M. Pirisi

Post-meal coagulation activation in diabetes mellitus: the effect of acarbose

SummaryIt has been previously demonstrated that hyperglycaemia activates haemostasis; diabetes mellitus is considered a thrombosis-prone state. Acarbose, by inhibiting dietary carbohydrate absorption, reduces post-meal hyperglycaemia. In this study we evaluated the effect of post-meal hyperglycaemia on two markers of coagulation activation: prothrombin fragments 1 + 2 and D-dimer. Seventeen non-insulin-dependent diabetic patients maintained on diet therapy alone were randomly assigned to receive — with a cross-over study design — acarbose (100 mg orally) or placebo before a standard meal. Blood samples for measurement of plasma glucose, insulin, prothrombin fragments 1 + 2 and D-dimer were drawn at 0, 60, 120 and 240 min. After both placebo and acarbose, hyperglycaemia and hyperinsulinaemia which followed a standard meal were accompanied by a significant increase of plasma concentration of prothrombin fragments 1 + 2 and D-dimer in comparison to their baseline values. Acarbose administration significantly reduced the rise of glucose, insulin, prothrombin fragments 1 + 2 and D-dimer from 0 to 240 min in comparison to placebo. We conclude that post-meal hyperglycaemia, at the level reached by many diabetic patients on diet therapy alone, induces a coagulation activation. Acarbose, by decreasing post-meal hyperglycaemia, may be useful in reducing meal-induced activation of haemostasis in diabetic patients.

Chronic lymphocytic sialoadenitis in HCV‐related chronic liver disease: comparison with Sjögren's syndrome

With the aim of morphologically characterizing chronic sialoadenitis in patients with hepatitis C virus (HCV) chronic liver disease, labial salivary gland biopsies from 22 chronic HCV liver disease and from 10 primary Sjögrens syndrome patients were compared. Only focus score (number of aggregates with more than 50 lymphocytes per 4 mm2 of glandular tissue) and grading of inflammation were able to discriminate significantly between the two patient groups. Duct ectasia, acinar depletion, presence of lymphoid aggregates with less than 50 lymphocytes and of lymphoid infiltration within intralobular salivary duct epithelium were evident in both disease groups and appeared to be non‐specific, mostly age‐related changes. In both patient groups plasma cell and lymphocyte typing showed similar features: T lymphocytes represented most of the lymphoid population, B lymphocytes were few unless follicles were present. Higher focus score values were associated with a plasma cell switch from an IgA to an IgM and/or IgG predominance. A greater morphological similarity was seen between biopsies of the primary Sjögrens syndrome group and those of female rather than male chronic HCV liver disease patients. Salivary gland tissue in HCV patients responds to damage in a fashion similar to primary Sjögrens syndrome, the only difference being a lesser degree of inflammation.

Iron Deposition and Progression of Disease in Chronic Hepatitis C Role of Interface Hepatitis, Portal Inflammation, and HFE Missense Mutations

Histologically detectable iron (HDI) and HFE mutations were searched for in liver biopsy specimens from 58 Italian patients with chronic hepatitis C, and morphologic features were compared to examine their reciprocal relation and their contribution to disease progression. HDI was evident in 48% of cases with features of nonhemochromatosis iron overload. Total, sinusoidal, and portal HDI increased with stage; grade was related to all iron scores because of the contribution of portal inflammation and interface hepatitis. HFE mutations were seen in 47% of patients with chronic hepatitis C and in 28% of control subjects; they were related to stage and the His63Asp mutation to portal HDI. On multivariate analysis, grade but not stage or HFE mutations was associated with HDI in all sites. Interface hepatitis with its sequelae (sinusoidal capillarization and microshunting) represents a major factor in iron deposition in chronic hepatitis C and justifies the features of HDI. HFE mutations are not responsible for HDI deposition but could favor the progression of virus-induced damage independently from interference with iron metabolism.

Immunosuppressive Treatment of Membranoproliferative Glomerulonephritis

The treatment of membranoproliferative glomerulonephritis (MPGN) is considered by most authors as unrewarding, and the disease progresses to end-stage renal disease (ESRD). We studied the effectiveness of a new immunosuppressive (IS) regimen by analyzing the rates of remission, relapse and progression to ESRD in 19 patients with MPGN. The treatment consisted of 4 phases: (1) induction with intravenous boluses of methylprednisolone plus cyclophosphamide (CPM) orally; (2) maintenance with oral prednisone (PDN) in an alternate-day regimen and CPM in a daily oral dose; (3) tapering during which PDN alone was slowly decreased; (4) discontinuation when CPM was omitted and PDN slowly withdrawn according to the steroid withdrawal schedule. At the end of the treatment that lasted on average 10 +/- 1 months, 15 patients remitted, 3 improved and 1 progressed. There were 8 relapses in 6 patients: 4 in 3 patients were treated with repeat cycles and remitted completely. Four patients who had relapsed after 4, 8, 11 and 13 years of remission refused retreatment and progressed rapidly to ESRD. All patients treated and retreated after relapsing had remissions, while renal failure and disease progression occurred in 1 patient only. Plasma creatinine averaged, in the whole group, 165 +/- 26 before, 156 +/- 30 after treatment and 224 +/- 57 microM/l at the end of 7.4 +/- 0.8 years of follow-up. An intensive IS regimen combining steroids and alkylating agents in high doses and for a prolonged time is effective in inducing remission and halting progression to ESRD in patients with MPGN.

A comparison of four serum markers of fibrosis in the diagnosis of cirrhosis.

C-terminal peptide of procollagen I, N-terminal peptide of procollagen III, collagen IV and serum prolyl hydroxylase were measured in 100 patients with cirrhosis and 71 patients with noncirrhotic chronic liver disease. Patients with cirrhosis had significantly higher mean values of prolyl hydroxylase, collagen IV, N-terminal peptide of procollagen III and C-terminal peptide of procollagen I as compared to noncirrhotic patients. This difference was maintained for collagen products even after stratification for alcohol intake, although all markers of fibrosis were higher in alcoholics. Stepwise logistic regression analysis showed that collagen IV, and N-terminal peptide of procollagen III were independently associated with cirrhosis. Receiver-operating characteristic (ROC) curves showed that collagen IV and N-terminal peptide of procollagen III perform more efficiently than C-terminal peptide of procollagen I and prolyl hydroxylase in identifying cirrhosis.

The albumin-bilirubin grade improves hepatic reserve estimation post-sorafenib failure: implications for drug development

Drug development in hepatocellular carcinoma (HCC) is limited by disease heterogeneity, with hepatic reserve being a major source of variation in survival outcomes. The albumin–bilirubin (ALBI) grade is a validated index of liver function in patients with HCC.

Non-specific increase of serum carbohydrate antigen 19-9 in patients with liver disease associated with increased circulating levels of adhesion molecules

Sialyl-Lewisa antigen (SLe(a)), the immune determinant of carbohydrate antigen 19-9 (CA 19-9), is the ligand of E-selectin. To verify the possibility of an association between nonspecific elevation of CA 19-9 and adhesion molecules, sera from 12 patients with acute hepatitis, 55 with non-cirrhotic chronic liver disease, 33 with cirrhosis and 25 with hepatocellular carcinoma, were tested for common liver function tests. Besides, CA 19-9 and soluble forms of E-selectin, VCAM-1 and ICAM-1 were measured immunoenzymatically. One-way analysis of variance demonstrated that mean CA 19-9 concentration differed among groups (F 15.27, P < 0.0001) with the highest values found in patients with acute hepatitis. By univariate analysis, the strongest correlation of CA 19-9 was with soluble ICAM-1, which by stepwise multiple regression analysis was the only independent predictor of elevated CA 19-9 (multiple R 0.560). The association between ICAM-1 and CA 19-9 might originate in the biliary cells where they might be simultaneously overexpressed during inflammatory processes.

Prognostic value of serum alpha-1-antitrypsin in hepatocellular carcinoma.

To evaluate serum alpha-1-antitrypsin (A1AT) as a prognostic factor in hepatocellular carcinoma, we studied 75 consecutive patients (60 male, 15 female, mean age +/- SD 63.0 +/- 9.3 years) in whom hepatocellular carcinoma developed with pre-existing cirrhosis. Median survival time was 245 days (range 4-1568+). 30 patients had serum A1AT concentration of < or = 2.20 g/l (Group A) while 45 (Group B) had alpha-1-antitrypsin > 2.20 g/l. Median survival was 518 days in Group A and 81 days in Group B (Mantel-Cox 20.95, P < 0.0001; hazard ratio 0.26, 95% confidence limits 0.15-0.46). By stepwise survival analysis, alpha-1-antitrypsin together with bilirubin, tumour size and blood urea nitrogen were chosen among 17 variables as the only independent predictors of survival. We conclude that measurement of serum A1AT concentration might be useful as an inexpensive, widely available prognostic marker of hepatocellular carcinoma.

Diagnostic Usefulness of Acute-Phase Protein Measurement in Hepatocellular Carcinoma

To compare the diagnostic usefulness as markers of hepatocellular carcinoma (HCC) of alpha1-antitrypsin, C-reactive protein, and alpha1-acid glycoprotein (all determined by nephelometric methods), we studied 132 subjects (74 male, 58 female): 43 had mild chronic liver disease, 32 cirrhosis, 24 HCC; 33 were controls. A total of 29.2% of the patients with HCC had alpha1-acid glycoprotein > 100 mg/dl, 75.0% had alpha1-antitrypsin > 220 mg/dl, 70.8% had C-reactive protein > 5 mg/L. In cirrhotics, frequencies were 3.1, 50.0 and 59.4%, respectively; in patients with mild chronic liver disease, 14.0, 11.6, and 32.6% (chi2 12.3, p < 0.01; chi2 47.3, p < 0.0001; chi2 38.0, p < 0.0001, respectively). alpha1-fetoprotein performed better than all acute-phase proteins. We conclude that, due to their low specificity and/or sensitivity, none of the three acute-phase reactants tested can be recommended for diagnostic use as biological markers of HCC in Western patients.

Anti-envelope antibodies in anti-hepatitis C virus (HCV) positive patients with and without liver disease

Our aim was to verify whether the presence of antibodies to HCV envelope protein might mark the occurrence of liver damage, as recently suggested in the literature. Sera from 104 patients (62 male, 42 female) were tested: 84 were positive and 20 were negative to a second generation enzyme immunoassay for anti-HCV antibodies; 51 patients had mild chronic liver disease (44 chronic hepatitis, seven steatosis), 43 had liver cirrhosis (superimposed by hepatocellular carcinoma in 18) and ten were asymptomatic anti-HCV positive subjects with normal liver function tests. Besides, all sera were tested by means of an enzyme immunoassay for the presence of serum antibodies to the synthetic peptide S24A (SIYPGHVSGH RMAWDMMMNW SPTA) derived from amino acids 307–330 of HCV polyprotein. Anti-S24A antibodies were detected in 40/84 sera positive and 1/20 negative at anti-HCV testing (Pearsonx 2 12.29; p=0.005). Among anti-HCV positive sera, no significant difference existed in anti-S24A status with regard to clinical evidence of liver disease, ALT concentration or HCV RNA positivity. Thus, anti-S24A antibodies are detectable in approximately half of HCV-positive sera, but they do not seem to add significant clinical information to existing tests or to be useful as putative markers of viraemia. Ziel der Stude war es, zu prüfen, ob die Anwesenheit von Antikörpern gegen das HCV-Hüllprotein ein Marker für das Auftreten einer Leberschädigung ist, wie jüngst vorgeschlagen wurde. Sera von 104 Patienten (62 Männer, 42 Frauen) wurden untersucht: in einem Enzymimmunoassay der zweiten Generation waren 84 Patienten positiv und 20 negativ für anti-HCV-Antikörper; 51 Patienten hatten eine leichte chronische Lebererkrankung (44 chronische Hepatitis, 7 Fettleber), 43 eine Leberzirrhose (davon 18 bei hepatozellulärem Karzinom) und 10 waren asymptomatisch anti-HCV-positiv bei normalen Leberfunktionstests. Zusätzlich wurden alle Sera auf Antikörper gegen das synthetische Peptid S24A (SIYPGHVSGH RMAWDMMMNW SPTA), das sich aus der Aminosäuresequenz (307–330) des HCV-Polyproteins ableitet, mit Hilfe eines Enzymimmunoassays getestet. Anti-S24A-Antikörper fanden sich im Serum von 39 der 84 anti-HCV-positiven und in einem der 20 anti-HCV-negativen Patienten (Pearsonx 2 11,71, p<0,001). Bei den anti-HCV-positiven Patienten ergab sich keine signifikante Differenz im anti-S24A-Status in Abhängigkeit von klinischen Anzeichen einer Lebererkrankung, von der ALT-Konzentration oder von der HCV-RNA-Positivität. Somit sind anti-S24A-Antikörper zwar in ungefähr der Hälfte der HCV-positiven Sera nachweisbar, aber sie scheinen weder zusätzliche, signifikante klinische Information gegenüber bekannten Tests zu liefern, noch scheinen sie sich als denkbarer Virämie-Marker zu eignen.SummaryOur aim was to verify whether the presence of antibodies to HCV envelope protein might mark the occurrence of liver damage, as recently suggested in the literature. Sera from 104 patients (62 male, 42 female) were tested: 84 were positive and 20 were negative to a second generation enzyme immunoassay for anti-HCV antibodies; 51 patients had mild chronic liver disease (44 chronic hepatitis, seven steatosis), 43 had liver cirrhosis (superimposed by hepatocellular carcinoma in 18) and ten were asymptomatic anti-HCV positive subjects with normal liver function tests. Besides, all sera were tested by means of an enzyme immunoassay for the presence of serum antibodies to the synthetic peptide S24A (SIYPGHVSGH RMAWDMMMNW SPTA) derived from amino acids 307–330 of HCV polyprotein. Anti-S24A antibodies were detected in 40/84 sera positive and 1/20 negative at anti-HCV testing (Pearsonx2 12.29; p=0.005). Among anti-HCV positive sera, no significant difference existed in anti-S24A status with regard to clinical evidence of liver disease, ALT concentration or HCV RNA positivity. Thus, anti-S24A antibodies are detectable in approximately half of HCV-positive sera, but they do not seem to add significant clinical information to existing tests or to be useful as putative markers of viraemia.ZusammenfassungZiel der Stude war es, zu prüfen, ob die Anwesenheit von Antikörpern gegen das HCV-Hüllprotein ein Marker für das Auftreten einer Leberschädigung ist, wie jüngst vorgeschlagen wurde. Sera von 104 Patienten (62 Männer, 42 Frauen) wurden untersucht: in einem Enzymimmunoassay der zweiten Generation waren 84 Patienten positiv und 20 negativ für anti-HCV-Antikörper; 51 Patienten hatten eine leichte chronische Lebererkrankung (44 chronische Hepatitis, 7 Fettleber), 43 eine Leberzirrhose (davon 18 bei hepatozellulärem Karzinom) und 10 waren asymptomatisch anti-HCV-positiv bei normalen Leberfunktionstests. Zusätzlich wurden alle Sera auf Antikörper gegen das synthetische Peptid S24A (SIYPGHVSGH RMAWDMMMNW SPTA), das sich aus der Aminosäuresequenz (307–330) des HCV-Polyproteins ableitet, mit Hilfe eines Enzymimmunoassays getestet. Anti-S24A-Antikörper fanden sich im Serum von 39 der 84 anti-HCV-positiven und in einem der 20 anti-HCV-negativen Patienten (Pearsonx2 11,71, p<0,001). Bei den anti-HCV-positiven Patienten ergab sich keine signifikante Differenz im anti-S24A-Status in Abhängigkeit von klinischen Anzeichen einer Lebererkrankung, von der ALT-Konzentration oder von der HCV-RNA-Positivität. Somit sind anti-S24A-Antikörper zwar in ungefähr der Hälfte der HCV-positiven Sera nachweisbar, aber sie scheinen weder zusätzliche, signifikante klinische Information gegenüber bekannten Tests zu liefern, noch scheinen sie sich als denkbarer Virämie-Marker zu eignen.