POS1456-HPR THE SERUM IRON LEVEL MIGHT BE USEFUL IN DETERMINING THE SEVERITY OF MALNUTRITION IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The Global Leadership Initiative on Malnutrition (GLIM) criteria, the first international criteria for diagnosis of malnutrition, was released in 2018 [1]. Patients with rheumatoid arthritis (RA) are thought to be prone to malnutrition due to decreased food intake and increased muscle catabolism caused by chronic inflammation or pain. However, there has been no report to assess the nutritional status of RA patients in accordance with the GLIM criteria. In addition, commonly used blood nutrient indicators such as albumin might not be appropriate as nutritional indicators for RA because these values are affected by inflammation.

Objectives:

This study aims to examine the rates of malnutrition in RA patients according to GLIM criteria, and the relationship between blood nutrient indicators and the severity of malnutrition.

Methods:

In this study, we conducted a cross-sectional survey of 135 female RA patients in 2020. According to the GLIM criteria, patients were considered to be malnourished if patients had one of the following phenotypic: (1) low body mass index, (2) non-volitional weight loss, (3) reduced muscle mass, and one of the following etiologic: (1) reduced food intake or assimilation, (2) disease burden/inflammatory condition. Reduced muscle mass was evaluated by measuring calf circumference, and inflammatory condition was evaluated by Disease Activity Score (DAS) 28. In accordance with the GLIM criteria, the severity of malnutrition was judged as three levels: no problem, moderate, and severe malnutrition. Albumin, transthyretin, transferrin, retinol binding protein, zinc, iron, ceruloplasmin, and total cholesterol were assessed as blood nutrition indicators. Also grip strength was assessed. We compared each nutritional indicator among the three groups according to the severity of malnutrition using age-adjusted analysis of covariance, and examined the relationship between each nutritional indicator and the severity of malnutrition using receiver operating characteristic (ROC) analysis.

Results:

In RA patients, 20% were classified as severe malnutrition, and 40% were moderate or more. Serum iron levels were significantly lower in the severe malnutrition group compared to the no problem group (p = 0.001). In ROC analysis, serum iron, zinc, albumin, and grip strength (area under curve; AUC; 0.680, 0.696, 0.636, 0.790, respectively) were significant parameters for classification of moderate and severe malnutrition. Serum iron and grip strength (AUC for respective parameters were 0.741, 0.747) were significant parameters for classification of severe malnutrition.

Conclusion:

Evaluation based on the GLIM criteria showed that about 40% of RA patients were under moderate or severe malnutrition. It was suggested that serum iron and grip strength might be useful to predict the severity of malnutrition.

References:

[1]Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. Clinical Nutrition 2019; 38: 1-9.

Acknowledgements:

We thank to Tomoko Nakatsuka, and the Center for Drug & Food Clinical Evaluation, Osaka City University Hospital, for management and collection of the study data. We also thank to study participants.

Disclosure of Interests:

Yoshinari Matsumoto Grant/research support from: Yamada Research Grant, Yuko Sugioka: None declared, Masahiro Tada: None declared, Tadasi Okano Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Kenji Mamoto: None declared, Kentaro Inui Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co., Ltd., Chugai Pharmaceutical Co., Ltd, Grant/research support from: anssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co., Ltd., Daiki Habu: None declared, Tatsuya Koike Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB

FRI0609-HPR NUTRIENTS INTAKE CONDITION RELATES TO MAINTENANCE LOW DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS DURING 6 YEARS: TOMORROW STUDY

Background:

We have previously reported that nutritional intake status might relate to disease activity (1). Nutritional survey on prospective cohort study in rheumatoid arthritis (RA) patients and information about relationship between nutritional intake status and disease activity was very limited.

Objectives:

This study aimed to obtain data from a cohort study for new nutritional therapy in RA patients.

Methods:

We used TOMORROW cohort study data which conducted from years of 2010 to 2020. Two hundred and eight RA patients, and 205 non-RA sex and age matched controls were investigated, and we analyzed data from 2011 to 2017. Nutritional intake status was compared between who maintain lower disease activity during 2011 to 2017 (LDA group) and being higher disease activity even once in 2011 to 2017 (non-LDA group). Disease activity was evaluated by DAS28-ESR in every year and nutritional intake status was surveyed by brief self-administered diet history questionnaire (BDHQ) in 2011 and 2017.

Results:

In RA patients, the change value from 2011 to 2017 of iron (odds ratio; 2.37), thiamin (OR; 2.96) and folic acid (OR; 3.16) intake which adjusted by energy intake, age, rheumatoid factor and medication status were extracted as independent factors for maintain LDA by multivariate logistic regression. These nutrients intake in RA patients was significantly lower than control both in 2011 and 2017. In RA patients, iron and folic acid intake in LDA group was significantly lower than non-LDA group in 2011. Folic acid intake was increased in LDA group and decreased in non-LDA group over time, and these nutrients showed significant differences in change value between LDA group and non-LDA group (p<0.05).

Conclusion:

The overtime change value in iron, thiamin and folic acid related to maintain six years low disease activity in RA patients.

References:

[1] Matsumoto Y, Sugioka Y, Tada M, Okano T, Mamoto K, Inui K, et al. Monounsaturated fatty acids might be key factors in the Mediterranean diet that suppress rheumatoid arthritis disease activity: The TOMORROW study. Clinical Nutrition 37:675-680, 2018

Disclosure of Interests:

Yoshinari Matsumoto Grant/research support from: Yamada Research Grant (grant No.249), Yuko Sugioka: None declared, Masahiro Tada: None declared, Tadashi Okano Grant/research support from: AbbVie, Eisai, Mitsubishi Tanabe Pharma Corporation and Nipponkayaku, Speakers bureau: AbbVie, Asahikasei, Astellas Pharma Inc, Ayumi Pharmaceutical, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiich Sankyo, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, Novartis Pharma, Ono Pharmaceutical, Pfizer, Sanofi, Takeda Pharmaceutical, Teijin Pharma and UCB, Kenji Mamoto: None declared, Kentaro Inui Grant/research support from: Janssen Pharmaceutical K.K., Astellas Pharma Inc., Sanofi K.K., Abbvie GK, Takeda Pharmaceutical Co. Ltd., QOL RD Co. Ltd., Mitsubishi Tanabe Pharma, Ono Pharmaceutical Co. Ltd., Eisai Co.,Ltd.,, Speakers bureau: Daiichi Sankyo Co. Ltd., Mitsubishi Tanabe Pharma, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., Ono Pharmaceutical Co. Ltd., Abbvie GK, Pfizer Inc., Eisai Co.,Ltd., Chugai Pharmaceutical Co., Ltd., Daiki Habu: None declared, Tatsuya Koike Grant/research support from: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB, Speakers bureau: AbbVie, Astellas Pharma Inc, Bristol-Myers Squibb, Chugai Pharmaceutical, Eisai, Janssen, Lilly, Mitsubishi Tanabe Pharma Corporation, MSD, Ono Pharmaceutical, Pfizer, Roche, Takeda Pharmaceutical, Teijin Pharma, and UCB

Add-on combination therapy with adefovir dipivoxil induces renal impairment in patients with lamivudine-refractory hepatitis B virus

Combination therapy with adefovir dipivoxil (ADV) and lamivudine (LAM) is recommended for patients infected with LAM-refractory hepatitis B virus (HBV). However, the effects of such therapy on renal function and serum phosphorus levels have not been fully evaluated. Combination therapy with ADV and LAM was given to 37 patients infected with LAM-refractory HBV, including 17 with hepatic cirrhosis. Serum HBV DNA levels decreased to below 2.6 log(10) copies/mL in 23 (62%) of 37 patients at 12 months, 25 (78%) of 32 patients at 24 months, and 16 (84%) of 19 patients at 36 months. Except for one cirrhotic patient, serum alanine aminotransferase levels were below 50 IU/L in all patients during combination therapy. Serum creatinine levels increased in 14 (38%) of 37 patients, and serum phosphate levels decreased to below 2.5 mg/mL in 6 (16%) of 37 patients during combination therapy. Patients who received combination therapy for 36 months or longer had a significantly incidence of elevated serum creatinine levels. Fanconi syndrome occurred in a 57-year-old woman with cirrhosis after ADV was added to LAM. Combination therapy with ADV and LAM can maintain biochemical remission in patients with LAM-refractory HBV. However, the dosing interval of ADV should be adjusted according to renal function and serum phosphate levels in patients receiving long-term treatment.

Development of hepatocellular carcinoma in patients with chronic hepatitis C who had a sustained virological response to interferon therapy: a multicenter, retrospective cohort study of 1124 patients

BACKGROUND

Interferon (IFN) improves hepatic inflammation/fibrosis and reduces the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C (CH-C). However, HCC develops in some patients who have a sustained virological response (SVR) to IFN therapy. We designed this study to establish a follow-up protocol for patients with CH-C who have SVR to IFN therapy.

METHODS

We retrospectively studied 1124 patients with CH-C who received IFN.

RESULTS

HCC developed in 3.5% of patients with SVR to IFN. As compared with SVR patients without HCC, SVR patients with HCC were predominantly male (P=0.003), older at the initiation of IFN therapy (P=0.002), and at a more advanced histologic stage of disease (P<0.001). However, three of the 13 SVR HCC patients had mild fibrosis. The mean interval from IFN therapy to the detection of HCC in SVR HCC patients was 5.8 years and did not differ significantly from that in non-SVR HCC patients (P=0.304). Although most patients with HCC received curative therapy, the prognosis of some SVR HCC patients was poor, probably because of insufficient follow-up, resulting in delayed detection of HCC.

CONCLUSIONS

SVR patients with CH-C who are elderly, male, or have an advanced histologic stage are at a high risk for the development of HCC after IFN therapy. We recommend that SVR patients should be observed carefully for more than 10 years after the completion of IFN therapy, even if they only have early fibrosis.

Effects of ribavirin combined with interferon-alpha 2b on viral kinetics during first 12 weeks of treatment in patients with hepatitis C virus genotype 1 and high baseline viral loads

This study aimed to find how ribavirin increases viral disappearance in patients with hepatitis C virus (HCV) of genotype 1 and high baseline viral loads (>5.0 x 10(5) copies/mL) when given with interferon (IFN). Using the real-time quantitative polymerase chain reaction, we measured serum HCV in 20 patients during the first 12 weeks of therapy with IFN-alpha 2b and ribavirin. Controls were 10 similar patients given IFN-alpha 2b alone. IFN-alpha 2b was given at 6 MU daily for 2 weeks, and then three times weekly. Ribavirin was given at 600 or 800 mg daily. Serum HCV RNA decreased rapidly in the first phase, during the first 24 h of therapy (day 0), and more slowly in the early second phase (days 1-14). The median decrease was by 1.41 and 0.078 log 10/day in these two phases in the combination therapy group, and 0.90 and 0.081 log 10/day in the monotherapy group. The difference between groups in the first phase was not significant (P = 0.24), nor was that in the next phase (P = 0.68). Later in the second phase, between days 14 and 84, the median decrease was larger in the combination therapy group (0.030 log 10/day) than in the monotherapy group (0.015 log 10/day, P = 0.035). In patients with HCV genotype 1 and high viral loads, the effects of ribavirin with IFN-alpha appeared slowly, after the earliest days of treatment. A long-term favourable outcome of combination therapy may be associated with a rapid viral decline in this later phase of therapy.

Comparison of real-time quantitative polymerase chain reaction with three other assays for quantitation of hepatitis C virus

BACKGROUND AND AIMS

Evaluation of serum levels of hepatitis C virus (HCV) is important for predicting the response to interferon treatment and monitoring its therapeutic efficacy. The aim of this study was to evaluate real-time quantitative polymerase chain reaction (PCR) as a method for the measurement of HCV-RNA.

METHODS

The subjects were 50 patients with chronic hepatitis C: 36 with genotype 1b, eight with genotype 2a, and six with genotype 2b. Samples were tested for HCV-RNA by using real-time quantitative PCR with the ABI Prism 7700 sequence detection system, a branched DNA signal amplification assay, and an Amplicor monitor test; and for HCV core protein by using a fluorescent enzyme immunoassay.

RESULTS

The detection range of the real-time quantitative PCR was between 10(1)-10(8) copies/mL of HCV-RNA. Hepatitis C virus RNA was detectable in all 50 samples by the use of real-time quantitative PCR, but was undetectable in 14 samples by the use of a branched DNA assay and in two samples by using the Amplicor monitor test; HCV core protein was undetectable in three samples. A significant correlation was found between the results of real-time quantitative PCR and those of the three other assays: branched DNA assay (r = 0.837, P < 0.0001), Amplicor monitor test (r = 0.853, P < 0.0001), and HCV core protein concentrations (r = 0.549, P < 0.0001).

CONCLUSIONS

Our results showed that the real-time quantitative PCR was a highly sensitive assay for the measurement of HCV-RNA.

Does ascorbic acid prevent retinopathy during interferon therapy in patients with chronic hepatitis C?

PURPOSE

Ascorbic acid was administered to patients with chronic hepatitis C to elucidate the mechanism of onset of retinopathy during interferon (IFN) therapy, and its prevention.

METHODS

The subjects were 62 patients with chronic hepatitis C who had been admitted to our hospital. For the IFN therapy, 6 MIU of natural IFN-alpha, or 10 MIU of recombinant human IFN-alpha 2b was administered every day for the first 2 weeks, followed by administration three times a week for 22 weeks. The patients were randomly assigned to a group receiving 600 mg/day of ascorbic acid or a group not receiving ascorbic acid (control group). The optic fundi were examined by ophthalmologists before the IFN therapy began and subsequently at weeks 2 and 4 and then every 4 weeks during the IFN therapy.

RESULTS

Retinopathy was found in 9 of the 31 patients (29%) in the ascorbic acid-treated group and in 11 of the 31 patients (35%) in the control group. The cumulative incidence of hemorrhage in the ascorbic acid-treated group was lower than that in the control group during the IFN therapy, but the difference between the two groups was not significant (P = 0.186). The cumulative incidence of cotton-wool spots in the ascorbic acid-treated group was almost same as that in the control group during the IFN therapy. The median platelet counts before the therapy was begun were 11.8 x 10(4)/mm2 in the group with hemorrhage and 16.6 x 10(4)/mm2 in the group without, and the lowest platelet counts during IFN therapy were 7.3 x 10(4)/mm3 in the group with hemorrhage and 9.5 x 10(4)/mm3 in the group without, indicating significantly lower values in the group with hemorrhage (P = 0.018 and P = 0.020, respectively). The lowest platelet counts during IFN therapy were 7.4 x 10(4)/mm3 in the group with cotton-wool spots and 9.7 x 10(4)/mm3 in the group without, indicating a significantly lower value in the group with cotton-wool spots (P = 0.036).

CONCLUSIONS

Ascorbic acid was not considered to be useful for the prevention of the retinopathy associated with IFN therapy in patients with chronic hepatitis C.

Usefulness of positron emission tomography with fluorine-18-fluorodeoxyglucose for predicting outcome in patients with hepatocellular carcinoma

OBJECTIVES

The present study was designed to assess the usefulness of positron emission tomography with fluorine-18-fluorodeoxyglucose (FDG-PET) for predicting outcome in patients with hepatocellular carcinoma.

METHODS

FDG-PET was performed in 48 patients with hepatocellular carcinoma. For quantitative evaluation, a region of interest (ROI) was placed over the area of maximum activity within the lesion. A background ROI was then placed over the nontumor region of the liver. The average activity within each ROI was subsequently corrected for radioactive decay, and the standardized uptake value (SUV) was calculated by dividing the tissue activity by the injected dose of radioactivity per unit body weight. SUV ratio was expressed as the tumor-to-nontumor ratio of the SUV.

RESULTS

The tumor-volume doubling time, as index of the growth rate of hepatocellular carcinoma, correlated significantly with SUV ratio but did not correlate with SUV. On the basis of the SUV ratio, the patients were divided into two groups of similar size: group A, SUV ratio of < or = 1.5; and group B, SUV ratio > 1.5. The cumulative survival rate was significantly lower in group B than in group A. On the basis of the SUV, the patients were divided into two groups of roughly equal size: group C, < or = SUV 2.6; and group D, > SUV 2.6. The cumulative survival rate was similar in these groups. On regression analysis with the Cox proportional hazards model, the SUV ratio and tumor number were significantly related to survival.

CONCLUSIONS

These results suggest that FDG-PET is useful not only for the evaluation of the malignancy of hepatocellular carcinoma but also for the prediction of outcome in patients with hepatocellular carcinoma.

Mesenteric desmoid with uptake on gallium-67 citrate scintigraphy

A 72-year-old man was hospitalized for further evaluation of a space-occupying lesion in the abdomen. Magnetic resonance imaging revealed a tumor 40 mm in diameter in the abdomen. Anterior Ga-67 citrate scintigraphy revealed a region of accumulation of radioactivity in the abdomen corresponding to the tumor. Mesenteric desmoid was diagnosed on the basis of histological findings for the excised tumor. These finding suggested that mesenteric desmoid may be one of the tumors which show high uptake of Ga-67.

Accessory spleen in the pelvis diagnosed by Tc-99m phytate scintigraphy

We report a 58-year-old woman with an accessory spleen in the left side of the pelvis. She visited our outpatient clinic complaining of lower abdominal discomfort. Abdominal ultrasonography revealed a tumor 4 cm in diameter in the left side of the pelvis. Color Doppler ultrasonography demonstrated plentiful pulsating blood flow. Magnetic resonance angiography revealed that the blood supply for the tumor was from a branch of the splenic artery. Scintigraphy with Tc-99m phytate revealed accumulation of radioactivity concordant with a mass in the left side of the pelvis, and the spleen was normally visualized. These findings suggested that this tumor was an accessory spleen, and the patient underwent no further invasive procedures.

A case of glucagonoma with high uptake on F-18 fluorodeoxyglucose positron emission tomography

Glucagonomas are relatively rare, and can be difficult to differentiate from other pancreatic tumors. A 62-year-old woman who had suffered from diabetes mellitus was hospitalized for further evaluation of a space-occupying lesion in the head of the pancreas and tumors in the liver. F-18 fluorodeoxyglucose positron emission tomography revealed accumulation of isotope corresponding to a tumor of the pancreas with a standardized uptake value of 4.3, and tumors in the liver with standardized uptake values of 2.4 and 2.8. The serum glucagon level was high (1,170 pg/ml) and the secretin tolerance test was negative. She was diagnosed with glucagonoma with a high serum glucagon level and clinical findings. It is suggested that glucagonoma may be one of the tumors which show high uptake of F-18 fluorodeoxyglucose.

Prevention of hepatocellular carcinoma in patients with chronic active hepatitis C and cirrhosis

In a prospective randomised controlled study, 90 patients with chronic active hepatitis C and compensated cirrhosis were assigned symptomatic treatment or interferon alfa (IFN-alpha). We report data on decompensation, detection of hepatocellular carcinoma, and mortality rates. IFN-alpha gave a sustained response in only a small proportion of patients, but worsening of compensated cirrhosis was prevented and development of hepatocellular carcinoma was inhibited, increasing the survival rate. The risk ratio of IFN-alpha versus symptomatic treatment decreased by 0.250 for progression to Child-Pugh grade B, 0.256 for detection of hepatocellular carcinoma, and 0.135 for a fatal outcome.

Method to detect substitutions in the interferon-sensitivity-determining region of hepatitis C virus 1b for prediction of response to interferon therapy

Substitutions deduced by direct sequencing in the interferon-sensitivity-determining region (ISDR) of hepatitis C virus (HCV) are related to patients' responses to interferon (IFN), but sequencing is time consuming and results are only for the dominant virus. We developed a rapid method to detect such changes. With serum from 50 patients with chronic hepatitis C (genotype 1b) given IFN-alpha, a way to detect changes in ISDR by hybridization with oligonucleotide probes that had a prototype nucleotide sequence of HCV-J was established. Hybridization intensity was expressed as optical density (OD(NS5A)). The method was checked with serum from 100 more patients. In the study of 50 patients, all 21 with the prototype sequences had a high OD(NS5A) (> or = 0.4), and all 8 patients with a mutant-type sequence had low values (< or = 0.2). Twelve (95% confidence interval, 36-81%) of 20 patients with OD(NS5A) of <0.4 and 2 (1%-22%) of 30 patients with OD(NS5A) > or = 0.4 had complete responses (CR). All nine (66%-100%) patients with OD(NS5A) <0.4 and little HCV RNA (<100 kIU/mL) had CR, but none (0%-14%) of the 24 patients with high values from both predictors had CR. In the study of 100 patients, OD(NS5A) and the HCV RNA level were independent predictors of the effects of IFN. By multivariate analysis, the odds ratio for a CR in patients with OD(NS5A) of > or = 0.4 was 0.015 (0. 001-0.190) compared with the other patients (P =.001). In conclusion, our method should be useful in identification of prototype strains, which generally resist IFN therapy.

Outcomes of dysplastic nodules in human cirrhotic liver: a clinicopathological study

The number of dysplastic nodules detected clinically has increased since patients with hepatitis virus-associated cirrhosis, who are at increased risk for hepatocellular carcinoma (HCC), began to undergo regular cancer surveillance. Although it is potentially important to determine which type(s) of nodule may be prone to progress to HCC, outcomes of dysplastic nodules have not been fully investigated. This prompted us to examine the outcomes of dysplastic nodules in cirrhotic patients clinicopathologically. We studied 33 dysplastic nodules of <20 mm in maximum diameter, diagnosed by fine needle aspiration biopsy under ultrasonography (US). These nodules were clinically followed, mainly by US examination, for up to 70 months. When the nodules enlarged or exhibited changes on US, they were histologically reexamined by second biopsy. Surprisingly, 15 of the 33 nodules (45.5%) disappeared, 14 nodules (42.4%) remained unchanged, and only 4 nodules (12.1%) progressed to HCC. The latter 4 nodules were all hyperechoic on US and were composed of clear cells with fatty change or small cells with increased nuclear density, and in all 4 patients serum was positive for hepatitis C virus antibody. Univariate analyses revealed that, although not significant, the hyperechoic nodules or nodules with small cell change showed a higher HCC progression rate in comparison with the hypoechoic nodules or the nodules without small cell change. In summary, most of the dysplastic nodules we followed disappeared or remained unchanged, but some progressed to HCC. Hyperechoic nodules in patients with hepatitis C virus-associated cirrhosis, which show small cell change with increased nuclear density, may be prone to progress to HCC.

Laparoscopic microwave coagulation therapy for hepatocellular carcinoma

BACKGROUND AND STUDY AIMS

Several different effective forms of treatment are available, singly or in combination, for patients with hepatocellular carcinoma (HCC). These include surgical resection, transcatheter arterial embolization, percutaneous ethanol injection, and percutaneous microwave coagulation therapy. In this study, we carried out laparoscopic microwave coagulation therapy (LMCT), using laparoscopic microwave electrodes to treat HCC.

PATIENTS AND METHODS

Under local anesthesia, 24 patients with HCCs located on or near the liver surface underwent LMCT under direct laparoscopic vision, with ultrasound guidance. LMCT was performed using microwave electrodes with tips ranging from 15-45 mm in length, and the effectiveness of the treatment was confirmed using contrast-enhanced computed tomography (CT) within two weeks of the LMCT procedure.

RESULTS

The mean longest axis of the 26 HCC nodules in 24 patients was 20 mm, and that of the coagulated areas including the nodules was 40 mm, with additional therapy being required in two patients. Complete efficacy of the treatment was observed in 21 patients (87.5%), but local recurrences were seen in three of them one year after LMCT. The three-year survival rate was 92%, but the number of patients included in the study was small. Hemostasis was complete, but mild pneumothorax occurred in three patients.

CONCLUSIONS

LMCT under local anesthesia is a minimally invasive and effective therapy when carried out on a single occasion to treat HCCs located near the liver surface, and it can be safely performed under direct visual guidance.

Assessment of hepatic blood flow by PET with 15O water: correlation between per-rectal portal scintigraphy with 99Tc(m)-pertechnetate and scintigraphy with 99Tc(m)-GSA

We performed positron emission tomography with 15O water (H2(15)O) to measure hepatic arterial and portal blood flow. In addition, portal haemodynamics and hepatic functional reserve were measured by per-rectal portal scintigraphy and scintigraphy with galactosyl human serum albumin, respectively. We studied 15 patients who had cirrhosis of the liver with underlying viral infection. After the intravenous injection of H2(15)O, positron emission tomography was performed. Blood samples were obtained after beginning the emission scan. The blood samples and positron emission tomographic images were analysed to calculate the radioactivity in the blood and liver. One-compartment model analysis was used to estimate hepatic arterial and portal blood flow. Computer acquisition of gamma-camera data was started just before the injection of 99Tc(m)-galactosyl human serum albumin. A receptor index and an index of blood clearance were calculated on the basis of the radioactivity of the liver and heart. A 99Tc(m)-pertechnetate solution was instilled into the rectum; serial scintigrams were performed and radioactivity curves for the liver and heart were recorded sequentially. A per-rectal portal shunt index was calculated from the curves. Median portal blood flow was 80 ml x 100 g(-1) x min(-1), median hepatic arterial blood flow was 56 ml x 100 g(-1) x min(-1), and median total hepatic blood flow was 138 ml x 100 g(-1) x min(-1) in patients with cirrhosis. The correlations between portal blood flow and the Child-Turcotte classification score, portal shunt index and receptor index were all significant. Our results show that hepatic arterial and portal blood flow can be measured by positron emission tomography with H2(15)O non-invasively and physiologically. This technique may be useful in pathophysiological studies of liver disease.

Effect of ethanol on bone mineral density of rats evaluated by dual-photon X-ray absorptiometry

Abuse of alcohol may derange bone metabolism and cause osteoporosis. Due to confounding factors associated with alcohol abuse, e.g., dietary deficiencies and liver damage, a study using an animal model is preferable to examine whether alcohol itself actually reduces bone density. We evaluated the effect of alcohol intake on bone in rats by dual-energy X-ray absorptiometry. Six-week-old male (n = 16) and female (n = 16) Wister rats were divided into two groups. Sixteen alcohol-exposed rats (8 male and 8 female) were fed Lieber's liquid diet and 16 control rats (8 male and 8 female) were fed a control liquid diet. The bone mineral density (BMD) and bone mineral content (BMC) of the right femur were measured before and after experimental feeding under anesthesia. The BMD of lumbar spine (L2-L4) of sacrificed rats was measured. For male rats, BMD and BMC decreased significantly in the alcohol group (P = 0.0132 and 0.0133, respectively) but did not decrease in control group. For female rats, BMD and BMC decreased significantly in the alcohol group (P = 0.0012 and <0.0001, respectively) but did not decrease in the control group. For male rats, the mean ratio of BMD after experimental feeding divided by BMD before experimental feeding was significantly lower in the alcohol group than in the control group (P = 0.0031). For female rats, the mean ratio of BMD after experimental feeding divided by BMD before experimental feeding was also lower in the alcohol group than in the control group (P = 0.0002). For male rats, the mean BMD of L2-L4 after experimental feeding was significantly lower in the alcohol group than in the control group (P = 0.0210). For female rats, the mean BMD of L2-L4 after experimental feeding was also significantly lower in the alcohol group than in the control group (P = 0.0006). These results indicate that alcohol intake decreased the BMD of rats in both spongy and cortical bone, and that the reduction of BMD was greater in female rats than in male rats.

Clinical need for both scintigraphy with technetium-99m GSA and per-rectal portal scintigraphy in some patients with chronic liver disease

Scintigraphy with 99mTc-diethylenetriaminepentaacetate with galactosyl human serum albumin (99mTc-GSA) and per-rectal portal scintigraphy are useful for evaluating hepatic functional reserve and portal circulation, respectively. We did the procedures simultaneously in some patients to examine the relationship between hepatic functional reserve and portal circulation in chronic liver disease. Scintigraphy with 99mTc-GSA was done in 10 healthy subjects, 45 patients with chronic hepatitis, and 165 patients with cirrhosis. Fifty-seven patients (13 with hepatitis and 44 with cirrhosis) also underwent per-rectal portal scintigraphy with 99mTc-pertechnetate within two weeks. A receptor index was calculated by dividing the radioactivity of the liver region of interest (ROI) by that of the liver-plus-heart ROI at 15 min after the injection of 99mTc-GSA. The index of blood clearance was calculated by dividing the radioactivity of the heart ROI at 15 min by that of the heart ROI at 3 min. A solution containing 99mTc-pertechnetate was instilled into the rectum, and serial scintigrams were taken while radioactivity curves for the liver and heart were recorded sequentially. A per-rectal portal shunt index was determined by calculating the ratio of counts for the liver to counts for the heart integrated for 24 seconds immediately after the appearance of the liver time-activity curve. The median receptor index was lower for more severe liver disorders, increasing in the order of chronic hepatitis, compensated cirrhosis and decompensated cirrhosis, and the median index of blood clearance was higher. The median receptor index was significantly lower when a complication (varices, ascites, or encephalopathy) was present, and the median index of blood clearance was higher. The shunt index was correlated significantly with the two other indices, but these values for some one-third of the patients disagreed in either indices. Scintigraphy with 99mTc-GSA and per-rectal portal scintigraphy with 99mTc-pertechnetate are both needed for accurate assessment of the severity of chronic liver disease before treatment-making decisions, because in some patients, results are not correlated.

Use of scintigraphy with 99mtechnetium galactosyl human serum albumin for staging of primary biliary cirrhosis and assessment of prognosis

BACKGROUND

Conventional models for prediction of survival in patients with primary biliary cirrhosis (PBC) are based on the results of blood tests and on the clinical condition, which may be affected by treatment. We evaluated the usefulness of hepatic receptor imaging with [99mtechnetium]-diethylenetriaminepentaacetic acid galactosyl human serum albumin (GSA) for the staging and prognosis of PBC without the need for reference to laboratory test results.

METHODS

The subjects were 45 patients with PBC, 10 healthy subjects, 62 patients with chronic hepatitis and 144 patients with cirrhosis. Computer acquisition of gamma-camera data was started just before the injection of 185 MBq [99mTc]-GSA and was stopped 20 min later. Time-activity curves were generated from regions of interest (ROI) for the heart and liver. A receptor index was calculated by dividing the radioactivity of the liver ROI by that of the liver-plus-heart ROI 15 min after the injection. An index of blood clearance was calculated by dividing the radioactivity of the heart ROI 15 min after the injection by that of the heart ROI 3 min after the injection.

RESULTS

The median receptor index was higher in patients with PBC than in those with cirrhosis. Among patients with PBC, the receptor index was lower in those with stage IV disease than in those in stages I, II or III. The index of blood clearance was lower in patients with PBC than in those with cirrhosis. Among patients with PBC, the index of blood clearance was higher in those with stage IV disease than in those in stages I, II or III. The receptor index was correlated significantly both to the risk score of the Mayo model and to the prognostic index of the Japanese model. The index of blood clearance was also correlated significantly to this score and prognostic index.

CONCLUSIONS

Hepatic receptor imaging with [99mTc]-GSA is useful for the evaluation of hepatic functional reserve, staging of PBC and assessment of prognosis.

Calcitriol for bone disease in patients with cirrhosis of the liver

BACKGROUND

Osteoporosis is associated with cirrhosis of the liver, but the effects of therapy for osteoporosis associated with cirrhosis are still controversial.

METHODS

We evaluated the effects of calcitriol (1alpha,25-dihydroxyvitamin D3) on bone mineral density (BMD) in 76 patients (26 men and 50 women) with cirrhosis who were assigned randomly to receive calcitriol (0.5 mg twice per day) or not. The BMD of the lumbar vertebrae was measured by dual-energy X-ray absorptiometry at least twice, 12-57 months apart.

RESULTS

For men, the mean annual change in BMD was 1.1% in the treated group and -0.4% in the control group. The median (25th and 75th percentiles) annual change in BMD was 0.6 (-0.1, 2.1%) in the treated group and -1.4 (-1.9, 1.6%) in the control group. The difference in the median annual change between the two groups was significant (P = 0.013). For women, the mean annual change in BMD was -0.5% in the treated group and -2.3% in the control group. The median (25th and 75th percentiles) annual change in BMD was -0.5 (-1.8, 1.3%) in the treated group and -1.5 (-3.8, -0.7%) in the control group. This difference was significant (P = 0.011).

CONCLUSIONS

Our results suggest that calcitriol can prevent bone loss and, therefore, may be useful for the treatment of bone disease in patients with cirrhosis of the liver.

Calcitriol for bone loss in patients with primary biliary cirrhosis

Because osteoporosis is a common complication of primary biliary cirrhosis, we evaluated the effects of calcitriol (1alpha, 25-dihydroxyvitamin D3) on bone mineral density in 34 women with primary biliary cirrhosis (stage I disease in 16 patients, stage II in 9, stage III in 4, and stage IV in 5). Patients were assigned randomly to receive calcitriol (0.5mg twice a day) or not. Bone mineral density of the lumbar vertebrae was measured by dual-energy X-ray absorptiometry at least twice during a period of 12-43 months. The mean annual change in bone mineral density was 0.1% in the treatment group and -3.1% in the control group. The median annual change (with 25th and 75th percentiles) in bone mineral density was 0.3% (-0.5%, 1.9%) in the treated group and -3.1% (-4.1%, -2.1%) in the control group. This difference between the two groups was significant (P = 0.0007, Mann-Whitney U-test). Our findings suggest that calcitriol prevents bone loss and may be an effective treatment for osteoporosis in patients with primary biliary cirrhosis.

Clinical usefulness of conjugated bilirubin levels in patients with acute liver diseases

We used a specific method to measure conjugated bilirubin levels in patients with acute liver diseases to examine its clinical usefulness. Conjugated and total bilirubin levels were measured in 102 samples obtained from six patients with acute liver diseases (three with fulminant hepatic failure, one with acute severe hepatitis and two with acute hepatitis; see text for criteria). Total and conjugated bilirubin levels were measured with Iatro T (total)-Bil and D (direct)-Bil kits (Iatron Laboratories Tokyo, Japan) and with conventional Nescauto T(total)-Bil and D(direct)-Bil VE kits (Nippor Shoji, Osaka, Japan). The Iatro D-Bil kit measures conjugated bilirubin correctly, while the Nescauto D-Bil VE kit measures some nonconjugated bilirubin and delta bilirubin as well as conjugated bilirubin. Total bilirubin levels determined by the two methods showed good correlation. The conjugated bilirubin level measured with the Iatro D-Bil kit was strongly correlated with the direct bilirubin level measured with the Nescauto D-Bil VE kit, but there was no correlation between the conjugated-to-total bilirubin ratio and the direct-to-total bilirubin ratio. When we examined the changes in bilirubin levels in our patients with respect to outcome, we found that the two patients in whom the ratio of conjugated-to-total bilirubin exceeded 0.3 died, while all four patients in whom the ratio remained below 0.3 survived. The ratio of direct-to-total bilirubin was unrelated to outcome. The conjugated bilirubin level measured with the Iatro kits was therefore considered useful for the diagnosis and follow-up of acute liver diseases.

Natural course of portal hemodynamics in patients with chronic liver diseases, evaluated by per-rectal portal scintigraphy with Tc-99m pertechnetate

Portal circulation can be evaluated in a relatively noninvasive way by per-rectal portal scintigraphy. We used this method to evaluate portal hemodynamics in patients with chronic liver diseases and underlying hepatic viral infection; the patients did not need surgery or sclerotherapy, or refused it, so changes in the natural course were identified. A solution of Tc-99m pertechnetate was instilled into the rectum, and serial scintigrams were taken while radioactivity curves for the liver and heart were produced. The per-rectal portal shunt index was calculated from the curves. In a longitudinal study, 70 patients (9 with mild chronic hepatitis, 10 with moderate chronic hepatitis, 7 with severe chronic hepatitis, 22 with cirrhosis but without varices, and 22 with both cirrhosis and varices) were examined at least twice at intervals of 12-102 months (mean, 39 months). The shunt index was higher for more severe disorders, increasing in the order of mild chronic hepatitis, moderate chronic hepatitis, severe chronic hepatitis, cirrhosis without varices, and cirrhosis with varices. The mean annual changes in the mean shunt index were 1.0% in mild chronic hepatitis, 4.4% in moderate chronic hepatitis, 6.1% in severe chronic hepatitis, 10.7% in cirrhosis without varices, and 6.2% in cirrhosis and varices. Cirrhotic patients were arbitrarily divided into two groups of roughly equal size on the basis of the shunt index at the first examination. In those with a shunt index of 30% or more, the mean annual change was 4.7%. The patients with a shunt index of less than 30% had a mean annual change of 11.8%. Changes in the portal hemodynamics were not steady. The shunt index rose gradually as disease advanced from mild to moderate and to severe chronic hepatitis and cirrhosis of the liver, after which the index rose rapidly when varices developed, slowing later.

[The influence of anti-interferon-alpha 2a antibodies in initial daily four-week interferon-alpha 2a therapy for chronic hepatitis C]

Thirty-two patients with chronic active hepatitis C were initially treated with 9 million units of interferon (IFN)-alpha 2a daily for 4 weeks and then thrice weekly for 20 weeks. The incidence of development and influence on clinical effectiveness of anti-IFN alpha 2a neutralizing antibodies measured by bioassay were investigated. Thirteen (41%) of the 32 patients developed antibodies, 4 (12.5%) of whom exhibited a high titer of 128 NU or greater. There was a significant difference (p < 0.05) between responders and non-responders in the low viral load group (less than 10(5) copies/50 microliters) in the incidence of antibody development, with antibodies present in 2 of the 9 responders (22%) and 5 of the 7 non-responders (71%). There was also a significant difference between the antibody-negative and antibody-positive patients in circulating HCV-RNA, 2-5AS activity and average ALT levels at the latter half of treatment. In addition, 2-5AS activity was significantly lower (p < 0.05) at completion of treatment in the high antibody titer group (128 NU or greater) than in the low antibody titer group. These results indicate that the development of anti-IFN neutralizing antibodies had a definite influence on the clinical course of IFN treatment for chronic hepatitis C.

Hereditary ceruloplasmin deficiency with hemosiderosis

Hereditary ceruloplasmin deficiency with hemosiderosis (aceruloplasminemia) is a new disease characterized by systemic hemosiderosis, diabetes mellitus, neurological abnormalities and pigment degeneration of the retina. Loss of the ferroxidase activity of ceruloplasmin results in systemic iron deposition and tissue damage. Neuroimaging studies reveal iron deposition in basal ganglia and in the red and dentate nuclei. Cerebellar ataxia, extrapyramidal signs and dementia develop after middle age. We report a patient with undetectable serum ceruloplasmin levels and the above clinical manifestations. Sequence analysis of the cDNA of ceruloplasmin from this patient revealed an insertion of adenine in exon 3; this produced a premature stop codon.

[Relationship between the condition of the liver in patients and carriers with hepatitis B virus (HBV) and whether there is intrafamilial clustering of HBV]

We analyzed the relationship between the presence of intrafamilial clustering of infection with hepatitis B virus (HBV) and the condition of the liver. Parents and siblings of subjects infected with HBV, some patients and some carriers, were tested for the presence of HBsAg, HBeAg, HBeAb, and liver damage. Then the original subjects with HBV were classified by the results into one of three groups. The subjects in the group without clustering had a higher rate of being seronegative for HBeAg than the groups with clustering, at all ages (P less than 0.01; test). Of the original subjects who were seronegative for HBeAg, the group without clustering had less damage of the liver than the groups with clustering. Of the subjects infected by horizontal transmission, the group without clustering had a higher rate of being seronegative for HBeAg and less damage of the liver than the groups with clustering. Subjects with HBV in a family with members who had normal liver function and who were seronegative for HBeAg were less likely to develop chronic hepatitis B than such subjects in a family with members having chronic liver damage. Thus the presence of intrafamilial clustering might affect the chance of subjects with HBV developing liver damage. The mode of infection and some genetic factors in the infected subjects seem to contribute to the condition of subjects with HBV infection.