Incidence and risk factors for hepatocellular carcinoma in 967 patients with cirrhosis

PURPOSE

To determine the incidence of hepatocellular carcinoma in cirrhosis and to examine the influence of age and sex, and the contribution of etiological factors.

METHODS

967 patients with liver cirrhosis and free of hepatocellular carcinoma were enrolled in this longitudinal, retrospective and observational study. Monitoring for hepatocellular carcinoma was scheduled at 3- to 6-month intervals. The mean (+/-SD) length of follow-up was 60.3+/-51.7 months (range 6 258).

RESULTS

During the observation period, hepatocellular carcinoma developed in 64 patients. The calculated annual incidence was 2.1%. The probability of being free of liver cancer was 92% at 5 years, 80% at 10 years, and 69% at 15 years. Age was the only independent risk factor for the development of malignancy in the multivariate analysis. There were no differences according to male sex, alcohol abuse, and chronic hepatitis B and C virus infection.

CONCLUSIONS

The annual incidence of hepatocellular carcinoma was 2.1%. These results, although confirming that age is a risk factor for hepatocellular carcinoma in cirrhosis, indicate that alcohol abuse, male sex, and concurrent hepatitis B and C virus infection do not involve a higher risk of developing liver cancer.

Influence of pretreatment lesions on histologic response to interferon therapy in chronic hepatitis C

We have assessed the predictive value of the grade of pretreatment liver lesions on histologic response to interferon therapy in patients with chronic hepatitis C. In 93 patients with chronic hepatitis C virus (HCV) infection who showed an initial response to interferon therapy, HCV RNA load and serum aminotransferase levels together with grade of liver histologic lesions were assessed at baseline and 6 months after treatment cessation. Regression of portal and periportal necroinflammation was observed only in sustained responders (normalization of aminotransferase levels and HCV RNA clearance). Neither short-term response nor the absence of virus was associated with significant histologic changes in the liver biopsies. Logistic regression analysis showed that pretreatment histologic lesion was an independent predictive factor of biologic response in the histologic regression of lesions 6 months after cessation of interferon treatment. In conclusion, a dense inflammatory necrotic activity is a positive predictor of histologic response in interferon-treated patients with HCV.

Prevalence and incidence of gallstones in liver cirrhosis

BACKGROUND

Our aim was to assess the prevalence and incidence of gallstone disease in patients with liver cirrhosis and to identify risk factors for cholecystolithiasis.

METHODS

We studied a cohort of 313 patients with liver cirrhosis confirmed by histology and/or laparoscopy and 357 patients free of liver disease, who had been referred for ultrasonographic examination of the upper abdomen. Hepatobiliary ultrasonography was performed when liver cirrhosis was diagnosed and every 6 months thereafter. Risk factors for cholelithiasis (age, gender, diet, pregnancy, diabetes, family history of cholelithiasis, etiology of cirrhosis, decompensated disease) were assessed.

RESULTS

The overall prevalence of gallstones in cirrhotic patients was 23.3%. In controls, the overall prevalence of cholecystolithiasis was 16.8%. After a median follow-up period of 65 months, 30 patients developed gallstones. The calculated annual incidence was 3.4%.

CONCLUSIONS

Given that the prevalence of gallstone disease is higher in cirrhotics than in noncirrhotic patients, cirrhosis of the liver may be considered a risk factor for cholecystolithiasis.

Clinical and morphological study of hepatocellular carcinoma associated with liver cirrhosis

We studied 104 patients diagnosed with hepatocellular carcinoma on the basis of pathological findings, in order to establish differences between patients with and without liver cirrhosis in addition to carcinoma. Among the former we also tried to identify differences between patients with previously diagnosed cirrhosis and those in whom cirrhosis was diagnosed at the same time as carcinoma. No significant differences were observed between patients in whom cirrhosis was diagnosed before or at the same time as carcinoma in relation to age, sex, etiologic factors or Child-Pugh grade. Differences were found with regard to motives for suspecting a tumor, frequency of splenomegaly, and platelet and leukocyte counts. No significant differences were found between patients with and without cirrhosis except in some laboratory findings (leukocytes, platelets, erythrocyte sedimentation rate and gammaglutamyl transpeptidase higher in the latter group, and alpha-fetoprotein higher in the former). There were no significant differences between cases of hepatocellular carcinoma that appeared as the first manifestation of liver cirrhosis and those that were diagnosed in patients with known cirrhosis. The clinical and biological differences between patients with and without cirrhosis can be explained by the associated chronic hepatic disease.

Maximal biliary transport of sulfobromophthalein in patients with a T-tube placed in the common bile duct

In 19 adult patients with choledocholithiasis who were operated on, excretion of free and conjugated sulfobromophthalein (BSP) in the bile collected through a T-tube inserted in the common bile duct was determined. The transport maximum (Tm) for BSP was calculated by the constant-infusion technique after an intravenous infusion of the dye at a rate of 0.3 and 0.09 mg/kg/min for the first and second hour, respectively. Free and conjugated BSP were measured in blood samples obtained at 30, 40, and 50 min of each hourly-infusion period, and in bile collected during the first 30 min (sample A) and between 30-50 min (sample B) after starting the first BSP infusion, and during the first 30 min (sample C) and between 30-50 min (sample D) after starting the second infusion. No correlations between Tm of BSP and glutathione transferase activity and between Tm and bilirubin and alkaline phosphatase in serum were found. Although there was an overall correlation between Tm of BSP and biliary excretion of BSP after 30 min of starting the BSP infusion (samples B, C and D) (r = 0.4716; P = 0.41), Tm values were always lower than recoveries of free BSP in bile. It seems that Tm of BSP (measured with the Wheeler's method) overestimates the actual values of biliary excretion of free BSP, and that the percentage of conjugated BSP in serum is related to the degree of impairment of biliary transport of BSP.

Plasma sulfobromophthalein disappearance in Gilbert's syndrome

BACKGROUND/AIMS

We studied the metabolism of sulfobromophthalein and its relationship with serum bilirubin levels in 40 patients with Gilbert's syndrome (type I 30; type II 6; type III 4).

MATERIAL AND METHODS

Plasma sulfobromophthalein disappearance studies were carried out and 72 hours later, serum bilirubin concentrations (total and unconjugated fraction) were determined at baseline and after 24 and 48 hours of dietary restriction to 400 calories/day.

RESULTS

The fractional transfer rate of sulfobromophthalein from plasma to liver was significantly higher in types I (14.7 +/- 3.4 ml/min) and II (14.9 +/- 2.7 ml/min) than in type III (8.7 +/- 1.5 ml/min). The fraction of the plasma sulfobromophthalein pool irreversibly cleared per min was significantly higher in type I (12.2 +/- 2.6 ml/min) than in types II (9.5 +/- 1.5 ml/min) and III (9.3 +/- 3.8). In all patients, serum bilirubin concentrations were significantly higher after fasting as compared with baseline. There was a significant correlation between the increments of serum unconjugated bilirubin levels after the fasting test and the transfer rate of sulfobromophthalein from plasma to liver (F = 9.8411, r = -0.4535, p = 0.003).

CONCLUSION

These findings indicate the presence of an active uptake system shared by bilirubin and sulfobromophthalein.

[Comparative study of the prevalence of hepatitis B virus infection and human immunodeficiency virus type 1 infection in the prison population between 1985 and 1992]

The prisoner population of the penitentiaries presents an elevated prevalence of hepatitis B virus (HBV) and human immunodeficiency type 1 (HIV-1) infection markers. In the last few years different measures have been developed to prevent infection. This study evaluates whether there have been changes in the prevalence of infection by these virus over the last few years within a penitentiary. A group of prisoners (n = 163) studied in 1985 were therefore compared with another group (n = 750) studied in 1992. Demographic, social, risk and penitentiary factors were included. In each of the subjects studied alanine aminotransferase (ALT), hepatitis B virus (HBsAG, antiHBs and antiHBc) and anti-HIV-1 markers were determined. It was globally observed that following the 7 years between the two studies there was a decrease in the prevalence of HBV (X = 14.63, p = 0.0001, OR = 2; CI 95%: 1.38-2.9), which was mainly observed in the group of prisoners with no drug addiction habits. No differences were observed with regard to the prevalence of anti-HIV-1 which remained similar among the IV drug consumers and not consumers (64% and 66.6% in 1985 and 1992, respectively). In conclusion, from 1985 to 1992 a decrease has been observed in the prevalence of hepatitis B virus infection in the penitentiary population while the prevalence of anti-HIV-1 has remained unchanged.

[The hepatitis C virus among the prison population of Valencia]

AIM

To know the prevalence of anti-VHC in the Valencia Male Penitentiary Centre.

DESIGN

A prospective study in which a representative sample of the inmates is included. In each case the anti-VHC and the ALT are studied. Serological results were correlated with history of intravenous drug addiction, alcohol abuse and duration and number of internments. INMATES: 750 inmates are included; they represent 41% of the people interned in this Centre during 1991.

RESULTS

A high prevalence (45%) of the serological marker for VHC infection was observed. The prevalence of anti-VHC+ among the drug addict inmates is around 90% and this situation was already found during the first year of drug addiction. Among non-drug addict inmates the prevalence is 14%. Hepatitis C virus infection has a correlation with the duration and number of internments; 75% of the inmates with high ALT values have anti-VHC+.

CONCLUSIONS

Nearly half of the inmates are infected with hepatitis C virus. The drug addict inmates are infected during the first year of their habit. The majority of the inmates with elevated ALT has anti-VHC+.

Effect of selenium compounds on murine B16 melanoma cells and pigmented cloned pB16 cells

The effects of selenium compounds such as sodium selenite, sodium selenate, seleno-DL-cystine and seleno-DL-methionine (100 microM and 10 microM) on B16 and pigmented cloned pB16 murine melanoma cells were investigated in vitro. At the tested concentrations, B16 cells showed a greater sensitivity to the toxic effects of sodium selenite and seleno-DL-cystine than pB16 cells, whereas no decrease of B16 and pB16 cell number was observed after incubation with sodium selenate or seleno-DL-methionine. Glutathione (GSH) percentages were strongly decreased only by selenite and seleno-DL-cystine; it was marked more in B16 than in pB16 cells. The pretreatment of B16 cells with a GSH depleting agent (10 microM buthionine-[S,R]-sulfoximine) did not significantly influence the cytotoxic effects of selenite and seleno-DL-cystine. On both cell populations, GSH preincubation (50 microM) enhanced the cytotoxicity of selenite whereas the survival of seleno-DL-cystine treated cells was increased. Glutathione peroxidase (GSH-Px) activity in B16 cells was more sensitive than in pB16 cells to the activating effect of selenite, and particularly of seleno-DL-cystine: however, cell-free controls indicated that activation was mainly due to glutathione reductase. The rate of 75Se (as sodium selenite) uptake in both cell populations was maximal within the first hour of incubation, with a preferential accumulation in the cytosol; after 24 h of incubation, the amount of 75Se in cytosol and pellet was approximately the same.(ABSTRACT TRUNCATED AT 250 WORDS)

Interferon decreases serum lipid peroxidation products of hepatitis C patients

Thiobarbituric acid reactive substances (TBARS) concentration in serum has been determined in healthy subjects and in patients suffering acute hepatitis and chronic cases of hepatitis C. Treatment with interferon of the chronic active hepatitis C patients, 5 x 10(6) U three times a week during 2 months, led in those patients whose SGPT activity normalized in serum, to a concomitant decrease in serum TBARS content. The possible theoretical involvement of peroxidation and antioxidants in this beneficial effect of interferon in hepatitis C patients is discussed. The results presented confirm the value of TBARS as laboratory test in the management of liver diseases and as a useful tool for the study of pathogenic and/or therapeutic mechanisms of this viral infection.

Crystal structure of adenylosuccinate synthetase from Escherichia coli. Evidence for convergent evolution of GTP-binding domains

The structure of the P2(1) crystal form of adenylosuccinate synthetase from Escherichia coli has been determined to a resolution of 2.8 A. The refined model for the enzyme gives an R factor of 0.20 and a root-mean-square deviation from expected bond lengths and angles of 0.016 A and 2.27 degrees, respectively. The dominant structural element of each monomer of the homodimer is a central beta-sheet of 10 strands. The first nine strands of the sheet are mutually parallel with right-handed crossover connections between the strands. The 10th strand is antiparallel with respect to the first nine strands. In addition, the enzyme has two antiparallel beta-sheets, comprised of two strands and three strands each, 11 alpha-helices and two short 3/10-helices. The overall fold of the polypeptide chain has not been observed heretofore in any other protein structure. Residues tentatively assigned to the active site of the enzyme on the basis of chemical modification and directed mutation cluster in two separate regions. Gly12, Gly15, Gly17, Lys18, Ile19, and Lys331 lie at one end of a crevice that measures 12 A by 30 A by 12 A deep. Lys140 and Arg147 are not part of this crevice, but instead lie at the interface between monomers of the dimer. Lys140 makes a salt link with Asp231 of a monomer related by molecular symmetry and Arg147 binds to the carbonyl of the same Asp231. Superposition of the p21 ras protein (Pai, E. F., Kabsch, W., Krengel, U., Holmes, K., John, J., and Wittinghofer, A. (1989) Nature 341, 209-214) onto the synthetase reveals significant correspondences between side chains of the two proteins. Residues which interact with GTP in the p21ras protein have structurally equivalent residues in the synthetase. The GTP molecule, when transformed to the coordinate frame of the synthetase, falls into the crevice defined by studies in directed mutation. We suggest that the similarities in the GTP-binding domains of the synthetase and the p21ras protein are an example of convergent evolution of two distinct families of GTP-binding proteins.

Chronic hepatitis and cirrhosis: evaluation by means of MR imaging with histologic correlation

To characterize the relationship between findings on magnetic resonance (MR) images and histologic changes in chronic liver disease, a prospective study was performed in 100 patients with chronic hepatitis and cirrhosis and 28 healthy subjects. Biopsy specimens, obtained in all patients before MR imaging, were evaluated with the histologic activity (HA) index; MR images were obtained with short inversion time inversion-recovery (STIR) and spin-echo sequences. On STIR images, normal livers were iso-intense to fat. Significant differences (P < .001) existed between signal intensity of normal livers and that of diseased livers, which were brighter than normal livers on STIR images. The ratio of signal intensity of liver to that of fat on STIR images was associated with an HA index grouped by severity (P < .05): Patients with higher HA scores had a brighter liver. Signal intensity ratios on MR images were statistically significantly associated with periportal and lobular necrosis and portal inflammation. The signal intensity of liver on STIR images is associated with the degree of histologic severity in patients with chronic liver disease.

Vanadium effect on the activity of horseradish peroxidase, catalase, glutathione peroxidase, and superoxide dismutase in vitro

The effect of vanadium (V) on the activity of horseradish peroxidase, catalase, glutathione peroxidase, and superoxide dismutase has been studied. A competitive inhibition pattern was evident for vanadate ions on the activity of horseradish peroxidase (Ki = 41.2 microM). No significant inhibitory effects were found when V(V) was tested with catalase and when either V(IV) or V(V) were assayed with glutathione peroxidase. For the latter, the effect of V on the different components of the reaction system was investigated. V(V) did not significantly affect SOD activity when assayed with the sulfite method, which is devoid of interferences with V(V); however, there was an apparent inhibitory dose-response pattern for either V(IV) or V(V) using the pyrogallol assay, owing to an interference of pyrogallol with the metal. Besides, no significant binding of V(IV) or V(V) to the enzyme could be demonstrated. The lack of a direct inhibitory effect of V on the activity of the main antioxidant enzymes suggests that many biological and toxicological effects of V may be mediated more by oxidative reactions of the metal or of its complexes with physiologically relevant biomolecules than by a direct modulation of enzymatic activities.

Immune response to hepatitis B vaccine in parenteral drug abusers

Responsiveness was assessed to a programme of vaccination of hepatitis B vaccine in a cohort of 197 intravenous drug addicts (mean age, 23.7 years) and their antibody response was compared with that of 271 healthy controls (mean age, 24.2 years). All participants were seronegative for hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs). The vaccination schedule consisted of three intramuscular injections (deltoid area) at months 0, 1 and 2. Although 70% of parenteral drug abusers received the three doses of vaccination, only 43.6% were evaluable for immune response. Fifty-eight per cent of heroin addicts and 80% of controls had evidence of anti-HBs seroconversion at 1 month after vaccination (chi 2 = 15.52, p less than 0.001). Geometric mean antibody titres were also significantly higher in controls (69.1 IU l-1; confidence interval 95%, 56.83 and 84.04) than in parenteral drug abusers (18.2 IU l-1; confidence interval 95%, 12.85 and 25.73) (F = 20.951, p less than 0.0001). The anti-HBs response was not influenced by coexistent anti-HBc, HCV antibody or HIV antibody seropositivity.

[A meta-analysis of controlled studies of the treatment of chronic hepatitis due to the hepatitis B virus]

BACKGROUND

Since the results obtained in controlled studies of antiviral treatment of chronic hepatitis by the hepatitis B virus are frequently insignificant the authors have undertaken a combined study of the different controlled trials with the meta-analysis technique.

METHODS

The results of 7 controlled trials of treatment with adenosin arabinoside (AAR) and 18 published studies on therapy of a control group with interferon were studied. Meta-analysis was performed by two methods: Mantel expressing the results in odds ratio (OR) and Cochram-Dersimonian-Laird which consider the results in differences of risk (RD).

RESULTS

The meta-analysis of AAR treatment shows a mean difference of response of 11% with no homogeneity among the different studies published. This lack of homogeneity may be due to the different selection criteria of the patients which determine very variable degrees of response. The controlled studies with interferon showed a mean difference of response of 20% with homogeneity of effects. No differences were observed in the degrees of response according to whether recombinant lymphoblastoid interferon was used or if the dose was of 5 or 10 megaunits per day. Non were differences observed in degrees of response with respect to the time in which the loss of viral DNA was evaluated.

CONCLUSIONS

Following analysis of the results it was concluded that interferon is clearly effective in the treatment of chronic hepatitis B and based on published studies adenosin arabinoside demonstrate less efficacy.

Aluminum effect on the activity of superoxide dismutase and of other antioxygenic enzymes in vitro

The effect of Al on superoxide dismutase (SOD) and on other antioxygenic enzymes: horseradish peroxidase, catalase, and glutathione peroxidase, has been investigated in vitro. In the case of SOD, the effect of metal chelators (EDTA and deferoxamine) and a possible synergistic effect with iron salts have also been tested using the pyrogallol assay. There is no significant inhibitory effect of Al on the activity of any of the above-mentioned enzymes. Noticeable increases in SOD activity were observed when metal chelators were added to the medium, but not when high concentrations of Al were present too, in the case of deferoxamine (DFO). The former fact seems to be a consequence of the chelation of transition metal ions that catalyze pyrogallol autoxidation by a mechanism not inhibitable by SOD, interfering in its action, which may account for part of the DFO antioxidant effect observed in vivo. The latter phenomenon could be owing to a saturation of the chelating capacity of DFO by an excess of Al present in the medium, which should bring the system back to the interfering conditions explained above. It can be concluded that Al, either in the presence or in the absence of iron salts, does not inhibit SOD activity in vitro. Moreover, no significant binding of Al to SOD was demonstrated, and the amounts of its metal constituents, Cu and Zn, were not affected by preincubation of the enzyme with Al. The effect of the different compounds tested on the rate of autoxidation of the indicating scavenger, pyrogallol, and a suitable hypothesis on their role in the oxidation process are also discussed.

[Recurrent benign intrahepatic cholestasis. A case report]

A case of benign and recurrent intrahepatic cholestasis in a 46 year old female is presented. This patient, who correctly coincided with the diagnosis criteria, had 2 episodes of jaundice and pruritus over a period of 4 years. The diagnosis criteria, clinical features, blood tests, etiopathogenesis and treatment are reviewed.

[Hepatic activity of glutathione transferase and bromsulphalein metabolism]

The gluthatione transferase activity has been studied in liver biopsies from patients suffering with different hepatic lesion and related to the bromsulphalein (BSP) maximal transport (MT) and the conjugated dye present in serum. Results prove that the MT of BSP is independent of the enzyme activity, but is correlated to the conjugated BSP present in serum during the first perfusion. The enzyme activity, the MT of BSP and BSP conjugated rare in serum are not related to the liver lesion stage. From the analysis of our results we conclude that in the beginning the BSP conjugated proportion is determined by the enzyme activity which is not a restrictive factor of the BSP maximal transport.

[Epidemiologic observations on the subject of phlebopathy of the legs and its dermatologic complications]

The authors carried out an epidemiological study on a group of 10032 patients with chronic venous insufficiency, composed of 2686 males (26.77%) and 7346 females (73.23%). The case report is divided into varicose diseases (83.30%) and sequelae of deep vein thrombosis (16.70%). As well as the relationship between sex and age is considered rate of dermatological complications, with regard both to the type of venous diseases (65.54% varicose and 34.46% post-thrombotic) and to their clinical manifestations. As well as any family connection, various environmental factors are taken into account such as the patient's work, noxae iatrogenic, pregnancy and obesity.

[A comparative study of the oral and rectal ammonium overload test in liver cirrhosis]

The ammonium loading test has been realized in 66 patients, 8 of them without clinical or laboratory data of hepatic disease and 58 diagnosed of hepatic cirrhosis (HC). In 40 patients with HC and 8 patients without liver disease the ammonium was administered by rectum and in the remaining 18 patients with HC it was administrated orally. In each case, non stagnant venous blood was drawn at 0, 30, 45, 60 and 75 minutes after the administration of ammonium and plasmatic levels were measured. The results show that in patients with HC there are no significant differences between rectal and oral administration although the rectal way presented less secondary effects and is better tolerated. The test is discriminatory when comparing patients with HC and patients without liver disease as well as between patients with HC and portal hypertension and those without clinical signs of portal hypertension.

Prevalence of liver disease and infection by hepatitis B, delta virus, and human immunodeficiency virus in two Spanish penitentiaries

We studied the prevalence of liver disease and the carrier state for hepatitis B (HBV), delta virus (HDV) and HIV-1 infection in two Valencian penitentiaries, one for males and the other for females. Serological results were correlated with history of intravenous drug addiction, alcohol abuse, homosexuality or prostitution (high-risk groups), and duration and number of internments. A high prevalence of increased transaminase levels (52.2%) and serological markers for HBV infection (66.5%) was observed amongst the inmates, figures being higher amongst high-risk individuals and inmates confined for more than 6 months. No signs of HDV or HIV-1 infection were found amongst the prison staff. Anti-HIV-1 positivity was observed most frequently amongst individuals combining both drug abuse and homosexuality/and prostitution.

Effect of L-carnitine upon ammonia tolerance test in cirrhotic patients

In a group of liver cirrhosis (LC) patients subjected to a rectal ammonium overload test, the effect of L-carnitine on ammoniemia and on the type A numerical connection and star clock psychomotor tests has been evaluated. On comparing 40 LC patients given L-carnitine with 40 control cirrhotics given a placebo, no significant differences were observed in ammonium levels after performing the overload test in both groups. However, on studying the patients with the greatest liver involvement, those given L-carnitine showed smaller elevations in ammoniemia and better responses to the psychometric tests than those receiving the placebo. The results obtained emphasize the need to continue testing the effect of L-carnitine using either similar tests or carrying out long-term evaluations to determine its protective effect in the appearance of hepatic encephalopathy, perhaps even including its evaluation in the treatment of established encephalopathy.

Kinetic analysis of the carboxypeptidase A hydrolysis of oligopeptides by reversed-phase high-performance liquid chromatography

A reversed-phase high-performance liquid chromatographic (HPLC)-based method was developed to follow the time course of the hydrolytic action of pancreatic carboxypeptidase A on oligopeptide substrates of the general formula benzoyl(glycyl)n-L-Phe, n being in the range 1-5. The proposed procedure is sensitive at the nanomolar level of substrate, but also allows the kinetics of substrate hydrolysis to be investigated over a wide range of concentrations. The prior quenching of the carboxypeptidase activity and the use of isocratic conditions for the rapid separation of the substrates and their products (in less than 8 min for the slowest one), allow the automation of the procedure, which could become an easy and versatile alternative to the commonly used spectrophotometric methods. A comparative evaluation of the use of a spectrophotometric method to measure carboxypeptidase A activity on the same substrates indicated that the latter is not valid for long oligopeptides (n greater than or equal to 2) at concentrations higher than 5 mM owing to an interference of a physico-chemical nature. For benzoylglycyl-L-Phe (n = 1), the apparent kinetic parameters were calculated by means of the HPLC method and by a well established spectrophotometric procedure, and both yielded similar values.