Distinctions in chronic active hepatitis based on circulating hepatitis-associated antigen

Seroimmunologic classification of chronic hepatitis in 57 children

A seroimmunologic evaluation of 57 children with chronic hepatitis is presented. Twenty-one patients had chronic persistent hepatitis and 36 had chronic active hepatitis. Serum samples obtained before treatment were tested for HBsAg, anti-HBs, anti-HBc, smooth muscle antibody, and antibody to endoplasmic reticulum. A persistently positive HBsAg was observed in the serum of 18 of the 21 patients with chronic persistent hepatitis. The chronic active hepatitis group was divided into three subgroups according to the presence of hepatitis B-virus markers (7 patients), smooth muscle antibody (10 patients), and endoplasmic reticulum antibody (9 patients). Determination of these markers could be useful for classifying children with chronic hepatitis.

Pathology of primary liver cancer

After a brief survey of the factors that play a role in the etiopathogenesis of human hepatocellular carcinomas, a detailed description is given of the macroscopic and microscopic features of human liver cancers as well as their association with cirrhosis. The ultrastructural features of liver cancers of various degrees of differentiation are described. The mode of spread, metastasis formation of primary liver cancers, and most frequent causes of death of liver cancer patients are reviewed.

Ascites: its correction by peritoneovenous shunting

Patients with refractory ascites and HRS should be considered to present an urgent indication for peritoneovenous shunting. The shunt offers a method of continuous reinfusion of ascitic fluid which corrects avid sodium retention, oliguria and azotemia. Severe encephalopathy, jaundice or peritoneal sepsis--common complications of cirrhosis--contraindicate installation of the shunt before improvement occurs. Associated cardiac disease does not contraindicate the use of the shunt provided that ascitic fluid is removed at the time of operation and large amounts of diuretics are used. This operation has also proved useful in ascites attributed to causes other than cirrhosis. The main complications include disseminated intravascular coagulopathy, hepatic coma and sepsis in a few patients. Results of a randomized prospective study indicate that the shunt should probably be considered in patients with diet-resistant massive ascites even before they prove to be refractory to diuretic therapy.

Familial clustering and immune response in family contacts of patients with HBsAg-positive liver cirrhosis

Families of 11 patients with hepatitis B surface antigen (HBsAg)-positive cirrhosis were studied to evaluate the immunologic correlates and extent of intrafamilial HBsAg clustering. Of 76 family contacts, 12 were identified to be asymptomatic carriers of HBsAg and two were diagnosed to have HSsAg-positive cirrhosis. The over-all HBsAg prevalence for the 76 contacts was 18% and that for all 87 members studied 29.0%. Serologic evidence of hepatitis B virus (HBV) infection (either HBsAg, anti-HBs, or both) was detected in 59% of all family members. HBsAg was more prevalent in males (47%) compared with females (16%), and anti-HBs was more prevalent in females (42%) compared with males (18%). Evidence of an immunologic response in clinically unaffected HBsAg-negative family contacts consisted of elevated serum IgG levels (mean 1660 mg/100 ml) and increased prevalence of anti-smooth muscle and antimitochondrial antibodies (16% and 6%, respectively). The prevalence of one or more autoantibodies in all HBsAg-negative family contacts was 20%, and it was higher in females (25%) than in males (13%). The present study demonstrates that HBsAg clustering occurs in families of patients with cirrhosis in the Jerusalem area and indicates that HBsAg-negative family contacts may have increased B-cell activity.

Chronic active hepatitis in patients with and without hepatitis B surface antigenemia

This study was designed to compare the clinical and immunological characteristics of the hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative (cryptogenic) forms of chronic active hepatitis. The data of 48 patients with chronic active hepatitis, 24 with persistent HBs antigenemia and 24 without HBsAg, were analysed. HBsAg was detected by counter-immunoelectrophoresis and radioimmunoassay. The clinical features, biochemical liver function tests, immunoglobulins, complement C3, antoantibodies, and cell-mediated immunoreactivity of the two forms of the disease were compared. Cirrhosis was found to occur more frequently at the time of diagnosis in the HBsAg-negative group, and the serum alkaline phosphatase level was raised significantly compared to the HBsAg-positive form. The elevation of the IgG level was greater in the cryptogenic form, but the difference was not statistically significant compared to the HBsAg-positive patients. There was a marked difference in the frequency of the mitochondrial antibodies, but not of the antinuclear factor and other autoantibody-like serum factors. Lymphoblastic transformation revealed a similar diminution in response to phytohaemagglutinin stimulation in both groups of patients compared to the normal controls. An increase of the 3H-thymidine incorporation was seen after stimulation with human liver mitochondrial antigen, and leukocyte migration inhibition could be observed with this antigen in both forms of chronic active hepatitis.

Hepatitis-B: a review

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.

Enhanced antibody responses in active chronic hepatitis: relation to HLA-B8 and HLA-B12 and porto-systemic shunting

Titres of antibodies to rubella, measles, smooth muscle, nuclei, and Escherichia coli were examined in relation to the presence of particular histocompatibility antigens in 57 patients with active chronic hepatitis, 8 of whom were HBsAg positive. With the exception of antibodies to E. Coli, the HBsAg-negative patients with HLA-B8 or HLA-B12 had higher titres than those with neither, and antibody titres were highest in the 7 cases with both these histocompatibility antigens. In contrast, E. coli antibody titres were not related to the presence of particular histocompatibility antigens but correlated closely with the degree of portosystemic shunting. None of the HBsAg-positive patients possessed HLA-B8, and titres of all the antibodies were significantly lower than in the HBsAg-negative cases. The increased antibody response in HBsAg-negative patients is likely to be due to a genetically determined increase in immunological responsiveness for which HLA-B8 and HLA-B12 are markers. The results obtained in healthy family members also suggest that this defect in immunoregulation is under polygenic control.

Hepatitis B surface antigen (HBsAg) in the liver of patients with hepatitis; a comparison with serological detection

Chronic hepatitis was diagnosed on liver biopsy of 76 patients; 52 (68%)had HBsAg. Of the 52 patients with HBsAg, 23% had HBsAg shown by immunofluorescence on the liver, while it could not be detected with radioimmunoassay on the serum; 77% had HBsAg detectable in liver and in serum, and none had HBsAg in serum only. HBsAg was detected more frequently in chronic aggressive hepatitis and active cirrhosis than in chronic persistent hepatitis and cirrhosis with little activity. No correlation was found in the different forms of chronic hepatitis between the HBsAg status on the one hand, and levels of transaminases, gammaglobulins, and auto-antibodies on the other. Acute hepatitis was diagnosed on liver biopsy of 24 patients; 50% had HBsAg. Liver tissue positivity was very low in the fully developed stage compared to serum positivity. In 146 patients with other liver ailments, both liver and serum were negative for HBsAg.

Chronic carriers of hepatitis B antigen (HBsAg). Histological, biochemical, and immunological findings in 31 voluntary blood donors

Among 289 HBsAg carriers detected by the Montreal Red Cross Blood Transfusion Service and seen by our group, 31 submitted voluntarily to liver biopsy. These 31 carriers have now been followed for 10-33 months (mean: 23) and all remained positive for HBsAg. 15 of these 31 subjects had lived in institutions during infancy or childhood and none were drug users. Histological examinations revealed 24 cases of chronic persistent hepatitis (CPH), 2 cases of chronic aggressive hepatitis, 2 with steatosis, and 3 with normal liver. On repeated determination, 16 of the 31 subjects had at least one elevated transaminase level. Transaminases levels could not be correlated with the histological diagnosis. 4 cases had positive antinuclear antibodies, all in the CPH group, a finding that could not be correlated with any clinical, biological, or histological findings. The search for other autoantibodies and the immunoglobulin determinations were totally unrewarding. Thus, it appears that chronic HBsAg carriers in Montreal voluntary blood donors often have chronic hepatitis, usually persistent, occasionally aggressive; liver biopsy still remains the most useful approach in the evaluation of these HBsAg carriers. The HBsAg-carrier state seems to be well tolerated, but further long-term studies are needed to understand the natural history of this condition.

Hepatitis B antigen and antibody in active chronic hepatitis and other liver diseases in Australia. A multicenter collaborative study

In a multicenter cooperative study, sera from 85 patients with active chronic hepatitis (ACH) were examined for the presence of hepatitis B (Australia) antigen (HBAg) by radioimmunoassay (RIA) and antibody to HBAg (anti-HBAg) by RIA and passive hemagglutination (PHA), the most sensitive currently available techniques. In addition, sera from 83 patients with other liver diseases 98 other hospital patients, and 67 healthy controls were tested. HBAg was detected in 3 of the 85 patients (four percent) with ACH. In a further 3 patients (four percent) anti-HBAg was detected. Thus, 6 patients with ACH (seven percent) had evidence of present or prior infection with the hepatitis B virus (HBV). HBAg was also detected in 7 of the patients with other liver diseases, 2 of the other hospital patients, and none of the healthy controls. Anti-HBAg was detected in 17 of the non-ACH subjects. These results indicate that neither persistent nor prior self-limited infection with HBV is a major factor in the pathogenesis of ACH in Australia.

Leucocyte migration inhibition in liver disease

Clinical and histological features provide evidence that immunological reactions of the cell-mediated type are abnormal in some forms of chronic liver disease. By using the leucocyte migration test of Søborg and Bendixen (1967), a correlate of cellular hypersensitivity in vitro, the authors studied the production of the migration inhibitory factor by lymphocytes exposed to a fetal liver homogenate in 88 patients with acute and chronic liver disease. Abnormality of leucocyte migration was found in aggressive chronic hepatitis (inhibition in 67% of patients), cryptogenic cirrhosis (inhibition in 43%, stimulation in 13% of patients), and primary biliary cirrhosis (stimulation in two, inhibition in two out of six patients). The results are compatible with the hypothesis that cellular immune response to liver antigens is important in the pathogenesis of such diseases.

Chronic liver disease and hepatitis-B antigen: a prospective study

A long-term follow-up of 45 patients with chronic hepatitis and 41 with cirrhosis is reported. Hepatitis-B antigen (HBAg) was present in 19 (42%) of the chronic hepatitis patients and in 20 (49%) of those with cirrhosis. The clinical course and biochemical and histological findings in the HBAg-positive and the HBAg-negative cases were similar, suggesting that HBAg-positive chronic liver disease is not a distinct clinical entity. The presence of antigen and autoantibodies was not found to be mutually exclusive. In HBAg-positive cases antigen tended to persist for months and years. When no irreversible lesions exist disappearance of the antigen may be a sign that the liver disease will resolve.

Treatment of chronic active hepatitis in children

Thirty-eight children with chronic active hepatitis are reported. Their mode of presentation was usually indistinguishable from acute viral hepatitis (63%). Extra hepatic manifestations were more common in those patients with an insidious onset. The twenty-eight patients tested for hepatitis B antigen (HB Ag) were all negative and SGOT values were higher (mean 1000 i.u./l) than those reported in adult patients with chronic active hepatitis. Thirty-three patients had marked elevation of serum gammaglobulin (mean 3·78 g/100 ml) and 34% had positive LE cells. All patients had histologic features of ‘aggressive’ hepatitis; in addition five biopsies also showed areas of submassive hepatic necrosis. The initial response to corticosteroid was excellent in all but three patients. To date drug therapy has been suspended in fifteen patients for periods of 3 months to 4 years and 7 months. There have been eight deaths. Three with hepatic insufficiency and two with sepsis. Three others have subsequently died following orthotopic liver transplantation.

Australia antigen and hepatitis in Accra, Ghana

Viral hepatitis in young adults in Accra, Ghana, is associated with Australia antigen (H.A.A.). Sera from 85 patients in hospital with viral hepatitis were available for determinations of H.A.A. Of the 16 patients whose serum was obtained within the first week of symptoms, 15 were positive. The only factor related to finding H.A.A. was the time between onset of symptoms and the collection of the serum sample. Persistence of H.A.A. was associated with persistence of jaundice in men but not in women. Previous epidemiological studies in Accra found no evidence for parenteral transmission of viral hepatitis and showed a shanty-town predilection pointing to faecal-oral transmission. It thus seems that H.A.A.-associated hepatitis is transmitted in West Africa either faecal-orally or by shanty-town associated arthropods. The finding that H.A.A. hepatitis is the usual hepatitis in young adults in Accra is in accord with the high prevalence of H.A.A. elsewhere in the general population in Africa and may be related to the high rate of cirrhosis and hepatoma in Africa.