Hans H. Brackmann

Bleeding Complications after Percutaneous Liver Biopsy

Background and Aims: To assess the risk of bleeding after percutaneous liver biopsy, we retrospectively analyzed 629 procedures with particular respect to patients with an increased a priori bleeding risk. Methods: Factors possibly related to the risk of bleeding were analyzed by univariate analysis. Those variables which were significant in the univariate analysis were then entered into a forward conditional logistic regression model. Results: Biopsy-related bleeding events defined as clinically overt complication (n = 10; 1.6%), an otherwise unexplained drop in serum hemogloblin concentration of greater than 2 g/dl (n = 45; 7.1%) or intra- or extrahepatic hematoma assessed by ultrasound (n = 17; 2.7%) were identified in 72 patients. 58% of the bleeding events occurred in patients with particular risk factors for bleeding. Biopsy-related mortality in the study cohort was 0.48%. Logistic regression analysis indicated mycobacterial infection [odds ratio (OR) 24.0], pre-biopsy prophylactic platelet substitution (OR 9.9), acute liver failure (OR 9.1), heparin administration on the day of biopsy (OR 8.7), advanced liver cirrhosis (OR 5.1), therapy with corticosteroids (OR 3.5) or metamizole (OR 2.8) and leukemia or lymphoma (OR 2.8) as significant (p ≤ 0.05) independent risk factors. Delayed bleeding (>24 h after biopsy) was identified in 70% of the bleeding events. Conclusions: In our study cohort which comprised a high proportion of patients with particular risk factors for bleeding, biopsy-related bleeding occurred more frequently and later than commonly observed and was associated with only a few prognostic factors. Considering these predictors before liver biopsy will aid to reduce the rate of bleeding complications.

Liver histopathology in patients with concurrent chronic hepatitis C and HIV infection.

To investigate the influence of human immunodeficiency virus (HIV) coinfection on preexisting long-term chronic C hepatitis (HCV) 68 liver biopsies from 22 HIV/HCV-coinfected, 13 HIV and 33 HCV-monoinfected patients and 71 livers obtained at autopsy from 26 HIV/HCV-coinfected and 45 HIV-monoinfected patients were studied by histo- and immunohistochemistry. All HIV patients had reached the advanced stage of immunodeficiency (stage III CDC), except for 3 haemophiliacs (stage II CDC). HCV infection was associated with a higher degree of portal, periportal and lobular inflammation — regardless of whether there was concurrent HIV infection. HIV/HCV coinfection was associated with a significantly higher rate of granulocytic cholangiolitis than HCV and HIV monoinfection (P < 0.05), a histological feature uncommon in C hepatitis. In HIV/HCV coinfection cholestasis was a predominant histological feature. HCV monoinfection and HCV/HIV coinfection were associated with the highest fibrosis index. In HIV/HCV coinfection centrilobular fibrosis was significantly more marked than in HCV monoinfection (P < 0.05), suggesting an HIV associated fibrogenic effect. Patients with chronic C hepatitis showed a significantly increased rate of posthepatitic cirrhosis compared with the patients without HCV infection (P < 0.05). At autopsy, 10 of the 20 HIV/HCV-coinfected haemophiliacs had developed cirrhosis because of chronic C hepatitis, whereas cirrhosis was found in only 2 of 6 HIV/HCV-coinfected non-haemophiliacs (1 case of chronic B and C hepatitis, and 1 case of chronic alcohol abuse). No cirrhosis was observed in the 45 autopsy patients with HIV monoinfection. The findings suggest that HIV coinfection aggravates the course of preceding long-term chronic C hepatitis by a more marked (centrilobular) fibrosis. HIV/HCV-coinfected patients are threatened by a higher rate of posthepatitic cirrhosis —particularly in multitransfused haemophiliacs — and cholestatic hepatopathy.

Antigen-specific cytokine response to hepatitis C virus core epitopes in Hiv/hepatitis C virus-coinfected patients

OBJECTIVE Epidemiological data indicate that hepatitis C virus (HCV) infection runs a more rapid and severe course of disease in HIV-coinfected patients, probably because of an altered immune response. DESIGN We investigated whether HCV-specific cytokine responses are affected by HIV coinfection. METHODS Using triple colour flow cytometry on peripheral blood lymphocytes after stimulation with the four major immunodominant HCV core T cell epitopes, CT1-CT4, we determined intracytoplasmic production of IFN-gamma, IL-2, IL-4, IL-10 and CD30 expression, a putative surrogate marker of type 2 cells. Fifteen patients with asymptomatic HIV/HCV coinfection (group A), 15 patients with chronic HCV infection (group B) and 10 HIV-infected patients without hepatitis C (group C) were included in the study. RESULTS In group A, HCV antigens induced significantly higher IL-2 and IFN-gamma production than groups B and C (P < 0.05). Groups A and B showed a similar induction of CD30, which was significantly higher than in group C (P < 0.001). Remarkably, in group A HCV antigens induced IL-4 production in addition to IL-10 and IFN-gamma in the CD30 subset, whereas in groups B and C no IL-4 induction was observed in this T cell subset (P < 0.002). CONCLUSION Our data suggest that asymptomatic HIV coinfection importantly alters the HCV-specific cytokine response towards a greater production of proinflammatory type 1 cytokines. Moreover, the antiviral activity of type 1 cytokines may be modified by an increased production of type 2 cytokines in the CD30 subset. The altered cytokine pattern may contribute to the adverse natural course of hepatitis C in HIV coinfection.

Factor VIII gene mutations found by a comparative study of SSCP, DGGE and CMC and their analysis on a molecular model of factor VIII protein

Abstract Screening of the factor VIII (FVIII) gene which spans 186 kb and codes for 26 exons, was originally hampered by its size but is now feasible because rapid DNA scanning methodologies have been developed. The present study for the first time directly compares the three most widely applied screening methods, denaturing gradient gel electrophoresis (DGGE), single-stranded conformational polymorphism (SSCP) and chemical mismatch cleavage (CMC) for their sensitivity of mutation detection in a selected group of ten haemophilia A patients. Nine of these patients are known to be cross-reacting material positive and eight exhibited a mild to moderate phenotype. Of the ten patients screened, we identified mutations in nine by all three screening methods. Of the mutations characterised, two are previously unpublished. T to C (S373P) and G to A (D525N). In one mildly affected haemophiliac, we identified a second T to C sequence change in the 5′ untranslated region at –601 bp, probably having no effect on FVIII gene expression. Modelling studies were performed on those mutations lying within the A domains of FVIII (D525N, R527W, I566T) to study the possible effect of these mutations on structure and/or function. When the three methods are performing optimally and have been standardised, our experience is that CMC and DGGE are equally efficient at sequence variation detection while SSCP is slightly less sensitive.

Effects of the CCR5-Δ32 mutation on antiviral treatment in chronic hepatitis C

Abstract Background/Aims : The CC-chemokine receptor (CCR) 5-Δ32 mutation may predispose to chronic liver disease and high level viremia in hepatitis C. However, it is unclear whether CCR5-Δ32 also affects the response to antiviral treatment. Methods : We determined CCR5 genotypes in patients with hepatitis C treated with either interferon-α ( N =78) or interferon and ribavirin ( N =78). In each group, rates of end of treatment responses (ETRs) and sustained virological responses (SVRs) were compared between CCR5-Δ32 carriers and homozygous CCR5 wildtype patients. Results : ETR and SVR were achieved in 25 and 12 patients with interferon-α and in 52 and 45 patients with interferon/ribavirin treatment, respectively. CCR5-Δ32 carriers had significantly lower ETR rates than homozygous CCR5 wildtype patients (10.5 vs. 39.0%; P =0.02), whereas SVR rates only showed a non-significant trend (5.3 vs. 18.6%). Multivariate analysis confirmed CCR5-Δ32 carriage as an independent negative predictor for ETR in interferon-α monotherapy (odds ratio: 0.16; 95% confidence limits: 0.032–0.82; P =0.03). In interferon/ribavirin treated patients CCR-Δ32 carriers and CCR5 wildtype patients had similar ETR rates [19.2% vs. 23.1%] and SVR rates [20.0% vs. 21.2%]. Conclusions : Response rates to interferon-α monotherapy are reduced in hepatitis C virus (HCV)-infected patients carrying the CCR5-Δ32 mutation. However, interferon/ribavirin combination treatment may overcome this negative effect of CCR5-Δ32.

Protection against parenteral HIV-1 infection by homozygous deletion in the C-C chemokine receptor 5 gene

OBJECTIVES To investigate the role of the CC chemokine receptor 5 (CCR5) for parenteral transmission of HIV-1. DESIGN The prevalence of the delta32 deletion within the CCR5 gene was determined in a cohort of 207 patients, who had received documented amounts of non-antibody-tested and non-inactivated clotting factor concentrate. METHODS Chromosomal DNA of haemophiliacs was isolated from whole blood. A portion of the CCR5 gene spanning the delta32 deletion was amplified by PCR. The resulting DNA fragments were analysed by agarose gel electrophoresis. RESULTS The rate of HIV-1 infection was correlated strongly with increasing amounts of inoculated clotting factor concentrate. None of the HIV-positive patients (n = 129) had the delta32/delta32 genotype, whereas 12 out of 78 HIV-negative haemophiliacs had the homozygous delta32 deletion. CONCLUSIONS The delta32/delta32 genotype was highly protective against HIV-1 infection, even in patients who had received millions of non-inactivated clotting factor units. As it is likely that in the early 1980s plasma pools were contaminated not only with monocyte-tropic HIV-1 strains, CCR5 appears to be the major mediator of HIV-1 infection. Furthermore, we conclude that there must be other protective mechanisms in multiply exposed non-infected haemophiliacs who have wild-type CCR5.

Male-to-female transmission of HIV in a cohort of hemophiliacs — Frequency, risk factors and effect of sexual counseling

SummaryThe incidence of male-to-female transmission of HIV infection was studied in a population of 198 sexual partners of hemophiliacs who tested HIV positive since 1984. The follow-up observation period was 1987–1992. Transmission occurred in 20 (10%) cases. The analysis of risk factors for transmission was performed in a subgroup of 57 hemophiliacs with seronegative sexual partners as compared to eight transmitters. Transmitters showed a significantly more advanced immune depletion at enrollment as well as at the end of the observation period. Furthermore, transmitters had a more advanced disease at the end of the study (75% vs. 29% CDC IV; p<0.01). Also virus cultures were more frequently positive in the transmitters than in the non-transmitters (71% vs. 42%). Regular sexual counseling was offered to all couples. After 1987, no new seroconversions were detected. However, two seroconversions in female partners of hemophiliacs outside the initial study population were observed. Both transmissions occurred during a period of severe clinical and immunological deterioration. This study shows that sexual partners of HIV-infected hemophiliacs with more advanced disease are at higher risk of infection with HIV. The frequency of male-to-female transmission of HIV in long-term monogamous sexual relationships practicing safer sex is low. Overall, disease awareness and counseling for safer sex seem to be effective in reducing transmission rates.ZusammenfassungDie Inzidenz der Übertragung der HIV-Infektion von Männern auf Frauen wurde in einer Population von 198 weiblichen Sexualpartnern von seit 1984 HIV-positiv getesteten Hämophilen untersucht. Die Nachbeobachtungsdauer erstreckte sich über die Jahre 1987–1992. Die Infektion wurde in 20 Fällen (10%) übertragen. Die Analyse von Risikofaktoren für die Übertragung von HIV wurde untersucht durch den Vergleich einer Untergruppe von 57 Hämophilen und seronegativen Partnern mit 8 Überträgern. Die Überträger zeigten zu Beginn als auch am Ende der Beobachtungszeit eine fortgeschrittenere Immundepletion. Darüber hinaus wiesen Überträger am Ende der Studie auch häufiger eine symptomatische Erkrankung auf (75% versus 29% CDC IV; p<0,01). Darüber hinaus war bei Überträgern 1991/92 häufiger eine positive Viruskultur nachweisbar (71% vs. 42%). Allen Paaren wurde eine regelmäßige Sexualberatung angeboten. Nach 1987 wurden keine neuen Serokonversionen beobachtet. Jedoch wurden zwei Serokonversionen bei Partnerinnen hämophiler HIV-infizierter außerhalb der ursprünglichen Population aufgedeckt. Beide Übertragungen erfolgten in einer Periode schweren klinischen und immunologischen Progresses. Unsere Studie zeigt, daß Sexualpartner von Hämophilen mit fortgeschrittener HIV-Infektion ein höheres Übertragungsrisiko aufweisen. Die Übertragungsfähigkeit von Männern auf Frauen ist auch bei langdauernden Sexualbeziehungen monogamer Paare, die safer sex praktizieren, gering. Das Wissen um das Vorliegen einer HIV-Infektion und Beratung über safer sex scheinen wirksam in der Verhütung von Neuinfektionen.

Hepatitis C-associated autoimmunity in patients coinfected with HIV

Abstract: Background: Hepatitis C virus (HCV) infection is associated with multiple extrahepatic manifestations. It is unclear to what extent extrahepatic manifestations occur in HIV/HCV coinfection.

Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1–24 years

Background Bleeding in the calf or ankle joint may lead to ankle equinus deformity, particularly in childhood and during adolescence. We assessed the long-term functional and radiographic results after Achilles tendon lengthening for ankle equinus deformity in hemophiliacs. Patients and methods Between 1975 and 1986, 30 hemophilic patients with pes equinus were surgically managed by Achilles tendon lengthening. Of these, 23 were followed up prospectively twice a year for an average of 13 (1–24) years. The mean age at operation was 29 (12–46) years. The clinical results were documented according to the score of the Advisory Committee of the World Federation of Hemophilia (WFH), while radio-graphs were evaluated using the Pettersson score. On average, preoperative ankle equinus deformity was 21 (5–55) degrees. Mean range of motion was 21 (5–42) degrees prior to surgery. Results At the first postoperative examination 1 year after surgery, 21/23 cases were improved, and 9/21 reached dorsiflexion to at least neutral position. At the last follow-up, ankle equinus deformity was 10 (4–20) degrees on average. 20/23 patients still showed significant improvement compared to their condition before surgery. 7 patients still had complete correction of the equinus deformity, while mean range of motion decreased constantly over the observation period. The clinical score was significantly improved 1 year after surgery and diminished only slightly afterwards. Radio-graphic outcome deteriorated, with scores rising from 4.3 (1–10) points preoperatively to 7.3 (3–12) points at last follow-up. Interpretation Most patients treated for hemophilic pes equinus by Achilles tendon lengthening experienced long-term benefit concerning the equinus deformity, but gradually lost overall movement of the ankle joint. Progression of the ankle arthropathy cannot be hindered. ▪

Differential expansion of T-cell receptor variable beta subsets after antigenic stimulation in patients with different outcomes of hepatitis C infection

Persistent antigenic stimulation during chronic hepatitis C may alter the T‐cell receptor variable chain beta (TCR BV) repertoire as well as the cytokine responses of hepatitis C virus (HCV)‐specific T lymphocytes. We analysed the distribution of the TCR BV subsets 2.1, 3.1, 5.1, 6.1, 8, 13.1, 13.6, 14.1, 17.1, 21.3 in relation to intracytoplasmic expression of interleukin‐2, interferon‐γ, interleukin‐4 and interleukin‐10. Using flow cytometry, CD45RO+ memory T cells of 27 patients with chronic hepatitis C, eight patients with resolved HCV infection and 16 non‐HCV‐related controls were studied with and without stimulation by the HCV core, NS3, NS4, NS5a and NS5b proteins. Patients with chronic and resolved hepatitis C differed by larger basal TCR BV2.1+, BV6.1+, BV17.1+ and BV21.3+ subsets in chronic hepatitis C, which were correlated to the numbers of T cells with spontaneous interleukin‐2 and interferon‐γ production (r=0·51–0·73, P<0·05). Upon HCV‐specific stimulation these subsets did not expand, whereas a marked in vitro expansion of TCR BV8+ T cells in response to all HCV proteins was selectively noted in chronic hepatitis C (P<0·05). This expansion of TCR BV8+ memory T cells was significantly correlated to HCV‐induced interleukin‐10 expression (r=0·58–0·98, P<0·01). Thus, differential involvement of selected TCR BV subsets may be related to the outcome of HCV infection.