Porphyria cutanea tarda as a predictor of poor response to interferon alfa therapy in chronic hepatitis C

BACKGROUND

Porphyria cutanea tarda (PCT) is sometimes associated with hepatitis C virus chronic infection. The aim of this study was to describe the effect of interferon alfa (IFN-alpha) in the treatment of patients with chronic hepatitis C and PCT.

METHODS

We treated a total of 66 patients with chronic hepatitis C with IFN-alpha 2b (5 MU t.i.w.) for 12 months. Twenty-two of these patients suffered from PCT as well. These patients differed from patients without PCT in that they were men, past history of alcohol abuse and HFE gene mutations were more common and the source of infection was almost always unknown.

RESULTS

Sustained virologic response was obtained in 19.7% of the 66 treated patients, 27.3% in the non-PCT group and 4.5% in the PCT group (P < 0.05). This difference could not be ascribed to the difference in sex of patients, history of alcohol abuse, HCV genotype or iron status.

CONCLUSION

Multivariate logistic regression analysis revealed that PCT is independently and significantly associated with non-sustained response to IFNalpha therapy. In conclusion, patients with chronic hepatitis C and PCT rarely responded to IFNalpha treatment.

Porphyria cutanea tarda as a Predictor of Poor Response to Interferon Alfa Therapy in Chronic Hepatitis C

BACKGROUND

Porphyria cutanea tarda (PCT) is sometimes associated with hepatitis C virus chronic infection. The aim of this study was to describe the effect of interferon alfa (IFN-a) in the treatment of patients with chronic hepatitis C and PCT.

METHODS

We treated a total of 66 patients with chronic hepatitis C with IFN-a 2b (5 MU t.i.w.) for 12 months. Twenty-two of these patients suffered from PCT as well. These patients differed from patients without PCT in that they were men, past history of alcohol abuse and HFE gene mutations were more common and the source of infection was almost always unknown.

RESULTS

Sustained virologie response was obtained in 19.7% of the 66 treated patients, 27.3% in the non-PCT group and 4.5% in the PCT group (P < 0.05). This difference could not be ascribed to the difference in sex of patients, history of alcohol abuse, HCV genotype or iron status.

CONCLUSION

Multivariate logistic regression analysis revealed that PCT is independently and significantly associated with non-sustained response to IFNa therapy. In conclusion, patients with chronic hepatitis C and PCT rarely responded to IFNa treatment.

Reversion of hepatobiliary alterations By bone marrow transplantation in a murine model of erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is characterized clinically by cutaneous photosensitivity and biochemically by the accumulation of excessive amounts of protoporphyrin in erythrocytes, plasma, feces, and other tissues, such as the liver. The condition is inherited as an autosomal dominant or recessive trait, with a deficiency of ferrochelatase activity. A major concern in EPP patients is the development of cholestasis with accumulation of protoporphyrin in hepatobiliary structures and progressive cellular damage, which can rapidly lead to fatal hepatic failure. The availability of a mouse model for the disease, the Fech(m1Pas)/Fech(m1Pas) mutant mouse, allowed us to test a cellular therapy protocol to correct the porphyric phenotype. When Fech/Fech mice received bone marrow cells from normal animals, the accumulation of protoporphyrin in red blood cells and plasma was reduced 10-fold but still remained 2.5 times above normal levels. Interestingly, in very young animals, bone marrow transplantation can prevent hepatobiliary complications as well as hepatocyte alterations and partially reverse protoporphyrin accumulation in the liver. Bone marrow transplantation may be an option for EPP patients who are at risk of developing hepatic complications.

Inhibition of erythrocyte aminolevulinate dehydratase by a 56.2-kD peptide from uremic plasma

Among the abnormalities in erythrocyte porphyrin metabolism already described in patients with chronic renal failure on hemodialysis, a decrease in blood aminolevulinate dehydratase activity has been reported, suggesting the presence in uremic plasma of an inhibitor of the enzyme. The aim of this work has been to isolate and characterize such an inhibitor. Blood samples from 105 patients with chronic uremia were collected; plasma was applied to Sephadex G-100 columns and the fraction with the highest inhibiting capacity was identified and purified by subsequent SDS-polyacrylamide gel electrophoresis, followed by electroelution and electroblotting. It was demonstrated that the factor present in plasma of uremic patients inhibited blood aminolevulinate dehydratase in a concentration-dependent manner; its inhibitory properties were abolished after heat, trypsin and TCA treatment indicating its peptidic nature. The purified inhibitor has an apparent molecular mass of 56.2 kD, it inhibits blood aminolevulinate dehydratase in a competitive way and the Ki value is 12x10(-6) M. The amino acid composition of the inhibitor has been determined and it has been found that its N-terminal amino acid is blocked. The isolated peptide may play a role in heme biosynthesis disturbances and in the pathogenesis of uremic anemia.

Folding and unfolding of delta-aminolevulinic acid dehydratase and porphobilinogen deaminase induced by uro- and protoporphyrin

In all the cutaneous porphyrias, alterations in the heme pathway lead to an excessive production and accumulation of porphyrins. Absorption of light energy by circulating porphyrins induces reactive oxygen species generation, which provoke enzyme inactivation and protein structure changes. Protein structure alterations induced by porphyrins with different physico-chemical properties on delta-aminolevulinic acid dehydratase (ALA-D) and porphobilinogen deaminase (PBG-D) were examined. The action of uroporphyrin (URO), a highly hydrophilic porphyrin, and protoporphyrin (PROTO), most hydrophobic, was tested. ALA-D and PBG-D were partially purified from bovine liver and exposed to URO or PROTO, both in the dark and under UV light. All experiments were performed in solution after removing the porphyrins. Treatment with 10 microM URO I or 10 microM PROTO IX reduced the activity of ALA-D and PBG-D. This effect increased with increasing time of exposure to porphyrins. Solubility of the enzymes in buffer containing 3 M KCl decreased with increasing time of porphyrin treatment; this may be because of exposure of hydrophobic residues that are normally shielded in the native protein structure. Tryptic digestion of ALA-D and PBG-D exposed to URO I or PROTO IX resulted in an increase of protein degradation products, indicating an enhanced susceptibility to proteolysis. Fluorescence emission of several enzymes aminoacids was greatly modified. The structural changes described were observed when the enzymes were exposed to porphyrins both in the dark or under UV light. However, they were more noticeable with UV light. These results suggest that porphyrins per se can act directly on protein structure and that this action may be enhanced by UV irradiation.

Abnormalities of heme biosynthesis in experimental acute renal failure

Several abnormalities of porphyrin metabolism have been described in patients with end-stage renal failure. Because the heme biosynthetic pathway in acute renal failure has not been studied hitherto, an experimental model was therefore induced in 30 dogs by ligation and transection of both ureters. Forty-eight h after this procedure, anemia and uremia developed, erythrocyte aminolevulinate dehydratase activity decreased, and plasma porphyrins increased in these 30 dogs, whereas seven sham-operated animals did not exhibit any alteration of these parameters. Uremic plasma showed a capacity to inhibit aminolevulinate dehydratase activity (mean, 11.1 +/- 5.8%) when incubated in vitro with erythrocytes from healthy dogs. Such findings are similar to those reported in uremic patients on hemodialysis or on continuous ambulatory peritoneal dialysis. Twenty-three of the 30 animals underwent a hemodialysis session (180 min) 48 h after ureteral ligation, using a polyacrylonitrile membrane dialyzer. In addition to reducing serum creatinine and urea levels, this procedure significantly reduced plasma porphyrin values. However, the activity of erythrocyte aminolevulinate dehydratase and the plasma capacity to inhibit this enzyme were not modified after the hemodialysis session. This results described here show that some of the abnormalities of heme biosynthesis described in chronic renal failure are detected early in an experimental model of acute renal failure. This study also confirms that, although most plasma porphyrins circulate bound to proteins, hemodialysis may reduce levels of plasma porphyrins when a high permeability membrane is used.

Heme biosynthesis in uremic patients on CAPD or hemodialysis

We have analyzed some parameters of porphyrin metabolism in 60 patients with end-stage renal failure, 20 of them on CAPD and the remaining on HD. In comparison with 56 control subjects, both groups of patients showed the three following findings: low erythrocyte aminolevulinate dehydrase activity, inhibition ability for the activity of this enzyme when their plasma was incubated in vitro with normal erythrocytes, and increased plasma porphyrin levels. Like anemia, these abnormalities were more remarkable in patients on HD who also exhibited increased erythrocyte protoporphyrin levels and compensatory porphobilinogen deaminase activities. Mean weekly porphyrin removal through dialysate was higher in CAPD (90.8 micrograms) than in HD patients (30.4 micrograms). Dialysate and plasma porphyrins were correlated in both circumstances (r = 0.714, P < 0.01 and r = 0.637, P < 0.05, respectively). The less pronounced porphyrin abnormalities found in CAPD patients with respect to HD patients may be due to the more efficient capability of peritoneal dialysis for removing from plasma protein-bound substances, as porphyrins and inhibitors of aminolevulinate dehydrase or other enzymes involved in erythropoiesis. Since no close relationship was found between these abnormalities of porphyrin metabolism and hematocrit values, the anemia of uremia cannot be merely considered as a direct consequence of altered heme biosynthetic pathway.

Effect of zinc or S-adenosyl-l-methionine on long term administration of low doses of lead to rats

Two alternatives for the treatment of lead intoxication, administration of zinc or a thiol donor, S-adenosyl-L-methionine (SAM), were analysed. Rats were exposed to lead (Pb)-acetate (60 mg/l) in drinking water during 90 days; one group also received SO4Zn in water (40 mg/l), while another received both Pb and SAM (5 mg/24 hr intraperitoneally. Erythrocytic delta-aminolaevulinic dehydratase (ALA-D) activity was significantly reduced (P < 0.001) both in rats receiving Pb alone and in rats receiving Pb and each of the other two treatments. The high erythrocytic uroporphyrinogen synthetase (URO-S) activity noticed in Pb administered rats, was significantly (P < 0.001) reduced in animals treated either with zinc or with SAM. Hepatic ALA-D activity tended to decrease while renal enzyme activity was not modified by the low level Pb exposure used in this work. Interestingly, SAM treated rats in both tissues exhibited significantly (P < 0.01) higher activities of the enzyme. It is argued that SAM treatment causes a surplus of thiols that allows the full expression of ALA-D catalytic activity.

Further evidence on the photodynamic and the novel non-photodynamic inactivation of uroporphyrinogen decarboxylase by uroporphyrin I

The action of uroporphyrin I (URO I) on the activity of red cell uroporphyrinogen decarboxylase (URO-D) in the dark and under UV light was studied. Light-dependent-and light-independent inactivation was observed. Both effects increased at increasing concentrations of URO I, the former reached its maximum at 150 microM of sensitizer. At 100 microM of URO I, both light and dark inactivation were temperature dependent amounting to about 50% at 30-37 degrees C. The velocity of dark inactivation increased with increasing temperature in the range of 0 to 45 degrees C. Photoinactivation can be ascribed to primary oxidation of essential amino acids, very likely histidyl residues, followed by secondary inter or intrapeptide cross-linking. Dark inactivation could be the result of both oxidation and cross-linking (although to a less degree than that produced by light) and also direct inhibition of the enzyme by induced conformational changes at its active site through binding of the porphyrin to the protein. When the action of URO I was tested on partially purified URO-D, the enzyme appeared to be more susceptible to the dark than to the light effect.

Photodynamic and non-photodynamic action of several porphyrins on the activity of some heme-enzymes

The action of porphyrins, uroporphyrin I and III (URO I and URO III), pentacarboxylic porphyrin I (PENTA I), coproporphyrin I and III (COPRO I and COPRO III), protoporphyrin IX (PROTO IX) and mesoporphyrin (MESO), on the activity of human erythrocytes delta-aminolevulinic acid dehydratase, porphobilinogenase, deaminase and uroporphyrinogen decarboxylase in the dark and under UV light was investigated. Both photoinactivation and light-independent inactivation was found in all four enzymes using URO I as sensitizer. URO III had a similar action as URO I on porphobilinogenase and deaminase and PROTO IX exerted equal effect as URO I on delta-aminolevulinic acid dehydratase and uroporphyrinogen decarboxylase. Photodynamic efficiency of the porphyrins was dependent on their molecular structure. Selective photodecomposition of enzymes by URO I, greater specificity of tumor uptake by URO I and enhanced porphyrin synthesis by tumors from delta-aminolevulic acid, with predominant formation of URO I, underline the possibility of using URO I in detection of malignant cells and photodynamic therapy.

Genetics and pathogenesis of human uroporphyrinogen decarboxylase defects

Two types of human porphyria, porphyria cutanea tarda (PCT) and hepatoerythropoietic porphyria (HEP), result from partial deficiency of uroporphyrinogen decarboxylase (UROD). About 20% of patients with PCT have a 50% decrease in UROD concentration in all tissues that is inherited as an autosomal dominant trait with low penetrance (type II PCT). Both this condition and its postulated homozygous counterpart, HEP, show genetic heterogeneity. Identification of a form of familial PCT in which the activity and concentration of erythrocyte UROD is normal, as in type I or sporadic PCT, suggests than an autosomal gene, not necessarily at the UROD locus, may be important in determining the onset of type I PCT. Clinically overt PCT results from a liver-specific process that causes reversible inactivation of UROD and which may be iron dependent. The predisposition to develop PCT in response to common hepatotoxic agents and other acquired factors may be determined by interaction between genes that control the concentration of active UROD in cells and genes that facilitate the inactivation process.

Photodynamic inactivation of red cell uroporphyrinogen decarboxylase by porphyrins

The effects of light and porphyrins on the activity of red cell uroporphyrinogen decarboxylase were studied. Photoinactivation of uroporphyrinogen decarboxylase was dependent on uroporphyrin concentration, irradiation time and temperature. Using 40 W/m2 of UV light intensity, 40-45% decreased activity was produced with 200 microM uroporphyrin I, at 37 degrees C and after 2 hr of illumination. It has been demonstrated that porphyrins photoinactivate uroporphyrinogen decarboxylase and a mechanism for this action in relation to skin lesions is proposed.

Is hepatoerythropoietic porphyria a homozygous form of porphyria cutanea tarda? Inheritance of uroporphyrinogen decarboxylase deficiency in a Spanish family

A patient with hepatoerythropoietic porphyria (HEP) is described. He was shown by a family study to be homozygous for a gene that causes greater than 95% suppression of erythrocyte uroporphyrinogen decarboxylase activity.

Studies on in vitro formation of complexes between porphyrins and chloroquine

Gel filtration and spectrophotometric studies revealed that uroporphyrin, heptacarboxylic-, and pentacarboxylic-porphyrins form in vitro complexes with chloroquine.

Hepatic acetylator phenotype in diabetes mellitus

Hepatic acetylator phenotype was determined using the sulphamethazine method in 32 patients with juvenile-onset diabetes mellitus and in 87 patients with the maturity-onset diabetes mellitus (Types I and II) and among 157 controls. No statistical differences were observed, neither for the incidence of acetylator phenotype among diabetics as compared with the control group, nor for the age at diagnosis of maturity-onset diabetes in slow and rapid acetylators. The incidence of diabetic retinopathy was similar among both phenotypes.

Follow-up studies of porphyrin excretion in porphyria cutanea tarda treated with p-aminobenzoic acid

The treatment of porphyria cutanea tarda (PCT) with p-aminobenzoic acid (PABA) was suggested because PABA is capable of reversing the porphyrinogenic action of 3,5-dicarbethoxy-1,4-dihydrocollidine (DDC) in rats. Three patients with PCT were treated with 3 g of PABA daily during 6 and 12 months and the urinary and faecal porphyrin excretion were serially analyzed by solvent extraction techniques and by thin layer chromatography of their methyl esters. PABA treatment did not show any apparent effect on porphyrin excretion.

Quantitation of red cell porphyrins by fluorescence scanning after thin-layer chromatography

This paper reports a new method for the quantitative determination of erythrocyte and plasma porphyrins by fluoroscanning of the methyl esters separated by thin-layer chromatography (TLC). After esterification overnight in the dark the polycarboxylated porphyrin methyl esters were extracted into chloroform and aliquots applied to the TLC plates within the range of quantities shown in a preliminary study to be directly proportional to fluorescence intensity. The accuracy and reliability of the technique was tested by comparison of RBC protoporphyrin values obtained by TLC with an established quantitative porphyrin solvent extraction method and with a rapid method presently in common use. Good correlation was demonstrated between the solvent extraction and the TLC techniques. The high sensitivity and adaptability of the TLC technique and its ability to clearly separate all the porphyrins present in the samples are discussed, along with the fluorescence mechanisms involved and the effects of instrumentation.