Psychosomatic aspects of liver transplantation

Forty patients received orthotopic liver transplants at Massachusetts General Hospital between May 21, 1983 and July 21, 1987 (mean follow-up: 64 weeks, range: 2-186 weeks). Twenty-seven patients (68%) were living as of July 21. Among survivors, 15 (56%) returned to full activity; and 7 (26%) were partially rehabilitated. Five patients were rehospitalized or recently transplanted. Successful outcome occurred most often among those who came to transplant early in the course of illness. All adults experienced preoperative anxiety and 17 (50%) of adults had some degree of hepatic encephalopathy. Following operation, 8 adults (24%) were referred for treatment of depressive disorder typically associated with deterioration of hepatic status, infectious complication or recurrence of cancer. Medical noncompliance required psychiatric intervention in 3 cases. Other psychiatric events an increasingly successful intervention of major scope and affords meaningful survival to many patients whose liver disease allow less than a year of life. Psychiatric consultation is an essential support to the transplant program.

Nonresponsiveness to hepatitis B vaccine in health care workers. Results of revaccination and genetic typings

Twenty-eight health care workers who had a poor antibody response when initially vaccinated with hepatitis B vaccine were revaccinated with three additional 20-microgram doses. Eight of the twenty nonresponders, who had levels of antibody to hepatitis B surface antigen (anti-HBs) of less than 8 estimated radioimmunoassay (RIA) units, and all 8 of the hyporesponders, who had anti-HBs levels of 8 or 16 RIA units, attained anti-HBs levels of 36 RIA units or more after revaccination. Tests for HLA-A, B, C, and DR; for complement proteins C2, C4A, C4B, and BF; and for the erythrocyte enzyme glyoxalase I were done in 17 nonresponders and 3 hyporesponders. Nine (45%) had HLA-DR7 and 8 (40%) had HLA-DR3, compared with an expected rate of 23% in the general population. At least one of two extended haplotypes (B44, DR7, FC31 or B8, DR3, SCO1) were detected in 6 of the 9 who did not respond to revaccination, compared with 2 of 11 who responded to a second course of vaccine. Poor responders to vaccine may benefit from revaccination, and genetic factors may modulate the immune response to vaccination.

Detection of hepatitis B virus X product using an open reading frame Escherichia coli expression vector

The genome of the hepatitis B virus (HBV) contains a sequence, designated X, capable of encoding a protein of 154 amino acids. To determine whether the putative protein synthesized from this region is antigenic, we examined the sera of HBV-infected patients for the ability to react with a hybrid protein that contained 133 amino acids encoded by the X region and portions of the bacterial ompF and beta-galactosidase genes. Some HBV-positive sera tested contained antibodies that specifically recognized the hybrid protein. All sera were from patients diagnosed as suffering from chronic active hepatitis. We conclude that the X region of HBV encodes a protein and that this protein is antigenic in some patients.

Non-A, non-B hepatitis: evolving epidemiologic and clinical perspective

Evidence for the existence of human hepatitis agents besides HAV and HBV is compelling. Transmitted predominantly by transfusion and percutaneous inoculation, the type of NANB hepatitis encountered most frequently is epidemiologically similar to type B hepatitis. NANB hepatitis accounts for more than 90% of TAH, but can be transmitted by nonpercutaneous routes as well. Approximately 15 to 30% of sporadic hepatitis cases are attributable by serologic exclusion to NANB hepatitis agents, and, in addition, there is an epidemic form of NANB hepatitis that resembles hepatitis A epidemiologically in its transmission by the enteric route. Clinical features of the predominantly percutaneously transmitted forms of NANB hepatitis are similar to those of hepatitis B, but tend to be less severe during acute illness, on the one hand, but to lead more frequently to chronic hepatitis, on the other; 40 to 60% of patients with TAH have chronic elevations of aminotransferase activity, often in an episodic, fluctuating pattern. CAH can be identified histologically in a majority of patients with chronic NANB TAH. Despite a relatively quiescent course, progression of such chronic cases may be quite insidious; cirrhosis occurs in 10 to 20% of patients with chronic hepatitis after acute TAH. The frequency of chronic liver disease after nonpercutaneously acquired sporadic NANB hepatitis tends to be lower, on the order of 10% or less, and chronic hepatitis has not been recorded after the epidemic type of NANB hepatitis. Evidence supports the existence of an asymptomatic chronic NANB hepatitis carrier state that is several-fold more frequent than the chronic HBV carrier state. Neither viruses nor virus markers have been described that fulfill accepted criteria reproducibly for a specific causal association with NANB hepatitis; on the other hand, evidence suggests (but does not prove) the existence of two different blood-borne NANB hepatitis agents and, in addition, an enterically transmitted NANB hepatitis agent. Effective therapy for and immunoprophylaxis against NANB hepatitis are lacking. Until specific screening tests are developed, interim screening based on indirect, nonvirus-specific tests may be the only practical approach to minimizing the frequency of NANB hepatitis after transfusion. Identification of virus-specific serologic markers remains a high priority.

Hepatitis in an adult with rubella

Rubella accompanied by serum aminotransferase elevations occurred in a 24-year-old woman. Although not generally recognized, hepatic involvement in adult rubella was the probable cause of her liver function test abnormalities. Sporadic hepatitis labeled as non-A, non-B may result from infection by common viruses such as rubella.

Absence of antibodies to HTLV-III in health workers after hepatitis B vaccination

A proportion of the plasma for the triply inactivated, plasma-derived hepatitis B vaccine produced in the United States is obtained from homosexual men. Because homosexual men are a high-risk group for the acquired immunodeficiency syndrome (AIDS), concern has emerged that the vaccine could harbor the AIDS agent. To evaluate this risk, we tested 15-month postvaccination serum samples for antibodies to human T-cell lymphotropic virus type III in 100 health care workers who had received inactivated hepatitis B vaccine lots made from plasma collected between 1977 and 1979 and 100 who had received placebo injections. None of the 200 health workers had serological evidence of human T-cell lymphotropic virus type III infection. These serological findings lend additional support to earlier epidemiologic and immunologic observations suggesting that hepatitis B vaccine does not transmit infection with an AIDS virus.

Revisiting the Holy Cross football team hepatitis outbreak (1969) by serological analysis

Clinical and biochemical data collected during the Holy Cross College football team hepatitis A outbreak in 1969 suggested that 32 team members had icteric hepatitis, 58 had anicteric illness, and only seven were not infected. Using a currently available radioimmunoassay, we tested stored serum samples obtained during the outbreak for IgM antibody to hepatitis A virus (IgM anti-HAV). Only individuals with icteric hepatitis were found to have IgM anti-HAV in serum; those with presumed anicteric illness were shown not to be infected with hepatitis A virus. The attack rate was thus only 34%, not 93% as originally reported, and the incidence of icteric illness in those infected was 100%, not 33%. This serological analysis of a classic outbreak of hepatitis A illustrates the utility and importance of IgM anti-HAV testing in seroepidemiologic investigations of hepatitis outbreaks.

Isolated antibody to hepatitis B surface antigen and response to hepatitis B vaccination

To determine the need for immunization of health workers with antibody to hepatitis B surface antigen (anti-HBs) as their only serologic marker of previous hepatitis B exposure, we studied the level, persistence, and immunologic specificity of isolated anti-HBs in 46 persons identified during screening for hepatitis B vaccine. We rescreened these persons 1 year later, administered a single dose of hepatitis B vaccine, and determined the anti-HBs level at 1, 2, and 8 weeks after vaccination. Isolated anti-HBs levels were low and antibody did not persist; 22 subjects tested had lost detectable anti-HBs within 19 months even though immunologic specificity was shown in vitro in 34. Anamnestic responses suggesting previous exposure and immunity were seen in only 10 subjects; 5 of these subjects had moderate-level, persistent anti-HBs. Although some persons with naturally acquired, isolated anti-HBs may be protected from hepatitis B, the immunologic specificity and protective value of anti-HBs, especially when levels are low, remain questionable.

Relapsing viral hepatitis type A

Three patients with a relapsing course of serologically confirmed viral hepatitis type A are presented. In addition, one patient had aminotransferase elevations for over 6 mo. In all three, hepatitis ultimately resolved. A relapsing or protracted course does not appear to alter the benign prognosis of hepatitis A.

Disease-specific amino acid infusion (F080) in hepatic encephalopathy: a prospective, randomized, double-blind, controlled trial

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.

Immunogenicity of hepatitis B vaccine in oncology patients receiving chemotherapy

We evaluated the immunogenicity and safety of three 40 micrograms doses of hepatitis B vaccine in oncology patients receiving chemotherapy. Of 76 patients screened for entry into the study, 13 (17%) already had been exposed to hepatitis B and were ineligible; 26 chose to join the study. The cumulative life-table response rate during the 12-month observation period was 70.8%; adequate immune response was linked to survival, 73% in survivors completing the study and 9% in nonsurvivors. Adverse effects were minor. We conclude that hepatitis B vaccine is safe and usually effective in inducing immunity in oncology patients younger than 60 years of age who are receiving chemotherapy.

Late-onset Wilson's disease with neurological involvement in the absence of Kayser-Fleischer rings

We report a patient with Wilson's disease whose case is unusual in two respects. First, the patient was 58 years of age when the diagnosis was made based on urinary, serum, and hepatic copper studies, as well as liver histological investigation. Second, despite the patient's neurological impairment, Kayser-Fleischer rings had not developed. We conclude that in patients with chronic, degenerative neurological disease, particularly when associated with hepatic dysfunction, the diagnosis of Wilson's disease should be considered regardless of age at onset or the absence of Kayser-Fleischer rings on slit lamp examination.

Immunogenicity of hepatitis B vaccine in renal transplant recipients

To evaluate the immunogenicity of hepatitis B vaccine in renal transplant recipients, we administered three 40-microgram doses of vaccine to 17 patients who had previously undergone transplantation and were on immunosuppressive therapy. Life-table analysis revealed a cumulative antibody response rate of only 17.6% at 12 months, and the three responders had low titers of antibody to hepatitis B surface antigen. There were no serious adverse effects and no episodes of graft rejection in responders or nonresponders. In addition, the ratio of helper/inducer (T4) to suppressor/cytotoxic (T8) T cells in vaccinees bore no relationship to the immunogenicity of the vaccine. These data indicate that hepatitis B vaccine is weakly immunogenic in renal transplant recipients and illustrate the need for vaccination prior to transplantation for maximal protection against hepatitis B virus infection.

Epidemiology and clinical impact of hepatitis D virus (delta) infection

We tested sera collected between 1976 and 1984 from 362 persons in a variety of epidemiologic categories with acute and chronic hepatitis B and from 76 hemophiliacs and drug addicts with hepatitis B antibodies for hepatitis D markers. Hepatitis D markers were common in hemophiliacs, drug addicts, Afghanistanis, prisoners and hemodialysis patients; rare in persons from other hepatitis-B endemic areas, persons with sporadic hepatitis B and homosexual men; and absent in health-care workers and institutionalized mentally retarded persons. No change was observed in the frequency of this infection during the 9 years of this study. We found hepatitis D markers in 5% of patients with acute hepatitis B, 1 of 3 with fulminant hepatitis and in 4 (1 in a homosexual male) of 12 episodes of acute hepatitis in hepatitis B carriers. Hepatitis D markers were more frequent in chronic liver disease (18%) than in asymptomatic hepatitis B carriage (2%), but there was no association between severity of chronic hepatitis and hepatitis D. These findings indicate that, to date, health-care workers and institutionalized mentally retarded persons have been spared from infection with this agent but suggest that homosexual males may not continue to be spared. Even in an area nonendemic for hepatitis D, this agent contributed to 20 to 30% of chronic hepatitis B and acute hepatitis superimposed on chronic hepatitis B infection.

Viral hepatitis vaccines

Purified from the plasma of hepatitis B carriers, hepatitis B surface antigen particles have been used in a vaccine to prevent hepatitis B. This plasma-derived vaccine is immunogenic, protective, and has an excellent safety record. Indications and strategies for preexposure and postexposure prophylaxis are reviewed. In addition, novel approaches to hepatitis B vaccine development are being pursued and will provide the basis for the next generation of vaccines. Early progress has also been made toward a hepatitis A vaccine, but clinical availability is not imminent.

Anaphylactic reaction and cardiopulmonary arrest following intravenous cyclosporine

Cyclosporine, a new immunosuppressive agent useful in recipients of a variety of organ transplants, has been associated with a number of adverse effects, most notably nephrotoxicity. This report describes a woman about to undergo liver transplantation in whom intravenous administration of cyclosporine was associated with an apparent anaphylactic reaction resulting in cardiopulmonary arrest. Similar reactions have thus far not been reported after oral administration of cyclosporine. Intravenous cyclosporine must be administered under close supervision and should be avoided in any patients with a history of prior allergic reactions to the drug or to a component of its intravenous formulation.

Should donor blood be screened for elevated alanine aminotransferase levels? A cost-effectiveness analysis

We examined the cost-effectiveness of alanine aminotransferase (ALT) screening of donor blood to prevent non-A, non-B posttransfusion hepatitis. Based on estimated costs of ALT screening, blood replacement, and medical evaluation of donors with high ALT levels, we concluded that screening at an ALT level of 45 IU would cost $3.82 per unit. In a population requiring an average of 3.7 units per transfusion, one case of hepatitis would be prevented for every 115 units screened, resulting in a cost of $439 per case prevented. With an estimated direct medical cost of $1,181 per case of non-A, non-B hepatitis, expected net savings for each case prevented would be $742. Screening at other ALT thresholds would be less cost-saving. Sensitivity analyses indicate that screening would be cost-saving for a wide range of cost estimates and number of units per transfusion. Alanine aminotransferase screening is warranted until more sensitive and specific screening tests for transmissibility of non-A, non-B hepatitis become available.

Hepatitis B vaccine in health care personnel: safety, immunogenicity, and indicators of efficacy

In a double-blind trial, we randomly assigned 1330 high-risk health care personnel to receive three 20-micrograms doses of hepatitis B vaccine or placebo. Among vaccine recipients 58% responded within 1 month and 97% within 9 months; there was no difference in immune response to the vaccine between men and women. Efficacy was evaluated after a mean follow-up of only 13.2 months, just before the vaccine was released commercially. Five hepatitis B infections were identified in placebo recipients and one in a vaccine recipient. Although the number of infections was too small to allow confident conclusions about protective efficacy of the vaccine, we saw a 67% reduction in the need for hepatitis B immune globulin after accidental hepatitis B inoculation in the vaccine group (relative risk, 5.08; 95% confidence intervals, 1.3 to 19.9). Minor side effects occurred with equal frequency after vaccine (28.7%) and placebo (27.2%) injections; no participant had a severe adverse reaction. Vaccination with the 20-micrograms hepatitis B vaccine was highly immunogenic and safe in health care workers.