Iron reduction as an adjuvant to interferon therapy in patients with chronic hepatitis C who have previously not responded to interferon: a multicenter, prospective, randomized, controlled trial.

Hepatic iron concentration has consistently been observed as being directly correlated with the response to interferon therapy in chronic hepatitis C virus (HCV). We therefore conducted a randomized, controlled trial comparing iron reduction by phlebotomy with iron reduction followed by retreatment with interferon in 96 patients with chronic hepatitis C who had previously not responded to a course of interferon. During the initial phase when all patients were undergoing phlebotomy, we found that serum alanine transaminase (ALT) activities decreased but by less than 50% from baseline in 67 patients (89%), decreased by more than 50% in 12 patients (13%) and became normal in 9 patients (9%) with no overall change in HCV-RNA levels. Subsequently no patient in either treatment group achieved a sustained virologic response. Improvements in necroinflammatory changes were noted in liver biopsy specimens in those patients receiving phlebotomy plus interferon (mean index 8.59 vs. 7.37, P <. 05). A slight but not statistically significant decrease in histologic activity index was noted in those subjects treated by phlebotomy alone (mean index 8.4 vs. 7.75, P not significant). We conclude that, although prior phlebotomy therapy does not improve the rate of sustained response to interferon retreatment, it does result in less liver injury manifested by a decrease in serum transaminase activity and a slight improvement in liver histopathology.

Extrahepatic manifestations of chronic hepatitis C.

A by-product of increasing experience with patients infected with the hepatitis C virus is the awareness of a variety of extrahepatic syndromes that seem to be associated with HCV infection. Recent investigations into the relationship between the hepatitis C virus and human cells, particularly lymphocytes, have resulted in possible pathophysiological interactions that may begin to explain some of the extrahepatic manifestations of hepatitis C virus infection. In this review, we will discuss some of the potential interactions from both pathophysiological and clinical viewpoints.

Alterations of chemosensory function in end-stage liver disease.

Taste and smell dysfunction has been documented in patients with both acute and chronic liver disease. The purpose of this study was to determine if chemosensory function is improved after restoration of hepatic function with liver transplantation. Nine subjects (seven women and two men) with end-stage liver disease participated in the study. Taste and smell detection and recognition thresholds were determined before and after transplantation. A significant improvement in detection of the taste of sodium chloride and the odor of phenethyl alcohol was found after transplantation. These findings may have clinical significance in food choices and nutritional status of these patients.

Relationship between biochemical and virological responses to interferon therapy in chronic hepatitis C infection. Consensus Interferon Study Group.

We have investigated the relationship between serum alanine aminotransferase (ALT) and hepatitis C virus (HCV) RNA in the assessment of responses to interferon (IFN) therapy in chronic HCV infection. Data from 704 patients with HCV infection who were randomized to receive consensus IFN-alpha (CIFN) 3 micrograms (n = 232 patients) or 9 micrograms (n = 232 patients), or IFN-alpha 2b 3 million units (MU) (n = 240 patients), were used for these analyses. All patients were treated three times weekly. Hepatitis C viral RNA (HCV RNA) was determined by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) with a lower limit of detection of 100 copies ml-1. Of patients with normal serum ALT concentrations, 53% (120/225) had undetectable HCV RNA at the end-of-treatment period and 47% (51/109) had undetectable HCV RNA at the end of the post-treatment observation period. In contrast, of the patients with undetectable HCV RNA, 75% (120/161) and 84% (51/61) had normal serum ALT activities at the end-of-treatment and post-treatment observations periods, respectively. The majority of patients with undetectable HCV RNA had normal ALT values. In contrast, only half of the patients with normal ALT values were negative for HCV. End-of-treatment HCV RNA response also better predicted sustained virological response than did end-of-treatment ALT response.

Peribiliary vascular plexus in primary sclerosing cholangitis and primary biliary cirrhosis.

The peribiliary vascular plexus plays an important role in physiology of bile flow. Disturbance of the microcirculation may contribute to ductal injury, but little is known about alterations in the vascular supply of small bile ducts in liver disease. Immunoperoxidase stains for vascular endothelium (Ulex europaeus, factor VIII-related antigen, CD34) were used to study the peribiliary vascular plexus in 20 cases of primary sclerosing cholangitis (PSC) and 27 cases of primary biliary cirrhosis (PBC), two diseases characterized by bile duct destruction. Normal liver from 10 autopsy cases of sudden cardiac death was used as a control. Interlobular bile ducts (20- to 80-microm diameter) were identified on AE1/AE3 immunostain; vessels adjacent to the basement membrane of these ducts were counted. Normal interlobular bile ducts had an average of 2.15 vessels per duct (range, 1.68 to 2.71). Few PBC or PSC cases had a normal number of peribiliary vessels. There was a trend toward vasopenia at higher stage, although vascular loss was noted in early stages as well. The pattern of vascular loss was different for the two diseases; in PSC, the periductal capillaries were often preserved but were pushed away from the basement membrane by concentric deposits of collagen. Small residual vessels could be identified within fibrous scars of obliterated bile ducts in PSC. In 4 stage 3 or 4 PSC cases with little bile duct injury, vessel/duct ratio approached normal levels. In PBC, vessels were obliterated in areas of granulomatous inflammation and heavy lymphocytic infiltrate around bile ducts. In conclusion, loss of peribiliary vessels is common in PSC and PBC. Vessel loss is seen in early stages and may contribute an element of ischemia to continued small bile duct loss but is probably secondary to the inflammatory process.

The pattern and phenotype of T-cell infiltration associated with human liver allograft rejection.

Although transplant biopsy remains the best means for assessing liver allograft dysfunction, the presence and degree of rejection often is difficult to determine by current histologic criteria. The added diagnostic and prognostic value of examining liver allograft biopsy specimens by immunopathologic methods, such as phenotyping inflammatory cell infiltrates, has been inconclusive. To examine the value of assessing the phenotype and location of T-cell infiltrates we compared findings in 20 liver transplant biopsy specimens obtained from patients undergoing allograft rejection with those in 20 biopsy specimens from patients with no evidence of rejection. Serial frozen sections from all biopsies were labeled by immunoperoxidase techniques using monoclonal antibodies to identify cells expressing CD3, CD4, CD8, CD45RA, and CD45RO. As expected, the median of average cell infiltrates was higher in the rejecting versus nonrejecting group for each cell phenotype and region. However, statistical comparisons indicated that only some combinations of cell phenotype and location were significantly greater in the rejecting versus nonrejecting groups. The median number of portal CD3+ T cells per high-power field was increased in the rejecting versus nonrejecting groups (15.15 v 5.00 cells/high-power field; P < .01). This primarily was the result of a significant increase in CD8+ cells (7.15 v 1.55 cells/high-power field; P < .0001). Examination of cells expressing CD45 isoforms also revealed a suggested increase (P < .04) in CD45RO+ "memory" but not in CD45RA "naive" T cells infiltrating portal areas. In lobular areas cell infiltrates of any examined phenotype were not significantly increased in the rejecting versus nonrejecting groups. These findings indicate that during liver allograft rejection the most characteristic changes involve an increase in T cells infiltrating the graft in portal regions and suggest that human liver allograft rejection preferentially involves memory CD8+ T cells directed at portal structures.

Proton magnetic resonance studies of the aggregation of taurine-conjugated bile salts.

The concentration dependence of the 500 MHz 1H-NMR spectra of taurocholate, taurochenodeoxycholate, taurodeoxycholate, and the monosulfate esters of taurochenodeoxycholate has been examined at 0.154 M NaCl in D2O. The resonances of the C18, C19, and C21 methyl groups and the C23 methylene group are differentially broadened with respect to the C25 and C26 methylene and C7 (or C12) methine groups with increasing bile salt concentration for each of the bile salts studied. These data confirm hydrophobic association and indicate that the side chain contributes to the hydrophobic surface of the bile salt. The chemical shift difference of the anisochronous C23 methylene protons is different in monomer and aggregate form. The C25 methylene protons are isochronous in monomeric form but anisochronous in aggregate form. The concentration dependence of the observed chemical shifts has been analyzed to estimate the critical concentration associated with the onset of these changes. The conformer population about the C22-C23 bond changes before the anisochronicity of the C25 methylene protons develops. This indicates that the C23 methylene group is affected by the initial stages of self-association, whereas specific motional constraints about the N-C25 bond in the taurine moiety are only induced in large primary micelles. The difference in the chemical shift of the C25 methylene protons depends on the structure of the bile salt. The relative magnitude of the shift differences is not altered by the presence of phosphatidylcholine. The data suggest that in primary micelles or mixed micelles the taurine moiety conforms to segregate the hydrophilic groups of the bile salt and effects greater van der Waals' contact between the hydrophobic surfaces.

Calcium binding by monosulfate esters of taurochenodeoxycholate.

The effect of sulfate esterification of the 3 alpha- or 7 alpha-hydroxyl groups of taurochenodeoxycholate on calcium binding was studied at 0.154 M NaCl in the presence and absence of phosphatidylcholine using a calcium electrode. For comparison, similar studies were made with taurochenodeoxycholate, taurodeoxycholate, and taurocholate. No high affinity calcium binding was demonstrable for any of these bile salts in pre-micellar solutions. Taurine-conjugated bile salts have greater affinity for calcium when in a micellar form. At elevated bile salt concentrations, the calcium binding of unsulfated dihydroxy taurine conjugates was similar to that of the monosulfate esters of taurochenodeoxycholate. The presence of phosphatidylcholine decreased calcium binding of the unsulfated dihydroxy bile salts and slightly increased calcium binding by taurocholate. However, the addition of phosphatidylcholine to monosulfate esters of taurochenodeoxycholate results in large increments in calcium binding. The results indicate that increased calcium binding due to the presence of phosphatidylcholine in bile salt solutions depends, in part, on the hydrophilicity of the bile salt and that the interaction of monosulfate esters of taurochenodeoxycholate with phosphatidylcholine leads to the formation of a high affinity calcium binding site.

Effects of monosulfate esters of taurochenodeoxycholate on bile flow and biliary lipids in hamsters.

The effect of the 3 alpha- and 7 alpha-monosulfate esters of taurochenodeoxycholate on bile flow and biliary lipids was compared to the effect of unsulfated taurochenodeoxycholate. Test bile salts were infused directly into the portal circulation through a catheter introduced into the splenic pulp. Recovery of unsulfated and sulfated bile salts was complete; no biotransformation of any of the administered compounds was noted. Equivalent choleresis was noted in response to administration of each of the test bile salts. Of particular interest, the biliary cholesterol and phospholipid content was tightly linked to biliary bile salt monosulfates; the slope of the line describing the relationship between bile salts and lipids was similar to that for the unsulfated bile salt. The critical micellar concentration of the 3 alpha- and 7 alpha-monosulfate esters was 19 mM and 18 mM, respectively. Sulfation of taurochenodeoxycholate, therefore, does not impair its bile secretory function. Despite a higher critical micellar concentration, biliary lipid excretion with monosulfate esters is equivalent to that seen with unsulfated bile salt. The role of hydrophobic/hydrophilic balance in the promotion of biliary lipid excretion may need to be redefined.

Detection of an oncofetal antigen (DU-PAN-2) in sera of patients with non-malignant hepatobiliary diseases and hepatomas.

DU-PAN-2 is a high-molecular-weight glycoprotein defined by a murine monoclonal antibody (MAb) elicited against a human pancreatic adenocarcinoma cell line. This MAb recognizes an oncofetal antigen present on the surface of normal pancreatic and bile-duct epithelium, normal bronchus epithelium, and some adenocarcinomas. Elevated levels of the antigen (greater than 400 U/ml) have been detected in the serum of 79% of patients with adenocarcinoma of the pancreas and in a small percentage of patients with other adenocarcinomas, by means of a competition radioimmunoassay. Here, we have studied DU-PAN-2 antigen levels in sera of patients with a spectrum of hepatobiliary diseases and controls. Serum DU-PAN-2 antigen was elevated in 59% of 112 patients with non-malignant hepatobiliary diseases and in 50% of hepatoma patients. None of 50 healthy controls had elevated serum DU-PAN-2 levels. Patients in every category of hepatobiliary disease studied had elevated median serum DU-PAN-2 levels; the highest median levels were seen in patients with primary biliary cirrhosis (1,296 U/ml) and the lowest in stable cirrhosis (300 U/ml). Elevated serum DU-PAN-2 levels in one patient with primary biliary cirrhosis and in one patient with hepatoma returned to normal following liver transplantation. Serum DU-PAN-2 levels did not correlate well with alkaline phosphatase, 5'-nucleotidase, bilirubin, or alpha-fetoprotein. Using an immunoperoxidase technique on formalin-fixed, deparaffinized liver sections, we showed that DU-PAN-2 MAb reacted heterogeneously with bile-duct epithelium but never stained hepatocytes or hepatoma cells. While serum DU-PAN-2 levels may be useful in detecting and monitoring pancreatic adenocarcinoma, they are not specific for this disease.

Rat hepatic bile acid sulfotransferase: enzyme response to androgens and estrogens.

Rat liver bile sulfotransferase activity can be divided into a fraction that reacts with a monoclonal antibody (PK1B) and another fraction that does not. This work was performed to analyze the known response of hepatic bile acid sulfotransferase activity to androgens and estrogens by determining the effect of treatment on the proportion of bile acid sulfotransferase activity that possessed the epitope for PK1B monoclonal antibody. Activity in treated animals was further characterized by high-performance liquid chromatography (HPLC) analysis following purification by PK1B-immunoadsorption chromatography. The results indicate that estrogens and androgens affect the subset of enzyme activity that has the PK1B epitope more than the population that does not. HPLC demonstrates that increases and decreases in activity that follow treatment with androgens and estrogens are mirrored by the proportion of the PK1B-reactive protein that exhibits a relative molecular weight (Mr) greater than 170,000. Radial immunodiffusion assays of hepatic supernatant using a polyclonal antibody raised against PK1B-reactive bile acid sulfotransferase show that changes in specific activity that follow treatment are the result of changes in enzyme protein concentration.

Rat hepatic bile acid sulfotransferase: identification of the catalytic polypeptide and evidence for polymeric forms in female rats.

A monoclonal antibody, PK1B, directed against rat liver bile acid sulfotransferase was used for the purification and characterization of the enzyme. Incubation of rat liver supernatant with the antibody followed by immunoprecipitation with Staphylococcus aureus cells demonstrated that PK1B reacted with 90% of the enzymatic activity present in the liver supernatant from female rats and 40 to 50% of the activity in male liver preparations. Immunoadsorption chromatography with PK1B bound to Sepharose isolated active enzyme which was purified greater than 75-fold. Sodium dodecyl sulfate-polyacrylamide gel electrophoretic analysis of this preparation in the presence of 2-mercaptoethanol demonstrated three polypeptides: Mr 29,500; 32,500, and 34,000. Western blot analysis indicated that PK1B recognized an epitope which was found only on the Mr 29,500 polypeptide. Two-dimensional gel electrophoresis associated the enzymatic activity with this Mr 29,500 band. High-pressure liquid chromatographic analysis of immunopurified enzyme defined three distinct, enzymatically active protein populations: I (Mr 400,000 to 170,000); II (Mr 130,000), and III (Mr 43,000). An Mr 29,500 polypeptide was the sole constituent of Peaks I and III and a major constituent of Peak II. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis in the presence and absence of 2-mercaptoethanol indicated that in Peak II, catalytically active Mr 29,500 protein is associated with the other two polypeptides by disulfide bonds. In contrast, Peak I consists of a polymer of Mr 29,500 polypeptide which is independent of disulfide interaction.

Androgens and estrogens affect hepatic bile acid sulfotransferase in male rats.

The effect of estrogens and androgens on hepatic glycolithocholate sulfotransferase activity was studied in male rats. Significant increases in specific activity were noted following treatment of rats for 21 days with 17 beta-estradiol, 17 alpha-ethynylestradiol, and the nonsteroidal estrogen agonists nafoxidine, tamoxifen, and diethylstilbestrol. Similar treatment of male rats with 5 alpha-dihydrotestosterone, hydrocortisone, norethindrone, and prolactin did not affect activity. To further assess the effect of androgens, male rats were castrated. Glycolithocholate sulfotransferase activity increased fivefold by 14 days after castration. Treatment of castrated rats with 5 alpha-dihydrotestosterone prevented the increase and maintained activity at the level of sham-operated animals. Castrated animals exhibited an additional increment in activity following treatment with 17 alpha-ethynylestradiol: specific activity in these animals rose to levels comparable with those measured in untreated female rats. These data suggest endogenous androgens maximally suppress hepatic glycolithocholate sulfotransferase activity in male rats. The data also indicate that activity is stimulated by estrogenic compounds of varied chemical structure and that stimulation is not solely due to suppression of androgen release by the testes as a consequence of estrogen treatment.

Acetaminophen hepatotoxicity. An alternative mechanism.

Alcohol-fed hamsters were used to study the mechanism by which acetaminophen initiates hepatotoxicity. Animals maintained on an ethanol-containing diet (Group B) exhibited an increased mortality rate after administration of acetaminophen (400 mg/kg) as compared to control hamsters (Group A). However, in those animals in which the ethanol-containing diet had been replaced by the control diet 24 hr before receiving acetaminophen (Group C), significant protection against acetaminophen toxicity was observed as compared to control animals (Group A). This observation correlates well with the finding that Group C hamsters had higher levels of glutathione and catalase than was found in either Group A or Group B animals. It was also demonstrated that acetaminophen was oxidized by cytochrome P-450, producing acetaminophen free radical and hydrogen peroxide. The free radical in the presence of oxygen was found to generate superoxide and presumably N-acetyl-p-benzoquinone imine. Microsomal lipid peroxidation was found to be stimulated markedly in the presence of acetaminophen. The role of glutathione in protecting hamsters from acetaminophen-mediated hepatotoxicity is discussed.

Solitary hepatic cyst and benign bile duct polyp: a heretofore unheralded association.

Solitary hepatic cysts are uncommon lesions that can produce jaundice by extrinsic compression on the extrahepatic biliary tree. In two recent cases of solitary hepatic cyst with jaundice, an intraluminal polypoid adenoma that obstructed the common hepatic duct was discovered. Concurrence of these two unusual lesions suggests that they may be associated. The importance of recognizing this association is illustrated by two case reports. In case 1, extrinsic compression by the cyst on the common hepatic duct was identified as the cause of jaundice at the initial operation. In case 2, choledocholithiasis was the initial explanation for the jaundice. In both cases, palpation and exploration of the proximal bile ducts with probes and catheters failed to discover the polyp. However, jaundice persisted postoperatively in both cases, and subsequent contrast radiography revealed an intraluminal filling defect in the common hepatic duct. In both cases, reoperation was required, and a benign bile duct polyp was discovered and excised. Thus, the presence of jaundice in a patient with a cystic hepatic mass should suggest the possibility of a concurrent bile duct polyp. Awareness of this possibility should permit recognition of such a polyp at initial operation.