Sequential and diagnostic features in primary biliary cirrhosis based on serial histologic study in 209 patients

Four forms of piecemeal necrosis--biliary, lymphocytic, ductular, and fibrotic--were identified in 605 liver biopsy specimens from 209 patients with primary biliary cirrhosis. Whereas lymphocytic piecemeal necrosis, often associated with lobular hepatitis, was most common in stages 2 and 3 of the classical histologic staging, biliary piecemeal necrosis was frequent in all stages, except stage 1, and the fibrotic form appeared to be a late, mainly cirrhotic feature. In 77% of patients cholestatic features predominated, whereas hepatitic changes producing some histologic overlap with chronic active hepatitis occurred in the remaining patients. These patterns tended to be maintained throughout the course of the disease. Large hypocellular scars found in 36% and 59% of stage 3 and 4 specimens, respectively, appeared to be a characteristic feature of biliary disease. The prevalence of classical features was assessed. The analysis of sequential biopsy specimens from those patients who died showed that cirrhotic transformation, increasing cholestasis (in particular with prominent hyaline inclusions), abundance of coarse collagen bundles, and "halo" formation at the margins of the fibrous septa were associated with a poor prognosis. We were unable to show that the presence of granulomas is associated with a more favorable course of the disease.

[Centrolobular liver cell necroses following occupational halothane contact. Association with antibodies to halothane altered liver cell components]

A report is given on a 24 year old nurse, who developed two episodes of fever, chills and malaise with high serum enzyme levels and histologic proof of extensive centrolobular hepatic necrosis in association with vocational halothane exposure in the operating theatre. A cause-effect relationship was suggested by the demonstration of antibodies against halothane-altered hepatocyte membrane components. Also, there was no indication of other known causes of a cytotoxic liver reaction. In certain predisposed individuals, halothane even in subanaesthetic concentrations is apparently able to induce liver cell damage. Only six further reports on such liver injuries in medical personnel could be found in the literature.

Double blind controlled trial of d-penicillamine in patients with primary biliary cirrhosis

One hundred and eighty nine patients with primary biliary cirrhosis were entered into a double blind, placebo controlled randomised trial starting in January 1978 to assess the therapeutic value of d-penicillamine 1200 mg daily. Eighteen of the 98 patients receiving d-penicillamine and 22 of the 91 placebo treated patients died during the study. Thirty six per cent of those on d-penicillamine and 8% of those on placebo were withdrawn from the study. No difference in overall survival was noted between the two groups of patients whether the results were analysed for the entire period of observation or only during the period in which the patients were receiving therapy. The mortality rate of those receiving d-penicillamine in histological stage I to II, however, was one third of that of the placebo group although this difference did not reach statistical significance. Using the occurrence rate ratio as the statistical method of analysis, no effect of d-penicillamine was noted on any clinical, biochemical or histological features examined, except the serum alanine aminotransferase activity which was greater in those on active treatment. In this trial we have been unable to establish any therapeutic benefit from the drug.

Mononuclear cell complement receptor blockade in primary biliary cirrhosis

Peripheral blood monocyte and lymphocyte receptors for Fc and C3b fragments were examined in vitro in patients with primary biliary cirrhosis and other chronic liver diseases using sheep red blood cells coated with anti-SRBC IgG1 (to detect Fc receptors) and with anti-SRBC IgM and complement (to detect C3b receptors). The number of C3b receptors detected on 100 monocytes was significantly lower in patients with primary biliary cirrhosis (23.0 +/- 12.0, mean +/- 1 SD) compared with normal controls (57.4 +/- 16.9) and other chronic liver disease (HBsAg negative chronic active hepatitis 62.0 +/- 17.0, alcoholic cirrhosis 50.9 +/- 4.0), while the number of Fc receptors detected on 100 monocytes was not significantly different in all the groups (primary biliary cirrhosis 72.8 +/- 28.6, chronic active hepatitis 74.7 +/- 14.0, alcoholic cirrhosis 58.0 +/- 13.5 and normal controls 69.6 +/- 19.9). When mononuclear cells isolated from normal individuals were pre-incubated with serum from patients with primary biliary cirrhosis before testing their receptor function there was a significant reduction in the number of C3b receptors detected per 100 monocytes (27.6 +/- 10.8) compared with pre-incubation with normal serum (72.0 +/- 18.0). This reduction in C3b-receptor function was again observed when the serum used for pre-incubation was depleted of circulating immune complexes; but when complement was further depleted from these sera, the number of C3b-receptors detected after pre-incubation was similar to normal values (64.0 +/- 11.8). Lymphocyte receptors showed a similar pattern of results. This implies a specific C3b receptor blockade on monocytes and lymphocytes from patients with primary biliary cirrhosis which appears to be because of blocking by serum factor(s) including complement fragments.

An enzyme-linked immunosorbent assay for detection of antibodies against halothane-altered hepatocyte antigens

Patients with massive liver cell necrosis that may follow halothane anaesthesia have a high incidence of circulating antibodies against halothane-induced hepatocyte antigens. In order to provide an objective and quantitative method for the detection of these antibodies, an enzyme-linked immunosorbent assay has been developed. Sera, after absorption with normal rabbit liver microsomal fraction, are tested for binding to microsomal fractions from control and halothane-pretreated rabbits. Those containing antibodies against halothane-induced determinants give significantly enhanced binding to halothane-altered fractions; this specificity was verified by absorption experiments. Using this method, halothane-related antibodies were detected in sera from 16/24 patients with halothane-associated liver failure, at titres ranging from 1:100 to 1:25600. Such antibodies were not detectable in sera from 26 normal blood donors, 5 healthy anaesthetists, 12 patients who had received multiple halothane anaesthetics but had normal liver function tests and 32 patients with a variety of other liver diseases. This rapid and reproducible assay should be of value for the detection of antibodies and for detailed investigation of patient antibody responses, and also for characterization of the route of production and metabolism of the antigen.

A simple enzyme-linked immunosorbent assay for detection of anti-mitochondrial antibodies

An enzyme-linked immunosorbent assay (ELISA) has been developed for detection of anti-mitochondrial antibodies (AMA) in patients' sera. Results are expressed as a mitochondrial binding index, calculated from binding of patients' antibodies to rabbit liver mitochondrial fraction and total liver homogenate. The incidence of AMA detectable by this method in 22 sera from patients with primary biliary cirrhosis was identical with that obtained by conventional immunofluorescence testing (86%), and there was a highly significant correlation between titres determined by the two methods (r = 0.828; P less than 0.01) although ELISA titres were far higher. AMA were also detectable by ELISA in sera from 9/22 patients with chronic active hepatitis, 1/38 patients with other liver diseases, 3/16 patients with syphilis, 2/16 patients with non-hepatic autoimmune diseases and 0/29 normal blood donors; of these, only 2 chronic active hepatitis sera were positive for AMA by immunofluorescence. The ELISA titre was significantly correlated with the mitochondrial binding index determined at a serum dilution of 1:200 (r = 0.793; P less than 0.01), allowing an estimate of antibody titre to be made from ELISA screening at this single serum dilution. This assay, which is simple and reproducible, may be of value as an objective method of screening for AMA.

Pharmacokinetic study of cyclosporin A (Sandimmun) in patients with primary biliary cirrhosis

The pharmacokinetics of cyclosporin A (CS-A) were studied in 10 patients with primary biliary cirrhosis (PBC) after oral administration in steady state. Mean values for area under the blood concentration-time curve (AUC), time to maximal blood concentration (tmax), maximal blood concentration (Cmax) and elimination half-life (t1/2,z) were similar to results of previous studies in transplant patients. The variation between patients was large. No significant correlations of pharmacokinetic data with biochemical or histological parameters were found. Because of the high variability of pharmacokinetic parameters, patients with PBC treated with CS-A need to be regularly controlled for nephrotoxicity by estimation of serum creatinine and bioavailability (trough blood levels).

Recurrence of autoimmune chronic active hepatitis following orthotopic liver grafting

In a 26-year-old woman who had received an orthotopic liver graft for end-stage autoimmune chronic active hepatitis, signs indicative of the original disease became apparent 18 months after transplantation, at a time when the maintenance dose of prednisolone had been reduced to 3 mg daily. In addition to anorexia, nausea, and weight loss there was a reappearance of spider naevi, serum autoantibodies, and elevated levels of immunoglobulin G. Features typical of chronic active hepatitis were observed on examination of the liver biopsy, and both the clinical and histological pictures were unlike those of other possible causes of liver dysfunction, such as chronic rejection, cyclosporine hepatotoxicity, and non-A non-B chronic hepatitis. Following substitution of azathioprine for cyclosporine and an increased dose of prednisolone (20 mg daily), there was a rapid improvement in the clinical state and both serum transaminases and immunoglobulins returned to normal values. Histological appearances in a repeat biopsy taken six months later were consistent with chronic active hepatitis in remission. This case provides further evidence of the importance of host factors in the pathogenesis of chronic active hepatitis and emphasizes the necessity for selecting appropriate immunosuppressive therapy in such patients after transplantation.

Antibodies to alcohol altered liver cell determinants in patients with alcoholic liver disease

Circulating antibodies reacting specifically with hepatocytes isolated from ethanol pretreated rabbits have been demonstrated by two techniques - induced cytotoxicity and immunofluorescence. In the cytotoxicity assay antibodies were found in seven of 19 (39%) of patients with alcoholic fatty liver (with or without fibrosis), six of 13 (46%) of those with alcoholic hepatitis, 15 of 36 (43%) of those with cirrhosis, and seven of 14 patients (50%) of those with hepatitis and cirrhosis. In the immunofluorescence studies, nine of 15 sera induced a granular pattern of fluorescence on the ethanol pretreated hepatocytes; two sera which induced significant cytotoxicity did not induce immunofluorescence. No ethanol related antibodies were found in normal individuals or in patients with other types of acute or chronic liver disease. These results show that antibodies directed against ethanol altered liver cell determinants are present in the serum of 43% of patients with alcoholic liver disease, and suggest a mechanism whereby chronic alcohol consumption may, by inducing antigenic changes in hepatocyte membranes, trigger a cell damaging immune reaction.

The Cambridge and King's College Hospital experience of liver transplantation, 1968-1983

The postoperative course of 138 transplants performed in 137 patients in the Cambridge and King's College Hospital series between May 2, 1968 and April 1, 1983 is presented. During the last 15 years, criteria for selection of transplant candidates has been improved and types of disease categories, both suitable and unsuitable for liver transplantation, have been defined. The acceptance of the concept of brain death and the use of heart-beating donors in the United Kingdom since 1976 has greatly improved the quality of donor organs. Changes in surgical technique, particularly with regard to biliary tract drainage, have reduced morbidity and mortality from biliary tract complications since 1975. The use of partial cardiopulmonary bypass in selected cases and changes in immunosuppressive drug regimens have not significantly improved our overall results. Despite these changes based on our experience, the perioperative mortality in the Cambridge and King's College Hospital series remains disturbingly high.

Effect of polyunsaturated phosphatidylcholine on immune mediated hepatocyte damage

Studies were carried out to investigate the mechanisms underlying the reduction of hepatocellular necrosis observed when polyunsaturated phosphatidylcholine was administered to patients with HBsAg negative chronic active hepatitis. After oral administration of the agent, the susceptibility of rabbit hepatocytes to both antibody dependent cell mediated cytotoxicity and mitogen induced lymphocyte cytotoxicity was substantially reduced. Short term in vitro incubation of either the hepatocytes or lymphocytes with polyunsaturated phosphatidylcholine had no effect on antibody dependent cell mediated cytotoxicity. As it has been shown that orally administered polyunsaturated phosphatidylcholine can be incorporated into the liver cell membrane, it is possible that polyunsaturated phosphatidylcholine exerts its effect by blocking the interaction between immune effector cells and hepatocytes.

Specific serological markers in the diagnosis of fulminant hepatic failure associated with halothane anaesthesia

The aetiology of massive liver-cell necrosis which developed in 16 patients following halothane anaesthesia was investigated by means of new serological techniques. In eight patients a specific halothane-related antibody was found, indicating that these patients were sensitized to halothane-altered liver-cell membrane components. In four patients, hepatitis A viral infection was responsible and among the remainder one was receiving anti-tuberculous drugs and one had received a blood transfusion, thus raising the possibility of a non-A non-B viral infection. There were no biochemical or histological differences between patients in the three groups.

Recurrence of primary biliary cirrhosis after liver transplantation

Three patients who had undergone orthrotopic liver transplantation for primary biliary cirrhosis and were being maintained on immunosuppressive therapy were investigated 31/2 to 41/2 years later because of the redevelopment of pruritus and mild jaundice. In one patient pigmentation was again evident, and all three had a rise in the titer of serum mitochondrial antibody after an initial fall. Liver histology showed features of primary biliary cirrhosis with non-suppurative destructive cholangitis, lymphoid aggregates, and increased deposition of copper-binding protein in the absence of cholestasis. None of these features was found in patients who had received grafts for other conditions and had lived for comparable periods, nor were they found in patients who had had rejection with bile-duct abnormalities. The overall findings indicate a recurrence of primary biliary cirrhosis in the donor organ.

Hepatic damage after exposure to halothane in medical personnel

Two surgeons, in whom liver damage developed after occupational exposure to sub-anaesthetic doses of halothane, were found to have a circulating antibody which reacted specifically with halothane-altered hepatocyte membrane components. This antibody had been found previously only in those patients in whom severe hepatic necrosis developed after exposure to halothane and in no other form of liver injury. It may provide a specific diagnostic marker in patients in whom there are other possible causes of liver damage and could, therefore, remove the need for a challenge exposure and its attendant risks.

Oxidative metabolism of halothane in the production of altered hepatocyte membrane antigens in acute halothane-induced hepatic necrosis

Previous investigations have shown that patients with fulminant hepatic failure after halothane anaesthesia have a circulating antibody which reacts with an antigen present on the surface of halothane-altered hepatocytes. In the present study, it has been shown that the expression of the antigen is associated with the oxidative metabolism of halothane, in contrast with results of other groups which have shown that the reductive route is involved in the direct hepatotoxic reaction attributed to halothane.

Improved survival after orthotopic liver grafting

A total of 108 orthotopic liver transplants have been carried out in the Cambridge/King's College Hospital series. Over 13 years, changes in patient selection, immunosuppression, and surgical and anaesthetic techniques have led to a steady improvement in results. Results obtained in the last 22 patients indicated that over half survive for one year. Although at considerable risk during the operation, patients with non-malignant cirrhotic diseases who survive one year have a good long-term chance of survival

Antibodies to the surface of halothane-altered rabbit hepatocytes in patients with severe halothane-associated hepatitis

Circulating antibodies reacting specifically with the cell membrane of hepatocytes isolated from halothane-anesthetized rabbits were detected in nine of 11 patients with fulminant hepatic failure after helothane-induced anesthesia. The immunoglobulin deposition, as revealed by immunofluorescence, showed a granular pattern on the hepatocyte surface membrane. Preincubation of halothane-pretreated, but not of control, hepatocytes with serum containing this antibody rendered them susceptible to cytotoxic effects of normal lymphocytes in vitro. Control studies using serum from subjects repeatedly exposed to halothane without the development of liver damage, and from patients with viral and toxic liver injury have confirmed the specificity of these findings to serve halothane-associated liver injury. These results provide further evidence of an immunologic component in this condition.

Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis

Seven of ten women with oral-contraceptive-associated liver tumours were found to have hepatocellular carcinoma. The diagnosis was often delayed, although hepatomegaly was always present on examination, and liver-function tests and erythrocyte sedimentation-rates were abnormal in most cases. Other investigations, including routine technetium liver scans and biopsy, were sometimes misleading. There were important differences in alpha-fetoprotein concentration, vascularity on angiography, and survival between liver tumours in pill users and non-users.

Bilateral sixth cranial nerve palsy in infectious mononucleosis

A 15-year-old girl who presented with a bilateral sixth nerve palsy caused by infectious mononucleosis is described. The neurological presentation of infectious mononucleosis is discussed.