Akihiko Okumura

Serum levels of IL-10, IL-15 and soluble tumour necrosis factor-alpha (TNF-α) receptors in type C chronic liver disease

We previously reported that the number of TNF‐α‐producing cells was increased in the liver of patients with type C chronic liver disease. To understand further the pathophysiology of this change, we examined serum levels of two soluble TNF receptors, TNF‐αRI (p55) and ‐αRII (p75), and IL‐10, all of which act as TNF‐α buffer, and IL‐15, a novel cytokine sharing many immunological activities with IL‐2, using ELISA methods. We studied control individuals and patients with type C chronic liver disease, including asymptomatic hepatitis C virus (HCV) carriers with persistently normal serum ALT values, and those with chronic hepatitis (CH), liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Both types of sTNF‐αR closely correlated with disease progression. Patients with LC and HCC had significantly elevated levels for sTNF‐αRII compared with the other patient groups and controls. Serum IL‐10 levels were significantly greater in all chronic liver disease groups than in controls. With respect to IL‐15, the values were high in CH, LC and HCC compared with those of controls. Notably, HCC patients showed highest values for both IL‐10 and IL‐15, with significant differences from the other patient groups. Serial determinations revealed that interferon (IFN) treatment for CH patients resulted in the suppression of circulating IL‐10 and IL‐15 levels along with decrease in serum aminotransferase values. Both cytokines remained at decreased levels after cessation of therapy in patients who went into clinical and virological remission. On the other hand, treatment did not affect serum levels of sTNF‐αRs. These findings indicate that serum levels of these molecules correlated with disease progress in chronic HCV infection, and that IL‐10 and IL‐15 may reflect the degree of inflammation in the liver. It is also suggested that both cytokines may be related to the development of HCC.

Mechanisms of increased insulin resistance in non-cirrhotic patients with chronic hepatitis C virus infection

Background and Aim:  Evidence showing a higher prevalence of diabetes mellitus (DM) in patients with chronic hepatitis C virus (HCV) infection has been accumulating. However, the reason why chronic HCV infection promotes DM remains unknown. In the present study, the authors focused on non‐cirrhotic and non‐diabetic patients with chronic HCV infection and evaluated the factors responsible for increases in insulin resistance.

Expression of Toll-like receptors in chronic hepatitis C virus infection

Background:  Toll‐like receptors (TLRs) are involved in innate immunity. Certain viruses interact with TLRs and mediate antiviral effects as well as immune responses. The aim of this study was to investigate the effect of TLRs on pathogenesis in hepatitis C virus (HCV)‐infected patients.

Reduction of liver stiffness by interferon treatment in the patients with chronic hepatitis C

Aim:  To assess the regression of liver fibrosis after interferon (IFN) treatment in patients with chronic hepatitis C, liver stiffness (LS) was measured repeatedly and the factors associated with reduction of LS were assessed.

Earlier loss of hepatitis C virus RNA in interferon therapy can predict a long‐term response in chronic hepatitis C

To distinguish responders from non‐responders early in interferon (IFN) treatment would be beneficial in patients with chronic hepatitis C. Those patients unlikely to respond would be spared the cost and hazard of prolonged treatment. Forty‐three chronic hepatitis C patients who had received IFN‐α therapy (6–9 MU; six times weekly for 2 weeks followed by thrice weekly for 22 additional weeks) were randomly enrolled into the present study. Serially obtained sera were retrospectively tested for HCV‐RNA by reverse transcription‐polymerase chain reaction (AmplicorTM HCV) with a low limit detection of approximately 102 copies/mL. Genotypes were determined by type‐specific primers. Sixteen subjects were defined as sustained responders (SR), who showed sustained loss of viraemia with normalized alanine aminotransferase values for at least 6 months of follow‐up after completion of therapy. The other 27 subjects were non‐responders (NR), whose viraemia persisted during follow‐up. Pretreatment serum HCV‐RNA levels (P< 0.0001) and the genotype (P<0.01) were significant predictors for sustained response to IFN therapy. Hepatitis C virus RNA was detectable in only one (6%) SR and in 23 (85%) NR at the second week of therapy (P< 0.0001) and was detected in none of the SR subjects and in 18 (67%) NR at the fourth week of therapy (P< 0.0001). Pretreatment viral load was correlated with the time until loss of viraemia. Multivariate analysis revealed that loss of viraemia at the second week of therapy was the strongest predictor for a long‐term response, followed by the initial viral load and loss of viraemia at the fourth week of therapy. These findings suggest that it is possible to predict a long‐term response to IFN as early as at the second and fourth weeks after the start of therapy by identifying the presence or absence of HCV‐RNA with a sensitive assay.

Cyclosporine therapy affects aminotransferase activity but not hepatitis C virus RNA levels in chronic hepatitis C

Interferon (IFN) therapy is of proven efficacy in chronic hepatitis C, but it is not universally effective and is often limited by side effects. Cyclosporine A (CsA) is a potent immunosuppressant widely used in organ transplantation. We conducted a pilot study to determine whether CsA therapy could affect aminotransferase activity and hepatitis C virus RNA levels in patients with chronic hepatitis C. Cyclosporine A was administered to 10 patients (mean age of 59 years; male: female = 9:1) who did not respond to IFN therapy previously and who had elevated serum alanine aminotransferase (ALT) values for at least 6 months. All patients were positive for HCV‐RNA by RT‐PCR with genotype 1b. Their mean duration of hepatitis was 15 years. Oral CsA was given for 3 months in a dose that was increased at 1 month intervals from 1.5–2.0 to 2.0–3.0 and 3.0–4.0 mg/kg per day. All patients completed the treatment schedule, although two patients developed mild non‐symptomatic hypertension. Serum ALT levels gradually decreased in all but one patient. The mean percentage decrease was 59.5% at the end of therapy (from 153 ± 82 to 62 ± 48 IU/L; P < 0.02). The ALT levels fell to the normal range in five patients, although once therapy was discontinued the enzyme levels tended to return to pretreatment levels. Serum aspartate aminotransferase and g‐glutamyl transpeptidase levels similarly decreased. The serum HCV‐RNA titre, determined by competitive RT‐PCR, did not change in any patient throughout the study period. There were no appreciable alterations in other laboratory tests, such as serum creatinine levels and lymphocyte subsets, except for an increase in serum alkaline phosphatase levels. These findings suggest that CsA, even in a relatively low dose, reduces serum aminotransferase levels without serious side effects in patients with chronic‐hepatitis C, although an antiviral effect was not noted.

Liver stiffness in extrahepatic cholestasis correlates positively with bilirubin and negatively with alanine aminotransferase

Aim:  Transient elastography is a non‐invasive tool to measure liver stiffness (LS), which has been reported to correlate with stage of liver fibrosis. Extrahepatic cholestasis was reported to cause elevated LS, which is considered to be attributed to the increased hydrostatic pressure in the liver. In the present study, the correlation of LS with laboratory data was investigated in extrahepatic cholestasis. The change of LS after biliary drainage was also assessed.

Serial analysis of hepatitis B virus core nucleotide sequence of patients with acute exacerbation during chronic infection

Recent studies suggest that hepatitis B virus (HBV) core region could be an immunological target and that amino acid (aa) substitutions are mostly restricted to a small segment located in the middle of the core region. We sequenced the middle portion of HBV core gene during the course of acute exacerbation of chronic hepatitis B, and compared aa variations between the region including ideal HLA‐A2 binding motifs and the nonbinding region. Five HBeAg+ chronic hepatitis patients with subtype adr (three with HLA‐A2 and two without HLA‐A2) were selected and using polymerase chain reaction (PCR) and cloning system, the central part of core region (nt 2063 to 2365, 303 bp) was sequenced in sera from each patient at three time points; before, at the peak of, and after exacerbation of hepatitis. The second set of sera showed higher aa substitution rates in five and in three out of five patients compared with those of the first and third sera, respectively. No significant difference was found in the aa substitution rates for the region with ideal HLA‐A2 binding motifs between patients with and without HLA‐A2. In asymptomatic HBV carriers with persistently normal aminotransferase values, alterations of the aa sequence were not observed within the same time frame. The results suggest that aa substitutions often occur at some particular positions in the middle of HBV core region during acute exacerbation of the disease under possible host immune pressures. Furthermore, unidentified epitopes appear to exist in the central part of HBV core region and HLA‐unrestricted lymphocytes may play a role in the immune response of chronic HBV carriers.

Deficiency of forkhead box P3 and cytotoxic T-lymphocyte-associated antigen-4 gene expressions and impaired suppressor function of CD4(+)CD25(+) T cells in patients with autoimmune hepatitis.

Aim:  Recently, forkhead box P3 (Foxp3), cytotoxic T‐lymphocyte‐associated antigen‐4 (CTLA‐4), glucocorticoid‐induced tumor necrosis factor receptor family‐related gene (GITR), and CD28 were identified as the key molecules that control the development and activation of CD4+CD25+ regulatory T cells (T‐reg). We investigated the expression pattern of these molecules on T‐reg, and investigated the ability of T‐reg to produce cytokines in patients with autoimmune hepatitis (AIH).

Use of the Model for End-Stage Liver Disease (MELD) score to predict 1-year survival of Japanese patients with cirrhosis and to determine who will benefit from living donor liver transplantation

BackgroundConsideration of the prognosis of patients with liver cirrhosis is important when determining the appropriate timing of liver transplantation. Especially in Japan, where 99% of liver transplants are from living donors, timing is very important not only for the patient but also for the family, who need time to consider the various factors involved in living donations.MethodsTo clarify the applicability of the Model for End-Stage Liver Disease (MELD) score in Japanese patients with cirrhosis, changes in the MELD score over 24 months were reviewed in 79 patients with cirrhosis who subsequently died of liver failure (n = 33) or who survived 24 months (n = 46). All patients had Child class B or C cirrhosis at the start of follow-up. We also compared their survival with that of 30 patients treated by living donor liver transplantation (LDLT) in our institute to determine the proper timing of transplantation in patients with cirrhosis.ResultsSignificant stratification of survival curves was observed for MELD scores of <12, 12–15, 15–18, and >18 (P = 0.0018). A significant survival benefit of LDLT was observed in patients with MELD score ≥15 (P = 0.0181), and significantly more risk with transplantation was observed in those with MELD score <15 compared with that of patients in whom the disease followed its natural course (P = 0.0168).ConclusionsMELD score is useful for predicting 1-year survival in Japanese patients with cirrhosis. MELD scores of 15 had discriminatory value for indicating a survival benefit to be gained by liver transplantation and thus can be used to help patients and their families by identifying patients who would benefit from LDLT.