 to 28 days, and all completed the treatment schedule. During therapy, serum values of DNA polymerase decreased in 6 and became negative in four patients. However, when therapy was discontinued, DNA polymerase levels increased to pretreatment levels in most cases. Serum HBeAg levels did not change during treatment. Serum aminotransferase levels transiently increased in 6 of the 10 patients during therapy; but once therapy was stopped, levels fell markedly. Side effects of interleukin 2 therapy included fever, chills, anorexia and fatigue. After 1 year of follow-up, three treated patients had lost HBeAg and had marked improvement in aminotransferase levels. These serologic and biochemical improvements occurred 1.5 to 11 months after therapy was stopped. Whether a 3- to 4-week course of interleukin 2 therapy leads to an increased rate of seroconversion from HBeAg to antibody in chronic type B hepatitis deserves further evaluation in prospectively randomized, controlled trials.

Occurrence of immunohistochemically detected small Mallory bodies in liver disease.

To determine the diagnostic significance of immunohistochemically detected small Mallory bodies (MBs) which are invisible by conventional stainings, we investigated the occurrence of MBs in liver tissue with alcoholic and nonalcoholic liver disease by immunoperoxidase staining with monoclonal anti-MB antibody, anti-NMB-3. In conventional stainings, MBs were detected in only six of 26 (23%) patients with alcoholic liver disease, and nine of 63 (14%) patients with nonalcoholic liver disease. On the other hand, MBs were detected in 20 of 26 (77%) patients with alcoholic liver disease, and 25 of 63 (40%) patients with nonalcoholic liver disease by immunoperoxidase staining. Immunohistochemically detected MBs were shown to possess the ultrastructural characteristics of MBs by immunoelectronmicroscopy in the four specimens. Our result indicates that the small MBs are not rare in nonalcoholic liver disease, and the presence of immunohistochemically detected small MBs is not a good marker of an alcoholic etiology.

Effects of interferon-alpha treatment on hepatitis B virus antigen-specific immunologic responses in patients with chronic hepatitis B.

Studies were undertaken to evaluate the relationship between the immune responses and the effectiveness of interferon-alpha treatment in 21 patients with HBeAg-positive chronic active hepatitis. Peripheral blood mononuclear cells (PBMC), obtained on four occasions during an 8-week course of IFN-alpha therapy, were cultured with recombinant HBcAg, purified HBeAg or pokeweed mitogen (PWM). During follow-up for 6 months after therapy, clearance of serum HBeAg was observed in eight patients designated as responders. Immunological responses of PBMC obtained before treatment did not differ between responders and non-responders. In responders, IFN-gamma and anti-HBc production was depressed during therapy, but recovered to above the pretreatment level at the end of and/or after cessation of therapy, while lymphocyte proliferation was enhanced during therapy with a subsequent decline to baseline value. In non-responders, such changes were modest throughout the study, and anti-HBc response remained decreased even after cessation of therapy. These results indicate that PBMC of responders have immunologically different responses to IFN-alpha therapy when compared with non-responders.

Randomized controlled trial of lymphoblastoid interferon alpha for chronic hepatitis C (comparison of 9-MU and 6-MU doses). IFN Treatment Group of Affiliated Hospitals of the Third Department of Internal Medicine at Nagoya University School of Medicine.

OBJECTIVE: We conducted a randomized controlled trial to compare the efficacy of two different dosages of lymphoblastoid interferon alpha (IFN) for the treatment of chronic hepatitis C. METHODS: Eighty-four patients with chronic hepatitis C were enrolled and randomly assigned into the two groups; group A was treated with 6 million units (MU) and group B with 9 MU daily for the first 2 wk, and then thrice weekly for an additional 14 or 22 wk. RESULTS: Eighty patients were evaluated (39 patients in group A and 41 in group B); 14 patients in group A (35.9%) and 15 in group B (36.6%) obtained sustained response. The percentages of patients who became negative for HCV RNA at the end of the second wk differed slightly between the groups, without statistical significance (56.4% and 68.3%). When assessed in detail, patients with genotype 1 and < 1 Meq/ml of viral load became negative for HCV RNA significantly more frequently in group B (eight of eight) than in group A (three of seven) (p < 0.05) at the end of the second week, whereas the sustained response rate was similar between the groups (five of eight and four of seven). Predictors of sustained response by multivariate analysis were low viral load (< 1.0 Meq/ml) and negativity of HCV RNA at the end of the second wk of IFN. CONCLUSIONS: The results indicated that there was no difference in sustained response rate between the 6-MU and 9-MU doses. The earlier disappearance of HCV RNA, at the end of the second wk or at least by the end of the fourth week, is an essential condition for sustained response.

Biochemical response to interferon therapy correlates with interferon sensitivity-determining region in hepatitis C virus genotype 1b infection.

Biochemical responders maintain normal alanine aminotransferase levels after interferon (IFN) therapy despite persistent presence of hepatitis C virus (HCV) RNA in their sera. There have been few reports on predictive factors for biochemical response. A region associated with sensitivity to IFN was identified in the nonstructural protein 5 A of genotype 1b [aa 2209-2248; IFN sensitivity-determining region (ISDR)]. The substitutions in ISDR correlate with sustained response to IFN. In this report, we assessed the association of ISDR with biochemical response. The sequences of ISDR were determined in 62 patients with HCV genotype 1b treated by IFN in two randomized controlled trials. 30 patients had wild ISDR (identical to HCV-J), 20 intermediate ISDR (1-3 amino acid substitutions compared with HCV-J), and 12 mutant ISDR (four or more amino acid substitutions). All 12 patients with mutant ISDR had a sustained response, while only one of those with wild or intermediate ISDR had a sustained response (P < 0.0001). In the 49 patients other than sustained responders, the patients with intermediate ISDR obtained biochemical response significantly more frequently (52.6%, 10/19) than those with wild-type ISDR (20.0%, 6/30) (P < 0.05). Multivariate analysis indicated the number of substitutions in ISDR as the most important predictor for biochemical response (discriminant coefficient=1.08, P < 0.05) and sustained response (discriminant coefficient=6.13, P < 0.0001). In phylogenetic analysis, clustering of sustained responders and biochemical responders was observed. These results demonstrate that the substitutions in ISDR are the most important predictor for biochemical response to IFN in patients infected with genotype 1b as well as for sustained response.