Tsunehisa Kawasaki

Serum thrombopoietin levels in patients with chronic hepatitis and liver cirrhosis

OBJECTIVES:Thrombocytopenia is a common manifestation of cirrhosis. The aim of this study was to examine the relationship between serum thrombopoietin concentrations, circulating platelet levels, and the stage of hepatic fibrosis in patients with chronic viral hepatitis.METHODS:The study included 48 patients with chronic viral hepatitis (14 with stage 1 fibrosis; five with stage 2 fibrosis; three with stage 3 fibrosis; 26 with cirrhosis) and 30 healthy volunteers. Serum thrombopoietin levels were measured using an enzyme-linked immunosorbent assay. Spleen size, platelet counts, and prothrombin time were measured.RESULTS:Thrombopoietin levels of patients with fibrosis stage 1 (2.50 ± 1.60 fmol/ml) or stage 2 (1.89 ± 0.65) were significantly higher than those in patients with cirrhosis (1.21 ± 0.55) or healthy volunteers (1.26 ± 0.74). Mean platelet counts of patients with cirrhosis (8.0 ± 4.6 × 104/μl) were significantly lower than those with fibrosis stage 1 (18.6 ± 3.9) or stage 2 (16.0 ± 5.8), or healthy volunteers (24.5 ± 7.3). Patients with cirrhosis had larger spleens (30.9 ± 18.4 cm2) than those with fibrosis stage 1 (18.2 ± 6.4). Platelet counts showed a significant inverse relationship to spleen size (ρ=−0.51, p < 0.0005) and a significant positive relationship with thrombopoietin levels (ρ= 0.34, p < 0.02). Thrombopoietin levels were significantly correlated to prothrombin time (ρ= 0.45, p < 0.005).CONCLUSIONS:Serum thrombopoietin levels are elevated in patients with an early stage of chronic viral hepatitis. As the disease progresses from mild fibrosis to cirrhosis, decreased production of thrombopoietin may contribute to the further development of thrombocytopenia in cirrhosis.

Successful interferon therapy reverses enhanced hepatic iron accumulation and lipid peroxidation in chronic hepatitis C.

OBJECTIVES:Hepatic iron deposition has been reported in chronic hepatitis C (CH-C), and iron-induced lipid peroxidation may be involved in the pathogenesis of CH-C. The aims of the present study were: 1) to determine whether patients with CH-C have evidence of enhanced hepatic lipid peroxidation and to evaluate its relation to iron status, compared with that in patients with chronic hepatitis B (CH-B); and 2) to assess the effect of interferon (IFN) therapy on hepatic iron and lipid peroxidation.METHODS:In the liver biopsies of 40 patients with CH-C and 26 patients with CH-B, immunohistochemical detection of 4-hydroxy-2-nonenal (HNE)-protein adducts for evaluation of lipid peroxidation was performed, and hepatic iron status was biochemically and histologically assessed. In 16 CH-C patients with normal serum transaminases and undetectable serum HCV-RNA >6 months after the end of IFN treatment (responders) and in 11 nonresponders, hepatic HNE-protein adducts and siderosis were evaluated in pre- and posttreatment liver biopsies.RESULTS:Hepatocytic HNE-protein adducts and iron deposits were more abundant in the patients with CH-C than in those with CH-B. No correlation was found between the levels of hepatocytic HNE-protein adducts and hepatic iron status in either of the two groups. In the responders to IFN treatment for CH-C, hepatocytic HNE-protein adducts disappeared or attenuated with improvement of hepatic siderosis after the treatment, whereas IFN treatment did not improve hepatocytic expression of HNE-protein adducts and hepatic siderosis in the nonresponders.CONCLUSIONS:Patients with CH-C have evidence of enhanced hepatic iron accumulation and lipid peroxidation compared to those with CH-B. In CH-C, hepatic siderosis and lipid peroxidation are improved with successful IFN treatment. These results suggest that hepatic lipid peroxidation and iron may potentially play contributory roles in the pathogenesis of CH-C.

Enhanced hepatic lipid peroxidation in patients with primary biliary cirrhosis.

OBJECTIVE:The mechanisms responsible for hepatic injury have not been fully clarified in primary biliary cirrhosis (PBC). It has recently been suggested that hepatic lipid peroxidation may be involved in the pathogenesis of PBC. The aims of the current study were to determine whether patients with PBC have evidence of enhanced hepatic lipid peroxidation and to evaluate its relationship to clinicopathological features.METHODS:Immunohistochemical detection of 4-hydroxynonenal (HNE) protein adducts was performed in the liver biopsies of 20 patients with PBC. Histological stages of PBC were evaluated. Orcein or Victoria blue staining was performed for detection of copper-associated proteins. The size of bile ducts was defined as the smallest diameter between the subepithelial basement membranes.RESULTS:All 20 patients had immunodetectable HNE protein adducts in the cytoplasm of damaged, but also intact, biliary cells. The mean diameter of bile ducts with HNE protein adducts was smaller than those without the adducts (61.0 ± 1.9 vs 122.5 ± 24.4 μm, respectively, p < 0.01). Out of 20 patients, 6 (30%) also had immunodetectable HNE protein adducts in hepatocytes preferentially located around the portal tracts. Most of the patients with hepatocytic HNE protein adducts had copper-associated protein granules in hepatocytes around the portal tracts and were classified as histological stage 3, whereas all of the patients without the adducts lacked copper-associated protein granules and were classified as histological stage 1 or 2. The patients with hepatocytic HNE protein adducts had higher levels of serum total bilirubin than did those without the adducts (2.9 ± 0.9 vs 0.7 ± 0.1 mg/dl, respectively, p < 0.01).CONCLUSIONS:Hepatic lipid peroxidation can occur in PBC and may be an early event in bile duct destruction. At advanced stages of PBC, hepatocellular lipid peroxidation may play a role in hepatocyte injury during cholestasis.

Failure to respond to interferon-alpha 2a therapy is associated with increased hepatic iron levels in patients with chronic hepatitis C.

ABSTRACTRecent reports suggest the hepatic iron concentration (HIC) may influence the activity of hepatitis and the response to interferon (IFN) therapy in patients with chronic hepatitis C (CH-C). We have evaluated iron status in 28 patients with CH-C and determined if pretreatment iron status can predict the response to IFN-α therapy in these patients. Increased serum iron, transferrin saturation, and ferritin levels were observed in 3 (11%), 11 (39%), and 5 (18%) patients, respectively. Hepatic iron deposits were histologically detected in 17 (61%) patients, and 14 of them had stainable hepatocytic iron. However, all HIC values were within the normal range (203–1279 μg/g). Seven of 17 patients treated with IFN-α for 6 mo had normalization of serum transaminases and disappearance of serum HCV-RNA (responders). Nonresponders had a significantly higher median HIC compared with responders (710 vs 343 μg/g, respectively;p < 0.05). There was no significant difference in other pretreatment iron parameters, serum HCV-RNA level, or HCV-genotype between responders and nonresponders. In conclusion, mild hepatic iron accumulation occurs in patients with CH-C. Increased hepatic iron stores are associated with poor response to IFN therapy. Pretreatment HIC may be an additional host-specific parameter with a predictive value for responsiveness to IFN therapy, in addition to well-known predictive viral factors.

Polyurethane-covered wallstents to recanalize wallstents obstructed by tumor ingrowth from malignant common bile duct obstruction

Four patients with malignant obstruction of the common bile duct had been treated with uncovered Wallstents and suffered from a reobstruction after 2–13 months (mean 5.3 months). Repeat cholangiography revealed severe stenosis of the stent lumen caused by tumor ingrowth through the mesh. A Wallstent with a self-made polyurethane-cover was inserted through the uncovered stent in these patients. The four patients were followed for 3–13 months (mean 6.3 months) until death. There was good drainage with no evidence of recurrent obstruction in all patients. We conclude that a covered Wallstent may extend patency of stented bile ducts, preventing tumor ingrowth in patients with neoplastic obstruction. Further observations are needed.

Interferon-α2a for chronic hepatitis B with e antigen or antibody: comparable antiviral effects on wild-type virus and precore mutant

Summary. Recombinant interferon‐α2a (IFN‐α2a) in a total dose of 702 MU was given to 31 patients: nine with wild‐type hepatitis B virus (HBV) and hepatitis B e antigen (HBeAg) (A); four with HBeAg and a mixed infection with wild‐type HBV and precore mutants (B); 11 with antibody to HBeAg (HBeAb) and a mixed infection (C); and seven with HBeAb and precore mutants alone (D). HBV DNA was not cleared in any patient in groups A and B. By contrast, in patients with HBeAb, HBV DNA was ultimately lost in four patients in group C, as well as in 10 patients in group D. Thus, patients with HBeAb and infected with precore mutants alone (D) lost serum HBV DNA more often than those with HBeAg and wild‐type HBV (A). Patients with low pre‐treatment levels of HBV DNA cleared virus more frequently, and the response of precore mutant to IFN was comparable with that of wild‐type HBV in patients who had a mixed infection. Based on these results, precore mutants do respond to IFN, and therefore, IFN is indicated in patients with HBeAb, especially those with low serum HBV DNA levels.

Glucose-6-phosphatase gene mutations in 20 adult Japanese patients with glycogen storage disease type 1a with reference to hepatic tumors

Background and Aims: A few cases are reported of liver neoplasms observed in patients with glycogen storage disease type 1a (GSD1a). Genetic analysis was carried out in adult Japanese patients with GSD1a and their family members, and hepatic tumors were also investigated in these patients.

Muscle cramps in chronic liver diseases and treatment with antispastic agent (eperisone hydrochloride)

To The Editor: Muscle cramps, which can be defined as involuntary and painful contractions of skeletal muscles, frequently occur in a variety of pathologic conditions related to neuromuscular, endocrine, or metabolic disease (1, 2), although muscle cramps sometimes occur in healthy persons. Among patients with liver disease, muscle cramps are most frequently seen in individuals with cirrhosis. Konikoff and Theodor reported that 88% of cirrhotic patients had experienced muscle cramps (3). We have prospectively determined the incidence of muscle cramps in patients with chronic liver diseases and in healthy individuals and have evaluated the effectiveness of treatment with eperisone hydrochloride, an antispastic agent (4), on muscle cramps in cirrhotic patients. One hundred seventy-six consecutive patients with chronic liver disease (103 males, 73 females, median age 54 years) visiting the liver clinic of Hamamatsu University Hospital and 142 healthy subjects (63 males, 79 females, median age 54 years) were examined. The group with chronic liver disease consisted of 80 patients with cirrhosis (44 males, 36 females, median age 59 years) and 96 patients with chronic hepatitis without cirrhosis (59 males, 37 females, median age 50 years). Patients with alcoholic liver injury were excluded because of the possibility that muscle cramps in alcoholics could be associated with alcoholic myopathy and/or neuropathy. No patients had drug-induced liver injury or any malignant neoplasm. Each subject was questioned about the frequency and localization of muscle cramps using a standardized questionnaire. Serum electrolytes (Na, K, CI, Ca) were measured in all of the cirrhotic patients, since a substantial number of these patients were taking diuretics flurosemide and/or spironolactone) for ascites and peripheral edema. An oral glucose tolerance test (75 g load) was also performed in all cirrhotic patients except for those who were known to be diabetic. The incidence of muscle cramps in patients with chronic liver diseases and healthy subjects is shown in Table 1. Twenty-five of 80 cirrhotics (31%) cornplained of frequent muscle cramps (more than once a week), while only 10 of 142 healthy subjects (7%) reported such a high frequency. The incidence of muscle cramps in the patients with chronic hepatitis without cirrhosis was 5%, which was not statistically different from healthy subjects. Most of muscle cramps (63% in the cirrhotics, 72% in patients with chronic hepatitis without cirrhosis, and 81% in healthy subjects) occurred in the calves. The incidence of muscle cramps in the toes, fingers, and thighs were 23%, 25%, and 19% for the cirrhotics, compared to 32%, I I%, and 5% for healthy subjects. The cirrhotic patients had a higher incidence of muscle cramps in the fingers or thighs than the patients with chronic hepatitis without cirrhosis or healthy subjects (P < 0.01). Serum electrolyte (Na, K, CI, Ca) concentrations as well as the administration of diuretics did not correlate with the frequency of muscle cramps in the patients with liver cirrhosis. There was no significant difference in the incidence of muscle cramps between cirrhotic patients with or without diabetes (27% versus 23%, respectively). To determine the efficacy of eperisone hydrochloride in the treatment of muscle cramps, doses of 150-300 mg per day were given orally to 21 of the 25 cirrhotic patients reporting frequent muscle cramps (more than once a week). This research was carried out in accordance with the Helsinki Declaration. Three of the remaining patients refused treatment, and one patient was not given the drug due to renal dysfunction. The frequency of muscle cramps was evaluated before and after eight weeks of treatment. Of 18 patients who continued the treatment for eight weeks, muscle cramps completely disappeared in 11 patients (61%), decreased in frequency in six (33%), and were unaltered in only one patient. Side effects were observed in four patients: fatigue occurred in one, epigastric discomfort in two, and dizziness in one patient. In three of these patients, the treatment was discontinued. No change in liver function tests was detected. The results of our study confirm the previous report that patients with liver cirrhosis experience a higher frequency of muscle cramps than healthy subjects (3). Although the pathophysiology of muscle cramps in liver cirrhosis still remains obscure, a suitable treatment for these distressing symptoms is

Case report: Hepatocellular carcinoma in type 1a glycogen storage disease with identification of a glucose-6-phosphatase gene mutation in one family.

Abstract A 40‐year‐old man with glycogen storage disease type 1a (von Gierke disease, GSD1a) developed hepatocellular carcinoma (HCC). Cold single‐strand conformation polymorphism (SSCP) with 12% glycerol identified the G727T mutation in the glucose‐6‐phosphatase (G6Pase) gene, which has been reported to be the most common mutation in Japanese GSD1a patients. This case report is the first documentation of HCC in a case with G727T mutation. Given the prevalence of HCC in GSD1a with various germline mutations, analysis is needed to confirm that the germline mutation in this case is really related to hepatocarcinogenesis. DNA analysis of the family pedigree of this case, revealed three individuals with GSD1a and seven heterozygous carriers of the G727T mutation. As the diagnosis of GSD1a in this family was made only after these three patients reached adulthood, DNA diagnosis may help early identification of GSD1a patients and prevention of the progression of the disease. This DNA‐based diagnosis permits prenatal diagnosis in at‐risk patients and may facilitate screening and counselling of patients clinically suspected of having this disease.

Response to Interferon-α2a in Patients with e Antigen-negative Chronic Hepatitis B

Sixty-eight consecutive patients with chronic hepatitis B received 702 million units of recombinant interferon-alpha 2a. Of the 24 patients negative for hepatitis B e antigen (HBeAg) in serum, the normalization of serum transaminase occurred in 14 (58%) at the completion of interferon therapy and in 13 (54%) at 12 months thereafter; it was normalized in 17 (39%) and 13 (30%), respectively, of the 44 HBeAg-positive patients. Of the HBeAg-negative patients, hepatitis B virus DNA was cleared from serum in six (25%) at the completion and in one (4%) at 12 months thereafter, in contrast to only one (2%, p < 0.05) and none of the HBeAg-positive patients, respectively. The 1896th nucleotide of G (G1896) for codon 28 for tryptophan or A (A1896) for the stop codon 28 in the precore region was determined by restriction fragment length polymorphism. The ten HBeAg-negative patients with A1896 only in the precore region had lower pretreatment levels of viral markers, which decreased more rapidly and extensively after interferon than in the 14 HBeAg-negative patients with a mixture of G1896 and A1896 or in the 44 HBeAg-positive patients. These results indicate that patients with HBeAg-negative chronic hepatitis B may respond better to interferon than HBeAg-positive patients, and that the precore mutant with the stop codon 28 may be sensitive to interferon.