Impaired response to high-dose interferon treatment in African-Americans with chronic hepatitis C

BACKGROUND/AIMS

The prevalence of hepatitis C virus infection in the USA is higher among African-Americans than among Caucasians. Despite this, little information is available on the course of hepatitis C virus infection in Blacks and in other minority groups. The aim of this retrospective case-control study was to determine the response rate to high dose interferon-alpha treatment in two racial groups with chronic hepatitis C virus infection.

METHODOLOGY

Thirty-one African-Americans and 62 Caucasians with chronic hepatitis C were considered in the study. The subjects were matched for gender, age, presence/absence of cirrhosis, histologic score, and viral genotype. All were treated with interferon-alpha (5 mU/day for 12 months). Three end-points (on-therapy, after 6 months of interferon-alpha, end-of-therapy, at the end of the 12 months of treatment, and off-therapy, 6 months after treatment) were chosen to describe the response to interferon-alpha treatment.

RESULTS

African-Americans had a significantly reduced response to interferon-alpha as compared to Caucasians at all end-points. At the on-therapy end-point, 26% of African-Americans were HCV-RNA negative and had normal transaminases level as compared to 60% of the Caucasians (P < 0.01); at the end-of-therapy end-point the rates were, respectively, 10% and 53% (P < 0.0001). No differences were detected in terms of pretreatment serum ALT, HCV-RNA, iron and ferritin levels or hepatic iron contents between the two groups.

CONCLUSIONS

African-Americans have a reduced response to high-dose interferon-alpha treatment as compared to Caucasians. Both environmental and genetic factors may be implicated in this impaired ability to clear hepatitis C virus infection.

The effect of high dose and short interval HBV vaccination in individuals with chronic hepatitis C

OBJECTIVES

The efficacy of the standard hepatitis B virus (HBV) vaccination schedule in individuals with chronic hepatitis C is reported to be reduced. Our aim was to assess the response rate to high dose, short interval HBV vaccination in such individuals.

METHODS

A total of 152 individuals with chronic hepatitis C were vaccinated with 40 microg of vaccine administered monthly for 3 months. Twenty-six individuals with no evidence of liver disease underwent the same vaccination schedule and were considered to be the control group. Hepatitis C virus (HCV)-positive subjects who did not seroconvert to anti-hepatitis B surface positivity after the third dose of the vaccine (nonresponder) were vaccinated with a fourth dose of vaccine (booster dose, 80 microg).

RESULTS

One hundred nine of the 152 individuals with chronic hepatitis C (72%) seroconverted to anti-hepatitis B surface positivity (> 10 mIU/ml), as compared to 24 of the 26 controls (92%, p < 0.05). Although individuals with chronic hepatitis C responded less frequently to high dose, short interval HBV vaccination than did the controls, no differences in terms of effective immunity (>100 mIU/ml) were evident among the two groups of responders (51% vs 54%). Also, no difference in response was reported between individuals with chronic active hepatitis C and controls (92% vs 80%). The response rate was significantly lower in cirrhotics than in the noncirrhotic group (54% vs 80%, p < 0.001). Besides cirrhosis, no other demographic or bioclinical factor was found to influence the response to vaccination. After the additional booster dose, the overall response was increased to 74% of the cirrhotics and 88% of the noncirrhotics. No major HBV vaccine-related adverse effects were seen.

CONCLUSIONS

A high dose, short interval HBV vaccination schedule is safe in individuals with chronic hepatitis C. From these data, it is suggested that a high dose and a short interval between HBV vaccinations may produce an effective and early antibody response in such patients.

The effect of high dose and short interval HBV vaccination in individuals with chronic hepatitis C

OBJECTIVES

The efficacy of the standard hepatitis B virus (HBV) vaccination schedule in individuals with chronic hepatitis C is reported to be reduced. Our aim was to assess the response rate to high dose, short interval HBV vaccination in such individuals.

METHODS

A total of 152 individuals with chronic hepatitis C were vaccinated with 40 microg of vaccine administered monthly for 3 months. Twenty-six individuals with no evidence of liver disease underwent the same vaccination schedule and were considered to be the control group. Hepatitis C virus (HCV)-positive subjects who did not seroconvert to anti-hepatitis B surface positivity after the third dose of the vaccine (nonresponder) were vaccinated with a fourth dose of vaccine (booster dose, 80 microg).

RESULTS

One hundred nine of the 152 individuals with chronic hepatitis C (72%) seroconverted to anti-hepatitis B surface positivity (> 10 mIU/ml), as compared to 24 of the 26 controls (92%, p < 0.05). Although individuals with chronic hepatitis C responded less frequently to high dose, short interval HBV vaccination than did the controls, no differences in terms of effective immunity (>100 mIU/ml) were evident among the two groups of responders (51% vs 54%). Also, no difference in response was reported between individuals with chronic active hepatitis C and controls (92% vs 80%). The response rate was significantly lower in cirrhotics than in the noncirrhotic group (54% vs 80%, p < 0.001). Besides cirrhosis, no other demographic or bioclinical factor was found to influence the response to vaccination. After the additional booster dose, the overall response was increased to 74% of the cirrhotics and 88% of the noncirrhotics. No major HBV vaccine-related adverse effects were seen.

CONCLUSIONS

A high dose, short interval HBV vaccination schedule is safe in individuals with chronic hepatitis C. From these data, it is suggested that a high dose and a short interval between HBV vaccinations may produce an effective and early antibody response in such patients.

Bronchoalveolar lavage fluid analysis in individuals with chronic hepatitis C

A number of disorders for which an association with hepatitis C virus infection exist. These disorders include essential mixed cryoglobulinemia, membranoproliferative glomerulonephritis, and idiopathic pulmonary fibrosis. This study was initiated to investigate the cellular content and lymphocyte subpopulations of bronchoalveolar lavage fluid obtained from individuals with chronic hepatitis C and to compare the results to those of controls. Eighteen patients with chronic hepatitis C (male/female, 6/12) and 14 healthy volunteers (male/female, 6/8), were studied. Bronchoalveolar lavage fluid was obtained from each; and the lymphocyte subtypes and the presence of HCV-RNA in the bronchoalveolar lavage fluid were determined. All anti-HCV positive subjects were HCV-RNA positive in serum. One (5.6%) had a HCV-RNA positive bronchoalveolar lavage. The total cell and neutrophil counts of the bronchoalveolar lavage fluid were significantly greater in patients with chronic hepatitis C as compared to controls (5,799.6 +/- 957.4 x 10(3)/ml vs. 1,835.7 +/- 447.8 x 10(3)/ml, P = 0.001; 1,175.8 +/- 634.7 x 10(3)/ml vs. 53.1 +/- 28.1 x 10(3)/ml, P = 0.029). In contrast, the lymphocyte, macrophage and eosinophil counts did not differ. No difference in the percentage, median or range of individual T cell subsets or B cell numbers in the bronchoalveolar lavage fluid existed between the groups. It is concluded that hepatitis C virus infection may be associated with an occult pulmonary inflammatory reaction manifested by an increased number of polymorphonuclear neutrophils in bronchoalveolar lavage fluid. This finding may contribute to the process that leads to idiopathic pulmonary fibrosis seen in a minority of cases of chronic hepatitis C.

Increased effective immunogenicity to high-dose and short-interval hepatitis B virus vaccination in individuals with chronic hepatitis without cirrhosis

Hepatitis B virus (HBV) vaccination is recommended for individuals with chronic liver disease. However, the response to standard doses of hepatitis B vaccines in such individuals has been poor. The aim of the present study was to assess the response to high-dose short-interval HBV vaccination in individuals with chronic liver disease of different aetiologies. A total two hundred and 24 subjects with chronic liver disease (138 chronic active hepatitis and 86 cirrhosis) and 26 healthy controls were vaccinated using a high-dose (40 microg) short-interval (monthly for 3 consecutive months) HBV vaccination schedule. One hundred and thirty-eight of the 224 subjects with chronic liver disease (62%) seroconverted to anti-HBs antibody positivity (>10 mIU/mL) after the third dose of vaccine as compared with 24 of the 26 controls (92%) (P < 0.01). The response rate was reduced in individuals with cirrhosis (36/86, 42%), particularly in alcohol-induced cirrhosis (2/17, 12%), as compared with individuals with chronic hepatitis (102/138, 74%) (P < 0.001). No significant HBV vaccination-related adverse effects were seen in individuals with or without cirrhosis as well as in the controls. High-dose short-interval HBV vaccination is safe and efficacious in individuals with chronic liver disease. The response to HBV vaccination is reduced in cirrhotics, particularly those with alcoholic cirrhosis. These data suggest that HBV vaccination should be accomplished early in an individual cause of chronic liver disease prior to the development of cirrhosis.

The impact of previous HBV infection on the course of chronic hepatitis C

OBJECTIVE

Individuals with chronic hepatitis C who are anti-HBc positive may carry an occult hepatitis B virus (HBV) infection that can affect their response to antiviral therapy.

METHODS

In this study the prevalence of anti-HBc and HBV-DNA positivity was assessed in the serum and liver of 285 HCV-RNA-positive subjects treated with interferon-alpha at 5 mU/day for 12 months. The response to interferon (normal ALT and undetectable serum HCV-RNA) was evaluated at three different endpoints: 1) after 6 months; 2) at the end of treatment; and 3) 6 months after interferon discontinuation.

RESULTS

Ninety individuals were anti-HBc positive (32%), 2 of these were HBV-DNA positive in serum and 7 in liver (8%). None of the anti-HBc-negative individuals was HBV-DNA positive in serum or liver. The prevalence of cirrhosis was greater in the anti-HBc-positive group than in the anti-HBc-negative group (p < 0.05), whereas HCV-RNA levels were lower. Anti-HBc-positive individuals had a lower response rate to interferon at 6 months and at the end of treatment as compared to anti-HBc-negative subjects (respectively 42% vs 66%, p < 0.01; and 32% vs 57%, p < 0.01). No difference between the two groups in terms of sustained response was detected 6 months after interferon discontinuation.

CONCLUSIONS

The prevalence of anti-HBc is high among HCV-positive individuals. HCV-positive individuals who are anti-HBc positive have: 1) a higher prevalence of cirrhosis; 2) lower HCV-RNA levels; and 3) an impaired ability to respond to interferon treatment.

Influence of sex hormonal status on alcohol-induced oxidative injury in male and female rat liver

BACKGROUND

Oxidative stress contributes to the development of liver injury after chronic alcohol intake. Women exhibit greater sensitivity to alcohol-induced liver disease than do men. The aim of the study was to determine the relationship between the sex hormone status of male and female rats and the degree of alcohol-induced oxidative stress in the liver.

METHODS

Male and female rats were pair-fed a liquid diet that contained 36% of their total daily calories as ethanol (EtOH group) or maltose (control group). Blood and liver samples were collected at the end of 8 weeks of diet.

RESULTS

Male EtOH rats experienced a reduction in plasma testosterone (T) and an increase in estradiol (E2) levels, with an increase in their calculated E2/T ratio with respect to their controls. Malonaldehyde (MDA) levels, an index of lipid peroxidation, and protein carbonyl content, an index of protein oxidation, in the liver were greater among the EtOH groups in females than in males. In males, an inverse correlation was found between hepatic MDA and circulating T levels, and a direct correlation was disclosed between MDA and estradiol levels. In addition, the hepatic histopathological score correlated inversely with the plasma T levels and directly with the calculated E2/T ratio, an index of feminization.

CONCLUSIONS

Alcohol-induced oxidative injury, which contributes to hepatic injury in both male and female rats, is enhanced in females compared with males. A role for plasma T levels in protecting male rat liver from ethanol-induced oxidative injury can be hypothesized.

Cirrhosis in Turner's syndrome: case report and literature review

A case of cryptogenic cirrhosis in a patient with Turner's syndrome is presented. The individual was admitted for upper gastrointestinal bleeding due to oesophageal varices. After failure of medical treatment, a transjugular intra-hepatic portal systemic shunt was used to control the bleeding. A liver biopsy revealed cirrhosis with minimal necro-inflammatory activity and no steatosis. Immunohistochemical staining for HCV, HBsAg and HBcAg was negative. No other risk factor for liver disease was recognized and none of the known causes of chronic liver disease was identified after a thorough evaluation for such. Turner's syndrome is a genetic disorder due to X chromosome monosomy in which a wide range of congenital anomalies can occur. Cardiac, renal and skeletal anomalies are all well recognized. The possible association of Turner's syndrome with cirrhosis is herein discussed along with a review of the published literature.

Hematopoietic stem cell transplantation from non-replicative hepatitis B virus carriers is safe

BACKGROUND/AIMS

Hepatitis B virus can cause serious problems in individuals undergoing organ transplantation. The aim of this study was to evaluate the hepatic events among HBs-Ag positive recipients and HBs-Ag negative recipients who received products from hepatitis B virus carriers.

METHODS

A total of 151 patients received an allogeneic hematopoietic stem cell transplantation at the Department of Hematology-Oncology, University of Ankara, between June 1989 and June 1998. Among these, eight HBs-Ag positive and four HBs-Ag negative recipients received a product from a hepatitis B virus positive donor. The median follow-up period for these 12 patients was 13.2 months.

RESULTS

Three of the eight HBs-Ag positive recipients died (one from hepatic failure); of the remainder, two are HBs-Ag negative, two HBs-Ag positive with normal liver injury tests and one HBs-Ag positive with elevated ALT levels. Of the four HBs-Ag negative recipients who received stem cells from a hepatitis B positive donor, two died; none of the patients in this group became HBs-Ag positive after transplantation.

CONCLUSION

Hepatitis B virus infection is a common problem in patients being considered for allogeneic hematopoetic stem cell transplantation, especially in areas where hepatitis B virus infection is endemic. We believe that the presence of HBs-Ag positivity is not an absolute contraindication for allogeneic hematopoetic stem cell transplantation unless the hepatitis B virus is in a replication phase.

Liver transplantation for chronic viral liver disease

Liver transplantation (LTx) for chronic viral liver disease has evolved rapidly during the last two decades. The major problem in cases of LTx for viral hepatitis is the extremely high rate of recurrent viral infection in the liver allograft. While recurrent hepatitis C virus (HCV) infection typically causes a mild hepatitis and has a slow progression, hepatitis B virus (HBV) infection of the liver allograft has been reported to result in cirrhosis in as short a period of time as 1 year. The risk of graft infection is greatest for patients with actively replicating virus. The high rate of disease recurrence, and the accelerated course of both HBV and HCV related liver disease post LTx, is a consequence of the high viral loads experienced by the allograft and the life-long immunosuppression required to prevent allograft rejection. Thus, efforts to clear virus prior to LTx, in order to prevent disease recurrence, are extremely important. In cases where this is not possible, the use of treatments directed at controlling or inhibiting recurrent disease in the allograft are essential. Hepatitis B immunoglobulin (HBIg) is an example of the latter, while the recent introduction of nucleoside analogues, molecules targeted at essential steps in viral replication such as lamivudine and famciclovir, are example of the former. The use of these two agents is likely to markedly change current approaches to transplantation for viral hepatitis.

Pathogenesis of hepatitis B and C-induced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is estimated to have an annual worldwide incidence of 0.25 to 1.2 million new cases per year. Both the prevalence and incidence of HCC vary markedly as a function of geography and the local prevalence of chronic viral hepatitis. Both chronic hepatitis B and chronic hepatitis C are recognized as risk factors for HCC. The prevalence of cirrhosis in individuals with HCC and chronic hepatitis B or C is reported to be 80.9% and 75.8%, respectively. HCC occurs at a lower rate in chronic viral hepatitis in the absence of cirrhosis. Moreover, hepatitis C virus (HCV) rather than hepatitis B virus (HBV) is associated with the majority of non-cirrhotic cases of HCC. It is probable that the ongoing process of hepatocyte necrosis and liver cell renewal coupled with inflammation, which is characteristic of chronic viral hepatitis, causes not only nodular regeneration and cirrhosis but also progressive genomic errors in hepatocytes as well as unregulated growth and repair mechanisms leading to hepatocyte dysplasia and, in some cases, hepatic carcinoma. Current concepts concerning virus-induced HCC are reported and discussed in the following review.

Immunosuppressive drug-induced leukoencephalopathy in patients with liver transplant

Organ transplantation has become a practical and effective option for patients with acute and/or chronic irreversible organ disease. However, solid organ transplantation is associated with many different complications which depend upon the specific surgical procedure and/or confounding medical problems (e.g. rejection, infection, adverse effect of immunosuppressive agents) experienced by a given patient. Tacrolimus and cyclosporin A are immunosuppressive drugs used to prevent rejection following allogeneic solid organ transplantation. Adverse events are common with both drugs and include long-term organ dysfunction, opportunistic infections, haematopoietic alterations, nephrotoxicity and neurotoxicity. Neurological complications, both central and peripheral, occur in 10-42% of transplant recipients using either of these two immunosuppressive agents. Two cases of reversible posterior leukoencephalopathy manifested by headache, nausea and seizures associated with the use of immunosuppressive drugs following liver transplantation are reported.

Interferon treatment of HCV positive cirrhotic patients

An estimated 3.5 million people in the United States have chronic hepatitis C. Each year, 8,000 to 10,000 of these chronically infected patients die of a liver-related complication of their infection. The introduction of effective blood screening assays has resulted in a remarkable decrease in the incidence of post-transfusion HCV infection. Nonetheless, hepatitis C remains an important clinical problem. Some important new treatment programs can help prevent the development and progression of compensated cirrhosis to either decompensated cirrhosis or HCC. Patients who present to the health care system with advanced chronic active hepatitis or cirrhosis have been treated with interferon. Of those studied, only IFN therapy has been shown to induce remissions of the hepatic inflammatory process and to eliminate viral infection in most treated cases. However, it is widely held assumption that cirrhotic individuals do not respond to IFN therapy and that the treatment of decompensated cirrhotic individuals with HCV infection is dangerous. We believe that this assumption is false. In many studies, cirrhotic patients with chronic hepatitis C have been shown to respond to IFN therapy. However, they do so at a rate of half that reported for individuals with non-cirrhotic chronic active hepatitis. There have been no reports of hepatic decompensation as a consequence of IFN treatment of cirrhotic individuals with chronic hepatitis C. The use of IFN for cirrhotic patients is reviewed.

Current and future therapies for HCV infection: what should the end point for treatment be?

Based upon all of the available data relating to the natural history, chemical course, and response to therapy of HCV, the following recommendations are made: 1) The primary end point for HCV therapy should be HCV clearance from all tissue sites, eg plasma, liver and others 2) Therapy should be provided for patients with early infections as they have the best chance of achieving a virologic response 3) Therapy should be offered to patients with cirrhotic disease, as prevention of hepatic decompensation and degeneration to hepatic cancer is possible 4) End stage decompensated disease should be treated, particularly if liver transplantation is being considered, in an effort to either eliminate or ameliorate disease recurrence 5) Combination therapies are preferable to monotherapy as they enhance the likelihood of a therapeutic response. Some of these include agents that reduce the frequency of IFN-induced untoward events (NSAIDs) 6) The approach to HCV infection should be to view it as an infectious disease. In this way, multi-agent therapy could be used to prevent the emergence of drug resistant mutants as well as to obtain earlier clearance of the infection than is possible with monotherapy.

Polymerase chain reaction for the detection of HCV-RNA: cryoglobulinaemia as a cause for false negative results

Polymerase chain reaction is widely used in clinical practice as a reliable assay for the detection and quantitation of hepatitis C virus RNA in serum and tissue. Due to the high sensitivity of the test, both false positive and false negative results can occur. The presence of cryoglobulins in serum samples represents a variable that can influence the result of a polymerase chain reaction assay leading to false negative results. In cases of hepatitis C virus infection associated with cryoglobulinaemia, it is extremely important to very carefully process the samples to be tested in order to avoid cryoglobulin precipitation and the consequent removal of the virus from the sample.

Interferon treatment of cirrhotic patients with chronic hepatitis C

Hepatitis C virus (HCV) infection is one of the more important infectious diseases yet to be conquered. An estimated 3.5 million people in the USA have chronic HCV. Each year, 8000 to 10000 of these chronically infected patients die of a liver-related complication of their infection. The introduction of effective blood screening assays has resulted in a remarkable decrease in the incidence of post-transfusion HCV infection. Nonetheless it is essential to have a treatment programme for chronic HCV disease that prevents the development and the progression of compensated cirrhosis to either decompensated cirrhosis or hepatocellular carcinoma, as many individuals present to the health care system with chronic active hepatitis or cirrhosis. A completely safe and effective treatment strategy for chronic HCV, with or without cirrhosis, remains to be developed. Of the various treatment alternatives currently available, only interferon (IFN) has been evaluated extensively. IFN therapy has been shown to induce remissions of the hepatic inflammatory process and also to eliminate the viral infection in some treated cases. As a result, the selection of patients for treatment and the dose and the duration of therapy with IFN are still controversial issues. It is widely held that cirrhotic individuals do not respond to IFN therapy and that treatment of decompensated cirrhotic individuals with HCV infection is dangerous. Here we review data regarding the available experience with IFN treatment of HCV-positive individuals with cirrhosis and compare the response rates of cirrhotics to those reported for individuals with chronic active HCV.

Hepatic osteodystrophy: a review

The physiopathology, diagnosis and treatment of hepatic osteodystrophy are discussed in this review. Hepatic osteodystrophy (HO) is a generic definition for the metabolic bone disease that may occur in individuals with chronic liver disease. Two distinct bone metabolic processes, osteoporosis (OP) and osteomalacia (OM) are combined together in various proportions in HO syndromes. The relative importance of these two diseases in a given case is quite variable. HO is a common complication among individuals with long time lasting hepatic disease, particularly those with cholestasis. Since advanced HO is difficult to treat and adversely affects both the quality of life and the long-term prognosis of patients with chronic liver disease, special care is required in order to prevent the development of clinical bone disease in individuals with advanced hepatic disease.

Successful medical treatment of an epithelioid hemangioendothelioma of liver

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of the liver of unknown etiology. Although HEH is usually characterized by a low grade malignancy and a good long-term prognosis, its growth can be progressive and lead to hepatic failure, extrahepatic metastasis and death. Several different antineoplastic agents have been proposed for cases of nonresectable HEH. We report the case of a 45-year-old man with HEH successfully treated with intravenous infusion of Adriamycin.