Antibodies to hepatocyte membrane antigens in chronic liver disease: detection by immunofluorescence after Bouin's fixation.

Using a modified indirect immunofluorescent (IF) technique in which cryostat tissue sections were fixed in Bouin's solution for ten minutes prior to reaction with sera under test, we have looked for antibodies to the hepatocyte membrane (HMA) in the sera of patients with chronic active hepatitis (CAH) and primary biliary cirrhosis (PBC). Samples were tested initially in parallel on unfixed and Bouin's-fixed rat composite blocks (kidney, stomach, liver) at a titer of 1:100 and those found to be positive were diluted further and reexamined. Conventional unfixed sections of rat composite block showed no liver membrane immunofluorescence although antinuclear (ANA), mitochondrial (AMA), and smooth muscle antibodies (SMA) were detected as anticipated. By contrast, prior Bouin's fixation abolished most of the fluorescence due to ANA, AMA and SMA but resulted in brilliant fluorescence of rat hepatocyte membranes in eleven of twelve patients with CAH (93%) and all ten patients with PBC. Only one of 22 normals (5%), one of 20 with collagen-vascular diseases (5%), and one of seven with nonimmunologic liver disease (14%) were positive for this hepatocyte membrane antibody. Bouin's fixation prior to IF is a simple technique which appears to alter the hepatocyte membrane so that HMA become detectable. The strong association of HMA with CAH and PBC suggests that this test might be of value and may contribute towards a further understanding of the pathogenesis of these conditions.

Hepatic membrane antibodies: studies of prevalence and specificity.

Using a newly developed assay for hepatic membrane-associated antibodies (HMA), we studied the prevalence and specificity of HMA in a variety of acute and chronic liver diseases to evaluate the usefulness of such an assay system. Sera were examined by indirect immunofluorescence on rat liver sections previously fixed in Bouin's fluid. As compared with a prevalence of 4% in 45 healthy controls, HMA were detected in 73% of 45 patients with chronic active hepatitis (CAH) (P less than 0.001) and in all 11 patients with primary biliary cirrhosis (PBC) (P less than 0.001). HMA were also present in 38% of 40 patients with acute viral hepatitis, 47% of 27 with alcoholic liver disease and 33% of 24 with other liver diseases not thought to be immunologically mediated. In 53 patients studied with other liver, gastrointestinal or autoimmune diseases, the prevalence of HMA was not increased over controls. Absorption studies showed that seven of 14 HMA positive sera contained specificities for polymerized human serum albumin (pHSA) or liver-specific protein (LSP) or both antigens. HMA positive samples reacted occasionally with rat kidney tubular epithelial membranes but did not appear to react with other tissues. These results demonstrate that HMA are present at higher prevalence in the autoimmune liver diseases than many previously described autoantibodies and are reactive in part to specificities on pHSA and LSP.

Membrane antigens in chronic active hepatitis: physicochemical and immunological studies of soluble liver homogenate fractions.

Since the liver membrane components termed liver-specific protein (LSP) and liver membrane antigen (LM-Ag) have been implicated as target antigens in chronic active hepatitis (CAH), we performed physicochemical and immunological analyses of these and other fractions obtained from liver homogenates. Supernatants were prepared from homogenates of human and rabbit liver by centrifugation at 105,000 g for 1 hr; after gel filtration on Sepharose 6B, the LSP fraction was obtained as the excluded peak I and LM-Ag as an included fraction, peak IIB. Comparison by immunodiffusion with reference LSP and guinea pig antisera to LSP confirmed the similarity of our fractions to reference preparations. Upon SDS-polyacrylamide gel electrophoresis (SDS-PAGE), human and rabbit peak I were found to contain at least 25 distinct protein bands with a wide range of molecular weights (14,000- greater than 100,000) and the other peaks were found to be equally heterogeneous. Thin-layer polyacrylamide gel isoelectric focusing (PAGIF) revealed 35-40 separate bands in both peaks I and IIB with a wide range of isoelectric points (3.5-10.0). These results indicate that liver homogenate fractions such as LSP and LM-Ag can no longer be considered as single protein preparations, and are in fact highly complex mixtures of multiple proteins. Further separation and characterization of such fractions will facilitate identification of liver antigens for use in in vitro immunological assays.

Elective conversion from cyclosporine to azathioprine in sensitized patients following cadaveric renal transplantation.

The safety of conversion from cyclosporine to azathioprine following renal transplantation in patients generally considered to be at immunologic risk for allograft loss has not been established. We examined a group of 59 patients who underwent cadaveric renal transplantation and elective conversion from cyclosporine to azathioprine 8.3 +/- 3.8 months following transplantation. Forty-three of these patients received a first transplant and had panel-reactive antibodies (PRA) less than 40% (unsensitized). Sixteen patients received at least their second allograft or had PRA of 40% or more (sensitized). Average follow-up was 17.9 +/- 8.2 months. Nine patients (15%) failed conversion as manifested by the need to restart cyclosporine 1 to 10 months following conversion. All were in the unsensitized group. Of those successfully converted, there were six allograft failures, two from patient death, one from acute rejection, one from recurrent diabetic nephropathy, and two from patient noncompliance. All were in the unsensitized group, although the difference from the sensitized group was not statistically significant (P = 0.051). There were three rejection episodes, all successfully reversed, in the sensitized group and six rejection episodes in the unsensitized group, five of which were reversed. Overall renal function improved in both groups as shown by a significant decrease in serum creatinine. Neither group required increased doses of steroid to compensate for lack of cyclosporine. From these data we can recommend conversion from cyclosporine to azathioprine in patients with cytotoxic antibodies or those undergoing retransplantation.