Chronic renal allograft dysfunction: the role of T cell-mediated tubular epithelial to mesenchymal cell transition

Chronic graft dysfunction is now the leading clinical problem after renal transplantation. The principal histopathologic lesion seen in this disease is tubular loss with concurrent interstitial fibrosis. Although the severity of acute rejection often correlates with that of subsequent chronic dysfunction, a direct link between these processes has remained elusive. This study was designed to test the hypothesis that intraepithelial T cells recruited to the renal tubules during acute rejection can directly induce fibrosis by causing tubular epithelial cells to undergo transformation to produce a motile population of activated fibroblasts. A study of renal allograft tissue sections showed the presence of the S100A4 marker of epithelial to mesenchymal transition in some tubular epithelial cells; the expression of this antigen was heterogeneous both within and between individual tubular cross-sections. Significantly, S100A4-expressing epithelial cells were frequently associated with infiltrating CD8+ T cells, and many coexpressed the Ki67 marker of proliferation. A parallel study of human renal cortical epithelial cells in primary culture demonstrated that S100A4 was induced by stimulation for 72 h with TGF-beta(1) and by direct contact with membrane-associated TGF-beta on MOLT-16 cells, a model intraepithelial T-cell line. Further experiments demonstrated that induction of transition coincided with a significantly increased potential for human renal epithelial cells to invade the tubular basement membrane. These data are consistent with a model in which intratubular T cells can present TGF-beta and directly induce adjacent tubular epithelial cells to transform to proliferating fibroblasts that migrate across the tubular basement membrane, producing fibrotic lesions within the renal interstitium.

Characterization of the genome and structural proteins of hepatitis C virus resolved from infected human liver

In the absence of satisfactory cell culture systems for hepatitis C virus (HCV), virtually all that is known about the proteins of the virus has been learned by the study of recombinant proteins. Characterization of virus proteins from patients with HCV has been retarded by the low virus titre in blood and limited availability of infected tissue. Here, the authors have identified a primary infection in a liver transplanted into an immunodeficient patient with chronic HCV. The patient required re-transplant and the infected liver, removed 6 weeks after the initial transplant, had a very high titre of HCV, 5 x 10(9) International Units (IU) per gram of liver. The density distribution of HCV in iodixanol gradients showed a peak at 1.04 g x ml(-1) with 73 % of virus below 1.08 g x ml(-1). Full-length HCV RNA was detected by Northern blotting and the ratio between positive- and negative-strand HCV RNA was determined as 60. HCV was partially purified by precipitation with heparin/Mn(2+) and a single species of each of the three structural proteins, core, E1 and E2, was detected by Western blotting. The molecular mass of core was 20 kDa, which corresponds to the mature form from recombinant sources. The molecular mass of glycoprotein E1 was 31 kDa before and 21 kDa after deglycosylation with PNGase F or endoglycosidase H. Glycoprotein E2 was 62 kDa before and 36 kDa after deglycosylation, but E2-P7 was not detected. This was in contrast to recombinant sources of E2 which contain E2-P7.

Covalent modification as a mechanism for the breakdown of immune tolerance to pyruvate dehydrogenase complex in the mouse

The autoimmune liver disease primary biliary cirrhosis (PBC) is characterized by the breakdown of normal immune self tolerance to pyruvate dehydrogenase complex (PDC). How tolerance is broken to such a central and highly conserved self antigen in the initiation of autoimmunity remains unclear. One postulated mechanism is that reactivity arises to an altered form of self antigen with subsequent cross-reactivity to native self. In this murine study, we set out to examine whether sensitization with a covalently modified form of self PDC can give rise to the pattern of breakdown of B-cell and T-cell tolerance to self PDC seen in PBC patients. The notion that altered self can lead to tolerance breakdown was studied by sensitizing SJL/J mice with a covalently modified (biotinylated) preparation of self murine PDC (mP/O-B). Subsequently, antibody and T-cell reactivities to unmodified self mP/O were studied. Sensitization with mP/O-B elicited high-titre, high-affinity antibody responses reactive with both the mP/O-B immunogen and, importantly, native mP/O. In addition, significant MHC class II restricted splenic T-cell responses to native mP/O (i.e., true autoimmune responses) were seen in mP/O-B sensitized animals. The breakdown of T-cell self tolerance to mP/O was not seen in animals sensitized with irrelevant biotinylated antigens. In conclusion, this study provides evidence to support the concept that exposure to covalently modified self PDC can, in the correct proimmune environment, replicate the full breakdown of B-cell and T-cell immune tolerance to PDC seen in PBC. One potential etiological pathway in PBC therefore could be the breakdown of tolerance to self PDC occurring after exposure to self antigen covalently modified in the metabolically active environment of the liver.

Monitoring methotrexate-induced hepatic fibrosis in patients with psoriasis: are serial liver biopsies justified?

BACKGROUND

Reports that up to 26% of subjects with psoriasis develop cirrhosis have led to a recommendation of serial liver biopsies after each cumulative dose of 1500 mg of methotrexate.

AIM

To evaluate the progression of liver injury in patients with psoriasis and the impact of monitoring by liver biopsy on their management.

METHODS

One hundred and twenty-one liver biopsies from 66 subjects (aged 11-79 years) with psoriasis, receiving a median cumulative dose of 3206 mg of methotrexate over a period of 280.5 weeks, were evaluated.

RESULTS

The assessment of advanced fibrosis according to the Ishak system (>or= 4) correlated perfectly with that of the Scheuer system (>or= 3) and poorly with that of the Roenigk scale (>or= 3b) (r2 = 1.0 and 0.31, respectively). Two of 24 pre-treatment biopsies showed advanced fibrosis and both subjects were heavy drinkers. The cumulative probabilities of advanced fibrosis (Ishak >or= 4) were 0%, 2.6%, 2.6%, 8.2% and 8.2% at cumulative doses of 1500, 3000, 4500, 5000 and 6000 mg, respectively. None of the subjects developed cirrhosis during follow-up or discontinued therapy on the basis of liver biopsy findings.

CONCLUSIONS

Advanced hepatic fibrosis with low-dose methotrexate therapy is much less frequent than previously reported. Pre-treatment or monitoring liver biopsies in accordance with the current guidelines have little impact on patient management.

Bacterial motif DNA as an adjuvant for the breakdown of immune self-tolerance to pyruvate dehydrogenase complex

Bacterial DNA containing unmethylated CpG dinucleotide motifs is immunostimulatory to mammals, skewing CD4(+) T-cell responses toward the Th1 phenotype. Autoreactive T-cell responses seen in primary biliary cirrhosis (PBC) are typically of the Th1 phenotype, raising the possibility that bacterial DNA might play a role in the generation of pathologic autoimmunity. We therefore studied the effects of CpG motif-containing oligodeoxynucleotides (ODN) on responses to pyruvate dehydrogenase complex (PDC, the autoantigen in PBC) in a murine model. Sensitization of SJL/J mice with non-self-PDC has been shown to result in induction of autoreactive T-cell responses to PDC sharing characteristics with those seen in patients with PBC. Administration of CpG ODN to SJL/J mice at the time of sensitization with PDC resulted in a significant skewing of splenic T-cell response to self-PDC, with significant augmentation of the Th1 cytokine response (interleukin [IL] 2 and interferon [IFN] gamma) and reduction of the Th2 response (IL-4 and IL-10). In fact, CpG ODN seemed to be more effective at biasing the response phenotype and as effective at inducing liver histologic change as complete Freund's adjuvant (CFA), the standard adjuvant used for induction of Th1 responses in murine autoimmune and infectious immunity models. In conclusion, our findings raise the possibility that bacteria play a role in the development of autoimmunity (in PBC at least) through the potential of their DNA to shift the T-cell responses toward the phenotype associated with autoimmune damage. Moreover, this study suggests caution in the therapeutic use of CpG ODN as vaccine adjuvants.

Primary biliary cirrhosis and other ductopenic diseases

Several distinct conditions are characterized by a reduction in the number of small and medium-sized intrahepatic bile ducts. These diseases are associated with progressive cholestasis, which in turn leads to biliary fibrosis and ultimately cirrhosis. The best-characterized ductopenic condition in adulthood is primary biliary cirrhosis (PBC) for which there is now strong evidence of an autoimmune cause. The antigenic targets are epitopes on proteins of the 2-oxoacid dehydrogenase complex within mitochondria. Some of these proteins appear to be aberrantly expressed at the surface of cholangiocytes in PBC. The basis for the breakdown in tolerance remains uncertain, although there is recent evidence to indicate that apoptosis may play a key role at early stages in the pathogenesis of the disease. Related conditions include autoimmune overlap syndromes and AMA-negative PBC (autoimmune cholangitis). Primary sclerosing cholangitis is clinically and histologically distinct, although there is evidence that it also may have an immune-mediated cause. Ductopenia may also arise on the basis of drug-induced injury; the best example of this is progressive cholestasis complicating chlorpromazine therapy.

Hepatitis and liver dysfunction with rifampicin therapy for pruritus in primary biliary cirrhosis

There is evidence to suggest that rifampicin is an effective second line therapy for controlling pruritus in patients with chronic cholestatic liver disease. It is most widely used as an antipruritic agent in the autoimmune cholestatic liver disease, primary biliary cirrhosis (PBC). Rifampicin has been reported as causing hepatitis in patients being treated for tuberculosis. Most reports of this have been confounded however by the concurrent use of other hepatotoxic antitubercular therapy. Here we report a single centre experience of the use of rifampicin in PBC, and describe three cases of significant hepatitis associated with rifampicin therapy. Two of these patients had significant impairment of liver synthetic function (necessitating liver transplantation in one case). These are the first reports of impaired hepatic synthetic function due to rifampicin monotherapy. Rifampicin caused significant hepatitis in 7.3% (95% confidence interval 2.5-19.4%) of patients treated for cholestatic liver disease in our centre.

Investigation of a mechanism for accelerated breakdown of immune tolerance to the primary biliary cirrhosis-associated autoantigen, pyruvate dehydrogenase complex

Primary biliary cirrhosis (PBC) is an autoimmune liver disease characterized by autoreactive T- and B-cell responses to the highly conserved enzyme pyruvate dehydrogenase complex (PDC). In this study we have examined the breakdown of T-cell tolerance to self-PDC using a mouse model. Female SJL/J mice were sensitized intraperitoneally with foreign-PDC (bovine) and/or self-PDC (murine) in complete Freund's adjuvant, and serum, spleen, and liver tissue was taken 8 weeks later. Animals sensitized with foreign-PDC produced IgG antibodies that were reactive with both foreign and self-PDC, but splenic T cells from these animals only responded to stimulation with foreign PDC. Sensitization with self-PDC elicited neither antibodies nor reactive T cells. Significantly, cosensitization with mixed self-PDC and foreign-PDC resulted in a full breakdown of self-tolerance, with generation of both antibody and T-cell responses to self-PDC of the type seen exclusively in human PBC patients. Mild bile duct lesions deficient in CD8(+) T cells were seen 8 weeks after sensitization with either foreign or self-PDC. However, after sensitization with mixed self-PDC and foreign-PDC, these lesions were significantly larger and heavily infiltrated by CD8(+) T cells. Liver-infiltrating T cells derived from the self-PDC and foreign-PDC cosensitized but not from control animals showed reactivity with self-PDC, suggesting a possible role for autoreactive PDC-specific T-cell responses in the pathogenesis of the observed histologic changes. It is likely that B-cell cross-reactivity between foreign and self-PDC enhances the potential for breakdown of T-cell self-tolerance by allowing efficient presentation of self-antigens in the inoculum. This model may provide a useful system for investigating the etiology and treatment of PBC.

Familial primary biliary cirrhosis and autoimmune cholangitis

AIM

Autoimmune cholangitis has been proposed as a separate disease entity from primary biliary cirrhosis without serum antimitochondrial antibodies. The ultimate answer to the question of whether autoimmune cholangitis and primary biliary cirrhosis are distinct will require detailed comparison of aetiologic factors and pathogenic mechanisms.

METHODS AND RESULTS

Two families are described each of which has one member with classical antimitochondrial antibody positive biopsy-proven primary biliary cirrhosis and a first degree relative with antimitochondrial antibody negative but antinuclear antibody positive autoimmune cholangitis (biopsy proven in one case). Study of such families should allow analysis of the contribution of shared genetic risk factors versus varying environmental triggering mechanisms to disease pathogenesis.

CONCLUSIONS

We suggest a European registry of families, such as the two described, which are rare within one centre, to facilitate elucidation of pathogenetic factors.

Managing chronic hepatitis C acquired through intravenous drug use

We retrospectively reviewed the provision and uptake of hospital services for 253 current and ex-intravenous drug users with hepatitis C virus (HCV). Overall, 237 attended at least one clinic (mean age 32 years, 70% male, 43% on maintenance methadone); 81% had evidence of active viral replication and 137 agreed to a liver biopsy to assess disease severity. Of these 137, 24% had mild chronic hepatitis with a low risk of progression to cirrhosis, but 9% had cirrhosis (mean age 40 years, mean time since initial intravenous drug use 15.8 years). Only 50 of the 100 patients in whom antiviral therapy was indicated, commenced treatment; 18 (36%) have had a sustained virological response. The natural history or response to treatment of chronic HCV in those who acquire it through intravenous drug use is not different to that previously reported for post-transfusion HCV. However, a substantial proportion default from follow-up or decline further intervention. As intravenous drug use is now the main risk factor for acquisition of HCV, these data have implications for future delivery of care aimed at limiting the morbidity of chronic HCV, and limiting the spread of hepatitis C virus infection amongst intravenous drug users.

Overexpression of HER2/neu in solid tumours: an immunohistochemical survey

AIMS

Using a standardized immunohistochemical assay we have evaluated 575 primary neoplasms of different histogenesis to determine the incidence of HER2 overexpression in some of the most common categories of human solid neoplasms. This study addresses the variable incidence of HER2 overexpression previously published for some tumour types.

METHODS AND RESULTS

The immunohistochemical staining was performed on paraffin sections of surgical specimens and a well-defined scoring system based upon numbers of HER2 receptors expressed on the cell surface was applied. Overexpression of HER2 as defined as a HER2 score of equal or greater than 2 was seen in breast cancer (22%), pulmonary adenocarcinoma (28%), colorectal adenocarcinomas (17%), pulmonary squamous (11%) and gastric adenocarcinomas (11%). As expected, the proportion of cases with a HER2 score of 3 was highest in breast cancer. Contrary to published results prostate and pancreas adenocarcinomas showed a very low incidence of HER2 overexpression.

CONCLUSIONS

Overexpression of HER2 is detected immunohistochemically in a proportion of epithelial neoplasms of diverse histogenesis in addition to ductal breast cancer. The standardized format of the assay will allow comparative analyses of studies performed at different institutions.

Tubulitis after renal transplantation: demonstration of an association between CD103+ T cells, transforming growth factor beta1 expression and rejection grade

BACKGROUND

Tubulitis is a defining feature for the diagnosis and management of acute renal allograft rejection. Lymphocytes extracted from rejecting renal tissue are known to express the alphaEbeta7-integrin (CD103), a receptor for E-cadherin expressed on epithelial cells. In this study, expression of CD103 was examined in situ in tubulitis associated with acute rejection.

METHODS

Immuno-labeling detected CD8+ and CD103+ lymphocytes and E-cadherin on epithelial cells in cryostat sections from 34 diagnostic biopsy specimens and a limited number of transplant nephrectomies. CD8+ and CD103+ intratubular cells were enumerated as mean numbers per tubular crosssection and median values were compared between rejection grades as were median ratios of CD103+ to CD8+ cells. Active transforming growth factor (TGF) beta1 was quantified in paraffin sections by immunofluorescence and confocal microscopical analysis. A parallel in vitro study quantified CD103+ T cells after allospecific activation with and without exogenous TGFbeta1.

RESULTS

CD8+ T cells were present in tubules and tubular interstitium in acute rejection. CD103+ T cells were restricted exclusively to the tubules. The numbers of intratubular CD8+ and CD103+ cells and the ratio of intratubular CD103+ to CD8+ cells increased significantly with tubulitis score (P values 0.005, 0.009, and 0.02, respectively). TGFbeta1 expression was wide-spread in tubules also increasing significantly with tubulitis score (P=0.034). In chronic rejection, CD103+ T cells and TGFbeta1 were present within both tubules and interstitial cell populations. The in vitro study demonstrated that addition of TGFbeta1 to activated, alloantigen-specific T cells increased the proportion of CD8+ cells that also expressed CD103.

CONCLUSIONS

These data indicate that specific upregulation of the alphaEbeta7-integrin by activated, intratubular T cells in acute renal allograft rejection could be a consequence of exposure to high local concentrations of TGFbeta1. The capacity of CD103+ T cells to bind E-cadherin on tubular epithelial cells may be an important factor in the pathogenesis of specific tissue damage observed in acute renal allograft rejection.

Experimental autoimmune cholangitis: a mouse model of immune-mediated cholangiopathy

BACKGROUND

Primary biliary cirrhosis (PBC) is characterised by intra-hepatic immune-mediated cholangiopathy (non-suppurative destructive cholangitis (NSDC)). Although auto-reactive immune responses against pyruvate dehydrogenase complex (PDC) have been characterised in PBC, the lack of an animal model of the disease has limited study of the mechanisms of disease induction and the development of novel approaches to therapy.

AIMS

To develop and validate a mouse model of immune-mediated cholangiopathy relevant for future use in the study of the aetio-pathogenesis and therapy of PBC.

METHODS

Female SJL/J, C57BL/6, NOD and BALB/c mice were sensitised with PDC, its purified E2/E3BP component, and a PDC-E2 derived peptide p163 (a dominant T-cell epitope in humans) in complete Freund's adjuvant (CFA). Morphological changes were assessed under light microscopy by a hepatic histopathologist blinded to the experimental details. Antibody responses to PDC were studied by ELISA and PDC inhibition assay.

RESULTS

An initial series of experiments was performed to survey the susceptibility of female mice of a range of strains to the induction of NSDC by i.p. sensitisation with PDC, PDC-E2/E3BP or p163 in CFA. Although each animal showed a specific antibody response following sensitisation, it was found that NSDC development (assessed at 30 weeks post-sensitisation) was restricted to SJL/J mice following sensitisation with any of the mitochondrial antigen preparations. A subsequent series of experiments was performed to examine the specificity and aetiology of this disease. Significant bile duct lesions were only seen in SJL/J animals following sensitisation with CFA containing PDC, and were absent from CFA only and un-sensitised controls. Kinetic analysis revealed that this pathology developed slowly, but a high incidence of animals with severe lesions was observed after 30 weeks.

CONCLUSIONS

We have described a model of experimental autoimmune cholangitis (EAC) with immunological (anti-PDC antibodies) and histological (immune-mediated cholangiopathy) features suggestive of PBC. This model may be useful in further defining the role of self-tolerance breakdown in the development of this condition.

Presentation and mortality of primary biliary cirrhosis in older patients

OBJECTIVES

many patients with primary biliary cirrhosis present for the first time aged over 65, but it is unclear whether the disease is different in older patients. We have examined presentation and mortality in relation to age at which primary biliary cirrhosis was first suspected clinically.

DESIGN

we identified 1023 patients from our regional primary biliary cirrhosis database with definite or probable primary biliary cirrhosis (689 definite); 397 (39%) presented aged > or =65. Definite primary biliary cirrhosis was defined as a positive antimitochondrial antibody titre > or =1/40, abnormal liver enzymes and compatible/diagnostic histology; probable as the presence of two of these indications.

RESULTS

there was no difference in presenting clinical features between the older and younger groups. Older patients were significantly less likely than younger to have had liver biopsy (50% vs 78%; P < 0.001). The 1023 patients had been followed for 8561 patient years. Follow-up was shorter (5.9+/-4 vs 9.8+/-5.5 years; P < 0.001) in the older group because of higher cumulative mortality (59% vs 33%; P < 0.001). Liver-related deaths were significantly commoner in the older group (18% vs 13%; P < 0.05). The mortality ratio for liver deaths (liver deaths per year of follow-up) was 2.4 times higher in the older group (0.031 vs 0.013).

CONCLUSIONS

patients with primary biliary cirrhosis who are over and under 65 have similar features on presentation. The annual risk of liver death is 2.4 times higher in those presenting over 65, reaffirming the importance of age as an independent prognostic factor in an unselected primary biliary cirrhosis population.

Stress-activated protein kinases in the activation of rat hepatic stellate cells in culture

BACKGROUND/AIMS

The signal cascades involved in the activation of hepatic stellate cells (HSC) are largely unknown. Factors initiating activation include tumour necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta, endothelin, and oxidative stress. In other cell types some of these have been reported to stimulate p38 mitogen-activated protein (MAP) kinase and c-Jun N-terminal kinase (JNK). We have therefore investigated the role of these kinases in HSC activation.

METHODS

HSC were isolated from male Wistar rats. Quiescent experiments were performed on day 2 HSC and transformed experiments on day 15 passage 1 HSC. Kinase activities were determined by immunoprecipitation and phosphorylation of specific substrate proteins and alpha-smooth muscle actin (SMA) expression by immunoblotting.

RESULTS

The constitutive activity of p38 MAP kinase was higher in transformed versus quiescent cells. In quiescent cells TNFalpha stimulated p38 MAP kinase and JNK activities 12- and 4-fold respectively and this was halved by 2-mercaptoethanol, an indirect antioxidant. Endothelin-1 activated both kinases in quiescent cells via the endothelin-B receptor, while TGFbeta had no effect. Both 2-mercaptoethanol and a p38 inhibitor (SB202190) inhibited alpha-SMA expression by day 5 cells.

CONCLUSIONS

The activation of p38 MAP kinase and JNK by TNFalpha and endothelin, together with the inhibition of this activation by 2-mercaptoethanol, provides indirect evidence supporting their role in HSC transformation. Direct evidence for a role for p38 MAP kinase is provided by the observations that its constitutive activity is higher in transformed versus quiescent cells and that its inhibitor reduces HSC activation in culture as assessed by alpha-SMA expression.

The role of phosphatidic acid in platelet-derived growth factor-induced proliferation of rat hepatic stellate cells

Platelet-derived growth factor (PDGF) is the most potent mitogen for hepatic stellate cells (HSCs) in vitro. The aim of this study was to investigate the role of the lipid-derived second messenger phosphatidic acid (PA) in mediating this effect and, in particular, to determine its interaction with the extracellular signal-regulated kinase (ERK) cascade. HSCs were isolated from rat livers. PA production was determined by lipid extraction and thin-layer chromatography (TLC) after prelabeling cells with [(3)H]myristate. ERK activity was measured by an in vitro kinase assay after immunoprecipitation. Mitogenic concentrations of PDGF, but not those of the relatively less potent mitogen, transforming growth factor alpha (TGF-alpha), stimulated the sustained production of PA from HSCs. Exogenous PA stimulated HSC proliferation and a sustained increase in ERK activity, and proliferation was completely blocked by the inhibition of ERK activation with PD98059. The stimulation of ERK by PDGF was of a similar magnitude but more sustained than that caused by TGF-alpha. These results suggest that the potent mitogenic effect of PDGF in HSCs may be caused, in part, by the generation of PA and subsequently by a more sustained activation of ERK than occurs with less potent mitogens that do not induce the production of this lipid second messenger.

Composition of the pulmonary interstitium during normal development of the human fetus

Normal lung development is dependent on epithelial-mesenchymal interactions. This study was undertaken to examine the structure of the interstitium of the developing human fetal lung, concentrating particularly on the first and second trimesters. Lung tissue was obtained at autopsy from nonmalformed, nonmacerated cases of spontaneous abortion (n = 15), stillbirth (n = 9), and very early neonatal death (n = 5) (range of gestations, 10-42 weeks). Paraffin-embedded tissue sections were examined using immunohistochemical methods to determine expression of collagens I, III, IV, V, and VI; the glycoproteins fibronectin and laminin; and the intermediate filaments vimentin, alpha-smooth muscle actin (alphaSMA), and desmin. Collagens III and VI and cells expressing alphaSMA were present consistently at points of airway branching and secondary crest formation, indicating a role for these components in the initiation and stabilization of airway branches in the developing lung. Desmin expression by stromal cells succeeded alphaSMA temporally, and may represent a marker of terminal smooth muscle differentiation within the airway; it was not detected in the vascular tree. Other components were widely expressed throughout the extracellular matrix, including basement membranes, at all gestations. The spatial and temporal patterns of expression of components of the lung interstitium provide clues to the mechanisms underlying normal human lung development and possible insights into the pathogenesis of fetal and neonatal lung disease.

Primary biliary cirrhosis once rare, now common in the United Kingdom?

There is a widespread impression that the number of patients with the autoimmune liver disease primary biliary cirrhosis (PBC) is increasing, although its incidence and prevalence vary widely. Using thorough case-finding methods and rigorous definitions to assess changes in incidence and prevalence with time and to explore the symptomatology and mortality of the disease in a large group of unselected patients, we performed a descriptive epidemiological study of PBC in a well defined population over a fixed period of time using established diagnostic criteria and with clinical follow-up of all cases. In a population of 2.05 million in northern England 770 definite or probable PBC cases were identified. Prevalence rose from 201.9 per 10(6) in the adult population and 541. 4 per 10(6) women over 40 in 1987 to 334.6 per 10(6) adults and 939. 8 per 10(6) women over 40 in 1994. Incidence was 23 per 10(6) in 1987 and 32.2 per 10(6) in 1994. Three hundred patients died in median follow-up of 6.27 years (141 liver deaths); the standardized mortality ratio was 2.85. At presumed diagnosis, 60.9% had no symptoms of liver disease. By June 1994 62% of prevalent patients had liver symptoms. PBC is apparently increasing. It is still unclear whether this is because of a true increase, case finding, or increased disease awareness. The study draws attention to (1) high mortality from liver disease and non-liver-related causes even in patients initially with no liver symptoms and (2) apparently poor diagnostic awareness of the disease.

Development of autoimmune hepatitis following liver transplantation for primary biliary cirrhosis

Two patients undergoing liver transplantation for classical end-stage primary biliary cirrhosis (PBC) are described, who went on to develop de novo autoimmune hepatitis (AIH) in the transplanted liver. The presentation, in both instances, was with malaise and lethargy. Markedly elevated serum transaminases were found, together with a raised serum IgG and/or globulin fraction and histological features on liver biopsy typical of AIH. Both cases had had changes in their immunosuppressive therapy before the onset of AIH episodes, and both rapidly responded to reinstitution of steroid therapy. The finding, in each case, of a coincidental multiple HLA class I allele match between the recipient and their liver donor suggests that HLA class I-restricted mechanisms may play an important role in the pathogenesis of AIH.

Enhanced ultrasensitive detection of structurally diverse antigens using a single immuno-PCR assay protocol

Our studies of DNA damage and repair in autoimmune disease, lymphomagenesis, and carcinogenesis, require identification of an immunoassay approach that is capable of ultrasensitive detection in a routine human tissue biopsy of several physicochemically diverse antigens, some of which will be present at very low level. Immuno-polymerase chain reaction (immuno-PCR) is a recently described method for ultrasensitive antigen detection that combines the amplification power of PCR with a method similar to a standard antibody capture, enzyme-linked immunosorbent assay (ELISA). As a test of the universality of immuno-PCR, and as an assessment of the suitability of this method for our studies, we used a single immuno-PCR protocol to assay purified forms of the following physicochemically diverse antigens: oligomeric pyruvate dehydrogenase complex (PDC; Mr 8.5 x 10(6)), the promutagenic DNA base adduct O(6)-methylguanosine (Mr 298) and its monomeric repair enzyme, O(6)-methylguanine-DNA methyltransferase (MGMT; Mr 22,000), and a peptide from the N-terminus of MGMT (Mr 2310). We found that all antigens could be ultrasensitively assayed using the single immuno-PCR protocol. Assay limits observed using antigen-specific (primary) antibodies at 1 microg/ml, were in the approximate range of 10(2)-10(9) molecules, with O(6)-methylguanosine being detected most sensitively. Sensitivity of the antigen assay appeared to positively correlate with primary antibody titres determined by ELISA. Furthermore, we observed a substantial increase in detection sensitivity for all antigens by the use of primary antibodies at the higher level of 10 microg/ml. The latter approach permitted antigen assay within the approximate range of 10(0)-10(7) molecules. The combination of higher titre primary antibodies and their use at higher input level, produced an increase of immuno-PCR assay sensitivity of up to four orders of magnitude greater than those previously reported through the use of this assay to measure other antigens. This represents up to a nine order of magnitude increase in immunoassay sensitivity compared to ELISA. Our findings provide compelling evidence that immuno-PCR is indeed a universal ultrasensitive antigen detection method. Using the indicated assay enhancements. immuno-PCR performed as detailed here can offer greatly increased sensitivity for antigen measurement compared to other methods. Thus, our findings suggest that parallel quantitation of several different antigens in very small samples of human tissue will be readily attainable using immuno-PCR.

Diagnosis and interpretation of steatosis and steatohepatitis

Steatosis--accumulation of triacylglycerol in hepatocytes--is a common finding in liver biopsy specimens. The commonest form is macrovesicular change, which occurs in response to a wide range of insults. In the absence of other features, the pathologist cannot ascertain the likely cause on morphological features alone but can give an indication of the severity of steatosis. Close clinicopathological correlation is required to establish the cause. In most instances, macrovesicular steatosis is at least potentially reversible. Although it may be thought of as a benign condition, it may be associated with the development of necroinflammation and fibrosis--so-called steatohepatitis. The classic example of this is alcoholic hepatitis, but there is increasing awareness of steatohepatitis occurring in nonalcoholics: NASH. Distinction between alcoholic hepatitis and NASH on purely histological grounds may be impossible; careful clinicopathological discussion is mandatory. Microvesicular steatosis is generally a more severe disease than the macrovesicular form and is seen in a variety of conditions in which there is either an inherited or an acquired defect in beta-oxidation of fatty acids; the former includes mitochondrial cytopathies and disorders of ureagenesis, and the latter includes acute fatty liver of pregnancy and Reye's syndrome. This review describes the morphological features of steatosis and steatohepatitis, considers their pathogenesis, and outlines the clinical significance of the different patterns of injury.

Anti-hepatocyte growth factor antibody inhibits hepatocyte proliferation during liver regeneration

In vitro studies have shown hepatocyte growth factor (HGF) to be a potent mitogen for hepatocytes. Direct evidence of a mitogenic role in vivo was sought by inhibiting HGF activity, using continuous administration of neutralizing antibody to rats which had a stimulus for liver regeneration. Alzet osmotic mini-pumps, administering a constant supply of anti-HGF monoclonal antibody (clone D9), were inserted intraperitoneally into male Wistar rats; an irrelevant isotypical antibody was administered to controls. Forty-five animals received an intragastric bolus of 40 per cent carbon tetrachloride (CCl4) and groups of three test and control animals were killed at 24 h intervals for 7 days. Treatment with anti-HGF monoclonal antibody significantly inhibited the levels of immunodetectable HGF in the sera of rats following CCl4 administration. In comparison with controls, hepatocyte proliferation as assessed by bromodeoxyuridine labelling in anti-HGF-treated animals was significantly inhibited at 24 h (P < 0.001), 48 h (P < 0.001), and 96 h (P < 0.05) post-CCl4 administration. In contrast, sinusoidal cell proliferation was not significantly different from controls at any time point. Inhibition of the parenchymal proliferative response to acute CCl4-induced liver injury by the in vivo neutralization of HGF provides direct evidence that this growth factor plays an important role in liver regeneration following necrosis.

Long-term safety and effectiveness of iron-chelation therapy with deferiprone for thalassemia major

BACKGROUND

Deferiprone is an orally active iron-chelating agent that is being evaluated as a treatment for iron overload in thalassemia major. Studies in an animal model showed that prolonged treatment is associated with a decline in the effectiveness of deferiprone and exacerbation of hepatic fibrosis.

METHODS

Hepatic iron stores were determined yearly by chemical analysis of liver-biopsy specimens, magnetic susceptometry, or both. Three hepatopathologists who were unaware of the patients' clinical status, the time at which the specimens were obtained, and the iron content of the specimens examined 72 biopsy specimens from 19 patients treated with deferiprone for more than one year. For comparison, 48 liver-biopsy specimens obtained from 20 patients treated with parenteral deferoxamine for more than one year were similarly reviewed.

RESULTS

Of the 19 patients treated with deferiprone, 18 had received the drug continuously for a mean (+/-SE) of 4.6+/-0.3 years. At the final analysis, 7 of the 18 had hepatic iron concentrations of at least 80 micromol per gram of liver, wet weight (the value above which there is an increased risk of cardiac disease and early death in patients with thalassemia major). Of 19 patients in whom multiple biopsies were performed over a period of more than one year, 14 could be evaluated for progression of hepatic fibrosis; of the 20 deferoxamine-treated patients, 12 could be evaluated for progression. Five deferiprone-treated patients had progression of fibrosis, as compared with none of those given deferoxamine (P=0.04). By the life-table method, we estimated that the median time to progression of fibrosis was 3.2 years in deferiprone-treated patients. After adjustment for the initial hepatic iron concentration, the estimated odds of progression of fibrosis increased by a factor of 5.8 (95 percent confidence interval, 1.1 to 29.6) with each additional year of deferiprone treatment.

CONCLUSIONS

Deferiprone does not adequately control body iron burden in patients with thalassemia and may worsen hepatic fibrosis.

Heterozygotes for HFE mutations have no increased risk of advanced alcoholic liver disease

BACKGROUND

Iron overload is common in the livers of alcoholics and may play a role in disease pathogenesis. An MHC like gene, HFE, has recently been identified that is mutated in most patients with hereditary haemochromatosis (C282Y in 90% and H63D in 45% of the remainder).

AIM

To examine the hypothesis that these mutations determine hepatic iron status in alcoholics and play a role in pre-disposition to advanced alcoholic liver disease.

METHODS

The HFE gene was genotyped in 257 patients with alcoholic liver disease and 117 locally matched healthy volunteers. In addition, iron staining was scored (0-4) on biopsy specimens from fibrotic/cirrhotic patients with and without HFE mutations matched for age and sex.

RESULTS

Some 15.7% of fibrotic/cirrhotic patients were C282Y heterozygotes compared with 13.7% of controls (p = 0.77). One control and three patients were C282Y homozygotes. Of chromosomes without the C282Y mutation, 68/442 (15.4%) of patients' chromosomes carried the H63D mutation compared with 36/216 (16.6%) of control chromosomes (p = 0.91). Significant (> grade 1) hepatocyte iron staining was seen in 6/23 C282Y heterozygotes and 4/26 H63D heterozygotes compared with 4/23 controls.

CONCLUSIONS

Possession of a single copy of either of the two HFE mutations influences neither liver iron content nor the risk of fibrotic disease in alcoholics.

Colonic epithelial cell proliferation in hereditary non-polyposis colorectal cancer

BACKGROUND

Despite the recent discovery of four genes responsible for up to 90% of all cases of hereditary non-polyposis colorectal cancer (HNPCC), there will still be families in whom predictive testing is not possible. A phenotypic biomarker would therefore be useful. An upwards shift of the proliferative compartment in colonic crypts is reported to be one of the earliest changes in premalignant mucosa.

AIMS

To assess the role of crypt cell proliferation as a phenotypic biomarker in HNPCC.

PATIENTS

Thirty five patients at 50% risk of carrying the HNPCC gene (21 of whom subsequently underwent predictive testing and hence gene carrier status was known) and 18 controls.

METHODS

Crypt cell proliferation was measured at five sites in the colon using two different techniques. Labelling index was determined using the monoclonal antibody MIB1 and whole crypt mitotic index was measured using the microdissection and crypt squash technique. The distribution of proliferating cells within the crypts was also assessed.

RESULTS

There were no significant differences in the total labelling index or mean number of mitoses per crypt, nor in the distribution of proliferating cells within the crypt, between the study and control groups at any site. When the 21 patients in whom gene carrier status was known were analysed separately there were no significant differences in the measured indices of proliferation between the HNPCC gene carriers and non-gene carriers.

CONCLUSION

Crypt cell proliferation is not a discriminative marker of gene carriage in HNPCC.

Anti-hepatocyte growth factor antibody inhibits hepatocyte proliferation during liver regeneration

In vitro studies have shown hepatocyte growth factor (HGF) to be a potent mitogen for hepatocytes. Direct evidence of a mitogenic role in vivo was sought by inhibiting HGF activity, using continuous administration of neutralizing antibody to rats which had a stimulus for liver regeneration. Alzet osmotic mini-pumps, administering a constant supply of anti-HGF monoclonal antibody (clone D9), were inserted intraperitoneally into male Wistar rats; an irrelevant isotypical antibody was administered to controls. Forty-five animals received an intragastric bolus of 40 per cent carbon tetrachloride (CCl4) and groups of three test and control animals were killed at 24 h intervals for 7 days. Treatment with anti-HGF monoclonal antibody significantly inhibited the levels of immunodetectable HGF in the sera of rats following CCl4 administration. In comparison with controls, hepatocyte proliferation as assessed by bromodeoxyuridine labelling in anti-HGF-treated animals was significantly inhibited at 24 h (P < 0.001), 48 h (P < 0.001), and 96 h (P < 0.05) post-CCl4 administration. In contrast, sinusoidal cell proliferation was not significantly different from controls at any time point. Inhibition of the parenchymal proliferative response to acute CCl4-induced liver injury by the in vivo neutralization of HGF provides direct evidence that this growth factor plays an important role in liver regeneration following necrosis.

Heterozygosity for hereditary hemochromatosis is associated with more fibrosis in chronic hepatitis C

Hepatic iron has been associated with more aggressive liver disease in chronic viral hepatitis. We evaluated whether the recently described C282Y mutation of the hemochromatosis gene, designated HFE (responsible for at least 83% of hereditary hemochromatosis), was associated with more advanced liver disease in chronic hepatitis C. One hundred thirty-seven patients with biopsy-proven chronic hepatitis C were studied and liver biopsies scored for necroinflammation (grade 0-18) and fibrosis (stage 0-6). Genomic DNA was amplified by polymerase chain reaction and the C282Y mutation identified by restriction with RsaI and electrophoretic separation of restriction fragments. Ten (7.3%) patients had the C282Y mutation. No C282Y homozygous patients were identified. Age, sex distribution, and estimated weekly alcohol consumption were not significantly different between those with and without the mutation. Serum ferritin was higher in the heterozygotes (mean, 339 microg/L) compared with homozygous wild types (153 microg/L; P = .0005). In the majority of patients, liver iron was graded 0 out of 4, but hepatocyte iron staining was more commonly present in heterozygotes compared with homozygous normals (30% compared with 4% [P = .02]). Liver disease was more advanced in those with the mutant allele (mean fibrosis stage: 3.6, compared with wild type: 1.5 [P = .01]). Cirrhosis was found more often in those with the mutation (40%) compared with those without (8.7%) (P = .01; odds ratio: 7.6 [1.9-31.2]). There was no significant difference in inflammation scores between heterozygotes and wild type (mean, 5.4 compared with 4.1). Hepatitis C virus (HCV)-RNA titers were measured by branched DNA assay (HCV RNA 2.0-Chiron), and there was no difference between heterozygous and homozygous normal patients. Thus, despite relatively minor increases in iron stores, individuals who are heterozygous for hemochromatosis appear to develop more fibrosis in chronic hepatitis C. Venesection may be useful therapy in this subgroup.

Macrophage and hepatic stellate cell responses during experimental hepatocarcinogenesis

The aim of the study was to assess the monocyte/macrophage and hepatic stellate cell responses during experimental diethylnitrosamine (DEN)-induced hepatocarcinogenesis. Diethylnitrosamine (50mg/L) was administered to 39 rats for 10 weeks; liver tissue was obtained at weeks 10, 16 and 19. In this model, necroinflammatory damage occurs during the period of DEN administration but thereafter subsides; dysplastic nodules and carcinomas subsequently develop. Monocytes/ macrophages were detected immunohistochemically using ED1 and ED2 monoclonal antibodies; hepatic stellate cells (HSC) were detected using antibodies to alpha-smooth muscle actin (alpha-SMA) (activated HSC) and glial fibrillary acidic protein (GFAP). Parenchymal ED1- and ED2-positive monocytes/macrophages and alpha-SMA-positive HSC increased at week 10 when there was ongoing DEN-induced necroinflammatory activity. ED1- and ED2-positive cells were also prominent at weeks 16 and 19, particularly around the periphery of dysplastic and carcinomatous nodules, with occasional macrophages between dysplastic hepatocytes. alpha-SMA-positive HSC were present within sinusoids between dysplastic cells and were more abundant at weeks 16 and 19 than in control or week 10 animals. Activated HSC were prominent in fibrous septa around and within dysplastic and carcinomatous nodules at weeks 16 and 19. In contrast, GFAP-positive HSC did not accumulate in developing septa or within dysplastic and carcinomatous nodules. We have demonstrated changes in the monocyte/ macrophage and HSC populations during the development of hepatocellular dysplasia and carcinoma at time points when there is little necroinflammatory activity; this may therefore represent a host response to hepatocyte dysplasia. The HSC activation may be mediated, in part, by monocyte/ macrophage-derived factors, but we speculate that it may also result from direct stimulation by factors released from dysplastic hepatocytes.

Hepatitis G virus does not cause significant liver disease after liver transplantation

The aim of this study was to determine the prevalence of infection with the newly described hepatitis G virus (HGV) in a liver transplant cohort, and to establish the frequency and nature of hepatitis in those with and without HGV infection. A reverse transcriptase-polymerase chain reaction technique was employed to determine viraemia in the patients, and liver biopsies taken at different times after transplantation were assessed histologically. Hepatitis G virus RNA was detected in 47% of the liver transplant recipients investigated. Those positive for HGV had received significantly more blood or blood products than the HGV-negative patients. The frequency of abnormal liver function tests was similar in HGV-positive and HGV-negative recipients. Bile duct epithelial cell damage was more frequently seen in those with HGV viraemia. This study indicates that almost half of the liver transplant recipients in Northern England are positive for HGV, and that infection is associated with exposure to blood and blood products. It appears that, in the immunosuppressed patient, HGV does not cause clinically significant liver disease, at least up to 2 years after transplantation. If HGV infection is associated with hepatitis outside this clinical setting, it is likely that the liver damage is immunopathologically mediated rather than as a result of direct viral cytotoxicity.

Autoimmune hepatitis in older patients

AIM

autoimmune hepatitis (AIH) is thought to present rarely in old people. The aims of the present study were to (i) review individuals diagnosed clinically as having AIH presenting over or under 65 years of age at Freeman Hospital, Newcastle, from 1979 to 1993 and (ii) compare diagnostic and histological scores, treatment and outcome, and hence provide a useful profile of the disease in older patients.

METHODS

310 individuals with a histological diagnosis of chronic hepatitis were identified, and review of the medical notes of 286 revealed 54 with a diagnosis of AIH. Of these, 12 (22%) were > or =65 years of age at presentation.

RESULTS

at presentation, the mean diagnostic score (according to the diagnostic scoring system devised by an international panel; maximum score, 17) of the whole group was 11.5 (SD 3.5) and the mean score for those > or =65 years was 9 (SD 3). The mean histological grade (intensity of necro-inflammatory activity; maximum, 18) for the elderly group was 6 (SD 2) compared with 4.5 (SD 0.5) for the whole group. Despite this, 42% of the elderly sufferers had received no immunosuppressive therapy (versus 12% of the younger group). At follow-up, 26% in both groups had developed cirrhosis. None of the elderly group (but 7% of the younger group) had died from complications of chronic liver disease.

CONCLUSION

we present data on 12 patients presenting at 65 years and over with AIH. In elderly individuals diagnosis may be more difficult, and treatment appears often to have been withheld. Despite this, and the more severe initial histological grade, the prognosis appeared no worse than in younger, usually correctly treated, patients.

Outcome of post-transfusion hepatitis C: disease severity in blood-component recipients and their implicated donors

The UK 'Look-back Program' identifies recipients of blood products from hepatitis C antibody (anti-HCV) positive donors. Of 60 such recipients tested by the Newcastle Transfusion Service, 28(46.7%) were anti-HCV-negative, 25(41.7%) were anti-HCV-positive, and seven (11.6%) had equivocal serology. We studied 29 anti-HCV-positive/indeterminate recipients and eight of their implicated donors, using serial liver function tests (LFTs), liver histology when clinically indicated, HCV RNA and serotyping. Presumed resolved hepatitis C, with persistently normal LFTs and negative HCV RNA, was found in 28%, of whom 63% had indeterminate anti-HCV by RIBA (1 band of 4 detected on third-generation recombinant immunoblot assay). Resolved hepatitis C was significantly more common in women (p < 0.05) and tended to be associated with younger age at transfusion. There was complete concordance in serotype between donor-recipient pairs. There was no correlation in disease severity between recipients and their implicated donors, nor between recipients from the same donor. A history of alcohol consumption above recommended 'safe' limits (median 30 units) was associated with more severe histological disease (p < 0.01). Host factors, including gender and alcohol consumption, may be important in determining the wide variability in outcome of post-transfusion hepatitis C.

Cushing's syndrome secondary to ectopic ACTH secretion from a primary ovarian carcinoma

We report a 63-year-old woman who presented with clinical and biochemical features of ACTH dependent Cushing's syndrome secondary to a primary ovarian carcinoma. The tumour produced very high levels of ACTH precursors, consistent with defective POMC processing.

Hepatocyte growth factor levels in liver and serum increase during chemical hepatocarcinogenesis

Hepatocyte growth factor (HGF) is mitogenic for hepatocytes and some tumor cell lines. Elevations in plasma HGF levels have been detected in patients with hepatocellular carcinoma (HCC), and it is possible that HGF is involved in the promotion and/or progression of tumor growth. We measured serum and liver tissue HGF levels during chemically induced hepatocarcinogenesis. Wistar rats were given diethylnitrosamine (DEN) in drinking water for 10 weeks with controls receiving drinking water only. Animals were killed at 10, 16, and 19 weeks. Liver HGF levels were determined from immunoblotted protein by scanning densitometry, and serum HGF levels were measured by sandwich enzyme-linked immunosorbent assay (ELISA). HGF was also immunolocalized in fixed liver tissue sections. In DEN-treated animals, at 10 weeks, there was necroinflammation but no dysplasia. Serum HGF was elevated compared with controls (P < .001) but there was no increase in liver HGF. At 16 weeks, there was liver cell dysplasia with minimal necroinflammation; serum and tissue HGF levels were both significantly elevated above controls. At 19 weeks, hepatocellular carcinomas (HCC) were present in five of six DEN-treated animals; liver HGF (P < .05) and serum HGF (P < .001) were both elevated compared with controls. HGF was localized in basement membranes around bile ducts and vessels and some perisinusoidal cells. Increased HGF immunolabeling was observed at 16 and 19 weeks, but dysplastic hepatocytes and tumor cells were HGF-negative. HGF may serve as a growth promoter at early stages during liver tumor development acting through possibly endocrine and paracrine pathways. Recent observations have described HGF as being mitoinhibitory for HCC cell lines; it is possible therefore that the continued up-regulation of HGF in the latter stages of our DEN model may inhibit tumor cell growth, and thus represent a form of antitumor host response.

Intra-observer and inter-observer variation in the histopathological assessment of chronic viral hepatitis

BACKGROUND/AIMS

The way in which liver biopsies showing chronic hepatitis are reported is undergoing re-evaluation. A related question is how the inflammatory and fibrotic changes in these liver biopsies can be semi-quantitatively assessed so that comparisons can be made between groups of patients and the effect of treatment on disease progression studied.

METHODS

We have carried out a blinded trial in which 20 cases of chronic viral hepatitis were assessed by five histopathologists, using the Knodell and Scheuer scoring systems (two of the most commonly used systems), on two separate occasions. The results were analysed using Kappa statistics, and also by seeing for how many slides the pathologists showed no significant disagreement.

RESULTS

While both systems produced good inter- and intra-observer variation when fibrosis was assessed the Scheuer system produced slightly higher Kappa values. The Scheuer system produced considerably better agreement when the severity of inflammation was examined. A multirater kappa analysis confirmed that both systems showed better agreement for fibrosis scores than for inflammation scores.

CONCLUSION

We conclude that, while both systems produced reasonable agreement, this was greater using the Scheuer system. When any new scoring system is being developed, the question of reproducibility needs active consideration.

Hepatic stellate cell activation occurs in the absence of hepatitis in alcoholic liver disease and correlates with the severity of steatosis

BACKGROUND/AIMS

There is now overwhelming evidence that hepatic stellate cells are the principal cells involved in hepatic fibrogenesis. In several different forms of liver injury it has been demonstrated that they proliferate and undergo phenotypic transformation (activation) into matrix-producing, myofibroblast-like cells in response to necroinflammation, mediated in part, by Kupffer cell-derived factors. In alcoholic liver disease, however, the observation that fibrosis can occur in the absence of alcoholic hepatitis has cast doubt on necroinflammation being an absolute pre-requisite for alcohol-related hepatic stellate cells proliferation/activation and subsequent fibrogenesis.

METHODS

Evidence for hepatic stellate cells activation has been sought in liver biopsies from 38 well-documented alcoholic patients with no evidence of alcoholic hepatitis or cirrhosis and eight normal controls. Activated hepatic stellate cells were identified immunohistochemically using a specific monoclonal antibody to detect cytoplasmic alpha smooth muscle actin (alpha-SMA), which is not present in quiescent cells. Kupffer cells were detected with the monoclonal antibody KP1 and collagen was stained using Sirius red. Immunoreactive cells and the amount of fibrosis were quantified, using a Kontron Vidas Image Analyser. Steatosis was graded from 0 (none-few hepatocytes containing fat) to 3 (> 2/3 hepatocyte containing fat).

RESULTS

Biopsies from alcoholic patients contained significantly greater numbers of activated hepatic stellate cells (alpha-SMA+ve) than control biopsies (average cell counts: 84 +/- 11/mm2 versus 23 +/- 5/mm2, p < 0.0001). There was no correlation between numbers of activated hepatic stellate cells and either numbers of Kupffer cells or amount of fibrosis. There was, however, a significant correlation between hepatic stellate cells activation and steatosis (grade 0, 15 +/- 7 cells/unit area (n = 4), grade 1, 56 +/- 16 (n = 13), grade 2, 85 +/- 20 (n = 9), grade 3, 137 +/- 19 (n = 12); p = 0.002, ANOVA).

CONCLUSIONS

These results suggest that neither necroinflammation nor an increase in Kupffer cells is an absolute prerequisite for hepatic stellate cells proliferation/activation and subsequent fibrogenesis in alcoholic liver disease. The correlation between alcohol-induced hepatic stellate cells activation and severity of steatosis is likely to reflect that both are attributable in part to the metabolic consequences of ethanol metabolism, namely increased concentrations of acetaldehyde and lipid peroxidation.

CD44 is expressed in hepatocellular carcinomas showing vascular invasion

CD44 and its variant isoforms are a group of transmembrane glycoproteins which play important roles in immune recognition, in lymphocyte trafficking, and in cell-cell and cell-matrix interactions. Although CD44 is expressed by some normal human epithelial and mesenchymal cells, upregulation of CD44 expression has been related to the metastatic potential of some malignant tumours. In this study of 27 hepatocellular carcinomas (HCCs), an indirect immunohistochemical method was used to investigate the distribution of CD44 in normal liver and to determine whether expression of the standard form of CD44 (CD44s), or two of its variant isoforms (CD44-v3 and CD44-v6), correlated with tumour grade, proliferation indices, or histological evidence of vascular invasion. Fifteen of the tumours were Edmondson grade II, four were grade III, and eight were grade IV. Liver cell dysplasia was present in adjacent liver parenchyma in three cases and vascular invasion was observed in ten HCCs. Vascular invasion was found to be more frequent in high grade HCCs and a significant correlation was observed between tumour proliferation indices and vascular invasion. CD44s was not expressed by epithelial cells of normal liver but was expressed by tumour cells in six HCCs; vascular invasion was present in five of these HCCs. Three CD44s-positive cases also expressed CD44-v3 and two of these also expressed CD44-v6. CD44 was not expressed in areas of hepatocyte dysplasia. There was a significant correlation between CD44 expression and the presence of vascular invasion, but not between CD44 expression and tumour grade or tumour proliferation indices. It is concluded that upregulation of cell surface CD44 expression on malignant hepatocytes is related to their tendency to vascular invasion and may have implications relating to metastasis and prognosis in patients with HCCs.

CD44 is expressed in hepatocellular carcinomas showing vascular invasion

CD44 and its variant isoforms are a group of transmembrane glycoproteins which play important roles in immune recognition, in lymphocyte trafficking, and in cell-cell and cell-matrix interactions. Although CD44 is expressed by some normal human epithelial and mesenchymal cells, upregulation of CD44 expression has been related to the metastatic potential of some malignant tumours. In this study of 27 hepatocellular carcinomas (HCCs), an indirect immunohistochemical method was used to investigate the distribution of CD44 in normal liver and to determine whether expression of the standard form of CD44 (CD44s), or two of its variant isoforms (CD44-v3 and CD44-v6), correlated with tumour grade, proliferation indices, or histological evidence of vascular invasion. Fifteen of the tumours were Edmondson grade II, four were grade III, and eight were grade IV. Liver cell dysplasia was present in adjacent liver parenchyma in three cases and vascular invasion was observed in ten HCCs. Vascular invasion was found to be more frequent in high grade HCCs and a significant correlation was observed between tumour proliferation indices and vascular invasion. CD44s was not expressed by epithelial cells of normal liver but was expressed by tumour cells in six HCCs; vascular invasion was present in five of these HCCs. Three CD44s-positive cases also expressed CD44-v3 and two of these also expressed CD44-v6. CD44 was not expressed in areas of hepatocyte dysplasia. There was a significant correlation between CD44 expression and the presence of vascular invasion, but not between CD44 expression and tumour grade or tumour proliferation indices. It is concluded that upregulation of cell surface CD44 expression on malignant hepatocytes is related to their tendency to vascular invasion and may have implications relating to metastasis and prognosis in patients with HCCs.

CD44 is expressed in hepatocellular carcinomas showing vascular invasion

CD44 and its variant isoforms are a group of transmembrane glycoproteins which play important roles in immune recognition, in lymphocyte trafficking, and in cell-cell and cell-matrix interactions. Although CD44 is expressed by some normal human epithelial and mesenchymal cells, upregulation of CD44 expression has been related to the metastatic potential of some malignant tumours. In this study of 27 hepatocellular carcinomas (HCCs), an indirect immunohistochemical method was used to investigate the distribution of CD44 in normal liver and to determine whether expression of the standard form of CD44 (CD44s), or two of its variant isoforms (CD44-v3 and CD44-v6), correlated with tumour grade, proliferation indices, or histological evidence of vascular invasion. Fifteen of the tumours were Edmondson grade II, four were grade III, and eight were grade IV. Liver cell dysplasia was present in adjacent liver parenchyma in three cases and vascular invasion was observed in ten HCCs. Vascular invasion was found to be more frequent in high grade HCCs and a significant correlation was observed between tumour proliferation indices and vascular invasion. CD44s was not expressed by epithelial cells of normal liver but was expressed by tumour cells in six HCCs; vascular invasion was present in five of these HCCs. Three CD44s-positive cases also expressed CD44-v3 and two of these also expressed CD44-v6. CD44 was not expressed in areas of hepatocyte dysplasia. There was a significant correlation between CD44 expression and the presence of vascular invasion, but not between CD44 expression and tumour grade or tumour proliferation indices. It is concluded that upregulation of cell surface CD44 expression on malignant hepatocytes is related to their tendency to vascular invasion and may have implications relating to metastasis and prognosis in patients with HCCs.

Characterisation of the DNA repair enzyme for O(6)-methylguanine in cirrhosis

BACKGROUND/AIMS

The reason(s) why cirrhosis is a major risk factor for the development of hepatocellular carcinoma worldwide are largely unknown. In a previous preliminary study, we reported deficiency of the repair enzyme for the highly promutagenic and potentially carcinogenic DNA base lesion, O(6)-methylguanine, in cirrhotic human liver. The aims of the present study were: (i) to confirm this observation in an extended series of cirrhosis patients, using a new DNA repair enzyme assay approach, (ii) to characterise the enzyme, in particular to seek physicochemical differences between control and cirrhotic liver that might account for the enzyme defect in cirrhosis, and (iii) to examine the relationship between magnitude of DNA repair deficiency in cirrhotic liver and aetiology of cirrhosis or male sex, both of which are independent risk factors of hepatocellular carcinoma.

METHODS

Tissue extracts containing DNA repair enzyme, O(6)-methylguanine-DNA methyltransferase, were prepared from liver biopsy samples from 41 patients with cirrhosis (10 viral (HBV and HCV), 17 alcohol and 14 autoimmune), 17 patients with non-cirrhotic diseased liver and 4 patients with histologically normal liver. Repair enzyme levels and electrophoretic profiles were both obtained using sodium dodecyl sulphate-polyacrylamide gel electrophoresis in conjunction with fluorography and densitometry.

RESULTS

We have demonstrated the feasibility of both analysing and reproducibly measuring DNA repair enzyme in small liver biopsy samples using the gel electrophoresis/densitometry approach for enzyme assay. Using the new densitometric assay approach, levels of O(6)-methylguanine-DNA methyltransferase were found to be significantly lower in cirrhotic compared to non-cirrhotic liver, with very low values obtained for two individuals who were incidentally found to have small hepatocellular carcinomas at the time of liver transplantation. There were no significant differences in enzyme levels between patients with cirrhosis of different aetiology, and between male and female patients. Methyltransferase was found to be present in all liver extracts as a major 23.1 kDA protein, along with other less abundant enzyme forms of both slightly higher and lower molecular weight; there were no obvious differences in size and relative abundance of these enzyme forms between liver samples from any of the patient and control groups. Our findings of enzyme instability and multiple forms led us to examine methyltransferase's amino acid sequence for the presence of primary structure motifs indicative of targeted degradation of the enzyme by intracellular proteases. We have identified a eukaryotic thiol protease active site motif and two cyclin-like "destruction box" motifs in the N-terminal half of the enzyme.

CONCLUSIONS

Our findings provide further evidence suggesting that deficiency in the ability to repair O(6)-methylguanine-DNA underlies the increased risk of hepatocellular carcinoma seen in patients with cirrhosis. The degree of DNA repair deficiency not varying between cirrhotic patients subgrouped according to other risk factors for hepatocellular carcinoma, suggests that DNA repair deficiency is only one of several contributory factors in liver carcinogenesis. The presence in methyltransferase of thiol protease active site and "destruction box" motifs may be of relevance to observed repair enzyme instability and presence of multiple enzyme forms in human liver extracts.

Transforming growth factor-alpha expression is altered during experimental hepatocarcinogenesis

In order to characterize the role of transforming growth factor-alpha (TGF alpha) during hepatocarcinogenesis, liver tissue was examined at 10, 16, and 19 weeks following initial 10-week diethylnitrosamine (50 mg l-1 drinking water) exposure in female Wistar rats. Liver tissue protein extracts were electrophoresed and transferred to nitrocellulose filters. Levels of tissue-derived TGF alpha and epidermal growth factor receptor (EGFr) were assessed using an anti-TGF alpha monoclonal antibody (Ab-1) and an anti-EGFr polyclonal antibody (AB-4), coupled with scanning densitometric quantification. Immunolocalization of TGF alpha was performed in Bouin's-fixed, paraffin-embedded liver tissue sections. The distribution and intensity of TGF alpha immunoreactivity varied according to the degree of dysplasia, severely dysplastic cells being strongly immunoreactive. At week 10, mild hepatocyte dysplasia and perivenular inflammation were evident, together with a corresponding increase in perivenular TGF alpha immunoreactivity. By week 16, foci of moderate to severe dysplasia were observed; at this stage, there was a decrease in perivenular immunoreactivity but a further increase in overall liver tissue TGF alpha levels. Some 'altered foci' and dysplastic nodules showed intense immunoreactivity for TGF alpha. At these time points, immunodetectable liver EGFr was found to decrease significantly in comparison with normal control tissue. TGF alpha immunoreactivity was observed in fully developed carcinomas at week 19, although some tumours were negative by immunohistochemistry. The up-regulation of immunodetectable TGF alpha and the concomitant down-regulation of EGFr demonstrated positive (P < 0.01) and negative (P < 0.001) correlations, respectively, with hepatocyte proliferation indices. These findings suggest that the TGF alpha/EGFr ligand receptor system may be important during tumour promotion and in the stimulation of continued proliferation in hepatocellular carcinomas.

Innervation of the liver: morphology and function

Although it has been known for many years that the liver receives a nerve supply, it is only with the advent of immunohistochemistry that this innervation has been analysed in depth. It is now appreciated not only that many different nerve types are present, but also that there are significant differences between species, especially in the degree of parenchymal innervation. This has stimulated more detailed investigation of the innervation of the human liver in both health and disease. At the same time, functional studies have been underlining the important roles that these nerves play in processes as diverse as osmoreception and liver regeneration. This article briefly reviews current understanding of the morphology and functions of the hepatic nerve supply.

CD44 is expressed in hepatocellular carcinomas showing vascular invasion

CD44 and its variant isoforms are a group of transmembrane glycoproteins which play important roles in immune recognition, in lymphocyte trafficking, and in cell-cell and cell-matrix interactions. Although CD44 is expressed by some normal human epithelial and mesenchymal cells, upregulation of CD44 expression has been related to the metastatic potential of some malignant tumours. In this study of 27 hepatocellular carcinomas (HCCs), an indirect immunohistochemical method was used to investigate the distribution of CD44 in normal liver and to determine whether expression of the standard form of CD44 (CD44s), or two of its variant isoforms (CD44-v3 and CD44-v6), correlated with tumour grade, proliferation indices, or histological evidence of vascular invasion. Fifteen of the tumours were Edmondson grade II, four were grade III, and eight were grade IV. Liver cell dysplasia was present in adjacent liver parenchyma in three cases and vascular invasion was observed in ten HCCs. Vascular invasion was found to be more frequent in high grade HCCs and a significant correlation was observed between tumour proliferation indices and vascular invasion. CD44s was not expressed by epithelial cells of normal liver but was expressed by tumour cells in six HCCs; vascular invasion was present in five of these HCCs. Three CD44s-positive cases also expressed CD44-v3 and two of these also expressed CD44-v6. CD44 was not expressed in areas of hepatocyte dysplasia. There was a significant correlation between CD44 expression and the presence of vascular invasion, but not between CD44 expression and tumour grade or tumour proliferation indices. It is concluded that upregulation of cell surface CD44 expression on malignant hepatocytes is related to their tendency to vascular invasion and may have implications relating to metastasis and prognosis in patients with HCCs.

Cellular distribution of androgen receptors in the liver

In order to determine the cellular distribution of androgen receptors (AR) in normal liver and to examine whether phenotypic changes occur in a variety of non-neoplastic liver diseases, cryostat sections of explanted livers removed from 52 consecutive patients undergoing orthotopic transplantation were immunostained using an anti-androgen receptor monoclonal antibody. In histologically normal liver, AR was immunolocalised to the nuclei of hepatocytes. The proportion of positive hepatocytes varied from about 50% to greater than 90%. Staining, of variable intensity, was restricted to parenchymal cells with no evidence of zonal heterogeneity with respect to labelling intensity. In tissue from patients with biliary cirrhoses and in some cases of alcoholic cirrhosis, labelling for AR was observed in areas of ductular metaplasia but not in areas of "typical" ductular reaction (ductular proliferation). Otherwise, no consistent abnormalities in immunolabelling were seen in any of the diseased livers.