51
|
Williams R, Gershwin ME. How, why, and when does primary biliary cirrhosis recur after liver transplantation? Liver Transpl 2007; 13:1214-6. [PMID: 17763403 DOI: 10.1002/lt.21143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
52
|
Abstract
BACKGROUND Cyclosporin A has been used for patients with primary biliary cirrhosis, but the therapeutic responses in randomised clinical trials have been heterogeneous. OBJECTIVES To assess the beneficial and harmful effects of cyclosporin A for patients with primary biliary cirrhosis. SEARCH STRATEGY Relevant randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, The Chinese Biomedical Database, and LILACS, and manual searches of bibliographies to June 2006. We contacted authors of trials and the company producing cyclosporin A. SELECTION CRITERIA Randomised clinical trials comparing cyclosporin A with placebo, no intervention, or another drug were included irrespective of blinding, language, year of publication, and publication status. DATA COLLECTION AND ANALYSIS Our primary outcomes were mortality, and mortality or liver transplantation. Dichotomous outcomes were reported as relative risk (RR) and if appropriate, Peto odds ratio with 95% confidence interval (CI). Continuous outcomes were reported as weighted mean difference (WMD) or standardised mean difference (SMD). We examined intervention effects by random-effects and fixed-effect models. MAIN RESULTS We identified three trials with 390 patients that compared cyclosporin A versus placebo. Two of them were assessed methodologically adequate with low-bias risk. Cyclosporin A did not significantly reduce mortality risk (RR 0.92, 95% CI 0.59 to 1.45), and mortality or liver transplantation (RR 0.85, 95% CI 0.60 to 1.20). Cyclosporin A significantly improved pruritus (SMD -0.38, 95% CI -0.63 to -0.14), but not fatigue. Cyclosporin A significantly reduced alanine aminotransferase (WMD -41 U/L, 95% CI -63 to -18) and increased serum albumin level (WMD 1.66 g/L, 95% CI 0.26 to 3.05). Significantly more patients experienced adverse events in the cyclosporin A group than in the placebo group, especially renal dysfunction (Peto odds ratio 5.56, 95% CI 2.52 to 12.27) and hypertension (SMD 0.88, 95% CI 0.27 to 1.48). AUTHORS' CONCLUSIONS We found no evidence supporting or refuting that cyclosporin A may delay death, death or liver transplantation, or progression of primary biliary cirrhosis. Cyclosporin A caused more adverse events than placebo, like renal dysfunction and hypertension. We do not recommend the use of cyclosporin A outside randomised clinical trials.
Collapse
Affiliation(s)
- Y Gong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Cochrane Hepato-Biliary Group, Rigshospitalet, Dept. 3344, Blegdamsvej 9, Copenhagen, DENMARK, DK-2100.
| | | | | |
Collapse
|
53
|
Abstract
BACKGROUND Azathioprine is used for patients with primary biliary cirrhosis, but the therapeutic responses in randomised clinical trials have been conflicting. OBJECTIVES To assess the benefits and harms of azathioprine for patients with primary biliary cirrhosis. SEARCH STRATEGY Randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, The Chinese Biomedical Database, and LILACS, and manual searches of bibliographies to September 2005. SELECTION CRITERIA Randomised clinical trials comparing azathioprine versus placebo, no intervention, or another drug were included irrespective of blinding, language, year of publication, and publication status. DATA COLLECTION AND ANALYSIS Our primary outcomes were mortality, and mortality or liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). Continuous outcomes were reported as weighted mean difference (WMD) or standardised mean difference (SMD). We examined the intervention effects by random-effects and fixed-effect models. MAIN RESULTS We identified two randomised clinical trials with 293 patients. Only one of the trials was regarded as having low bias risk. Azathioprine did not significantly decrease mortality (RR 0.80, 95% CI 0.49 to 1.31, 2 trials). Azathioprine did not improve pruritus at one-year intervention (RR 0.71, 95% CI 0.28 to 1.84, 1 trial), cirrhosis development, or quality of life. Patients given azathioprine experienced significantly more adverse events than patients given no intervention or placebo (RR 2.44, 95% CI 1.14 to 5.20, 2 trials). The common adverse events were rash, severe diarrhoea, and bone marrow depression. AUTHORS' CONCLUSIONS There is no evidence to support the use of azathioprine for patients with primary biliary cirrhosis. Researchers who are interested in performing further randomised clinical trials should be aware of the risks of adverse events.
Collapse
Affiliation(s)
- Y Gong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Cochrane Hepato-Biliary Group, Rigshospitalet, Dept. 3344, Blegdamsvej 9, Copenhagen, Denmark, DK-2100.
| | | | | |
Collapse
|
54
|
Abstract
BACKGROUND & AIMS A number of immunosuppressive therapies have not been associated with clinical benefit in primary biliary cirrhosis (PBC). The use of more potent immunomodulatory therapies, however, could raise concerns over the risk of adverse effects such as the development of lymphoma. Therefore, we sought to describe the frequency, clinical spectrum, and outcomes among patients with PBC and a concomitant diagnosis of lymphoma. METHODS Patients with PBC evaluated at the Mayo Clinic between January 1, 1976-December 31, 1997 comprised the study cohort. Medical records were abstracted for demographic and clinical information including the temporal relationship between diagnoses and potential risk factors for lymphoma. RESULTS From a total of 2192 patients, the frequency of lymphoma was observed at 0.6% (13 cases). The majority of patients (54%) had PBC before they were diagnosed with lymphoma, whereas 23% of cases were diagnosed in conjunction with PBC. Non-Hodgkin's lymphoma (69%) was observed in most cases with disease involvement above the diaphragm (38%). Treatment in the form of chemotherapy (n = 3), radiation (n = 2), and surgery (n = 6) was provided for 11 patients. Seven (54%) patients did not have evidence for recurrent disease, whereas 3 (23%) patients died of progressive lymphoma. CONCLUSIONS The baseline risk for lymphoma in patients with PBC is estimated at <1%. Clinical trials with potent immunosuppressive therapies for PBC should not be prohibited on the basis of concerns regarding a baseline predisposition for lymphoma in this population.
Collapse
Affiliation(s)
- Chakri Panjala
- Division of Gastroenterology/Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | | | | |
Collapse
|
55
|
Gong Y, Christensen E, Gluud C. Azathioprine for primary biliary cirrhosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd006000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
56
|
Gong Y, Christensen E, Gluud C. Cyclosporin A for primary biliary cirrhosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2005. [DOI: 10.1002/14651858.cd005526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
57
|
Abstract
BACKGROUND Methotrexate, a folic acid antagonist with immunosuppressive properties, has been used to treat patients with primary biliary cirrhosis. The therapeutic responses to methotrexate in randomised clinical trials have been heterogeneous. OBJECTIVES To assess the beneficial and harmful effects of methotrexate for patients with primary biliary cirrhosis. SEARCH STRATEGY Relevant randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register (June 2004), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 2, 2004), MEDLINE (January 1966 to August 2004), EMBASE (January 1980 to August 2004), and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. SELECTION CRITERIA Randomised clinical trials comparing methotrexate with placebo, no intervention, or another drug were included irrespective of blinding, language, year of publication, and publication status. DATA COLLECTION AND ANALYSIS Our primary outcomes were mortality and mortality or liver transplantation. Dichotomous outcomes were reported as relative risk (RR) and hazard ratio (HR) if applicable. Continuous outcomes were reported as weighted mean difference (WMD). We examined intervention effects by using both a random-effects model and a fixed-effect model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. MAIN RESULTS We identified four trials (370 patients) that compared methotrexate with placebo with or without ursodeoxycholic acid as co-intervention. One additional trial (87 patients) compared methotrexate with colchicine without and later with ursodeoxycholic acid as co-intervention. The methodological quality of the trials was low. We did not find significant effects of methotrexate on pruritus, fatigue, liver complications, liver biochemistry, liver histology, or adverse events. The pruritus score (WMD - 0.68, 95% CI - 1.11 to - 0.25), the levels of serum alkaline phosphatases (WMD - 0.41, 95% CI - 0.70 to - 0.12) and plasma immunoglobulin M (WMD - 0.47, 95% CI - 0.74 to - 0.20) were significantly lower in the patients receiving methotrexate. AUTHORS' CONCLUSIONS Methotrexate increased mortality in patients with primary biliary cirrhosis. We do not recommend methotrexate for patients with primary biliary cirrhosis outside randomised trials.
Collapse
Affiliation(s)
- Y Gong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Dept. 7102, Blegdamsvej 9, H:S Rigshospitalet, Copenhagen, Denmark, DK-2100.
| | | |
Collapse
|
58
|
Theal JJ, Toosi MN, Girlan L, Heslegrave RJ, Huet PM, Burak KW, Swain M, Tomlinson GA, Heathcote EJ. A randomized, controlled crossover trial of ondansetron in patients with primary biliary cirrhosis and fatigue. Hepatology 2005; 41:1305-12. [PMID: 15915460 DOI: 10.1002/hep.20698] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fatigue is common in primary biliary cirrhosis (PBC). Altered central serotonergic neurotransmission may be involved in its pathogenesis. This multicenter, randomized, double-blind, placebo-controlled, crossover trial evaluated the efficacy of ondansetron, a selective 5-HT3 receptor subtype antagonist, for treating fatigue in PBC. A crossover design was chosen, allowing subjects to serve as their own controls-appropriate to evaluate fatigue, a subjective symptom. Sixty patients with clinically stable PBC, a Fatigue Severity Score (FSS) > 4, and no other identifiable cause for fatigue were enrolled. Subjects were randomized to receive ondansetron (4 mg) or placebo orally 3 times daily for 4 weeks (period 1). Subjects then crossed over, after a minimum 1-week washout period, for a further 4 weeks of ondansetron or placebo (period 2). Fatigue was measured at the beginning and end of each period by using the FSS and Fatigue Impact Scale (FIS). Six patients withdrew; the remaining 54 subjects had a mean baseline FSS of 5.55 (+/-0.1). Response to study medication in period 1 versus period 2 was not uniform; thus, it was necessary to analyze the trial periods separately. In period 1, there was no significant additional fatigue reduction on ondansetron over placebo. During period 2, FSS and FIS decreased significantly on ondansetron versus placebo (P = .001). However, period 2 results were invalidated because drug side effects unblinded subjects (constipation affected 63.0% of patients taking ondansetron, versus 13.3% on placebo). In conclusion, ondansetron administration did not confer clinically significant fatigue reduction when compared with placebo in our study population.
Collapse
Affiliation(s)
- Jeremy J Theal
- Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
59
|
Abstract
BACKGROUND Primary biliary cirrhosis is a chronic progressive cholestatic liver disease of presumed autoimmune etiology, characterised by the destruction of small intrahepatic bile ducts and the eventual development of cirrhosis and liver failure. Its progression may be influenced by immunosuppression. Glucocorticosteroids are potent immunosuppressive agents, but they are associated with significant adverse effects, including osteoporosis. OBJECTIVES To systematically evaluate the beneficial and harmful effects of glucocorticosteroids versus placebo or no intervention for patients with primary biliary cirrhosis. SEARCH STRATEGY The Cochrane Hepato-Biliary Controlled Trials Register,The Cochrane Library, MEDLINE, EMBASE, and the full text of the identified studies were searched until June 2004. The search strategy included terms for primary biliary cirrhosis and glucocorticosteroids (including the names of frequently used preparations). Previous research groups and manufacturers were contacted for additional references. No language restrictions were applied. SELECTION CRITERIA Double-blind, single-blind, or unblinded randomised clinical trials evaluating any preparation of glucocorticosteroids versus placebo or no intervention in patients with primary biliary cirrhosis diagnosed by abnormal liver function tests and either anti-mitochondrial antibodies or histology were included. Additional agents were allowed if they were administered to both groups equally. DATA COLLECTION AND ANALYSIS The quality of the randomised clinical trials was evaluated by methodology components (generation of allocation sequence; allocation concealment; blinding; follow up). Analyses were performed according to the intention-to-treat method with missing data being accounted for by imputation. MAIN RESULTS Only two underpowered trials (reporting 36 and 40 patients) were identified. These differed markedly in their inclusion criteria and treatment protocols. Both stated that they used placebo. However, allocation concealment was unclear. Only one trial reported any patient deaths. No significant improvement in mortality was identified (odds ratio (OR) 0.42, 95% confidence interval (CI) 0.10 to 1.76). Improvements in serum markers of liver inflammation and liver histology were identified. Potentially prognostically linked markers such as bilirubin and albumin were incompletely reported. Bone mineral density (weighted mean difference -2.84%, 95% CI -4.16 to -1.53) and the number of patients with any adverse event (OR 8.99, 95% CI 2.15 to 37.58) were significantly increased in the glucocorticosteroid group. AUTHORS' CONCLUSIONS There is insufficient data to support or reject the use of glucocorticosteroids for patients with primary biliary cirrhosis. It may be appropriate to consider a large prospective randomised clinical trial on this topic.
Collapse
Affiliation(s)
- M Prince
- Centre for Liver Research, 5th floor, William Leech Building, Framlington Place, Newcastle, UK, NE3 IUD.
| | | | | |
Collapse
|
60
|
Abstract
BACKGROUND D-penicillamine is used for patients with primary biliary cirrhosis due to its hepatic copper decreasing and immunomodulatory potentials. The results from randomised clinical trials have been inconsistent. OBJECTIVES To systematically review the beneficial and harmful effects of D-penicillamine for patients with primary biliary cirrhosis. SEARCH STRATEGY We identified trials through electronic searches of The Cochrane Hepato-Biliary Group Controlled Trials Register (September 2003), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003), MEDLINE (January 1966 to September 2003), EMBASE (January 1980 to September 2003), The Chinese Biomedical CD Database (January 1979 to August 2003), and LILACS (1982 to 2003); through manual searches of bibliographies; and by contacting authors of the trials and pharmaceutical companies. SELECTION CRITERIA We included randomised clinical trials comparing D-penicillamine with placebo/no intervention or other control intervention irrespective of language, year of publication, and publication status. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the methodological quality of the trials and extracted data, validated by a third reviewer. The primary outcomes were 1) mortality and 2) a combination of those who died or underwent liver transplantation. We analysed dichotomous outcomes as relative risk (RR) with 95% confidence interval (CI) by a fixed effect model and a random effects model. We investigated sources of heterogeneity by subgroup analyses and tested the robustness of our findings by sensitivity analyses. MAIN RESULTS We included seven trials randomising 706 patients with primary biliary cirrhosis. D-penicillamine compared with placebo/no intervention tended to increase mortality (RR 1.34, 95% CI 1.09 to 1.64, fixed; RR 1.46, 95% CI 0.85 to 2.50, random). However, there was substantial heterogeneity. No significant differences were detected regarding the risks of mortality or liver transplantation, pruritus, liver complications, progression of liver histological stage, or the levels of liver biochemical variables (except alanine aminotransferase). D-penicillamine versus placebo/no intervention significantly increased the risk of adverse events (RR 3.11, 95% CI 2.33 to 4.16, fixed; RR 4.18, 95% CI 1.38 to 12.69, random). REVIEWERS' CONCLUSIONS D-penicillamine did not appear to reduce the risk of mortality, but significantly increased the occurrences of adverse events in patients with primary biliary cirrhosis. We do not support the use of D-penicillamine for patients with primary biliary cirrhosis.
Collapse
Affiliation(s)
- Y Gong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Dept. 7102, Blegdamsvej 9, H:S Rigshospitalet, Copenhagen, DK-2100, Denmark.
| | | | | |
Collapse
|
61
|
Strassburg CP, Manns MP. [Primary biliary liver cirrhosis and overlap syndrome. Diagnosis and therapy]. Internist (Berl) 2004; 45:16-26. [PMID: 14735240 DOI: 10.1007/s00108-003-1127-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Primary biliary cirrhosis represents a chronic cholestatic liver disease of unknown etiology. It primarily affects females, is associated with extrahepatic immune-mediated syndromes, shows an immunogenetic association with HLA DR8, and displays serum autoantibodies, which makes an autoimmune etiology likely. The diagnosis is reached in patients with elevated alkaline phosphatase, gamma glutamyl transferase and bilirubin levels who exhibit normal bile ducts upon ultrasound examination, and in whom specific antimitochondrial autoantibodies are detectable. Half of all PBC patients additionally show specific antinuclear autoantibodies. Immunosuppressive therapy is ineffective; steroids, transplant immunosuppressants, colchicine, d-penicillamine and methotrexate are of limited clinical benefit. Ursodeoxycholic acid has few side effects and leads to a biochemical response and a delay of disease progression in most cases. When ursodeoxycholic acid therapy is ineffective an overlap syndrome with autoimmune hepatitis can be present, which can respond to steroid treatment. The only curative option is liver transplantation which should be considered when bilirubin levels exceed 100 microM/l.
Collapse
Affiliation(s)
- C P Strassburg
- Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover.
| | | |
Collapse
|
62
|
Dohmen K, Mizuta T, Nakamuta M, Shimohashi N, Ishibashi H, Yamamoto K. Fenofibrate for patients with asymptomatic primary biliary cirrhosis. World J Gastroenterol 2004. [PMID: 15040040 DOI: 10.1016/s0270-9139(03)80786-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM Primary biliary cirrhosis (PBC) is a chronic, cholestatic disease of autoimmune etiology, the histology of which shows a destruction of the intrahepatic bile duct and portal inflammation. Ursodeoxycholic acid (UDCA) is now used as a first-line drug for asymptomatic PBC (aPBC) because it is reported that UDCA decreases mortality and prolongs the time of liver transplantation. However, only 20-30% of patients respond fully to UDCA. Recently, lipoprotein-lowering agents have been found to be effective for PBC. The aim of this study was to examine the safety and efficacy of fenofibrate, a member of the fibrate class of hypolipidemic and anti-inflammatory agent via peroxysome proliferatory-activated receptor alpha, in patients with aPBC. METHODS Fenofibrate was administered for twelve weeks in nine patients with aPBC who failed to respond to UDCA. UDCA was used along with fenofibrate during the study. The data from aPBC patients were analyzed to assess the biochemical effect of fenofibrate during the study. RESULTS The serum levels of alkaline phosphatase (ALP) (285+/-114.8 IU/L) and immunoglobulin M (IgM) (255.8+/-85.9 mg/dl) significantly decreased to 186.9+/-76.2 IU/L and 192.9+/-67.5 mg/dL respectively, after fenofibrate treatment in patients with aPBC (P<0.05). Moreover, the titer of antimitochondrial antibody (AMA) also decreased in 4 of 9 patients with aPBC. No adverse reactions were observed in any patients. CONCLUSION Fenofibrate appears to be significantly effective in treating patients with aPBC who respond incompletely to UDCA alone. Although the mechanism of fenofibrate on aPBC has not yet been fully clarified, combination therapy using fenofibrate and UDCA might be related to the anti-immunological effects, such as the suppression of AMA production as well as its anti-inflammatory effect.
Collapse
Affiliation(s)
- Kazufumi Dohmen
- Department of Internal Medicine, Okabe Hospital, 1-2-1 Myojinzaka Umi-machi Kasuya-gun Fukuoka 811-2122 Japan.
| | | | | | | | | | | |
Collapse
|
63
|
Dohmen K, Mizuta T, Nakamuta M, Shimohashi N, Ishibashi H, Yamamoto K. Fenofibrate for patients with asymptomatic primary biliary cirrhosis. World J Gastroenterol 2004; 10:894-8. [PMID: 15040040 PMCID: PMC4727018 DOI: 10.3748/wjg.v10.i6.894] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: Primary biliary cirrhosis (PBC) is a chronic, cholestatic disease of autoimmune etiology, the histology of which shows a destruction of the intrahepatic bile duct and portal inflammation. Ursodeoxycholic acid (UDCA) is now used as a first-line drug for asymptomatic PBC (aPBC) because it is reported that UDCA decreases mortality and prolongs the time of liver transplantation. However, only 20-30% of patients respond fully to UDCA. Recently, lipoprotein-lowering agents have been found to be effective for PBC. The aim of this study was to examine the safety and efficacy of fenofibrate, a member of the fibrate class of hypolipidemic and anti-inflammatory agent via peroxysome proliferatory-activated receptor α, in patients with aPBC.
METHODS: Fenofibrate was administered for twelve weeks in nine patients with aPBC who failed to respond to UDCA. UDCA was used along with fenofibrate during the study. The data from aPBC patients were analyzed to assess the biochemical effect of fenofibrate during the study.
RESULTS: The serum levels of alkaline phosphatase (ALP) (285 ± 114.8 IU/L) and immunoglobulin M (IgM) (255.8 ± 85.9 mg/dl) significantly decreased to 186.9 ± 76.2 IU/L and 192.9 ± 67.5 mg/dL respectively, after fenofibrate treatment in patients with aPBC (P < 0.05). Moreover, the titer of antimitochondrial antibody (AMA) also decreased in 4 of 9 patients with aPBC. No adverse reactions were observed in any patients.
CONCLUSION: Fenofibrate appears to be significantly effective in treating patients with aPBC who respond incompletely to UDCA alone. Although the mechanism of fenofibrate on aPBC has not yet been fully clarified, combination therapy using fenofibrate and UDCA might be related to the anti-immunological effects, such as the suppression of AMA production as well as its anti-inflammatory effect.
Collapse
Affiliation(s)
- Kazufumi Dohmen
- Department of Internal Medicine, Okabe Hospital, 1-2-1 Myojinzaka Umi-machi Kasuya-gun Fukuoka 811-2122 Japan.
| | | | | | | | | | | |
Collapse
|
64
|
Abstract
BACKGROUND Colchicine has been used for patients with primary biliary cirrhosis because of its immunomodulatory and antifibrotic potential. The therapeutical responses to colchicine in randomised clinical trials were inconsistent. OBJECTIVES To evaluate the beneficial and harmful effects of colchicine in patients with primary biliary cirrhosis. SEARCH STRATEGY We identified trials through electronic searches of The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials on The Cochrane Library, MEDLINE, EMBASE (September 2003), and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies. SELECTION CRITERIA Randomised clinical trials comparing colchicine with any kind of control therapy were included irrespective of language, year of publication, and publication status. DATA COLLECTION AND ANALYSIS The primary outcomes were the number of deaths and the number of death and/or patients who underwent liver transplantation. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence interval (CI). We examined intervention effects by using both a fixed effect model and a random effects model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses. MAIN RESULTS Eleven randomised clinical trials involving 716 patients with primary biliary cirrhosis fulfilled the inclusion criteria. No significant differences were detected between colchicine and placebo/no intervention on the number of deaths (RR 1.21, 95% CI 0.71 to 2.06), the number of deaths and/or patients who underwent liver transplantation (RR 1.00, 95% CI 0.67 to 1.49), liver complications, liver biochemical variables, liver histological measurements, and adverse events. Trial methodology was generally low and some trials had high drop-out rate. A best-worst-case-scenario analysis showed no significant effect of colchicine on mortality (RR 0.59, 95%CI 0.30 to 1.15), while a worst-best-case-scenario analysis showed a significant detrimental effect of colchicine on mortality (RR 2.28, 95% CI 1.17 to 4.44). Colchicine significantly decreased the number of patients without improvement of pruritus (RR 0.75, 95% CI 0.65 to 0.87). However, this estimate was based on only 156 patients from three trials. The effect of the combined treatment with ursodeoxycholic acid was not significantly different from that of colchicine alone. REVIEWERS' CONCLUSIONS We did not find evidence either to support or refute the use of colchicine for patients with primary biliary cirrhosis. As we are not able to exclude a detrimental effect of colchicine, we suggest that it is only used in randomised clinical trials.
Collapse
Affiliation(s)
- Y Gong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Dept. 7102, Blegdamsvej 9, H:S Rigshospitalet, Copenhagen, Denmark, DK-2100
| | | |
Collapse
|
65
|
Abstract
No single agent or combination of agents has been shown to unequivocally delay the need for liver transplantation or reduce mortality in patients with PBC. Given this uncertainty, what, if any, specific therapy should be recommended? The agents with the strongest scientific proof of efficacy in well-designed clinical trials are ursodiol, azathioprine, and cyclosporine. Ursodiol is clearly the least toxic of these three. Other agents, such as methotrexate, have shown impressive results in anecdotal studies but have never been adequately tested in randomized clinical trials. Thus, based on the current evidence, imperfect as it is, ursodiol appears to be the safest and potentiaily the most effective specific therapy for patients with PBC. Azathioprine and methotrexate may be the best alternatives for patients who cannot tolerate or do not respond to ursodiol therapy, primarily because their safety has been established in large and lengthy clinical trials. Cylosporine could be considered in patients who fail other treatments (Table 3). We can hope that a safe, highly-effective treatment for patients with PBC will ultimately be discovered. Trials to unequivocally demonstrate the efficacy of new agents will have to be extremely well designed, however, and will require large numbers of patients followed for an extended period of time.
Collapse
Affiliation(s)
- Robert L Carithers
- University of Washington, 1959 NE Pacific Street, Box 356174, Seattle, WA 98195-6174, USA.
| |
Collapse
|
66
|
Affiliation(s)
- Cynthia Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Mayo Building W 19 A, 200 1st street SW, Rochester, MN 55905, USA
| | | |
Collapse
|
67
|
Abstract
Primary biliary cirrhosis is a chronic cholestatic liver disease of adults. This disorder is characterised histologically by chronic non-suppurative destruction of interlobular bile ducts leading to advanced fibrosis, cirrhosis, and liver failure. The precise aetiopathogenesis of primary biliary cirrhosis remains unknown, although dysregulation of the immune system and genetic susceptibility both seem to be important. Affected patients are typically middle-aged women with abnormal serum concentrations of alkaline phosphatase. Presence of antimitochondrial antibody in serum is almost diagnostic of the disorder. Identification of primary biliary cirrhosis is important, because effective treatment with ursodeoxycholic acid has been shown to halt disease progression and improve survival without need for liver transplantation. However, therapeutic options for disease-related complications-including fatigue and metabolic bone disease-remain unavailable. Mathematical models have been developed that accurately predict the natural history of primary biliary cirrhosis in individuals. Despite advances in understanding of the disease, it remains one of the major indications for liver transplantation worldwide.
Collapse
Affiliation(s)
- Jayant A Talwalkar
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
| | | |
Collapse
|
68
|
Abstract
Pruritus is often the most troublesome symptom in patients with chronic liver disease, particularly when cholestasis is a prominent feature. The exact pathogenesis is unknown, but empirical treatment, such as cholestyramine, based on a liver-based origin of pruritus, has been used for many years. Recently, evidence for a central mechanism for pruritus has been obtained and opioid antagonists have been tried clinically with some benefit, but their use is not widespread. In addition, the pruritus associated with intrahepatic cholestasis of pregnancy can now be alleviated in many cases by ursodeoxycholic acid. As it also improves foetal outcome, this should become first-line therapy. We review the pathogenesis and therapy of pruritus, highlighting practical aspects to help with patients with seemingly intractable pruritus.
Collapse
Affiliation(s)
- M Mela
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK
| | | | | |
Collapse
|
69
|
Bach N, Bodian C, Bodenheimer H, Croen E, Berk PD, Thung SN, Lindor KD, Therneau T, Schaffner F. Methotrexate therapy for primary biliary cirrhosis. Am J Gastroenterol 2003; 98:187-93. [PMID: 12526956 DOI: 10.1111/j.1572-0241.2003.07173.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Preliminary data suggested possible benefits of methotrexate in primary biliary cirrhosis. We assessed the effectiveness of methotrexate use in primary biliary cirrhosis and its tolerance in patients with this disease. METHODS A total of 110 primary biliary cirrhosis patients began methotrexate 15 mg/wk; for most, ursodeoxycholic acid was added during the study. We analyzed data from patients completing 5 yr of treatment with methotrexate to assess its effect on biochemical and histologic parameters after 5 yr of therapy. Based on an intent to treat analysis, we also compared survival of our patients (n = 110) with that of patients in a previously published, placebo-controlled trial of ursodeoxycholic acid (n = 180). RESULTS Only half of the study group completed 5 yr of methotrexate therapy. Therapy did not prevent progression of disease, as indicated by a rising Mayo risk score. Portal fibrosis tended to remain the same. Methotrexate did not diminish the risk of death or liver transplantation when compared with ursodeoxycholic acid or placebo; however, ursodeoxycholic acid use decreased the risk of death or transplant (p = 0.006). CONCLUSIONS Methotrexate is not well tolerated in primary biliary cirrhosis. The toxicity of methotrexate and its inability to prevent complications of progressive liver disease or improve survival and the need for liver transplantation limits its utility. The benefits of ursodeoxycholic acid were again confirmed.
Collapse
Affiliation(s)
- Nancy Bach
- Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
70
|
Khettry U, Anand N, Faul PN, Lewis WD, Pomfret EA, Pomposelli J, Jenkins RL, Gordon FD. Liver transplantation for primary biliary cirrhosis: a long-term pathologic study. Liver Transpl 2003; 9:87-96. [PMID: 12514778 DOI: 10.1053/jlts.2003.36392] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although recurrent primary biliary cirrhosis (PBC) after liver transplantation (LT) has been reported, the full spectrum of changes and progression to fibrosis and cirrhosis is not yet established. We performed a detailed retrospective clinicopathologic analysis of 43 patients who underwent LT for PBC. Eight patients (18.6%) had definite recurrent PBC with florid duct lesions, 5 patients (11.6%) had recurrence with features of autoimmune liver disease, not otherwise specified (AILD-NOS), 7 patients (16.3%) had plasmacytosis only, 4 patients (9.3%) had chronic rejection, 18 patients (41.9%) have no recurrence at present, and 1 patient (2.3%) had acquired hepatitis C. Although definite diagnoses of PBC and AILD-NOS recurrences (n = 13) were made 1 month to 14 years (median, 4 years) post-LT, all patients had plasmacytosis in their earlier biopsy specimens. Also, these patients showed similar pre-LT and post-LT clinical features, with progressive fibrosis in 4 of 8 and 2 of 5 patients, respectively. Four of 13 patients with definite recurrence and 14 of 18 patients with no recurrence were administered azathioprine (AZA) as part of their post-LT therapy (P =.01). Six of 13 and 16 of 18 patients currently are alive, with median follow-ups of 11 and 5 years, respectively. No significant differences were seen with donor-recipient group A, group B, group O blood type, sex, or HLA mismatches; native liver histological characteristics; or tacrolimus-based therapy. In conclusion, recurrent autoimmune liver disease was seen in 30% of patients after LT for PBC and had features of PBC and/or AILD-NOS. Progression seen in 46% of patients was associated with late graft failure. Patients with no recurrent disease had shorter follow-up periods and more frequent immunosuppression, including AZA; some may still develop recurrence with longer follow-up.
Collapse
Affiliation(s)
- Urmila Khettry
- Department of Anatomic Pathology, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | | | | | | | | | | | | | | |
Collapse
|
71
|
Abstract
BACKGROUND Primary biliary cirrhosis is a rare autoimmune liver disease and an effective treatment has been difficult to establish. Some randomised clinical trials have found an effect of ursodeoxycholic acid for primary biliary cirrhosis. OBJECTIVES Evaluate the beneficial effects and adverse effects of peroral ursodeoxycholic acid for primary biliary cirrhosis versus placebo or no intervention. SEARCH STRATEGY The Controlled Trials Register of The Cochrane Hepato-Biliary Group, The Cochrane Library, MEDLINE, EMBASE and the full text of the identified studies were searched until April 2001. The electronic searches were done by entering the search terms 'ursodeoxycholic acid', 'UDCA', 'primary biliary cirrhosis', and 'PBC'. SELECTION CRITERIA Randomised clinical trials evaluating ursodeoxycholic acid administered perorally at any dose versus placebo or no intervention in patients with primary biliary cirrhosis diagnosed by any method. Only trials using an adequate method for randomisation were included, regardless of blinding and language. DATA COLLECTION AND ANALYSIS The methodologic quality of the randomised clinical trials was evaluated by components and the Jadad-score. The following outcomes were extracted: mortality, liver transplantation, pruritus, other clinical symptoms (jaundice, portal pressure, (bleeding) oesophageal varices, ascites, hepatic encephalopathy, hepato-renal syndrome, autoimmune conditions), liver biochemistry, liver function, liver biopsy findings, quality of life, and adverse events. All analyses were performed according to the intention-to-treat method. MAIN RESULTS A total of 16 randomised clinical trials evaluating ursodeoxycholic acid against placebo (n = 15) or no intervention (n = 1) in 1422 patients were identified. The median Jadad-score was 3 (range 1-5). A number of trials described as double blind had problems with the blinding. Neither mortality (odds ratio = 0.94; 95% confidence interval (CI) 0.60 to 1.48), liver transplantation (odds ratio = 0.83; 95% CI 0.52 to 1.32), mortality or liver transplantation (odds ratio = 0.90; 95% CI 0.65 to 1.26), pruritus, fatigue, autoimmune conditions, quality of life, liver histology, or portal pressure were significantly affected by ursodeoxycholic acid (given in doses of 8-15 mg/kg/day for three months to five years). However, ursodeoxycholic acid significantly (P < 0.05) reduced ascites, jaundice, and biochemical variables such as serum bilirubin and liver enzymes. Ursodeoxycholic acid was not significantly associated with adverse events. Including data after patients had been switched onto open label ursodeoxycholic acid confirmed the findings regarding the lack of a significant effect of ursodeoxycholic acid on mortality and mortality or liver transplantation. A significant (P = 0.04) effect was, however, observed on the incidence of liver transplantation (odds ratio = 0.68; 95% CI 0.48 to 0.98). REVIEWER'S CONCLUSIONS Ursodeoxycholic acid has a marginal therapeutic effect for primary biliary cirrhosis. On the positive side, ursodeoxycholic acid has few side effects. The general usage of ursodeoxycholic acid for primary biliary cirrhosis needs reevaluation.
Collapse
Affiliation(s)
- C Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, H:S Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark, DK-2100.
| | | |
Collapse
|
72
|
Schlichting J, Leuschner U. Drug therapy of primary biliary diseases: classical and modern strategies. J Cell Mol Med 2001; 5:98-115. [PMID: 12067457 PMCID: PMC6737770 DOI: 10.1111/j.1582-4934.2001.tb00144.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- J Schlichting
- Medizinische Klinik II, Johann-Wolfgang Goethe Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
| | | |
Collapse
|
73
|
Abstract
Although primary biliary cirrhosis (PBC) is generally a progressive disease, the rate of progression varies greatly from one patient to another. The terminal phase is characterized by hyperbilirubinaemia (>100 micromol/l), a major decrease in the number of intrahepatic bile ducts, and extensive fibrosis or cirrhosis. It is now well established that orthotopic liver transplantation is the treatment of choice for patients entering the terminal phase of the disease.A variety of therapeutic agents have been proposed for treatment of patients with PBC. However, most have been found ineffective or too toxic to be widely used. In contrast, there is accumulating evidence from large therapeutic trials that long-term administration of ursodeoxycholic acid (UDCA) is safe and prolongs survival free of liver transplantation. Treatment with UDCA slows the histological progression and delays the onset of cirrhosis. In patients who have a sub-optimal response to UDCA therapy alone, the combination of colchicine or methotrexate with UDCA has minimal or no additional benefit, whereas that with corticosteroids is more promising but not yet demonstrated. Among causes of non-response to UDCA therapy, the most common is the PBC-autoimmune hepatitis overlap syndrome. The benefit from the combination of corticosteroids and UDCA in this setting is obvious.Further studies are needed to define the patients who are most likely to respond to UDCA therapy and to assess the benefit of combined medical treatments.
Collapse
Affiliation(s)
- R Poupon
- Service d'Hépato-gastroentérologie, Hôpital Saint-Antoine, Paris, France
| | | |
Collapse
|
74
|
Potentiation of CD3-induced expression of the linker for activation of T cells (LAT) by the calcineurin inhibitors cyclosporin A and FK506. Blood 2000. [DOI: 10.1182/blood.v95.9.2733.009k06_2733_2741] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The activation of blood cells, including T cells, triggers intracellular signals that control the expression of critical molecules, including cytokines and cytokine receptors. We show that T-cell receptor (TCR) ligation increases the cellular level of the protein linker for activation of T cells (LAT), a molecule critical for T-cell development and function. T-cell activation increased LAT messenger RNA, as determined by reverse transcription–polymerase chain reaction and by Northern blotting. The TCR-induced increase in LAT expression involved the activation of the serine/threonine kinases PKC and MEK, because inhibitors of these kinases blocked the increase in LAT. Accordingly, the PKC activator phorbol myristate acetate up-regulated LAT expression. Strikingly, the calcineurin inhibitors cyclosporin A (CsA) and FK506 strongly potentiated TCR-induced LAT expression, suggesting that the activation of calcineurin following TCR ligation negatively regulates LAT expression. Accordingly, Ca++ ionophores, which can activate calcineurin by increasing intracellular Ca++, blocked the TCR-induced increase in cellular LAT. CsA and FK506 blocked the Ca++ionophores' inhibitory effect on LAT expression. Notably, CsA and FK506 preferentially up-regulated TCR-induced LAT expression; under the same conditions, these compounds did not increase the expression of 14 other molecules that previously had been implicated in T-cell activation. These data show that TCR-induced LAT expression involves the activation of the PKC-Erk pathway and is negatively regulated by the activation of calcineurin. Furthermore, the potentiation of TCR-induced LAT expression by CsA and FK506 suggests that the action of these agents involves up-regulating the cellular level of critical signaling molecules. These findings may have important therapeutic implications.
Collapse
|
75
|
Pasha T, Heathcote J, Gabriel S, Cauch-Dudek K, Jorgensen R, Therneau T, Dickson ER, Lindor KD. Cost-effectiveness of ursodeoxycholic acid therapy in primary biliary cirrhosis. Hepatology 1999; 29:21-6. [PMID: 9862844 DOI: 10.1002/hep.510290116] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Ursodeoxycholic acid (UDCA) is a safe and effective treatment for patients with primary biliary cirrhosis (PBC), but the cost of this drug has raised concerns regarding cost-effectiveness. The aim of our study was to determine the cost-effectiveness of UDCA in PBC. We compared the costs and outcomes of managing PBC patients with and without UDCA. From two previously published trials, the effectiveness of UDCA was determined by comparing the annual reduction in the development of ascites, varices, variceal bleeding, encephalopathy, liver transplantation, and death between the treatment groups. Average annual costs for each of these events were estimated based on literature and institutional data. Approximately twice as many major events occurred in the placebo group compared with the UDCA group. The relative risk (RR) of liver transplantation (1.95; 95% CI: 1.14-3.68) and development of esophageal varices (3. 11; 95% CI: 1.57-10.65) were significantly higher in the placebo group compared with the UDCA group. There were no significant increases in the RR of ascites, variceal bleeding, encephalopathy, or death between the two groups. Based on the estimated annual cost of managing these events and the annual costs of UDCA ($2,500), there was an annual cost savings per patient of $1,372. Compared with the placebo group, patients receiving UDCA had a lower incidence of major complications and lower medical care costs.
Collapse
Affiliation(s)
- T Pasha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester 55905, MN, USA
| | | | | | | | | | | | | | | |
Collapse
|
76
|
Vercauteren SB, Bosmans JL, Elseviers MM, Verpooten GA, De Broe ME. A meta-analysis and morphological review of cyclosporine-induced nephrotoxicity in auto-immune diseases. Kidney Int 1998; 54:536-45. [PMID: 9690221 DOI: 10.1046/j.1523-1755.1998.00017.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The risk-benefit ratio of cyclosporine A (CsA) is much more critical in some auto-immune diseases in comparison to transplantation medicine, due to its renal toxic potential. The present meta-analysis is based on an a priori defined methodology, and is linked with a review of CsA-induced morphological lesions, in order to draw relevant conclusions with regard to CsA-induced nephrotoxicity in auto-immune diseases. METHODS Only controlled, randomized trials with a treatment period of two months or more, published from January 1979 to August 1996, were selected for the evaluation of functional renal impairment due to CsA treatment. To assess the risk of developing nephrotoxicity during CsA therapy, individual peak rises in serum creatinine level were compared between the CsA-treated group and the control group. Nephrotoxicity was defined as an increase in serum creatinine level of 50% or more above baseline at least once during the study period. Papers reporting CsA-induced renal morphological lesions were reviewed. RESULTS A risk difference of 20.9% for developing nephrotoxicity, between a therapy with CsA and an alternative therapy, was found. Already after a treatment period of 12 months with low dose CsA (< or = 5 mg/kg/day), de novo nonspecific morphological damage could be induced in patients with auto-immune diseases. CONCLUSIONS From this analysis of the literature, it is obvious that a therapy with CsA in patients affected by auto-immune diseases is not without risk. A rigorous evaluation of the risk-benefit ratio is strongly recommended for each patient, with strict monitoring of serum creatinine and CsA trough levels during treatment. Renal biopsies during treatment must be seriously taken into consideration in patients who develop even a slight renal functional impairment, particularly when prolonged therapy of longer than one year, even with low dose CsA (< or = 5 mg/kg/day), is given.
Collapse
Affiliation(s)
- S B Vercauteren
- Department of Nephrology-Hypertension, University of Antwerp, Belgium
| | | | | | | | | |
Collapse
|
77
|
Batts KP, Wang X. Recurrence of primary biliary cirrhosis, autoimmune cholangitis and primary sclerosing cholangitis after liver transplantation. Clin Liver Dis 1998; 2:421-35, xi. [PMID: 15560041 DOI: 10.1016/s1089-3261(05)70016-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Given the usually prolonged natural history of primary biliary cirrhosis, autoimmune cholangitis, and primary sclerosing cholangitis, and the relatively recent introduction of orthotopic liver transplantation, our understanding of recurrence of these autoimmune diseases after orthotopic liver transplantation has been slow to evolve. Present data suggest that after orthotopic liver transplantation, patients with primary biliary cirrhosis will have persistence of serum antimitochondrial antibodies, develop histologic lesions suggestive of recurrent primary biliary cirrhosis with a frequency in the 8% to 16% range at 2 to 5 years after orthotopic liver transplantation, but will demonstrate little if any symptomatic disease as a consequence. Although data are extremely limited, autoimmune cholangitis patients will have a similar post-transplant course (without antimitochondrial antibodies). Recurrence of primary sclerosing cholangitis remains the most controversial, however, these patients probably develop nonanastomotic intrahepatic and extrahepatic strictures more frequently than patients without primary sclerosing cholangitis, with a frequency in the 20% to 25% range at 3 to 5 years. With longer patient follow-up and additional studies, it is hoped that our understanding of recurrent autoimmune biliary diseases will grow considerably in the future.
Collapse
Affiliation(s)
- K P Batts
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | |
Collapse
|
78
|
Mattalia A, Lüttig B, Rosina F, Leung PS, Van de Water J, Bauducci M, Ciancio A, Böker KH, Worman H, Cooper RL, Manns M, Ansari A, Rizzetto M, Gershwin ME. Persistence of autoantibodies against recombinant mitochondrial and nuclear pore proteins after orthotopic liver transplantation for primary biliary cirrhosis. J Autoimmun 1997; 10:491-7. [PMID: 9376077 DOI: 10.1006/jaut.1997.0156] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Primary biliary cirrhosis is an autoimmune disease characterized by high titer autoantibodies predominantly against mitochondrial antigens PDC-E2, BCOADC-E2 and OGDC-E2. Currently orthotopic liver transplant (OLT) is the major form of treatment for end-stage primary biliary cirrhosis (PBC), but it is still unclear whether the autoimmune response continues post-transplantation. In this study we took advantage of a well-defined collection of sera collected serially before and after liver transplantation. We assayed these sera for quantitative and isotype-specific titers of antibodies against a set of recombinant mitochondrial autoantigens. We also studied reactivity to gp210. Serum samples were taken before transplantation and at intervals of 6 months, 1, 2, and 3 years after OLT. Before OLT 24/35 patients were AMA-positive, including seven out of the 35 to PDC-E2 alone, eight to both PDC-E2 and OGDC-E2, six to both PDC-E2 and BCOADC-E2, two to BCOADC-E2 alone and one to OGDC-E2. Following OLT, the frequency of sera that responded to PDC-E2 alone increased from seven to 12/35. Similarly, reactivity to BCOADC-E2 slightly increased from two to four out of 35. However, there was an overall decrease in sera that responded to more than one antigen. Neither Ig isotype nor subclass of the autoimmune response changed following OLT. Findings with gp210 were similar, in that reactivity to gp210 was found in nine out of 35 patients pre-OLT; following OLT the frequency decreased to seven out of 35 patients. Overall, the titers of AMAs decline slightly during the first year post-OLT, but are equivalent to pre-OLT values by 6 months. Moreover, the antibody subclass/ isotype remained unchanged. These data suggest that the removal of a diseased PBC liver has little, if any, impact on the serological characteristics of PBC. Moreover, it provides information regarding the natural history of PBC, particularly on the long latency time for disease development.
Collapse
Affiliation(s)
- A Mattalia
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA 95616, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
79
|
Affiliation(s)
- M M Kaplan
- Division of Gastroenterology, New England Medical Center, Boston, MA 02111, USA
| |
Collapse
|
80
|
Bennett WM, DeMattos A, Meyer MM, Andoh T, Barry JM. Chronic cyclosporine nephropathy: the Achilles' heel of immunosuppressive therapy. Kidney Int 1996; 50:1089-100. [PMID: 8887265 DOI: 10.1038/ki.1996.415] [Citation(s) in RCA: 351] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- W M Bennett
- Division of Nephrology, Hypertension and Clinical Pharmacology, Oregon Health Sciences University, Portland 97201, USA
| | | | | | | | | |
Collapse
|
81
|
Galperin C, Gershwin ME. Immunopathology of primary biliary cirrhosis. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1996; 10:461-81. [PMID: 8905119 DOI: 10.1016/s0950-3528(96)90053-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Our understanding of the immunopathology of PBC has dramatically changed with the application of molecular biology techniques in clinical medicine. This has allowed, not only the possibility of characterizing mitochondrial autoantigens fully at the molecular level, but also the identification of specific sites on these molecules that are targetted by autoreactive B and T cells. In addition, the expression of cloned antigens has facilitated the development of the most reliable assays currently available for the detection of mitochondrial autoantibodies. The assessment of the pathogenic capacity of autoreactive T cells, as well as the characterization the PDC-E2 'look alike' molecule expressed on the cell membrane of PBC biliary epithelial cells, remain the major unsolved issues in this disease. Ideally, the continuous effort from both basic and clinical scientist in understanding the pathogenic mechanisms of PBC will lead to more specific, effective, and safer modalities of treatment.
Collapse
Affiliation(s)
- C Galperin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis School of Medicine 95616, USA
| | | |
Collapse
|
82
|
Abstract
The majority of cholestatic liver diseases can be diagnosed with a carefully performed history taking, physical examination, and appropriate imaging studies. In a minority of cases, however, liver biopsy may be necessary to establish the diagnosis. In addition to the treatment of the specific liver disease, therapy should address the management of complications unique to cholestasis and progressive liver failure.
Collapse
Affiliation(s)
- T M Pasha
- Mayo Clinic, Rochester, Minnesota 55905, USA
| | | |
Collapse
|
83
|
Ikeda T, Sato C, Noguchi O, Kobayashi F, Tozuka S, Sakamoto S, Marumo F. Improvement of peripheral blood lymphocyte subsets in primary biliary cirrhosis after ursodeoxycholic acid therapy. J Gastroenterol Hepatol 1996; 11:366-72. [PMID: 8713704 DOI: 10.1111/j.1440-1746.1996.tb01385.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Immunological abnormalities frequently observed in patients with primary biliary cirrhosis are considered to be related to the pathogenesis of this disease. We performed a prospective trial to evaluate whether immune mechanisms play a role in the effectiveness of ursodeoxycholic acid (UDCA) therapy. Fifteen female patients with primary biliary cirrhosis were followed for 1 year and were then treated with UDCA (600 mg/day) for another year. Laboratory tests, including peripheral blood lymphocyte subsets assessed by dual colour fluorescence analysis using monoclonal antibodies against respective T cell markers, were evaluated at the beginning of the study, at the start of therapy and at the end of therapy. In primary biliary cirrhosis, the proportion of cytotoxic T cells, suppressor inducer T cells and alpha beta-receptor bearing T cells were significantly lower than in healthy controls. No significant changes were observed in the proportions during the year before the therapy. These reductions, however, recovered to normal ranges after 1 year of UDCA therapy. These changes were associated with an improvement in the serum levels of aspartate aminotransferase, alkaline phosphatase, gamma-globulin and IgM. The close correlation between the improvement in the imbalance of lymphocyte subsets after the therapy and the clinical status suggests that an immunological process may play a role in the effectiveness of therapy in primary biliary cirrhosis.
Collapse
Affiliation(s)
- T Ikeda
- Department of Internal Medicine, Yokosuka Kyousai Hospital, Kanagawa, Japan
| | | | | | | | | | | | | |
Collapse
|
84
|
Abstract
Immunomodulatory agents represent a unique group of therapies that are not biologics and have relatively specific, noncytotoxic effects on the immune system. Cyclosporine has been the most widely tested of the immunomodulatory agents and shown efficacy in a variety of autoimmune diseases as well as monotherapy in established rheumatoid arthritis. FK-506 and rapamycin, agents similar to cyclosporine, are being tested in human transplantation, with only arthritis studies having been done in animals. Tilomisole, imuthiol, and mycophenolate mofetil have been studied in limited rheumatoid arthritis trials with positive effects. Although more specific and with manageable short-term side effects, this group of therapies requires more studies to establish their efficacy and long-term safety.
Collapse
Affiliation(s)
- D E Yocum
- Arizona Health Sciences Center, University of Arizona, Tucson, USA
| |
Collapse
|
85
|
Ikeda T, Tozuka S, Noguchi O, Kobayashi F, Sakamoto S, Marumo F, Sato C. Effects of additional administration of colchicine in ursodeoxycholic acid-treated patients with primary biliary cirrhosis: a prospective randomized study. J Hepatol 1996; 24:88-94. [PMID: 8834030 DOI: 10.1016/s0168-8278(96)80191-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIMS Although ursodeoxycholic acid is effective for the treatment of primary biliary cirrhosis, some patients do not respond to this treatment. The objective of the present study was to investigate the effects of additional administration of colchicine in ursodeoxycholic acid-treated patients with primary biliary cirrhosis. METHODS Twenty-two patients with primary biliary cirrhosis treated with ursodeoxycholic acid (600 mg/day) for 30 months were randomly assigned to two groups: group 1, colchicine (1 mg/day) and ursodeoxycholic acid (n = 10); group 2, ursodeoxycholic acid alone (n = 12). RESULTS In group 1, there were significant decreases in mean serum levels of alkaline phosphatase, total bilirubin, gamma-glutamyltranspeptidase, alanine aminotransferase, aspartate aminotransferase, and IgM, and these changes were more remarkable in those who responded poorly to ursodeoxycholic acid. In contrast, there were no significant changes in those values in group 2. CONCLUSIONS Additional administration of colchicine to ursodeoxycholic acid may be beneficial for patients with primary biliary cirrhosis, especially those who respond poorly to ursodeoxycholic acid. It is necessary, however, to further confirm the efficacy of colchicine by examining histological changes and following the patients for longer periods.
Collapse
Affiliation(s)
- T Ikeda
- Department of Internal Medicine, Yokosuka Kyousai Hospital, Kanagawa, Japan
| | | | | | | | | | | | | |
Collapse
|
86
|
Abstract
Pruritus is a common symptom in patients with hepatobiliary disease. Numerous treatments have been attempted. We review published therapeutic trials for hepatobiliary pruritus and utilize statistical analysis to evaluate treatment results. Randomized placebo-controlled studies show cholestyramine, rifampin, naloxone, S-adenosylmethionine, prednisolone, and propofol to be effective. Suggestions for future studies of the treatment of hepatobiliary puruitus are proposed.
Collapse
Affiliation(s)
- C S Connolly
- Division of Dermatology, Philadelphia College of Osteopathic Medicine, PA, USA
| | | | | |
Collapse
|
87
|
Jorgensen RA, Dickson ER, Hofmann AF, Rossi SS, Lindor KD. Characterisation of patients with a complete biochemical response to ursodeoxycholic acid. Gut 1995; 36:935-8. [PMID: 7615288 PMCID: PMC1382637 DOI: 10.1136/gut.36.6.935] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ursodeoxycholic acid (UDCA) leads to biochemical and clinical improvement in many patients with primary biliary cirrhosis (PBC); although, the response is variable. This study compared UDCA treated patients with complete normalisation of biochemical functions to those without such improvement. Of the 65 patients receiving UDCA, 12 (19%) showed normalisation of liver biochemical functions at two years. The remaining 53 patients showed a less complete response. Mean (SD) alkaline phosphatase and total serum bilirubin values were significantly lower at entry in the patients whose liver biochemistry tests normalised (912 (732) U/l v 1417 (1021) U/l, p = 0.003, and 0.7 (12.1 (5.2) mumol/l v 38.9 (48.5) mumol/l, p = 0.0002, respectively), and percentage of UDCA in biliary bile acid was higher (56.3 (9.5)% v 38.3 (21.1)%, p = 0.03). Patients with biochemically and histologically less severe disease, and greater enrichment of biliary bile with UDCA, are more likely to respond favourably to the drug. The main objective of continued study will be to find out if normal liver biochemical functions can retard disease progression. The association of greater UDCA enrichment with complete biochemical responses suggests that higher doses of UDCA should be evaluated.
Collapse
Affiliation(s)
- R A Jorgensen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | | | |
Collapse
|
88
|
|
89
|
Duclos-Vallée JC, Hadengue A, Ganne-Carrié N, Robin E, Degott C, Erlinger S. Primary biliary cirrhosis-autoimmune hepatitis overlap syndrome. Corticoresistance and effective treatment by cyclosporine A. Dig Dis Sci 1995; 40:1069-73. [PMID: 7729266 DOI: 10.1007/bf02064201] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We report a case of primary biliary cirrhosis-autoimmune hepatitis overlap syndrome treated with cyclosporine A. Features of primary biliary cirrhosis were pruritus, high titer of antimitochondrial antibodies, inflammatory infiltrates surrounding interlobular bile ducts, and periportal granuloma. Features suggestive of autoimmune hepatitis were high titer of antinuclear antibodies, very high total immunoglobulins, and piecemeal necrosis. Because corticosteroids and ursodeoxycholic acid were inefficient, cyclosporine A was started at a dose of 3 mg/kg/day. A dramatic improvement in clinical condition, liver tests, and histology was noted. Discontinuation of cyclosporine A was followed by a clinical and histological relapse. Cyclosporine A reintroduction was again associated with a significant improvement. This case report suggests that in corticoresistant cases cyclosporine A could be an effective therapy for primary biliary cirrhosis-autoimmune hepatitis overlap syndrome.
Collapse
|
90
|
Poupon R, Poupon RE. Ursodeoxycholic acid therapy of chronic cholestatic conditions in adults and children. Pharmacol Ther 1995; 66:1-15. [PMID: 7630925 DOI: 10.1016/0163-7258(94)00073-c] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Cholestasis can be defined as the manifestation of defective bile acid transport from the liver to the intestine. Most chronic cholestatic conditions can progress towards cirrhosis. At this stage, liver transplantation is the treatment of choice. Most of the drugs so far evaluated show some degree of efficacy but have major side effects. Given that ursodeoxycholic acid (UDCA) has no apparent toxicity in humans, it was postulated that long-term treatment with this drug might displace endogenous bile acids and thus reverse their suspected toxicity. We demonstrated that long-term UDCA therapy slows the progression of primary biliary cirrhosis and reduces the need for liver transplantation. In this review, we give the rationale for the use of UDCA in cholestasis and discuss its possible mechanisms of action. We also give an overview of current data on UDCA therapy of chronic cholestatic disorders in adults and children.
Collapse
Affiliation(s)
- R Poupon
- Unité d'Hépato-Gastroentérologie, Hôpital Saint-Antoine, Paris, France
| | | |
Collapse
|
91
|
Boxt LM, Katz J, Reagan K. Drug-induced changes in the radiographic appearance of the heart. Semin Roentgenol 1995; 30:49-61. [PMID: 7899883 DOI: 10.1016/s0037-198x(05)80006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- L M Boxt
- Department of Radiology, College of Physicians and Surgeons of Columbia University, New York, NY
| | | | | |
Collapse
|
92
|
Nakamura M, Ishibashi H, Matsui M, Shimoda S, Hayashida K, Koike K, Niho Y. Peripheral B lymphocyte repertoire to mitochondrial antigen in primary biliary cirrhosis--positive correlation between the disease activity and the frequency of circulating B lymphocytes specific for pyruvate dehydrogenase complex. Autoimmunity 1995; 21:253-62. [PMID: 8852516 DOI: 10.3109/08916939509001944] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
B lymphocytes committed to the production of IgG antibodies (Abs) to mitochondrial antigen such as pyruvate dehydrogenase complex(PDC) were quantitated in the peripheral blood of patients with primary biliary cirrhosis(PBC) using Epstein-Barr virus as a polyclonal activator of human B lymphocytes. B lymphocytes committed to the production of IgG Abs to PDC were found in high frequency in patients with PBC(0.54 +/- 0.16%, mean value +/- SE, of total IgG-producing B lymphocytes) in contrast to type C chronic hepatitis and healthy subjects in which they were less than 0.01%. The frequency of these B lymphocytes specific for PDC increased in parallel to the progression of the Scheuer's stage from I to II (stage I: 0.35 +/- 0.23%, stage II: 1.04 +/- 0.32%), but decreased with further progression to stage IV (stage III: 0.39 +/- 0.21%, stage IV: 0.07 +/- 0.06%). In addition, B lymphocytes specific for PDC decreased in the peripheral blood during the administration of cyclosporin A; this was accompanied by an improvement of lymphocyte infiltration severity in the liver. These data indicate that B lymphocytes specific for PDC are present in the peripheral blood of patients with PBC and their frequency reflects the degree of the lymphocyte infiltration in the liver.
Collapse
Affiliation(s)
- M Nakamura
- First Department of Internal Medicine, Kyushu University, Fukuoka, Japan
| | | | | | | | | | | | | |
Collapse
|
93
|
Román ID, Coleman R. Disruption of canalicular function in isolated rat hepatocyte couplets caused by cyclosporin A. Biochem Pharmacol 1994; 48:2181-8. [PMID: 7811299 DOI: 10.1016/0006-2952(94)90352-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Isolated rat hepatocyte couplets were used to study the effects of different concentrations of cyclosporin A in relation to canalicular function. Canalicular function was assessed by counting the percentage of couplets which were able to accumulate the fluorescent cholephile cholyl lysyl fluorescein (CLF) into the canalicular vacuole between the two cells, i.e. canalicular vacuole accumulation (CVA). At lower doses, the immunosuppressor increased the CVA, reaching 121 +/- 3.86% of control at 25 nM cyclosporin A. However, higher doses of cyclosporin A induced a concentration-dependent inhibition of CVA to 64.0 +/- 3.51% of control at 100 nM. Modifications in canalicular area (as % couplet area) were also observed. Image analysis of the fluorescent image showed that cyclosporin A (25 nM) increased canalicular area by 25% (of control); however, this parameter decreased to 36% of control at 100 nM cyclosporin A. In addition, at 100 nM, cyclosporin A reduced the proportion of couplets retaining CLF within the canaliculus to 75.0 +/- 6.59% of control. Treatment of couplets with cyclosporin A (0-2 microM) for 15 min revealed that reduced glutathione (GSH) intracellular content does not change significantly at these doses. However, alteration in pericanalicular F-actin at 100 nM cyclosporin A may be an important factor in the disruption of the canalicular function induced by higher doses of the immunosuppressor.
Collapse
Affiliation(s)
- I D Román
- School of Biochemistry, University of Birmingham, Edgbaston, U.K
| | | |
Collapse
|
94
|
Teoh KL, Rowley MJ, Zafirakis H, Dickson ER, Wiesner RH, Gershwin ME, MacKay IR. Enzyme inhibitory autoantibodies to pyruvate dehydrogenase complex in primary biliary cirrhosis: applications of a semiautomated assay. Hepatology 1994. [PMID: 7927255 DOI: 10.1002/hep.1840200518] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Sera from patients with primary biliary cirrhosis inhibit the activity of the mitochondrial pyruvate dehydrogenase complex. We utilized this effect to develop a simple, miniaturized, semiautomated spectrophotometric assay as a diagnostic aid. The sera studied were from 71 patients with primary biliary cirrhosis and 62 other subjects. The assays included enzyme inhibition, immunofluorescence on HEp-2 cells, enzyme-linked immunosorbent assay using recombinant pyruvate dehydrogenase complex-E2 and immunoblotting on bovine heart mitochondria. With the 71 primary biliary cirrhosis sera, on which M2 antibody was detected by immunofluorescence in 64 (90%), antibodies against pyruvate dehydrogenase complex were detected in 53 (83%) by means of enzyme inhibition, in 57 (89%) by means of enzyme-linked immunosorbent assay and in 60 (94%) by means of immunoblotting. Of the 64 sera positive by immunofluorescence, 60 reacted with pyruvate dehydrogenase complex-E2 on immunoblotting, and the miniaturized enzyme inhibition assay was positive in 53 of these. The enzyme inhibition assay and enzyme-linked immunosorbent assay were calibrated to give a specificity of 100%. At this level, the sensitivities for detection of pyruvate dehydrogenase complex antibody were 83% and 87%, respectively. We found no significant changes in levels of reactivity with the enzyme inhibition assay or enzyme-linked immunosorbent assay according to disease stage. Treatment with cyclosporine was accompanied by a significant decrease in levels of antibody to pyruvate dehydrogenase complex-E2 that matched improved indexes of biochemical liver function.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- K L Teoh
- Center for Molecular Biology and Medicine, Monash University, Clayton, Victoria, Australia
| | | | | | | | | | | | | |
Collapse
|
95
|
Leuschner U, Güldütuna S, Imhof M, Hübner K, Benjaminov A, Leuschner M. Effects of ursodeoxycholic acid after 4 to 12 years of therapy in early and late stages of primary biliary cirrhosis. J Hepatol 1994; 21:624-33. [PMID: 7814810 DOI: 10.1016/s0168-8278(94)80111-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Twenty-two patients with primary biliary cirrhosis were treated with ursodeoxycholic acid, 10 mg/kg per day. Fourteen patients with stages I/II were treated for 4-12 years (mean 7.5), and eight patients with stages III/IV for 5-12 years (mean 6.5). Twelve of 13 patients with early stages became asymptomatic. Aminotransferases, cholestasis-indicating enzymes and IgM improved (p < 0.01) and remained low during the whole treatment period. Ursodeoxycholic acid was the predominant serum bile acid, and lithocholic acid did not increase in the serum but did increase in the stool. Of eight patients with stages III/IV, seven were symptomatic, and four became asymptomatic. In all eight patients, laboratory data improved. Of these eight patients three experienced haemorrhage from oesophageal varices, two had to be transplanted, and one of them died. In one patient splenic rupture occurred, and in three liver function tests deteriorated. Although the number of patients was small, this is the longest treatment period so far reported. Ursodeoxycholic acid had no side effects for up to 12 years, and in patients with early stages it seemed to have a beneficial effect on symptoms and the progression of the disease. However, even with up to 12 years of therapy, ursodeoxycholic acid did not cause antimitochondrial antibodies to disappear either in the early or in the late stages, it was unable to prevent rebound effects during therapy intermission even after more than 5 years of continuous therapy, there was no decisive influence on liver histology and it did not cure the disease. Finally, although ursodeoxycholic acid improved life quality and laboratory data in all patients with late stages of the disease, it did not prevent complications due to cirrhosis.
Collapse
Affiliation(s)
- U Leuschner
- Department of Gastroenterology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | | | | | | | | | | |
Collapse
|
96
|
McCormick PA, Scott F, Epstein O, Burroughs AK, Scheuer PJ, McIntyre N. Thalidomide as therapy for primary biliary cirrhosis: a double-blind placebo controlled pilot study. J Hepatol 1994; 21:496-9. [PMID: 7814794 DOI: 10.1016/s0168-8278(94)80092-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Thalidomide has been reported to be effective in treating graft-versus-host disease, a condition with many clinical and pathological similarities to primary biliary cirrhosis. We performed a double-blind, placebo-controlled pilot study to assess the efficacy of thalidomide in 18 patients with biopsy-proven primary biliary cirrhosis (10 thalidomide, 8 placebo). Each patient was treated for 6 months and had a liver biopsy before and after treatment. Side effects, particularly sedation and fatigue, were more common on thalidomide and two patients were withdrawn from this group. There were no improvements in liver function tests or in liver histology, assessed morphometrically. A number of patients treated with thalidomide reported an improvement in pruritus. This study suggests that thalidomide is unlikely to be effective in altering the natural history of primary biliary cirrhosis.
Collapse
Affiliation(s)
- P A McCormick
- University Department of Medicine, Royal Free Hospital School of Medicine, London, United Kingdom
| | | | | | | | | | | |
Collapse
|
97
|
Robson SC, Neuberger JM, Williams R. The influence of cyclosporine A therapy on sex hormone levels in pre- and post-menopausal women with primary biliary cirrhosis. J Hepatol 1994; 21:412-6. [PMID: 7836711 DOI: 10.1016/s0168-8278(05)80321-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The mechanism underlying sex hormone disturbances in post-menopausal women with primary biliary cirrhosis is unclear, but these alterations may occur as a consequence of liver disease. As cyclosporine may have some therapeutic potential is this condition, we have evaluated short-term alterations in plasma sex hormone levels in 11 pre- and 19 post-menopausal women with primary biliary cirrhosis following randomisation to cyclosporine A or placebo therapy. Baseline sex hormone binding globulin levels were markedly depressed in all pre-menopausal women but were elevated for the post-menopausal group when compared to standard reference ranges. Testosterone and dihydrotestosterone levels were low or markedly depressed in both patient groups. Androstendione concentrations tended to be higher than the normal range in the post-menopausal group. Oestradiol levels were within the normal range for the pre-menopausal group but were relatively higher in the post-menopausal group than in other normal post-menopausal women. Cyclosporine A therapy resulted in significant decreases in sex hormone binding globulin levels (26.6 +/- 5.0 to 16.2 +/- 4.6 nmol/l; p < 0.05) in the premenopausal group and reduction in total (336 +/- 163 to 140 +/- 132 pmol/l; p < 0.01) and free (6 +/- 5 to 2 +/- 3 pmol/l; p < 0.05) oestradiol levels in the post-menopausal group at 6 months. There were no significant alterations in other hormonal parameters. No temporal changes occurred in the placebo group. Cyclosporine A therefore induces significant but variable sex hormone changes in both pre- and post-menopausal women with primary biliary cirrhosis.
Collapse
Affiliation(s)
- S C Robson
- Institute of Liver Studies, Kings College Hospital, London, UK
| | | | | |
Collapse
|
98
|
Poupon RE, Poupon R, Balkau B. Ursodiol for the long-term treatment of primary biliary cirrhosis. The UDCA-PBC Study Group. N Engl J Med 1994; 330:1342-7. [PMID: 8152446 DOI: 10.1056/nejm199405123301903] [Citation(s) in RCA: 325] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ursodiol (ursodeoxycholic acid) therapy leads to major improvements in patients with primary biliary cirrhosis. The benefit of long-term treatment is uncertain. METHODS We randomly assigned 145 patients with biopsy-proved primary biliary cirrhosis to receive ursodiol (13 to 15 mg per kilogram of body weight per day) (72 patients) or placebo (73 patients). After two years of follow-up, because of the benefit from ursodiol, all patients completing the study received ursodiol in an open trial and were monitored for two more years. The end points in the assessment of efficacy were as follows: progression of disease, as defined by the presence of hyperbilirubinemia, variceal bleeding, ascites, or encephalopathy; liver transplantation or a referral for that procedure; and liver transplantation (or a referral) or death. RESULTS Disease progressed significantly less frequently in the ursodiol group than in the placebo group (P < 0.002; relative risk, 0.28; 95 percent confidence interval, 0.12 to 0.63). The probability of liver transplantation or a referral for that procedure and the probability of transplantation or death were significantly lower in the group assigned to ursodiol than in the group assigned to placebo (for transplantation alone, P = 0.003; relative risk, 0.21; 95 percent confidence interval, 0.07 to 0.66; for transplantation or death, P = 0.005; relative risk, 0.32; 95 percent confidence interval, 0.14 to 0.74). High bilirubin levels and, to a lesser extent, signs of cirrhosis at entry into the trial were predictive of disease progression, liver transplantation or a referral, and transplantation or death. CONCLUSIONS Long-term ursodiol therapy slows the progression of primary biliary cirrhosis and reduces the need for liver transplantation.
Collapse
|
99
|
Abstract
The utility of MRI using magnetization transfer (MT) enhanced pulse sequences to diagnose hepatic cirrhosis in a rat model was investigated. Hepatic T1 was measured with and without MT off-resonance RF pulses in 17 treated and six control rats. The livers were evaluated histologically, and the hydroxyproline content quantitatively measured. We did not find a statistically significant linear correlation between the MR relaxation times and the degree of tissue injury. However, the MR measurements performed with MT were superior to those without differentiating the treated and control groups. Specifically, the T1 times were 695 +/- 76 ms for the treated group, versus 748 +/- 61 ms in the controls; P = 0.095. The T1sat times were also lower in the treated group, with statistical significance: 367 +/- 51 ms versus 421 +/- 38 ms, P = 0.016. Finally, the change in the relaxation rates (the inverse of the relaxation times) with and without saturation were 1.31 +/- 0.22 s-1 (treated group) versus 1.05 +/- 0.12 s-1 (controls), which differed significantly, P = 0.001.
Collapse
Affiliation(s)
- A M Aisen
- Department of Radiology, University of Michigan, Ann Arbor
| | | | | |
Collapse
|
100
|
Heathcote EJ, Cauch-Dudek K, Walker V, Bailey RJ, Blendis LM, Ghent CN, Michieletti P, Minuk GY, Pappas SC, Scully LJ, Steinbrecher UP, Sutherland LR, Williams CN, Witt-Sullivan H, Worobetz LJ, Milner RA, Wanless IR. The Canadian Multicenter Double-blind Randomized Controlled Trial of ursodeoxycholic acid in primary biliary cirrhosis. Hepatology 1994. [PMID: 8175136 DOI: 10.1002/hep.1840190512] [Citation(s) in RCA: 241] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ursodeoxycholic acid, a dihydroxyl bile acid normally present in human beings in minimal amounts, becomes incorporated into the bile salt pool when taken orally. In cholestasis, bile acids are retained in the liver and are hepatotoxic. Ursodeoxycholic acid is the least-known hepatotoxic bile acid, has choleretic properties and is reported to benefit patients with chronic cholestasis. In a nationwide Canadian controlled trial, 222 patients with primary biliary cirrhosis were treated with ursodeoxycholic acid (14 mg/kg/body wt/day) or placebo for 24 mo. Only patients with a diagnosis confirmed by liver biopsy and serum positive for antimitochondrial antibodies were enrolled; 88% were symptomatic on entry. The primary outcome measure was percent change in total serum bilirubin from baseline to final follow-up. Treated patients (111) and controls (111) were comparable with regard to age, gender, biochemical parameters and liver histological condition. Although treatment was not associated with any improvement in symptoms, ursodeoxycholic acid therapy caused the bilirubin to fall significantly within the first 3 mo of therapy (p < 0.001). Significant falls in serum alkaline phosphatase, aminotransferases, cholesterol and IgM levels were also noted in the treated group. Improvement in some histological features was observed but there was no difference between the groups in the number of patients who reached the endpoints of death or liver transplantation. Ursodeoxycholic acid, given to patients with primary biliary cirrhosis, leads to an improvement in serum markers of cholestasis. A larger sample size is needed to determine whether ursodeoxycholic acid therapy has a beneficial effect on the survival of patients with primary biliary cirrhosis.
Collapse
Affiliation(s)
- E J Heathcote
- Department of Medicine, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|