The significance of blood transfusion in non-A, non-B chronic liver disease in Japan

Hepatocellular carcinoma: recent trends in Japan

During the past 20 years, primary liver cancer, 95% of which is hepatocellular carcinoma (HCC), has ranked third in men and fifth in women as a cause of death from malignant neoplasm in Japan. The numbers of deaths and death rate from HCC showed a sharp increase beginning in 1975. Although both hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes, HCV-related HCC has accounted for most of the recent increase and now represents 75% of all HCC in Japan. Geographically, HCC is more frequent in western than eastern Japan, and the death rate of HCC in each prefecture correlates with prevalence of anti-HCV. Among patients with HCV-related HCC, a history of blood transfusion was a relatively important source of infection in the 1990s, whereas community-acquired infections increased after 2000. There was a negative correlation between the duration from onset of infection to development of HCC and the age at onset. Interferon therapy for chronic hepatitis C has reduced the risk for HCC, indicating that early detection of HCV carriers and better treatment will contribute to improved outcomes. Nationwide screening for HCV and HBV began in 2002 in Japan, and reduction of HCC is anticipated. Further research should focus on mechanisms of carcinogenesis by HCV and HBV, development of more effective treatments, and establishment of early detection and treatment approaches. Better understanding of HCC unrelated to HCV and HBV and possibly because of steatohepatitis and diabetes should also be a major concern in future studies.

Chronic hepatitis C. Implications for health-related quality of life

Hepatitis C viral infection with its sequelae is a significant healthcare problem. Hepatitis C infects nearly 4 million Americans with almost half of these unaware of their infection. Many of those individuals infected with hepatitis C develop chronic hepatitis C and in 15% of these patients, the infection will progress to cirrhosis within 20 years. Several cross-sectional and longitudinal studies have demonstrated the negative impact of chronic hepatitis C on health-related quality of life. This review describes what is currently known about the impact of chronic hepatitis C on health-related quality of life during pharmacologic treatment and after liver transplantation. It is important to note that few studies have prospectively followed patients over time with respect to quality of life or examined other factors including symptoms, markers of disease progression, or host immune function. Studies suggest that patients with chronic hepatitis C, even without major disease-related complications, perceive themselves to be unwell and have significant changes in their physical and mental well being. Such results have important implications for nursing care and management. Intervention studies focused on self-care management with an emphasis on symptom reduction are warranted.

Hepatitis C in clinical practice

Hepatitis C virus infection is now one of the most important causes of chronic liver disease. Primary care physicians play an important role in the diagnosis and initial work-up of patients infected with this virus. Understanding which patients may be at risk is the first step. By understanding the correct use of hepatitis C virus diagnostic testing and the risk and benefits of antiviral therapy, providers will be better equipped to screen and counsel their patients.

Hemophilia. A new approach to an old disease

The history of hemophilia diagnosis and therapy has been a turbulent one. We are coming full circle, back to the use of genetics as the main diagnostic tool for this disease. Therapeutically, the retroviruses that ravaged one generation of hemophiliac patients now may participate in the cure for the next generation. The hemophilia community hopes that the future of hemophilia care will follow a course guided by this modified quote from James Russell Lowell: "New times demand new measures, and men [and women]. As the world advances and in time outgrows the laws that in our fathers' [and mothers'] days were the best, doubtless after us some purer scheme will be shaped out by wiser man [and women] than we, made wiser by the steady growth of truth."

The efficacy of prophylactic interferon alfa-2b in preventing recurrent hepatitis C after liver transplantation

Clinical recurrence of hepatitis C after liver transplantation can lead to cirrhosis, liver failure, and death. In patients undergoing liver transplantation for hepatitis C, we assessed the efficacy of interferon alfa-2b (IFN) in preventing recurrent hepatitis. We randomized 86 patients to either an IFN group (3 MU three times a week starting within 2 weeks after transplantation and continued for 1 year) or a control (no IFN) group. Recurrence, the primary end point, was diagnosed on biopsy performed at 1 year or for abnormal biochemistries. HCV RNA levels were measured by branched-chain DNA (bcDNA) assay and arbitrarily defined as low, moderate, or high (< 10 x 10(5), 10-100 x 10(5), or > 100 x 10(5) Eq/mL, respectively). Data on 30 IFN patients and 41 no-IFN patients who survived > or = 3 months were reviewed. Mean follow-up was 669 +/- 228 days for IFN patients and 594 +/- 254 days for no-IFN patients. IFN patients were less likely to develop recurrent hepatitis (8 IFN vs. 22 no-IFN patients, P = .017, log rank analysis). IFN and 1-month HCV RNA level were independent predictors of recurrence. IFN reduced the risk of recurrence by a factor of 0.4 (P = .04, Cox proportional hazards model); HCV RNA level > 100 x 10(5) Eq/mL at 1 month after transplantation increased the risk by a factor of 3.1 (P = .01). Low, moderate, and high viral levels at 1 and 3 months were associated with significantly different rates of recurrence in IFN patients (P = .05 at 1 month and P = .003 at 3 months) but not in untreated patients (P = .28 at 1 month and P = .25 at 3 months). In patients with two or more rejections, the risk of recurrence was increased by a factor of 2.17 (P = .05). On 47 1-year biopsies (24 IFN; 23 no IFN), piecemeal necrosis was more common in untreated patients (P < .02). One- and 2-year patient survival, respectively, was 96% and 96% with IFN and 91.2% and 87.2% without (P = NS). Prophylactic IFN reduced the incidence of recurrent hepatitis after transplant. Although IFN was most effective in patients with low HCV RNA levels, we also noted an effect in patients with moderate levels. IFN did not prevent viremia, suggesting that it may work through alternative mechanisms.

Immunopathology of hepatitis C

Hepatitis C virus (HCV) infection becomes persistent in the majority of instances in the face of a humoral and cellular immune response, and persistent HCV infection is associated with chronic hepatitis. In particular, cytotoxic T lymphocytes (CTL), crucial in the eradication of virus-infected cells, have been observed in the liver and the peripheral blood of chronically infected patients, suggesting that CTL cannot completely eliminate the virus, and may contribute to chronic liver injury. In this review, the potential host and the viral factors involved in the pathogenesis of chronic HCV infection will be discussed with emphasis on the HLA-A2 restricted peripheral blood CTL response and its relationship to liver disease and viral load.

Indications for and timing of liver transplantation

The tremendous success of OLT as a highly effective treatment for patients with end-stage liver disease has resulted in a rapid increase in the number of candidates for the procedure. Refinements in organ preservation, improvements in surgical technique and immunosuppression, and better postoperative management have contributed to improved survival rates. The discrepancy between the paucity of organs and the increasing numbers of potential recipients will continue to worsen until there are extraordinary breakthroughs in providing alternatives to human whole-organ livers, such as xenografts or cultured hepatocyte infusions. For now, the vast majority of patients with life-threatening liver disease are not likely to receive a liver graft. Thus, the issues of patient selection and timing of OLT have become even more relevant. Prompt referral to a transplant center is not only in the patient's best interest, but also it has been shown to be cost-effective. Over the last 30 years, it has become clear that hepatic malignancy, initially a common reason for OLT, should be an indication for transplantation only in highly selected individuals. The role of adjuvant chemotherapy needs to be defined, and proven treatment alternatives need to be developed. New antiviral agents may enable a large group of patients with chronic hepatitis B to be successfully transplanted, placing even greater demands on the already limited supply of donor livers. Hepatitis B appears to be species specific, and it is conceivable that xenotransplantation from a nonsusceptible donor species may confer protection to HBV reinfection, eliminating the problems of an inadequate donor supply. Until novel approaches, including xenotransplantation, gene therapy, or replacement of hepatic function by cultured hepatocyte infusions, become a widespread reality, future allocation policies may highlight outcome as well as urgency as a fundamental variable to determine if transplantation is reasonable. Survival rates have been shown to fall with advancing levels of urgency, resulting in a conflict between equity and efficacy in organ allocation. As waiting lists for liver transplantation continue to grow, it is becoming increasingly apparent that patients must be referred to a transplant center earlier in the course of liver disease.

Interferon therapy for chronic hepatitis C

Interferon alone is currently the treatment of choice for chronic hepatitis C. The optimal treatment regimen continues to be defined and refined by clinical studies. The variability of the response to interferon seems to be influenced by several factors, including liver histology, viral genotype, level of viraemia, number of predominant quasispecies, and perhaps the type of interferon and treatment regimen. It is therefore quite likely that, in the future, treatment regimens will be tailored to the individual patient in order to maximize the likelihood of a beneficial outcome. It is also likely that the increasing availability of sensitive, quantitative, and affordable assays of hepatitis C viral levels will allow physicians to assess treatment response quite differently from the way we do so today. This will change our philosophy such that we will begin to view and treat chronic hepatitis C as an infection, instead of simply as a liver disease.

Heterogeneity of hepatitis C virus

A great deal of information on the molecular heterogeneity of hepatitis C virus (HCV) has been achieved since its discovery in 1989. However, little is known about the clinical significance of these variations. Based on the degree of sequence variation, HCV has been classified into six major groups or types, differing by 31-34% at the nucleotide level over the entire virus genome. Each type is divided into several subtypes that differ by 20-23% in nucleotide sequence. Viruses within the same subtype are up to 10% divergent and, within infected individuals, vary by up to 1.5%. Genotype distributions are not homogeneous around the world and may reflect both historical and recent parenteral routes of transmission. The clinical implication of these genomic variations are not yet fully elucidated: genotype 1b has been associated with end-stage liver disease, including liver cirrhosis and hepatocellular carcinoma, but this finding might rather reflect its earlier introduction to the populations studied. Consistent evidence exists that types 2 and 3 have a higher response rate to interferon treatment than type 1, although the interplay between genotype and viral load in determining the response is still unclear. Immunohistochemical studies indicate a stronger activation of the endogenous interferon system in the liver of patients infected with type 1 compared to those infected with types 2 and 3, explaining, at least in part, its low responsiveness to exogenous interferon treatment. Biological, sequence-dependent variations of genotypes have been poorly investigated to date, but differential efficiency of translation activity of the 5' non-coding region has been reported. The availability of "in vitro" systems for evaluating pathogenetic aspects and neutralization mechanisms will improve the present knowledge on this world-wide infectious disease and on the clinical usefulness of distinguishing between genotypes.

Hemophilia 1996. New approach to an old disease

The history of hemophilia diagnosis and therapy has been a turbulent one. We are coming full circle, back to the use of genetics as the main diagnostic tool for this disease. Therapeutically, the retroviruses that ravaged one generation of hemophiliac patients now may participate in the cure for the next generation. The hemophilia community hopes that the future of hemophilia care will follow a course guided by this modified quote from James Russell Lowell: "New times demand new measures, and men [and women]. As the world advances and in time outgrows the laws that in our fathers' [and mothers'] days were the best, doubtless after us some purer scheme will be shaped out by wiser men [and women] than we, made wiser by the steady growth of truth."

Persistent hepatitis C viremia after acute self-limiting posttransfusion hepatitis C

Persistent viremia after clinical or subclinical hepatitis C virus (HCV) infection is believed to occur in patients with chronic hepatitis C, but little is known about the duration of HCV replication in patients with acute hepatitis who have recovered or the relation of HCV viremia with the kinetics of antibodies to HCV (anti-HCV). We tested HCV-RNA and anti-HCV in serial serum samples from 41 patients with posttransfusion non-A, non-B hepatitis, followed for an average of 6 years after transfusion. Serum HCV-RNA was measured by nested polymerase chain reaction, which used primers from the 5' untranslated region of the HCV genome. Anti-HCV were tested with first- and second-generation enzyme-linked immunosorbent assays (ELISA 1 and ELISA 2), and with a second-generation recombinant immunoblot assay. Of the 41 patients, 10 recovered and 31 progressed to chronic liver disease. HCV-RNA was detected in serum before or simultaneously with the onset of hepatitis in all cases, and lasted between 2 and 6 weeks in 5 of the 10 patients who recovered, whereas it persisted for the entire follow-up period in every case with chronic hepatitis and in the remaining 5 patients with self-limiting hepatitis. Anti-HCV were detected with ELISA 2 in the first serum sample, with raised serum transaminases in 57% of patients, but in only 6% with ELISA 1. In the sample obtained 1 month after the onset of hepatitis, anti-HCV were detected with ELISA 2 in 94% of patients, but in 34% with the ELISA 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic hepatitis in haemophilia

Chronic hepatitis affects almost all haemophiliacs treated with non-virally inactivated clotting factor concentrates. The virus responsible is hepatitis C (HCV) and most patients have non-neutralising antibodies with circulating virus. Although the majority also have evidence of past infection with hepatitis B, less than 5% are chronic carriers of HBsAg. Chronic hepatitis C can be associated with severe and progressive liver disease but the development of complications is slow. Treatment with recombinant interferon alpha given subcutaneously normalises the liver function in 50% of patients, but 50% of responders relapse on stopping treatment. Liver transplantation is successful in patients with advanced liver disease and it offers the added advantage of phenotypic cure of the haemophilic state.

Clinical significance of antibodies to nonstructural and core proteins of hepatitis C virus in posttransfusion hepatitis patients during long-term follow-up

To clarify the long-term clinical significance, antibody to hepatitis C virus (HCV) was examined using core (p22) and nonstructural (C100-3) protein assays in sera of 18 patients with non-A,non-B posttransfusion hepatitis (PTH-NANB) who were selected retrospectively. Each patient had been followed for more than 5 years after the development of the disease. They were divided into three groups according to clinical outcome: acute hepatitis that resolved within 1 year, group 1 (n = 3); chronic hepatitis that resolved within 1-4 years, group 2 (n = 4); and chronic hepatitis that persisted for 5 years or longer, group 3 (n = 11). Sixteen of the 18 were positive for anti-C100-3 and anti-p22, one was positive for anti-p22 alone, and one was negative for both. In ten of the 16 (62.5%), anti-p22 appeared before anti-C100-3. The anti-C100-3 titer peaked about 12 months after disease onset in all cases and thereafter declined gradually, finally becoming negative in groups 1 and 2, while the titer fluctuated in group 3. The mean titer in group 3 at 12 months (69.2 units) significantly exceeded that of groups 1 (4 units) and 2 (8.2 units). Group 1 was seronegative for HCV antibodies and HCV RNA at the last examination, suggesting the cessation of HCV replication. Group 3 remained positive for those markers, indicating the continued replication of HCV.(ABSTRACT TRUNCATED AT 250 WORDS)

Is a hemoglobin of 10 g/dL required for surgery?

The "10/30" (hemoglobin/hematocrit) rule has long been recognized and accepted in the medical community as the threshold for transfusion in the perioperative setting. However, an increasing number of publications suggest there is no absolute threshold for transfusion, and that this decision should be based on an assessment of the overall clinical picture presented by the patient. This article reviews the risks associated with blood transfusions, and the data in humans and animals that describe the benefits of transfusion. Recommendations on the trigger for red cell transfusion are provided.

Persistence of viremia in patients with type-C chronic hepatitis during long-term follow-up

To clarify the evolution of antibody to hepatitis C virus (anti-HCV) and of liver histologic findings during the natural course of type-C chronic hepatitis, 111 patients with biopsy-proven chronic hepatitis type C were consecutively enrolled in this study and were followed up biochemically, serologically, and histologically for more than 5 years. All were positive for the first- and second-generation antibody to HCV (anti-HCV-1 and anti-HCV-2). None received antiviral therapy during the follow-up period. At the end of follow-up, all remained positive for anti-HCV-2, but four patients turned negative for anti-HCV-1. HCV RNA, detected by the polymerase chain reaction method, was tested serially in 20 patients who persisted positive anti-HCV-1 and in 4 patients who lost anti-HCV-1. HCV RNA disappeared from only two patients, who lost anti-HCV-1 during the follow-up period. A normalization of the serum transaminase level was found in only two patients, who lost both anti-HCV-1 and HCV RNA. A repeat liver biopsy was performed in 62 patients with chronic hepatitis who were persistently positive for all HCV markers and in 4 patients who lost anti-HCV-1. Of the 62 patients who retained all HCV markers, 16 progressed to hepatocellular carcinoma, 6 to cirrhosis of the liver, and 1 had a normal liver, whereas the remaining 39 had chronic hepatitis. Two patients who lost both anti-HCV-1 and HCV RNA showed a normal liver. Of two patients who lost only anti-HCV-1 one progressed to hepatocellular carcinoma and one to chronic hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical assessment and incidence of hepatitis C RNA in 50 consecutive RIBA-positive volunteer blood donors

OBJECTIVES

(i) To assess evidence of liver disease in 50 consecutive volunteer blood donors who were anti-hepatitis C virus (anti-HCV) antibody positive and who were referred to one hepatologist; (ii) to assay for viral RNA in serum in these patients.

SETTING

Royal Prince Alfred Hospital, a teaching hospital of the University of Sydney.

PATIENTS

Fifty people who were detected by the NSW Red Cross Blood Transfusion Service to be anti-HCV antibody positive and to have a positive result on recombinant immunoblot assay (RIBA) were assessed by one hepatologist for symptoms, signs and biochemical evidence of hepatic dysfunction. These patients were consecutive referrals from this source. Sixteen of these patients also consented to liver biopsy assessment. All patients had serum assayed for viral RNA by polymerase chain reaction with a combination of 3' and 5' primers.

RESULTS

The 50 blood donors consisted of 28 men and 22 women, with a mean age of 34.5 years. Forty-six patients were asymptomatic. Only six had a past history of hepatitis while 14 had minor signs of chronic liver disease. In 28, injecting drug use was thought the most likely source of exposure to HCV. The minimal mean time since exposure to HCV in these patients was 8.8 +/- 5.2 years. Eight patients had received a blood transfusion at a mean time of 15.0 +/- 9.8 years from the time of consultation. The mean maximum level of alanine aminotransferase (ALT) in all 50 patients was 102.8 U/L. Five patients had persistently normal ALT levels; another 22 had at least one normal ALT level. Liver biopsies indicated chronic persistent hepatitis in 11 patients, mild chronic active hepatitis in three patients and more severe chronic active hepatitis in one. One patient had cirrhosis on biopsy. Forty-two patients had viral RNA detected in serum.

CONCLUSION

Chronic infection with HCV in blood donors was invariably asymptomatic; 78% of patients had no signs of chronic liver disease and 68% had a maximum hepatic transaminase level of less than 100 U/L. Although severe liver disease was seen in two of 16 biopsies, the majority of these patients have mild liver disease despite a mean of about 10 years since exposure to the virus. Eighty-four per cent of patients had evidence of viral RNA in serum.

[European Acute Transfusion Hepatitis Interferon Study (EATHIS)]

Since 1989, a prospective, multicentric and collaborative study, named European Acute Transfusion Hepatitis Interferon Study (EATHIS), involving 16 blood centres in France is coordinated by a task force in collaboration with the Viral Hepatitis and Recipients working groups of the French National Society of Blood Transfusion. A phase of recipient screening may be completed by a therapeutic interferon protocol. Among 1,476 transfused recipients receiving an average of 4.4 blood components, 1,011 were followed up at least four months. The incidence of non-A, non-B post-transfusion hepatitis (PTH) was varying from 0.1 to 6% at the different locations. Out of 15 hepatitis cases, 10 were diagnosed as post-transfusional. These preliminary data indicate a reduced incidence of PTH, with a mean of 1% for the period 1989-1991. It emphasises the importance of a transfusion vigilance program including follow up and testing for transaminases and specific viral markers.

The risks of blood transfusion: the relative influence of acquired immunodeficiency syndrome and non-A, non-B hepatitis

PURPOSE

The acquired immunodeficiency syndrome epidemic has greatly increased concern about the risk of blood transfusion. Many transfusions are now autologous, and when these are not available, both physicians and patients are more likely to question the advisability of transfusion. We evaluate the risk of preoperative blood transfusion and the contribution of human immunodeficiency virus (HIV) infection to that risk.

METHODS

We used decision analysis to characterize the risk associated with HIV infection in days of life lost. The contributions to risk of acute transfusion reaction, hepatitis B, and non-A, non-B hepatitis are also estimated. Sensitivity analyses show the implications for transfusion risk of recent information about HIV infection in the blood supply and a new test for hepatitis C.

RESULTS

The analysis shows that the contribution of HIV infection to the risk of death from transfusion, expressed in days of life expectancy lost, has become extremely small over the last several years. Currently, HIV infection accounts for less than 1% of the risk of death, while non-A, non-B hepatitis accounts for 97% to 98%. Further reductions in the risk of HIV infection, even to zero, will make relatively little difference in the safety of transfusion. The analysis also shows that the remaining risk from transfusion should decrease sharply, by more than two thirds, with the adoption of the test for hepatitis C.

CONCLUSIONS

Efforts to improve the safety of blood should focus on reducing the risk of non-A, non-B hepatitis. The remaining risk of HIV infection is very small.

Clinical aspects and epidemiology of hepatitis B and C viruses in hepatocellular carcinoma in Japan

The incidence of hepatocellular carcinoma (HCC) in Japan has increased over the past two decades. Of the 379 patients with HCC treated at Shinshu University Hospital over the past 20 years, 112 underwent treatment between 1971 and 1980 and 267 were treated between 1981 and 1990. The prevalence of hepatitis B virus-associated HCC and hepatitis C virus-associated HCC was 54% and 34%, respectively, during the first decade and 31% and 60%, respectively, during the second decade. Major factors contributing to the increased incidence of HCC include an increase in the incidence of type C chronic hepatitis and an increase in the incidence of cirrhosis of the liver, which in turn are the result of blood transfusions received about 30 years ago. Donated blood testing positive for hepatitis C virus antibody is currently rejected from the blood supply. However, the occurrence of post-transfusion hepatitis with the potential to develop into HCC has not been entirely eliminated. In addition, there is an as yet unelucidated route of horizontal transmission of hepatitis C virus.

The preservative-exchange method using a sextuple-bag system for a 10-week storage period of red blood cells

Prolonged storage of red blood cells in a liquid state was achieved by replacing the preservative using a sextuple-bag system. The bag system consists of one primary bag containing citrate-phosphate-dextrose (CPD) solution, three satellite bags containing saline-adenine-glucose-phosphate-maltose (SAGP-maltose) solution, and two empty satellite bags to remove plasma and buffy coat. Preservative can be exchanged three times in this closed system. The system is able to supply nutrients, such as glucose, and to remove harmful metabolites, such as lactic acid, by exchanging the preservative during storage. As a result, red cells stored by this method showed much higher levels of total adenylate and morphological score after the second preservative exchange, when compared with red cells stored by the conventional method (P < 0.01). Judging from these two in-vitro parameters, red cells may tolerate storage for at least 10 weeks in a liquid state. This method might be useful for 'predeposit autologous transfusion', as it is more convenient and more cost effective than the freeze-preservation method.

Post-transfusion NANBH in the light of a test for anti-HCV

The incidence of post-transfusion hepatitis (PTH) varies over an order of magnitude in different parts of the world. For example, prospective studies from Spain and the UK reveal rates of PTH of approximately 10 and 0.5% respectively. Similarly the association of a history of transfusion in patients with chronic liver disease varies widely; in Japan, with high rates of PTH, the association appears obvious whereas in the UK less obvious. These factors must be taken into account when assessing the cost-effectiveness of pre-transfusion screening for anti-HCV. A useful approach to assessing the value of screening donors for anti-HCV is to study prospectively the correlation of anti-HCV and PTH. In carefully selected cases of PTH, the correlation of anti-HCV and PTH in donor-recipient sets of samples may be very high. However, the predictive value of 'first-generation' assays for anti-HCV in routine studies of unselected cases of PTH may be less than 20% in countries with low rates of transfusion-transmitted non-A, non-B hepatitis (NANBH). The anti-HCV screening tests and supplementary assays are continually evolving. More recent assays incorporate structural as well as non-structural antigens in both types of ELISA used for screening and in the supplementary tests such as the recombinant based immunoblots.(ABSTRACT TRUNCATED AT 250 WORDS)

Can the response to interferon treatment be predicted in patients with chronic active hepatitis C?

Twenty-one of 40 patients with chronic non-A, non-B hepatitis (37 anti-HCV positive) were randomised to receive interferon alpha 2b (3 million units subcutaneously thrice weekly for 24 weeks) and then to be observed for six months. Among the other 19 patients (controls) randomised to be observed without treatment for 12 months, eight have subsequently been treated with interferon for six months. One treated patient and three controls were lost to follow-up. A return to normal serum alanine aminotransferase levels which lasted until the end of the treatment period occurred in 18 (64%) of the 28 patients given interferon (and in 13 of 21 (62%) randomised to treatment), but only in one of the 16 untreated controls (p less than 0.001). Multivariant analysis indicated that, compared with the ten nonresponders, the 18 patients who responded to interferon were more likely to have acquired infection by intravenous drug abuse than by blood transfusion (p less than 0.05), and were more likely to have histologically less severe chronic liver disease (p less than 0.01). Thus, all 13 patients with less severe liver disease histologically responded to interferon, but only five of 15 patients with cirrhosis or bridging fibrosis responded. Among 17 responders followed for more than four months, five (28%) are still in remission a median of 13 months (range four months to 24 months) after stopping interferon. The characteristics which favoured a response during treatment also appeared to distinguish those who experienced sustained post-treatment remission.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of antibody to hepatitis C virus in Japanese patients with viral hepatitis: relationship between anti-HCV antibody and the prognosis of non-A, non-B post-transfusion hepatitis

In a retrospective study, antibody to hepatitis C virus (anti-HCV antibody) was measured in 80 patients with acute viral hepatitis (type A, 18; type B, 21; type non-A,non-B, 41). Anti-HCV antibody was found in 12 of 20 patients (60%) with non-A,non-B post-transfusion hepatitis (NANB-PTH) and in 9 of 21 patients (43%) with sporadic NANB hepatitis (NANB-SPO). Patients with acute hepatitis type A or type B did not have anti-HCV antibody. The number of patients who developed chronic hepatitis was greater in the group with anti-HCV antibody than in the anti-HCV negative group in both NANB-PTH and NANB-SPO. The difference was significant in those with NANB-PTH (P less than 0.05). To investigate the relationship between the long-term prognosis of NANB-PTH and the course of anti-HCV, we studied anti-HCV antibody in 12 patients who developed chronic type C hepatitis (C-CH) after PTH and followed them for more than 5 years after the development of PTH. One year after the development of PTH, all 12 had anti-HCV antibody. Five lost anti-HCV antibody (group 1) while 7 remained positive (group 2) at the final examination. Four of the 5 patients in group 1 had normal serum transaminases; however, abnormal transaminase persisted in all 7 patients in group 2 until the end of follow-up (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Interrelationship of blood transfusion, non-A, non-B hepatitis and hepatocellular carcinoma: analysis by detection of antibody to hepatitis C virus

To clarify the relationship between hepatitis C virus infection and the development of hepatocellular carcinoma as sequelae of non-A, non-B posttransfusion hepatitis, 231 patients with chronic non-A, non-B hepatitis (96 with chronic hepatitis, 81 with cirrhosis and 54 with hepatocellular carcinoma) were analyzed for antibody to hepatitis C virus and were compared with 125 patients with chronic hepatitis B (50 with chronic hepatitis, 46 with cirrhosis and 29 with hepatocellular carcinoma). Antibody to hepatitis C virus was detected in 89.6%, 86.4% and 94.4% of patients with non-A, non-B hepatitis-related chronic hepatitis, cirrhosis and hepatocellular carcinoma, respectively, compared with 6%, 17.4% and 34.5% with similar diseases related to hepatitis B. A history of transfusion was documented in 52%, 33% and 42% of anti-hepatitis C virus-positive cases of chronic hepatitis, cirrhosis and hepatocellular carcinoma. The mean intervals between the date of transfusion and the date of diagnosis of anti-hepatitis C virus-positive chronic hepatitis, cirrhosis and hepatocellular carcinoma were 10, 21.2 and 29 yr, respectively. In 21 patients with transfusion-associated hepatocellular carcinoma, anti-hepatitis C virus was present in each serial sample available for testing, including samples obtained up to 14 yr before the diagnosis of hepatocellular carcinoma. These data suggest the slow, sequential progression from acute hepatitis C virus-related non-A, non-B hepatitis through chronic hepatitis and cirrhosis to hepatocellular carcinoma and support a causal association between hepatitis C virus and hepatocellular carcinoma.

Chronic liver disease. A case control study of the effect of previous blood transfusion

A means of assessing hepatitis NANB virus infection, via blood transfusion, as a cause of chronic liver disease was investigated in a hospital in each of two cities in England. Patients with chronic liver disease were matched for age and sex with other patients in the same hospital and histories taken included details of previous operations and blood transfusions; if these were within ten years of the study enquiries were made of hospital records officers. All positive histories were found correct, but about one third of previous transfusions had been omitted by both case and control patients. Sixty-seven male and 35 female patients with chronic liver disease and their controls were included in analyses. The only clear difference which emerged related to residence for more than a year in the Middle or Far East by male case- (40%) or control- (21%) patients (P less than 0.05). The exclusion of patients with this history left only 34 pairs in which five (15%) of the case patients and one (3%) of the control patients had a transfusion history: this difference was not statistically significant. Although the study results have shown no clear evidence of blood transfusion as a major cause of chronic liver disease in Britain, the study method, with sufficient numbers to allow analyses of newly diagnosed patients with confirmed transfusion histories, could be used to provide an ongoing assessment of the risk.

Blood transfusion, alcohol consumption, and cigarette smoking in causation of hepatocellular carcinoma: a case-control study in Fukuoka, Japan

In the present study, we investigated the association between hepatocellular carcinoma (HCC) and hepatitis B virus infection (HBV), blood transfusion and drinking and smoking habits by comparing 124 HCC cases and 250 controls. We confirmed a very high relative risk (RR), i.e. 31.0 (P less than 0.001), among persons who were positive for serum hepatitis B surface antigen (HBsAg). However, the prevalence of serum HBsAg positives among our cases was only 21%, about half of those reported earlier, indicating a role of other etiological factors. Those who have a history of blood transfusion showed a significantly elevated RR of 3.0 (P less than 0.001) or 4.9 (P less than 0.001), and most of them (85%) were non-carriers of HBV. Thus, the past history of blood transfusion is an important risk factor among the Japanese. Unidentified non-A, non-B hepatitis viruses in transfused blood probably play a significant role in causing HCC. We estimated that 15% of male HCCs were attributable to blood transfusion. A positive relationship between alcohol consumption and HCC was detected, particularly among HBsAg-negative subjects with no history of blood transfusion who had drunk heavily in their younger years. RR estimates were not great (e.g., heavy drinkers: 2.5), but a substantial proportion of HCC may be attributed to drinking because of common drinking habits among Japanese males. Smoking was also found to have a positive association, but the relationship at a young age was less clear, and further investigation is needed to clarify the etiological role of smoking.

Rationale for surrogate testing to detect non-A, non-B hepatitis

NANB hepatitis was initially recognized in 1975 and 13 years later, the exact etiology of this presumed viral disease remains uncertain. The acute illness is relatively mild with only about 25% of patients becoming icteric. Nevertheless, at least one half of the patients have evidence of chronic infection, and, as recently recognized, 10% to 20% develop severe liver disease. Because approximately 2% of patients who receive transfusions and whose underlying medical condition permits long term follow-up develop posttransfusion hepatitis, procedures for reducing this risk are considered prudent. Unfortunately specific tests for detecting NANB hepatitis are not available, and it is unlikely that such tests will be available in the near future. Hence, testing by surrogate or nonspecific tests (ALT and anti-HBc) were recommended because evidence from two studies conducted during the 1970s showed these tests identify some donors thought to transmit the infection. However, randomized, controlled prospective studies to determine whether these tests will, in fact, reduce NANB posttransfusion hepatitis were not performed. By the mid-1980s it was apparent these studies would not be performed nor were studies to determine the incidence of NANB posttransfusion hepatitis in the post-AIDS screening era likely to be initiated. Therefore, surrogate testing, as the best available method for reducing posttransfusion hepatitis, was implemented in the United States in 1986-87.

Serial assay for IGM anti-HBc in patients with anti-HBe-positive chronic hepatitis and its significance for long-term prognosis

Serial assays for immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc) were performed in 51 patients with antibody to hepatitis B e antigen (anti-HBe) in their sera. IgM anti-HBc was detected periodically and persistently in 8 (53%) of 15 patients with chronic hepatitis whose serum glutamic pyruvic transaminase (GPT) levels were elevated and was not detected in 36 patients with normal serum GPT levels. Antibody to delta agent was not detected in any of the patients. Of the eight patients positive for IgM anti-HBc, four had a high titer of IgM anti-HBc and either developed liver cirrhosis (three cases) or died due to massive hepatic necrosis (one case); the other four showed a low level of IgM anti-HBc and either recovered (two cases) or developed chronic persistent hepatitis (two cases). Of seven patients negative for IgM anti-Hbc, two had a fatty liver, and five, who had a history of blood transfusion, had chronic hepatitis. Thus, even though anti-HBe may be present, if the titer of IgM anti-HBc is high, the histological activity can be expected to increase, and the prognosis will be poor. If the titer of IgM anti-HBc is low, the histological activity may be expected to decrease, and the prognosis may be good. In patients with abnormally high serum GPT but without IgM anti-HBc, another type of hepatitis or a secondary form of liver disease should be considered.

A case of acute non-A, non-B sporadic hepatitis with evolution of liver cirrhosis on serial histologic follow-up

Progression of acute non-A, non-B (NANB) posttransfusion hepatitis to liver cirrhosis has been well recognized as in hepatitis B infection, whereas no progression of acute NANB sporadic hepatitis to liver cirrhosis has yet been documented. We reported a 29-year-old male with prolonged transaminase elevations in whom acute NANB sporadic hepatitis progressed to histologically confirmed cirrhosis during follow-up of about 3 years. It is suggested that some of the cryptogenic cirrhosis of non-B type may develop from acute NANB sporadic hepatitis and long-term observation is also needed in patients with acute hepatitis of this category.