Drug effects on the liver. An updated tabular compilation of drugs and drug-related hepatic diseases

Generic and chemical names of drugs and the possible adverse effects of these drugs on the human liver are tabulated. Most drugs compiled in these tables have been approved by the Federal Drug Administration. They are currently available in the United States, and they are listed in the 1983 Physicians' Desk Reference. Some important investigational drugs are listed also. The tables include: (1) generic names of drugs that have caused a characteristic morphologic change, such as granulomatous hepatitis; (2) morphologic diagnoses that have been documented after administration of each drug; and (3) references that can be matched to each drug and to its effects on the liver.

Diethylstilbestrol-induced jaundice in the Chinese and Armenian hamster

An unusual and impressive hyperbilirubinemia was induced in Chinese hamsters by administration of diethylstilbestrol (DES). This icterus was dose-dependent and affected females more severely than males. However, a similar mortality was detected in both sexes. Another hamster, the Armenian hamster, was even more susceptible to the icteric and lethal effects of DES. The hamster model of DES-induced icterus showed many clinical dissimilarities when compared to the human estrogen-induced jaundice, simple cholestatic jaundice. Furthermore, hepatic pathology was distinctly different as canalicular cholestatic was absent although other degenerative and regenerative hepatocellular changes were present. Livers of Armenian hamsters were more severely affected than were livers from Chinese hamsters and contained Mallory bodies even within 1 week after DES treatment. A modest, nonlethal jaundice also was detected in European hamsters after DES injection, whereas Syrian hamsters were not affected even after larger doses. This unique sensitivity to DES, and the spectrum of sensitivity within these related hamsters (Armenian greater than Chinese greater than European vs. resistant Syrian) provide an interesting model for study of DES effect on hepatic function.

Should homosexuals be vaccinated against hepatitis B virus? Cost and benefit assessment

The recent introduction of a vaccine against hepatitis B has raised the questions of who should be offered it and what the cost would be of a vaccination programme. An analysis was performed of the financial costs and benefits of such a programme designed to prevent acute hepatitis B in male homosexuals in the United Kingdom. Under various assumptions the total costs of screening and vaccination ranged from 2.2m pounds to 3m pounds for a five year programme and from 3.3m pounds to 4.8m pounds for a 10 year programme. The benefits over the same two periods for the programme, depending on two different assumptions of mortality prevented, ranged 3.9m pounds to 13.7m pounds and from 7m pounds to 24.4m pounds. Thus considerable savings may be made to the national economy by offering vaccination to homosexuals. These savings are obtained after consideration of only the acute aspects of hepatitis B. Had it been possible to determine the costs of the chronic sequelae of this disease the savings, compared with the costs, would have been greatly increased.

Cholic acid amelioration of light and electron microscopic hepatic lesions in experimental protoporphyria

We studied the effects of cholic acid treatment on hepatic histology and ultrastructure in mice with griseofulvin-induced protoporphyria. After 5 weeks of feeding griseofulvin alone, control mice developed darkly pigmented livers which by light microscopy showed birefringent, brown pigment deposits in bile ducts and ductules, sinusoidal Kupffer cell aggregates, and occasionally in hepatocytes and bile canaliculi. Electron microscopy demonstrated aggregated protoporphyrin crystals at these sites as well as membrane blebs and reduction of microvilli in bile canaliculi. In contrast, experimental mice that were concomitantly fed cholic acid and griseofulvin developed no detectable pigment on light microscopy, only rare protoporphyrin crystals on electron microscopy and minimal bile canalicular abnormalities. This study suggests that protoporphyrin transport into bile is enhanced by cholic acid treatment and results in a significant reduction in hepatic protoporphyrin deposition and associated abnormalities of liver morphology.

Natural history of hepatitis B virus infection in renal transplant recipients--a fifteen-year follow-up

Hepatitis B virus (HBV) markers were measured in 83 immunosuppressed renal transplant patients who were followed for periods of 2 to 15 years. Sixty-nine patients were negative for HBsAg before transplantation, of whom 14 were positive for anti-HBs. The remaining 14 patients were HBsAg positive prior to transplantation. Eighteen patients were identified as being HBsAg positive during the follow-up period. Four patients acquired primary type B hepatitis; one died of submassive hepatic necrosis and the remaining three became chronic HBV carriers with positive HBeAg, DNA polymerase, and HBV DNA. Several patterns of HBV expression were observed in HBsAg-positive patients. Four patients were HBsAg, HBeAg, DNA polymerase, and HBV DNA positive prior to transplantation, and these markers persisted. Reactivation of HBV replication occurred in eight patients, seven of whom were HBsAg positive and HBeAg and anti-HBe negative originally; one patient was anti-HBc positive. A single patient was HBsAg and anti-HBe positive and remained so for 22 months. The remaining previously HBsAg-positive patient is currently HBsAg negative. These serological data suggest that reactivation of HBV replication or continued hepatitis B virion replication occurs as commonly or more commonly than de novo infection in renal transplant recipients. The presence of HBeAg in serum predisposes to long-term Dane particle expression in immunosuppressed patients, whereas anti-HBe-positive carriers may not always be susceptible to reactivation of HBV replication despite immunosuppression.

Kinetic and electrophoretic properties of native and recombined isoenzymes of human liver alcohol dehydrogenase

Ten, electrophoretically distinct, molecular forms of alcohol dehydrogenase have been isolated from a single human liver by affinity and ion-exchange chromatography. The starch gel electrophoresis patterns after the dissociation-recombination of the forms are consistent with the hypothesis that they arise from the random combination of alpha, beta 1, gamma 1, and gamma 2 subunits into six heterodimeric and four homodimeric isoenzymes. Large differences in kinetic properties are observed for the homodimeric isoenzymes, alpha alpha, beta 1 beta 1, gamma 1 gamma 1, and gamma 2 gamma 2. At pH 7.5, the Km value of beta 1 beta 1 for ethanol is 0.049 mM and that of alpha alpha is 4.2 mM. Forms gamma 1 gamma 1 and gamma 2 gamma 2 do not obey Michaelis-Menten kinetics at pH 7.5 but exhibit negative cooperativity with Hill coefficients of 0.54 and 0.55 and [S]0.5 values of 1.0 and 0.63 mM, respectively. However, all isoenzymes display Michaelis-Menten kinetics for ethanol oxidation at pH 10.0 with Km values ranging from 1.5 to 3.2 mM. The maximum specific activity of beta 1 beta 1 is considerably lower than that of the other three homodimers at both pH 7.5 and 10.0. The Km values of the four homodimers for NAD+ at pH 7.5 range from 7.4 to 13 microM and those for NADH, from 6.4 to 33 microM. Ki values for NADH range from 0.19 to 1.6 microM. At pH 7.5, the kinetic properties of alpha alpha and beta 1 beta 1, prepared in vitro from dissociated and recombined alpha beta 1, are similar to those of the native homodimers. The forms gamma 1 gamma 1 and gamma 2 gamma 2, prepared from dissociated and recombined alpha gamma 1 and beta 1 gamma 2, respectively, exhibit negative cooperativity with Hill coefficients that are similar to those seen with the respective native homodimers.

Randomised, controlled study of transhepatic obliteration of varices and oesophageal stapling transection in uncontrolled variceal haemorrhage

Percutaneous transhepatic obliteration and surgical stapling transection of the oesophagus with the EEA gun were compared prospectively in the treatment of uncontrolled oesophageal variceal haemorrhage unresponsive to conservative measures. Twenty patients with cirrhosis, with a patient portal vein and who were considered suitable for general anaesthesia and surgery, were randomised to two treatment groups (10 patients each). Immediate arrest of haemorrhage was achieved in 17 patients (nine surgery, eight obliteration). In one other patient, stapling transection succeeded where attempted transhepatic obliteration failed, and in another patient obliteration succeeded where attempted transection had failed. One patient continued to bleed and died following attempts at both procedures. Two other patients also died in hospital, without rebleeding following surgery. Variceal rebleeding during the same hospital admission occurred in two patients in the obliteration group and in none after surgery. Oesophageal stapling transection compares very favourably with a non-surgical technique such as transhepatic obliteration of varices in the emergency treatment of uncontrolled variceal haemorrhage in patients with moderate liver failure.

Collagen formation by the hepatocyte in primary monolayer culture and in vivo

Immunohistochemical techniques were used to confirm biochemical evidence that parenchymal cells isolated from adult rat liver and maintained in nonreplicating monolayer culture for 2 days synthesized type IV basement membrane collagen. On continued incubation in serum-free medium, the hepatocytes also synthesized the interstitial collagens, types I and III. Consistent with these results in culture, type IV collagen was localized to the hepatocytes in slices of pathologic rat liver. Hence collagen formation is a previously unrecognized function of the hepatocyte that may be important in the pathogenesis of liver fibrosis or cirrhosis.

Pathology of hepatocellular carcinoma in Japan. 232 Consecutive cases autopsied in ten years

The pathologic findings of 232 consecutive cases of hepatocellular carcinoma (HCC) autopsied during the past ten years at Kurume, Japan, were analyzed from the point of view of global epidemiology, in relation to clinical feature, and in regard to incidence, age, sex, etiologic factors, size of liver, changes in noncancer parenchyma, gross type of tumor, extrahepatic metastases, intravascular and intraductal growths, cancer cell histology, hepatitis B surface antigen (HBsAg) in hepatocytes and cancer cells, liver cell dysplasia, and frequency and clinicopathologic characteristics of minute HCC. Furthermore, postmortem hepatic arteriography and portography were done in 152 livers for comparison with gross anatomy and celiac angiograms. It was found that: (1) epidemiologically, HCC in Japan is distinct from that in the West that it is frequently encapsulated, livers are generally small because of frequent and advanced cirrhosis and small cancer, minute HCC, is not uncommon at autopsy, cirrhosis most commonly associated is the one with thin stroma and medium size nodules, and micronodular cirrhosis is very rare despite frequent alcohol abuse; (2) HCC is increasing in incidence; (3) HBsAg is frequently found in parenchyma; (4) liver cell dysplasia is indirectly related to HBsAg with no evidence for premalignancy; (5) the lung is the most frequent site of metastasis but peritoneal dissemination is unusual; (6) intraportal tumor growth is very common and the hepatic vein is less frequently affected; (7) growth in the major bile duct is frequently associated with intraportal growth and clinically presents as obstructive jaundice; and (8) tumor is supplied solely by arteries and celiac arteriograms are closely correlated with gross pathologic findings.

Hepatic reactions to cyclofenil

Thirty patients with hepatic reactions to cyclofenil, a non-steroidal drug with a stimulating effect on ovulation, are reviewed. The liver damage was probably related to metabolic idiosyncrasy, and was reversible in all patients.

Decreased activity of uroporphyrinogen decarboxylase caused by 2,4,5,3',4'-pentabromobiphenyl in chick embryo hepatocyte cultures. Difference in activity in intact or homogenized cells

Uroporphyrinogen decarboxylase activity was investigated in cultures of chick embryo liver by two different methods: (1) analysis of porphyrin composition following incubation of intact cells with delta-aminolevulinic acid; and (2) a more conventional direct enzymic assay of cell homogenates. Activity was detectibly decreased following exposure of cells to 100 ng/ml 2,4,5,3',4'-pentabromobiphenyl using the first method, but not the second. This decrease in activity was reversed by homogenizing the cells treated with 100 ng/ml pentabromobiphenyl. It is concluded that the direct homogenate assay of the enzyme may miss or underestimate decreases in its in vivo activity.

Relationship between kinetics of liver alcohol dehydrogenase and alcohol metabolism

Since alcohol dehydrogenase (ADH) catalyzes the rate-limiting step for ethanol metabolism, knowledge of the steady-state kinetics of ADH in liver is fundamental to the understanding of the pharmacokinetics of ethanol elimination. Accordingly, we have determined the kinetic properties of purified ADH isoenzymes in rat and human liver. At low ethanol concentrations, rat liver ADH obeys the Theorell-Chance mechanism and the equation predicts that activity in vivo is limited below Vmax mainly by NADH inhibition. At ethanol concentrations above 10 mM, substrate inhibition, consistent with the formation a dead-end ADH-NADH-ethanol complex, also becomes a rate-limiting factor. ADH activity, calculated from this equation and the concentrations of substrates and products present in liver during ethanol oxidation, agrees well with ethanol elimination rates measured in vivo. With human liver ADH, large differences are observed in the kinetic properties of 5 homodimeric isoenzymes: gamma 1 gamma 1 and gamma 2 gamma 2 exhibit negative cooperativity for ethanol saturation, while alpha alpha, beta 1 beta 1 and beta ind beta ind obey Michaelis-Menten kinetics. At pH 7.5, Km values for ethanol and Vmax values range 0.048 mM and 9 min-1 for beta 1 beta 1 to 64 mM and 560 min-1 for beta ind beta ind, respectively. Therefore, individuals with different ADH phenotypes should display different ethanol elimination profiles.

Relationship of pretransplant hepatobiliary disease to bile duct damage occurring in the liver allograft

Histopathological features of nonsuppurative destructive cholangitis have been described in primary biliary cirrhosis, chronic graft-vs-host disease, and chronic rejection of human liver allografts. To determine whether or not susceptibility to injury of interlobular bile ducts was related to the original hepatobiliary disease requiring transplantation, we compared the histopathology of allografts transplanted into two groups of patients. The first group consisted of patients whose original hepatobiliary diseases primarily affect bile ducts: primary biliary cirrhosis, sclerosing cholangitis, and biliary atresia. The second group consisted of patients whose original hepatobiliary diseases do not result in injury to interlobular bile ducts. In 32 liver allografts studied histopathologically, the original disease did not recur. Interlobular bile duct damage occurred, however, in 17 of the 32 and resembled that seen in primary biliary cirrhosis. The spectrum of bile duct injury included mononuclear inflammation of the bile duct epithelium, destruction of the bile duct epithelium, and dissolution of the bile duct. There was no relationship between the frequency or severity of bile duct damage and original hepatobiliary disease, age, sex, duration of allograft survival, or cause of death. We conclude that nonsuppurative destructive cholangitis occurs frequently in liver allografts and represents one component of allograft rejection. This lesion resembles, in many respects, that seen in primary biliary cirrhosis so that histopathological differentiation may be difficult.

Hepatitis B immune complex glomerulonephritis: simultaneous glomerular deposition of hepatitis B surface and e antigens

A case of a 29-year-old homosexual male with chronic hepatitis B infection, cryoglobulinemia, and glomerulonephritis is described. The glomerular lesions were not readily classified, but exhibited features consistent with immune complex deposits, in both peripheral loop (predominantly epimembranous) and mesangial sites. Immunofluorescence studies, which included the use of a monoclonal antibody, showed that HBsAg was present in mesangial deposits but not in peripheral loop deposits. Immunoperoxidase studies employing HRP-conjugated anti-HBc and anti-HBe provided evidence that the epimembranous deposits contained HBe. Studies of the patient's serum revealed high titers of HBsAg, low titers of HBeAg, as well as anti-HBe and anti-HBc. The cryoglobulins contained small amounts of HBsAg, HBeAg, and anti-HBc, but anti-HBe and anti-HBs antibodies were not found. The possible mechanisms accounting for accumulation of HBsAg and HBeAg in glomeruli are discussed. In addition, the literature concerning the nature of hepatitis B antigens found in glomerular deposits is reviewed.

Ultrastructure of alcoholic hyaline filaments in alcoholic hepatitis

Ultrastructure of alcoholic hyaline (AH) in alcoholic hepatitis was observed to demonstrate the relationship between AH filaments and intermediate filaments (IFs). Type 1, Type 2 and Type 3 AH were noted in hepatocytes, and the filaments in these types of AH showed similar ultrastructural findings as already reported. Two different kinds of filaments were noted in the Type 2 AH. The large on showed 160 to 200 A in a diameter and the small one showed around 100 A in diameter. Of the 29 cases with alcoholic hepatitis, a new type of AH was noted in the rosette forming hepatocytes in 2 cases of alcoholic hepatitis. The filaments of this AH in rosette forming hepatocytes showed 40 to 60 A in diameter and shorter length compared with Type 2 AH. These filaments with 40 to 60 A diameter were quite different from IFs. Our results indicate that AH in alcoholic hepatitis is not induced by the simple accumulation of the IFs.

Indications for use of hepatitis B vaccine, based on cost-effectiveness analysis

To formulate indications for the use of hepatitis B vaccine, we examined the cost effectiveness of three strategies: vaccinating everyone; screening everyone and vaccinating those without evidence of immunity; and neither vaccinating nor screening, but passively immunizing those with known exposure. Estimates of the hepatitis attack rate, prevalence of immunity, and frequency of known exposure were made for three representative populations: homosexual men, surgical residents, and the general population of the United States. Screening followed by vaccination of homosexual men and vaccination without prior screening of surgical residents would result in savings of medical costs. Neither screening nor vaccination is the lowest-cost strategy for the general population. Vaccination of susceptible persons will save medical costs for populations with annual attack rates above 5 per cent. Vaccination may be considered cost effective (or cost saving when indirect costs are included) for populations with attack rates as low as 1 to 2 per cent.

Hepatic copper overload and features of Indian childhood cirrhosis in an American sibship

We studied the clinical histories of four white American siblings who died at 41/2 to six years of age of an unknown form of cirrhosis, in an effort to identify the etiologic factors in this familial syndrome. The family history disclosed no Indian heritage or parental consanguinity. The children were born and raised in New Jersey. Each had been well until progressive lethargy, abdominal swelling, jaundice, and fever developed four to seven months before death. The liver histopathology in each case closely resembled that of Indian childhood cirrhosis and included severe panlobular liver-cell swelling with Mallory body formation, prominent pericellular fibrosis, "micro-micronodular" cirrhosis, and marked deposits of copper and copper-binding protein. Hepatic copper levels were as high as 2083 microgram per gram of tissue (normal, less than 50 microgram). A number of features distinguish this syndrome from Wilson's disease and familial cholestatic disorders of childhood. A genetically determined disturbance in copper metabolism appears to be the most likely cause.

Hepatocellular carcinoma in women: probable lack of etiologic association with oral contraceptive steroids

To investigate the possibility of an association between oral contraceptive steroids (CS) and hepatocellular carcinoma (HCC), we reviewed 128 cases of HCC in women collected between 1953 and 1980. There were 48 cases under the age of 40, and 13 of these (27%) had used CS. However, 62% of HCC associated with CS and 58% of HCC in women under 40 not using CS were classified histologically as "fibrolamellar" carcinoma. This subtype of HCC occurs predominantly in young people, both male and female. The apparent increase in HCC in young women can be explained by the presence of cases of fibrolamellar carcinoma in this age group, an the apparent association with CS is probably coincidental.

Lack of correlation between hepatic mitochondrial membrane structure and functions in ethanol-fed rats

A current hypothesis suggests that alterations in the chemical composition and the subsequent changes in the structure of the membrane could account for the functional derangements observed in the hepatic mitochondria of animals fed ethanol for extended periods. An examination of this hypothesis reveals that the liver mitochondria of ethanol-fed rats show a dissociation between the respiratory functions and the lipid composition and microviscosity of the membranes.

Hepatitis-B virus infection in black children with hepatocellular carcinoma

The hepatitis B virus (HBV) status of six unselected South African Black children, aged 10 to 16 years, with hepatocellular carcinoma (HCC) was investigated. The characteristics of the tumor were similar to those seen in Black adults. Hepatitis B surface antigen and antibody to the core antigen were present in the serum of all the children, and hepatitis Be antigen was detected in four of the children. The serum of the two patients without e antigen was positive for e antibody, and all sera were negative for hepatitis B surface antibody. Taken in conjunction with the HBV status of southern African Black adults with HCC, these findings raise the possibility that nearly all, if not all, Black patients with this tumor are or have been infected with HBV. Moreover, if HBV is oncogenic, tumor formation may occur within 10 years of the initial infection, which occurs in early childhood in southern African Blacks.

Structural properties of adenovirus DNA's

The current study presents the case of a 9-year-old Chinese boy who presented with eosinophilia and elevated serum levels of immunoglobulin G4 (IgG4). A bone marrow puncture identified an elevated eosinophil rate of 23% (normal range, <5%), which indicated eosinophilia. However, gene analysis, fluorescent in situ hybridization and other examinations, including bone marrow aspiration, blood routine, auto-antibody tests and parasitic and allergens screening, contradicted a diagnosis of secondary or clonal eosinophilia. Furthermore, the patient exhibited multiple lymph node swelling and a lymph biopsy strongly indicted a pathological diagnosis of IgG4-related disease (IgG4-RD). His peripheral blood flow cytometry confirmed an elevated count of plasmablasts, which is specific to IgG4-RD. The patient responded well to therapy with prednisone and remained healthy in all follow-ups. By taking all these factors into consideration, the boy was diagnosed with IgG4-RD. It is difficult to distinguish IgG4-RD from hypereosinophilic syndrome and the potential association between the two remains unclear. However, the present case study serves as a reminder that IgG4-RD may occur in children and medical professionals should not neglect this possibility.

Removal of cellular debris formed in the Disse space in patients with cholestasis

Using electron microscopy, we investigated how cellular debris, formed in the Disse space during cholestasis, was cleared. Ten patients with cholestasis of varied origin and severity were studied and compared with 10 controls without liver disease. In cholestatic patients, sinusoidal cells contained variable amounts of amylase PAS-positive material. In clean perfusion-fixed sinusoids the endothelial cells often appeared swollen and active, with few fenestrations. Hepatocyte blebs and cellular debris were sometimes seen in the Disse space. Two mechanisms were apparently involved in the clearing process: phagocytosis by macrophages either infiltrated into the Disse space, or forming the barrier; and the passage of debris from the Disse space into the sinusoidal lumen through the endothelial wall. Debris was either forced through enlarged pores or through the wall, with a progressive invagination followed by an outpouching in the lumen. The force, possibly provided by endothelial massage, may not be sufficient to push out cellular debris from the Disse space; morphological data seemed to indicate that endothelial damage may be a necessary factor. Debris present in the lumen was phagocytized by numerous active macrophages. Cellular debris was not observed in the Disse space of control patients.