Therapy for chronic hepatitis C.

BACKGROUND/AIMS: in Hungary, over the past 5 years more than 900 patients with chronic hepatitis C have been examined for treatment with interferon at 16 major hepatology centres, using unified diagnostic and therapeutical criteria. Authors give an account of their experiences on the clinical features of patients with chronic hepatitis C and report the results of the interferon therapy. METHODS: a total of 993 patients--virtually the entire Hungarian hepatitis C patient population who had been referred for interferon treatment--were included in the program. Actually, the sustained efficacy of the therapy was evaluated in 724 cases. Treatment protocols (dose of interferon and duration of therapy) have changed with time from a weekly dose of 3x3 MU IFN for 6 months in the first period, to 3x3-5 MU for 12 months in the second period, and finally in the third period a combination therapy with ribavirin has also been introduced. RESULTS: in the first period, the end-of-treatment response (ETR) was 35%, sustained response (SR) 13%, the second phase schedule resulted in 42% ETR and 22% SR, while in the third period, ETR was 49% and SR 36%, respectively. Fibrosis in histology and baseline pretreatment HCV-RNA level appeared as predictors of response. The duration of treatment and the total dose of interferon exerted a moderate effect on therapeutic efficacy. Neither age nor gender influenced the outcome. CONCLUSIONS: our results-obtained in a Central East European country-are in accordance with findings of suboptimal efficacy of traditional interferon monotherapy for chronic hepatitis C reported in the West, and suggest the benefit of the combination treatment of interferon with ribavirin.

C5b-9 and interleukin-6 in chronic hepatitis C. Surrogate markers predicting short-term response to interferon alpha-2b.

BACKGROUND: Available data and our observations suggest that elevated levels of interleukin (IL)-6 and -10 and some complement parameters may be associated with a poor response to IFN alpha. We evaluated how baseline levels of C5b-9, IL-6, and IL-10 influence the outcome of IFN alpha treatment. METHODS: Fifty-one patients with established chronic hepatitis C were enrolled and treated with IFN alpha-2b. Before and after a 12-week-IFN-treatment (3 MU or 5 MU tiw) serum levels of IL-6, IL-10, C5b-9 and RNA of hepatitis C virus (HCV) were assessed. Sera of 46 sex- and age-matched, healthy blood donors served as control. RESULTS: While two-thirds of patients was considered 'responder', 14 patients had no significant decrease either in HCV RNA or in ALT levels. In the responder's group lower baseline levels of IL-6 and C5b-9 were found than those in the 'non-responder' group. As a result of IFN therapy HCV RNA and C5b-9 levels significantly decreased. While the serum concentration of IL-6 increased during the follow-up period, regarding IL-10, no change was observed. In patients with 'low' baseline levels of C5b-9 (<2053 ng/ml) IFN alpha resulted in a significantly (P = 0.0005) higher decrease in HCV RNA level. Regarding 'low' IL-6 values (< 1.47 pg/ml) similar but somewhat less significant (P = 0.0039) difference was found if the change of HCV RNA was investigated. The odds ratio of patients with low IL-6 and/or C5b-9 to responding to IFN alpha treatment was almost 10 times (CI: 9.1 (1.8-50.9)) higher as compared with patients without 'low' levels of these parameters. CONCLUSION: Our data suggest that serum level(s) of IL-6 and/or C5b-9 taken prior to the initiation of IFN treatment may serve as surrogate marker(s) in evaluating patients with chronic hepatitis C whether to get IFN alpha in monotherapy or to consider having combination therapy in the form of IFN alpha-ribavirin.

Changes in the acute phase complement component and IL-6 levels in patients with chronic hepatitis C receiving interferon alpha-2b.

In order to study the effect of interferon alpha on the levels of acute phase complement proteins in vivo, serum concentrations of C9 and C1-inhibitor (C1-INH) were measured in patients with chronic hepatitis C before and 3 months after the beginning of interferon alpha2b therapy. Serum levels of the activation product of terminal complement pathway, C5b-9, HCV RNA and IL-6 were also determined. IFN alpha treatment significantly (P<0.0001) increased the serum concentrations of both complement proteins. C5b-9 levels were found to significantly decrease during the same period of time. When the patients were divided into responders or non-responders (more or less than 50% decrease in plasma HCV RNA concentrations) C9 and C1-INH levels were elevated only in the responder patients. There was no correlation between the changes of IL-6 levels or the amounts of IFN alpha administrated on one hand, and the changes in the complement protein levels on the other. These findings suggest that the marked increase in the serum concentrations of the acute phase complement proteins is a secondary phenomenon due to the IFN alpha-caused diminution of the viral load and the resulting immune complex-induced complement activation.

Amino acid sequence homology of factor C produced by Streptomyces griseus with regulatory proteins of zinc finger type.

Factor C is a regulatory protein produced by Streptomyces griseus 45H. Factor C-like antigen can be detected in the most diverse species examined. It is also present in human serum with an average of 219.4 U/ml of narrow dispersion. The level of factor C-like antigen shows an increase in the sera of patients with different hepatic disorders (341 U/ml), some values being 3-7 times higher than normal (600-1500 U/ml). Correlation was found between the elevated antigen levels and the amount of the bilirubin in the sera of patients with liver cirrhosis. Amino acid sequence homology was found between factor C and zinc finger motifs of several known DNA binding proteins. In fact, factor C was successfully bound to and eluted from a Zn2+ affinity column. Our data show that factor C is probably a zinc finger type DNA binding protein.

[Interferon therapy in cryoglobulinemic membranoproliferative glomerulonephritis associated with hepatitis C virus infection]. / Interferon kezelés hepatitis-C vírusfertózéssel társult cryoglobulinaemiás membranoproliferatív glomerulonephritisben.

The authors report the case of a 38 year old man with horseshoe kidney who developed a severe nephroso-nephritis syndrome, caused by cryoglobulinemic membranoproliferative glomerulo-nephritis. A combination of steroid and cyclophosphamide treatment resulted in partial improvement, but was discontinued after 12 weeks due to adverse reactions, with a consequent early relapse. The 4 week course of cyclosporine monotherapy proved ineffective and signs of cryoglobulinemia appeared. The elevation of transaminase, manifested during the immunosuppressive therapy demonstrated the presence of underlying chronic C hepatitis. In the light of the liver biopsy result, interferon treatment was commenced at a dose of 3 million unit thrice weekly. After 4 months of interferon treatment the persistent nephrotic range proteinuria decreased to below 0.5 g/day. Four months later clinical signs of cryoglobulinemia disappeared, and after the 10th month of interferon treatment no cryoglobulin could be detected in the patient's sera. After one year, the interferon treatment was discontinued following a negative PCR result for HCV. However, one month later the proteinuria increased and the quantitative hepatitis C virus nucleic acid test in sera became positive again. Our case demonstrates that interferon therapy may be effective in the treatment of cryoglobulinemic glomerulonephritis responding poorly to the immunosuppressive therapy, though larger doses or longer periods of treatment may be required to prevent relapses.

[Effect of interferon-alpha2b therapy in chronic hepatitis C]. / Interferon-alpha 2B kezelés hatása chronicus C hepatitisben.

In chronic hepatitis C the interferon treatment given three times a week in a dosage of 3 million units (MU) normalizes the values of alanin-amino-transferase in a part of cases (25-40%), and produces bettering in the subjective complains of patients. In the short term therapy (3-6 months) the activity of ALT increases again after leaving the therapy, and the disease becomes active. The aim of this multicenter study in Hungary was to give newer data in the case of longterm efficacy with alpha-interferon. Ninety-one patients with chronic hepatitis C were selected into the open prospective clinical study in university and hospital departments. Treatment protocol was the following: Patients with chronic hepatitis C diagnosed by clinical and histological methods were treated with interferon-alpha 2B given 3 times a week in a dosage of 3 MU. Treatment period had lasted for one year and afterwards the patient had been on control for an other half a year. In non responder cases after 3 month treatment with interferon the dose of therapy was increased for 3 x 5 MU. In 37 cases (40.6%) out of 91 patients the authors found longterm sustained remission and in other 22 cases (24.2%) they observed a partial remission (among them 5 cases with late relapse). The rate of longterm sustained remission under 40 years was higher, than above 40. Higher rate was found when the treatment was started with a shorter chronicity of the disease. On te basis of the results the authors conclude: Interferon-alpha 2B is a good therapeutic modality for the treatment of patients with chronic hepatitis C. Efficacy of therapy is higher in younger patients and also in earlier application.

[Effect of paracetamol on the acid hemolysis of erythrocytes, with special reference to the intracellular glutathione level]. / Paracetamol hatása a vörösvérsejtek savi haemolysisére, különös tekintettel az intracellularis glutathion szintre.

The authors give account of their study concerning the effect of paracetamol on the acid haemolysis, and glutathione content of human erythrocytes. In vitro, paracetamol decreased intracellular glutathione content in a dose dependent manner. This may lead to an increased sensitivity of erythrocytes to the haemolytic effect of hydrochloric acid, what may explain the dose dependent decrease of time of haemolysis, presented in form of dynamic haemolysis curve. In vivo four hours following the oral intake of 500 mg paracetamol, although the intracellular glutathione content did not decrease significantly, shortening of the time of acid haemolysis could be demonstrated in more than half of the persons studied. No haemolysis was caused by the given dose of the drug.

[Acute viral hepatitis: pathogenesis and clinical manifestations]. / Akut virushepatitisek: pathogenesis és klinikai manifesztációk.

This is a review of several mechanisms in the acute and chronic progress of viral hepatitis. Investigation of these mechanisms may have an important role in the diagnosis and treatment of chronic hepatitis. Clinical features of acute non-A, non-B hepatitis were studied in 110 patients. Most of the patients had a surgical intervention or/and received blood transfusion previously. The clinical course of the cases was very mild and most of the patients have the cholestatic form of the disease. A 39% anti-HCV antibody seropositivity rate was seen in these cases.

The effect of silibinin (Legalon) on the the free radical scavenger mechanisms of human erythrocytes in vitro.

The effect of Legalon was investigated parallel with that of Adriblastina (doxorubicin) and paracetamol on some parameters characterizing the free radical scavenger mechanisms of human erythrocytes in vitro and on the time of acid hemolysis performed in aggregometer. Observations suggest that Adriblastina enhances the lipid peroxidation of the membrane of red blood cells, while paracetamol causes significant depletion of intracellular glutathione level, thus decreasing the free radical eliminating capacity of the glutathione peroxidase system. Legalon on the other hand, is able to increase the activity of both superoxide dismutase and glutathione peroxidase, which may explain the protective effect of the drug against free radicals and also the stabilizing effect on the red blood cell membrane, shown by the increase of the time of full haemolysis.

Autoantibody against liver cell membrane and killer cell activity in chronic liver diseases.

The aim of our present study was to examine the ADCC reaction against liver cell in various chronic liver diseases on the basis of indirect evidence. Forty-nine liver patients and one hundred and twenty-three healthy controls were examined. Anti-LSP autoantibody was determined on rat liver membrane by using the indirect immunofluorescent method. On the other hand, Killer-cell activity against human erythrocyte target cells was established in the lymphocytes of peripheral blood. Anti-LSP autoantibodies were demonstrated in seven patients and were associated with the high Killer-cell activity in six cases. Specific ADCC reaction to liver cell membrane can be assumed if anti-LSP autoantibody presence is topped with increased Killer-cell activity.

[Clinical aspects of zinc]. / A cink klinikai vonatkozásai.

In the literature an increasingly large body of evidence has revealed disturbances of zinc metabolism and a consecutive zinc deficit in a broad spectrum of chronic diseases. The authors call attention to the therapeutic benefit of zinc substitution mainly in chronic hepatic diseases, pancreatitis and colitis, as well as in diabetes and in several cases of immunodeficiency with various complications. Since suitable preparations are not available on the market 'possibilities concerning zinc substitution are rather limited. There is a real need for completing our therapeutic arsenal with an up-to-date zinc preparate, possibly in combination with a magnesium compound.

Attempt with oral immunobiotherapy (broncho-vaxom) and immunochemotherapy (broncho-vaxom + neomycin) for the elimination of bacteria in symptom-free "other Salmonella" carriers.

Forty-five symptomless "other Salmonella" carriers were treated; stool became negative for Salmonella in 22 of the 25 patients treated with Broncho-Vaxom (88%) and in 16 of the 20 patients treated with Broncho-Vaxom + Neomycin (80%) (who had discharged Salmonella for not longer than one month previously). This result is very favourable when compared to data of references of thoroughly controlled patients according to which 69% was the highest rate of bacterial negativity obtained in the treated patients who discharged "other Salmonellas" for not longer than 1 month. The stool of all 10 patients admitted as symptomless carriers of "other Salmonellas" became negative for bacteria in response to the mentioned therapy (in 6 cases of Group I, and 4 cases of Group II). Treatment was unsuccessful primarily in chronic alcohol addicts and toxicosis cases (13%). The unresponsiveness of the two patients suffering from cholelithiasis and excreting also "other Salmonella" with the bile deserves attention. In such cases the positivity of the bile for Salmonella was a reason for exclusion from the study. Further studies (completed with immunological data) are required to assess the value of Broncho-Vaxom immunobiotherapy, and Broncho-Vaxom + Neomycin immunotherapy.

Detection of platelet-associated IgG in chronic immune thrombocytopenic purpura using antibody-coated polyacrylamide beads.

Platelet-associated IgG (PAIgG) was detected by means of anti-human IgG coated polyacrylamide beads ("Immunobeads") technique in 32 patients with chronic ITP. Both a direct test (with in vivo sensitized platelets) and an indirect test (with in vitro loaded platelets) were carried out. The percent of rosette forming beads was both in the direct test (41.2%) and in the indirect test (32.6%) significantly higher in the cases of chronic ITP patients than in the controls (2.5% and 3.2%, respectively). These results confirm the diagnostic value of this new, relatively simple and rapid method in routine clinical practice.

In vitro and in vivo demonstration of the cytoprotective effect of (+)-cyanidanol-3.

In vitro and in vivo investigations were undertaken to demonstrate cytoprotective effect of (+)-cyanidanol-3 on human erythrocytes. The time of full haemolysis induced by hydrochloride acid was measured and dynamic haemolysis curve was recorded with an aggregometer. In vitro, following a one-hour incubation of erythrocytes with (+)-cyanidanol-3 at 37 degrees C, significant increase of the haemolysis time could be demonstrated. The most expressive cytoprotective effect was observed at (+)-cyanidanol-3 concentrations of 2, 5 and 10 micrograms/ml. In vivo, two hours following the oral administration of 1.5 g Catergen, an increase of the haemolysis time for about 25% could be demonstrated. This simple method seems to be suitable for the investigation of the membrane stabilizing effect of (+)-cyanidanol-3.

Serum alpha-fetoprotein in chronic liver disease.

The serum alpha-fetoprotein level was measured by radioimmunoassay in 20 normal subjects and in 118 patients with chronic liver disease. The highest concentrations were found in the group of hepatocellular carcinoma. Compared with the controls, higher values were demonstrable in the other groups of liver disease as well. This is attributed to the more or less marked regeneration of liver tissue, which is never absent in any type of liver disease studied, and in the case of fatty degeneration, to the alpha-fetoprotein inducing effect of alcohol. The importance of alpha-fetoprotein estimation in the diagnosis of hepatocellular carcinoma and monitoring of its therapy, as also in the assessment of activity and regeneration in other forms of chronic liver disease, are pointed out. Countercurrent electrophoresis has been found unreliable for the measurement of alpha-fetoprotein.

Lymphocytes bearing both T and B markers in lymphoproliferative disorders.

The appearance of dual-marked (D) lymphocytes, i.e. lymphocytes having both T and B markers, was investigated in patients with acute (ALL) and chronic lymphocytic leukaemia (CLL) as well as with non-Hodgkin's lymphoma (NHL). E-rosette and immunobead-rosette techniques were combined and simultaneously administered, and the combination was found to be simple, fast and reproducible. D cells could be detected also in normal peripheral blood, however, only in a low percentage. In the blood of 4 patients suffering from ALL, in 2 with CLL and in 1 with NHL the number of D cells were increased significantly. In ALL the relative number of these cells decreased during remission and increased in relapses; thus the determination of the relative frequency of D cells might have prognostic value and could be useful in the choice of an optimal therapeutic protocol.