Meri Koulentaki

Dermatological Manifestations in Primary Biliary Cirrhosis Patients: A Case Control Study

OBJECTIVES:Primary biliary cirrhosis (PBC), a disease of probable autoimmune etiology that affects the small intrahepatic bile ducts of mainly middle-aged women is commonly associated with pruritus, xanthomatous lesions, and melanosis. We conducted a prospective study to systematically describe the skin disorders of a group of PBC patients.METHODS:A prospective evaluation and analysis of dermatological manifestations including oral and genital lesions was carried out, in 49 PBC patients (45 females and 4 males). Median age 63 yr (range 35–87 yr). They were compared with 45 age and sex matched controls, selected among persons attending the dermatologic outpatient clinic.RESULTS:A total of 330 skin disorders were found in the 49 PBC patients versus 76 in the 45 controls; 31.5% of all lesions were skin fungal infections. Of all lesions analyzed with the Bonferonni rule of multiple comparisons significantly more common in PBC patients were plantar mycoses, onychomycoses, and interdigital mycoses. Pruritus was found in 69.3% of patients versus 22.2% of controls, xerosis in 69.3%versus 2.2%, dermographism in 57.1%versus 4.4%, and melanosis in 46.9%versus 0%. In 38.7% of the PBC patients the dermatologic lesion was the presenting symptom.CONCLUSIONS:PBC patients present with a wide variety of cutaneous manifestations varying in severity. Multiple skin fungal infections have been found even in the early stages. Since in more than one third of our PBC patients the dermatologic lesion was the presenting sign or symptom leading to diagnosis we believe that physicians should be aware so that a prompt and early diagnosis may be achieved.

Prevalence of hepatitis B and C markers in high-risk hospitalised patients in Crete: a five-year observational study

BackgroundSo far the prevalence of viral hepatitis infection in hospitalized patients has not been extensively studied. Therefore we conducted the present five-year observational study to evaluate the prevalence of HBV and HCV infection in high-risk hospitalized patients of Crete, the largest Greek island, Due to the homogeneous population, epidemiological studies can be accurately done.MethodsThe study was carried out in two out of four District General Hospitals, and in the University Hospital of the island. Markers for HBV and HCV were studied and statistically evaluated according to age, sex and geographical area, in a well-defined hospitalized population.ResultsThe total prevalence of HBsAg and anti-HCV in the three prefectures during the five-year study is 2.66% and 4.75% respectively. Overall the relative risks were higher in males than females for each hepatitis marker (p < 0.001). Higher prevalence of HBcAb was found in the 41–60 years age group for both sexes (males 36.17%, females 27.38%). Peak HBsAg prevalence was found in the age group of 21–40 and 41–60 years for males (5.4%) and females (3.09%) respectively. Anti-HCV prevalence increases with age reaching the highest prevalence in the age group of 41–60 years for males (7.19%) and in the 61–90 years age group for females (7.16%). For both sexes significant differences between the three locations were identified. For HBsAg a higher prevalence in Heraklion (3.96%) compared to Chania (2.30%, males: p < 0.0001, females: p < 0.05) and Rethymnon (1.45%, males: p < 0.01, females: p < 0.0001) was detected. For HCV a significantly higher prevalence in Heraklion (6.54%) compared to Chania (2.39%, males: p < 0.001, females: p < 0.001) but not in Rethymnon (5.15%, NS). A lower prevalence rate of HBcAb in Heraklion compared to Chania (20.07% versus 23.05%, males: p < 0.001, females: p < 0.001) was found.ConclusionsThese results were possibly overestimated, but nevertheless reflect the situation of the general population within the island as shown by our previous publications in other study groups. Moreover they contribute to the mapping of viral hepatitis prevalence in a geographical area of Southern Europe and may be helpful in planning public health interventional strategies.

Ulcerative Colitis Associated with Primary Biliary Cirrhosis

Primary biliary cirrhosis and ulcerative colitisare two diseases with many features of autoimmunity.Thirteen cases of coexistence of the two diseases havebeen reported in the literature so far. Patients are usually younger and more often males thanthe ordinary primary biliary cirrhosis patient, whilethe colitis is mild and easily controllable. In ahomogeneous population of 550,000 inhabitants of the island of Crete, 412 cases of ulcerativecolitis and 82 individuals with primary biliarycirrhosis or autoimmune cholangitis have beenidentified. In two cases, coexistence of the twodiseases was found. Immunological screening for AMA positivity in150 ulcerative colitis sera disclosed no further cases.Prevalence of primary biliary cirrhosis in ulcerativecolitis patients seems at least 30 times higher than in the general population in our area. Apossible immunological link between the two diseases isdiscussed.

Survival of Anti-Mitochondrial Antibody-Positive and -Negative Primary Biliary Cirrhosis Patients on Ursodeoxycholic Acid Treatment

The survival of 85 anti-mitochondrial antibody (AMA)-positive (mean Mayo risk score, 5.11) and 19 AMA-negative (mean Mayo risk score, 4.77) primary biliary cirrhosis patients, under ursodeoxycholic acid not subjected to liver transplantation, was compared with the estimated survival of a simulated control group of untreated patients created with the updated Mayo model and a control group from the general population. In the first 7 years 3 AMA-negative patients died, versus 12 under the Mayo model (P=0.01), and 10 AMA-positive patients, versus 26 under the Mayo model (P<0.005), with 7 expected deaths from the general population (P<0.0001). At 10 years the cumulative survival differed in the treated patients overall (P<0.0001) but not in the early primary biliary cirrhosis (stages I–II) patients compared to the general population. Therefore the survival of our patients treated with ursodeoxycholic acid is higher than that predicted from the Mayo model. Early treatment may prolong survival.

Ursodeoxycholic acid reduces increased circulating endothelin 2 in primary biliary cirrhosis

Background : Endothelins and nitric oxide regulate sinusoidal blood flow and the perfusion of the peribiliary vascular plexus.

Differential detection of nuclear envelope autoantibodies in primary biliary cirrhosis using routine and alternative methods.

BackgroundDetection of autoantibodies giving nuclear rim pattern by immunofluorescence (anti-nuclear envelope antibodies - ANEA) in sera from patients with primary biliary cirrhosis (PBC) is a useful tool for the diagnosis and prognosis of the disease. Differences in the prevalence of ANEA in PBC sera so far reported have been attributed to the methodology used for the detection as well as to ethnic/geographical variations. Therefore, we evaluated the prevalence of ANEA in sera of Greek patients with PBC by using methods widely used by clinical laboratories and a combination of techniques and materials.MethodsWe screened 103 sera by immunoblotting on nuclear envelopes and indirect immunofluorescence (IIF) using cells and purified nuclei. Reactivities against specific autoantigens were assessed using purified proteins, ELISA, immunoprecipitation and mass spectrometry.ResultsWe found higher prevalence of ANEA when sera were assayed by IIF on purified nuclei or cultured cells (50%) compared to Hep2 commercially available slides (15%). Anti-gp210 antibodies were identified in 22.3% and 33% of sera using ELISA for the C-terminal of gp210 or both ELISA and immunoprecipitation, respectively. Immunoblotting on nuclear envelopes revealed that immunoreactivity for the 210 kDa zone is related to anti-gp210 antibodies (p < 0.0001). Moreover, we found that sera had antibodies for lamins A (6.8%), B (1%) and C (1%) and LBR (8.7%), whereas none at all had detectable anti-p62 antibodies.ConclusionsThe prevalence of ANEA or anti-gp210 antibodies is under-estimated in PBC sera which are analyzed by conventional commercially available IIF or ELISA, respectively. Therefore, new substrates for IIF and ELISA should be included by clinical laboratories in the analysis of ANEA in autoimmune sera.

Presence of disease specific autoantibodies against liver sinusoidal cells in primary biliary cirrhosis.

AIM To investigate the presence of autoantibodies directed against liver sinusoidal cells in primary biliary cirrhosis (PBC). METHODS Liver biopsies from 21 PBC patients were studied and compared with 12 liver biopsies from disease controls [3 patients with hepatitis B (HBV) virus, 3 patients with hepatitis C virus (HCV), 3 patients with non-alcoholic steatohepatitis and 3 patients with acute alcoholic hepatitis (AAH)]. As healthy controls, we used tissue specimens adjacent to metastatic liver adenocarcinoma. Normal serum was taken from staff members of the unit. The determination of the cell type targeted by autoantibodies present in the patients sera was performed by indirect immunofluorescence (IIF) analysis using paraffin-embedded liver sections as a substrate. Sera from homologous or heterologous PBC patients or sera from the disease control group were used as primary antibodies. The presence of autoantibodies was identified using confocal microscopy. RESULTS In total, 18/21 (85.7%) PBC patients exhibited positive staining in the sinusoidal cells, 10/21 (47.6%) in lymphocytes, 8/21 (38%) in cholangiocytes and 7/21 (33.3%) in hepatocytes, when homologous serum and fluorescein isothiocyanate-conjugated immunoglobulin type G (IgG) secondary antibody were used. PBC sections incubated with heterologous PBC serum showed reduced staining (20% for sinusoidal cells, 20% for lymphocytes, 20% for cholangiocytes and 13.3% for hepatocytes). When IgM immunoglobulin, instead of IgG, was used as secondary antibody, positive staining was observed in 75% of lymphocytes, 62.5% of cholangiocytes, 37.5% of hepatocytes and 50% of the sinusoidal cells with a much stronger staining intensity. No staining was observed when either normal or PBC sera were used as a primary antibody on liver sections from the disease control group. When PBC sera were incubated with healthy control sections, weak positive staining of cholangiocytes was observed in 3/21 (14.3%) PBC serum samples. Steatohepatitis serum on PBC sections gave a positive staining of some hepatocytes and lymphocytes but no staining on viral hepatitis sections. Incubation with HBV sera stained some hepatocytes, cholangiocytes and intra-sinusoidal or portal lymphocytes of PBC, HBV and AAH patients but not HCV patients. CONCLUSION In this study, for the first time in diseased liver tissue, we have demonstrated that a large proportion of PBC patients have disease specific autoantibodies against liver sinusoidal cells.

Increased serum activin a differentiates alcoholic from cirrhosis of other aetiologies

Introduction, background and aim Activin A is a molecule of the TGF superfamily, implicated in liver fibrosis, regeneration and stem cell differentiation. However, data on activins in liver diseases are very few. The authors therefore studied serum levels of Activin A in chronic liver diseases. To identify the origin of Activin A, levels in the hepatic vein were estimated and expression of Activin A was studied in isolated rat Kupffer and stellate cells. Methods 162 patients participated in the study: 39 with Hepatocellular Carcinoma (HCC, 19 viral cirrhosis associated, 20 alcoholic cirrhosis associated), 18 with Chronic hepatitis C (CHC), 47 with Primary Biliary Cirrhosis (PBC, 26 stage I–II and 21 stage IV), 22 with Alcoholic cirrhosis (hepatic vein blood available in 16), 20 with HCV cirrhosis (hepatic vein blood available in 18) and 16 patients with alcoholic fatty liver with mild to moderate fibrosis but no cirrhosis. 19 normal controls were also included. A commercially available ELISA was used for serum determinations and a semiquantitative PCR for Activin A expression in isolated rat Kupffer and Stellate cells. Results Activin-A levels were significantly increased (p<0.001) in serum of patients with alcoholic cirrhosis (median 673 pg/ml, range 449–3279), compared to either controls (149 pg/ml 91–193) or patients with viral cirrhosis (189 pg/ml, 81–480), CHC (142 pg/ml, 65–559) PBC stage I–II (100 pg/ml 59–597) and PBC stage IV (104 pg/ml, 81–579). Only patients with alcoholic cirrhosis associated HCC had significantly increased levels of activin-A (2403 pg/ml, 1561–7220 pg/ml). Activin A mRNA was strongly expressed in both Kupffer and stellate cells. Conclusions Serum levels of Activin A are increased in patients with alcohol related cirrhosis or HCC and can discriminate these patients from cirrhotics of other aetiologies.

CXCR3 axis in patients with primary biliary cirrhosis: a novel mechanism of action of ursodeoxycholic acid

Introduction Background and Aim: The CXC chemokines, MIG, IP-10 and I-TAC, are known to attract CXCR3+ T lymphocytes. CXCR3 gene generates two distinct mRNAs, CXCR3A and CXCR3B, by alternative splicing. In Primary Biliary Cirrhosis (PBC), intrahepatic bile ductules are destroyed by T lymphocytes. We investigated therefore the CXC chemokine axis in this disease. Methods Mig, IP-10 and I-TAC mRNAs expression was studied by RT-PCR in 20 liver biopsies from PBC patients (Ludwig stage II/III) and compared with normal biopsies (NCs = 20). Serum chemokines were assessed by ELISA in 44 PBC patients (Ludwig stage II/III) and 20 normals. Measurements were repeated six months after Ursodeoxycholate (UDCA) treatment. CXCR3A and CXCR3B mRNAs expression were examined in immunomagnetically sorted CD3+ peripheral blood lymphocytes (PBL) by RT-PCR, pre and post treatment. Flow cytometry evaluated the expression of CXCR3+ in PBL of NC and patients. Results A marked mRNA expression of MIG and IP10, but not of I-TAC, was found in PBC patients. Serum MIG (72.86 pg/ml) and IP-10 (660.1 pg/ml) were significantly increased in PBC, compared to NC (33.47 pg/ml and 37.58 pg/ml, respectively). There was a significant reduction of these proteins after treatment with UDCA (40.95 pg/ml for MIG and 289.2 pg/ml for IP-10). I-TAC was not different between groups. CXCR3A mRNA expression was found in PBLs from PBC patients and NCs. CXCR3B mRNA was expressed in 4/20 (19%) NCs and 20/20 PBC patients. Flow cytometry revealed a significantly lower CXCR3 expression in NCs (13.5%) than in PBC (37.2%) which was reduced (28.1%, p < 0.01) after UDCA administration. Conclusion These data suggest a possible role of CXCR3-binding chemokines and their receptor in the aetiopathogenetic recruitment of lymphocytes in PBC and a new mechanism of action of UDCA.