E. Anthony Jones

Treatment of chronic non-A, non-B hepatitis with recombinant human alpha interferon

We treated 10 patients who had chronic non-A,non-B hepatitis with recombinant human alpha interferon in varying doses (0.5 to 5 million units) daily, every other day, or three times weekly for up to 12 months. In 8 of the 10 patients, elevated serum aminotransferase levels decreased rapidly during therapy and eventually fell into the normal or nearly normal range. In two of these patients, the interferon therapy was stopped after four months, and in both cases, a prompt return of aminotransferase activities to pretreatment values occurred. Prolonged treatment was associated with a sustained improvement in aminotransferase levels; in three cases, biopsy specimens obtained after one year of therapy showed marked improvement in hepatic histology, even though low doses of alpha interferon had been used. These preliminary findings, although not adequately controlled, suggest that long-term, low-dose alpha interferon therapy may be effective in controlling the disease activity in some patients with chronic non-A,non-B hepatitis. A prospective controlled trial is now needed to assess the role of interferon therapy in this disease.

Randomized, controlled trial of recombinant human α-interferon in patients with chronic hepatitis B

Forty-five patients with chronic hepatitis B were entered into a randomized controlled trial of recombinant human alpha-interferon therapy. All patients had hepatitis B surface antigen in serum for at least 1 yr and had stable serum levels of both hepatitis B virus deoxyribonucleic acid and hepatitis B e antigen. During the 4-mo period of therapy, 10 of 31 (32%) treated patients and only 1 of 14 (7%) control patients became negative for serum hepatitis B virus deoxyribonucleic acid and deoxyribonucleic acid polymerase. All 10 patients who became negative for serum hepatitis B virus deoxyribonucleic acid subsequently had a marked improvement in serum aminotransferase activities and lost hepatitis B e antigen from serum, and 9 of them had improvement in liver histology. Comparison of responders to nonresponders indicated that female sex and a high initial level of serum aspartate aminotransferase correlated best with response to interferon therapy. These findings indicate that a 4-mo course of recombinant alpha-interferon can induce a remission in disease in approximately one-third of patients with chronic hepatitis B.

HEPATIC ENCEPHALOPATHY AND THE γ-AMINOBUTYRIC-ACID NEUROTRANSMITTER SYSTEM

Abstract γ-Aminobutyric acid (GABA), the principal inhibitory neurotransmitter of the mammalian brain, is synthesised by gut bacteria. In a rabbit model the development of hepatic encephalopathy was associated with increased levels of GABA in plasma, increased permeability of the blood-brain barrier, increased numbers of binding-sites for GABA and benzodiazepines in the brain, and a pattern of neural activity similar to that induced by drugs which activate the GABA neurotransmitter system. It is postulated that in liver failure gut-derived GABA passes through a permeable blood-brain barrier and induces its own receptors in the brain, that gut-derived GABA contributes to the neural inhibition of hepatic encephalopathy, and that an increased number of drugbinding sites mediates enhanced sensitivity to barbiturates and benzodiazepines in liver failure.

A controlled trial of naloxone infusions for the pruritus of chronic cholestasis.

To test the hypothesis that opioid agonist activity contributes to the pruritus of cholestasis, a placebo-controlled single-blinded trial of naloxone, an opioid antagonist, was conducted in eight patients with primary biliary cirrhosis. After discontinuation of all conventional antipruritic medications, one or two continuous (24-hour) IV infusions of naloxone (0.2 micrograms.kg-1.min-1) and placebo solution were administered consecutively in an order that was not predetermined. Pruritus was assessed subjectively by means of four hourly recordings of a visual analogue score. In addition, objective measurements of scratching activity that were independent of gross body movements were continuously recorded using an apparatus specifically designed to measure the frequencies associated with this activity. No side effects associated with naloxone infusions were observed. Only scratching activity data obtained for the same periods of day and night during both naloxone and placebo infusions were compared. Naloxone infusions were consistently associated with a decrease in values of the scratching activity index. In addition, in 50% of the patients the infusions were associated with a decrease in visual analogue score. The mean decrease in scratching activity ranged from 29% to 96% (mean, 50%; P less than 0.001). These findings imply that increased opioid agonist activity contributes to scratching activity in cholestatic patients.

The mechanism of intestinal uptake and transcellular transport of IgG in the neonatal rat

Abstract The transport of immunoglobulins across the intestinal mucosa of neonatal rats provides an excellent model for the study of transcellular protein transport. The mechanism of intestinal uptake and transcellular transport of plasma proteins has been studied in 12-14-day old rats using intraduodenally administered radioiodinated proteins. Appreciable quantities of rat IgG, mouse IgG, rabbit IgG, and all four subclasses of human IgG were taken up by the intestinal wall (19-54% of administered dose at 4 hr) and transported to the animal (10-35% of administered dose at 4 hr). In contrast there was little or no uptake of human IgM, IgA, and IgE and little or no transport of human IgM, IgA, IgD, IgE, albumin, transferrin, and ceruloplasmin. Both the uptake and transport of labeled IgG were significantly inhibited by unlabeled IgG. Further insight into the transport process was obtained from the observation that an appreciable proportion of the label of IgG in intestinal wall homogenates, but not in plasma or intestinal washings, migrated in a sucrose ultracentrifugation gradient much more rapidly than did the administered 7S molecules. This pattern was not observed with other proteins studied. This apparent binding of labeled IgG was also markedly inhibited by unlabeled IgG. In subcellular fractionation studies of intestinal homogenates the complexed labeled IgG was shown to be associated predominantly with cell membrane rather than cell sap fractions. In addition IgG could be shown to bind to purified enterocyte microvillous membranes in vitro. It is concluded that in the neonatal rat: (a) the major processes involved in both intestinal uptake and transport of IgG are specific and saturable; (b) intestinal transport is associated with complexing of IgG molecules with membranes, most probably with enterocyte microvillous membranes; and (c) the part of the IgG structure involved in this process is probably similar to that involved in the concentration-catabolism effect but is not identical to that mediating other non-antigen combining functions of IgG. Our data are consistent with the existence of specific receptors for IgG on enterocyte microvillous membranes of the neonatal rat. Such receptors would be necessary for the specific uptake and transport of these molecules.

Primary Biliary Cirrhosis: A Model Autoimmune Disease

: Primary biliary cirrhosis is characterized by chronic inflammation and necrosis of the intrahepatic bile ducts and by chronic cholestasis. The presence of autoantibodies in serum, the association of this disease with other autoimmune diseases, the histologic appearance of typical hepatic lesions, the presence of bile duct lesions that resemble those seen in chronic graft-versus-host disease, and the possible recurrence of a chronic cholestatic syndrome in patients having hepatic transplants indicate that immune mechanisms play a role in the syndromes pathogenesis. Patients have diminished function of suppressor T cells that may be due to abnormal activation of suppressor T cells caused by interactions with autologous non-T cells. This nonspecific immunologic defect and other immune defects may cause the autoimmune manifestations of primary biliary cirrhosis. Treatments to arrest the diseases progress have included corticosteroids, azathioprine, cyclosporin, and D-penicillamine. These treatments, which affect immune functions, have not had a beneficial effect on the disease process. Better understanding of the pathogenesis of primary biliary cirrhosis is needed to develop specific immunotherapies.

Endogenous opioids accumulate in plasma in a rat model of acute cholestasis

To obtain data on the degree to which the opioid system is changed in cholestasis, endogenous opioid activity in plasma of rats with acute cholestasis was determined 5 days after bile duct resection. Total plasma opioid activity was determined using a radioreceptor technique that measured the displacement of the opiate receptor ligand [3H]-DAMGO from lysed synaptosomal fractions of normal rat brain. Plasma total opioid activity was threefold greater in bile duct-resected rats than in sham-operated and unoperated controls (P less than or equal to 0.05). Plasma levels of the individual endogenous opioid, methionine-enkephalin, were determined using a sensitive radioimmunoassay, and the specificity of the assay was confirmed using high-performance liquid chromatography. In cholestatic rats, plasma methionine-enkephalin levels were more than six-fold greater than in sham-operated controls (P less than or equal to 0.001) and more than 17-fold greater than in unoperated controls (P less than or equal to 0.001). However, plasma methionine-enkephalin levels accounted for less than 5% of total plasma opioid activity after bile duct resection. Plasma methionine-enkephalin levels in both cholestatic plasma and plasma from sham-operated animals were stable when incubated in vitro despite the presence of undiminished activity of the major enkephalin-degrading enzymes. Thus, protection of methionine-enkephalin from degradation may be a factor contributing to the elevated plasma levels of methionine-enkephalin found in cholestasis. The magnitude of the increase in plasma endogenous opioid activity in bile duct-resected rats provides support for the hypothesis that endogenous opioids contribute to the pathophysiology of cholestasis.

Lipoprotein abnormalities in primary biliary cirrhosis: Association with hepatic lipase inhibition as well as altered cholesterol esterification

The nature and etiology of plasma lipoprotein abnormalities in patients with varying stages of primary biliary cirrhosis (PBC) were assessed. Two distinct lipoprotein patterns were observed. In patients with early and intermediate histologic stages of PBC, mild elevations of very low density lipoproteins and low density lipoproteins (LDLs), and marked increases in high density lipoproteins (HDLs) were often noted (group 1). In contrast, patients with advanced disease had marked elevations in LDLs with the presence of lipoprotein-X, and a significant decrease in HDLs (group 2). The lipoprotein pattern in group 1 was characterized by a normal ratio of free cholesterol to total cholesterol, whereas in group 2, this ratio was elevated. In plasma from group 1 patients only spherical micelles were observed on electron microscopy, whereas in plasma from group 2 patients bilayered disks could be seen in LDLs and HDLs. The increase in HDLs observed in group 1 subjects was associated with elevations in HDL2, whereas in group 2 subjects only very low amounts of HDL3 were observed on analytic ultracentrifugation. Mean plasma apolipoprotein B and C-II concentrations were increased in both groups; but apolipoprotein A-I and AII values were divergent, with group 1 subjects having elevated values,and group 2 subjects having decreases values. Mean postheparin hepatic lipase activity was decreased in both groups of patients with PBC due to the presence of an inhibitor in PBC plasma, while altered cholesterol esterification was only observed in group 2. These data indicate that hepatic lipase inhibition may play an important role in the pathogenesis of the lipoprotein abnormalities seen in early and intermediate PBC, and these abnormalities are then further modified by altered cholesterol esterification in advanced disease.

Randomized trial of chlorambucil for primary biliary cirrhosis

Twenty-four patients with primary biliary cirrhosis were entered into a prospective, randomized trial of chlorambucil therapy. Thirteen patients received chlorambucil (0.5-4 mg/day) and 11 patients received no therapy; all have been followed for 2-6 yr (mean, 4.1 yr). Two control but no treated patients died. Average serum bilirubin, serum aspartate aminotransferase activities, and albumin levels improved or remained unchanged in treated patients but worsened in controls. Serum alkaline phosphatase levels did not change in either group. Immunoglobulin M levels decreased and became normal in all treated patients but in only 3 control patients. Liver biopsy histology revealed an improvement in inflammatory cell infiltrate in treated patients in comparison with controls, but no significant change in degree of fibrosis or the histologic stage of disease. Side effects of therapy included bone marrow suppression necessitating discontinuation of the drug in 4 patients. These findings indicate that chlorambucil therapy may retard the progression of primary biliary cirrhosis. Whether such therapy will ultimately decrease morbidity and improve survival in this disease can only be demonstrated by large-scale, placebo-controlled trials.

Amelioration of hepatic encephalopathy by pharmacologic antagonism of the GABAA-benzodiazepine receptor complex in a rabbit model of fulminant hepatic failure

Three separate, but allosterically interacting, sites on the gamma-aminobutyric acid (GABA) supramolecular complex in the brain were pharmacologically blocked in rabbits with hepatic encephalopathy due to galactosamine-induced fulminant hepatic failure to determine whether decreased GABAergic neurotransmission can ameliorate the syndrome of hepatic encephalopathy. Bicuculline (a GABAA receptor blocker), Ro 15-1788 (a benzodiazepine receptor antagonist), or isopropylbicyclophosphate (a chloride channel blocker) consistently induced a transient but unequivocal decrease in the clinical severity of the encephalopathy and also corrected the abnormal pattern of the visual evoked response associated with hepatic encephalopathy. Rabbits with hepatic encephalopathy exhibited increased resistance to the convulsive effects of bicuculline. In encephalopathies induced in rabbits by gamma-vinyl-GABA (an inhibitor of GABA catabolism) or diazepam (a benzodiazepine receptor agonist), abnormalities of the visual evoked response similar to those found in hepatic encephalopathy occurred and were corrected by bicuculline and Ro 15-1788, respectively. These findings suggest that in hepatic encephalopathy due to fulminant hepatic failure (a) there is increased GABAergic tone, (b) an amelioration of encephalopathy can be induced by blockade of GABA or benzodiazepine receptors, (c) benzodiazepine receptor antagonists may be of clinical value in the management of hepatic encephalopathy, and (d) an endogenous substance with GABA potentiating properties may be present in hepatic encephalopathy.