Characterization of the B cell response of patients with anti-liver cytosol autoantibodies in type 2 autoimmune hepatitis

Anti-liver cytosol type 1 (LC1) autoantibody is detected in 30% of sera from patients with type 2 autoimmune hepatitis (AIH), and is the only circulating autoantibody in 10% of cases. Human formiminotransferase cyclodeaminase (FTCD) has been shown to be the specific liver antigen recognized by anti-LC1 autoantibodies. The aim of this study was to identify the dominant epitope on human FTCD and to analyze antigenic-site sequences for clues on the development of AIH. Recombinant proteins and peptides covering the entire cDNA of human FTCD were tested against anti-LC1 autoantibodies. Conformational epitopes were found throughout the protein but linear epitopes were found exclusively in the C-terminal 146 amino acids. Two groups of sera with different reactivities were found: 69%of the sera recognized two specific linear epitopes at positions 428-434 (NTPEEKD) and 440-447 (LQEGLRRA) of human FTCD; others reacted only with a discontinuous epitope between the amino acids at position 395 and 528. FTCD autoantibody production is thus a polyclonal-antigen-driven B cell response. Autoantibodies against conformational or discontinuous epitopes were found in all patients and two-thirds also recognized linear epitopes on human FTCD.

A 10 year follow up study of patients transplanted for autoimmune hepatitis: histological recurrence precedes clinical and biochemical recurrence

BACKGROUND AND AIM

Autoimmune hepatitis (AIH) has been reported to recur after orthotopic liver transplantation (OLT) in 10-35% of patients in small series with a short follow up. The aim of the present study was to examine the clinical and histological outcome more than 10 years after OLT for AIH.

PATIENTS AND METHODS

Seventeen women with a mean age of 30 (12) years at the time of OLT, selected from among 44 patients transplanted for AIH, were followed for more than 10 years. The criteria for definite AIH, as established by the International Autoimmune Hepatitis Group, were met in every case. Liver biopsies were performed 1, 2, 5, and 10 years after OLT, and when indicated by abnormal liver function tests. Specimens were examined for evidence of recurrent AIH, namely interface hepatitis, lobular activity, portal lymphoplasmocytic infiltration, and fibrosis. Other signs of recurrence included hypertransaminasaemia, serum autoantibodies, and the response to steroid reintroduction or significant steroid dose increments.

RESULTS

AIH recurred in 7 (41%) of 17 patients. In four patients histological abnormalities were detected by means of protocol biopsies 1-5 years before the onset of biochemical abnormalities. Two patients developed severe recurrences after 10 and 15 years, respectively, and required treatment with steroids and tacrolimus. In the other three patients histological recurrence was detected 0.6-3 years post-OLT, concomitantly with biochemical abnormalities.

CONCLUSIONS

AIH recurred in 41% of patients followed for more than 10 years after OLT. As histological signs preceded biochemical abnormalities in four patients (23.5%), regular liver biopsy is warranted after OLT. Detection of isolated histological signs may call for closer follow up and/or a change in immunosuppressive therapy.

Identification of rat targets of anti-soluble liver antigen autoantibodies by serologic proteome analysis

BACKGROUND

Anti-soluble liver antigen (SLA) autoantibodies are specific for autoimmune hepatitis type 1 and are the only immunologic marker found in 15-20% of hepatitis cases previously considered cryptogenic. Anti-SLA antibodies react with the 100 000g supernatant from rat liver homogenate, but the molecular targets remain controversial.

METHODS

We characterized anti-SLA targets by one- and two-dimensional immunoblotting analysis. The recognized proteins were identified by peptide mass fingerprint analysis after matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

RESULTS

Three proteins of 35 kDa and pI 6.0, 50 kDa and pI between 6.0 and 6.5, and 58 kDa and pI between 6.5 and 7.0 were stained more intensely by anti-SLA positive-sera than by control sera. After in-gel tryptic digestion, MALDI-TOF analysis of the generated peptides enabled the clear identification of N-hydroxyarylamine sulfotransferase, isoforms of alpha-enolase, and isoforms of catalase.

CONCLUSIONS

Possible antigens for anti-SLA antibodies include a sulfotransferase, alpha-enolase(s), and catalase(s). Two-dimensional electrophoresis combined with mass spectrometry offers a versatile tool to identify molecular targets of autoantibodies and thus to improve diagnostic tools and the understanding of the immune process.

Anticardiolipin antibodies in patients with multiple sclerosis do not represent a subgroup of patients according to clinical, familial, and biological characteristics

BACKGROUND

In multiple sclerosis (MS), case control studies have shown that anticardiolipin antibodies (aCL Ab) are more frequent than in the general population and that aCL Ab positivity may be associated with specific clinical characteristics.

OBJECTIVES

To determine whether patients with MS who are positive for aCL Ab have specific characteristics.

METHODS

285 consecutive patients with MS were tested for aCL Ab positivity. Patients also underwent complete autoimmune screening and were systematically evaluated for clinical characteristics and individual or family history of autoimmune disease.

RESULTS

aCL Ab positivity was found in 42 patients (15%). The main isotype was aCL IgM (32 patients, 11%). Demographics and clinical characteristics including sex, age at onset, course of the disease, expanded disability status scale score, and progression index were not different between aCL Ab positive and aCL Ab negative patients. Clinical systems involved at onset or during the course of the disease were not different from what is usually observed in MS. aCL Ab positivity was not associated with an increased frequency of autoimmune disease and was not predictive of a family history of autoimmune disease. Patients positive for aCL IgM were more frequently positive for the presence of non-organ specific antibodies (53% v 39%, respectively, p = 0.02).

CONCLUSIONS

These results do not support the hypothesis that patients with MS with aCL Ab constitute a subgroup of MS according to demographic clinical and familial characteristics. The greater frequency of other antibodies in aCL Ab positive patients suggests that they only reflect a more general autoimmune activation in MS.

[Autoimmune hepatitis. Physiopathologic, clinical, histological, and therapeutic features]

Autoimmune hepatitis is characterized by an inflammation of the portal tract with lymphocytes and plasma cells, an hypergammaglobulinemia and a variety of circulating autoantibodies. The presence of smooth muscle antibodies and/or antinuclear antibodies define type 1. Type 2 is characterized by the presence of liver-kidney--microsomal antibodies. Environmental, genetic and infectious factors may explain the autoreactivity of T cells. Different non specific clinical features may be present. Sometimes the presentation may be an acute hepatitis; in the remainder, the disease may not be recognized until liver damage is advanced. Hypergammaglobulinemia and presence of circulating autoantibodies are the key for diagnosis. The association of prednisolone in combination with azathioprine remains the established treatment. If relapse or non response occur, other immunosuppressive therapy such as cyclosporin may be useful. Liver transplantation is reserved for (sub)fulminant forms and end stage liver disease.

Polyspecificity of antimicrosomal thyroid antibodies in hepatitis C virus-related infection

OBJECTIVES

The outcome of dysthyroidism and the presence of antithyroid antibodies in patients with chronic hepatitis C virus (HCV) infection receiving interferon-alpha therapy is clearly established. However, the prevalence and the specificity of antithyroid antibodies in HCV patients before interferon-alpha therapy remain controversial. The aim of the present study is to clarify within a large population of HCV patients the prevalence of antithyroid antibodies before interferon-alpha therapy and to determine whether their immunodominant antigen is the same as described in autoimmune thyroiditis.

METHODS

Sera from 99 patients with chronic hepatitis C before (n = 99) and after (n = 37) interferon-alpha treatment were investigated for the presence of antimicrosomal and antithyroperoxidase antibodies assessed by indirect immunofluorescence and ELISA, respectively. Dot blotting on human thyroid lysate was designed to further characterize these autoantibodies. Data were compared to those obtained with sera of patients with autoimmune thyroiditis (n = 75) and healthy subjects (n = 96).

RESULTS

In HCV patients, antimicrosomal antibodies were found with a higher proportion before interferon-alpha therapy (12.1%) than after therapy (8%). Thyroperoxidase constitutes the main antigen in only 4% before treatment, a prevalence similar to that observed in healthy controls.

CONCLUSIONS

The prevalence of antithyroid antibodies is low in patients with chronic hepatitis C before interferon-alpha therapy. Thyroperoxidase may not be their main target. Further studies are required to determine whether HCV infection leads to a breakdown of tolerance to a thyroid self-protein other than thyroperoxidase.

Successful tacrolimus therapy for a severe recurrence of type 1 autoimmune hepatitis in a liver graft recipient

A 34-year-old woman underwent orthotopic liver transplantation (OLT) for decompensated type 1 autoimmune hepatitis (AIH). She was administered standard triple-drug immunosuppressive therapy (cyclosporine, steroids, and azathioprine). Ten years after OLT, she developed a recurrence of AIH, with emergence of serological markers of autoimmunity (high anti--smooth muscle antibody [ASMA] titer, high serum gamma globulin level), abnormal liver function test results, and characteristic histological features on liver biopsy. Despite intensified steroid therapy, her clinical and liver function deteriorated. The onset of cutaneous alternariosis led to a steroid dose reduction and cyclosporine replacement by tacrolimus. Clear-cut amelioration was observed, with an improvement in liver function test results and reduction in ASMA titer. One year after the recurrence of AIH, the patient has normal liver function and physical findings. Tacrolimus therefore may be effective in patients with severe recurrent autoimmune liver disease. Further studies are needed to assess tacrolimus therapy in patients who fail to respond to standard immunosuppressive therapy.

Familial lupus erythematosus. Clinical and immunologic features of 125 multiplex families

Evidence for a genetic susceptibility to systemic lupus erythematosus (SLE) in humans is based on the high concordance rate observed in identical twins and on the relatively high incidence of familial cases. Although recent genetic studies have lead to significant advances in the identification of new susceptibility genes in SLE, no large clinico-pathologic study of familial SLE has been reported to date. In the present study, we describe the main clinical and immunologic features of 125 lupus multiplex families including at least 2 cases of SLE and/or discoid lupus erythematosus (DLE), recruited through a French national survey starting in July 1997. Medical records of all affected members were reviewed by the same investigator, all available family members were interviewed using the same standardized procedure, and blood was drawn for autoantibodies typing. Clinical and immunologic features of 90 probands from multiplex SLE families were compared with those of 100 sporadic SLE patients sharing the same French Caucasian origin. The 125 lupus multiplex families included 282 affected members (2.3 patients per family); of the 125 families, 96 were of French Caucasian origin. One hundred multiplex families included 2 affected relatives, while 25 included 3 or more affected individuals. The relationship between affected members was sibs (45%), parent-offspring (31%), and second-degree (24%). An autosomal dominant mode of inheritance was strongly suggested in 1 extended pedigree with 6 clinically affected members, and a recessive pattern was suspected in 5 other families. No obvious mode of inheritance could be suspected in most of the remainder. Among French Caucasians, sex ratio, mean age at onset, and clinical and biologic SLE-related manifestations were not significantly different in multiplex compared with sporadic SLE cases. The analysis of these 125 multiplex families suggests a genetic heterogeneity that should be considered for ongoing genomic screening.

Antibodies to soluble liver antigen: an additional marker in type 1 auto-immune hepatitis

BACKGROUND/AIMS

Auto-immune hepatitis patients are divided into two well-defined subgroups on the basis of immunoserological markers, i.e. anti-actin cable and/or anti-nuclear antibodies for the auto-immune hepatitis type 1, anti-liver/kidney microsome type 1 and/or anti-liver cytosol type 1 for the autoimmune hepatitis type 2. Controversial antibodies to a soluble liver antigen have been proposed as a diagnostic marker for the putative auto-immune hepatitis type 3. The aim was to investigate the implication of anti-soluble liver antigen antibodies in the diagnosis of auto-immune hepatitis and their ability to define auto-immune hepatitis type 3.

METHODS

Sera from 483 patients with hepatic and non-hepatic diseases, and 102 sera from blood donors were analyzed by an inhibition capture enzyme-linked immunosorbent assay.

RESULTS

Anti-soluble liver antigen antibodies were found in 13 of the 106 (12%) auto-immune hepatitis type 1 patients and 10 of the 49 (20%) cryptogenic hepatitis patients tested. In contrast, they were not detected in auto-immune hepatitis type 2 (n=54), primary sclerosing cholangitis (n=37), primary biliary cirrhosis (n=52), hepatitis C virus infection (n=105), alcoholic hepatitis (n=25), various non-hepatic autoimmune disorders (n=55) and in healthy blood donors (n=102). The clinical and biological features of antisoluble liver antigen-seropositive patients were similar to those of auto-immune hepatitis type 1 and did not distinguish a subgroup of auto-immune hepatitis.

CONCLUSION

The data support the concept that antisoluble liver antigen-positive cryptogenic hepatitis is similar to auto-immune hepatitis type 1. Anti-soluble liver antigen antibodies can be considered as an additional and specific auto-immune hepatitis type 1 diagnostic marker.

Autoantibodies associated with acute rejection after liver transplantation for type-2 autoimmune hepatitis

Autoantibodies, markers of autoimmune diseases, can also be detected in chronic allograft rejection. However, the appearance of these autoantibodies in acute rejection after orthotopic liver transplantation has not yet been reported. Liver-kidney-microsome type-1 (LKM-1) antibodies directed against the autoantigen cytochrome CYP2D6 define a group of patients with autoimmune hepatitis type-2 (AIH-2), distinct from autoimmune hepatitis type-1 (AIH-1) in which anti-nuclear antibodies and anti-smooth muscle antibodies (SMA) with actin specificity are present in patient sera. Autoantibodies were studied by the quantitative CYP2D6 radioligand assay (RLA) that uses a radiolabeled CYP2D6 as antigen, immunoblotting using recombinant CYP2D6 protein and human liver microsomal and cytosolic fractions, and indirect immunofluorescence (IIF) using rat kidney-stomach-liver cryostat sections. In addition, the specificity of anti-SMA was detected by IIF on HEp2 cell line harvested with colchicin. This report describes the time course of CYP2D6 antibodies and the appearance of anti-SMA (without anti-actin, cytokeratin and vimentin reactivity) associated with acute rejection during a 2-year follow-up, in a patient who underwent transplantation at end-stage type 2 autoimmune hepatitis. In addition, we report a new reactivity against an unknown 40-kDa protein using a rat cytosolic fraction. The detection of autoantibodies in sequential samples may be important to better predict rejection or relapse, and to establish adequate therapy.

[Clinical significance of antiribosomal antibodies. Study Group on Autoimmunity (GEAI)]

PURPOSE

Autoantibodies directed against the ribosomal P proteins, P0, P1 and P2 (anti-P), have been related to lupus-related psychosis and/or depression. The diagnostic value of antibodies directed against other ribosomal proteins or 28S RNA (anti-no-P) remains unknown. A multicenter study including ten centers belonging to the study group for autoimmune diseases (GEAI) was conducted in order to determine the diagnostic value of anti-P and anti-no-P antibodies in a large population of patients.

METHODS

The patients were selected on the basis of the presence of serum anti-ribosomal antibodies detected by indirect immunofluorescence (IF) on rat liver/kidney/stomach/pancreas sections and human HEp2 cells. The clinical course of all patients was studied using a predetermined survey. The specificity of anti-P antibodies were determined by Western blot.

RESULTS

Anti-ribosomal antibodies were found in 82 patients. Fifty-five of them had systemic lupus erythematosus and 27 had another disease. Only 54% of the anti-ribosomal antibodies detected by IF were anti-P and were found in 69% of the patients with systemic lupus erythematosus. Anti-no-P antibodies (46%) were preferably detected in patients who suffered from another disease (78%). In patients with systemic lupus erythematosus, neurological and psychiatric disorders were more frequent in the no-P group (47% vs. 16%, P < 0.01) than arthritis, which was found more frequently in the P group (78% vs. 53%, P < 0.05).

CONCLUSION

Anti P antibodies do not constitute a specific diagnostic marker of systemic lupus erythematosus, and lupus-related neuropsychiatric disorders would be preferably associated with the presence of anti no-P antibodies.

[Autoantibodies in hepatology]

The diagnosis of autoimmune liver disease (primary biliary cirrhosis, autoimmune hepatitis, and primary sclerosing cholangitis) can be made by assaying specific autoantibodies in the serum. A review is presented of these antibodies, the methods used to detect them, and the antigens identified to date. Hepatitis C is the most common cause of autoantibody production in liver diseases and is also discussed.

Habitual abortions in 678 healthy patients: investigation and prevention

The objective of this study of patients with habitual abortion (HA), was to determine their autoimmune profile and to try to prevent new abortions using low-dose aspirin for 7 months with prednisone in the first trimester only, or with low-dose aspirin alone. A total of 678 healthy patients with three or more HA were investigated for antiphospholipid antibodies, antinuclear and antithyroid antibodies. Among these patients, 277 pregnant women were treated, 214 were given prednisone and aspirin (161 autoantibody-negative and 53 autoantibody-positive women), and 63 autoantibody-negative women received aspirin alone. Autoantibodies were present in 33.9% of the patients, in 82.6% of them anticardiolipin antibodies were found to be isolated or associated with antiprothrombin, antithyroid, circulating anticoagulant, antinuclear or anti-beta2 glycoprotein 1 antibodies. In autoantibody-negative pregnant women treated by prednisone and aspirin or aspirin alone, the success rate of live births was 90.7% (146 out of 161) and 74.6% (47 out of 63) respectively (P < 0.01). In autoantibody-positive patients treated with prednisone and aspirin the success rate was 84.9% (45 out of 53) (not significant). Prednisone and aspirin seemed to be as efficient in autoantibody-negative or positive women but better than aspirin alone in autoantibody-negative women. A double-blind trial is in progress to confirm these results.

Autoepitope mapping and reactivity of autoantibodies to the dihydrolipoamide dehydrogenase-binding protein (E3BP) and the glycine cleavage proteins in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is an autoimmune liver disease characterized by the presence of antimitochondrial antibodies (AMA) directed primarily against the E2 subunits of the pyruvate dehydrogenase complex, the branched chain 2-oxo-acid dehydrogenase complex, the 2-oxoglutarate dehydrogenase complex, as well as the dihydrolipoamide dehydrogenase-binding protein (E3BP) of pyruvate dehydrogenase complex. The autoantibody response to each E2 subunit is directed to the lipoic acid binding domain. However, hitherto, the epitope recognized by autoantibodies to E3BP has not been mapped. In this study, we have taken advantage of the recently available full-length human E3BP complementary DNA (cDNA) to map this epitope. In addition, another lipoic binding protein, the H-protein of the glycine cleavage complex, was also studied as a potential autoantigen recognized by AMA. Firstly, the sequence corresponding to the lipoic domain of E3BP (E3BP-LD) was amplified by polymerase chain reaction and recombinant protein and then purified. Immunoreactivity of 45 PBC sera (and 52 control sera) against the purified recombinant E3BP-LD was analyzed by enzyme-linked immunosorbent assay (ELISA) and immunoblotting. Secondly, reactivity of PBC sera was similarly analyzed by immunoblotting against H-protein. It is interesting that preabsorption of patient sera with the lipoic acid binding domain of E3BP completely removed all reactivity with the entire protein by immunoblotting analysis, suggesting that autoantibodies to E3BP are directed solely to its lipoic acid binding domain. Fifty-three percent of PBC sera reacted with E3BP-LD, with the majority of the response being of the immunoglobulin G (IgG) isotype (95%). Surprisingly, there was little IgM response to the E3BP-LD suggesting that the immune response was secondary because of determinant spreading. In contrast, H-protein does not appear to possess (or expose) autoepitopes recognized by PBC sera. This observation is consistent with structural data on this moiety.

Description of a new DRB1*11 allele (DRB1*1132)

We describe a new DRB1*11 allele which is similar to DRB1*11011 except at codon 74, where a GCG is changed for a GTG leading to an alanine/valine substitution. This new allele was carried by a Caucasian patient suffering from rheumatoid arthritis and by her healthy daughter. The motif at codon 74 of the new DRB1*11 is not found in any other known DRB alleles, nor among the published DQA1, DQB1, DPA1 or DPB1 alleles, and therefore suggests a mechanism of point mutation.

High incidence of antitissue antibodies in patients experiencing chronic liver allograft rejection

BACKGROUND

The precise immunologic mechanisms responsible for chronic rejection of liver allografts are unknown. We have recently shown in a rodent model that recipients of liver allografts developed non-major histocompatibility complex antitissue antibodies. The aim of the present study was to test this hypothesis in the clinical setting.

METHODS

Posttransplant sera of 14 patients undergoing chronic rejection and of 48 control patients (12 liver transplant patients with chronic active hepatitis or liver cirrhosis related to hepatitis C virus [HCV] infection and without chronic rejection, 10 with sclerosing cholangitis, and 26 with normal liver function tests and liver biopsy) were tested for the presence of antitissue antibodies by indirect immunofluorescence. Pretransplant sera of all these patients lacked antitissue antibodies.

RESULTS

Antitissue antibodies were detected in 71% of patients who developed chronic rejection (before or at the time of chronic rejection). This incidence was significantly greater than that observed in patients not undergoing rejection (HCV-related chronic active hepatitis, 16%; sclerosing cholangitis, 0%; normal liver biopsy, 7%). All these autoantibodies were directed against the smooth muscle and/or the nucleus. In two patients, anti-smooth muscle antibodies had an antiactin or antivimentin specificity.

CONCLUSIONS

These results show a strong association between chronic allograft rejection and the development of antitissue antibodies and suggest that these antibodies could be used to identify patients at high risk of developing chronic rejection after liver transplantation.

A new approach to cytochrome CYP2D6 antibody detection in autoimmune hepatitis type-2 (AIH-2) and chronic hepatitis C virus (HCV) infection: a sensitive and quantitative radioligand assay

Antibodies specific for cytochrome CYP2D6, formally known as liver-kidney-microsome type-1 antibodies (LKM-1), are characteristically found in a subgroup of patients presenting autoimmune hepatitis. They are also found in some patients with chronic HCV infection. These autoantibodies are usually detected by indirect immunofluorescence, immunoblotting and ELISA tests. In an attempt to set up a more sensitive detection assay we developed a quantitative immunoprecipitation radioligand assay using a 35S-methionine-labelled CYP2D6 antigen obtained by in vitro transcription and translation synthesis. All 16 sera from AIH-2 patients strongly bound to this CYP2D6 antigen. Two of the nine sera (22%) from AIH-2 patients that presented only liver cytosol-1 antibodies also bound to CYP2D6. All 24 sera from HCV patients that were positive for LKM-1 antibodies by indirect immunofluorescence were also positive using this CYP2D6 radioligand assay. Lastly, all 15 sera from HCV patients negative for LKM-1 antibodies were negative by this test. The present results support the view that this quantitative radioligand assay is more sensitive than immunoblotting and ELISA CYP2D6 assays, and that it could be used in combination with indirect immunofluorescence assay.

Prevalence of serum antibodies to hepatitis C virus is not increased in patients with multiple sclerosis

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Antimitochondrial antibodies in patients with chronic hepatitis C

Although autoantibodies have been found in the serum of patients with chronic hepatitis C virus (HCV) there has been no convincing evidence of the presence of antimitochondrial antibodies, until now. Sera from 460 untreated patients with chronic hepatitis C were tested for antimitochondrial antibodies, using an indirect immunofluorescence technique; and if they tested positive for the antibodies (titer more than 1:50), they also were treated by Western blot analysis. Seven (1.5%) sera were positive. None of the patients had biological or histological evidence of primary biliary cirrhosis. Antimitochondrial antibodies recognized one of the oxo-dehydrogenase multienzyme complexe's epitopes by Western blot assay in three patients only. All seven patients were then treated by interferon alpha for six months. None showed exacerbation of liver disease during treatment. HCV-RNA disappeared from the serum in one patient who became negative for anti-M2 antibodies. The four patients who did not respond to interferon-alpha therapy, and the two who relapsed after treatment withdrawal, had sustained positive antimitochondrial antibodies. These data suggest that: 1) antimitochondrial antibodies present in patients with chronic hepatitis C do not always recognize the same epitopes as in primary biliary cirrhosis; 2) these antibodies may disappear after eradication of HCV, suggesting that the production of antimitochondrial antibodies is linked to the presence of the virus and 3) the clinical and biological course of chronic hepatitis C, and the response to interferon-alpha therapy, does not seem to be different in patients who are positive for antimitochondrial antibodies.

Specificity and sensitivity of gp210 autoantibodies detected using an enzyme-linked immunosorbent assay and a synthetic polypeptide in the diagnosis of primary biliary cirrhosis

Between 10% and 42% of patients with primary biliary cirrhosis (PBC) have been reported to have autoantibodies directed against a restricted epitope of gp210, a glycoprotein of the nuclear pore membrane. The prevalence and specificity of these antibodies was studied in a French series of 285 patients with PBC and 497 control individuals affected with other liver or autoimmune diseases. Sera were analyzed by an enzyme-linked immunosorbent assay (ELISA) that used a synthetic polypeptide containing the predominant autoepitope of gp210, in parallel to immunoblotting of gp210 protein and immunofluorescence microscopy. Autoantibodies to the gp210 epitope detected by ELISA were 25.5% sensitive and 99.5% specific for the diagnosis of PBC. These results were in agreement with a 99.4% specificity with immunoblotting analysis and a 96.6% specificity with immunofluorescence. In a subset of PBC patients without detectable antimitochondrial autoantibodies (AMA), gp210 autoantibodies were found in 7 of 15 patients (47%). Therefore, gp210 autoantibodies are highly specific for PBC and may be of particular utility in assessing patients without AMA or with other atypical presentations.

Antineutrophil cytoplasmic autoantibodies in autoimmune liver and inflammatory bowel diseases

Perinuclear antineutrophil cytoplasmic autoantibodies have been described in inflammatory bowel diseases and in primary sclerosing cholangitis. Because the data concerning their occurrence are conflicting, we have used indirect immunofluorescence on ethanol-fixed neutrophils to test the sera from a large population of 382 patients with various liver and digestive diseases: in particular, from 27 patients with primary sclerosing cholangitis, 105 patients with autoimmune chronic active hepatitis, 30 patients with primary biliary cirrhosis and 124 patients with inflammatory bowel disease. The prevalence of the perinuclear antineutrophil cytoplasmic autoantibodies was 37% in ulcerative colitis and 15% in Crohn's disease. They would not be helpful in the differential diagnosis between these two inflammatory bowel diseases. Within the group of autoimmune liver diseases, perinuclear antineutrophil cytoplasmic autoantibodies were detected in 44% of sera from patients with primary sclerosing cholangitis and in 36% of sera from patients with type I autoimmune active hepatitis, but not in primary biliary cirrhosis. When primary sclerosing cholangitis was associated with an inflammatory bowel disease, the prevalence of these autoantibodies was 60%. They were 88% specific for primary sclerosing cholangitis and 86% specific for type I autoimmune active hepatitis. Despite their moderate sensitivity and specificity in primary sclerosing cholangitis, they remain the only serologic marker of this autoimmune liver disease. Moreover, they turned out to be a more sensitive marker for inflammatory bowel disease with associated primary sclerosing cholangitis.

Kinetics of anti-M2 antibodies after liver transplantation for primary biliary cirrhosis

BACKGROUND/AIMS

Orthotopic liver transplantation is currently considered as the treatment of choice for primary biliary cirrhosis in the terminal stage and, as for other autoimmune liver disease, the risk of recurrence of the disease within the graft has been raised. There is, however, some discrepancy about the risk of recurrence based on pathological analysis. In addition, pathological recurrence of primary biliary cirrhosis within the graft is not always associated with a rise in the serological markers of the disease. In order to clarify this situation, we have monitored antimitochondrial antibodies before and after transplantation.

METHODS

Antimitochondrial antibodies were detected by indirect immunofluorescence (variation in antibody titers) and the antimitochondrial antibodies-2 by western blotting (variation in the number of peptides recognized in 16 primary biliary cirrhosis patients followed for at least 4 years after transplantation.

RESULTS

Antimitochondrial antibody titers had normalized 1 year after transplantation in seven patients, declined in seven others and remained unchanged in two. Over the 4 years of follow up, four patients demonstrated a subsequent increase in antimitochondrial antibody titers. Western blot analysis demonstrated the loss of one or more bands in seven patients during the first operative year after transplantation and in three other patients thereafter; in six patients the western blotting profile remained identical to that obtained before transplantation. The important changes generally occurred during the first year post-transplantation, without significant changes thereafter, except for three patients who demonstrated a secondary reappearance of the initially lost band. Disappearance of all bands was never observed. There was no concordance between the normalization of antimitochondrial antibody titers (indirect immunofluorescence) and the reduction in the number of peptides recognized (western blotting). Serum bilirubin and alkaline phosphatase levels had normalized by 1 year after transplantation, and remained normal thereafter. Routine liver biopsies performed on a yearly basis did not disclose any pattern suggestive of primary biliary cirrhosis recurrence.

CONCLUSIONS

Antimitochondrial antibody titers decreased in primary biliary cirrhosis patients after liver transplantation, although antimitochondrial antibodies-2 never disappeared as assessed by western blotting. In the present study these features were not associated with biochemical or histological (correction of histoclogical) evidence of primary biliary cirrhosis recurrence.

Association of antimitochondrial antibodies type 5 and anti-beta 2 glycoprotein I antibodies in the antiphospholipid syndrome

OBJECTIVE

To evaluate if antimitochondrial type 5 antibodies (AMA5) might be included among antiphospholipid syndrome (APS) markers.

METHODS

In a retrospective study, blood variables of 48 patients with AMA5 were analyzed in relationship with clinical and biological markers of APS and systemic lupus erythematosus (SLE).

RESULTS

We observed a high prevalence of false biological test for syphilis (95%), lupus anticoagulant (LAC) (71%), anticardiolipin antibodies (aCL) of IgG (71%) and IgM (75%) isotype, positive direct Coombs' test (54%), thrombocytopenia (52%), anti-B2 glycoprotein I antibodies (38%). Twenty-nine patients (61%) had at least one clinical manifestation of APS; 42% had recurrent arterial and/or venous deep thrombosis and 21% had recurrent fetal loss. But, for 2 patients, AMA5 were the sole detected immunological marker. Moreover, SLE was observed in 35% of the patients. These were different from 100 control patients with SLE with the respect to skin involvement and dsDNA antibodies which were less frequent (p < 0.01) and aCL, LAC, false biological test for syphilis (p < 0.001), positive direct Coombs' test and thrombocytopenia (p < 0.05) which were more frequent.

CONCLUSION

Our data suggests (1) AMA5 is another marker of the APS (2) in patients with SLE, AMA5 seems to be a marker of a subset of SLE. This appears to justify the routine detection of these antibodies.

Comparisons of double immunodiffusion, ELISA, western blot and CAPE blot for the detection of anti-SSA antibody: study of anti-SSA prevalence in systemic lupus erythematosus

The specificity and sensitivity of anti-SSA (Ro) antibody detection by double immunodiffusion, ELISA, western blot and a new method named CAPE blot were studied. Using 79 normal sera, 61 sera positive for anti-SSA (Ro) antibodies (double immunodiffusion), and 39 sera without anti-SSA (Ro) antibodies but containing anti-Sm, anti-RNP, anti-SSB (La), anti-Scl 70 and anti-PCNA antibodies, we compared ELISA, western blot and CAPE blot with the immunodiffusion assay. The sensitivities of the three methods were 100, 62 and 100%, respectively. Sera from 196 patients with systemic lupus erythematosus (SLE) were tested. The prevalence of anti-SSA (Ro) antibodies in this group was scored as 26% by double immunodiffusion, 47% by ELISA, 25% by western blot and 38% by CAPE blot.

[Development of an immunoenzyme assay technique of ELISA type for detecting anti-SSB antibodies. Comparative study of 2 kits]

The anti-SSB antibodies were measured using two enzyme immunoassays (ELISA). The difference between the both results from the preparation of the SSB antigenic extract. The first method, developed in our laboratory, uses a purified SSB antigen extracted from calf thymus, while the other uses an antigen cloned by genetic engineering. We have realized an analytic investigation about the repetability, the reproducibility and the detection limit of our ELISA method and we have refined its evaluation in using a clinic study carried out on 203 subjects (55 had a Sjögren syndrome, 47 had a systemic lupus erythematosus, 17 had a rheumatoid arthritis, 13 a progressive systemic sclerosis, 10 a polymyositis and 61 healthy subjects (blood donors)). These measures were worked out in order to compare them with the Ouchterlony method of reference. The results we have obtained are totally similar to the ELISA methods, with a global correlation factor of 0.96 in spite of the difference on the preparation of SSB antigenic extract. The enzyme immunoassay is a lot more sensitive than the Ouchterlony method since, for a Sjögren sample, we obtain a sensitivity of 0.69 while the sensitivity is only of 0.51 for the immunoprecipitation. In the lupus sample, the sensitivity is respectively of 0.42 and 0.25.

Characterization of the liver cytosol antigen type 1 reacting with autoantibodies in chronic active hepatitis

An autoantibody to liver cytosol was previously described in childhood autoimmune chronic active hepatitis type 2. The antigen, liver cytosol antigen type 1, was for the first time partially purified using gel filtration and ion exchange chromatography, and it was characterized using immunodiffusion, immunoblot and sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis of the immunoprecipitate. Immunoblot detected a unique antigenic peptide at 62 kD from human cytosol and at 58 kD from rat cytosol. The same peptides were also detected when immunoprecipitates of liver cytosol antigen type 1 and autoantibodies to liver cytosol antigen were submitted to sodium dodecyl sulfate-polyacrylamide gel electrophoresis. A polymeric structure, probably a tetramer, is suggested for native liver cytosol antigen type 1 because in gel filtration chromatography liver cytosol antigen type 1 was eluted as a protein of a molecular weight between 240 and 290 kD when human liver cytosol was fractionated and between 220 and 270 kD from rat liver cytosol. Liver cytosol antigen type 1 is probably poor in carbohydrates because it was not stained by periodic acid-Schiff stain. The autoantibodies to liver cytosol were frequently found in association with antiliver kidney microsomal autoantibodies type 1, which are directed against the cytochrome P-450 of the IID6 subfamily. Antiliver kidney microsomal autoantibodies type 1 but not antiliver cytosol autoantibodies were found in association with antibodies to hepatitis C virus. Autoantibodies to liver cytosol antigen type 1 seem to be a more specific marker for autoimmune hepatitis type 2 than antiliver kidney microsomal antibodies type 1 autoantibodies.

Long-term follow-up study of 164 patients with definite systemic sclerosis: classification considerations

To evaluate the usefulness of recently proposed schemes of classification for systemic sclerosis an extensive cross-sectional study of a series of 164 consecutive patients with long-term systemic sclerosis was undertaken. There were 47 cases of proximal sclerosis, 93 of distal sclerosis and 24 of complete CREST syndrome. The study included clinical, visceral, immunological and follow-up data. In addition, a quantitative clinical score was calculated for each patient, thus providing indications for prognosis. Data were expressed according to three conventional systems of classification: The ARA system, the diffuse versus limited systemic sclerosis system and the early cutaneous involvement system. The most reliable indications of severe outcome were: proximal sclerosis, trunk skin involvement, presence of anti Scl 70 autoantibody, pulmonary and/or heart involvement and age. Diagnosis and prognosis were not generated by the same items. Prognosis indicators proved more accurate for groups than for individuals. Mortality was 1 death per 149 patient X years of follow-up from diagnosis. We conclude that the ARA criteria for classification should be recognized as a standard, but patients with complete CREST syndrome should be included in the distal group. Other systems of classification, principally 2-way versus 3-way criteria, allow different subsets of patients that correlate with prognosis and the severity of the disease, and could be used for therapeutic purposes.

Serological arguments for classifying Raynaud's phenomenon as idiopathic

Twenty-five patients with idiopathic Raynaud's phenomenon were followed prospectively for a mean period of 48 months. Clinical and laboratory assessments were performed on admission and on followup. The sera were analyzed for the presence of autoantibodies (antinuclear, antiskeleton and antiorganelle antibodies). Sixteen patients were antinuclear antibody positive and 2 anticentromere antibody positive. Eight patients produced antivimentin, 5 antimitochondrial, 4 anti-Golgi complex, and 3 anticentriol antibodies. Eleven patients produced antidesmosome antibodies. Only one patient (anti-RNP and antidesmosome antibody positive) developed a systemic disease (mixed connective tissue disease) during followup. The initial screening of sera may help to classify Raynaud's phenomenon as idiopathic more accurately.

Detection of autoantibodies to Sm antigen in systemic lupus erythematosus by immunodiffusion, ELISA and immunoblotting: variability of incidence related to assays and ethnic origin of patients

Autoantibodies to small nuclear ribonucleoproteins (snRNP) were studied using the techniques of immunodiffusion, ELISA, and immunoblotting in the sera of 150 patients with systemic lupus erythematosus (SLE), and of 29 patients with mixed connective tissue disease; 900 control patients and 100 normal blood donors were examined simultaneously. The incidence of anti-Sm antibodies in French SLE patients was low compared with the occurrence observed in similar studies in USA (even when highly sensitive assays were used) but was of the same magnitude as European results. Frequency of anti-Sm antibodies in SLE patients varied moderately when detected by immunodiffusion (12%), or by immunoblotting (17%), however, it seems that the ethnic and/or genetic background of patients induces more significant differences. SLE patients from the French West Indies had anti-Sm antibodies in 39% of cases when detected by immunodiffusion and in 50% when immunoblotting was used. In these patients the incidence of the antibodies was five times more frequent than that of mainland French patients. Immunization against snRNP does not seem to be a common feature of all SLE patients.

[Idiopathic portal hypertension associated with connective tissue disease similar to systemic lupus erythematosus]

A case of idiopathic portal hypertension associated with connective disease resembling systemic lupus erythematosus is described. The patient was a 50-year-old woman with splenomegaly, ascites, esophageal varices, and pancytopenia, but without extrahepatic portal obstruction or cirrhosis of the liver. Electron microscopy of the liver showed perisinusoidal fibrosis. High titers of autoantibodies against proliferating cell nuclear antigen (PCNA) were found in the sera as well as in ascites; anti-DNA antibodies appeared after anti-PCNA antibodies and remained thereafter at a moderate titer. The possibility of an immunological process in the pathogenesis of idiopathic portal hypertension is discussed.

[Antinuclear antibodies in primary biliary cirrhosis]

Antinuclear and antinuclear membrane autoantibodies are detected by indirect immunofluorescence in sera of 62 p. 100 of primary biliary cirrhosis patients; when anti-SS-A (Ro) and anti-SS-B (La) autoantibodies were included, 70 percent of patients had at least one type of antinuclear antibody. Of 89 patients with primary biliary cirrhosis, 30 had either Raynaud's phenomenon, Sjögren's syndrome or the CREST syndrome. Some antinuclear antibodies, anticentromere and speckled S1 type, seem to correlate with the associated connective tissue disease. Antibodies showing the S3 pattern (multiple nuclear dots) and antibodies to nuclear membrane may be present independently of an association with connective tissue disease. In the classical technical conditions used to detect anti-tissue and anti-mitochondrial autoantibodies on tissue sections, antinuclear antibodies like anti-centromere or S3 may not be detected and/or identified. Primary biliary cirrhosis patient sera for antinuclear antibodies determination must be screened by at least two assays: indirect immunofluorescence on a human cell line, like HEp-2, and immunodiffusion. The last assay must be performed even if antinuclear antibodies are undetected by immunofluorescence.

[Anti-Scl-70 and anti-centromere autoantibodies. Biological markers of 2 forms of systemic scleroderma]

The diagnostic and prognostic value of anti-Scl-70 autoantibodies in systemic scleroderma and other connective tissue diseases was investigated. A clinical and immunological study consisting of a search for anti-Scl-70 autoantibodies by immunodiffusion and immunoblot and a search for anti-centromere autoantibodies and antinuclear factors by indirect immunofluorescence was conducted in 57 cases of systemic scleroderma, 45 cases of CREST syndrome, 41 patients with suspected systemic scleroderma but who did not respond to the American rheumatism association (ARA) criteria, 35 cases of systemic lupus erythematosus, 8 cases of polymyositis, 40 cases of Raynaud's phenomenon and 48 controls. Anti-Scl-70 autoantibodies were found by immunodiffusion in 40 and by immunoblot in 45 cases of scleroderma with lesions proximal to the metacarpo-phalangeal joint (a major ARA criterion) and in 3 patients with suspected scleroderma but only one minor criterion: sclerodactyly. In systemic scleroderma with proximal lesions, the anti-Scl-70 autoantibody has a sensitivity of 0.85 and a specificity of 0.99. Anti-centromere autoantibodies were present in 39 cases of complete or incomplete CREST syndrome, 3 cases of Raynaud's phenomenon probably evolving towards a connective tissue disease and 1 case of systemic scleroderma with proximal lesions. The anti-Scl-70 and anti-centromere autoantibodies seem unable to coexist in the same patient and appear to be markers of two forms of scleroderma with different courses and prognoses. The Scl-70 antigen, which is the target of the anti-Scl-70 antibody, has been identified as topoisomerase 1, and a functional abnormality of this enzyme might contribute to some of the chromosomal abnormalities described in scleroderma.

Characteristics of clometacin-induced hepatitis with special reference to the presence of anti-actin cable antibodies

The clinical, biochemical, histopathological and immunological features of 30 cases of clometacin-induced hepatitis are described. The age range of the patients was 32-84 years with a notable female predominance of 29:1. The hepatitis was highly cytolytic with high values of transaminases but with little or no cholestasis. Gammaglobulins were higher than 18 g/l in 73% of the cases. 25 liver biopsies were performed and showed acute hepatitis with a predominant centrilobular necrosis in 17; chronic aggressive hepatitis was noted in 8 cases but 1 showed concomitant cirrhotic changes. Anti-tissue antibodies were looked for in all cases. Anti-smooth muscle antibodies of anti-actin cable type (titre 1/80 to 1/2, 560) were detected in 19 cases, anti-nucleus antibodies in 16 cases which were associated to the former in 14 cases. The above findings show that clometacin produces a hepatitis syndrome quite akin to autoimmune chronic active hepatitis (lupoid hepatitis) and to the hepatopathy induced by oxyphenisatin.

Antibody to liver cytosol (anti-LC1) in patients with autoimmune chronic active hepatitis type 2

A new autoantibody was detected by immunoprecipitation in the serum of 21 patients with chronic active hepatitis. The antibody reacted against a soluble cytosolic antigen in liver. The antibody was organ specific but not species specific and was therefore called anti-liver cytosol antibody Type 1 (anti-LC1). In seven of 21 cases, no other autoantibody was found; the remaining 14 cases had anti-liver/kidney microsome antibody Type 1 (anti-LKM1). With indirect immunofluorescence, a distinctive staining pattern was observed with the seven sera with anti-LC1 and without anti-LKM1. The antibody stained the cytoplasm of hepatocytes from four different animal species and spared the cellular layer around the central veins of mouse and rat liver that we have called juxtavenous hepatocytes. The immunofluorescence pattern disappeared after absorption of sera by a liver cytosol fraction. The 14 sera with both antibodies displayed anti-LC1 immunofluorescent pattern after absorption of anti-LKM1 by the liver microsomal fraction. The anti-LC1 was found in the serum only in patients with chronic active hepatitis of unknown cause. Anti-LC1 antibody was not found in sera from 100 patients with chronic active hepatitis associated with anti-actin antibody classic chronic active hepatitis Type 1, 100 patients with primary biliary cirrhosis, 157 patients with drug-induced hepatitis and a large number of patients with liver and nonliver diseases. This new antibody was considered a second marker of chronic active hepatitis associated with anti-LKM1 (anti-LKM1 chronic active hepatitis) or autoimmune chronic active hepatitis Type 2.

[The diagnostic value of anti-DNA antibodies depends on the technic used for their detection]

Three anti-native DNA antibody detecting assays were compared using sera from 948 patients with clinical symptoms of connective tissue disease and 55 definite systemic lupus erythematosus patients. The Farr assay was more effective than the two other assays in the diagnosis of lupus. Anti-DNA antibody detection by ELISA was as sensitive as the Farr assay; in contrast indirect immunofluorescence on Crithidia luciliae had a significantly lower sensitivity, detecting less than one out of two cases of lupus detected. Particularly ELISA but also indirect immunofluorescence may give positive results in the absence of lupus, so that results obtained by each of these assays must be confirmed by the Farr assay if they are used in the diagnosis of lupus. The significance of antibodies detected by one assay but not by the others is discussed.

[Hepatic function and significance of the increase in serum concentrations of IgA in alcoholic cirrhosis]

Elevated serum gammaglobulin concentrations are frequently observed in patients with liver cirrhosis. Predominant elevation of the IgA is generally considered as suggestive of an alcoholic aetiology. The aim of this study was to define the factors that determine the serum concentration of IgA in alcoholic cirrhosis. Twenty-seven patients with alcoholic cirrhosis were studied. Serum concentrations of IgG, IgA and IgM were measured by immunonephelometry. Hepatocellular function was assessed by the Child-Turcotte score, the prothrombin time and the intrinsic clearance of indocyanine green. The importance of intra-hepatic shunts was estimated according to the intact hepatocyte theory, and the degree of hepatic necrosis by serum levels of transaminases. It was noted that: 1) the IgA concentration correlated significantly with the Child-Turcotte score and with the decrease of the prothrombin time, intrinsic clearance and the functional fraction of hepatic blood flow; 2) there was no such correlation between the serum concentration of IgA and the total hepatic blood flow or transaminase levels; 3) there was no correlation between serum concentration of IgG or IgM and the factors studied. These results suggest that in alcoholic cirrhosis, increase in serum IgA, reflects the degree of impairment of hepatic function and intrahepatic shunting.

[Immunoallergic complication induced by rifampicin with disseminated intravascular coagulation]

In a 48-years old woman, intermittent rifampicin treatment induced an immunoallergic reaction with digestive disorders, haemolysis, acute renal failure and prolonged prothrombin time. The reintroduction of rifampicin, 17 days later, resulted in a similar, though more severe, reaction associated with diffuse haemorrhages from disseminated intravascular coagulation, this association being exceptional. The responsibility of rifampicin was demonstrated by the chronological relationship between clinical symptoms and administration of the drug, and by the presence in the patient's serum of anti-rifampicin antibodies. The antigen-antibody reaction with complement activation and haemolysis probably explains the disseminated intravascular coagulation.