Jay H. Lefkowitch

A Randomized, Controlled Trial of Interferon Alfa-2b Alone and after Prednisone Withdrawal for the Treatment of Chronic Hepatitis B

Abstract Background and Methods. Chronic hepatitis B is a common and often progressive liver disorder for which there is no accepted therapy. To assess the efficacy of treatment with interferon, we randomly assigned patients with chronic hepatitis B to one of the following regimens: prednisone for 6 weeks followed by 5 million units of recombinant interferon alfa-2b daily for 16 weeks; placebo followed by 5 million units of interferon daily for 16 weeks; placebo followed by 1 million units of interferon daily for 16 weeks; or observation with no treatment. Results. Hepatitis B e antigen and hepatitis B viral DNA disappeared from serum significantly more often in the patients given prednisone plus interferon (16 of 44 patients, or 36 percent) or 5 million units of interferon alone (15 of 41; 37 percent) than in the untreated controls (3 of 43; 7 percent; P<0.001); the difference between those given 1 million units of interferon (7 of 41; 17 percent) and the controls was not significant. The strongest indep...

Nomenclature of the finer branches of the biliary tree: Canals, ductules, and ductular reactions in human livers

The work of liver stem cell biologists, largely carried out in rodent models, has now started to manifest in human investigations and applications. We can now recognize complex regenerative processes in tissue specimens that had only been suspected for decades, but we also struggle to describe what we see in human tissues in a way that takes into account the findings from the animal investigations, using a language derived from species not, in fact, so much like our own. This international group of liver pathologists and hepatologists, most of whom are actively engaged in both clinical work and scientific research, seeks to arrive at a consensus on nomenclature for normal human livers and human reactive lesions that can facilitate more rapid advancement of our field. (HEPATOLOGY 2004; 39:1739–1745.)

Promotion of Hepatocellular Carcinoma by the Intestinal Microbiota and TLR4

Increased translocation of intestinal bacteria is a hallmark of chronic liver disease and contributes to hepatic inflammation and fibrosis. Here we tested the hypothesis that the intestinal microbiota and Toll-like receptors (TLRs) promote hepatocellular carcinoma (HCC), a long-term consequence of chronic liver injury, inflammation, and fibrosis. Hepatocarcinogenesis in chronically injured livers depended on the intestinal microbiota and TLR4 activation in non-bone-marrow-derived resident liver cells. TLR4 and the intestinal microbiota were not required for HCC initiation but for HCC promotion, mediating increased proliferation, expression of the hepatomitogen epiregulin, and prevention of apoptosis. Gut sterilization restricted to late stages of hepatocarcinogenesis reduced HCC, suggesting that the intestinal microbiota and TLR4 represent therapeutic targets for HCC prevention in advanced liver disease.

Pathological diagnosis of chronic hepatitis C: A multicenter comparative study with chronic hepatitis B

BACKGROUND Hepatic histological responses described in hepatitis C virus (HCV) infection include bile duct damage, lymphoid follicles and/or aggregates in portal tracts, large- and small-droplet fat, Mallory body-like material in hepatocytes, liver cell dysplasia and multinucleation, and activation of sinusoidal inflammatory cells. The specificity of these lesions for HCV infection is uncertain. METHODS In two multicenter trials of recombinant interferon alfa therapy for chronic hepatitis C and B, the frequency of these eight lesions in pretherapy and posttherapy liver biopsy specimens was examined to determine the set of features, if any, that distinguishes HCV from hepatitis B virus (HBV) infection. The lesions were scored in 317 HCV biopsy specimens and 299 HBV specimens. RESULTS Stepwise logistic regression determined a set of three features more likely to be seen in HCV than in HBV infection: bile duct damage [odds ratio (OR), 4.7; 95% confidence interval (Cl), 1.8-12.3], lymphoid follicles and/or aggregates (OR, 2.4; 95% Cl, 1.2-4.7), and large-droplet fat (OR, 2.4; 95% Cl, 1.4-4.1). A fourth lesion, Mallory body-like material, was seen only in HCV biopsy specimens (OR, 71.6; 95% Cl, 4.4-996.1). CONCLUSIONS These four histological lesions are useful pathological parameters in the diagnosis of liver disease caused by HCV.

Autoimmune Acute Liver Failure: Proposed Clinical and Histological Criteria

Identifying autoimmune hepatitis as the etiology of acute liver failure (ALF) is potentially important, because administering corticosteroids might avoid the need for liver transplantation. However, clinical and histological criteria of autoimmune ALF (AI‐ALF) have not been defined. Liver sections (biopsies and explants) from a 72‐patient subset of the ALF Study Group Registry with indeterminate ALF were reviewed by a pathologist blinded to all clinical data and were diagnosed with probable AI‐ALF based on four features suggestive of an autoi mmune pathogenesis: distinctive patterns of massive hepatic necrosis (present in 42% of sections), presence of lymphoid follicles (32%), a plasma cell–enriched inflammatory infiltrate (63%), and central perivenulitis (65%). Forty‐two sections (58%) were considered probable for AI‐ALF; this group demonstrated higher serum globulins (3.7 ± 0.2 g/dL versus 3.0 ± 0.2 g/dL; P = 0.037) and a higher prevalence of antinuclear and/or anti–smooth muscle antibodies (73% versus 48%; P = 0.034) compared to those without histology suggestive of probable AI‐ALF. Thirty patients concordant for autoantibodies and probable AI‐ALF upon histological analysis were more likely to have the classical autoimmune hepatitis phenotype (female predominance [72% versus 48%; P < 0.05], higher globulins [3.9 ± 0.2 g/dL versus 3.0 ± 0.2 g/dL; P < 0.005], and higher incidence of chronic hepatitis in long‐term follow‐up [67% versus 17%, P = 0.019]) compared to the population without concordant AI‐ALF histology and autoantibodies. Conclusion: Patients with indeterminate ALF often have features of autoimmune disease by histological analysis, serological testing, and clinical recurrence during follow‐up. In contrast to classical autoimmune hepatitis, histological features of AI‐ALF predominate in the centrilobular zone. (HEPATOLOGY 2011;53:517‐526)

Mixed Hepatocellular–Cholestatic Liver Injury after Pioglitazone Therapy

Context Thiazolidinedione agents are useful in the management of type 2 diabetes mellitus. Unfortunately, the first two drugs in this class, troglitazone and rosiglitazone, have been associated with hepatic injury. In 2001, clinicians reported a case of liver injury associated with pioglitazone, the newest thiazolidinedione. Contribution This report describes mixed hepatocellularcholestatic liver injury in a patient who had been taking pioglitazone for 6 months. Liver enzyme values returned to normal 6 weeks after the patient discontinued pioglitazone therapy. Implications Hepatic injury can occur in association with pioglitazone as well as with the other drugs in this class. The frequency of this complication and its risk factors remain unknown. The Editors Thiazolidinedione hypoglycemic agents act primarily by decreasing insulin resistance and are useful in the management of type 2 diabetes mellitus (1). Troglitazone (Rezulin, Parke-Davis, Morris Plains, New Jersey) is a thiazolidinedione that has been associated with severe hepatic injury and has been withdrawn from the market in the United States and in Europe (2, 3). Rosiglitazone (Avandia, SmithKline Beecham [now GlaxoSmithKline], Philadelphia, Pennsylvania) is also in this class, and isolated cases of liver damage have occurred in patients during rosiglitazone treatment (4, 5). Pioglitazone (Actos, Takeda Pharmaceuticals North America, Lincolnshire, Illinois) is the newest thiazolidinedione drug; only one case of liver injury attributable to this agent has previously been published (6). We describe a patient who developed acute, reversible mixed hepatocellularcholestatic liver injury while being treated with pioglitazone. This case has been reported to the manufacturer and to the U.S. Food and Drug Administration. Case Report A 49-year-old electrician was referred for evaluation of hepatitis. He had a 6-year history of type 2 diabetes mellitus that was initially treated with glyburide, 5 mg twice daily. Subsequently, metformin, 850 mg three times daily, was added to his regimen. Six months before presentation, he began taking pioglitazone, 15 mg/d; 2 months before presentation, the daily dose was increased to 30 mg. Neither troglitazone nor rosiglitazone was administered. The patients medical history included systemic arterial hypertension, which was well controlled by lisinopril (5 mg/d), and gastroesophageal reflux disease, for which the patient took a maintenance course of omeprazole (20 mg/d). The patient had been taking both drugs for 4 years. Liver chemistry profiles obtained at approximately 6-month intervals had been normal. Colonoscopy performed 3 years earlier for hemorrhoidal bleeding and diarrhea showed only diverticulosis. The patient had no history of gallstones or cholangitis. Six weeks before our evaluation, the patient developed anorexia, nausea, and upper abdominal discomfort but had no rash or fever. He lost 2.7 kg (6 lb). Stool culture and examination for ova and parasites were negative. Results of liver enzyme tests and a complete blood count were normal. Peripheral blood smear showed a normal leukocyte differential count. One week before our evaluation, hyperglycemia was noted, and pioglitazone was increased to 45 mg/d. Several days later, the patient noted scleral icterus and acholic stools. At that time, total bilirubin level was 97 mol/L (5.7 mg/dL) (normal range, 5 to 17 mol/L [0.3 to 1.0 mg/dL]), aspartate aminotransferase level was 1.9 kat/L (114 U/L) (normal range, 0 to 0.58 kat/L [0 to 35 U/L]), alanine aminotransferase (ALT) level was 3633 nkat/L (218 U/L) (normal range, 0 to 583 nkat/L [0 to 35 U/L]), and alkaline phosphatase level was 5.2 kat/L (normal range, 0.5 to 2.0 kat/L). Pioglitazone therapy was discontinued. Results of abdominal sonography were normal, and results of serologic studies for hepatitis A, B, and C and for EpsteinBarr virus were negative. The patient was referred to us for hepatology consultation. The patient reported no alcohol use; occupational exposure to hepatotoxins; or risk factors for hepatitis A, B, and C. He had no history of recreational drugs or travel. Physical examination revealed that he was icteric, but there were no cutaneous stigmata of liver disease. The abdomen was not tender, and he did not have hepatosplenomegaly or ascites; results of guaiac tests of the stool were negative. Liver chemistry findings had worsened. Total bilirubin level was 178 mol/L (10.4 mg/dL), direct bilirubin level was 120 mol/L (7.01 mg/dL), aspartate aminotransferase level was 7.8 kat/L (467 U/L), ALT level was 8117 nkat/L (487 U/L), and alkaline phosphatase level was 11.2 kat/L. Antinuclear, antismooth-muscle, and antimitochondrial antibodies were undetectable. Iron and iron saturation were normal, and there were no antibodies to cytomegalovirus. Results of repeated sonography and a computed tomography scan were normal. Hepatitis B surface antigen and antibodies to hepatitis A, B, and C and EpsteinBarr virus were again undetectable. Repeated complete blood count with differential was again normal. Percutaneous liver biopsy was performed and showed mild centrilobular cholestasis in hepatocytes and bile canaliculi, accompanied by lymphocytic infiltrates in portal tracts. Portal infiltrates were diffuse but mild and consisted almost entirely of lymphocytes, with occasional neutrophils but no eosinophils. Interface hepatitis was absent. Several portal tracts contained damaged bile ducts, characterized by altered nuclear polarity and stratification and patchy intraepithelial lymphocytes (cholangiolitis) (Figure 1). The combination of cholestasis with portal inflammation and bile duct damage is a mixed hepatocellularcholestatic type of liver injury that is compatible with drug hepatotoxicity (7). Figure 1. Liver biopsy specimen showing mild portal lymphocytic inflammation. curved arrow straight arrow Because we suspected that pioglitazone was the hepatotoxic agent, the patient continued taking lisinopril, glyburide, metformin, and omeprazole throughout the illness. Liver chemistry findings improved gradually. Two weeks later, total bilirubin level was 45 mol/L (2.66 mg/dL), aspartate aminotransferase level was 0.4 kat/L (24 U/L), ALT level was 1417 nkat/L (85 U/L), and alkaline phosphatase level was 6.5 kat/L. Results of liver tests continued to improve (Figure 2), and after another 4-week interval, all liver chemistry findings were normal and the patient felt fine. Three months later, liver chemistry findings remained normal. Figure 2. Serum liver enzyme value associated with pioglitazone administration. Discussion Pioglitazone is useful in the treatment of type 2 diabetes mellitus because it improves insulin sensitivity in muscle and adipose tissue and inhibits hepatic gluconeogenesis. It can be used as monotherapy or in combination with other oral hypoglycemic agents or with insulin. During premarketing drug trials, 0.26% of 1526 patients taking pioglitazone had asymptomatic increases in ALT level that were more than three times the upper limit of normal. Similar abnormalities were seen in 0.25% of 793 placebo-treated patients (8). The abnormalities were reversible and were not thought to be clearly related to therapy with pioglitazone. A single case report recently described a patient who developed hepatitis after 7 months of pioglitazone therapy; the patient had elevated serum ALT and alkaline phosphatase levels (6). Several features of our case support pioglitazone as the cause of hepatic injury. First, other causes of acute hepatitis (including viral, autoimmune, and metabolic disorders), as well as biliary obstruction, were reasonably excluded. The data, including clinical presentation, previous colonoscopy results, normal results on ultrasonography, lack of history of inflammatory bowel disease, and resolution of liver test abnormalities after discontinuation of pioglitazone therapy, did not support a possible diagnosis of primary sclerosing cholangitis. Second, findings on liver biopsy were consistent with drug hepatotoxicity. Third, the patient began to steadily improve within a few days of stopping pioglitazone therapy and continued to improve until results of serum liver enzyme tests were completely normal. Because a repeated liver biopsy was not performed, we can only presume, not prove, that a morphologically normal liver was restored (9). Hepatic injury due to troglitazone and rosiglitazone is believed to be idiosyncratic, and this is probably also the case with pioglitazone. However, the discrepancy between the many cases of troglitazone hepatotoxicity and the few cases attributable to rosiglitazone and pioglitazone could be related to specific features of troglitazone, such as its unique tocopherol side chain (10). Hepatotoxicity in our patient developed after 6 months of pioglitazone treatment; in the report by Maeda (6), hepatotoxicity was seen after 7 months. Although these time frames fall within the described range preceding troglitazone liver injury in men and women, they exceed the mean intervals of 88 and 63 days, respectively (2). The changes seen on liver biopsy in our patient were considerably milder than those reported in troglitazone toxicity, where severe centrilobular and bridging necrosis were common (2). Our patient had also received glyburide, metformin, lisinopril, and omeprazole but did not become ill until the addition of pioglitazone. Whether these agents together with pioglitazone can exert a combination effect or adversely alter pioglitazone metabolism was difficult to assess in this case. Although a therapeutic trial with corticosteroids was considered, the absence of both peripheral and hepatic eosinophilia and the rapid improvement after discontinuation of pioglitazone therapy made this unnecessary. In summary, we describe the clinical course and findings on liver biopsy in a patient with significant hepatic injury associated with pioglitazone. Physicians should be a

RAGE limits regeneration after massive liver injury by coordinated suppression of TNF-α and NF-κB

The exquisite ability of the liver to regenerate is finite. Identification of mechanisms that limit regeneration after massive injury holds the key to expanding the limits of liver transplantation and salvaging livers and hosts overwhelmed by carcinoma and toxic insults. Receptor for advanced glycation endproducts (RAGE) is up-regulated in liver remnants selectively after massive (85%) versus partial (70%) hepatectomy, principally in mononuclear phagocyte-derived dendritic cells (MPDDCs). Blockade of RAGE, using pharmacological antagonists or transgenic mice in which a signaling-deficient RAGE mutant is expressed in cells of mononuclear phagocyte lineage, significantly increases survival after massive liver resection. In the first hours after massive resection, remnants retrieved from RAGE-blocked mice displayed increased activated NF-κB, principally in hepatocytes, and enhanced expression of regeneration-promoting cytokines, TNF-α and IL-6, and the antiinflammatory cytokine, IL-10. Hepatocyte proliferation was increased by RAGE blockade, in parallel with significantly reduced apoptosis. These data highlight central roles for RAGE and MPDDCs in modulation of cell death–promoting mechanisms in massive hepatectomy and suggest that RAGE blockade is a novel strategy to promote regeneration in the massively injured liver.

Steatohepatitic hepatocellular carcinoma (SH-HCC): a distinctive histological variant of HCC in hepatitis C virus-related cirrhosis with associated NAFLD/NASH.

In explant livers with chronic hepatitis C (HCV-C) we have noted a distinctive histologic variant that we have termed steatohepatitic hepatocellular carcinoma (SH-HCC) with features resembling non-neoplastic steatohepatitis, including large droplet steatosis, ballooning of malignant hepatocytes, Mallory-Denk bodies, inflammation, and pericellular fibrosis. This study was undertaken to further describe the characteristics and prevalence of this histologic variant in HCV-C and any possible association with underlying risk factors for nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). We selected two 2-year periods (mid-2003 to mid-2005 and 2007 to 2008), from which selected explant livers with HCV-C and HCC were examined to determine the characteristics and frequency of SH-HCC. The underlying cirrhotic liver was also reassessed for steatosis and evidence of steatohepatitis. Clinical records were consulted for concomitant NAFLD and NASH risk factors. The SH-HCC variant was found in a total of 22 of 62 HCC cases (35.5%). Fourteen of the 22 patients with SH-HCC (63.6%) had at least one known risk factor for NAFLD/NASH including diabetes (6 of 22, 27.3%), obesity (6 of 22, 27.3%), hypertension (11 of 22, 50%), and hyperlipidemia (5 of 22, 27.8%). In 14 of the 22 cases (63.6%) of SH-HCC, the non-neoplastic liver showed changes of NAFLD/NASH superimposed on otherwise typical features of HCV-C. In conclusion, in our series of HCV-C explants, approximately one-third of HCCs show a distinctive histological variant termed SH-HCC. Underlying risk factors for NAFLD and for NASH were identified in 63.6% of our cases. Moreover, non-neoplastic tissue in HCV-C explants showed changes of NAFLD/NASH in 63.6% of cases. These results suggest a possible NAFLD/NASH pathway leading to SH-HCC in the setting of HCV-C which requires further investigation in the future.

Kupffer Cell Aggregation and Perivenular Distribution in Steatohepatitis

Cytokine release from inflammatory cells, endotoxin, lipid peroxidation, and generation of reactive oxygen species are among the factors currently thought to be important in the pathogenesis of alcoholic and nonalcoholic steatohepatitis (SH). To more fully evaluate the role of mononuclear inflammatory cells in SH, 11 needle liver biopsies showing SH were selected for immunohistochemical staining to analyze the type and distribution of mononuclear inflammatory cells, including T and B lymphocytes and Kupffer cells (using immunostains for CD3, CD4, CD8; CD20; and CD68, respectively). An additional seven biopsies showing normal or fatty liver were also selected for CD68 immunostaining. Immunohistochemistry showed mild to moderate (1+ to 2+) numbers of T cells, with equal representation of CD4 and CD8 cells. T cells were found in portal tracts and in regions of SH. B cells were only rarely present. CD68 staining of simple fatty liver and normal liver showed elongated, spindle-shaped Kupffer cells diffusely distributed along the sinusoids throughout the lobules. In contrast, in cases of SH, there was prominent enlargement and aggregation of Kupffer cells in perivenular regions. Scattered large vacuoles of fat that had appeared to be within hepatocytes on routine stain were found actually to be within Kupffer cells. These results support the concept that hepatic Kupffer cells are a major immune effector cell in the pathogenesis of steatohepatitis. A potential direct Kupffer cell role in hepatic lipid processing is also postulated.

Hepatic neurofibromatosis, malignant schwannoma, and angiosarcoma in von Recklinghausen's disease

Liver involvement by neurofibromatosis is rare. This report describes a young man with von Recklinghausens disease and hepatic neurofibromas who developed a large right hepatic lobe malignancy and died of massive intratumor hemorrhage. Postmortem examination showed the tumor to be composed of both malignant schwannoma and angiosarcoma and to have arisen from contiguous neurofibromas in portal tracts. Widespread pulmonary metastases consisted of the angiosarcomatous elements alone. The expression of malignant schwannoma and angiosarcoma phenotypes in this tumor may be related to a common histogenesis from cells of the neural crest.