Free "small" and IgG-associated "large" hepatitis B e antigen in the serum and glomerular capillary walls of two patients with membranous glomerulonephritis

Nude mice bearing human primary hepatocellular carcinoma that produces hepatitis B surface, core, and e antigens, as well as deoxyribonucleic acid polymerase

A primary hepatocellular carcinoma, from a patient carrying hepatitis B virus, was transplanted to athymic nude mice, and maintained through eight passages involving 39 mice. Hepatitis B surface and e antigens were detected in the circulation of tumor-bearing mice. Hepatitis B surface, core, and e antigens were demonstrated in tumor cells. Hepatitis B core particles were visualized in the tumor extract by immune electron microscopy, and they exhibited an activity of deoxyribonucleic acid polymerase. In the tumor tissue, deoxyribonucleic acid of hepatitis B virus was present both in integrated and extrachromosomal forms. Nude mice carrying the tumor would provide opportunities for studying the replication of hepatitis B virus and the expression of its various proteins, and also for evaluating the efficacy of virustatic drugs in interrupting the persistent infection.

Hepatitis B virus replication in acute glomerulonephritis with chronic active hepatitis

A 3 year old boy who had chronic active hepatitis type B with features of ongoing liver damage and active virus replication, developed acute membranous glomerulonephritis two years after the clinical onset of liver disease, when both hepatitis B e antigen and antibody were detectable in serum. After withdrawal of short term steroid treatment and resolution of hepatitis B virus replication, both glomerulonephritis and chronic hepatitis went into remission. Some months later hepatitis B surface antigen was no longer found in serum.

Hepatitis B surface antigenemia in North American children with membranous glomerulonephropathy. Southwest Pediatric Nephrology Study Group

We describe 11 North American children with hepatitis B-associated membranous glomerulonephropathy (MGN). The children are predominantly black boys (seven of 11) and younger (mean age 5.3 years) than children with idiopathic MGN (10.6 years) or lupus-associated MGN (13.4 years). Most of the patients (10 of 11) had nephrotic syndrome, and although clinical evidence of liver disease was present in only one child, eight of 10 patients had elevated aspartate amino transferase levels. Liver biopsies performed in three children revealed chronic persistent hepatitis in two and chronic active hepatitis in one. Hepatitis B surface antigen was found in the serum of one of the parents of five patients and in the brother of one patient. Low serum C3 values were observed in all 11 children at some stage of their illness. Renal biopsy specimens revealed stage II or III glomerular capillary wall changes, and immunofluorescence studies revealed three or more glomerular immunoreactants in 10 of 11 biopsies. One patient developed end-stage renal disease 9 years after presentation of nephrotic syndrome; the duration of follow-up of the other 10 patients is limited at this time. We conclude from these data that hepatitis B-associated MGN is more frequent in North American children than previous reports have suggested, is most commonly seen in young black boys, and is characterized by low serum C3 levels. It appears, therefore, to be a distinct clinicopathologic entity.

Hepatitis B surface antigenaemia and glomerulopathies in children

Serum HBsAg positivity prevalence was studied on 98 children affected by various nephropathies or obstructive uropathies and on a control group of 71 children, consecutively admitted into the same clinical ward, suffering from other than hepatic or renal diseases. No significant difference was found between the group of children with non-glomerular nephropathies or obstructive uropathies and the control group. The prevalence of HBsAg positivity was significantly higher in male children with membranous glomerulopathy and in those with lipoid nephrosis than in the control group. All HBsAg positive children with glomerulopathies were chronic carriers of the hepatitis B virus. However, though left undemonstrated, there still lies a probable pathogenetic relationship between the hepatitis B virus infection and membranous glomerulopathy. The authors hypothesize that an impaired immune response in male children with lipoid nephrosis may account for both the hepatitis B virus infection and the development of the glomerular disease.

Deposition of hepatitis B e antigen in membranous glomerulonephritis: identification by F(ab')2 fragments of monoclonal antibody

The pathogenic ability of hepatitis B e antigen (HBeAg) to induce membranous glomerulonephritis was evaluated by the most specific method presently available. Monoclonal antibody was raised against HBeAg, and F(ab')2 fragments were obtained and labeled with fluorescence. By this reagent, 10 out of 16 patients with membranous glomerulonephritis with hepatitis B surface antigen in the serum revealed granular deposition of HBeAg along glomerular capillary walls. Among the cases with glomerular HBeAg deposits, nine had detectable HBeAg in the serum and one had antibody to HBeAg (anti-HBe). The specificity of HBeAg staining was ascertained by blocking and inhibition tests, and the fluoresceinated anti-HBe F(ab')2 reagent did not stain the glomerular immune deposits in the patients with membranous glomerulonephritis who did not carry hepatitis B virus (HBV). None of the studied patients showed deposition of hepatitis B surface or core antigens in the glomerulus. On the basis of these results, immune complexes involving HBeAg may induce membranous glomerulonephritis in persons who carry HBV.

Associated focal and segmental glomerulosclerosis in the acquired immunodeficiency syndrome

Of the 92 patients with the acquired immunodeficiency syndrome (AIDS) who were seen at our institution over a two-year period, 9 acquired the nephrotic syndrome (urinary protein greater than 3.5 g per 24 hours) and 2 had azotemia with lesser amounts of urinary protein. Five of these 11 patients had a history of intravenous-heroin addiction, but in the remaining six, there were no known predisposing factors for nephropathy. In nine patients (including the six non-addicts) the course of renal disease was marked by rapid progression to severe uremia. Renal tissue examined by biopsy in seven patients and at autopsy in three revealed focal and segmental glomerulosclerosis with intraglomerular deposition of IgM and C3. In the 11th patient, renal biopsy revealed an increase in mesangial matrix and cells, with deposition of IgG and C3 consistent with a mild immune-complex glomerulonephritis, and severe interstitial nephritis. We conclude that focal and segmental glomerulosclerosis may be associated with AIDS and suggest that rapid deterioration to uremia may characterize this renal disease.

The role of infectious agents in the aetiology and pathogenesis of childhood nephrotic syndrome in Africa

Childhood nephrotic syndrome is common in Africa where infectious agents are prevalent. This paper reviews the possible aetiological role of infectious agents in childhood nephrotic syndrome in Africa. There is a strong association, possibly causal, between childhood nephrotic syndrome on the one hand and Plasmodium malariae, Schistosoma mansoni and hepatitis B antigens on the other. Beta-haemolytic streptococci are less strongly associated with nephrotic syndrome, and a few other organisms are suspect. The many ubiquitous infectious agents and the prevalence of multiple infections make it difficult to define the role of any single infectious agent or to determine the interaction between the various agents. Control or eradication of infectious diseases should lower the incidence of childhood nephrotic syndrome in Africa.

[Kidney involvement in liver diseases: morphology]

Primary liver diseases are often associated with disturbance of the renal function, but only two hepatic lesions are due to glomerular changes: hepatitis B and alcoholic liver disease. Hepatitis B associated with immune complex glomerulonephritis seems to be a rare condition in adults, however children are more often involved. Glomerular changes consist of membranous deposition of immune complexes, mainly corresponding to membranous glomerulonephritis, seldom to the membranoproliferative type. Because membranous glomerulonephritis develops due to deposition of small size soluble complexes, and the hepatitis B antigens alone are estimated to be greater than soluble nephritogenic complexes, most probably low molecular weight antigenic components of the hepatitis antigens are involved in the formation of glomerulonephritis. Alcoholic liver disease is often combined with glomerulosclerosis and mesangial IgA deposition resembling the morphological pattern of IgA mesangial glomerulonephritis. These common features implicate a similar pathogenesis of both diseases. Furthermore, experimental and clinical data indicate raised serum levels of IgA and IgA deposition within glomerula and other organs in the same manner, but the cause of high serum levels of IgA remains still obscure, and may be different in both diseases.

Hepatitis B virus associated membranous glomerulonephritis

The incidence of persistent hepatitis B surface (HBs) antigenaemia was studied in 114 nephrotic children with glomerulonephritis. Twenty five (24 boys) of 28 cases of membranous glomerulonephritis were HBs antigen (HBsAg) carriers. Only 9 of the remaining 86 patients with nephropathies other than membranous glomerulonephritis were HBsAg positive. HBsAg immune complexes were seen in the sera by electron microscopy. On radioimmunoassay both HBsAg and antibody (anti-HBs), and HBeAg and antibody (anti-HBe) were often detected concurrently, HBsAg was not shown in the glomerular capillary wall. HBs antigenaemia persisted in 80% of patients after recovery from glomerulonephritis but remission of the proteinuria correlated well, although not fully, with seroconversion to anti-HBe. The natural history of hepatitis B virus (HBV) associated glomerulonephritis in childhood is one of slow recovery. A few patients are left with mild asymptomatic proteinuria but progressive renal failure is rare. The 14% incidence of membranous glomerulonephritis in nephrotic children in this area is much higher than that found by the international study of kidney disease in children in well developed countries and is probably related to a high HBV carrier rate. A search for HBV markers should be included in the investigation of persistent glomerulonephritis, particularly in countries with a high prevalence of HBV carriers.

The role of hepatitis B surface antigen in Nigerian children with nephrotic syndrome

Hepatitis B surface antigen was detected by radioimmunoassay in the sera of 18 out of 50 (36%) children with nephrotic syndrome and in 28 of 61 (45.9%) controls. Immunofluorescent studies of kidney biopsies showed HBsAg, IgG, IgM and C3 deposits in a granular pattern in the biopsies of 12 children with nephrotic syndrome and in none of the control kidney biopsies, even though there was no significant difference between the frequencies of HBsAg in the sera of these two groups. We conclude that these findings are indicative of an aetiologic role for HBsAg in these patients.

Glomerulonephritis associated with liver cirrhosis

The glomerular changes of 50 autopsy cases of liver cirrhosis of different etiologies, such as alcohol abuse, HB virus infection, and nonA-nonB virus infection, were studied by light, immunofluorescence and electron microscopy. The glomerular changes observed were as follows; membranoproliferative glomerulonephritis (MPGN) type 1 (7 cases), mild form or early stage of MPGN type 1 (7 cases), mesangial proliferative glomerulonephritis with subendothelial deposits (13 cases), and mesangial proliferative glomerulonephritis without subendothelial deposits (12 cases). These glomerular changes were frequently accompanied by predominant IgA deposition (78% of the immunofluorescence positive cases). Minimal glomerular changes without electron dense deposits were 11 cases, in which IgA was not present in the glomeruli. Thus, glomerulonephritis associated with liver cirrhosis has revealed a spectrum of glomerular changes from MPGN type 1 to mesangial proliferative glomerulonephritis with a common feature of predominant IgA deposition, despite various etiological factors of liver cirrhosis, such as alcohol abuse, hepatitis B virus infection, and nonA-nonB virus infection. A pathophysiological condition of liver cirrhosis, e.g. reduced phagocytic activity of the reticuloendothelial system of the cirrhotic liver, is thought to be a major factor for development of these glomerular changes. The pathogenesis of IgA predominant glomerulonephritis associated with liver cirrhosis may be concerned in the pathogenesis of IgA nephropathy, which still remains to be clarified.

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.

De novo membranous nephropathy in human renal allografts: report of nine patients

Nine new patients with de novo membranous nephropathy (MN) are reported. The onset of MN, as defined by onset of nephrotic-range proteinuria, ranged from 11 to 30 months after transplantation. Five of the nine patients returned to hemodialysis within 4 to 26 months after the onset of nephrotic syndrome. No known exogenous (for example, ALS or HBsAg) or endogenous antigens could be demonstrated as the cause in any of the nine patients. The possibility that excellent tissue compatibility might increase the risk of subsequent de novo MN is suggested by the finding of four patients with "full house" HLA-A,B mismatch. This phenomenon occurs in approximately one in 100 to 200 transplants. It is suggested that de novo MN is not as unusual as heretofore believed and that its prognosis is poor.

Renal glomerular changes associated with liver cirrhosis

Renal glomerular changes associated with 79 liver cirrhosis cases were studied by light and electron microscopy, and immunofluorescent methods. The glomerular changes were classified as follows: 1) Mixed membranous and proliferative glomerulonephritis type having subepithelial, subendothelial, mesangial and paramesangial deposits (37 cases), 2) membranous glomerulonephropathy type (6 cases), 3) IgA nephropathy type (3 cases), and 4) glomerulosclerosis types (5 cases). Clinically, the patients with marked renal glomerular changes and proteinuria, hematuria, and retention by the PSP test. It was suggested that the essential renal glomerular changes in liver cirrhosis was immune-complex mediated glomerulonephritis and that glomerular sclerosis was merely a secondary change to glomerulonephritis.

Significance of circulating HBs antigen-antibody immune complexes in patients with HBs antigen-positive liver disease

The nature of circulating immune complexes (CIC) which appear in patients with type B hepatitis was investigated using a method of Raji cell fluorescent immunoassay. CIC were found in seventeen of thirty-five cases (48.6%) with HBs antigen (HBsAg)-positive liver diseases (4/8 cases with acute hepatitis, 9/18 cases with chronic hepatitis, and 4/9 cases with liver cirrhosis), whereas no CIC were detectable in sera of ten asymptomatic, healthy carriers with HB virus. Among the seventeen cases with CIC-positive liver diseases, HBs antigen-antibody immune complexes (HBsIC) were demonstrated in eleven (65%). A high incidence (54%) of proteinuria was observed in patients with CIC-positive liver disease compared to those without them (10%). Moreover, 83% of patients with HBsIC were associated with proteinuria. A case of fulminant type B hepatitis showed high titers of both CIC and HBsIC during the acute phase of the disease; in the recovery stage, the titers decreased to within normal ranges. These results demonstrate that HBsAg is a possible antigen in CIC during type B hepatitis. Determination of serum HBsIC is significant for the clinical evaluation of HB virus-related liver diseases.

Abnormalities of T-cell subsets in glomerulonephritis and systemic lupus erythematosus

In this study, three kinds of monoclonal antibodies directed at human T lymphocytes, produced by mouse hybridomas and termed OKT3, OKT4, and OKT8, were used in an indirect immunofluorescence assay, to analyze the distribution of peripheral T lymphocyte subsets in 41 patients with glomerulonephritis (GN) and 11 patients with systemic lupus erythematosus (SLE). As assessed by functional studies, OKT4 and OKT8 defined the helper and cytotoxic/suppressor T lymphocytes subsets, respectively, whereas OKT3 recognized all peripheral T-cells. Among GN patients, the ones presenting membranous GN (MGN), IgA disease, and lipoid nephrosis associated with segmental and focal hyalinosis (FGS) showed significant decrease of their peripheral cytotoxic/suppressive T cells. On the contrary, no significant alteration was found in the peripheral T cell distribution of patients with membranoproliferative GN (MPGN) and lipoid nephrosis associated with minimal-change GN (MCGN). Unexpectedly, there was a tendency for peripheral cytotoxic/suppressive T lymphocytes to be high in the majority of SLE patients, and only two of these subjects exhibited a relative decrease in peripheral OKT8 marked cells. The steroid therapy received by our patients might account for this discrepancy with previous reports of altered suppressor function in active SLE.

Nodular regenerative hyperplasia of the liver with membranous glomerulonephritis

Nodular regenerative hyperplasia of the liver is an uncommon disorder, the main consequence of which is portal hypertension, hepatocellular decompensation being uncommon. A case associated with membranous glomerulonephritis is reported, in which death was caused by fulminant hepatic failure.

Hepatitis B surface antigen deposition in the blood vessel walls of urticarial lesions in acute hepatitis B

Urticaria is known to occur in the pre-icteric phase of acute viral hepatitis. Often such urticaria is a symptom of a serum sickness-like syndrome which can be a prodrome of viral hepatis. Immune complexes are thought to be pathogenetic in this condition. In this paper we present two patients with a serum sickness-like syndrome, urticaria and hepatitis B. By immunofluorescence techniques Hepatitis B surface antigen, CIq and C3 could be demonstrated in the blood vessels of the superficial dermis. These findings are consistent with the immune complex hypothesis.

Immunological aspects of nephrotic syndrome in northern Nigeria

Immunological aspects of 40 northern Nigerian children with nephrotic syndrome of recent onset are reported. Eight our of 30 had hepatitis-associated antigen in their sera. Hypocomplementaemia was rare. Measurement of serum C3, C4, and ASOT was not of diagnostic value. Proteinuria selectivity index was poor in half of the patients, and appeared t o depend on the severity of the kidney lesion. Abnormal immunofluorescence of kidney glomeruli to immunoglobulins, complement, Plasmodium malariae, and Plasmodium falciparum was found in 26 of the 29 children. The pattern of immunofluorescence was chiefly granular and was confined to the glomeruli. IgM was predominant. It was concluded that immunological reaction is involved in the pathogenesis of nephrotic syndrome in northern Nigerian children.

Membranous glomerulonephritis secondary to hydatid disease

To study the association of hydatid disease of the liver with a nephrotic syndrome we processed renal biopsy tissue for light microscopy, immunofluorescence and electron microscopy studies. These procedures disclosed the typical features of a membranous nephropathy whereas indirect immunofluorescence revealed glomerular deposits of hydatid antigen. Rabbits, previously immunized with bovine hydatid fluid, provided the specific antiserum. Clearly, the pathogenicity of this parasitosis derives, in part, from its immunologic repercussions. In this regard, our results support an etiopathogenic role for hydatid antigen in an immune-mediated glomerulonephritis.

Hepatic glomerulonephritis. Role of hepatitis B surface antigen (HBsAg)

A possible role of HBsAg in hepatic glomerulonephritis was evaluated in kidney specimens from 104 patients with various diseases. Huang's method using formalin-fixed and paraffin-embedded sections was applied to the kidney from 65 cases. Only 4 (3.8%) with liver cirrhosis had glomerular HBsAg deposition; 3 on frozen and one on paraffin sections. In one case of crescentic glomerulonephritis, HBsAg appeared to have had a pathogenetic role with glomerular immunofluorescence dominant for IgM, less intense IgG and negative IgA. The glomerular HBsAg in the remaining 3 patients with hepatic IgA glomerulonephritis was likely to be concomitant or superimposed. One of them had a nephrotic syndrome for which corticosteroid treatment was given, resulting in a near-complete remission and disappearance of HBsAg in the glomeruli, but the glomerular immunohistology was unaffected by the treatment. The present findings suggest that HBsAg has only a minor role.

The prognosis of the healthy HBsAg carrier state. A 5- to 8-year follow-up study

Thirty-six persons found to be healthy HBsAg carriers by routine donor screening from 1970 to 1973 were offered a follow-up examination in 1978. A total of 21 out of the 34 still living carriers were reexamined clinically, serologically, and biochemically. Seventeen of the 20 still HBsAg-positive carriers had anti-HBe, and 2 were HBeAg-positive. Liver biopsy in these two carriers showed chronic persistent hepatitis. No biochemical abnormalities were found in any but one who was HBeAg-positive and one who was negative for both HBeAg and anti-HBe. Anti-HBc titers varied between 1:3,600 and 1:83,000. Circulating immune complexes were demonstrated in 30% of the healthy HBsAg carriers. On the basis of 5-8 years' follow-up it is concluded that the healthy HBsAg carrier state is a benign condition that has not affected the carrier's quality of life. Progression to a severe, chronic liver disease was not observed in any of the healthy carriers. The importance and nature of circulating immune complexes in healthy HBsAg carriers was unknown and need further investigation.

Infection and chronic rheumatic disease in children

It is clear that various microbial agents can cause acute and chronic rheumatic disease by several mechanisms, that different agents, some perhaps yet unknown, may cause the same disease in different patients, and that genetic factors are important, perhaps crucial, to this host response. In trying to elucidate how microbe-host interactions result in chronic rheumatic disease, interest currently centers on the roles of genetic factors, of bacterial infections including endogenous flora, of cross-reactive microbial and host antigens, and of the immune response to them. As in the past, progress in understanding these complex interactions will probably be incremental and intermittent.

Hepatitis B e antigen and antibody: detection by radioimmunoassay in chimpanzees during experimental hepatitis B

Hepatitis B e antigen (HBeAg) and its antibody (anti-HBe) were evaluated using a sensitive radioimmunoassay (RIA) in weekly serum samples obtained from nine chimpanzees experimentally infected with hepatitis B virus (HBV). In two chimpanzees with HBV infection with detectable hepatitis B surface antigen (HBsAG) for less than five weeks, and in one chimpanzee with documented HBV infection with no detectable HBsAg, HBeAg was not detected; in all three, anti-HBe became detectable early in the infection. In six chimpanzees in which HGsAg was detected for 16 weeks or longer, HBeAg was detected early in the infection; in five, anti-HBe became detectable and HBeAg undetectable prior to the clearance of HBsAg. The sixth remained HGsAg-positive and HBeAg-positive for more than two years and never developed anti-HBe. These results confirmed the sensitivity of this RIA and its value in predicting the course of HBV infections.