Liver transplantation--perspective from Hong Kong

BACKGROUND/AIMS

We report our experience of 27 orthotopic liver transplantations in 26 patients performed at Queen Mary Hospital, Hong Kong during the period of October 1991 to October 1995.

PATIENTS AND METHODS

There were 19 adults and 7 pediatric patients with a mean age of 29 years (range 8 months to 62 years). The underlying liver diseases of the 26 patients were biliary atresia (n = 6), Alagille syndrome (n = 1), primary biliary cirrhosis (n = 2) cryptogenic cirrhosis (n = 2), alcoholic cirrhosis (n = 5), Wilson's disease (n = 1), fulminant hepatic failure (n = 3), polycystic liver (n = 2), secondary biliary cirrhosis (n = 1), HBV cirrhosis (n = 2) and autoimmune hepatitis with hepatocellular carcinoma (n = 1). The pathology leading to re-transplantation in a pediatric patient was post-transplant hepatitis of unknown etiology. The liver grafts were obtained from 19 brainstem dead and 8 living donors. The pediatric patient requiring re-transplantation received a left lateral segment graft from her mother. Two adults received left lobe grafts from their family members.

RESULTS

The overall graft survival is 88% and patient survival is 92%. There were only 2 deaths: one patient developed primary graft nonfunction and died from intracerebral bleeding 39 days after transplantation and the other died from graft rejection resistant to salvage by steroid pulse and OKT3. The other patients are well with functioning grafts.

CONCLUSIONS

We hope that the current success rate can convince people in our locality in cadaveric organ donation so that living donors do not run the risk of dying from the operation, although the risk is estimated to be very small.

Prevalence of metronidazole resistant Helicobacter pylori strains among Chinese peptic ulcer disease patients and normal controls in Hong Kong

BACKGROUND

A study was conducted to evaluate the prevalence of metronidazole resistant Helicobacter pylori strains among the Chinese in Hong Kong. The efficacy of the triple therapy that contains metronidazole as one of the anti-microbial agents in eradication of the metronidazole susceptible and the metronidazole resistant strains was also assessed.

METHODS

Culture for H pylori was attempted from antral biopsy specimens of 70 peptic ulcer and 51 control subjects. Successfully cultured H pylori strains were tested for metronidazole susceptibility. Twenty six peptic ulcer disease subjects who had received a course of triple therapy were also reassessed four to six weeks later for successful eradication of H pylori infection.

RESULTS AND CONCLUSIONS

H pylori was successfully cultured from antral biopsy specimens in 69 of 80 (86%) of the infected subjects. The overall metronidazole resistance rate was 53.5% (37 of 69). There was a significantly higher metronidazole resistance rate among H pylori isolates from the asymptomatic controls (20 of 25) than the peptic ulcer disease subjects (17 of 44) (p = 0.0007). Twenty three of 32 (73%) women and 14 of 37 (38%) men harboured the metronidazole resistant strains. There was no sex or age difference as far as the prevalence of metronidazole resistant strains were concerned within each study group. Pre-treatment metronidazole susceptible H pylori were significantly more likely to respond to the triple therapy used than those with the metronidazole resistant ones (14 of 15 v five of 10) (p = 0.021).

Recurrent infection of Legionella pneumonia: a case report

A 75-year-old male veteran presented with bilateral pneumonia upon admission. He had an episode of Legionnaires' disease in 1991 with complete treatment of erythromycin 500 mg orally every six hours for three weeks. After admission, recurrence of Legionnaires' disease was suspected due to increased serum Legionella antibody (1:128) and strong positive sputum Legionella antigen. Erythromycin and other parental antibiotics were administered, but respiratory failure developed promptly, followed by multiple organ failure syndrome that involved the liver, lung, bone marrow and kidney. He died 42 days after admission. We reviewed seven cases that had been reported and found recurrence of Legionella pneumonia possible after a successful treatment, especially for immunocompromised hosts. Early empirical therapy with erythromycin is recommended.

Transcatheter arterial chemoembolization in inoperable hepatocellular carcinoma: four-year follow-up

PURPOSE

To evaluate the efficacy of repeated chemoembolization in patients with inoperable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

One hundred thirty-two patients with HCC underwent transcatheter arterial chemoembolization with an emulsion of iodized oil and cisplatin. In 104 patients, "light" gelatin sponge embolization was also used. Chemoembolization was repeated every 1.5-3.0 months in most patients (range, one to 18 chemoembolization sessions).

RESULTS

In 74 patients, the HCCs became smaller or disappeared after chemoembolization. Decreases in size were seen in 55 of 76 HCCs 9 cm or smaller, 17 of 42 HCCs between 9 and 18 cm, and two of 14 HCCs larger than 18 cm. Use of gelatin sponge pledgets enhanced the response in tumors larger than 9 cm. Seven of 74 HCCs that responded to chemoembolization increased in size later. New daughter nodules that appeared at other sites responded to chemoembolization in 24 of 40 patients. Further new nodules appeared in 14 of 24 patients, and in six patients they responded to therapy. Median survival was 26 months for patients with responsive HCCs and 5 months for those with unresponsive lesions.

CONCLUSION

Tumor size at the start of chemoembolization influenced the response to treatment and survival. The addition of gelatin sponge improved results only in tumors larger than 9 cm. Recurrence after an initial response was due more to the appearance of new daughter nodules in new locations rather than recrudescence of the presenting tumor.

Transesophageal echocardiography in the detection of inferior vena cava and cardiac metastasis in hepatocellular carcinoma

Antemortem diagnosis of inferior vena cava (IVC) and cardiac metastasis of hepatocellular carcinoma (HCC) is difficult but important before consideration of curative resection. There are only a few cases of cardiac metastasis of HCC which have been diagnosed antemortem by echocardiography. Accordingly, 18 consecutive patients with HCC who were potential candidates for curative resection were studied by transthoracic (TTE) and transesophageal echocardiography (TEE). One (6%) and two (11%) patients had cardiac and IVC metastasis of HCC, respectively, which was detected by two-dimensional TTE. In contrast, by using TEE, four patients (22%) showed tumor invasion of the IVC, of whom two (11%) had tumor mass extending into the right atrium (RA). There was no significant difference in age, serum level of alpha-fetoprotein, and percentage of right liver lobar involvement between those with and without cardiac metastasis. Patients without cardiac metastasis detected on TTE or TEE had significantly longer mean duration of survival (5.0 +/- 2.1 vs. 2.1 +/- 1.0 months; p < 0.05). In summary, TEE may be more useful than TTE in the detection of cardiac metastasis of HCC, which occurred in 22% of patients whose primary tumor was considered to be surgically resectable in our series. This can be safely performed in patients with HCC and can provide optimal visualization of the IVC and RA. The high prevalence of subclinical cardiac metastasis in HCC mandates the use of TEE in all patients with HCC prior to surgical intervention.

Malignant lymphoma presenting as tracheal tumor: a case report

A 66-year-old male presented with dyspnea and cough for 1 month. Fiberoptic bronchoscopy disclosed a huge tumor over the posterior wall of the trachea 1 cm below the vocal cord and biopsy pathology was diffuse, small cleaved lymphoma. Primary malignant lymphoma of the trachea is extremely rare. Its clinical course varies widely, and has no accepted standard of management. We describe herein the whole clinical course of this patient, which is not similar to previous reports. The relation of primary tracheal lymphoma to mucosa-associated lymphoid tissue (MALT) is also discussed.

Hepatic expression of hepatitis B virus genome in chronic hepatitis B virus infection

The expression of hepatitis B virus (HBV) DNA in the liver was studied by nonisotopic in situ hybridization and correlated with liver histology, different phases in the natural evolution of chronic hepatitis B, and hepatic expression of HBV antigens in 251 Chinese patients with chronic HBV infection. A good correlation was found between the detection of HBV-DNA by in situ hybridization and serum HBV-DNA (P < .01). Chronic active hepatitis had the highest HBV-DNA detected in cytoplasm and nuclei, compared with livers showing minimal change, chronic persistent hepatitis, cirrhosis, and hepatocellular carcinoma. HBV-DNA in cytoplasm exceeded HBV-DNA in nucleus in all patients except in livers with hepatocellular carcinoma. Hepatic HBV-DNA correlated with disease activity (P < .02) and the correlation was highly significant with intralobular activity (P < .001). Patients in the early viral replicative phase of infection had higher levels of cytoplasmic and nuclear HBV-DNA compared with the late viral nonreplicative phase. Cytoplasmic and nuclear HBV-DNA correlated with hepatic expression of HBcAg and HBsAg (P < .05 in both cases), but not with HBeAg. These data indicate that hepatic expression of HBV-DNA follows the natural history of chronic HBV infection and is associated with active liver disease.

[Diagnostic value of ultrasonically guided lung aspiration in pneumonia]

To determine the diagnostic value of ultrasonic lung aspiration for patients with pneumonia, 60 patients with a tentative diagnosis of pneumonia were included in this study. After recording ultrasonographic findings, lung aspiration was done with a spinal needle and aspirated specimens were sent for Papanicolaou, May-Giemsa, acid fast, and Gram stains. The remaining specimens were sent for bacterial, mycobacterial and fungal culture. Twelve patients were excluded from the study because of the final diagnosis of non-infectious pulmonary diseases. In 28 cases of bacterial pneumonia, the diagnostic sensitivity of smear was 50% and culture 61%. The overall sensitivity of needle aspiration and culture was 71%. In 11 cases of bacterial pneumonia with a negative bacterial culture result, 7 cases were afebrile at the time of examination. To increase the diagnostic yield, needle aspiration should be performed at the acute stage of bacterial pneumonia. In 15 cases of pulmonary tuberculosis, the diagnostic rate of acid-fast smear was 47% and mycobacterial culture was 46%. The overall sensitivity of smear and culture was 60%. The diagnostic rate of needle biopsy was 75% and cytologic examination was 77%. Needle biopsy and cytologic examination enhanced the diagnostic rate of sputum-negative pulmonary tuberculosis. Cryptococcosis was documented by smear and needle biopsy in all of the five cases of cryptococcosis. Cryptococcosis is not easily detected by routine cytologic examination, and clinical information is still necessary to enhance the diagnostic rate. Our results show that ultrasonically guided lung aspiration is a technique with a high diagnostic yield and a low complication rate for various types of pneumonia. It is especially useful for patients without satisfactory clinical responses or without accurate microbiologic diagnosis.

[The changes of central and peripheral nerve conduction and the effect of thyroxine replacement in thyroidectomized rats]

The aim of this study is to make serial BAEPs and PNCS in hypothyroid rats in order to provide objective and quantitative methods of detecting dysfunction of the central and peripheral nervous system in hypothyroid status and elucidating the relationship between the recovery potential and the duration of hypothyroid status. Thyroidectomy was performed in eighteen naive 5-month-old Sprague-Dawley rats in order to induce hypothyroid status, which was confirmed by RIA study 1-2 months after the surgery. Initial BAEP and PNCS were performed in two groups of the hypothyroid animals 1 and 3 months after thyroidectomy. Following the initial examination, thyroxin replacement therapy was given to each hypothyroid group, and then followed by BAEPs and PNCS at two month intervals, up to twice normal studies or six months after the initiation of therapy. In the BAEP study, the prolonged I-V inter-peak latency was the most consistent abnormal finding in all hypothyroid rats. Delayed peak latencies as well as prolonged I-III and III-V inter-peak intervals occurred when the hypothyroid status was longer than one month. We noted that the longer the hypothyroid status, the more severe the central conduction dysfunction. Nonetheless, these abnormalities always returned to normal after the replacement therapy if the hypothyroid state was shorter than 3 months in duration. For the PNCS study, all groups of thyroidectomized rats showed the normal results. We think the peripheral nervous system of rats may be more resistant to damage by hypothyroidism than the central nervous system.

Pathogenic role of hepatitis B virus in hepatitis B surface antigen-negative decompensated cirrhosis

This study was conducted to determine the rate of detection of serum hepatitis B virus (HBV) DNA in hepatitis B surface antigen (HBsAg)-negative decompensated cirrhotic patients who had hepatitis B core and/or surface antibodies (anti-HBc and/or anti-HBs), and to compare the outcome of HBsAg-positive cirrhotic patients who did or did not clear HBsAg during follow-up. Six (5%) of 121 HBsAg-positive cirrhotic patients lost HBsAg after 0.2 to 17.1 years (mean, 9.1 +/- 6.2 yr) of follow-up. The cumulative rates of loss of HBsAg at 1, 5, 10, and 15 years were, respectively, 1.3%, 1.3%, 7.4%, and 44.5%. Compared with the patients who remained HBsAg-positive, those who lost HBsAg had milder disease at presentation and significantly longer survival. Of the patients who lost HBsAg, 83% had improvement in liver function after the loss of HBsAg, and all were alive at the time of writing (0.8 to 5.7 years after loss of HBsAg), whereas 27% of those who remained HBsAg-positive had died and 29% had deterioration in liver function. The rate of detection of serum HBV DNA by polymerase chain reaction (PCR) assay was higher in HBsAg-positive cirrhotic patients who lost HBsAg:67% versus cirrhotic patients who had no previous history of chronic HBV infection; 16% (cryptogenic) and 29% (hepatitis C virus and/or alcohol-induced liver disease). In summary, we found that using PCR, serum HBV DNA can be detected in 28% of HBsAg-negative cirrhotic patients who were studied, but the pathogenic significance of such small amounts of virus is not clear.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinicopathological features of hepatitis C virus antibody negative fatal chronic hepatitis C after renal transplantation

Clinical course and serial liver histology of a patient who developed fatal chronic active hepatitis C after renal transplantation are presented. This patient developed persistently deranged liver biochemistry 3 months after transplantation, despite normal liver enzyme values during the preceding 3 years on hemodialysis. In addition to increased parenchymal enzyme concentrations, the levels of ductal enzymes were also markedly elevated, with peak levels of alanine aminotransferase and gamma-glutamyl transpeptidase 7 and 100 times, respectively, the normal upper limit. The patient was persistently seronegative for hepatitis C virus (HCV) antibodies, but positive for HCV RNA. Treatment with alpha-interferon for 6 months, initiated after the development of early cirrhosis, resulted in no improvement, and the patient died from liver failure 36 months after renal transplantation. Serial liver histology, examined four times from 11 months to 36 months after transplantation, showed progressive deterioration from chronic active hepatitis to cirrhosis. This patient illustrates the uncommon complication of rapidly progressive and ultimately fatal liver disease due to HCV infection after renal transplantation. Early recognition with anti-HCV and HCV RNA assays as well as histologic assessment are crucial for the identification of patients with a poor prognosis who might benefit from therapeutic intervention before irreversible liver damage.

Clinicopathologic features of hepatitis C virus infection in renal allograft recipients

The clinicopathologic features, the natural history, and the prognostic indicators of hepatitis C virus (HCV)-related liver disease in renal allograft recipients have not been well defined. Among 220 renal allograft recipients, 21 were seropositive for HCV RNA, which persisted on prospective follow-up for 40 months. Elevations in alanine aminotransferase and alkaline phosphatase were noted after renal transplantation in 15 (71.4%) and 9 (42.9%) patients, respectively, with 11 (52.4%) showing recurrent or persistent abnormalities. Mortality from liver failure was noted in 1 patient. Persistence of abnormal liver biochemistry was associated with an early onset of biochemical derangement after transplantation, and a longer dialysis duration (P < 0.05). HCV-related liver pathology was assessed in 13 patients by histologic scoring with respect to "hepatitic activity," "bile duct damage," and "architectural abnormality," adding up to a "total" score. Six (46.2%) of 13 initial liver biopsies showed significant chronic liver disease. Liver histology correlated with mean alanine aminotransferase and alkaline phosphatase levels after renal transplantation, and was more severe in patients with persistent biochemical abnormalities. Early onset of abnormal liver biochemistry after transplantation and persistently abnormal biochemistry were independent predictors of worse total and activity scores (P < 0.05). Renal transplant recipients demonstrated lower activity scores when compared with nonimmunosuppressed subjects with chronic hepatitis C (P = 0.03). HCV RNA was detectable in all 23 liver specimens tested. We conclude that significant, potentially life-threatening liver pathology manifests in about half of renal transplant recipients with chronic HCV infection. Liver histology correlates with the longitudinal biochemical profile. Patients with early onset of biochemical abnormalities and persistently deranged liver biochemistry are at risk of developing severe liver disease.

Hepatic expression of interferon-alpha in chronic hepatitis B virus infection

Hepatic expression of interferon-alpha (IFN-alpha) was examined by immunohistochemistry in 90 Chinese patients (M/F 67:23, age: 14-69) with a spectrum of hepatitis B virus (HBV)-related chronic liver diseases. Immunoreactive IFN-alpha was detected in sinusoidal cells in 79 patients (88%) and in mononuclear cells in 59 patients (65.6%). Patients with active liver diseases (chronic active hepatitis, active cirrhosis, N = 55) had a higher level of IFN-alpha expression compared to patients with inactive histology (N = 35; sinusoidal cells, P < 0.01; mononuclear cells, P < 0.01). Cytoplasmic HBsAg, nuclear HBcAg, and cytoplasmic HBcAg were detected in 79 (88%), 42 (47%), and 23 (27%) patients respectively. Expression of IFN-alpha in mononuclear cells correlated with the expression of cytoplasmic HBcAg (P < 0.05) but not with nuclear HBcAg or cytoplasmic HBsAg. When the patients were divided into four different phases according to the natural history of chronic HBV infection, patients in the active liver disease phase had higher IFN-alpha expression compared to the immunotolerant and late phase patients (P < 0.01). Using double immunohistochemical staining, both IFN-alpha and cytoplasmic HBcAg were frequently detected near inflammatory infiltrates but no correlation existed between the hepatic expression of HBsAg and IFN-alpha. These data indicate that IFN-alpha is expressed in the liver in HBV-related active liver diseases and that the reported suboptimal production of IFN-alpha by PBMC in HBV-related chronic active liver diseases may be due to a redistribution of the IFN-alpha-producing mononuclear cells into the liver, the site of inflammation.

Female children respond to recombinant hepatitis B vaccine with a higher titre than male

One-hundred and eighty Chinese children [age range 5 months to 12 years, seronegative for all hepatitis B virus (HBV) markers] of parents seropositive for HBV surface antigen (HBsAg) were randomized to receive doses of either 10 or 20 micrograms of recombinant yeast-derived HBV vaccine at intervals of 0, 1, and 6 months. Six children defaulted and three other children (1.7 per cent) seroconverted to anti-HBc positivity without detectable HBsAg in the serum. All other children attained an anti-HBs titre of > 10 mlU/ml after three doses. Both 10 and 20 micrograms/dose regime gave a similar geometric mean titre (GMT) of anti-HBs. Children aged 0-4 responded with a similar titre compared with children aged > 4. Female children responded with a significantly higher GMT than male children and this was due to a high proportion of female children with higher peak titres. No major side-effects were encountered. We conclude that recombinant HB vaccine is highly immunogenic, well tolerated and equally effective with doses of both 10 and 20 micrograms and that girls responded with a higher anti-HBs titre compared with boys.

Relationship between intrahepatic expression of hepatitis B viral antigens and histology in Chinese patients with chronic hepatitis B virus infection

Hepatic cellular and subcellular expression of hepatitis B virus (HBV) antigens--HBsAg, HBcAg, and HBeAg--in 143 Chinese patients with chronic HBV infection were studied by immunohistochemical techniques. Nuclear expression of HBcAg and nuclear and cytoplasmic expression of HBeAg showed a secular trend decreasing from the carrier state and chronic persistent hepatitis (CPH), through chronic active hepatitis (CAH), to cirrhosis with or without hepatocellular carcinoma. In contrast, cytoplasmic HBcAg expression was significantly greater in patients with CPH and CAH (P < .0108). In addition, cytoplasmic HBcAg correlated significantly with lobular activity, portal inflammation, and hepatitic activity (P < or = .007). Expression of cytoplasmic HBcAg also exceeded cytoplasmic HBeAg and nuclear HBcAg in liver specimens showing significant damage (P < .038). HBsAg, however, showed no secular trend and was not related to liver histology. The authors' findings support the theory that HBcAg is also the viral target antigen for immune-mediated liver damage in Chinese patients with chronic HBV infection.

The hepatitis C virus genome: a guide to its conserved sequences and candidate epitopes

A comprehensive analysis of reported hepatitis C virus genomic sequences comprising 151 partial or complete nucleotide sequences and 159 partial or complete amino acid sequences revealed an irregular composition of conserved and variable regions. There were but eight conserved nucleotide sequences, none outside the 5' noncoding and structural regions. A search among conserved amino acid sequences revealed 14 candidate B-cell epitopes, which were chosen mainly on the basis of their hydrophilicity profiles. Twenty five candidate T-cell epitopes were selected according to the criteria of absolute conservation of amino acid sequence, together with characteristic sequence motifs, amphipathic helical structure, or both. Conserved peptide sequences, with the characteristics of both B- and T-cell epitopes, were identified in the nonstructural 5 (NS5) region of the genome.

Five-year follow-up of a prospective randomized trial of hepatitis B recombinant DNA yeast vaccine vs. plasma-derived vaccine in children: immunogenicity and anamnestic responses

In a prospective randomized trial, 318 children aged between 3 mo and 11 yr who were negative for all hepatitis B markers were randomized to receive two 5-micrograms doses of hepatitis B recombinant DNA yeast vaccine at 0 and 1 mo (group 1), three 5-micrograms doses of hepatitis B recombinant DNA yeast vaccine at 0, 1 and 6 mo (group 2) or three 10-micrograms doses of plasma-derived hepatitis B vaccine (group 3). The HBs antibody response rate at 8 mo was between 93% and 99%; it was still 75% to 87% at 5 yr in all three groups. Geometric mean titers at 1 yr were 83, 1,085 and 858 mIU/ml in groups 1, 2 and 3, respectively. These values had decreased after 5 yr to 47, 131 and 250 mIU/ml. Subjects in group 1 showed a significantly less proportional drop in geometric mean titer at the fifth year than did subjects in group 2 (p = 0.05) or group 3 (p = 0.015). None of the children developed HBc antibody, even after 5 yr of follow-up. We noted 42 episodes of significantly increased HBs antibody titers, probably due to anamnestic response, even when the titers had dropped to low levels. The mean age at which anamnestic response occurred was 8.7 yr.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of inoperable hepatocellular carcinoma by transcatheter arterial chemoembolization using an emulsion of cisplatin in iodized oil and gelfoam

Eighty patients with inoperable hepatocellular carcinoma (HCC) were treated by transcatheter arterial chemoembolization using an emulsion of Lipiodol and Cisplatin. In 59 patients, gelfoam embolization was also given. The tumour size ranged from 0.5 cm to 33 cm in maximum diameter with the median diameter being 8 cm. The chemoembolization sessions were repeated every 1 1/2 to 3 months. The number of sessions the patients underwent varied from 1 to 11, with the mean number of sessions being 3.7. The HCC either disappeared completely or decreased in size in 44 patients (55%). In patients having an HCC of 12 cm or less in size, 31 out of 41 (75.6%) who had the addition of gelfoam demonstrated decrease in tumour size, while seven out of 11 (63.6%) without the addition of gelfoam demonstrated decrease in tumour size. In patients having an HCC of more than 12 cm in size, only six out of 18 (33.3%) who had the addition of gelfoam demonstrated reduction in tumour size and none of the 10 patients without the addition of gelfoam responded. Thus, HCCs of 12 cm or less in size responded better than larger ones to chemoembolization (P < 0.0001) while the addition of gelfoam enhanced the response (P = 0.039). The 1 year survival rate for the 80 patients was 53% and the 2 years survival rate was 38%. The median survival was 13 months. For patients having an HCC of 12 cm or less in size, the 1 year and 2 year survival rates were 69% and 47% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The variability of the hepatitis B virus genome: statistical analysis and biological implications

A statistical analysis of the nucleotide sequence variability in 14 published hepatitis B virus (HBV) genomes was carried out using parametric and nonparametric methods. A parametric statistical model revealed that the different regions of the genome differed significantly in their variability. The conclusion was supported by a nonparametric kernel-density model of the HBV genome. Genes S, C, and P, region X, the precore region, and the pre-S2/pre-S1 regions were ranked in order of increasing variability. In many instances, conserved regions of the genome identified with sequences of known function in HBV biology. However, other characterized regions (such as pre-S) showed much variability despite the involvement of their encoded peptides in specific functions. Point mutations that may result in the formation of stop codons and amino acid changes may affect the clinical picture of HBV infection and may be reflected in atypical serological patterns.

Recombinant interferon-alpha in inoperable hepatocellular carcinoma: a randomized controlled trial

To evaluate the clinical efficacy of interferon-alpha in hepatocellular carcinoma, 71 adult Chinese patients with histologically proven inoperable hepatocellular carcinoma were randomized to receive recombinant interferon-alpha 2a (50 x 10(6) IU/m2) intramuscularly three times a week (n = 35) or no antitumor therapy (n = 36). The survival of interferon-alpha-treated patients was significantly better than that of patients who received no antitumor therapy (p = 0.0471); median lengths of survival were 14.5 and 7.5 wk, respectively. Objective tumor regression greater than 50% was observed in 31.4% (11 of 35) of patients receiving interferon-alpha. Interferon-alpha induced tumor regression greater than 50% in 11 (31.4%) patients. Compared with the group receiving no antitumor therapy, the interferon-alpha therapy group had more tumor regression (p < 0.0001) and less tumor progression (p = 0.001). This high-dose interferon-alpha therapy was relatively well tolerated; only 34.3% of patients required reduction of dosage by one third or one half because of persistent fatigue. Two patients with diabetes mellitus (one also had tabes dorsalis) exhibited mental deterioration that might have been partially attributable to interferon-alpha therapy. We conclude that interferon-alpha is useful in a proportion of Chinese patients with inoperable hepatocellular carcinoma, both in prolonging survival and in inducing tumor regression.

Re-evaluation of alpha-interferon treatment of chronic hepatitis B using polymerase chain reaction

To re-evaluate the efficacy of 3 treatment trials involving 272 Chinese patients with chronic hepatitis B virus infection, serial serum samples were tested from 60 patients treated with alpha-interferon with or without prednisone priming and 12 control patients, who were negative for hepatitis B virus deoxyribonucleic acid using dot-blot hybridization. Serial samples were tested using nested polymerase chain reaction with primer sets chosen from the surface and core antigen coding regions. The 19 patients who did not show persistent serological change remained hepatitis B virus deoxyribonucleic acid positive using the polymerase chain reaction assay. Three of the 4 patients (75%) who lost hepatitis B surface antigen and 9 of 51 (17.6%) who lost hepatitis B e antigen became negative from 0 to 60 months after the e-seroconversion. All patients negative for the polymerase chain reaction assay had normal transaminase levels. Pooling the 3 trials together, 11 of 188 (5.9%) treated patients and 1 of 84 (1.2%) control patients became hepatitis B virus deoxyribonucleic acid negative. The difference was not statistically significant. As assayed by the polymerase chain reaction assay, patients who were treated with alpha-interferon with or without steroid priming and lost hepatitis B e antigen within 12 months were more likely to subsequently lose the virus completely from the serum (11 of 33) than those who lost hepatitis B e antigen after 12 months (none of 13; p = 0.029).

Seroepidemiological survey of hepatitis E in Hong Kong by recombinant-based enzyme immunoassays

The agent that causes the enterally transmitted form of non-A, non-B hepatitis has been cloned and called hepatitis E virus (HEV). We have carried out a seroepidemiological survey on the prevalence of hepatitis E in Hong Kong. In a retrospective study, serum from 394 patients with acute viral hepatitis and 355 healthy subjects was tested for antibodies to HEV (anti-HEV) with a recombinant-based enzyme immunoassay. 65 (16.5%) patients with hepatitis were positive for IgM anti-HEV and 23 (5.8%) were also positive for IgM anti-HEV. Of 18 patients diagnosed as having acute non-A, non-B, non-C hepatitis, 6 were IgM anti-HEV positive. 17 (6%) patients in whom acute hepatitis A was diagnosed were also infected with HEV. None of 70 patients with acute hepatitis B or C or exacerbation of chronic hepatitis B was IgM anti-HEV positive. 57 (16.1%) of the healthy subjects were positive for IgG anti-HEV. The prevalence of IgG anti-HEV was higher in subjects over 20 years old than in younger subjects (24% vs 4%, p < 0.0001). IgG anti-HEV was detected in 26% of subjects who were positive for IgG antibody to HAV and in 7% of those negative for that antibody (p < 0.0001). We demonstrated the validity of the recombinant-based enzyme immunoassays for the diagnosis of hepatitis E. Our results suggest that hepatitis E accounts for a third of non-A, non-B, non-C hepatitis in Hong Kong and that coinfection of hepatitis A and E can occur.