Nonprogressive course of non-A, non-B chronic hepatitis in multitransfused hemophiliacs

Eleven hemophiliacs with chronic liver disease were studied prospectively for 6 yr, with liver function tests and liver biopsies carried out at intervals of 3 yr. The second series of biopsies, compared with the first series, showed continuation of chronic persistent hepatitis in four patients, change to chronic lobular hepatitis in two, and spontaneous improvement of the disease in the four cases who had had chronic active hepatitis characterized by moderate piecemeal necrosis. One patient with active cirrhosis died of liver failure during the follow-up period. Study of the serum and intrahepatic markers for hepatitis B and delta viruses suggests that chronic liver disease is nonprogressive in hemophiliacs who have no intrahepatic viral marker.

Acute hepatitis non-A, non-B following administration of factor VIII concentrates

A retrospective survey on clinical hepatitis in patients with bleeding disorders was performed. Nine episodes of hepatitis non-A, non-B occurred in 8 out of 20 patients (40%) with mild hemophilia A or von Willebrand's disease, who had been treated with commercial factor VIII concentrates. Only two episodes of hepatitis B occurred during the study period. The non-A, non-B attack rate after the first treatment was 40% with factor VIII concentrate obtained from large plasma pools (= 2,000 donors) including professional plasma donors as compared to 8% after treatment with factor VIII concentrate obtained from smaller (100-250 donors) plasma pools from Scandinavian donors.

High frequency of low plasma haptoglobin values found in hemophilia A patients on prophylactic treatment with factor VIII concentrates - a sign of hemolysis?

Low plasma haptoglobin values have been observed in hemophilia A patients on regular prophylactic treatment with factor VIII concentrates. Two of 3 patients treated with fraction I-0 (Kabi) and 7 of 11 patients treated with high-purity concentrates (Hyland) had low haptoglobin values. Four of 8 patients who were treated with high-purity concentrates prescreened for a low content of anti-A and anti-B immunoglobulins still showed low haptoglobin levels. Unexpectedly, 2 patients of blood group 0 showed low haptoglobin values. The presence of irregular erythrocyte alloantibodies and/or other contaminants of the concentrates might thus also be a cause of hemolysis resulting in an increased consumption of haptoglobin. Elevated lactate dehydrogenase levels were also frequent. No correlations were found between albumin, aspartate or alanine aminotransferase levels and haptoglobin levels.

Recurrent acute hepatitis following the use of factor VIII concentrates

During a 3-yr period, a patient with hemophilia A experienced 5 episodes of acute hepatitis within 7-16 days following 5 separate infusions of factor VIII (FVIII) concentrates. Although the exact mechanism of the recurrent hepatitis remains unclear, these episodes most likely represented repeated allergic reactions to an antigenic protein derived from the FVIII concentrates. Although no evidence was found for a specific humoral immune response to FVIII in the circulation of the patient, an isolated cellular immune response was suggested by the finding of in vitro lymphocyte stimulation in response to the FVIII concentrate. This unusual type of posttransfusion hepatitis must be added to the list of adverse responses to FVIII concentrates.

Non-A/non-B hepatitis in experimentally infected chimpanzees: cross-challenge and electron microscopic studies

Inoculation of eight chimpanzees with factor VIII, factor IX, or "H" strain plasma resulted in enzymatic and histopathologic evidence of non-A/non-B hepatitis in all eight animals. Challenge of two chimpanzees convalescent from factor VIII-induced disease with either factor IX or "H" strain plasma resulted in non-A/non-B hepatitis only in the animal inoculated with factor IX materials. Reciprocal cross-challenge of a chimpanzee convalescent from factor IX-induced disease with factor VIII also produced unequivocal enzymatic and histopathologic evidence of non-A/non-B hepatitis. Cross-challenge of a chimpanzee convalescent from "H" strain-induced non-A/non-B hepatitis with factor VII did not cause a second bout of non-A/non-B hepatitis. These findings suggest the factor VIII materials and "H" strain plasma used in these studies share a common etiologic agent (or agents), but that factor VIII and factor IX may contain two distinct agents. Electron microscopic (EM) examination of thin-sectioned, acute-phase liver biopsies from all but one of the chimpanzees receiving the primary inocula revealed the presence of abnormal hepatocyte cytoplasmic structures previously shown to be associated with non-A/non-B hepatitis. Crystalline structure containing 25 to 30 nm particles were visualized by EM in the cytoplasm of endothelial or Kupffer cells in acute-phase liver biopsies obtained from three chimpanzees inoculated with either factor VIII materials or "H" strain plasma.

IgG4: a possible mediator of anaphylaxis in a haemophiliac patient

Immunological investigations have been carried out on a haemophiliac patient who had developed severe anaphylaxis to bovine factor VII administration. Results have shown that the development of anaphylaxis in this patient was associated with a sudden increase in total and specific IgG4 antibodies. The significance of this observation is discussed in relation to current evidence suggesting the involvement of IgG4 antibodies in some anaphylactic conditions.

The high risk of chronic liver disease in multitransfused juvenile hemophiliac patients

Eighty-seven asymptomatic children with either hemophilia A or B were treated before they were 21 years of age. Seventy-two received factor concentrates and 15 cryoprecipitate or fresh-frozen plasma only. Thirty-two of the 72 in the former group have persistently elevated alanine aminotransferase values compared to one of 15 in the latter group. In a subset of children treated with factor concentrates before five years of age, four of seven are chronically HBsAg positive. Liver biopsies were performed in 13 of the 32 asymptomatic patients with abnormal ALT values in the fraction group. It is recommended that until further data become available, children with mild hemophilia and all less than 5 years of age should receive only cryo or FFP.

Cryoprecipitate: its use and effects in canine coagulum pyelolithotomy

A fibrin clot forming an extractable cast or "coagulum" of the pyelocalyceal system was developed and characterized using a blood product not previously described--single donor type specific cryoprecipitate. The physical properties of the cryoprecipitate coagulum were investigated and compared with other described formulations. Simulated coagulum pyelolithotomy was performed in vivo in 11 canine kidneys with no adverse effect upon creatinine clearance or anatomic integrity. The advantages of the cryoprecipitate are detailed and a new, simplified operative technique is described.

Experimental infection of chimpanzees with antihemophilic (factor VIII) materials: recovery of virus-like particles associated with non-A, non-B hepatitis

Non-A, non-B viral hepatitis was transmitted to four colony-born chimpanzees by infusion of three lots of antihemophilic factor (factor VIII) implicated in the transmission of non-A, non-B hepatitis to two human recipients. All four inoculated animals showed histopathological evidence of viral hepatitis, and all demonstrated significant ALT elevations between seven and one-half weeks after inoculation. Acute-phase plasma from one of the infected chimpanzees (no. 771) was shown to induce non-A, non-B hepatitis in two other chimpanzees approximately three weeks after their inoculation. In addition, an acute-phase open liver wedge biopsy obtained from animal no. 771 was processed and examined by immune electron microscopy (IEM) for virus-like particles with convalescent serum from a serologically confirmed case of non-A, non-B hepatitis. Twenty-five to 30 nm (mean = 27 nm) diameter virus-like particles that were either "full" or "empty" were identified in this liver preparation by IEM. Two additional chimpanzees inoculated with a cesium chloride gradient fraction of an isopycnically banded liver homogenate (animal no. 771) also developed elevated ALT activity two to two and one-half weeks later. Our findings have experimentally verified that commercially produced factor VIII materials can induce non-A, non-B hepatitis in champanzees and that the disease can be subpassaged in these animals by inoculation of either acute-phase plasma or liver. These results also provide evidence for the association of 27 nm-diameter virus-like particles with non-A, non-B viral hepatitis.

Transfusion-related short-incubation hepatitis in hemophilic patients

Nine episodes of a unique short-incubation form of hepatitis were observed during five years in six hemophilic children after infusion with commercial factor VIII concentrate prepared by two different manufacturers. Five patients with a single episode had no previous infusion for 14 months to 14 years. One patient with several episodes had no previous infusion for at least seven months preceding each episode. The illness was mild and self-limited. No seroconversions to cytomegalovirus, Epstein-Barr virus, toxoplasmosis, or hepatitis A virus occurred. Acute hepatitis B virus infection was also excluded. The findings suggest the presence of one or more non-A, non-B hepatitis agents associated with factor VIII concentrates.

Percutaneous liver biopsy and chronic liver disease in haemophiliacs

Systematic screening of forty-seven haemophiliacs in Sheffield revealed abnormal liver-function tests in thirty-six (77%), with a tendency for these abnormalities to persist. To assess the importance of these abnormalities, percutaneous liver biopsy was carried out on eight symptom-free patients under factor-VIII cover. A wide spectrum of chronic liver disease was demonstrated, including chronic aggressive hepatitis and cirrhosis. The liver pathology bore no relation to clinical history or to biochemical findings. Hepatitis-B-virus markers were common, but evidence suggests that this is not the only factor contributing to the development of liver disease. The high incidence of chronic liver disease seems to be a recent development and is probably related to factor-concentrate replacement therapy.

Commercial factor VIII associated hepatitis, 1974-75, in the United Kingdom: a retrospective survey

A retrospective survey of transfusion hepatitis associated with a brand of commercial Factor VIII was carried out in 24 Haemophilia Centres from January 1974 until December 1975. Of 371 patients who were transfused with this product, and were followed up, 78 cases of hepatitis affecting 66 patients were found (17.7%). Two types of hepatitis were observed: hepatitis B and non-B hepatitis, the latter with an incubation period of between 8 and 60 days. Twelve patients contracted two types of hepatitis, non-B followed by hepatitis B. Only one patient died after contracting hepatitis B. Four of the suspect batches of concentrate were found to be positive for HBsAg by radioimmunoassay. There was evidence that the presence of hepatitis B surface antibody in a patient's serum prior to exposure was associated with immunity to hepatitis B. Evidence was presented suggesting that the non-B hepatitis observed was not due to hepatitis A. The factors affecting the incidence of transfusion hepatitis in haemophiliacs were discussed.

[Alteration of platelet function during intensive replacement therapy in haemophilia A (author's transl)]

This report describes two patients with haemophilia A who developed a transient thrombocytopathy with haemorrhagic diathesis during post-operative high-dose replacement therapy with antihaemophilic globulin. At the time of the bleeding the factor VIII-activity was in the normal range in both patients. The fibrinogen level, however, was elevated to 1700 mg-% and the factor VIII-associated antigen rose to more than 6-fold. At no time of replacement therapy with antihaemophilic globulin could either fibrinogen split products or fragments of the factor VIII-protein be detected by the usual methods. In view of the results of the thrombocyte aggregation experiments the authors postulate a disturbance of platelet function at the level of the membrane surface due to an overload of increased amounts of circulating proteins. Both the possible interference of dialysable factor VIII-components and the role of immunpathologic phenomena are discussed.

Hemophiliac with hemolytic anemia resulting from factor VIII concentrate

Bilateral herniorrhaphy was successfully performed on a group AB hemophiliac with cirrhosis of the liver. Adequate hemostasis was maintained with infusions of commercial factor VIII concentrates and fresh frozen plasma. An anti-A antibody mediated hemolytic reaction occurred in the postoperative period. Hemolysis subsided after the cessation of commercial factor VIII infusions. The risk of such hemolytic reactions could be eliminated through the use of group-specific cryoprecipitated factor VIII.

Hemolysis caused by factor VIII concentrates

Immune hemolytic anemia is a recognized complication of the use of factor VIII concentrates. Hemolysis is obscured often by the presence of active bleeding. Where hemolysis has been demonstrated, red blood cell (RBC) destruction has been attributed to anti-A antibodies found in the transfused material. We present two episodes of hemolysis associated with the use of factor VIII concentrate. In the first, a high titer of "immune" anti-A (1:256) was present in the factor VIII. In the second, the patient's RBCs were group B, and the hemolysis was caused by anti-B antibody in the factor VIII concentrate. In addition, the antibody titer in the material that was received was much lower than previously described. The RBC destruction presumably occurred because of the massive dosage of factor VIII concentrate administered on order to overcome a factor VIII inhibitor.

Unusual intravascular material in the brain. Autopsy findings in a patient treated with antihemophilic factor concentrates

Widespread vascular occlusion caused by unusual particulate material in the brain of a patient who was intensively treated with antihemophilic factor (AHF) concentrates prior to death is described. The intravascular particles were seen partially or completely occluding both veins and arteries of small caliber in the brain and also to a much lesser extent in other organs. The resultant small focal infarcts were predominantly distributed in the cerebral white matter. The pathogenesis of this apparently unique vascular occlusive phenomenon and its relationship, if any, to the massive AHF concentrate infusion in this patient remain unknown.

An adverse pulmonary reaction to cryoprecipitate in a hemophiliac

An adult with classif Hemophilia A experienced a very severe reaction to transfusion with cryoprecipitate which was manifested as an adverse pulmonary reaction with marked hypoxemia in spite of oxygen therapy. The patient had neither leukoagglutinins nor lymphocytoxic, anti-platelet, or anti-Gm antibodies. His IgA level was normal. The possibility that debris in the cryoprecipitate from leukocytes and platelets contributed to the reaction is discussed.

[Treatment of hemophilia A with actor VIII concentrate in urological operations and injuries of the urinary tract]

A congenital tencency to bleeding can nowadays be successfully treated by substitution of the missing clotting factors. One patient with a slight hemophilia A had a renal calculus removed without complications by pyelotomy, using an antihemophilic Factor VIII concentrate. A 16-year-old boy with a severe form of hemophilia A suffered a renal trauma with retroperitoneal hemorrhage. He was treated conservatively with Factor VIII concentrate and partial function of the kidney was retained. Substitution therapy for operative or conservative procedures and the requirements and expense are discussed.