Mikio Nishioka

Present status of autoimmune hepatitis in Japan - correlating the characteristics with international criteria in an area with a high rate of HCV infection

BACKGROUND/AIMS A nationwide survey of autoimmune hepatitis (AIH) was carried out in Japan. METHODS Four hundred and ninety-six patients were enrolled by questionnaires sent to 101 hospitals with hepatology specialists. RESULTS The clinical features of Japanese AIH were as follows: most patients were middle-aged women; serum autoantibodies, especially antinuclear antibody, were frequently positive, serum IgG level was high, and HLA-DR4 was the major HLA allotype. Liver-kidney microsomal type 1 antibody was positive in nine of 79 patients tested. Eight of these antibody positive patients were also positive for antinuclear antibody and five for anti-smooth muscle antibody. Ninety-two percent of the patients showed piecemeal necrosis and 60% bridging necrosis; plasma cell infiltration in the portal areas was observed in 50% of the patients. Only 12.3% were diagnosed as having liver cirrhosis. A favorable effect of corticosteroid, normalization of serum transaminases, was observed in 89% of 317 patients, who were treated with an initial dose of over 30 mg/day. Sixty-two patients were positive for hepatitis C virus (HCV) markers. In these patients, however, only one patient was liver-kidney microsomal type 1 antibody positive. Corticosteroid was effective in 30 (81%) of 37 HCV-marker-positive patients treated with this agent. Thus the efficacy of corticosteroid did not differ from that in AIH patients without HCV infection (90%). Similarly, interferon treatment was used in 20 patients, all of whom were positive for HCV-RNA, and resulted in 50% efficacy as determined by normalization of the serum transaminase level 6 months after treatment. The International Diagnostic Scoring System for the diagnosis of AIH worked well in these patients, except for HCV-infected individuals, that is, approximately 10% of the total of AIH patients.

Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function.

To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (<12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min,P<NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P=NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.

Patterns of nuclear immunofluorescence and reactivities to recombinant nuclear antigens in autoimmune hepatitis

BACKGROUND/AIMS Antibodies to nuclear antigens have not been fully characterized in autoimmune hepatitis. The aims of this study were to determine the different patterns of immunofluorescence associated with antinuclear antibodies and to correlate these patterns with reactivities to recombinant nuclear antigens and clinical manifestations of autoimmune hepatitis. METHODS Sera from 65 patients were tested by indirect immunofluorescence and by enzyme immunoassay for antibodies to recombinant centromere, ribonucleoproteins, and ribonucleoprotein complexes. RESULTS Homogeneous and speckled patterns of immunofluorescence occurred with similar frequencies (34% vs. 38%) in the majority of patients (72%). Patients with speckled patterns were younger and had higher serum aspartate aminotransferase levels at presentation than counterparts with other patterns. Antibodies to centromere (42%) and 52K ribonucleoprotein complex (23%) were the most common reactivities. Of the 35 patients with antibodies, 16 (46%) had multiple specificities. Individual reactivities were not associated with specific immunofluorescent patterns, and they did not identify patients with distinctive features. CONCLUSIONS Antinuclear antibodies produce mainly homogeneous and speckled patterns of immunofluorescence in patients with autoimmune hepatitis. Speckled patterns are associated with a younger age and greater aminotransferase activity. Multiple autoantibodies are frequently associated with each immunofluorescent pattern. Antibodies to centromere and the 52K ribonucleoprotein complex have a previously unrecognized high frequency and uncertain significance.

Combination therapy of bezafibrate and ursodeoxycholic acid in primary biliary cirrhosis: a preliminary study

Combination therapy of bezafibrate and ursodeoxycholic acid in primary biliary cirrhosis: a preliminary study

Relationship between esophageal dysfunction and neuropathy in diabetic patients.

OBJECTIVE:Few studies have compared esophageal dysfunction with diabetic neuropathy, and their relationship is not yet clear. The aim of this study was to investigate the relationship between esophageal function and diabetic neuropathy.METHODS:A total of 59 patients with type 2 diabetes were studied. Long-term ambulatory esophageal pH and motility monitoring were performed. The motor nerve conduction velocity (MCV) and coefficient of variation of R-R intervals (CVRR) were also examined.RESULTS:The 59 patients were classified into four groups: group 1 consisted of patients with both diabetic autonomic neuropathy (DAN) and diabetic motor neuropathy (DMN), group 2 had DMN alone, group 3 had DAN alone, and group 4 had neither DAN nor DMN. In pH monitoring, differences were observed among the four groups in DeMeester score, total number of acid reflux episodes, and % time pH < 4 (p < 0.05). A correlation was observed between % time pH < 4 and MCV; however, no correlation with CVRR was observed. In motility monitoring, differences were observed among the four groups in amplitude of peristaltic waves (p < 0.001), rising velocity of peristaltic waves (p < 0.01), and percentage of effective peristalsis (p < 0.01). A correlation was observed between esophageal motility and MCV; however, no correlation with CVRR was observed.CONCLUSIONS:Esophageal motility disorder and abnormal acid reflux were related to DMN in diabetic patients. A significant correlation was found between esophageal dysfunction and MCV. However, no significant correlation was found between esophageal dysfunction and CVRR.

A multi-center double-blind controlled trial of ursodeoxycholic acid for primary biliary cirrhosis.

SummaryA multi-center double-blind controlled trial of ursodeoxycholic acid (UDCA) for treatment of primary biliary cirrhosis (PBC) was carried out. Twenty two and 23 patients were treated with 600mg/day UDCA and placebo, respectively, for 24 weeks. In UDCA - treated patients, fall of serum aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and gamma glutamyltranspeptidase activities started within 4 weeks after start of the trial and continued throughout the trial period. The serum IgM level fell in 7 UDCA-treated patients examined but not in 10 placebo-treated patients examined. Serum bilirubin concentration showed no significant change at the end of the study in either of UDCA- and placebotreated group of patients. There was no significant difference between these two groups with respect to the frequency of improvement of pruritus. In UDCA-treated patients, serum bile acid composition changed markedly, though its concentation showed no significant change. The percentage of total bile acid which ursodeoxycholic acid took up increased, whereas those which cholic acid, chenodeoxycholic acid and deoxycholic acid took up were decreased.

Frequency and significance of antibodies to P450IID6 protein in Japanese patients with chronic hepatitis C.

BACKGROUND/AIMS The aims of the current study were to assess the frequency and the significance of antibodies to cytochrome P450IID6 protein (anti-P450IID6) in various diseases among Japanese patients. METHODS Sera from 541 patients were tested by indirect immunofluorescence, and the specificity of anti-P450IID6 was ascertained by either enzyme immunoassay (ELISA) or Western blot using recombinant antigen or rat liver microsomes. RESULTS Anti-P450IID6 was found in only 6 of 235 patients (2.6%) with chronic active hepatitis (CAH) positive for hepatitis C virus (HCV) antibody and quantitative HCV-RNA with genotypes II and IV. The predominant epitopes on immunoblots were 66 and 50KD, a 10KD band being the newly underfined microsomal antigen. Even in the patients negative for autoantibodies to nuclear antigens (ANA) by routine indirect immunofluorescence test, various ANA were detected by the newly developed recombinant ELISA. These patients were younger, with lower gamma-globulin and IgG levels than patients with autoimmune hepatitis. Three of five patients with anti-P450IID6 responded well to interferon therapy and one received prednisone when interferon was ineffective. Interestingly, only this patient was diagnosed as definite autoimmune hepatitis according to the criteria proposed by the International Autoimmune Hepatitis Group (IAHG). The other five patients who did not satisfy the IAHG criteria might be considered as CAH-C with autoimmune features. No autoimmune hepatitis patients positive for anti-P450IID6 were identified in the current study, indicating that the variant is very rare in Japan. CONCLUSIONS Anti-P450IID6 in CAH-C patients in Japan is not as rare as expected. Anti-P450IID6 among Japanese patients has uncertain significance and precludes further characterization of CAH-C with autoimmune features, which might require interferon therapy.

Frequency and significance of antibodies to histones in autoimmune hepatitis

As part of ongoing studies to define the nature of anti-nuclear antibodies in autoimmune hepatitis and assess their clinical significance, we tested sera from 65 patients who had previously been screened for reactivities to recombinant ribonucleoproteins (U1RNP-A and U1RNP-70K), ribonucleoprotein complexes (52K SSA/Ro and 60K SSA/Ro) and centromere (Cenp-B) for antibodies to histones by enzyme immunoassay. Twenty-three specimens were reactive to histones (35%). Eleven of the 23 seropositive specimens were also reactive to other nuclear antigens (48%); 12 specimens (52%) were reactive only to histone. Histone-reactive sera did not have a characteristic pattern by indirect immunofluorescence. Patients with antibodies to histones were indistinguishable from other by age, gender, clinical and laboratory findings. HLA phenotype, or responses to corticosteroid therapy. Eighteen sera (28%) that had demonstrated nuclear reactivity by indirect immunofluorescence lacked reactivity to the five recombinant nuclear antigens and histones. We conclude that antibodies to histones are common in autoimmune hepatitis and that they are an important species associated with antinuclear reactivity. In some patients, they may be the only findings. Seropositive patients lack distinctive features or different outcomes after therapy. Reactivities against other nuclear antigens probably exist and remain undefined.

Effects of Lycopene and Sho-saiko-to on Hepatocarcinogenesis in a Rat Model of Spontaneous Liver Cancer

The Long-Evans Cinnamon (LEC) rat is a well-characterized model of spontaneous hepatocarcinogenesis. It has been shown that dietary administration of lycopene or the herbal medicine Sho-saiko-to (TJ-9) has anticarcinogenic activity, although the mechanism by which these products protect against carcinogenesis is not well known. We investigated the outcome of administration of lycopene and TJ-9 on the occurrence of hepatic neoplasia in LEC rats. A diet containing 0.005% lycopene (originally the product of tomato oleoresin containing 13% lycopene) and 1% TJ-9 (crude extracts of 7 herbs: bupleurum root, pinellia tuber, scutellaria root, jujube fruit, ginseng root, glycyrrhiza root, and ginger rhizome) was administered from 6 weeks of age until the rats were sacrificed at 76 weeks of age, at which time most of the nontreated animals were known to have hepatocellular carcinoma (HCC). Development of HCC in treated groups was analyzed histologically by comparison with untreated controls. Glutathione S-transferase placental form (GST-P) was analyzed by an immunohistochemical method. Concentration of copper, iron, and zinc, which appear to play a role in hepatocarcinogenesis in LEC rats, was analyzed. The percent areas of HCC in the liver specimens of control, lycopene, and TJ-9 groups were 17.9 ± 17.1%, 27.2 ± 20.8%, and 27.6 ± 18.4%, respectively. These intergroup differences were not significant. The percent area, number of areas, and mean size of area staining positively for GST-P revealed no significant differences between the groups. The number of GST-P-positive areas within the HCC lesions was greater in the TJ-9 group than in the control or lycopene group (p = 0.024 and p = 0.012, respectively). The study also demonstrated a lower concentration of iron in livers of the lycopene group than the control group (p = 0.019). There were no differences in serum α-fetoprotein levels or the cumulative survival rates between the groups. In conclusion, long-term administration of lycopene or TJ-9 did not reduce the risk of hepatocarcinogenesis in LEC rats.

High prevalence of antibodies to recombinant CENP‐B in primary biliary cirrhosis: Nuclear immunofluorescence patterns and ELISA reactivities

The purpose of the present study is to evaluate the centromeric pattern on human laryngeal tumour (HEp‐2) cells by indirect immunofluorescent (IIF) test and to compare their reactivities with a newly developed recombinant centromere protein B enzyme linked immunosorbent assay (CENP‐B ELISA) test using sera of antinuclear antibody (ANA)‐reactive primary biliary cirrhosis (PBC) patients. Antimitochondrial antibody (AMA) subtypes (PDC‐E2, BCOADC‐E2, OGDC, protein X, and PDC‐E1α) by Western blot were also investigated to see whether they have any effect on the expression of CENP‐B reactivities. A centromeric pattern (anticentromere antibody [ACA]) was detected in 11 of 25 (44%) PBC patients whereas CENP‐B reactivity was found in 15 (60%) of them. There were some differences in IIF patterns and CENP‐B reactivities. One PBC serum with indistinguishable ANA pattern reacted with CENP‐B. Eight of 15 (53%) CENP‐B reactive patients had other autoimmune‐like disorders. Of 181 healthy sera, none was reactive for ACA either by IIF or by ELISA test. There was a correlation between ACA IIF and CENP‐B ELISA titres (r= 0.824, P < 0.001). However, no correlation was observed between either CENP‐B or AMA reactivities and/or between either autoantibodies or laboratory and histologic indices of PBC. These findings suggest that recombinant CENP‐B ELISA appears to be more sensitive in identifying ACA than IIF, underlying its potential value as a screening test for the diagnosis of PBC complicated with other autoimmune‐like disorders. The presence of multiple autoantibodies in PBC sera may reflect heterogeneous antigens recognition, and requires further study to identify target antigens at cellular and molecular levels.