Alessandra Colantoni

Pathogenesis of hepatitis B and C‐induced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is estimated to have an annual worldwide incidence of 0.25 to 1.2 million new cases per year. Both the prevalence and incidence of HCC vary markedly as a function of geography and the local prevalence of chronic viral hepatitis. Both chronic hepatitis B and chronic hepatitis C are recognized as risk factors for HCC. The prevalence of cirrhosis in individuals with HCC and chronic hepatitis B or C is reported to be 80.9% and 75.8%, respectively. HCC occurs at a lower rate in chronic viral hepatitis in the absence of cirrhosis. Moreover, hepatitis C virus (HCV) rather than hepatitis B virus (HBV) is associated with the majority of non‐cirrhotic cases of HCC. It is probable that the ongoing process of hepatocyte necrosis and liver cell renewal coupled with inflammation, which is characteristic of chronic viral hepatitis, causes not only nodular regeneration and cirrhosis but also progressive genomic errors in hepatocytes as well as unregulated growth and repair mechanisms leading to hepatocyte dysplasia and, in some cases, hepatic carcinoma. Current concepts concerning virus‐induced HCC are reported and discussed in the following review.

The impact of previous HBV infection on the course of chronic hepatitis C

OBJECTIVE:Individuals with chronic hepatitis C who are anti-HBc positive may carry an occult hepatitis B virus (HBV) infection that can affect their response to antiviral therapy.METHODS:In this study the prevalence of anti-HBc and HBV–DNA positivity was assessed in the serum and liver of 285 HCV–RNA-positive subjects treated with interferon-α at 5 mU/day for 12 months. The response to interferon (normal ALT and undetectable serum HCV–RNA) was evaluated at three different endpoints: 1) after 6 months; 2) at the end of treatment; and 3) 6 months after interferon discontinuation.RESULTS:Ninety individuals were anti-HBc positive (32%), 2 of these were HBV–DNA positive in serum and 7 in liver (8%). None of the anti-HBc-negative individuals was HBV–DNA positive in serum or liver. The prevalence of cirrhosis was greater in the anti-HBc-positive group than in the anti-HBc-negative group (p < 0.05), whereas HCV–RNA levels were lower. Anti-HBc-positive individuals had a lower response rate to interferon at 6 months and at the end of treatment as compared to anti-HBc-negative subjects (respectively 42% vs 66%, p < 0.01; and 32% vs 57%, p < 0.01). No difference between the two groups in terms of sustained response was detected 6 months after interferon discontinuation.CONCLUSIONS:The prevalence of anti-HBc is high among HCV-positive individuals. HCV-positive individuals who are anti-HBc positive have: 1) a higher prevalence of cirrhosis; 2) lower HCV–RNA levels; and 3) an impaired ability to respond to interferon treatment.

High doses of alpha-interferon are required in chronic hepatitis due to coinfection with hepatitis B virus and hepatitis C virus: long term results of a prospective randomized trial.

OBJECTIVE:Coinfection with hepatitis B (HBV) and hepatitis C (HCV) viruses is associated with a more severe liver disease, increased frequency in the development of hepatocellular carcinoma, and resistance to interferon (IFN) therapy when performed with the standard dosages used in single infections. In the attempt to verify whether the outcome of IFN therapy in patients with hepatitis B and hepatitis C coinfection can be improved, we have planned a prospective, randomized trial with medium to high dosages of interferon three times a week for 6 months.METHODS:Thirty patients with HBV-HCV coinfection, and chronic hepatitis were randomized to receive either 6 or 9 MU α-interferon three times a week for 6 months. Patients were HBsAg positive, anti-HBe positive, HBV DNA negative by dot blot (6/30 positive by polymerase chain reaction), and anti-HCV-positive, HCV RNA positive. Pretreatment and posttreatment liver biopsies were performed.RESULTS:Five patients treated with 9 MU IFN consistently cleared HCV RNA and HBV DNA, whereas none of those treated with 6 MU reacted in a similar fashion (p = 0.045). Responders showed significant improvement of histological activity index in comparison with nonresponders (mean Ishak score pretreatment versus posttreatment p = 0.002). Long term follow-up showed that none of the patients treated with high doses developed cirrhosis whereas 4/14 treated with low doses did develop cirrhosis.CONCLUSION:Even though the percentage was not very high, the sustained response, the striking histological improvement, and the lack of development of cirrhosis achieved in these patients, indicate that with HBV-HCV coinfection, a trial with high doses of interferon is strongly recommended.

Hyperdynamic circulation of advanced cirrhosis: a re-appraisal based on posture-induced changes in hemodynamics

Little is known about the effect of posture on the circulatory abnormalities of advanced cirrhosis. We evaluated the systemic hemodynamics, measured by Doppler-echocardiography, atrial natriuretic factor, plasma renin activity and plasma norepinephrine, in 10 patients with cirrhosis and ascites and 10 healthy controls, after 2 h of standing and during lying down for a further 2 h. Standing hemodynamic patterns of controls and patients with cirrhosis did not differ significantly. The latter, however, showed higher plasma renin activity, norepinephrine and atrial natriuretic factor. The assumption of the supine position led to greater increases in cardiac index and atrial natriuretic factor, and reduction in systemic vascular resistance in patients with cirrhosis. Norepinephrine and plasma renin activity declined in both groups to a similar extent, while heart rate only slowed in controls. Thus, after 2 h in the supine position, patients with cirrhosis showed hyperdynamic circulation with increased cardiac index and heart rate and reduced systemic vascular resistance. Norepinephrine, plasma renin activity and atrial natriuretic factor were also elevated. The hyperdynamic circulation in advanced cirrhosis appears during or is enhanced by lying down. This finding suggests that this syndrome is, at least in part, attributable to excessive blood volume translocation towards the central area. However, the persistent activation of renin-angiotensin and sympathoadrenergic systems suggests that a concomitant reduced vascular sensitivity to vasoconstrictors concurs in its development.

Hepatic Apoptosis and Proliferation in Male and Female Rats Fed Alcohol: Role of Cytokines

BACKGROUND The female liver is more sensitive to the toxic effect of chronic alcohol intake than the male liver. The aim of the study was to compare the influence of gender and sex hormonal status on apoptosis and cell proliferation following chronic ethanol intake. METHODS Male and female rats were pair fed for 8 weeks a liquid diet containing 36% of their total daily calories as ethanol (ETOH group) or sucrose (control group). Liver samples were analyzed for apoptosis and hepatocyte proliferation by immunohistochemistry. The hepatic production of factors able to influence cell death and proliferation, such as tumor necrosis factor alpha (TNFalpha) and interleukin 6 (IL-6) were determined. RESULTS In both male and female rats, ethanol intake promoted apoptosis in the liver. This effect of ethanol was more evident in female than male rat livers. Hepatic TNFalpha levels, which promote apoptosis, are significantly more elevated in female than in male livers. Hepatic IL-6 production, which promotes hepatocyte proliferation, was induced by ethanol only in males, but not female animals. CONCLUSION This observed difference in cytokine responses may contribute to the enhanced sensitivity of female liver to EtOH-induced injury.

Cellular immunity after ethanol exposure and burn injury: Dose and time dependence

Acute ethanol exposure prior to burn injury increases the immune dysfunction seen with burn alone, which has been partially attributed to increased circulating and splenic macrophage production of interleukin-6 (IL-6). The current studies examined the effect dose and timing of ethanol exposure prior to burn on cellular immunity. Mice with high (300 mg/dl) circulating levels of ethanol at the time of burn demonstrated further suppression of the delayed type hypersensitivity (DTH) and splenocyte proliferative responses in comparison to mice with moderate (100 mg/dl) ethanol levels. Interestingly, the increase in macrophage IL-6 secretion seen at the moderate dose was not augmented at the high dose; however, the circulating IL-6 levels did reveal a further increase at the high ethanol dose. There were no alterations in splenocyte subset populations and/or apoptosis at the moderate vs. the high ethanol dose. Moderate ethanol exposure 24 h, in comparison to 30 min, before injury resulted in similar decreases in the DTH. These results suggest that the dose-dependent effects of ethanol on immunity following burn injury are not the result of splenic macrophage IL-6 production as shown at the moderate dose and that the immune suppressive effects of ethanol in this model persist after it is cleared from the circulation.

Plasma endothelin-1 and -3 in cirrhosis: relationship with systemic hemodynamics, renal function and neurohumoral systems

BACKGROUND/AIMS The postural change from upright to supine is a physiological maneuvre which increases central blood volume. This model was used to investigate the effects of changes in effective volemia on plasma endothelin-1 and -3 concentrations in cirrhosis. METHODS Plasma endothelin concentrations, measured by radio-immunoassay, were determined in 20 patients with cirrhosis, 10 of whom has ascites, and nine healthy control subjects, in the upright posture and 30, 60 and 120 min after the assumption of the supine position. RESULTS In the upright posture, endothelin-1 was 8.9 +/- 0.4 pg/ml and endothelin-3 3.7 +/- 0.6 (mean +/- SEM) pg/ml in control subjects. Endothelin-1 was increased only in patients with ascites (12.7 +/- 1.4 pg/ml, p < 0.05; patients without ascites: 9.7 +/- 0.7 pg/ml), while endothelin-3 was elevated in both patients with and without ascites (8.0 +/- 1.5 pg/ml, p < 0.01; 5.9 +/- 0.5 pg/ml, p = 0.01, respectively). In the supine position, no significant changes in endothelin-1 or -3 occurred either in patients with ascites or in controls throughout the observation period, while a reduction in endothelin-3 was found in compensated patients after 30 and 60 min. In patients, we found negative correlations between endothelin-3, but not endothelin-1, and mean arterial pressure, both in upright (r = -0.59; p < 0.01) and supine (r = -0.56; p = 0.01) positions, atrial natriuretic factor (r = 0.50; p < 0.05) and plasma renin activity (r = 0.67; p = 0.001) in the supine position alone. In patients with ascites, endothelin-1 was inversely correlated with both glomerular filtration rate (upright: r = -0.62; p = 0.06; supine: r = -0.71, p < 0.05) and renal sodium excretion (upright: r = -0.82; p < 0.01; supine: r = -0.88; p < 0.001). CONCLUSIONS Plasma endothelin-1 and -3 were increased in cirrhosis with ascites, while, in pre-ascitic cirrhosis, only endothelin-3 was increased in the upright posture. Although increased endothelin-3 was associated with features suggesting a reduced effective volemia, it is likely that other mechanisms than hypovolemia were mainly responsible for high plasma endothelin levels. Increased endothelin production may play a role in circulatory and renal function abnormalities of advanced cirrhosis.

Estrogen Receptor Classification for Hepatocellular Carcinoma: Comparison With Clinical Staging Systems

PURPOSE Several scoring systems to evaluate patients with hepatocellular carcinoma (HCC) exist. A good scoring system should provide information on prognosis and guide therapeutic decisions. The presence of variant liver estrogen receptor (ER) transcripts in the tumor has been shown to be the strongest negative predictor of survival in HCC. The aim of this study was to compare the predictive value of the commonly applied clinical scoring systems for survival of patients with HCC with that of the evaluation of ER in patients with HCC (molecular scoring system). MATERIALS AND METHODS HCC was staged according to the Okuda classification, Barcelona Clinic Liver Cancer classification, Italian classification system (CLIP), French classification, and ER status in 96 patients. Analysis of survival was performed according to the Kaplan-Maier test and was made for each classification system and ER. A comparison between classifications was made by univariate and multivariate analysis. RESULTS Among the clinical classification systems, only the CLIP was able to identify patient populations with good, intermediate, and poor prognosis. On multivariate analysis, ER classification was shown to be the best predictive classification for survival of patients with HCC (P <.0001). This difference was the result of a better allocation of patients with ominous prognosis (variant ER) having nevertheless good clinical score. CONCLUSION The evaluation of the presence of wild-type or variant ER transcripts in the tumor is the best predictor of survival in patients with HCC. Its accuracy in discriminating patients with good or unfavorable prognosis is significantly greater than that of the commonly used scoring systems for the staging of HCC.

Ethanol exacerbates T cell dysfunction after thermal injury

To understand the mechanism of suppressed immunity following alcohol consumption and thermal injury, we analyzed T cell functions in a mouse model of acute alcohol exposure and burn injury. Mice with blood alcohol levels at approximately 100 mg/dl were given a 15% scald or sham injury. Mice were sacrificed 48 h after injury. Our data demonstrated a 20-25% decrease in Con A-mediated splenic T cell proliferation (p<0.01) and 45-50% decrease in interleukin-2 (IL-2) production (p<0.01) following burn injury compared to the T cells from sham animals. A further decrease in the proliferation (25-30%) and IL-2 production (40-45%) was detected in T cells derived from burned animals receiving alcohol as compared to burn alone. No significant change in the proliferation and IL-2 production was observed in splenic T cells derived from sham-injured mice regardless of alcohol exposure. Additionally, there was no demonstrable difference in splenocyte apoptosis in any treatment group. These results suggest that alcohol consumption prior to burn injury causes a greater decrease in T cell proliferation and IL-2 production compared to either burn or alcohol injury alone that may further attenuate the cell-mediated immunity and thus enhance susceptibility to infection.

Can hepatitis B core antibody positive livers be used safely for transplantation: hepatitis B virus detection in the liver of individuals who are hepatitis B core antibody positive.

A major impediment to the wider application of clinical liver transplantation is the paucity of acceptable organs. Most centers refuse organs that come from donors who are hepatitis B core antibody positive because of a fear of transmission of hepatitis B virus (HBV) infection to the recipient. The risk related to the use of such donor organs has never been assessed in an ordered manner. The presence or absence of polymerase chain reaction detectable HBV-DNA in liver tissue of individuals undergoing liver biopsy for clinical reasons was assessed in 133 consecutive patients. A total of 8.2% of these livers resulted positive for HBV-DNA; interestingly the rate was higher among those who were hepatitis B surface antibody positive (12.5%) as compared to those without detectable hepatitis B surface antibody (5.7%). These data provide measures of putative risk for HBV infection in liver transplant recipients associated with the use of organs obtained from a hepatitis B core antibody positive donor.