Repeated Transplantation of Microencapsulated Hepatocytes for Sustained Correction of Hyperbilirubinemia in Gunn Rats

In previous studies we demonstrated that transplantation of microencapsulated hepatocytes could correct congenital hyperbilirubinemia in Gunn rats for 4 to 6 wks. Reduction in hyperbilirubinemia followed a single transplantation of isolated encapsulated hepatocytes (IEH). After 4 to 6 wks of transplantation IEH gradually lose their functionality. To sustain long-term supplementation of liver function we have investigated the efficacy of monthly IEH transplantations for 6 mo. Hepatocytes, isolated from young Wistar rats, were microencapsulated with a collagen matrix within an alginate-poly L-lysine composite membrane. We transplanted IEH intraperitoneally into homozygous Gunn rats at monthly (4-wk) intervals for 6 mo. Control Gunn rats received intraperitoneal transplantations of empty microcapsules. Total serum bilirubin was measured in the IEH-transplanted and control Gunn rats at weekly intervals for the duration of the 6-month study. A significant (p < 0.01) and sustained decrease (by nearly 50%) in total serum bilirubin levels was observed following monthly IEH transplantations in Gunn rats for the duration of the study. No such decrease in total serum bilirubin levels was seen in the controls. The Gunn rats exhibited good tolerance for the multiple IEH transplantations. Thus, repeated IEH transplantations may be one strategy for providing long-term supplementation of liver function in congenital metabolic liver disease.

Hepatocyte Immobilization on Phema Microcarriers and its Biologically Modified Forms

Polyhydroxyethylmethacrylate (PHEMA) based microcarriers with different bulk structures were prepared by a phase inversion polymerization technique. PHEMA surfaces were further modified chemically by glow-discharge treatment, and biologically by covalent attachment of fibrinogen and collagen. Hepatocytes were isolated from young male Wistar rats using an in situ portal vein collagenase perfusion technique. Freshly isolated hepatocytes were seeded at 6 × 105 cells/mL and microcarrier concentration was 10 g/L. Stationary microcarrier cultures were carried out in standard (nontissue culture) polystyrene petri dishes in a humidified 5% CO2 incubator at 37 ± 0.5°C. Cell attachment was followed by light microscopy by taking samples from the culture medium every 30 min. Urea and protein syntheses by microcarrier-attached hepatocytes were determined by standard techniques. Nonswellable (highly cross-linked) hydrophilic PHEMA microcarriers did not support cell attachment and viability. However, swellable (low cross-linked) PHEMA microcarriers (pretreated in FBS) allowed high attachment and cell spreading. PHEMA microcarriers treated in dimethylaminoethylmethacrylate (DMAEMA) glow-discharge plasma also improved the cell attachment characteristics of the PHEMA microcarriers. The highest attachment efficiencies (immobilization yields) were observed with the biologically modified PHEMA microcarriers, especially modified with fibronectin. Metabolic activity, as estimated by urea and protein syntheses, was also higher in these microcarriers.

Extensive in vivo angiogenesis following controlled release of human vascular endothelial cell growth factor: implications for tissue engineering and wound healing

Vascular endothelial cell growth factor (VEGF) has strong stimulating effects on vascularization. Though very potent, VEGF is rapidly degraded due to its short half-life and when administrated by uncontrolled and nonspecific methods; however, its systemic administration in large doses can cause harmful side effects. Controlled release technology would allow delivering desired levels of bioactive VEGF within extended periods and permit examination of the in vivo effects of the compound in a broader way. The objective of this study was to determine the in vitro release behavior of VEGF from calcium alginate microspheres and the potency of this controlled release system in promoting localized neovascularization at the subcutaneous site of the rat model. In vitro release of human VEGF165 (2 and 4 microg/cm3 microsphere) was studied for 3 weeks under static conditions at 25 degrees C, and daily hormone release was measured using a competitive enzyme immunoassay. Following an uncontrolled release within the first 4 days, a quite constant zero-order VEGF release of 50 to 90 and 70 to 120 ng/day was achieved from 2 and 4 microg/cm3 polymer loaded microspheres respectively. In vivo angiogenesis was studied for a period of 8 weeks and evaluated using immunoperoidase staining and histopathological measurements. In vivo studies with rats (n = 24) showed a considerable level of capillary network formation at the epigastric groin fascia of VEGF microsphere-implanted rats starting from the first week. The most extensive neovascularization was observed in the group with 3 week postimplanted 4 microg VEGF containing microspheres; this level of vascularization was quite similar after 8 weeks. While the control group showed no evidence of angiogenesis, the difference in VEGF-induced neovascularization is statistically significant (p < 0.03). Immunostaining of the specimens showed a strong relationship between the release of human VEGF and neovascularization. The controlled VEGF release system described here promotes vigorous angiogenesis and has applicability for tissue engineering and wound healing studies.

Hepatitis C screening strategies in hemodialysis patients

Hepatitis C virus (HCV) infection is common in patients undergoing chronic hemodialysis, with an estimated yearly incidence of 0.2% and prevalence between 8% and 10%. Although a screening strategy based on alanine aminotransferase (ALT) values is currently recommended, this strategy has not been evaluated for cost-effectiveness compared with other potential screening strategies. A comparison therefore was made using a decision-analysis model of a simulated cohort of 5,000 hemodialysis patients followed up for 5 years. Using direct medical costs, three strategies were evaluated, including: (1) ALT values with confirmatory testing (biochemical), (2) serial enzyme-linked immunosorbent and strip immunoblot assay testing (serological), and (3) polymerase chain reaction (viral). Under baseline assumptions, the per-patient cost of screening hemodialysis patients for HCV was $378 for biochemical-based testing, $195 for serological-based testing, and $696 for viral-based testing. Our model was robust when varying the costs of testing, as well as the incidence and prevalence of HCV infection. Results of sensitivity analysis by varying costs, HCV incidence, and HCV prevalence indicated that serological-based screening was less costly than biochemical testing. Biochemical testing was in turn less costly than viral-based screening. Serological-based testing was also more effective in the diagnosis of de novo HCV infection, with a likelihood ratio of 85, in contrast to the likelihood ratio of 44 with biochemical-based testing using viral-based screening as the gold standard. A serological-based screening strategy is less costly and more effective than biochemical-based screening in the diagnosis of de novo HCV infection. Serological-based screening should be considered for HCV screening in hemodialysis populations.

Automated RIBA HCV strip immunoblot assay: a novel tool for the diagnosis of hepatitis C virus infection in hemodialysis patients

Hemodialysis (HD) patients remain a high-risk group for hepatitis C virus (HCV) infection. Serological assays (enzyme-linked immunosorbent assays, ELISAs) are the only tests currently approved by the Food and Drug Administration in the United States for the diagnosis of HCV. The RIBA HCV Strip Immunoblot Assay (SIA) is an established method for supplemental testing of repeat reactive hepatitis C ELISA patients on HD. However, the current manual procedure is labor intensive, requiring subjective band scoring and result interpretation. Recently, the automated CHIRON RIBA HCV Processor System has been designed to perform RIBA supplemental testing. The CHIRON RIBA HCV Processor System consists of a bench-top instrument that provides objective evaluation of the RIBA immunoblot strips, by measuring the light differentially reflected from the developed bands and white background, creating a density of reflectance. The CHIRON RIBA HCV Processor System assesses the intensity of each of the reactive bands in relation to the intensity of the internal control bands on each RIBA HCV strip. Comparison between processor and manual protocols was performed using a large (n = 200) cohort of ELISA 3.0 HCV negative and positive patients on maintenance HD. The test characteristics of RIBA HCV 3.0 SIA were identical with manual and automated runs. The relative intensity values of antigenic bands by the CHIRON RIBA HCV 3.0 Processor System between anti-HCV positive and negative patients were significantly different; only 15 of 784 (1.9%) antigenic bands had borderline reactivities. The correlation of test results between manual and automated runs was very high (kappa value 0.989). Among positive results by RIBA HCV 3.0 SIA, there was a strong concordance between manual and automated runs with regard to the pattern of reactivity (kappa value 0.943). The discordant results between manual and automated protocols were attributable to increased variability of antigen scores close to the cutoff value for both tests. In conclusion, the CHIRON RIBA HCV 3.0 Processor System is capable of performing RIBA HCV 3.0 SIA in the HD population accurately with minimal operator involvement. The test characteristics of RIBA HCV 3.0 SIA were identical by manual and automated runs. There was a strong correlation between the results of the manual and automated runs; the few discordant results between the two procedures were mostly due to increased variability of antigen scores close to the cutoff value for both tests. The Centers for Disease Control and Prevention in the USA have recently included chronic HD patients among those persons for whom routine HCV testing is recommended; HCV-infected patients on HD often have a high rate of indeterminate results by manual RIBA technology which is operator dependent for band scoring and result interpretation. The CHIRON RIBA HCV 3.0 Processor System may be very useful for supplemental anti-HCV testing of ELISA repeat reactive specimens in clinical practice within dialysis units.

Serum alanine aminotransferase in hepatitis c screening of patients on hemodialysis

It is recommended that patients on hemodialysis (HD) therapy undergo regular screening for hepatitis C virus (HCV) infection by using alanine aminotransferase (ALT) values. However, the utility of using ALT values in this setting is unknown. The aim of this prospective study at the University of California Los Angeles Hepatitis Screening Program is to determine the sensitivity, specificity, and predictive values of an elevated ALT level for the diagnosis of HCV infection in HD patients. We screened 2,440 HD patients from 39 dialysis centers for viral infection by using hepatitis antibody serological testing and ALT values. We found the sensitivity and specificity of a newly elevated ALT level for acute HCV infection to be 83% and 90%, respectively. According to Bayes' theorem, the positive predictive value was 4% and the positive likelihood ratio was 8.74. For chronic HCV infection, the sensitivity of a newly elevated aminotransferase level was 21%, and specificity was 91%. The positive predictive value was 16% (according to Bayes' theorem), and the positive likelihood ratio was 2.47. The negative predictive value of a newly elevated aminotransferase value was 99% for acute HCV infection and 94% for chronic HCV infection. Our results indicate that although a newly elevated aminotransferase level is sensitive and specific for acute HCV infection, its positive predictive value is inadequate. A newly elevated aminotransferase level was neither sensitive nor positively predictive of chronic infection. Therefore, an elevated ALT level is an ineffective method for screening for HCV infection in HD patients.

Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: A National Heart, Lung, and Blood Institute collaborative study

Persons with non-A, non-B hepatitis (cases) identified in 5 transfusion studies in the early 1970s have been followed ever since and compared for outcome with matched, transfused, non-hepatitis controls from the same studies. Previously, we reported no difference in all-cause mortality but slightly increased liver-related mortality between these cohorts after 18 years follow-up. We now present mortality and morbidity data after approximately 25 years of follow-up, restricted to the 3 studies with archived original sera. All-cause mortality was 67% among 222 hepatitis C-related cases and 65% among 377 controls (P = NS). Liver-related mortality was 4.1% and 1.3%, respectively (P =.05). Of 129 living persons with previously diagnosed transfusion-associated hepatitis (TAH), 90 (70%) had proven TAH-C, and 39 (30%), non-A-G hepatitis. Follow-up of the 90 TAH-C cases revealed viremia with chronic hepatitis in 38%, viremia without chronic hepatitis in 39%, anti-HCV without viremia in 17%, and no residual HCV markers in 7%. Thirty-five percent of 20 TAH-C patients biopsied for biochemically defined chronic hepatitis displayed cirrhosis, representing 17% of all those originally HCV-infected. Clinically evident liver disease was observed in 86% with cirrhosis but in only 23% with chronic hepatitis alone. Thirty percent of non-A, non-B hepatitis cases were unrelated to hepatitis viruses A,B,C, and G, suggesting another unidentified agent. In conclusion, all-cause mortality approximately 25 years after acute TAH-C is high but is no different between cases and controls. Liver-related mortality attributable to chronic hepatitis C, though low (<3%), is significantly higher among the cases. Among living patients originally HCV-infected, 23% have spontaneously lost HCV RNA.

Serotyping strip immunoblot assay for assessing hepatitis C virus strains in dialysis patients

Recent accumulated evidence shows that dialysis patients are a high-risk group for hepatitis C virus (HCV) infection. Assessment of HCV genotype distribution among dialysis patients may be important because specific viral genotypes are associated with different clinical manifestations, disease progression, and response to antiviral therapy. However, polymerase chain reaction-based methods are cumbersome and unsuitable for analyzing large cohorts of dialysis patients with HCV. Instead, this information can be obtained by using a novel recombinant immunoblot assay (RIBA) recently developed for determining HCV serotype. The RIBA HCV serotyping strip immunoblot assay (SIA; Chiron Corporation, Emeryville, CA), is based on an immunoblot strip with five lanes of immobilized serotype-specific HCV peptides from the nonstructural (NS4) and core regions of the genomes of HCV types 1, 2, and 3. HCV serotype is deduced by determining the greatest intensity of reactivity to the NS4 serotype-specific HCV peptide band in relation to the internal control band (human immunoglobulin G) intensity on each strip. HCV core peptide reactivity is used only in the absence of NS4 reactivity. We compared RIBA HCV serotyping SIA with genotyping using sera from a large (n = 107) cohort of HCV-infected patients undergoing chronic hemodialysis (HD). We successfully serotyped 79 of 107 patients (74%) undergoing HD. We found a remarkable concordance (65 of 70 results; 93%) between RIBA HCV serotyping SIA and genotyping (line probe assay [LiPA]) techniques (kappa = 0.786) with sera from viremic patients infected with a known genotype. Only 5 of 70 patients (7%) had apparently discordant results. In a subset of patients (28 of 107 patients; 26%) not typed by RIBA HCV serotyping SIA, most (24 of 28 patients; 86%) were successfully genotyped by LiPA technology. It was possible to assess serotype reactivity in some patients (9 of 107 patients; 7%) who could not be genotyped. The distribution of HCV serotypes was associated with the antibody response against HCV proteins and the patterns of reactivity by RIBA HCV 2.0 SIA. In conclusion, (1) we found good agreement between serotyping and genotyping methods in our large cohort of dialysis patients infected with HCV; (2) the impaired immunocompetence conferred by uremia may limit serotyping analysis in some HCV-infected patients undergoing HD; (3) RIBA HCV serotyping SIA may be useful in tracking transmission routes for HD patients who cleared the virus and have only anti-HCV antibody; and (4) the distribution of HCV serotypes was associated with the antibody response against HCV proteins and the patterns of reactivity by RIBA HCV 2.0 SIA. Assessment of HCV strains appears to be very useful in the routine clinical activity of nephrologists within HD units because consistent biological differences among HCV strains exist. RIBA serotyping SIA is a simple, inexpensive, and highly reproducible assay to obtain information about HCV types in the HD setting.

Biological dynamics of viral load in hemodialysis patients with hepatitis C virus

The biological dynamics of hepatitis C virus (HCV) viremia in uremic patients with chronic infection have not been fully characterized. We prospectively studied fluctuations of HCV-RNA in sera from 52 patients with end-stage renal disease who were undergoing maintenance hemodialysis (HD) and had chronic HCV infection. We measured HCV viremia monthly over the course of 13 months with the branched-chain DNA (bDNA) signal amplification assay and prospectively analyzed liver function, expressed by monthly serum aspartate (AST) and alanine aminotransferase (ALT) determinations. We observed three different patterns of HCV viremia: (1) patients persistently positive by bDNA assay (persistent viremia; 23 of 52 patients; 44%), (2) individuals with alternatively positive and negative results (intermittent viremia; 17 of 52 patients; 33%), and (3) patients persistently negative by bDNA assay (12 of 52 patients; 23%). The HCV viral load over the follow-up was greater among patients with persistent compared with intermittent viremia (persistent, 31.7 x 10(5) Eq/mL; range, 6.3 x 10(5) to 16.03 x 10(6) Eq/mL versus intermittent, 10.4 x 10(5) Eq/mL; range, 1.1 x 10(5) to 9.4 x 10(6) Eq/mL; P = 0.0001). In addition, patients with persistent viremia had over time greater AST and/or ALT activities than the intermittent group (AST: persistent, 26.5 IU/L; range, 9.6 to 73.7 IU/L versus intermittent, 21.3 IU/L; range, 8 to 56.8 IU/L; P = 0.001 and ALT: persistent, 14.7 IU/L; range, 3.7 to 57.9 IU/L versus intermittent, 10.9 IU/L; range, 2.3 to 52.1 IU/L; P = 0.001). In the group with persistent viremia, the mean difference between maximum and minimum values of HCV-RNA observed in each individual patient was 2.09 +/- 0.7 natural logarithm (Log(n)) and in intermittent viremic patients, 1.55 +/- 1 Log(n) (P = 0.045). The HCV load at study entry (19.4 x 10(5) Eq/mL) was rather low and did not change versus the end of follow-up in all patients (P = not significant [NS]). In the entire group, the fluctuations in HCV-RNA levels over time between and within individuals were not significant (P = NS). No difference in variability of HCV-RNA values over time between patients infected with different HCV genotypes was seen. In conclusion, three different patterns of HCV viremia in HD over time were assessed; one third of viremic patients had intermittent viremia, and those patients had less HCV-RNA, enzyme-linked immunosorbent assay, and aminotransferase activity than did patients with persistent HCV load. Larger fluctuations in HCV RNA levels occurred in patients with persistent than with intermittent HCV viremia. However, the viremic HCV load was low and relatively stable over a 13-month follow-up in our population. Studies with longer observation periods are warranted to understand fully the natural history of HCV in these immunosuppressed individuals.

Epidemiology and natural history of hepatitis G virus infection in chronic hemodialysis patients

Patients on chronic hemodialysis (HD) have recently been identified as having a high prevalence of hepatitis G virus (HGV) infection. The clinical significance of HGV in this population remains unclear, with no data available as to the acquisition and natural history of HGV infection in this group.

AIMS

To assess the prevalence and risk factors of HGV in a large cohort of chronic HD patients, and to evaluate the incidence and clinical consequences of HGV over time in this population.

METHODS

Paired sera from 292 patients undergoing chronic HD treatment in four units in the Los Angeles area were tested for HGV RNA before and after they had been on HD for a mean period of 9.7 +/- 1.9 months. HGV was tested by a single-step RT-PCR using two couples of primers located in two different portions (5'UTR, NS5a) of the genome. The amplified products were detected by hybridization with 5' biotin-labeled probes specific for each region.

RESULTS

At study entry there were 50 HGV RNA-positive patients, thus the HGV prevalence was 17% (50/292). The multivariate analysis by ordinal logistic regression model showed association (p = 0.0013) between HGV RNA and the location of patients among the HD units. No other significant associations were observed. Three (3/50 = 6%) HGV RNA-positive patients at study entry and 3 (3/41 = 7%) at the end of the follow-up showed a mild increase of alanine aminotransferase (ALT) activity in absence of other apparent causes of liver damage. 35 (70%) out of 50 HGV viremic patients had persistently detectable viremia during the study period; 15 (30%) had non-persistently detectable HGV RNA in the second serum specimen. There was no significant difference between the patients with persistently detectable HGV RNA and those who showed non-persistently detectable HGV viremia with regard to demographic, clinical or virological features. Six patients without detectable HGV viremia at the start of the study showed de novo HGV infection during the follow-up, thus the HGV incidence was 3.07% per year. These individuals did not simultaneously acquire HBV or HCV markers; de novo HGV infection was not associated with other demographic, clinical or virological features. One (16.7%) out of 6 individuals with HGV acquisition had persistently raised ALT levels and chronic HBsAg positivity. The prevalence of HGV was 14% (41/292) at the end of the observation period.

CONCLUSIONS

The prevalence of HGV in our HD population was high; HGV positivity was strongly associated with the location of HD patients among the units; some HD individuals with current HGV infection showed biochemical signs of liver disease without other apparent causes. De novo acquisition of HGV occurred within HD units in the absence of evident parenteral risk factors for HGV other than their presence in the HD environment. A large portion of HGV viremic patients showed non-persistently detectable HGV viremia during the study. Acquisition of HGV was not associated with a rise in ALT activity unlike prior experience with de novo HCV in HD patients. Further investigations are warranted to explain the modes of HGV acquisition and the clinical significance of HGV in th HD population.

Epidemiology of Helicobacter pylori in chronic haemodialysis patients using the new RIBA H. pylori SIA

BACKGROUND

There are few data concerning the epidemiology of H. pylori in patients on chronic haemodialysis (HD) treatment. These surveys concerned small populations and were made with ELISA technique. However, ELISA-based assays do not differentiate between strains of H. pylori that are associated with ulcers. Recent literature reports that formation of ulcers correlates strongly with the expression of cytotoxin-associated protein (CagA) and vacuolating cytotoxin (VacA) of H. pylori.

METHODS

A novel serological test (RIBA H. pylori strip immunoblot assay (SIA)) has been recently introduced, it uses the H. pylori lysate (Lys) along with two additional purified recombinant antigens derived from CagA and VacA of H. pylori.

AIM

To study the epidemiology of H. pylori using RIBA H. pylori SIA among chronic HD patients and blood donors as a control group. In addition, the activity of H. pylori was analysed by immunoblot technique in a group of patients with documented ulcers and normal renal function.

RESULTS

The prevalence of antibody towards H. pylori among HD patients, blood donors, and patients with documented ulcers was 56% (127/228), 53% (84/158), and 100%, (21/21) respectively; the difference was significant (P=0.0001). The frequency of anti-H. pylori-positive individuals was significantly higher in patients with documented ulcers than HD patients and blood donors, 21/21 (100%) vs 211/386 (55%), P=0.0001. The frequency of antibody to H. pylori in the HD population was significantly associated with race (P= 0.005); no relationship between anti-H. pylori antibody and numerous demographic, biochemical, and clinical features of patients was seen. The frequency of antibodies against virulent strains of H. pylori in HD patients and blood donors with H. pylori was 60% (76/127) and 61% (51/84) respectively; it was 86% (18/21) among individuals with documented ulcers. No significant difference among these three groups occurred.

CONCLUSIONS

The frequency of antibody towards H. pylori by RIBA H. pylori SIA was high both in HD patients and blood donors; patients with documented ulcers and normal renal function had significantly higher frequency of anti-H. pylori antibody. The anti-H. pylori antibody rate among HD patients was strongly associated with race. The prevalence of antibody against virulent strains of H. pylori did not change among HD patients and control groups. Studies in large cohorts of HD patients with documented peptic ulcer disease are in progress.

Detection of de novo hepatitis C virus infection by polymerase chain reaction in hemodialysis patients

Patients on chronic hemodialysis (HD) treatment have been identified by serological testing, including second- and third-generation enzyme-linked immunosorbent assay (ELISA), as a high-risk group for hepatitis C virus (HCV) infection. Previous studies have shown that de novo cases of HCV may occur in HD units in the absence of other parenteral exposures, which suggests the spread of HCV between patients. In addition, the reverse-transcription polymerase chain reaction (RT-PCR), which directly detects HCV virus, has identified HCV infection in chronic HD patients who are seronegative. The aim of this study was to determine the incidence of HCV infection detected by RT-PCR technology in a large cohort of chronic HD patients. One hundred and twenty chronic HD patients, HCV-negative by serological assays (second-generation ELISA) and molecular techniques (branched DNA and RT-PCR), were observed for a mean period of 9.5 months. They were tested monthly for serum alanine aminotransferase levels (ALT) and by second-generation ELISA. At the end of the follow-up period, they were again evaluated by branched DNA and RT-PCR testing. HCV RNA was detected in patients' sera by RT followed by PCR using two separate primer sets from the 5'-untranslated region of the HCV genome. Southern blot was performed using a digoxigenin-labeled probe. Two patients who had HCV RNA detectable by RT-PCR at the end of the follow-up period remained branched-DNA-negative. Thus, the incidence of de novo acquisition of HCV infection in the current investigation was 2.1% per year. In 1 patient RT-PCR positivity and anti-HCV ELISA seroconversion occurred. The 2nd patient remained anti-HCV ELISA-negative, although viremic. In both patients, the onset of positivity by RT-PCR was associated with a rise of ALT levels into the 'abnormal range' in our laboratory. In these 2 patients, de novo acquisition of HCV infection was observed in the absence of obvious parenteral risk factors other than their presence in the HD environment. In conclusion, de novo acquisition of HCV infection may be undetected by ELISA and branched-DNA assays. The need to monitor chronic HD patients by serial ALT testing is emphasized. RT-PCR should be incorporated into diagnostic testing for HCV infection in chronic HD patients. RT-PCR technology can identify HCV in HD individuals with raised ALT activity.

Hepatitis C: controversies, strategies and challenges

Risk factors for hepatitis C infection include I.V. drug use (42%); history of blood transfusion (6%); exposure to multiple heterosexual partners (6%); exposure to a household contact (3%); health care employment (2%); or hemodialysis (1%). Forty percent of patients have no identifiable risk factors. The HCV is a single-stranded, positive-sense RNA virus. Six major genotypes have been identified; each contains a series of subtypes. In the U.S., prevalences are type 1 (74%); type 2 (15%); type 3 (6%); and type 4 (1%). Within an infected individual, HCV also exists as a spectrum of closely related genotypes referred to as a quasispecies, and more complex quasispecies correlate with longer duration of disease, higher levels of viremia, genotype 1 infection, and poorer response to interferon therapy. Diagnosis is made by measuring anti-HCV by EIA, with confirmation by RIBA or HCV RNA. Patients with chronic HCV infection, with or without aminotransferase elevation, have detectable serum RNA by PCR. Standard therapy is interferon alfa 2b (Intron A) at a dosage of 3 million units 3 times a week for 6 months. This results in a 40%-50% complete response at the end of treatment (normal aminotransferases and undetectable HCV RNA), but relapse occurs in 60%-80% of cases over the next six months. Longer (12 month to 18 month) courses are now widely advocated. Better patient selection, e.g., those with low serum HCV RNA levels and absence of cirrhosis, and increased duration of therapy may lead to better response rates. Combination therapy with other antiviral agents, such as ribavirin, has dramatically reduced relapse rates.

The impact of managed care on gastroenterology

Managed care has emerged out o pressures to reduce the high cost of healthcare and has brought about unprecedented change and uncertainty for the specialist. To flourish in a managed care environment the subspecialist will need to rely on strategic planning. Four emerging approached to healthcare lend themselves to strategic planning. They are 1) practice-based clinical trials, 2) outcomes research, 3) clinical practice guidelines, and 4) systems-based disease management. This report explains how subspecialists in private practice can participate in and profit from each of these new approaches.

The bioartificial liver: state-of-the-art

The rationale for artificial liver support is based on the hypothesis that if essential liver functions can be restored during the critical phase of liver failure, it should be possible to improve the survival of patients with severe liver disease. In the case of bridge-to-transplantation, it should provide the patient sufficient metabolic support until a donor liver can be found and transplanted. Since the management of acute liver failure requires the replacement of the liver's myriad metabolic functions, the idea of a hybrid bioartificial liver (BAL) support system has been proposed. BAL systems incorporate a biological (hepatocytes) and a synthetic housing component (plastic housing shell and semipermeable membrane) coupled in such a way as to facilitate the delivery of essential liver functions. Of the several BAL designs that have been proposed, only the capillary hollow-fiber based systems have been rapidly developed for clinical trials. Capillary hollow-fiber based BAL devices are basically off-the-shelf artificial kidney membranes that have been modified for use as an artificial liver. However, most capillary hollow-fiber based BAL designs have inherent physical limitations of total diffusion surface area and capacity for hepatocyte mass. We have proposed a novel BAL design using microencapsulated hepatocytes to overcome these physical limitations. This new BAL design (UCLA-BAL) involves the direct hemoperfusion of a packed-bed column of microencapsulated porcine hepatocytes within an extracorporeal chamber. In extensive animal studies using a well-characterized animal model fulminant hepatic failure (FHF), we demonstrated that the UCLA-BAL system had superior diffusion surface area and a higher capacity for hepatocytes compared to conventional capillary hollow-fiber based BAL devices. UCLA-BAL treatment significantly (P<0.001), improved the survival rate of FHF animals and significantly (P<0.01) prolonged the survival time of similar animals with very severe liver injury. BAL treatment was convenient, easy to operate and well tolerated, and did not adversely affect the animal's hemodynamics during treatment. We therefore suggest that the UCLA-BAL is a significant improvement over conventional, first-generation, capillary hollow-fiber BAL systems.

Xenotransplantation of fetal porcine hepatocytes in rats using a tissue engineering approach

Hepatocytes can be successfully transplanted into highly vascular sites such as the spleen, liver, and lungs. Subcutaneous sites lack adequate vascularization to nutritionally support transplanted hepatocytes. We recently reported that matrix-immobilized angiogenic growth factors, e.g., endothelial cell growth factor (ECGF), can induce a high degree of neovascularization. Using this technique, we explored the possibility of transplanting isolated fetal porcine hepatocytes to create liver tissue organoids at a specific subcutaneous site. We evaluated chitosan as a scaffold biomaterial because of its structural similarity to glycosaminoglycans; glycosaminoglycans play a critical role in cell attachment, differentiation, and morphogenesis. Freshly isolated fetal porcine hepatocytes (FPH) (viability greater than 97%) were cultured on modified chitosan scaffolds and transplanted into rat groin fat pads with or without ECGF-induced neovascularization. Cell density and attachment kinetics on chitosan were examined by scanning electron microscopy (SEM) and quantified using a flavianic acid binding assay. Hepatocyte viability and liver organoid formation were examined immunohistochemically. FPH transplanted without prior neovascularization died within 1 day post-transplantation. When transplanted after ECGF-induced neovascularization, FPH thrived for at least 2 weeks and formed liver tissue like structures. Immunohistochemical analysis revealed the presence of hepatocyte-specific cytokeratin staining as well as the presence of alpha-fetoprotein. Light microscopy and SEM revealed that FPH did not change their morphology after attachment to the chitosan surfaces. Thus, chitosan-based biomaterial surfaces have good hepatocyte attachment properties. However, extensive neovascularization is essential for hepatocyte survival and organoid formation. In the future, chitosan-based biomaterials may be useful as scaffolds for creating liver tissue organoids.

Quantitative assessment of HCV load in chronic hemodialysis patients: a cross-sectional survey

Recent evidence has been accumulated showing that chronic hemodialysis (HD) patients have a very high prevalence of antibodies to hepatitis C virus (HCV). In contrast, there is little information addressing the virological characteristics of HCV infection in this population.

AIM

To measure HCV viral load and to correlate this with demographic, biochemical, and clinical features of a large cohort of HCV-infected patients on chronic HD.

METHODS

394 chronic HD patients were tested by branched-DNA signal amplification assay, anti-HCV enzyme-linked immunosorbent assay 2.0, and on the basis of the aspartate aminotransferase/alanine aminotransferase (AST/ALT) activity. Multivariate analysis by ordinal logistic regression model was performed: age, gender, race, time on HD, allocation of the patients among the HD units, etiology of end-stage renal disease, HBsAg status, anti-HCV positivity, HCV genotype, and AST/ALT levels were independent factors, and viremic levels of HCV in serum were assumed as dependent variables.

RESULTS

88 (22.3%) patients showed serological and/or virological signs of HCV infection. 59 (15%) out of 394 had detectable HCV RNA in serum, the mean HCV load was 19.4 x 10(5) (95% CI, 6.06 x 10(7) to 6.2 x 10(4)) Eq/ml. According to the criteria suggested by others [J Infect Dis 1994;169:1219-1225], there were 8 (13.5%) individuals with high-titer viremia (>1 x 10(7) Eq/ml) in the subset of viremic patients. A small subset (8/394 or 2%) of individuals was seronegative, but viremic; 29 (7%) out of 394 were seropositive without detectable HCV RNA in serum. Univariate analysis showed that the frequency of anti-HCV positivity was significantly higher in viremic patients as compared with individuals with no detectable HCV viremia: 51/59 (86%) vs. 29/335 (8.6%), p = 0.0001. Serum AST and ALT levels were significantly higher in viremic patients than in individuals with no detectable HCV RNA in serum: 23.8 (95% CI 60.8-9.3) vs. 17.1 (95% CI 50.4-5.8) U/l (p = 0.009) and 14.4 (95% CI 48.9-4.3) vs. 9.8 (95% CI, 37.3- 2. 5) U/l (p = 0.008). Logistic regression analysis showed an association between HCV viremia and anti-HCV positivity (p = 0. 00001) and ALT activity (p = 0.01).

CONCLUSIONS

Hepatitis C virus infection is highly prevalent in the HD population; the viral load is relatively low, and it was associated with elevated hepatic enzyme levels and anti-HCV positivity. No other clinical characteristics were associated with HCV RNA levels. Seronegative but viremic patients were also found. Longitudinal studies with long follow-up periods are necessary to evaluate the course of HCV load over time in this population.

Hepatocyte attachment on biodegradable modified chitosan membranes: in vitro evaluation for the development of liver organoids

Extracellular matrix structures including glycosaminoglycans play a critical role in cell attachment, differentiation, and morphogenesis. We evaluated chitosan ([1-->4] linked 2-amino-2-deoxy-beta-D-glucan) as a biomaterial for hepatocyte attachment because of its structural similarity to glycosaminoglycans. Freshly isolated rat and fetal porcine hepatocytes were seeded on chitosan membranes that had been previously blended with collagen, gelatin, or albumin to improve biocompatibility and surface roughness. The optimal cell density and attachment kinetics were quantified. The metabolic activity was investigated by measuring daily urea and total protein secretion by the cells for 2 weeks. While collagen blended-chitosan membranes provided a good attachment surface for rat hepatocytes, albumin and gelatin blended chitosan membranes were superior for fetal porcine hepatocyte attachment. The optimal attachment was maintained with membranes of medium molecular weight (Mr = 750,000 daltons) chitosan, at 3-4 x 10(4) cells/cm2 after 3 h of incubation. In vitro experiments demonstrated that fetal porcine hepatocytes survived at least 14 days when seeded on the chitosan-albumin matrix, demonstrating that this biomaterial can provide suitable cell attachment scaffolds for creating liver tissue organoids.

Acquisition of hepatitis C virus in hemodialysis patients: a prospective study by branched DNA signal amplification assay

Serological data indicate that hepatitis C virus (HCV) infection is very common among chronic hemodialysis (HD) patients. Circumstantial evidence suggests that hemodialysis per se is an important risk factor for this infection. We used a novel methodology, the branched DNA (bDNA) signal amplification assay, which is capable of detecting HCV RNA and of quantifying HCV viral load in serum, to prospectively determine the rate of acquisition of HCV infection in 274 anti-HCV-negative patients undergoing HD treatment in four hemodialysis units. Moreover, we used bDNA testing to analyze the dynamics of HCV acquisition among HD patients, a high-risk group for HCV infection with immune compromise conferred from uremia. Two patients were identified with de novo acquisition during 1 year of prospective bDNA testing. Thus, the HCV incidence was 0.73% per year. De novo acquisition of HCV infection was observed in the absence of identifiable parenteral risk factors. Both patients showed the same pattern of HCV acquisition: they underwent an initial viremic phase that was associated with an increase in alanine transaminase (ALT) activity and that preceded the anti-HCV seroconversion. This was followed by HCV RNA clearance and normalization of ALT activity. Anti-HCV positivity occurred 1 and 2 months after the ALT increase in the first and second patients, respectively. Although HCV incidence was low (0.73%), further research is warranted to set the optimal policy for eliminating the risk of nosocomial transmission of HCV in the HD setting. Our findings show the pattern of HCV acquisition in chronic HD patients and emphasize the need to screen the HD population for ALT measurement combined with anti-HCV testing for detecting hepatitis C. HCV RNA testing can identify HCV before seroconversion in individuals with deranged liver function tests. The acquisition of HCV in HD patients without identifiable risk is confirmed.

Automated RIBA hepatitis C virus (HCV) strip immunoblot assay for reproducible HCV diagnosis

A comparison between the CHIRON RIBA hepatitis C virus (HCV) processor and manual systems was performed by using 88 specimens repeatedly reactive by the second-generation HCV enzyme-linked immunosorbent assay (ELISA) (HCV 2.0 ELISA) and 111 random specimens from volunteer donors. For the second-generation RIBA HCV strip immunoblot assay (SIA) (RIBA HCV 2.0 SIA), test results correlated strongly between the manual and the automated runs (kappa value, 0.937). For the RIBA HCV 3.0 SIA, the correlation of the test results was also high (kappa value, 0.899). Among the specimens with positive results by RIBA HCV 2.0 and 3.0 SIAs, there was a very strong concordance of the test results between the manual and the automated runs with regard to the reactive bands. Nine samples had discordant results between the manual and the automated runs; this was probably attributable to increased variability in antigen scores close to the cutoff values for both tests. Run-to-run and within-run testing by the CHIRON RIBA HCV Processor System showed a very low rate of conflicting values. In conclusion, the CHIRON RIBA HCV Processor System is capable of performing RIBA HCV 2.0 and 3.0 SIAs accurately with minimal operator involvement. In addition, the CHIRON RIBA HCV Processor System shows excellent reproducibility, with the potential for operator-to-operator and site-to-site variability being greatly reduced. Our data indicate that this novel methodology may be very useful for supplemental anti-HCV testing of specimens repeatedly reactive by ELISA in routine clinical assessments and epidemiologic evaluations.

Controlled release of endothelial cell growth factor from chitosan-albumin microspheres for localized angiogenesis: in vitro and in vivo studies

Endothelial cell growth factor (ECGF) stimulates vascularization, however its relatively short half-life requires this angiogenic factor to be frequently administrated by non-specific and uncontrolled methods. This work describes the use of biocompatible chitosan, a polysaccharide having structural similarity to glycosaminoglycans, -albumin microspheres, as well as its fiber form, as a potential delivery system for the controlled and localized release of ECGF. Chitosan-albumin microspheres (400-600 microns) and fibers, formed in 0.5 M sodium hydroxide-methanol solution were incubated with ECGF. In vitro release was performed in PBS at 37 degrees C, under constant stirring. In vivo experiments were realized by implanting ECGF loaded matrices subcutaneously into rat groin fascia. After an initial ECGF burst of 1.32-1.62 mg (22-27%) within the first 2 hours, a daily release of 120-420 micrograms (2-7%) during the first, and 60-240 micrograms (1-4%) during the second week was observed from M(r) 70.000, 750.000, and 2,000.000 chitosan containing microspheres of 6 mg/ml loading. ECGF release rate of < 30 micrograms (0.5%)/day was maintained during the third week of experiments. By the increase in ECGF loading (12 mg/ml polymer), while the amount of release increased, percent release decreased. Chitosan-albumin fibers gave a ECGF release rate nearly similar to microspheres, and in vivo studies demonstrated a high degree of neovascularization for both types of implants, starting from 7 day-post implantation. Control animals that received ECGF injection did not show any significant neovascularization, after same period of time.

Health-related quality of life, patient outcome, and managed care: the road ahead

The delivery of healthcare in the industrialized world is currently undergoing fundamental change due to a number of factors. These include market forces driving institutions to contain and reduce cost; the rapid emergence of new treatments; the recognition of unexplained regional variations in the delivery of care; and patients' increasing sophistication and involvement as consumers of healthcare resources. As a result, the practice of medicine is entering a new era of scrutiny. Demonstrating a treatment's safety and efficacy is no longer sufficient justification for its use. There is a need to evaluate the appropriateness of medical care based on both cost and patient outcomes measures, including health-related Quality of Life (HRQOL). This type of research is in the interests of healthcare provider organizations, physicians, and patients alike. Outcomes research in the GI diseases is expanding rapidly due to the potential for cost savings and increased quality of care. It is important that gastroenterologists become trained and take part in the design, conduct, and analysis of outcomes studies to maximize these gains.

Inflammatory bowel disease: a new assessment

The etiologies of Crohn's disease and inflammatory bowel disease remain undefined. A growing body of evidence suggests that genetic factors play at least a permissive role while a variety of initiating agents, varying from bacteria to viruses, to a vast array of inert antigens have been postulated, but clear-cut cause and effect relationships have not been established. Recently, a resurgence of interest in Mycobacteria paratuberculosis has developed. Regardless of the initiating cause, growing evidence continues to suggest an immunomodulatory role for the immune system in perpetuating the chronicity of these illnesses. Treatment approaches have been directed against possible initiating agents as well as against the elements which may establish chronicity. Thus currently antibiotics and anti-mycobacterial drugs are being utilized. A variety of anti-inflammatory and/or immunosuppressive agents, including prednisolone, cyclosporine, 6-mercaptopurine, as well as many 5-aminosalicylic acid products comprise a growing armamentarium.

Transplantation of microencapsulated hepatocytes for liver function replacement

Recent advances in cell biology and biotechnology have lead the way for a greater understanding of cell function and the potential therapeutic use of transplanted cells for treating a wide array of illnesses. Treatment of disease by transplantation of normal healthy cells, for the replacement of specific biological deficiencies or as a form of auxiliary support for a failing organ, offers important therapeutic applications and also serves as a model for assessing cellular physiology. In the long-term, cell transplantation may also have potential in the development of artificial organ support systems for sustaining patients with severe and chronic diseases such as diabetes, liver failure, endocrine and exocrine disorders, neurological abnormalities, and congenital metabolic defects. Several groups have demonstrated the feasibility and efficacy of cell transplantation in providing specific function in various experimental animal models of human disease. However, without adequate immunosuppression, complications due to tissue rejection remain a significant problem. Microencapsulation of cells within a synthetic semipermeable membrane, prior to transplantation, has been proposed for circumventing immunological complications following transplantation. The microcapsule's semipermeable membrane allows permeant molecules to freely diffuse across while preventing the microencapsulated cells from escaping. This membrane also keeps unwanted substances, such as cells and antibodies, from entering the microcapsule. Thus, microencapsulation provides an innovative and unique technique for the transplantation of foreign tissue and cells without the need for immunosuppression.

Artificial liver support: state of the art

Severe liver disease is very often life-threatening and dramatically diminishes quality of life. Liver support systems based on detoxification alone have proven ineffective because they cannot correct biochemical disorders. An effective artificial liver support system should be capable of carrying out the liver's essential processes such as synthetic and metabolic functions, detoxification, and excretion. It should be capable of sustaining patients with fulminant hepatic failure, preparing patients for liver transplantation when a donor liver is not readily available (i.e., bridge to transplantation), and improving the survival and quality of life for patients for whom transplantation is not a therapeutic option. Recent advances in cell biology, tissue culture techniques, and biotechnology have led the way for the potential use of isolated hepatocytes in treating an array of liver disorders. Isolated hepatocytes may be transplanted to replace liver-specific deficiencies or as an important element of an auxiliary hybrid, bioartificial extracorporeal liver support device, which are important therapeutic applications for treating severe liver disease. Although several hepatocyte-based liver support systems have been proposed, there is no current consensus on its eventual design configuration. Furthermore, application of tissue engineering technology, based on cell-surface interaction studies proposed by our group and others, has enhanced interest in the development of highly efficient hybrid, bioartificial, liver support devices.

Collagen and fibronectin immobilization on PHEMA microcarriers for hepatocyte attachment

Polyhydroxyethylmethacrylate (PHEMA) microcarriers in a size range of 150-250 microns were prepared by a suspension polymerization in an aqueous phase containing magnesium oxide. The hydroxyl groups on the PHEMA microcarriers were activated by cyanogen bromide. In order to improve cell attachment, cell-adhesive proteins, namely, collagen and fibronectin were immobilized onto PHEMA microcarriers. The nonspecific adsorption values for collagen and fibronectin were 0.10 mg collagen/g PHEMA and 0.044 mg fibronectin/g PHEMA, respectively. Collagen and fibronectin immobilization on PHEMA microcarriers were studied at different pH by using single protein solutions containing different amounts of proteins, at a constant temperature of 20 degrees C. The maximum immobilizations were 0.85 mg collagen/g PHEMA (at pH: 9.5) and 0.52 mg fibronectin/g PHEMA (at pH: 7.4). Hepatocyte attachment onto these biologically modified PHEMA microcarriers was studied. Hydrophilic PHEMA microcarriers did not support cell attachment. High hepatocyte attachment yields (up to 75% surface coverage) were observed on collagen and fibronectin immobilized PHEMA microcarriers.

In vitro slow release profile of endothelial cell growth factor immobilized within calcium alginate microbeads

Although a variety of angiogenic growth factors have been isolated, its appropriate in vivo delivery remains problematic due to nonspecific, uncontrolled delivery by conventional methods. We have investigated calcium alginate microbeads as a vehicle for the controlled slow-release of endothelial cell growth factor (ECGF). Three different microbead compositions, dependent on ECGF amount and alginate percentage were studied. Microbeads were incubated in a 1.5% calcium chloride solution and release of ECGF into solution was measured spectrophotometrically at specific timepoints. Our results show release rate and amount released after the first 2 hours are dependent on initial quick delivery of ECGF in the first 2 hours after which a sustained controlled release occurred for 4-5 days. Beyond this point, release at a slower rate was noted for at least approximately 2 weeks. Calcium alginate microbeads demonstrated a controlled and predictable rate of release and that the amount of ECGF delivered can be varied by varying the initial concentration of ECGF in the microbeads. Based on these observations we conclude that calcium alginate microbeads are a convenient and practical vehicle for sustained ECGF delivery.

Hepatitis C in 1994

Since the discovery of hepatitis C in 1989 its role in the development of acute and chronic liver disease has been carefully evaluated. Hepatitis C has a mean incubation period of between 6 and 8 weeks. It is often indolent and asymptomatic. Interferon may be helpful in chronically infected patients. After 6 months of therapy approximately 40-50% enter remission. Relapses are common however, up to 80% within 6 months. Effective long-term treatment has not yet been established.

Hepatitis infection in immunocompromised patients

The current literature fails to address the long-term course of hepatitis infection in the immunocompromised patient, in large part because of the characteristically slow progression of this disease. An overview of the literature available fails to demonstrate evidence that immunosuppression per se promotes progression of hepatitis. In fact, many studies document a relatively low incidence of chronic active hepatitis or cirrhosis in immunocompromised patients; however, properly designed, prospective studies of sufficient numbers of patients with long-term follow-up are not available. Thus, no reliable conclusions are possible at this time.

Current views of the etiology of inflammatory bowel disease

The cause or causes of Crohn's disease and of ulcerative colitis (UC) remain uncertain. Despite extensive investigations aimed at searching for immunologic or infectious causes, clear evidence suggesting an underlying etiology is lacking. Recent studies involving mycobacteria suggest that occasional patients thought to have Crohn's disease may indeed be infected with a mycobacterium. However, clear cause-and-effect relationships have not been established. Future efforts to establish the relationship between environmental factors, including infectious agents, and immunologic mediators seem appropriate on the basis of available data. For the present, the causes or cause of these diseases remains obscure.

Non-A, non-B post-transfusion hepatitis. Looking back in the second decade

OBJECTIVE

To determine the long-term course of non-A, non-B post-transfusion hepatitis.

DESIGN

Follow-up in 1989 to 1992 of patients prospectively identified as having contracted non-A, non-B post-transfusion hepatitis between 1972 and 1980.

SETTING

A university hospital.

PATIENTS

Patients who were prospectively followed from receipt of blood products and in whom otherwise unexplained abnormalities in their serum alanine aminotransferase levels developed without serologic evidence of exposure to hepatitis A or B.

MEASUREMENTS

The presence or absence of clinical evidence of liver failure or symptoms of chronic hepatitis.

RESULTS

Of 90 patients identified in the 1970s, 80 were recontacted and evaluated between 1989 and 1992. Based on the current status of these 80 patients and on the last known status of the remaining patients, the following observations were made: 1) Although about 40% had some symptoms during the early phase of the disease, none subsequently experienced significant clinical problems related to hepatic inflammation; 2) eight patients (seven with chronic hepatitis) developed hepatic failure; and 3) life-table analysis showed that the probabilities of developing clinical evidence of cirrhosis after 16 years of disease in the entire cohort, in the subgroup who developed chronic hepatitis, in the patients who had hepatitis C, and in those with chronic hepatitis C were 18%, 21%, 17%, and 20%, respectively.

CONCLUSIONS

For most of the study patients, non-A, non-B post-transfusion hepatitis was a biochemical and histologic disease that had not yet caused hepatic symptoms. If hepatic failure does occur, it is usually seen only after 10 or more years of disease. Before that time, many infected persons die due to other disease processes.

Cryopreserved microencapsulated hepatocytes--transplantation studies in Gunn rats

Hepatocyte transplantation has been shown to provide significant metabolic support in several animal models of liver diseases. However, for it to be a viable alternative for supplementation of liver function in disease, large quantities of isolated hepatocytes would be necessary. At the present time there are no inexpensive routine methods for cryopreservation of hepatocytes. Existing procedures are cumbersome and require expensive programmable freezers. Hepatocyte cultures are sensitive and easily damaged in handling. By utilizing techniques of microencapsulation and cryopreservation we have attempted to overcome these problems. We have developed a simple, convenient, and inexpensive technique for the long-term storage of hepatocytes. Biological activity of the nonfrozen isolated encapsulated hepatocytes (IEH) and cryopreserved IEH (cIEH) was assessed both in tissue culture and by transplantation in Gunn rats. Significant urea and protein syntheses were detectable during the 10-day culture period even in the 30-day cIEH. Additionally, transplanted IEH and cIEH significantly reduced hyperbilirubinemia in Gunn rats for up to 30 days posttransplantation. Control (empty) microcapsules did not lower serum bilirubin levels. Thus we conclude: (1) cryopreservation of IEH is a convenient and cost-effective method for preserving and storing hepatocytes; (2) cryopreserved IEH function as well as nonfrozen IEH both in vitro and in vivo; (3) microencapsulation may protect hepatocytes from the adverse effects of cryopreservation.

Non-A, non-B posttransfusion hepatitis: comparing C and non-C hepatitis

Using assays to detect antibodies against antigens (C-100, 5-1-1, C-22 and C-33) of the hepatitis C virus, we tested stored sera from 40 patients prospectively identified as having non-A, non-B posttransfusion hepatitis. The 28 patients who demonstrated seroconversion ("documented hepatitis C") had more severe initial disease; all 20 cases of chronic hepatitis occurred in this subgroup. Only 2 of the 12 patients who did not demonstrate such seroconversion even had symptoms. In the group of patients with documented hepatitis C, chronic hepatitis was more commonly seen in men (89%) than in women (40%). The patients in whom antibody to the C-100 antigen developed were younger and had received more blood than had those patients who had hepatitis C diagnosed by demonstration of antibodies to the 5-1-1, C-22 or C-33 antigen (or all three). The proportion of cases of posttransfusion hepatitis that could be associated with antibody sero-conversion decreased around the time that blood banks switched to an all-volunteer system. The hepatitis seen in patients who failed to demonstrate serological evidence of hepatitis C virus exposure was usually clinically unimportant; it may or may not have been due to viral infection.

Mycobacteria in Crohn's disease: DNA probes identify the wood pigeon strain of Mycobacterium avium and Mycobacterium paratuberculosis from human tissue

Mycobacterium paratuberculosis is known to cause Johne's disease, a granulomatous ileitis in ruminants, and may be involved in some cases of Crohn's disease. Like M. paratuberculosis, the wood pigeon strain of Mycobacterium avium may also show mycobactin dependence on primary isolation that is attenuated on further subculturing. A wood pigeon strain, M. avium restriction fragment length polymorphism (RFLP) type A/I, is also capable of causing granulomatous ileitis in experimental animal models but is not known to cause disease in humans. M. avium RFLP type A is associated with disease in immunocompromised hosts. Three DNA probes, pMB22 and the two subclones pMB22/S4 and pMB/S12, were found to be capable of distinguishing among M. paratuberculosis, M. avium type A, and M. avium type A/I (wood pigeon strain) on the basis of RFLPs. These DNA probes were used to identify two mycobacterial isolates (M. paratuberculosis and M. avium type A/I, wood pigeon strain) derived from the intestinal tissues of two patients with Crohn's disease. In addition, the wood pigeon strain of M. avium was identified from a patient with ulcerative colitis, and M. avium RFLP type A was identified from a patient with colonic carcinoma. This is the first time that M. avium A/I (wood pigeon strain) is known to have been isolated from human tissue. There are too few isolates to speculate about the etiological significance of mycobacteria and inflammatory bowel disease, but it is reasonable to conjecture that M. paratuberculosis may be responsible for some cases of Crohn's disease and that the wood pigeon strain of M. avium may also be an inflammatory bowel disease pathogen in humans.

A morphological and functional evaluation of transplanted isolated encapsulated hepatocytes following long-term transplantation in Gunn rats

In this study we investigated the fate of microencapsulated hepatocytes following long-term (6 months) transplantation in Gunn rats. Isolated hepatocytes were microencapsulated with a collagen matrix within an alginate-poly L-lysine composite membrane. Isolated, encapsulated hepatocytes (IEH) or free (unencapsulated) isolated hepatocytes were intraperitoneally transplanted into homozygous Gunn rats that exhibit congenital hyperbilirubinemia. Control Gunn rats received empty microcapsules. Total serum bilirubin was measured at weekly intervals for one month post-IEH transplantation, every two weeks for the next month, and monthly thereafter for up to six months. IEH samples were biopsied from the Gunn rats at monthly intervals and analyzed by light and electron microscopy. A significant (p < 0.01) decrease in total serum bilirubin was observed in IEH transplanted animals during the first month of transplantation. Thereafter, total serum bilirubin levels gradually returned to pre-transplantation levels. A mild, transient decrease in total serum bilirubin was seen in animals transplanted with free (unencapsulated) hepatocytes. No decrease in total serum bilirubin levels was seen in the Gunn rats transplanted with control (empty) microcapsules. Transplanted IEH retained its normal ultrastructure for up to one month and intact microcapsules showed no evidence of hepatocyte rejection, at this time. Degenerative changes observed in the IEH beginning at 2 months post-transplantation, suggests that repeated transplantations may be necessary for long-term effectiveness of IEH therapy.

Long-term mortality after transfusion-associated non-A, non-B hepatitis. The National Heart, Lung, and Blood Institute Study Group

BACKGROUND

Acute non-A, non-B hepatitis after blood transfusion often progresses to chronic hepatitis and sometimes culminates in cirrhosis or even hepatocellular carcinoma. However, the frequency of these sequelae and their effects on mortality are not known.

METHODS

We traced patients with transfusion-related non-A, non-B hepatitis who had been identified in five major prospective studies conducted in the United States between 1967 and 1980. We matched each patient with two control subjects (identified as the first and second controls) who received transfusions but who did not have hepatitis. The mortality rates in the three groups were determined with use of data from the National Death Index and Social Security Death Tapes. Cause-specific mortality was determined by reviewing death certificates.

RESULTS

Vital status was established for over 94 percent of the 568 patients who had had non-A, non-B hepatitis and the two control groups (526 first controls and 458 second controls). After an average follow-up of 18 years, the estimate by life-table analysis of mortality from all causes was 51 percent for those with transfusion-associated non-A, non-B hepatitis, as compared with 52 percent for the first controls and 50 percent for the second controls. The survival curves for the three groups were virtually the same. Mortality related to liver disease was 3.3, 1.1, and 2.0 percent, respectively, among the three groups (P = 0.033 for the comparison of the group with non-A, non-B hepatitis with the combined control group). Seventy-one percent of the deaths related to liver disease occurred among patients with chronic alcoholism.

CONCLUSIONS

In this long-term follow-up study, there was no increase in mortality from all causes after transfusion-associated non-A, non-B hepatitis, although there was a small but statistically significant increase in the number of deaths related to liver disease.

Improved function of microencapsulated hepatocytes in a hybrid bioartificial liver support system

Conventional methods of microencapsulating isolated hepatocytes with Type I collagen matrix have provided metabolic liver support in experimental animal models of acute liver failure and congenital metabolic liver disease. We compared the biological function of transplanted microencapsulated hepatocytes cultured on standard Type I collagen (Vitrogen) and a commercially available liver basement-membrane-like extract from a mouse sarcoma (Matrigel). Isolated hepatocytes were microencapsulated with Matrigel and Vitrogen within an alginate-poly-L-lysine composite membrane. Isolated encapsulated hepatocytes (IEH) were transplanted intraperitoneally into homozygous Gunn rats that exhibit congenital hyperbilirubinemia. Control Gunn rats received empty or no microcapsules. Total serum bilirubin and conjugated bilirubin in bile were measured at weekly intervals for one month. Significant (p < 0.01) decreases in total serum bilirubin were observed in all IEH transplanted animals. No such decrease was seen in control animals. Gunn rats that received Matrigel had significantly (p < 0.05) lower serum bilirubin values and significantly (p < 0.05) higher conjugated bilirubin in bile than those that received Vitrogen. We conclude that hepatocytes microencapsulated with Matrigel functioned better than those with Vitrogen. This improved in vivo biological response underscores the importance of using the appropriate cell attachment substratum to enhance the function of a hybrid bioartificial liver support system based on transplanted hepatocytes.

Hepatitis C: what progress?

The new serologic assay for hepatitis C has made it possible to identify patients infected with this agent and to better characterize their clinical illness and its sequelae. As the clinical entity has become better recognized, our understanding of the infectious process has also progressed. Hepatitis C is a chloroform-sensitive RNA virus, only 30-60 nm in diameter, containing a lipid coat. Both erythrocytes and plasma can transmit infection. The viral genome consists of single-stranded linear RNA of approximately 10 kilobases. The first serologic assay developed was a radioimmunoassay, followed shortly by an enzyme-linked immunoassay. Secondary tests for specificity now exist. Blood donor populations may have a significant frequency of false positives on the antibody test, making it important that positive results be confirmed with a secondary assay. The antibody is only detected 2 months after infection, by means of currently available assays, and may not appear in many patients until 3 to 6 months after infection. Hepatitis C infection is commonly chronic. This may lead to an asymptomatic chronic carrier state without demonstrable liver disease, or to chronic progressive or non-progressive hepatitis.

Restoration of liver function in Gunn rats without immunosuppression using transplanted microencapsulated hepatocytes

Microencapsulation of cells within synthetic semipermeable membranes is a novel technique that enables the transplantation of cell cultures without the need for immunosuppression. We have previously shown that transplanted isolated encapsulated hepatocytes can provide sufficient short-term metabolic support to improve the survival of animals with galactosamine-induced fulminant hepatic failure. Here we have demonstrated the feasibility of isolated encapsulated hepatocyte transplantation in providing long-term metabolic liver support in Gunn rats. Gunn rats have a congenital inability to conjugate bilirubin and thus exhibit lifelong hyperbilirubinemia. We studied the feasibility of isolated encapsulated hepatocyte transplantation in restoring this specific liver function. Free hepatocytes, isolated from male Wistar rats, were microencapsulated with collagen within a trilayered sodium alginate-poly-L-lysine-sodium alginate membrane using techniques developed in our laboratory. A total of 45 Gunn rats underwent intraperitoneal transplantation with free hepatocytes (5 x 10(7], isolated encapsulated hepatocytes (5 x 10(7], control (empty) microcapsules or no transplant (untreated controls). Serum bilirubin levels were monitored daily for 10 days after transplantation, and subsequent weekly samples were obtained for up to 1 mo. Microcapsules were studied by light and electron microscopy 1 mo after transplantation. During the first week after transplantation, the mean maximum reduction in serum bilirubin levels for the isolated encapsulated hepatocytes, free hepatocytes and control microcapsule transplanted groups was 45.7%, 18.6% and 14.3%, respectively. For up to 1 mo thereafter the mean reduction in serum bilirubin levels in these respective groups was 34.8%, 13.5% and 3.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Etiology of inflammatory bowel diseases: where have we been? Where are we going?

The cause or causes of Crohn's disease and of ulcerative colitis remain uncertain. In spite of extensive investigations, searching for immunologic or infectious causes, clear evidence suggesting an underlying etiology is lacking. Recent studies involving mycobacteria suggest that occasional patients thought to have Crohn's disease may indeed be infected with a mycobacterium. However, clear cause-and-effect relationships have not been established. Future efforts at trying to establish the relationship between environmental factors, including infectious agents, and immunologic mediators seem appropriate on the basis of available data. For the present, the causes or cause of these diseases remains obscure.

Hepatitis 1990

In recent months newer concepts have evolved in our understanding of infection with the viruses that cause acute viral hepatitis. The natural course of hepatitis A has been described, and reliable diagnostics for its identification are now available. The early development of serologic assays for hepatitis B virus infection resulted in a rapid expansion of our knowledge of the serologic identification of this virus and of the natural course of the agent. Improved serologic tests have shown that infection with the virus is far more common than was appreciated in previous years. Its association with the development of chronic liver disease in up to 10% of infected patients is well documented. Among the most exciting events in our understanding of viral hepatitis has been the development of an assay to detect antibody to hepatitis C virus. This has enabled us to determine that posttransfusion hepatitis is usually due to a single hepatitis C viral agent. Unfortunately, the available antibody assay is associated with a high degree of false positivity and requires the utilization of a secondary test for specificity or a naturalization test to identify true positives. It is clear, however, that a person who has this antibody and who is also positive for a secondary test for specificity is likely to harbor an infectious agent in his or her blood. Hepatitis C is associated with an unusually high degree of chronicity, exceeding 50% in many studies. Second-generation assays have already been developed, and it is likely that we will shortly see a great expansion of our serologic diagnostic capabilities.(ABSTRACT TRUNCATED AT 250 WORDS)

Preliminary report on isolation of mycobacteria from patients with Crohn's disease

Several investigators have recently described the isolation of slow growing mycobacteria from the tissues of patients with Crohn's disease (CD). The primary purpose of this study was to culture and identify mycobacteria from the intestines of patients with CD and other intestinal diseases (control tissues). The culture methods were designed to eliminate most rapid-growing mycobacteria and to enhance the isolation of slow growing mycobacteria. Eighty-two surgically resected intestinal tissue samples were cultured over a four-year period: 27 tissues were from CD patients and 55 from patients with other intestinal diseases. After 4-12 months of culture, five mycobacteria were isolated, but only two have been identified thus far. Both of these organisms appeared to have initially grown as spheroplasts, but revertant bacteria were cultivated after transfer into fresh media. Four of the mycobacteria were from CD tissues, and one isolate was from a control tissue. Two of the isolates have been identified as M. chelonei subsp. abscessus, strain 390 and M. paratuberculosis strain 410. This M. paratuberculosis is similar to the previously identified M. paratuberculosis strains isolated from other human intestinal tissues from patients with CD. Both strains 390 and 410 were inoculated into neonatal goats, but they failed to reproduce a CD-like disease. The isolation of four mycobacteria from 27 CD tissues and only one from 55 control tissues strengthens the findings of previous investigators and supports the hypothesis that mycobacteria may be etiologically associated with some cases of Crohn's disease.

Antibiotics and inflammatory bowel diseases

In evaluating the medical literature dealing with antibiotics and inflammatory bowel diseases, I cannot help but recall the adage: "Those who have enthusiasm have no controls and those who have controls have no enthusiasm." There just are not enough data to justify the use of most antibiotics in the treatment of most patients with Crohn's disease or ulcerative colitis. An increasing body of data does support the use of metronidazole in selected patients with Crohn's disease, especially those with perianal disease or fistulae. However, this drug has important side effects that may preclude its long-term use. Other antibiotics have been inadequately tested and there is not adequate evidence to support their use.

Diagnostic usefulness of testing for anti-HBc IgM in acute hepatitis B

Numerous tests to detect anti-HBc IgM have been developed and shown to have different degrees of sensitivity and specificity. One of these assays, Corzyme-M (Abbott Laboratories, North Chicago, Ill.), recently became commercially available. The present study was undertaken to evaluate the clinical utility of this anti-HBc IgM test in establishing the diagnosis of acute hepatitis B using sera from a group of 42 prospectively followed individuals who had been exposed to hepatitis B virus. The Corzyme-M test was highly sensitive in detecting recent hepatitis B virus infection. All 30 patients with symptomatic and 12 with asymptomatic acute hepatitis B virus infection developed anti-HBc IgM. However, the timing of sample testing relative to onset of symptoms in symptomatic patients was important, inasmuch as 2 of 23 patients were negative for anti-HBc IgM early in the symptomatic period, although all were HBsAg positive. The duration of anti-HBc IgM positivity after acute infection was variable, ranging from 2 to 134 weeks. In 14% of patients, anti-HBc IgM remained detectable for more than 1 year. From the data, recommendations are given regarding the usefulness of anti-HBc IgM testing in the diagnosis of acute hepatitis B virus infection.