Current Papers in Liver Disease - June, 1996

By Howard J. Worman, M. D.
Columbia University

This is a past issue of Current Papers in Liver Disease.

Click here for information on Current Papers and the current issue.

Conry-Cantilena, C., VanRaden, M., Gibble, J., Melpolder, J., Shakil, A. O., Viladomiu, L., Cheung, L., DiBisceglie, A., Hoofnagle, J., Shih, J. W., Kaslow, R., Ness, P., and Alter, H. J. 1996. Routes of infection, viremia, and liver disease in blood donors found to have hepatitis C virus infection. New England Journal of Medicine. 334:1691-1696.

In this study, the authors examined volunteer donors of whole blood from the Greater Chesapeake and Potomac Region of the American Red Cross for antibodies against hepatitis C virus (HCV) from March 1991 through August 1994. Of 954,316 consecutive donations screened for antibodies against HCV using a first or second generation ELISA, 4585 repeatedly tested positive and 481 (10%) were enrolled in the study. Of the 481 subjects studied, 248 were confirmed to be positive for HCV antibodies on the Recombinant Immunobolt Assay (RIBA), 102 had indeterminate results on RIBA and 131 tested negative. In a logistic-regression analysis, significant risk factors for a positive RIBA test were history of blood transfusion, intranasal cocaine use, intravenous drug use, sexual promiscuity (defined as a history of sexually transmitted disease, sex with a prostitute, five or more sexual partners per year or a combination of these) and ear piercing among men (but not among women). Nine of 85 sexual partners of donors with HCV antibodies also had HCV antibodies, but 8 either used intravenous drugs or had received a blood transfusion. HCV RNA was detected by reverse transcription-polymerase chain reaction in 213 (86%) of donors with HCV antibodies on RIBA, 3 with indeterminate RIBA results and none with negative RIBA tests. Of the donors with HCV antibodies, 69% had biochemical evidence of chronic liver disease and, of 77 who had liver biopsies, 5 had severe chronic hepatitis or cirrhosis, 66 had mild-to-moderate chronic hepatitis and 6 had no evidence of hepatitis. This study identifies the risk factors for HCV infection in volunteer blood donors. Of note is that 42% of donors with HCV antibodies detected used intravenous drugs even though these donors denied such use when questioned directly at the time of blood donations.

Schreiber, G. B., Busch, M. P., Kleinman, S. H., and Korelitz, J. J., for The Retrovirus Epidemiology Donor Study. 1996. The risks of transfusion-associated viral infections. New England Journal of Medicine. 334:1685-1690.

Donated blood is screened for the presence of antibodies against several transmissible viruses. The greatest risk to the safety of the blood supply is donation of blood by seronegative donors during the infectious window period when the donors are undergoing seroconversion. In this study, the authors estimated the risk of transmitting the human immunodeficiency virus (HIV), the human T-cell lymphotropic virus (HTLV), the hepatitis C virus (HCV) and the hepatitis B virus (HBV) from screened units of blood donated during the window period following a recent, undetected infection. The risks were calculated based on data from 586,507 persons who each donated blood more than once between 1991 and 1993 at five US blood centers for a total of 2,318,356 allogeneic blood donations. Among donors whose units passed screening tests, the risk of giving blood during an infectious window period were estimated to be 1 in 493,000 for HIV, 1 in 641,000 for HTLV, 1 in 103,000 for HCV and 1 in 63,000 for HBV. HBV and HCV accounted for 88 percent of the aggregate risk of 1 in 34,000. These results suggest that the risk of transmitting HIV, HTLV, HCV and HBV infection by screened blood is low and provide data to make decisions about the implementation of new and more expensive assays for direct detection of these viruses.

Villanueva, C., Balanzo, J., Novella, M. T., Soriano, G., Sainz, S., Torras, X., Cusso, X., Guarner, C., and Vilardeli, F. 1996. Nadolol plus isosorbide mononitrate compared with sclerotherapy for the prevention of variceal rebleeding. New England Journal of Medicine. 334:1624-1629.

Bleeding from esophageal varices is a leading cause of mortality in patients with cirrhosis. Patients who bleed from esophageal varices are at an increased risk for rebleeding and death after treatment of the initial episode. Endoscopic sclerotherapy and beta-blockers have both been used to prevent recurrent bleeding. Meta-analysis has shown that sclerotherapy is more effective in preventing rebleeding but that there is no apparent difference in survival when compared with beta-blockers. In this study, the authors randomized 86 hospitalized patients with cirrhosis and bleeding from esophageal varices to preventive treatment with either repeated sclerotherapy (43 patients) or nadolol (a beta-blocker) plus isosorbide-5-mononitrite (a vasodilator). Baseline data were similar in the two groups and the median follow-up was 18 months in both. In the medication group, 11 patients had rebleeding compared with 23 in the sclerotherapy group. The actuarial probability of remaining free of rebleeding was significantly higher in the medication group. There also was a trend towards increased survival in the medication group but it was not statistically significant. Treatment complications were significantly more common in the sclerotherapy group. In the medication group, a larger percent decrease in the hepatic venous pressure was associated with a decreased probability of rebleeding. The results of this study suggest that nadolol plus isosorbide mononitrate may be superior to repeated sclerotherapy in the prevention of rebleeding from esophageal varices.

Muto, Y., Moriwaki, H., Ninomiya, M., Adachi, S., Saito, A., Takasaki, K. T., Tanaka, T., Tsurumi, K., Okuno, M., Tomita, E., Nakamura, T., and Kojima, T. 1996. Prevention of second primary tumor by an acyclic retinoid, polyprenoic acid, in patients with hepatocellular carcinoma. New England Journal of Medicine. 334:1561-1567.

Hepatocellular carcinoma is a difficult malignancy to cure with a high rate of recurrence and the development of second primary tumors after treatment. Secondary chemoprevention may therefore have a role in the treatment of patients who undergo surgical resection or percutaneous ethanol injection therapy as treatment. The authors of this study previously discovered an acyclic retinoid, polyprenoic acid, that binds to retinoic acid-binding proteins involved in transcriptional activation. Polyprenoic acid inhibits chemically induced hepatocarcinogenesis in rats and spontaneous hepatocellular carcinomas in mice. It also has previously been demonstrated to be safe in phase I clinical trials on humans. In the present study, the authors prospectively studied 89 patients who were disease-free based on ultrasound and computerized tomography examinations after surgical resection of a primary hepatocellular carcinoma or the percutaneous injection of ethanol. Patients were randomized to receive either polyprenoic acid or placebo for 12 months and underwent ultrasound examinations every three months after randomization. After a median follow-up of 38 months, 12 patients (27%) in the polyprenoic acid group had new or recurrent tumors as compared with 22 patients (49%) in the placebo group (P = 0.04). The major difference was in the development of tumors that were most likely second primary hepatocellular carcinomas. The adjusted relative risk of the development of second primary hepatocellular carcinoma in patients receiving polyprenoic acid was 0.31. Oral polyprenoic acid appears to prevent second primary hepatocellular carcinomas after surgical resection of the original tumor or the percutaneous injection of ethanol. At the time of publication, there was no difference in survival in the placebo and control groups which may or may not be detected with longer follow-up. Although not clearly stated in the paper, the patients in this study likely had fairly well-compensated liver disease and chemoprevention with polyprenoic acid may not be of value in patients with advanced cirrhosis and hepatocellular carcinoma.

Kanai, F., Shiratori, Y., Yoshida, Y., Wakimoto, H., Hamada, H., Kenegae, Y., Saito, I., Nakabayashi, H., Tamaoki, T., Tanaka, T., Lan, K.-H., Kato, N., Shiina, S., and Omata, M. 1996. Gene therapy for alpha-fetoprotein-producing human hepatoma cells by adenovirus-mediated transfer of the herpes simplex virus thymidine kinase gene. Hepatology. 23:1359-1368.

Hepatocellular carcinoma is one of the most difficult malignancies to treat, especially when multiple foci or distant metastasis are present. In this experimental study, the authors developed a novel adenoviral vector that may someday be useful in treating this malignancy using gene therapy. They developed a recombinant replication-defective adenovirus containing the human alpha-fetoprotein promoter/enhancer to direct cell type-specific expression of the herpes simplex virus (HSV) thymidine kinase gene. As most hepatocellular carcinomas (and fetal liver) express alpha-fetoprotein but adult hepatocytes do not, this recombinant adenovirus should direct cell-specific expression of HSV thymidine kinase in only tumor cells. Hepatocellular tumor cell lines that produced alpha-fetoprotein were sensitive to killing with gancyclovir when infected with the recombinant adenovirus. About 10% of non-infected bystander cells were also sensitive to killing. Cell lines that did not express alpha-fetoprotein were not sensitive to gancyclovir when infected with this virus. Although many hurdles still exist, recombinant adenovirus transfer of the HSV thymidine kinase gene under the control of a tumor-specific promoter followed by treatment with gancyclovir may hold promise as a treatment for solid neoplasms in humans.

Chemello, L., Cavalletto, L., Casarin, C., Bonetti, P., Bernardinello, E., Pontisso, P., Donada, C., Belussi, F., Martinelli, S., Alberti, A., and the TriVeneto Viral Hepatitis Group. 1996. Persistent hepatitis C viremia predicts late relapse after sustained response to interferon-alpha in chronic hepatitis C. Annals of Internal Medicine. 124:1058-1060.

Patients with chronic hepatitis C who respond to interferon-alpha with a normalization of serum aminotransferase activities often relapse after treatment is discontinued. This study from Italy examined 107 patients with chronic hepatitis C who received interferon-alpha and had normal serum alanine aminotransferase activities one year after treatment. Of these 107 patients, 27 (25%) had serum hepatitis C viral RNA detected by reverse transcription-polymerase chain reaction and 80 (75%) did not one year after discontinuation of therapy. The patients with persistent serum viral RNA were older, were treated with a smaller dose of total interferon-alpha and had a higher prevalence of infection with viral genotype 2 and a lower prevalence of infection with viral genotype 3. In patients who had follow-up liver biopsies, active inflammation was significantly more common in those with detectable serum viral RNA. In a prospective follow-up for an additional 6 to 36 months, none of the RNA negative patients had elevations in their serum alanine aminotransferase activities whereas 8 of the 27 (30%) with detectable serum viral RNA developed such elevations. These results suggest that one year after treatment with interferon-alpha, patients with undetectable serum viral RNA may have a complete and permanent response whereas those with detectable serum viral RNA do not.

Masuko, K., Mitsui, T., Iwano, K., Yamazaki, C., Okuda, K., Meguro, T., Murayama, N., Inoue, T., Tsuda, F., Okamoto, H., Mitakawa, Y., and Mayumi, M. 1996. Infection with hepatitis GB virus C in patients on maintenance hemodialysis. New England Journal of Medicine. 334:1485-1490.

The hepatitis G virus (HGV)/hepatitis GB virus-C (HGBV-C) is a recently characterized Flavivirus that may cause acute and chronic hepatitis. In this study, 519 patients in Japan on maintenance hemodialysis were examined for the presence of serum HGV/HGBV-C RNA by reverse transcription-polymerase chain reaction. Viral RNA was detected in 16 patients (3.1%) as compared with 4 of 448 (0.9%) healthy blood donors (P<0.03). None of the 16 patients with detectable serum HGV/HGBV-C RNA had elevated serum aminotransferase activities or other evidence of clinical liver disease. Seven of the 16 patients with HGV/HGBV-C infection had concurrent hepatitis C infection and one was infected with hepatitis B. Of the 519 hemodialysis patients studied, 107 (20.6%) had detectable serum hepatitis C virus RNA but only 6 of these had abnormally elevated serum aminotransferase activities. Fifteen of the study patients (2.9%) were hepatitis B surface antigen positive. Eight patients with HGV/HGBV-C infection were studied for 7 to 16 years and in all except for one the infection was persistent. In five of these patients, HGV/HGBV-C RNA was detected after blood transfusion. Sequencing of a small portion of the viral genome showed that the nucleotide sequences of various isolates can vary up to approximately 20 percent. These results show that patients on maintenance hemodialysis are at increased risk for HGV/HGBV-C infection. [In a letter to the editor in the same issue of this journal (de Lamballerie, X., Charrel, R. N., and Dussol, B. 1996. Hepatitis GB virus C in patients on hemodialysis. New England Journal of Medicine. 334:1549), 57.5 percent of 61 French hemodialysis patients examined were found to be infected with HGV/HGBV-C.] HGV/HGBV-C produces persistent infections and, in maintenance hemodialysis patients, infection appears to result in minimal or no clinical liver disease.

Niederau, C., Heintges, T., Lange, S., Goldmann, G., Niederau, C. M., Mohr, L., and Haussinger, D. 1996. Long-term follow-up of HBeAg-positive patients treated with interferon alfa for chronic hepatitis B. New England Journal of Medicine. 334:1422-1427.

Interferon-alpha has been shown in several randomized, controlled trials to be beneficial in the treatment of patients with chronic hepatitis B and serum HBeAg. Treatment (generally with 5,000,000 units of interferon-alpha2b for 4 months) leads to loss of serum HBeAg and HBV DNA on dot-blot assay in about 40-50% and loss of HBsAg in 1%-10% of patients. Less is known about the long-term outcome of treated patients. In this study, a cohort of 103 patients treated with interferon-alpha for chronic hepatitis B (HBeAg-positive) were followed for a mean of 50 months. A non-randomized group of 53 untreated patients served as controls. Similar to previous results, 53 (51%) of patients no longer had detectable HBeAg or HBV DNA on dot-blot assay and 10 (9.7%) no longer had HBsAg after treatment. Only 7 of the untreated patients lost HBeAg and all remained positive for HBsAg. During follow-up, 6 interferon-treated patients died of liver failure and 2 required orthotopic liver transplantation; all 8 of these remained HBeAg-positive after treatment. Another 8 treated patients developed complications of cirrhosis and 7 of these remained HBeAg-positive after treatment. In contrast, 13 of 53 untreated patients died or suffered complications of cirrhosis. Overall survival and survival without clinical complications were significantly longer in patients who lost HBeAg after treatment (P=0.004 and P=0.018, respectively) than in those who did not. In a regression analysis, loss of HBeAg was the strongest predictor of survival. This study shows that loss of HBeAg after treatment with interferon-alpha is associated with improved clinical outcomes.

Lau, J. Y. N., Davis, G. L., Prescott, L. E., Maertens, G., Lindsay, K. L., Qian, K., Mizokami, M., Simmonds, P., and the Hepatitis Interventional Therapy Group. 1996. Distribution of hepatitis C virus genotypes determined by line probe assay in patients with chronic hepatitis C seen at tertiary referral centers in the United States. Annals of Internal Medicine. 124:868-876.

Hepatitis C virus (HCV) has been classified into six major genotypes. These genotypes have different worldwide distributions and may cause liver disease of different severity. In this study, a line probe assay was used to determine the HCV genotype in 438 patients in the United States. The line probe assay is based on the polymerase chain reaction (PCR) and nucleic acid hybridization. After reverse transcription of RNA isolated from patient serum, a portion of the HCV cDNA is amplified by PCR using labeled primers. The amplified, labeled DNA is then hybridized to a strip containing probes of various HCV genotypes and the strips washed under stringent conditions. The first finding in this study was that the results of this assay were consistent with those of several different assays used in the past to determine HCV genotypes. Of 438 patients referred to 10 tertiary treatment centers in the United States for consideration for inclusion in experimental antiviral programs, 71.5% were infected with HCV genotype 1, 13.5% genotype 2, 5.5% genotype 3 and 1.1% genotype 4. Subtype 1a, which is prevalent only in the United States, and subtype 1b were approximately equal among patients infected with genotype 1. Mixed infections were present in 3.7% of cases and genotype could not be determined in 4.8% of specimens. Patients with genotype 1 were more likely to have acquired hepatitis C by blood transfusion and to have had longer estimated durations of infection than patients with genotypes 3 and 4. Disease activity did not differ significantly among patients infected with genotypes 1, 2 or 3 but those with genotype 4 had lower levels of viremia. These results show that the line probe assay can reliably determine HCV genotypes and that genotype 1 is the most common among patients in the United States seen at tertiary referral centers.

Bandin, O., Courvalin, J.-C., Poupon, R., Dubel, L., Homberg, J.-C., and Johanet, C. 1996. Specificity and sensitivity of gp210 autoantibodies detected using an enzyme-linked immunosorbent assay and a synthetic peptide in the diagnosis of primary biliary cirrhosis. Hepatology. 23:1020-1024.

The diagnosis of primary biliary cirrhosis (PBC) is based on combined clinical, biochemical, immunological and histological criteria. Central to the diagnosis is the detection of autoantibodies against the E2 subunits of mitochondrial oxo acid dehydrogenase complexes which are approximately 90% sensitive and 100% specific. Autoantibodies that recognize a restricted region of an integral membrane protein of the nuclear pore complex called gp210 are also common in patients with PBC. In this study, 285 patients with PBC and 497 control patients in France were examined for the presence of antibodies against the predominant autoepitope of gp210. The presence of gp210 autoantibodies was 25.5% sensitive and 99.5% specific for the diagnosis of PBC. Furthermore, in 15 patients without detectable antimitochondrial antibodies, 7 (47%) had gp210 autoantibodies. Testing for gp210 autoantibodies may be a useful complement to testing for antimitochondrial antibodies in the diagnosis of patients with PBC.

Chenard-Neu, M.-P., et al. 1996. Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure - a multicenter European study. Hepatology. 23:1119-1127.

Fulminant hepatic failure is acute liver disease complicated by hepatic encephalopathy within three months after the onset of jaundice. Fulminant hepatic failure has a high mortality rate and orthotopic total liver transplantation is an acceptable life-saving therapy. The drawback of total liver transplantation is life-long immunosuppression. Auxiliary liver transplantation, a procedure in which part of the native liver is left in situ, is designed to provide temporary support until normal hepatic function has recovered. Thus study, performed at 12 different European centers, was designed to evaluate the use of auxiliary liver transplantation in 30 patients. Twenty-five of 30 patients were younger than 50 years old. Causes of fulminant hepatic failure were hepatitis A (4), hepatitis B (7), acetaminophen toxicity (5), other drugs (6), autoimmune hepatitis (2), preeclampsia (1) and unknown (5). After a mean follow-up of 18 months, 19 of the 30 patients (63%) were alive and 13 (43%) had normal native liver function with discontinued immunosuppression. These encouraging preliminary results suggest that a large-scale prospective study of auxiliary liver transplantation for fulminant hepatic failure may be warranted.

Bollinger, M. E., Arredondo-Vega, F. X., Santisteban, I., Schwarz, K., Hershfield, M. S., and Lederman, H. M. 1996. Brief report: hepatic dysfunction as a complication of adenosine deaminase deficiency. New England Journal of Medicine. 334:1367-1371.

Complete adenosine deaminase deficiency causes severe combined immunodeficiency that is inherited as an autosomal recessive trait. Adenosine deaminase knockout mice die perinatally of hepatocellular degeneration, however, hepatotoxicity attributed to adenosine deaminase deficiency has not been previously described in humans. In this case report, the authors describe a neonate with this deficiency and prolonged hyperbilirubinemia and hepatitis. The patient was heterozygous for two different point mutations in the adenosine deaminase gene each of which encoded a protein that lacked enzyme activity. The serum bilirubin concentration and aminotransferase activities were elevated soon after birth and liver biopsy showed early giant-cell transformation, enlarged foamy hepatocytes, portal and lobular eosinophilic infiltrates and bile stasis. Within days of treatment with polyethylene glycol-modified adenosine deaminase, serum bilirubin concentrations and aminotransferase activities decreased as serum adenosine deaminase activity increased. Serum bilirubin concentration became normal after 55 days of enzyme replacement therapy. This case report suggests that adenosine deaminase deficiency can directly cause hepatic disease in humans.