Quantitative analysis of hepatitis C virus-specific CD8(+) T cells in peripheral blood and liver using peptide-MHC tetramers

It is believed that the hepatitis C virus (HCV)-specific CD8(+) cytotoxic T lymphocytes (CTLs) play a role in the development of liver cell injury and in the clearance of the virus. To develop a direct binding assay for HCV-specific CTLs, we generated two peptide-MHC tetramers by using the recombinant HLA A2.1 molecule and A2-restricted T cell epitopes of the HCV NS3 protein. With these reagents we are able to detect specific CD8(+) cells in the blood of 15 of 20 HLA-A2(+), HCV-infected patients, at a frequency ranging from 0.01% to 1.2% of peripheral CD8(+) T cells. Phenotypic analysis of these specific cells indicated that there is a significant variation in the expression of the CD45 isoforms and CD27 in different patients. A 6-hour incubation of one patient's blood with NS3 peptides resulted in the activation of the epitope-specific CD8(+) cells, as indicated by their expression of CD69 and IFN-gamma. We also detected NS3-specific CD8(+) T cells in the intrahepatic lymphocyte population isolated from liver biopsies of two HCV-infected patients. The frequency of these specific CD8(+) cells in the liver was 1-2%, at least 30-fold higher than in the peripheral blood. All of the intrahepatic NS3-specific CD8(+) T cells were CD69(+), suggesting that they were activated CTLs. Direct quantitation and characterization of HCV-specific CTLs should extend our understanding of the immunopathogenesis and the mechanism of clearance or persistence of HCV.

Progression of cardiomyopathy and neuropathy after liver transplantation in a patient with familial amyloidotic polyneuropathy caused by tyrosine-77 transthyretin variant

Familial amyloidotic polyneuropathy is an inherited form of amyloidosis associated with a mutant form of a protein called transthyretin. The Methionine-30 variant is the most frequent mutation observed. This disorder is caused by deposition of this protein as amyloid in several organs, such as the heart, kidneys, and peripheral nervous system. The disease is always progressive and fatal, and patients die 7 to 10 years after the onset of symptoms. Liver transplantation is at present the only choice for these patients because it provides improvement of symptoms and/or stops progression of the disease in most patients. We report the case of a patient who showed clear progression of cardiomyopathy and neuropathy after liver transplantation.

Response to treatment with interferon-alfa in patients with chronic hepatitis C and high titers of -M2, -M4 and -M8 antimitochondrial antibodies

The prevalence of antimitochondrial antibodies (AMA) in chronic hepatitis C is 2%; titers of AMA are usually low (< 1:40). The prevalence decreases to 0.5% when the results are verified by determination of the M2 subtype (anti-M2, ELISA). In patients in whom both hepatitis C virus (HCV) and AMA are present, the therapeutic decision to give interferon-alfa is complicated, because AMA may be 'real', and if it reflects primary biliary cirrhosis, cholestasis can be triggered or exacerbated. This does not occur when AMA positivity results from induction by hepatotropic C virus; however, this is rarely the case when AMA titers are high (> 1:160).

OBJECTIVE

to undertake a preliminary analysis of the submitochondrial profile of AMA in three patients with chronic hepatitis C and positive AMA titers (> 1:160).

METHODS

we determined antibodies to submitochondrial particles (subtypes) -M2, -M4 and -M8 by ELISA, complement binding (CB) and western immunoblotting with Immunoblot-M2 or WIB-M2 (immunoreactive bands).

RESULTS

two patients were positive for mitochondrial subtypes by ELISA (IgG/IgM subclass) and CB (ELISA M2 470/365 in patient 1 and 600/1370 in patient 2; M4 490/1200 in patient 2. CB M2 1:128, M4 1:64, M8 1:64 in patient 1, M2 1:128 in patient 2). Immunoreactive epitopes (bands) were detected with WIB-M2 for 70, 56, 51, 45 and 36-kDa molecules. Interferon-alfa treatment was unsuccessful, with biochemical exacerbation of cholestasis. In contrast, the patient with no submitochondrial particles according to ELISA, CB and WIB-M2 results responded favorable to this drug.

CONCLUSION

these preliminary results suggest that analyses to detect antibodies to submitochondrial particles (-M2, -M4 and -M8 subtypes) and -M2-immunoreactive epitopes in patients with chronic hepatitis C and AMA titers > 1:160 facilitates the diagnosis of primary biliary cirrhosis, and establishes a contraindication for treatment with interferon-alfa despite the presence of HCV infection.

High incidence of allograft cirrhosis in hepatitis C virus genotype 1b infection following transplantation: relationship with rejection episodes

The natural history of hepatitis C virus (HCV) infection following liver transplantation and predictors of disease severity remain controversial. The aims of the study were to assess in a homogeneous population of 81 cyclosporine-based HCV-infected liver transplant recipients mostly infected with genotype 1b and undergoing strict protocol annual biopsies: 1) the histological progression of posttransplantation HCV disease and, in particular, the incidence of HCV-related graft cirrhosis within the first 5 years after surgery; and 2) the relationship between progression to cirrhosis and i) rejection episodes and ii) first-year liver biopsy findings. We studied 81 consecutive HCV-RNA-positive patients (96% genotype 1b) undergoing liver transplantation between 1991 and 1996 with a minimum histological follow-up of 1 year. All patients received cyclosporine-based immunosuppression and underwent protocol yearly liver biopsies for the first 5 years. The mean histological follow-up was 32 months (range, 12-60 months). Biopsies were scored according to the histological activity index (HAI), with separate evaluation of grade (activity) and stage (fibrosis). Histological hepatitis, present in 97% of patients in the most recent biopsy, was moderate or severe in 64%. Twelve patients developed HCV-related cirrhosis at a median time of 24 months (range, 12-48 months), with an actuarial rate of HCV-cirrhosis of 3.7%, 8.5%, 16%, 28%, and 28% at 1, 2, 3, 4, and 5 years, respectively. Rejection was significantly more common among patients with cirrhosis versus those without (83% vs. 48%; P =.02), with an association between the incidence of cirrhosis and the number of rejection episodes: 5%, 15%, and 50% in patients without rejection, one and two episodes, respectively (P =.001). The degree of activity and fibrosis score in the first-year biopsy were higher in patients who developed cirrhosis than in those who did not (P =.008 and.18, respectively). In conclusion, HCV genotype 1b-infected liver recipients are at a high risk of developing graft cirrhosis in the first 4 to 5 years following transplantation, especially those with previous rejection episodes. First-year liver biopsies may help to sooner identify patients at the highest risk, improving further patient management.

[Incidence of de novo neoplasms after liver transplantation]

BACKGROUND

De novo malignancy developing after transplantation constitutes a well-known complication or organ transplantation, mainly described among renal recipients.

AIM

To determine the incidence of de novo internal malignancies (excluding therefore skin cancers and recurrent hepatocellular carcinoma) in a cohort of 183 patients undergoing liver transplantation (OLT) between 6/1/1991 and 12/1/1996 with a minimum follow-up of 12 months and under cyclosporine-azathioprine-prednisone.

PATIENTS AND METHODS

The study comprised 183 patients (mean age: 53 [8] years, with 70% males) whose charts were reviewed retrospectively. Rejection, steroids treatment, methyl-prednisolone bolus and OKT3 use were compared in the cases and in the matched control group.

RESULTS

Seven malignancies were detected: 3 lung carcinomas, 1 larynx, 1 prostate, 1 colon and 1 ovarian. The mean age was 53 (8) years. The diagnosis of cancer was made at an average time of 24 (17) months (range, 10-54) post-OLT. Three patients died with a mean survival of 31 (16) months. OLT indication was mainly for viral liver disease (5/7). Although not statistically significant, immunosuppression data were higher among patients with cancer than in the matched group. Two additional patients developed post-transplantation lymphoproliferative diseases at 2 and 9 months, respectively.

CONCLUSION

We observed a wide variety of malignancies after OLT, but no associated factor was found, even though there was a trend to higher doses of immunosuppression in patients with cancers. The institution of preventive measures and surveillance programs may allow for early institution of therapy, improving therefore the survival.

Liver transplantation in hepatitis C. A Spanish multi-centre experience

OBJECTIVE

The purpose of this retrospective survey was to determine the prevalence and outcome of hepatitis C virus (HCV) infection in cirrhotic patients undergoing liver transplantation (OLT) in Spain in 1992.

METHODS

Post-OLT HCV infection was defined by anti-HCV (second-generation ELISA) and/or PCR. Patients were divided into groups A (HCV-positive pre-OLT: n = 124, 46%) and B (HCV-negative pre-OLT: n = 145, 54%).

RESULTS

HCV infection was more prevalent in patients originally diagnosed as having non-A non-B cirrhosis (97%) and cryptogenic cirrhosis (79%) than in patients with cholestatic or metabolic diseases. Group A patients were older (53.3+/-7.9 versus 47.6+/-9.7; P< 0.05) and had a higher prevalence of hepatocellular carcinoma (22% versus 4%, P< 0.05). Post-OLT HCV infection was 99% in group A versus 4% in group B (P< 0.05). Histological hepatitis developed in 39% (66% in group A versus 14% in group B, P< 0.05) with similar follow-up. Chronic rejection occurred in 6% (3% in group A versus 8.5% in group B, P= 0.07). Retransplantation rate (overall 8%) and two-year patient survival did not differ between groups (79% versus 72%). Graft survival was higher in group A (74% versus 65% at 2 years, P= 0.04).

CONCLUSIONS

HCV-cirrhosis represented the most frequent indication for OLT in Spain in 1992. While HCV recurrence was universal, de novo acquisition was rare. HCV accounted for most post-OLT hepatitis (87%), but was not associated with chronic rejection, nor with a higher retransplantation rate. Patient survival was not different in HCV patients compared to a control group after a follow-up of 2-3 years. Therefore, at present, HCV-cirrhosis is an acceptable indication for OLT.

Early development of chronic active hepatitis in recurrent hepatitis C virus infection after liver transplantation: association with treatment of rejection

BACKGROUND/AIMS

We retrospectively studied 63 consecutive patients (mean age 54+/-8) with hepatitis C virus genotype 1b recurrence after liver transplantation and with a minimum histological follow-up of 1 year, in order to determine whether an early severe recurrence, defined as the development of chronic active hepatitis within the first 2 years post-liver transplantation, was associated with increased immunosuppression.

METHODS

The 1st year immunosuppression data (rejection episodes, boluses of methyl-prednisolone, cumulative doses of prednisone and azathioprine, OKT3 use) were recorded, and evaluated as predictive of severe recurrence at 1 and 2 years post-liver transplantation. Chronic active hepatitis and rejection were defined by histological criteria. Immunosuppression consisted of cyclosporine, azathioprine and prednisone. The treatment of rejection was based on a "bolus" of 1 g methyl-prednisolone/3 days.

RESULTS

At 1 year, 64% (40/63) of the patients had chronic active hepatitis, whereas of the 40 patients who had a 2nd year biopsy available, 75% had chronic active hepatitis at 2 years. At 1 year post-liver transplantation, no significant association was observed between immunosuppression and the development of chronic active hepatitis. In contrast, at 2 years, rejection (p=0.006), treatment of rejection (p=0.05), methyl-prednisolone boluses (p=0.013) and the number of rejection episodes (p=0.0034) occurring during the 1st year post-liver transplantation were significantly more common in patients with chronic active hepatitis. There was also a trend towards higher cumulative steroids (9447+/-3176.5 vs 7891.5+/-2111 mg) and higher cumulative azathioprine doses (13472+/-11154 vs 6233.5+/-5937 mg) in patients with chronic active hepatitis as compared to those who did not develop chronic active hepatitis.

CONCLUSIONS

Rejection and/or its treatment may accelerate the natural history of hepatitis C virus genotype 1b infection post-liver transplantation.

Hepatitis B and C viruses: molecular identification and targeted antiviral therapies

Four agents are in clinical development for the treatment of chronic hepatitis B infection. These nucleoside analogs are incorporated into the growing DNA chain and terminate replication. Lamivudine, a cytadine analog that inhibits the synthesis of negative strand DNA from pre-genomic RNA, predictably inhibits replication and improves liver enzymes and histology in infected individuals. Following cessation of treatment, relapse is common, and genetic causes of viral resistance have been described. Other drugs for HBV infection include famciclovir, a guanosine analog that has also shown to suppress replication in immunocompetent as well as in immunocompromised patients; lobucavir, a guanosine analog; and adevfovir, an adenine nucleotide analog. The future of drug therapy against HBV likely includes combination agents with one or more nucleoside/nucleotide analogs and immune stimulants, such as interferon, or therapeutic vaccines. Recent advances in the treatment of HCV have been less impressive. An effective vaccine is greatly needed yet development in the near future is unlikely. Recommendations for therapy of chronic HCV have been proposed following the National Institutes of Health Consensus Conference. Interferon alpha is advised in patients with elevated serum alanine aminotransferases and liver histology demonstrating active hepatitis, regardless of level of pretreatment viremia or infecting genotype. Therapy should be continued for three months, at which time response should be assessed. If a biochemical and/or virological response has been achieved, treatment should be continued for a year. Trials are underway to evaluate interferon in combination with ribavirin. Recent identification of the crystalline structure of the HCV NS3 protease promises development of effective inhibitors of this critical viral enzyme.

Treatment of chronic hepatitis C with interferon-alpha. Clinical histological and virological implications

OBJECTIVE

to identify pretreatment predictive factors of long-term biochemical and virological response to interferon-alpha in chronic hepatitis C and to determine the effects of a second course of interferon-alpha in patients who responded but relapsed after interferon withdrawal.

DESIGN

retrospective analysis.

SETTING

outpatient liver clinic of a tertiary hospital in Spain.

PATIENTS

112 patients with chronic hepatitis C were treated with recombinant interferon-alpha (3 MU three times a week for 6 months). Twenty-four patients who responded but relapsed after interferon withdrawal were treated with a second course of interferon (3 MU three times a week for 12 months).

RESULTS

seventy-two patients were non-responders (64%), 11 patients had a sustained response (10%) and 29 patients responded but relapsed after interferon withdrawal (26%). Five (25%) of the 24 patients who relapsed and were treated with a second course of interferon experienced a sustained response (mean follow-up: 10 months). By multivariate analysis, four pretreatment variables were found to be predictive of a complete response: age < 40 years (p = 0.0004), history of IVDA (p = 0.001), low serum levels (p = 0.013), and genotype 3 (p = 0.01). Two variables were found to be predictive of a sustained response: short duration of HCV infection (p = 0.09) and genotype 3 (p = 0.01). Sustained responders appeared to have lower HCV-RNA levels than those with complete response who relapsed and non-responders. HCV viremia levels were not associated with the severity of liver histology, duration of disease or the source of hepatitis.

CONCLUSIONS

in the present study a low sustained response rate was observed using a standard interferon-alpha regimen (3 MU three times a week for 6 months). The sustained response rate increased slightly with a second course of interferon-alpha (3 MU three times a week for 12 months) in patients with a complete response who relapsed after interferon withdrawal. Sustained response is related to viral genotype and duration of HCV infection.

Hyperlipidemia in liver transplant recipients: prevalence and risk factors

Hyperlipidemia is common in transplant patients. Although a causal relationship to the use of cyclosporine is accepted, additional risk factors are as yet unidentified. Eighty-five liver transplant recipients treated with standard triple immunosuppression with a survival of at least 6 months were evaluated. Pretransplantation and posttransplantation variables were analyzed as predictive factors of posttransplantation hyperlipidemia. Serum cholesterol and triglyceride levels were considered elevated if they were > 250 mg/dL and > 150 mg/dL, respectively. Before and after transplantation, hyperlipidemia occurred in 8% (95% confidence interval [CI], 3% to 16%) and 66% (95% CI, 55% to 76%), respectively. After transplantation, 47% (95% CI, 36% to 58%) of the patients had isolated high triglyceride levels, 12% (95% CI, 6% to 21%) had both elevated cholesterol and triglyceride levels, and 7% (95% CI, 3% to 15%) had isolated elevated cholesterol levels. Hypertriglyceridemia occurred early after transplantation (67% by first month) and persisted nearly unchanged throughout the first year. In contrast, cholesterol levels increased with time (5%, 13%, and 27% at 1, 3, and 6 months, respectively). In univariate analysis, factors predictive of hypercholesterolemia included female sex, pretransplantation cholestatic liver disease, pretransplantation cholesterol levels > 141 mg/dL, and > 3 methylprednisolone "boluses." In multivariate analysis, only a pretransplantation cholesterol level of > 141 mg/dL (odds ratio [OR], 5.5; 95% CI, 1.4 to 21) was an independent risk factor. Risk factors associated with hypertriglyceridemia included pretransplantation hepatocellular liver disease (OR, 6.8; 95% CI, 1.2 to 40) and posttransplantation renal dysfunction (OR, 5.4; 95% CI, 1.9 to 15.4). Hyperlipidemia is a frequent finding in liver transplant recipients, and hypertriglyceridemia is the most common abnormality. Hypertriglyceridemia can be predicted on the basis of pretransplant hepatocellular disease and posttransplant renal dysfunction. Pretransplant serum cholesterol level is an independent risk factor for posttransplant hypercholesterolemia.

Hepatitis G virus infection in patients with hepatitis C virus infection undergoing liver transplantation

BACKGROUND & AIMS

Hepatitis G virus (HGV) is transmissible by blood transfusion, but its role in chronic liver disease is unknown. The aim of this study was to determine the prevalence of HGV infection in patients infected with hepatitis C virus (HCV) undergoing transplantation and evaluate the effects of HGV coinfection on the course of posttransplantation HCV infection.

METHODS

One hundred twenty-four patients infected with HCV undergoing liver transplantation were studied. Serum samples were tested for HCV and HGV RNA; HCV RNA was quantitated by branched DNA assay, and HCV genotype was determined.

RESULTS

The prevalence of pretransplantation and posttransplantation HGV infection was 24% and 28%, respectively. Pre-transplantation HGV infection was positively correlated with posttransplantation HGV infection (P < 0.001). Pretransplantation clinical features were not different in patients infected with HCV with and without HGV infection. Posttransplantation HCV RNA levels were not significantly different in patients with and without HGV coinfection, but HCV genotype 1b was more frequent in patients with HGV coinfection. There were no differences in the histological severity of posttransplantation liver disease, graft, and patient survival between patients with and without HGV infection.

CONCLUSIONS

Although HGV coinfection is frequent in patients with end-stage HCV disease undergoing liver transplantation, there is no association between the presence of HGV coinfection and the severity of liver disease post-transplantation, graft, or patient survival.

[Isolated hepatic transplant in patient with cystic fibrosis]

Cystic fibrosis (CF) is a recessive autosomic disease with multiorgan, although predominantly pancreatic and pulmonary, involvement. Liver involvement is infrequent in children under the age of 5 years, but increases progressively with time. It is characterized by the development of focal biliary cirrhosis with eventual appearance of portal hypertension. During the last few years the more effective control of the pulmonary complications, which are the main cause of mortality, has led to an increase in the survival of these patients and thus the number of patients with CF and liver involvement is greater every day. In these cases, the prognosis is bad and most patients die in 4 to 5 years. Isolated liver transplantation is a recently proposed alternative for patients who have developed liver cirrhosis but who maintain acceptable pulmonary function. The case of a 14-years-old patient in whom liver transplantation was performed with good results after 8 months of follow-up is presented. Improvement in the nutritive state and pulmonary function was observed.

[Familial prevalence in chronic intestinal inflammatory disease. Differences among groups of patients with and without a familial history]

OBJECTIVE

To assess the prevalence of familial occurrence in patients with inflammatory bowel disease and to evaluate the differences among groups of patients with and without familial history.

PATIENTS AND METHODS

Complete information about sex, age of onset of inflammatory bowel disease, initial location, extracolonic manifestations and perianal disease (in Crohn's disease) was obtained from 187 patients, 99 with Crohn's disease, and 88 with ulcerative colitis.

RESULTS

In 9 patients (9%) with Crohn's disease and 11 (12.5%) with ulcerative colitis, at least one first-degree relative also had inflammatory bowel disease. Three relatives of patients with Crohn's disease had ulcerative colitis and no relative of patients with ulcerative colitis had Crohn's disease. As compared with the group of patients with ulcerative colitis and no familial history, patients with familial history had more frequently distal location and extra-colonic manifestations. No differences were observed among patients with Crohn's disease and familial or non familial history.

CONCLUSIONS

Prevalence of inflammatory bowel disease in relatives of patients with Crohn's disease or ulcerative colitis is increased. In ulcerative colitis, it is possible to segregate two different groups according to familial history.

[Chronic autoimmune hepatitis following cholestatic hepatitis caused by droxicam]

Droxicam in a nonsteroid antiinflammatory from the oxicam family which acts as a pro-drug, being transformed into pyroxicam after being hydrolized in the stomach and has induced several cases of cholestatic or mixed hepatitis. A clinical observation in which droxicam provoked initial cholestatic hepatitis which later developed into chronic autoimmune hepatitis is presented. It has been postulated that, after causing cholestatic hepatitis by hypersensitivity and within the context of a previous autoimmune entity such as vitiligo, this drug triggered a silent autoimmune liver disease which was demonstrated clinical, analytical and histopathological manifestations 18 months later and required permanent immunosuppressive treatment.

[Droxicam-induced toxic hepatitis]

We present four cases of hepatitis with clinical features indicating a direct link with Droxicam. In all the cases, the presentation was that of acute hepatitis with subsequent resolution, whereas one patient developed autoimmune chronic active hepatitis. A full evaluation including ultrasound, liver biopsy, and serologic markers supported the diagnosis. Due to the fact that the "Dirección General de Farmacia y Productos Sanitarios" has approved the postponement of dispensation of products with Droxicam from February 25, 1995, this drug should not be considered anymore in the future as a potential cause of liver injury (acute or chronic hepatitis).

Genome detection in liver and peripheral blood mononuclear cells: predictor factors of sustained response in patients with chronic hepatitis C

BACKGROUND

In chronic hepatitis C, relapses of liver disease occur in as many as 50% of patients responding to interferon (IFN) therapy. Although the presence of serum hepatitis C virus (HCV) RNA at the end of therapy predicts a relapse, its absence is not a reliable indicator of cure. In this study we have determined whether responders to IFN (normalization of liver chemistry and clearance of serum HCV-RNA) harbour HCV-RNA in the liver and peripheral blood mononuclear cells (PBMCs), and whether finding the genome at these sites has prognostic significance.

METHODS

After the conclusion of therapy, we tested for HCV-RNA in the liver of all the patients (anti-HCV-positive): 16 complete responders with normalization of liver chemistry and clearance of serum HCV-RNA and five non-responders. In 13 of the 16 complete responders we also tested for HCV-RNA in PBMCs. Patients were followed up for 9 months.

RESULTS

Liver HCV-RNA was detected in each of the five non-responders and in four of the 16 complete responders (25%). The viral genome was detected in the PBMCs of six complete responders (46%). During follow-up a relapse of hepatitis C occurred in the 10 complete responders with liver or PBMC HCV-RNA but in only one (16%) of the six complete responders without HCV-RNA in liver or PBMCs.

CONCLUSION

Reliable information on the prognosis of chronic hepatitis C responders can only be obtained by testing for HCV-RNA in serum, liver and PBMCs at the end of therapy. Patients with HCV-RNA at any of these sites stand a high risk of disease relapse. The risk is low but not abolished in patients without detectable HCV-RNA.

[Prevalence and clinical significance of autoantibodies in chronic hepatitis C treated with interferon alfa]

Autoantibodies against non organ-specific may be induced by IFN treatment in HCV liver chronic disease. In order to assess this issue and its clinical significance, 44 patients with chronic hepatitis C (anti HCV and RNA-HCV +) treated with IFN were evaluated. In 13 patients (29.5%) the following autoantibodies were detected during the treatment: AAML (5), AAN (9), ALK-M (4). Only in the A-LKM + patients there was a slight increase in aminotransferases with a reappearance of the viremia. Moreover 2 of these patients showed a flare of their liver disease without systemic findings. During the follow up (28) months one of the patients normalized the aminotransferases with clearance of serum HCV RNA. There were no statistical differences in the sustained response rate between patients with (2/13) or without (4/31) autoantibodies. The development of AAN, AAML and ALKM at low titer during IFN treatment in CH-C is without clinical relevance. However, ALKM detection is occasionally associated with the "breakthrough" phenomenon with HCV eradication, suggesting an immuno-modulatory activity of IFN.

Does the healthy hepatitis C virus carrier state really exist? An analysis using polymerase chain reaction

To determine whether the presence of hepatitis C virus (HCV) viremia correlates with the severity of liver disease in anti-HCV-positive apparently healthy blood donors, we studied 98 blood donors found positive for anti-HCV using enzyme-linked immunosorbent assay (ELISA). Each subject underwent a liver biopsy, a test for HCV RNA in the serum by polymerase chain reaction (PCR), and a panel of liver injury tests. As a result, 97% of the anti-HCV-positive blood donors had some type of histological abnormality:22 (22%) had minimal changes, 1 (1%) had chronic lobular hepatitis, 40 (41%) had chronic persistent hepatitis (CPH), and 32 (33%) had chronic active hepatitis (CAH). Only 3 subjects had a normal liver histology. HCV RNA was detectable in the serum in 65% of the anti-HCV-positive donors. HCV RNA in serum was detectable in none of the donors with a normal liver histology, in 36% (confidence interval [CI], 17% to 59%) of those with minimal changes, in 70% (CI, 53% to 83%) of those with CPH, and in 87% (CI, 71% to 96%) of those with CAH (P = .00001). HCV RNA was detectable in 75% of the donors with elevated (> 45 U/L) alanine transaminase (ALT) values and in 59% of those with normal ALT levels (P = not significant). The incidence of chronic hepatitis was higher in HCV RNA-positive than in HCV RNA-negative donors (88% vs. 50%; P = .00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic sclerotherapy versus oesophageal transection in the prevention of variceal rebleeding

OBJECTIVE

To compare sclerotherapy with oesophageal transection in the prevention of rebleeding in patients with oesophageal varices.

DESIGN

A prospective trial.

PATIENTS

Forty-one patients with cirrhosis and variceal bleeding.

METHODS

After recovering from an acute episode of oesophageal variceal bleeding patients were randomized into two groups. One patient was excluded. Twenty-two patients were treated with sclerotherapy (group 1) and 18 underwent an oesophageal transection (group 2), with a shorter elapsed time from randomization to treatment in group 1. Both groups were similar with regard to clinical and biochemical features and variceal size. Failure, defined in group 1 as rebleeding or incomplete eradication after four sclerotherapy sessions, occurred in five (22.7%) patients; in group 2, rebleeding occurred in two (11.1%) patients (no statistically significant difference).

CONCLUSION

Although the survival rate was similar in both groups, sclerotherapy is preferable to oesophageal transection because it requires a shorter duration of hospitalization and has fewer complications.

[Combined endoscopic treatment with extracorporeal lithotripsy in chronic calcifying pancreatitis]

In the management of severe chronic pancreatitis, a variety of new endoscopic methods have been proposed as an alternative to traditional surgery. The main goal of these procedures is the remission of pain. They include pancreatic endoscopic sphincterotomy with subsequent endoscopic extraction, which can be associated to extracorporeal shock-wave lithotripsy for stone desintegration before removal of large calculi, and to the insertion of a pancreatic stent in case of a pancreatic duct stricture. We present two cases of severe chronic pancreatitis managed successfully with this endoscopic treatment.