Interferon alfa-2a therapy in cryoglobulinemia associated with hepatitis C virus

Pre-malignant and malignant lymphoproliferations in an HCV-infected type II mixed cryoglobulinemic patient are sequential phases of an antigen-driven pathological process

Type II mixed cryoglobulinemia (MC) is a systemic vasculitis characterized by the presence in the serum of a monoclonal cryoprecipitable IgM with rheumatoid factor (RF) activity. Hepatitis C virus (HCV) has been recognized as its major etiologic factor. Because MC frequently evolves into overt B-cell non-Hodgkin's lymphoma (NHL), chronic HCV infection is hypothesized to lead to both benign and malignant lymphoproliferative disease. In this study, we investigated mutations in the V(H) and V(K) genes of the B-cell clone originating the overt B-cell lymphoma in a subject with MC. Mutational patterns were analyzed longitudinally in two bone marrow biopsies obtained at the stage of MC, as well as in multiple involved tissues (bone marrow, liver, and peripheral blood cells) at the stage of overt NHL. Hybridization of variable-diversity-joining (VDJ) PCR products with a probe specific for the neoplastic clone indicated that the lymphoma originated from one of the clones over-stimulated during MC. This clone producing an IgM highly homologous to a protein with RF specificity may explain the MC syndrome in the patient. Moreover, the presence of an IgH ongoing mutation process and the expression of an Ig antigen receptor significantly homologous to an anti-HCV protein support the hypothesis that the MC syndrome and the subsequent evolution to NHL are antigen-driven lymphoproliferative processes possibly sustained by HCV. Furthermore, the marked reduction in intra-clonal diversity in the last bone marrow biopsy obtained at the stage of overt NHL points out a minor dependence of the cells on the antigen-driven mechanism, although an intrinsic propensity of the neoplastic cell to undergo replacement mutations cannot be excluded.

Mixed cryoglobulinemia: new concepts

The most documented extrahepatic manifestation of hepatitis C virus (HCV) infection is mixed cryoglobulinemia (MC). MC is characterised by the presence of temperature-sensitive protein complexes: in type II MC, cryoglobulins are composed of a monoclonal rheumatoid factor (usually, IgMkappa) against polyclonal IgG. In type III MC, all components are polyclonal. The presence of microheterogeneity and other new types of cryoglobulins is a novel and recent observation. The production of different autoantibodies and circulating immune complexes, including the cryoglobulins, are responsible for systemic vasculitis and various organ damage. In a limited number of MC patients, a malignancy, that is B-cell non-Hodgkin's lymphoma or hepatocellular carcinoma, may also develop. Finally, results of interferon and/or ribavirin treatments in MC patients represent an indirect proof for the pathogenetic link between MC and HVC infection. The discovery of the relation between HCV infection and MC shows the striking association between a viral infection and an autoimmune disease and, thus, a potential link between the systemic autoimmune and lymphoproliferative disorders.

Splenectomy may improve the glomerulopathy of type II mixed cryoglobulinemia

Many patients with type II mixed cryoglobulinemia have been shown to be infected with hapatitis C virus (HCV). Therefore, interferon-alfa has become the first choice of treatment for patients with HCV-associated cryoglobulinemia. However, the disease often relapses after the discontinuation of interferon therapy. The long-term effect of interferon therapy is controversial. Therefore, a more effective therapy needs to be developed. A 62-year-old Japanese woman was admitted to our hospital for the examination of abnormal liver function tests, severe edema, and purpura in her lower extremities. Glomerulopathy secondary to HCV-related cryoglobulinemia was suspected. Her serum creatinine was increased to 2.1 mg/dL. Interferon therapy was considered initially. However, because of pancytopenia caused by liver cirrhosis and splenomegaly, splenectomy was performed in February 1997, before the start of interferon therapy. Renal biopsy specimen taken at the time of the splenectomy showed typical cryoglobulinemic glomerulonephritis. Gradually, after surgery, the patient's thrombocytopenia and anemia improved, her proteinuria and hematuria were decreased, her cryocrit dropped from 15% to 5%, the Ccr increased from 21.1 mL/min to 48.8 mL/min, and the purpura in her lower extremities disappeared. A repeat renal biopsy performed in May 1998 showed marked histological improvement. Splenectomy is not widely accepted as a treatment for cryoglobulinemia. Our case suggests the possibility that the monoclonal-IgM component of the type II cryoglobulin may be formed in the spleen. In conclusion, splenectomy may be an effective therapy for cryoglobulinemia in patients with HCV-positive liver cirrhosis and pancytopenia secondary to splenomegaly.

Symptomatic cryoglobulinemia

1. Treatment of symptomatic cryoglobulinemia is exceedingly challenging due to the multisystemic nature of its presentation, the variability of its course, and the paucity of effective therapeutic options supported by randomized controlled clinical trials. 2. Patients with mild, relatively asymptomatic disease should be observed without introduction of systemic therapy. 3. Patients with symptomatic type I secondary cryoglobulinemia should be treated as appropriate for their underlying lymphoproliferative or plasmaproliferative disorder. 4. Patients with secondary type II or type III cryoglobulinemia should be treated for their underlying connective tissue, lymphoproliferative, or liver disorder or infection. 5. First line treatment for symptomatic, essential type II or type III cryoglobulinemia associated with hepatitis C should include interferon (IFN)-alpha. Depending on the severity of clinical presentation, adjuvant corticosteroids or plasmapheresis should be considered. 6. Life-threatening or acute organ-threatening presentations should be managed with combined modality therapy, which should include high-dose corticosteroid, plasmapheresis, or alkylator-based therapy. 7. Many chemotherapeutic and immunosuppressive strategies have been tried but not systematically tested; their value is therefore unknown. 8. Challenges for the future of treating symptomatic cryoglobulinemia include devising better therapies and more systematic evaluation of existing therapies.

Hepatitis C virus risk: a hepatitis C virus related syndrome

BACKGROUND

The association between mixed cryoglobulinemia (MC) and hepatitis C virus (HCV) infection has been recently described in many reports.

OBJECTIVE

The aim of this study was to evaluate the long-term prognosis of hepatitis C virus-positive patients affected by mixed cryoglobulinemia with or without kidney involvement.

PATIENTS

At total of 119 hepatitis C virus-positive patients affected by mixed cryoglobulinemia were divided in two groups. Group A: mixed cryoglobulinemia without kidney involvement (103 cases); group B: mixed cryoglobulinemia with glomerulonephritis (GN) (16 cases). A further 37 patients affected by mesangio-proliferative glomerulonephritis (MPGN) were evaluated as controls (group C).

METHODS

Anti-hepatitis C virus antibodies were determined by commercial kits and hepatitis C virus-RNA was detected by polymerase chain reaction (PCR) amplification of the 5' untranslated region (5'UTR) of the virus. The hepatitis C virus genotype was determined according to Okamoto. Liver biopsy was performed in 62 patients, bone marrow biopsy in 65 patients, and kidney biopsy in all patients with proteinuria.

RESULTS

In group A, 46 patients (45%) were affected by chronic liver disease (CLD), 21 (20%) by low-grade non-Hodgkin's lymphoma (NHL) and 16 (15%) by both diseases. All patients of group B were affected by type I membrano-proliferative glomerulonephritis, 3 (19%) by chronic liver disease, 6 (37%) by low-grade non-Hodgkin's lymphoma, and 7 (44%) by both diseases. Several genotypes of hepatitis C virus were found, but Type 1b was prevalent. In group C, no patient showed chronic liver disease or non-Hodgkin's lymphoma. Younger age, higher mean blood pressure, lower C4 serum level, and poorer survival significantly distinguished group B from group A. Survival rates at 5 years were: 87.4% for group A, 89.5% for group C, and 50.0% for group B. None of the patients of group B developed kidney failure requiring dialysis, whilst infections were the leading cause of death.

CONCLUSIONS

In hepatitis C virus-positive patients, the presence of mixed cryoglobulinemia associated with kidney involvement seems to indicate a new syndrome characterized by immune system impairment, lack of progression to kidney failure, and poor survival (hepatitis C virus-Risk syndrome).

Complex management issues: management of HCV in the atypical patient

Some patients with chronic hepatitis C virus (HCV) infection demonstrate atypical features of presentation and clinical course. These features may be due to direct or indirect effects of the underlying HCV infection or may be part of a separate clinical syndrome. Patients that can be categorized as 'atypical' include immunosuppressed individuals (hypogammaglobulinaemic, co-infected with human immunodeficiency virus, recipients of solid organ or haematopoietic cell transplants, those with associated disease requiring chronic immunosuppressive therapy and patients with chronic renal failure on haemodialysis) as well as patients with various extra-hepatic (HCV-associated mixed cryoglobulinaemia, membranoproliferative glomerulonephritis etc) or autoimmune manifestations. Since many of these patients have been excluded from the large trials evaluating the efficacy of interferon-alpha alone or in combination with ribavirin, data regarding management are limited. In this chapter, the available information regarding the treatment of these patients is reviewed and the frequently encountered therapeutic dilemmas discussed. Finally, some reasonable therapeutic approaches are suggested while the need for controlled studies for these groups of patients is emphasized.

Hepatitis C: an update on the silent epidemic

Hepatitis C virus (HCV) currently infects an estimated 2-3 million people in the United States and 175 million people globally. Over 80% of infected patients go on to develop chronic disease. Most patients remain asymptomatic despite silent, insidious progression of the disease. The sequelae of HCV-induced chronic liver disease accounts for 8,000-10,000 deaths annually in the United States and is currently the leading indication for liver transplantation. The cost of this epidemic to the United States was estimated in 1991 at $600 million in terms of medical expenses (excluding costs related to liver transplantation) and work lost. Over the last decade, since the viral genome of HCV was first sequenced in 1989, there has been a great increase in understanding of this infection. This review summarizes current knowledge about the hepatitis C epidemic with particular reference to epidemiology of infection, viral characteristics, risk factors for disease, diagnostic testing, clinical manifestations, and current, as well as potential, therapeutic options.

Prevalence and risk factors for the presence of serum cryoglobulins in patients with chronic hepatitis C

To assess the prevalence and risk factors for cryoglobulinaemia associated with hepatitis C virus (HCV) infection, we studied 360 consecutive patients with chronic hepatitis C (191 men, median age 57 years; 86 [24%] with cirrhosis). One-hundred and sixty-eight (47%) had circulating cryoglobulins (mean levels 208 +/- 256 mg l-1), predominantly of type III (80%; and 20% type II). Cryoglobulins were more common in women than in men (56% vs 39%, P=0.001) and in patients with cirrhosis than in those with chronic hepatitis (57% vs 43%, P=0.024). Cryoglobulinaemic patients more frequently had high levels of serum immunoglobulin M (IgM) (57% vs 30%, P=0.001), immunoglobulin G (IgG) (84% vs 70%, P=0.002) and rheumatoid factor (45% vs 16%, P=0.001); low levels of serum C3 (15% vs 4%, P=0.001) and C4 (51% vs 26%, P=0.001); and low numbers of platelets (21% vs 12%, P=0.018), than patients without cryoglobulins. The presence of cryoglobulins was not correlated with hepatitis duration (cryopositives, 12 +/- 7 years; cryonegatives, 11 +/- 8 years) or HCV genotype (HCV 1b, 48% vs 53%; HCV 2a, 35% vs 29%, cryopositive vs cryonegative patients respectively). By multivariate analysis, female gender (odds ratio [OR] 1.675; confidence interval [CI] 1. 055-2.661), elevated serum IgM (OR 2.296; CI 1.438-3.665), IgG (OR 1. 952; CI 1.114-3.422), rheumatoid factor (OR 3.213; CI 1.889-5.465) and low C4 (OR 1.859; CI 1.138-3.038) could reliably predict the presence of cryoglobulins. When the pathogenic variables IgG, rheumatoid factor and C4 were excluded from analyses, only levels of serum cholinesterase activity < 4500 U independently predicted (OR 3. 663, CI 1.258-10.184) the presence of cryoglobulins. Fifty per cent of the patients with chronic hepatitis C circulated cryoglobulins, with preference for those with a greater impairment of liver function, as revealed by serum cholinesterase activity.

Prevalence of hepatitis C virus-associated mixed cryoglobulinemia after liver transplantation

Hepatitis C virus (HCV) infection is associated with mixed cryoglobulinemia and membranoproliferative glomerulonephritis. After orthotopic liver transplantation (OLT), isolated cases of HCV-associated mixed cryoglobulinemia have been reported. We determined the prevalence and clinical characteristics of mixed cryoglobulinemia in HCV-infected liver transplant recipients at our institution. Between January 1991 and February 1998, a total of 191 OLTs were performed in 178 patients. Among these transplant recipients, 53 patients (29.8%) had positive serological test results for HCV infection by second-generation enzyme-linked immunosorbent assay. We studied 31 HCV-positive (HCV+) and 21 HCV-negative (HCV-) transplant recipients (control group). Renal and liver function studies were performed, and cryoglobulin, rheumatoid factor, C3, C4, and serum HCV RNA levels and genotype were determined. Results were compared using unpaired Student's t-test for continuous variables and Fisher's exact test for categorical variables. Baseline characteristics were similar between the groups. Six patients in the HCV+ group (19%) had mixed cryoglobulins present at the time of evaluation compared with none in the HCV- group (P =. 036). The only parameter associated with cryoglobulins in the HCV+ group was rheumatoid factor (P <.01). In 3 HCV+ patients with cryoglobulins, extrarenal signs of cryoglobulinemia were present. Glomerulonephritis was found in 4 HCV+ patients. Two patients with purpura and cryoglobulinemia had reduced clinical manifestations after antiviral therapy. In conclusion, mixed cryoglobulinemia was found in approximately 20% of the HCV+ liver transplant recipients. The presence of purpura or glomerulonephritis suggests HCV-associated mixed cryoglobulinemia, a clinical syndrome that may respond favorably to antiviral therapy.

Treatment of autoimmune and extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus (HCV) infects mononuclear cells and may be responsible, as are other viruses, for immunologic disorders. The immunologic abnormalities observed in HCV infections are usually non-specific (i.e. cryoglobulinemia, immune complex deposits, autoantibodies). The association with cryoglobulinemia is clear and cryoglobulinemia-related symptoms are usually improved by interferon alpha treatment, although patients often relapse after the end of treatment. The relationship with other immunologic abnormalities is less clear. The occurrence of antismooth muscle or anti-nuclear antibodies does not seem significantly different in hepatitis C infection than in other hepatic disorders, particularly hepatitis B. However, anti-liver kidney microsomal (LKM1) antibodies are present significantly more often than in patients with other liver diseases. When clinical, histologic and biological findings suggest HCV infection with chronic hepatitis, interferon alpha or combination therapy with ribavirin are treatment options When the clinical context and results of laboratory tests suggest an autoimmune disorder or overlap syndromes (i.e. both autoimmune and viral hepatitis), interferon should not be given as a first intention, since revelation or exacerbation of autoimmune hepatitis has been reported with interferon. A marked prevalence of anti-HCV antibodies has also been reported in patients with sialadenitis, lichen planus and thyroiditis. Interferon may induce or worsen these immunologic diseases, but there are very few studies showing improvement of these manifestations with interferon.

Acute hepatitis C complicated by pancreatitis: another extrahepatic manifestation of hepatitis C virus?

In hepatitis C virus (HCV) infection a number of extrahepatic manifestations have been described, generally caused by immune phenomena. Here we report a case of acute pancreatitis, detected during an acute hepatitis C infection, in an elderly female patient.

New and emerging therapies for collagen-vascular diseases

Cutaneous disease is frequent in many of the rheumatic disorders. Some of these disorders such as lupus erythematosus, dermatomyositic, scleroderma, and vasculitis are defined by their cutaneous manifestations. As investigation increases our understanding of these disorders, available therapy becomes more logical and less empiric. This article deals with some of the newer therapies for these disorders.

Extrahepatic manifestations associated with hepatitis C virus infection. A prospective multicenter study of 321 patients. The GERMIVIC. Groupe d'Etude et de Recherche en Medecine Interne et Maladies Infectieuses sur le Virus de l'Hepatite C

From January 1996 to January 1997, 321 patients with an average age of 46 +/- 16 years and chronically infected with hepatitis C virus (HCV) were prospectively enrolled in a study designed to determine the prevalence of extrahepatic manifestations associated with HCV infection in a large cohort of HCV patients, to identify associations between clinical and biologic manifestations, and to compare the results obtained in human immunodeficiency virus (HIV)-positive versus HIV-negative subsets. In a cross-sectional study, clinical extrahepatic manifestations, viral coinfections with HIV and/or hepatitis B virus, connective tissue diseases, and a wide panel of autoantibodies were assessed. Thirty-eight percent (122/321) of patients presented at least 1 clinical extrahepatic manifestation including arthralgia (60/321, 19%), skin manifestations (55/321, 17%), xerostomia (40/321, 12%), xerophthalmia (32/321, 10%), and sensory neuropathy (28/321, 9%). Main biologic abnormalities were mixed cryoglobulins (110/196, 56%), thrombocytopenia (50/291, 17%), and the presence of the following autoantibodies: antinuclear (123/302, 41%), rheumatoid factor (107/280, 38%), anticardiolipin (79/298, 27%), antithyroglobulin (36/287, 13%) and antismooth muscle cell (27/288, 9%). At least 1 autoantibody was present in 210/302 (70%) of sera. By multivariate logistic regression analysis, 4 parameters were significantly associated with cryoglobulin positivity: systemic vasculitis (p = 0.01, odds ratio OR[ = 17.3), HIV positivity (p = 0.0006, OR = 10.2), rheumatoid factor positivity (p = 0.01, OR = 2.8), and sicca syndrome (p = 0.03, OR = 0.27). A definite connective tissue disease was noted in 44 patients (14%), mainly symptomatic mixed cryoglobulinemia and systemic vasculitis, HIV coinfection (23%) was associated with 3 parameters: anticardiolipin (p = 0.003, OR = 4.18), thrombocytopenia (p = 0.01, OR = 3.56), and arthralgia or myalgia (p = 0.017, OR = 0.23). HIV-positive patients presented more severe histologic lesions (p = 0.0004). Extrahepatic clinical manifestations in HCV patients involve primarily the skin and joints. The most frequent immunologic abnormalities include mixed cryoglobulins, rheumatoid factor, antinuclear, anticardiolipin, and antithyroglobulin antibodies. Cryoglobulin positivity is associated with systemic vasculitis and rheumatoid factor and HIV positivity. HIV coinfection is associated with arthralgia or myalgia, anticardiolipin antibodies, and thrombocytopenia.

Hepatitis C and renal failure

Chronic hepatitis C virus (HCV) infection is common among patients with chronic renal failure. This chronic viral infection can result in significant morbidity and mortality. Liver failure from chronic hepatitis C is one of the leading causes of death among long-term survivors of renal transplantation. HCV infection also can be a cause of glomerulonephritis and nephrotic syndrome. Recognition of these conditions is important to optimize the management of these patients.

Cryoglobulinemia

Cryoglobulinemia may be found in a spectrum of disorders spanning clear-cut-B-cell neoplastic states, in which cryoprecipitation manifests as ischemic or occlusive vasculopathy, to a variety of immune complex diseases, in which vasculitis or glomerulonephritis may occur. Symptomatic cryoglobulinemia is many diseases, driven by and driving antibody-antigen responses, hepatic dysfunction, lymphoproliferation, and immune complexes. Distinguishing features that cause only some cryoglobulins to be symptomatic, elucidating the pathogenic mechanisms of HCV in cryoglobulin formation, and devising better therapies and more systematic evaluation of existing therapies are among the challenges for the future. Prognostication and classification will continue to rely on Brouet's classification (types I, II, and III), but additional features will probably include the presence or absence of HCV, HCV factors (genotype, titer), coexisting infections, B-cell clone burden, host factors, and immune system interactions (B- and T-cell idiotype networks, cytokines). Although antiviral therapy is a reasonable option for HCV-associated cryoglobulinemia, not all patients are HCV-positive, and only 60% to 80% of HCV-positive patients respond to IFN. In addition, not all patients tolerate IFN, and in those who do, the response is often short-lived once the treatment is discontinued. Only creative strategies, systematically studied, will provide long-awaited solutions.

Mixed cryoglobulinaemia associated with hepatitis C virus infection: a predictor factor for treatment with interferon?

BACKGROUND AND AIMS

Mixed cryoglobulinaemia (MC) is a frequent finding among patients infected with hepatitis C virus (HCV). The response to treatment with alpha-interferon (alpha-IFN) in these patients is linked to predictive factors. The aim of this study was to ascertain whether the presence of MC was a predictive factor of response in patients treated with alpha-IFN for chronic hepatitis due to HCV.

METHODS

Thirty-two patients with MC and HCV infection (24 with chronic hepatitis and eight with cirrhosis) were compared with 30 patients with HCV infection without MC (23 chronic hepatitis, seven cirrhosis) of a similar mean age. All were treated with lymphoblastoid alpha-IFN, at 3 MU, t.i.w., for 6-12 months and then followed up.

RESULTS

No statistical difference was observed between the two groups in terms of sustained response (P = 0.83), relapse (P = 0.88) and non-response (P = 0.92). The mean follow up was 24.3 months (range 17-28) for patients with sustained response and for the patients with MC and 22.6 months (range 15-26) for patients without MC.

CONCLUSIONS

The presence of cryoglobulinaemia does not influence the response to alpha-IFN in patients with chronic HCV infection.

Mixed cryoglobulinaemia in patients with chronic hepatitis C infection: prevalence, significance and relationship with different viral genotypes

In order to analyse the prevalence and significance of cryoglobulinaemia in patients with chronic hepatitis C virus (HCV) infection and the possible relationship of cryoglobulinaemia with the genotypes of HCV, we studied 89 patients with chronic HCV infection, 42 healthy controls and 22 patients with alcoholic cirrhosis. The patients with HCV were divided into three different groups according to the presence of cirrhosis and alanine aminotransferase levels. Moreover, in 20 patients with HCV and cryoglobulinaemia, HCV RNA sequences were quantified in serum and in cryoprecipitate. Cryoglobulins were detected more frequently in patients with chronic HCV infection than in healthy controls (42.6% vs. 4.7%; P<0.0001). Cryoglobulins were present in 68.4% of patients with HCV-related cirrhosis, which was nearly twice the figure in noncirrhotic HCV-infected patients and alcoholic cirrhotic patients. There were no differences in age, sex, aminotransferase levels or HCV genotype distribution in HCV-infected patients with or without cryoglobulinaemia. Only 13% of patients with chronic HCV infection and cryoglobulins showed symptoms of cryoglobulinaemia. There was a linear association between HCV RNA concentration in sera and in cryoprecipitates (P<0.0005). Patients with chronic HCV infection had a high prevalence of cryoglobulinaemia, especially in advanced forms of the disease, but clinical findings are few. There was no relationship with the genotype of HCV. The presence of HCV RNA in cryoprecipitates supported the hypothesis on the aetiological role of HCV in mixed cryoglobulinaemia.

Low virological response to interferon in children with chronic hepatitis C

BACKGROUND/AIMS

Children with chronic hepatitis C were recently found to have higher rates of sustained response to interferon compared to adults. The aim of this study was to verify the response to interferon using frequent viremia measurements.

METHODS

Sera from 25 children (13 males; mean age 7.9 years) with chronic hepatitis C, treated with recombinant alpha-2b interferon for 12 months, were tested for liver function tests and viremia levels for a median of 27.5 months. Autoantibodies were evaluated during and after interferon.

RESULTS

Fifteen patients completed 12 months of interferon; treatment was stopped in 10 other patients. In 11 (44%) patients viremia was undetectable already at the second administration of interferon; one of them remained viremia-free up to the end of follow-up and had persistently normal alanine-aminotransferase levels (complete sustained responder). A complete sustained response was observed only in one other patient, who normalized alanine aminotransferase and cleared viremia from the 3rd month of therapy. Three patients with persistent viremia normalized alanine-aminotransferase from the 3rd week of therapy up to the end of follow-up (biochemical sustained responders). Viremia was undetectable during treatment in four patients, who stopped interferon because of worsening in hypertransaminasemia. Three of these four patients were anti-liver-kidney microsomal type 1-positive.

CONCLUSIONS

In this study the response rate to interferon was very low and viremia and transaminase findings were often discordant.

Sustained response to interferon-alpha or to interferon-alpha plus ribavirin in hepatitis C virus-associated symptomatic mixed cryoglobulinaemia

BACKGROUND

Hepatitis C virus (HCV) infection has been associated with mixed cryoglobulinaemia.

AIM

To investigate the efficacy of anti-viral therapy on the eradication of HCV and its clinical manifestations in patients with HCV-associated symptomatic mixed cryoglobulinaemia.

PATIENTS AND METHODS

18 out of 32 patients with symptomatic mixed cryoglobulinaemia (MC group) received a 12-month course of interferon (3 MU three times a week, subcutaneously). Nonresponders or relapsers to this therapy were treated with interferon plus ribavirin (1200 mg/day, orally) for 12-months. 226 patients with HCV infection and without cryoglobulins were studied in comparison (Hepatitis C group). Serial quantification of serum HCV-RNA and cryoglobulins were performed.

RESULTS

In the MC group, 10 out of 18 patients (55%) receiving interferon showed an end of treatment response, but at the end of follow-up, only five (28%) patients had a sustained response. In the hepatitis C group, 91 patients (47%) showed an end of treatment response but only 42 (20%) a sustained response. In the MC group alanine transaminase, cryocrit and rheumatoid factor decreased significantly in responders, with an improvement or disappearance of the MC-associated clinical manifestations. Alanine transaminase, cryocrit and rheumatoid factor increased in the relapsers and the clinical manifestations reappeared. Nonresponders and relapsers to interferon in the MC group were retreated with interferon plus ribavirin. Five out of eight nonresponders showed a end of treatment response but it was sustained in three of them. In the relapsers, treatment with combined therapy achieved a sustained response in four out of the five patients (80%).

CONCLUSIONS

Interferon as monotherapy or combined with ribavirin is a safe and effective treatment in patients with HCV-associated MC. The presence of cryoglobulins does not affect the response to anti-viral treatment in patients with HCV infection. The eradication of HCV is associated with an improvement or disappearance of MC-associated clinical manifestations.

Hepatitis C infection and B-cell non-Hodgkin's lymphoma in British Columbia: a cross-sectional analysis

OBJECTIVES

To determine the prevalence of hepatitis C virus (HCV) infection in patients with B-cell non-Hodgkin's lymphoma (NHL) in British Columbia.

DESIGN

A cross-sectional analysis.

SETTING

The British Columbia Cancer Agency (BCCA), a Canadian provincial tertiary oncology referral center.

SUBJECTS

Consecutive patients with B-cell NHL registered onto the BCCA lymphoma database in 1996 and part of 1997 and a control group of patients with T-cell NHL registered on the database from 1995 through 1997. Patients with HIV infection were excluded from the analysis. A second control group (n = 1085) consisted of health-care workers tested for HCV infection following a needle-stick injury.

INTERVENTIONS

Stored sera from patients with B-cell NHL (n = 88) and T-cell NHL (n = 37), identified from the database, were tested for the presence of HCV infection with commercially available serologic tests.

MAIN OUTCOME MEASURES

HCV seropositivity in the B-cell lymphoma group compared to the control groups (T-cell NHL and health-care workers).

RESULTS

2.3% of the B-cell NHL group, none of the T-cell NHL group and 1% of the health-care worker control group were positive for HCV infection. These results were not statistically significantly different.

CONCLUSION

Patients in British Columbia with B-cell NHL do not have an increased prevalence of HCV infection. These data suggest that the lymphotrophism of HCV may differ by regional, racial and genotypic variations around the world.

Response to interferon alpha treatment and disappearance of cryoglobulinaemia in patients infected by hepatitis C virus

BACKGROUND

Mixed cryoglobulinaemia is closely associated with hepatitis C virus (HCV) infection.

AIM

To assess in a prospective open study the efficiency of interferon alpha treatment of cryoglobulinaemia, as reflected by the disappearance of cryoglobulins and clinical manifestations of the disease, and to analyse the factors predictive of a response to interferon.

METHOD

Eighty seven consecutive patients with chronic hepatitis C treated for the first time with interferon at a dose of 3 x 10(6) international units three times a week for six months were studied. Forty three patients had cryoglobulins, which were responsible for clinical manifestations in 12.

RESULTS

At the end of interferon treatment, cryoglobulins had disappeared in 39% of the patients. A clinical improvement (except for neuropathies) was observed in all patients. Six months after interferon treatment was stopped, the same rate of response (normal alanine aminotransferase values and undectable HCV RNA) was observed in patients with or without cryoglobulins. Only 14% of patients still had undetectable cryoglobulins, and all of them also had undetectable serum HCV RNA. The disappearance of cryoglobulins was found less frequently in patients with clinical symptoms than in asymptomatic ones, but the difference was not significant. Sustained responders were more often men, infected by genotype 2 or 3, with a lower pretreatment viral load.

CONCLUSION

The presence of cryoglobulins does not seem to affect the response to interferon in HCV infected patients. The improvement in cryoglobulinaemia is strongly associated with a virological response, reinforcing the hypothesis of a direct role for HCV in the pathogenesis of this disease.

Viral genotypes as determinants of autoimmune expression in chronic hepatitis C

OBJECTIVE

To correlate viral genotypes with the immune manifestations of chronic hepatitis C and evaluate the effect of immune features on disease expression and response to antiviral treatment.

DESIGN

We undertook a retrospective analysis of 67 patients with chronic hepatitis C.

MATERIAL AND METHODS

Patients were selected for study if they had been screened for autoantibodies and concurrent immune diseases and if viral genotyping had been performed or was possible. Concurrent immune manifestations and responses to interferon therapy were determined.

RESULTS

Of the 67 patients, 18 (27%) had one or more immune features. Immune manifestations occurred as commonly in patients with genotype 1 as in those with other genotypes (30% versus 14%; P = 0.3). Concurrent immune features did not distinguish patients, and responses to interferon therapy were similar between patients with and those without immune manifestations. None of the 14 patients with concurrent immune diseases or high-titer autoantibodies (serum titers, 1:320 or more) entered remission during interferon treatment. In contrast, 6 of 53 patients without concurrent immune diseases and no or low-titer autoantibodies had treatment-related remission. These differences, however, were not statistically significant (0% versus 11%; P = 0.3).

CONCLUSION

Autoantibodies and concurrent immune diseases are not associated with a particular viral genotype, clinical profile, or treatment outcome. Larger studies are necessary for complete assessment of the influence of prominent immune manifestations on treatment response.

Interferon-alpha may exacerbate cryoblobulinemia-related ischemic manifestations: an adverse effect potentially related to its anti-angiogenic activity

The discovery of the strong association between hepatitis C virus (HCV) infection and the development of mixed cryoglobulinemia has motivated active testing of antiviral-directed alternative therapies. Several trials have demonstrated that classic cryoglobulinemia-associated manifestations improve with interferon-alpha (IFNalpha) treatment. Herein we report on 3 HCV-infected patients with severe cryoglobulinemia-related ischemic manifestations who were closely followed up during IFNalpha therapy. Clinical evaluations with special attention to ischemic lesions, liver function tests, and cryocrit determinations were serially performed. In addition to prednisone and immunosuppressive agents, the patients received IFNalpha at 3 x 10(6) units, 3 times per week for 2 months, 3 months, and 4 months, respectively. In all 3 patients, systemic features improved, liver function results returned to normal, and cryocrit values decreased. However, ischemic lesions became less vascularized and ischemia progressed, leading to transmetatarsal and subcondylar amputation, respectively, in 2 of the patients and fingertip necrosis and ulcer enlargement in the third. Skin biopsies performed before IFNalpha therapy and after 2 months of IFNalpha therapy in the third patient showed a significant decrease in subepidermal microvessels. When IFNalpha was discontinued, the lesions finally healed. Cryoglobulinemia-related ischemic lesions may worsen during IFNalpha treatment, presumably through a decrease in inflammation-induced angiogenesis. The anti-angiogenic activity of IFNalpha may delay the appropriate healing of ischemic lesions.

Mutations in Immunodominant T Cell Epitopes Derived from the Nonstructural 3 Protein of Hepatitis C Virus Have the Potential for Generating Escape Variants That May Have Important Consequences for T Cell Recognition

One of the most disturbing features of hepatitis C virus (HCV) is its long-term persistence in the host. One hypothesis to explain this phenomenon is that HCV escapes immune recognition through its intrinsic hypermutability. To determine whether immunodominant T cell epitopes derived from HCV nonstructural 3 (NS3) protein might be subject to sequence variations leading to escape mutants, we examined sequence variations of one IL-2-producing epitope, NS3358–375, and one IL-10-producing epitope, NS3505–521. By PCR amplification, cloning, and sequencing, we observed significant sequence variations in the two epitopes, although the selection intensity for each epitope was different. For NS3358–375, more variants were observed, and for NS3505–521, fewer mutations were observed. Moreover, functional studies revealed that three NS3358–375 and one NS3505–521 variants failed to stimulate T cell proliferation, and two other NS3358–375 and NS3505–521 variants weakly stimulated T cell responses. Our results are consistent with immune selection of viral variants at the epitope level, which may enable HCV to evade host defenses over time.

Renal manifestations of hepatitis C infection

Hepatitis C is an important cause of renal disease, and renal complications may be the presenting manifestation of hepatitis C infection. About half of patients present with evidence of renal insufficiency, and up to one quarter present with nephrotic syndrome. Others present with proteinuria or evidence of diminished renal function. The pathogenesis of hepatitis C-associated renal disease remains incompletely defined, but most evidence suggests that glomerular injury results from deposition of circulating immune complexes in the subendothelium and mesangium. Membranoproliferative glomerulonephritis, with or without cryoglobulinemia, is the most common renal lesion. Interferon alpha-2b is currently the treatment of choice. However, success is limited, with many patients failing to respond or suffering relapse upon discontinuation of therapy. Studies of newer treatment modalities, such as longer courses of interferon or the use of ribavirin or immunosuppressive agents, are underway. Hepatitis C-associated renal disease may progress to end-stage renal failure requiring dialysis in about 10% of patients.

Extrahepatic manifestations of chronic hepatitis C infection and the interrelationship between primary Sjögren's syndrome and hepatitis C in Swedish patients

OBJECTIVE

To analyse the frequency of some extrahepatic manifestations of chronic hepatitis C virus (HCV) infection in northern European patients, including a postulated association between HCV and primary Sjögren's syndrome (SS).

DESIGN

Cohort study.

SETTING

Department of Medicine, Malmö University Hospital, Sweden.

PATIENTS

Twenty-one patients with HCV infection and 53 with primary SS (according to the Copenhagen criteria).

MAIN OUTCOME MEASURES

Cryoglobulins were analysed in all patients, while patients with primary SS were investigated with regard to markers of HCV infection, and HCV patients with objective tests of SS (Schirmer-1 test, break-up time, van Bijsterveld score, sialometry, labial salivary gland biopsy) and antibodies against nuclear antigens, smooth muscle (SMA) and mitochondria (AMA). HCV antigens in small salivary glands from lower lip biopsies were detected by immunohistochemical analysis.

RESULTS

Only one of the SS patients had detectable cryoprecipitates, while another was HCV-positive. None of the 21 HCV patients had cryoprecipitates. A total of 14/21 (67%) patients with HCV infection had at least one abnormal objective test suggestive of xerostomia or keratoconjunctivitis sicca, while eight (38%) had objective evidence of both eye and salivary gland involvement. HCV antigens were not detected in affected glands. Only two patients had clinical symptoms of SS, and two fulfilled the Copenhagen criteria for SS. None of the HCV-positive patients had detectable antibodies against SS-A, SS-B, RNP, Jo-1, PCNA or Scl-70, and the frequency of ANA/SMA/AMA was low.

CONCLUSIONS

While involvement of salivary and lacrimal glands was common in Swedish patients with HCV infection, cryoglobulinaemia was not observed. The pathogenetic mechanism responsible for glandular inflammation appears to be different from that in primary SS. HCV infection does not seem to be an aetiological factor for primary SS in this population. These observations suggest that viral, genetic or possibly environmental factors may be responsible for the reported high frequencies of systemic complications associated with chronic hepatitis C infection in southern Europe.

Therapeutic apheresis for renal disorders

Many primary renal diseases are associated with either antibody deposition within the glomerulus or an antibody associated autoimmunity, as may be seen with certain vasculitidies. Other immunoglobulins may be nephrotoxic or glomerulopathic; such may be the case with myeloma related light chains or cryoglobulins. Given the rapid removal of immunoglobulins by therapeutic plasma exchange, this modality has been considered an appealing management option in the treatment of these autoimmune related renal diseases. Although not classically considered as autoimmune diseases, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are related syndromes which often involve the kidneys. In many cases therapeutic plasma exchange has been found to be a useful treatment modality for these microangiopathic hemolytic anemias. This paper will provide a concise review of the renal indications for therapeutic plasma exchange.

Effects of ribavirin on hepatitis C-associated nephrotic syndrome in four liver transplant recipients

BACKGROUND

Hepatitis C virus infection (HCV) is associated with a variety of extrahepatic disorders such as membranoproliferative glomerulonephritis (MPGN), which is generally due to cryoglobulinemia. After liver transplantation for HCV cirrhosis, alpha-interferon treatment against the recurrence of HCV in the liver graft is poorly effective and may induce intractable graft rejection.

METHODS

We describe the cases of four liver transplant recipients treated with ribavirin for HCV-related glomerulopathy and nephrotic syndrome.

RESULTS

The nephrotic syndrome was attenuated or disappeared during ribavirin therapy, and patients showed a marked decrease in proteinuria and an increase in albuminemia. The syndrome relapsed in two patients when ribavirin therapy was stopped, and a favorable response was again obtained in both cases when the treatment was resumed. The main adverse effect of ribavirin was anemia in two patients with renal impairment. No graft rejection occurred.

CONCLUSIONS

These findings suggest that continuous therapy with low doses of oral ribavirin may improve the proteinuria of hepatitis C-related glomerulonephritis, at least in liver transplant recipients.

Treatment of hepatitis C infection in patients with renal disease

Hepatitis C virus infects 20-40% of the end-stage renal disease population, and has been associated with essential mixed cryoglobulinemia and several forms of immune-complex glomerulonephritis. Overall, treatment with interferon alpha has been disappointing, although certain situations may benefit from dosing regimens that differ in the amount of drug and duration of treatment from the conventional interferon doses currently recommended for non-renal patients.

Rheumatologic manifestations of gastrointestinal diseases

One of the most significant extraintestinal manifestations of gastrointestinal diseases is rheumatologic disorders. The gastrointestinal diseases with rheumatologic manifestations can be divided into two major categories: intestinal disorders and disorders of the liver, biliary tree, and pancreas. The cause of diseases in each of these categories is different. Although intestinal permeability and immune responsiveness are frequently implicated in disorders of the intestine, diseases of the liver, biliary tree, and pancreas usually involve the production of autoantibodies, cytokines, or enzymes. Treatment of rheumatologic complications frequently involves therapy directed at the underlying gastrointestinal disease.

A clinical and virological study of hepatitis C virus-related cryoglobulinemia in Germany

BACKGROUND/AIMS

Several reports, especially from Southern Europe, have demonstrated a close association between hepatitis C virus (HCV) infection and mixed cryoglobulinemia. In this study we have analyzed the significance of HCV-related cryoglobulinemia in Germany.

METHODS

Sera from 79 patients with cryoglobulinemia of type I (n=21), II (n=28) or III (n=30) were investigated for HCV markers. Furthermore, 132 consecutive patients with chronic hepatitis C were studied for the presence of cryoglobulins. Genotypes of HCV were determined according to Simmonds, and HCV-RNA concentrations were measured in patients with and without cryoglobulinemia.

RESULTS

In 79 patients with cryoglobulinemia we found anti-HCV antibodies in 17 (22%) and HCV-RNA in 11 patients (14%). HCV antibodies were more frequent in essential (44%) compared to secondary mixed cryoglobulinemia (15%). In 132 patients with chronic HCV infection cryoglobulins were detected in 37 patients (28%), in 21 of them at low levels. Clinical symptoms due to cryoglobulinemia were observed in eight of the 37 patients, severe vasculitis in three patients with high cryocrit-levels and cryoprecipitation at room temperature. HCV genotype 1 and subtype 1b were most prevalent, both in patients with and without cryoglobulinemia, and mean HCV-RNA levels were not different between the two groups. Comparison of HCV-RNA levels in cryoprecipitates, supernatant and native serum suggests binding of HCV-RNA to the cryoprecipitate with different affinity in individual patients.

CONCLUSIONS

The lower prevalence of HCV-related cryoglobulinemia in our study compared with data from Italy and France suggests a south-north gradient in the prevalence of HCV-associated cryoglobulinemia in Europe.

Hepatitis C virus infection-associated non-cryoglobulinaemic monoclonal IgMkappa gammopathy responsive to interferon-alpha treatment

BACKGROUND/AIMS

An association of HCV infection with lymphoproliferative disorders, particularly B-cell non-Hodgkin's lymphoma has been described. In the majority of reported patients, mixed cryoglobulinaemia was present as well. Rarely, HCV-associated lymphoproliferative disorders have been observed in the absence of cryoglobulinaemia. In these latter patients, the response to interferon-alpha is largely unknown.

CASE REPORT

We report a case of an asymptomatic 31-year-old male with chronic HCV infection and non-cryoglobulinaemic monoclonal IgMkappa gammopathy responsive to interferon-alpha therapy. Prior to therapy, elevated plasma transaminase activities known for longer than a year, serum anti-HCV antibodies and HCV RNA detected by reverse transcriptase-polymerase chain reaction were present. Serum IgM concentration was markedly elevated, immunofixation demonstrated monoclonal serum IgM, and urine kappa-light chains were detected. Cryoglobulins were undetectable in several consecutive serum samples. Bone marrow aspirate and biopsy specimens were unremarkable. Further evaluation, e.g. by ultrasonography and radiography, did not reveal evidence for lymphoma. Treatment with interferon-alpha2a for 12 months resulted in a long-term sustained response to HCV infection and in a normalisation of serum IgM concentration.

CONCLUSION

Therefore, the corresponding effects of interferon-alpha on HCV infection and on a monoclonal B-cell population observed in the present case might suggest a pathogenetic connection, similarly, to what has been described for HCV and mixed cryoglobulinaemia. The molecular events, however, leading to HCV-induced monoclonal B-cell expansion remain unknown.

Mixed cryoglobulinaemia: a cross-road between autoimmune and lymphoproliferative disorders

Mixed cryoglobulinaemia (MC) is a systemic vasculitis, secondary to the deposition in small and medium-sized blood vessels of circulating immune complexes, mainly the cryoglobulins, and complement. MC is characterised by a typical clinical triad (purpura, weakness, arthralgias) and by one or more organ involvement: chronic hepatitis, glomerulonephritis, peripheral neuropathy, skin ulcers and diffuse vasculitis. In a limited number of MC patients, a malignancy, that is B-cell non-Hodgkin's lymphoma or hepatocellular carcinoma, may also develop. Hepatitis C virus (HCV) infection has been found in the majority of patients with MC; the frequency of HCV markers (91%) was significantly higher than other rheumatic diseases (6.4%), namely systemic lupus, Sjögren's syndrome, rheumatoid arthritis and systemic sclerosis, or healthy controls (1.2%). The HCV infection of lymphoid tissues may represent the remote event leading to B-lymphocyte proliferation responsible for autoantibodies and immune-complex production. In a similar way, HCV infection may also be involved in the pathogenesis of other autoimmune (glomerulonephritis, thyroiditis, lung fibrosis, autoimmune hepatitis, porphyria cutanea tarda) and lymphoproliferative disorders (monoclonal gammopathies, B-cell lymphomas). MC shares numerous clinico-serological and pathological features with the above disorders. HCV seems to be their common etiological agent; however, a variable combination of unknown co-factors (infectious, genetic, environmental) should be determinant for the appearance of different clinical patterns.