HLA-B8, immunoglobulins, and antibody responses in alcohol-related liver disease

Prevalence and significance of autoantibodies in patients with alcoholic liver disease

OBJECTIVE

This study aimed to evaluate the prevalence and significance of serum autoantibodies in alcoholic liver disease (ALD) patients.

METHODS

In total, 90 male patients diagnosed with ALD or ALD overlapping with chronic hepatitis B (CHB) were included and their medical records were retrospectively reviewed. Clinical data and laboratory findings were collected. Anti-nuclear antibody (ANA), anti-mitochondrial antibody (AMA) and anti-smooth muscle antibody (SMA) were detected by indirect immunofluorescent assay.

RESULTS

Autoantibodies were found in 69.6% (48/69) of patients with ALD and 66.7% (14/21) of those with ALD overlapping with CHB. The prevalence of total ANA in ALD patients was 63.8% (44/69). High titers of autoantibodies and multi-autoantibodies were found to be more often associated with cirrhosis than non-cirrhosis. There was a significant difference in the levels of globulin, white blood cell and platelet count (P < 0.05) between patients with positive and negative autoantibodies. However, the values of the other parameters were similar in the two groups. Patients with ALD more frequently had positive autoantibodies than those with CHB alone (69.6% vs. 37.5%, P < 0.01). And 10.4% of ALD patients with positive autoantibodies had systemic autoimmune or vascular diseases, which was not found in the CHB patients.

CONCLUSIONS

Autoantibodies are frequently present in patients with ALD and correlate to advanced liver disease. A high prevalence of autoantibodies in ALD may indicate that alcoholic-associated immune disturbance occurs during the development of the disease.

Drinking status of heavy drinkers detected by arrival time parametric imaging using sonazoid-enhanced ultrasonography: study of two cases

Chronic heavy consumption of alcohol is associated with increased risks of developing liver cirrhosis, hepatocellular carcinoma, and esophageal varices. Cessation of alcohol consumption is the most important requirement in treating these diseases. However, judging whether patients have actually maintained abstinence from alcohol requires reliance on their reports, which vary substantially across individuals using the test methods currently available. Arrival time parametric imaging (At-PI) using Sonazoid-enhanced ultrasonography is regarded as a useful approach for assessing the progression of lesions that have developed in liver parenchyma. In this study, we report two cases for whom this approach was successfully applied to indicate the drinking status of a heavy drinker. At-PI enables approximate and objective assessment of the drinking status of patients, independent of their reports; therefore, it is a promising method for providing information about drinking status.

Autoantibodies and immunoglobulins in alcoholic steatosis and cirrhosis

Antinuclear antibodies were significantly more prevalent (p less than 0.01) in 143 patients with alcoholic cirrhosis than in 64 patients with alcoholic steatosis and in 94 controls. Smooth muscle antibodies were significantly more prevalent (p less than 0.05) in patients with alcoholic steatosis and cirrhosis than in controls. The prevalence of antimitochondrial antibodies and IgG liver membrane antibodies did not differ significantly between the three groups. Immunoglobulin G, A, and M concentrations were only occasionally increased in patients with steatosis. Patients with cirrhosis had significantly increased (p less than 0.005) concentrations of immunoglobulins G, A, and M when compared to patients with steatosis. These results indicate that the degree of liver damage has more effect than chronic alcoholism on the humoral immune system. Whether this influence is direct or indirect remains to be established.

Influence of alcohol on antimicrobial immunity

Prolonged consumption of excessive amounts of alcohol by itself, as well as possibly leading to a state of alcoholism, has been a long-standing biological/social problem. As a major public health concern, there is an estimated expenditure of about 20% of total health care costs for medical/hospital care related to alcohol-induced illness. In addition, a significant proportion of both men and women who are hospitalized can be classified as alcoholics. This review focuses primarily on one of the many biomedical problems attributed to alcohol abuse--its adverse effects on our immune-defense system. A considerable body of evidence has mounted, over the past several decades, indicating that those who abuse alcohol are more susceptible to certain infectious disorders and are more prone to bacteremia. Such infections tend to be continuous and are often associated with a high rate of mortality. Also, along these lines, various and suitable animal models have been developed to further elucidate what the causes are for the greater frequency and severity of infectious illnesses, and this review deals primarily with those studies linking alcohol abuse to disruption in the normal functioning of the host's immune surveillance system. Based on the results from both clinical and experimental studies, it would seem that exposure to high levels of alcohol causes decreased humoral and cellular immune responses, thereby seriously limiting our ability to be protected from certain infectious agents.

Liver and kidney diseases

The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.

Autoantibodies in alcoholic liver disease

Despite many decades of research, the reasons why only a relatively small proportion of individuals who consume excessive quantities of alcohol develop clinically significant liver disease remain unknown. The association with features of autoimmune diseases, including hypergammaglobulinaemia, circulating autoantibodies, inheritance of certain immunogenetic (HLA) markers and response to corticosteroid therapy in some patients has led to a persistent impression that altered immune regulation with a relative loss of self-tolerance underlies susceptibility to the development of the more severe forms of alcoholic liver disease (alcoholic hepatitis and/or cirrhosis). However, review of the data from the numerous studies that have been conducted over the past 30 years fails to reveal sufficiently convincing evidence that autoimmunity plays a primary role in alcohol-related liver damage. In particular, most of the wide range of circulating autoantibodies that have been reported in patients are found mainly at low titres, are not confined to those with severe liver injury, and are probably more likely to be a response to the hepatic insult than causally related to liver damage. Additionally, an association with various HLA phenotypes has not been confirmed by meta-analysis. Interpretation is complicated by evidence that alcohol may have direct effects on some components of the immune system but, if there is an immunogenetic basis for alcoholic liver disease, the present evidence suggests that this might be related more to cytokine gene polymorphisms than to a predisposition to autoimmunity per se.

Increased serum concentration of IgA2 subclass and IgA2/IgA1 ratio: specific markers of chronic alcoholic abuse?

Enhanced serum IgA concentrations are common in alcoholic liver cirrhosis, but functional differences between IgA subclasses and their relation with interleukin-6 (IL-6) have not been described. Distinct immunoregulatory mechanisms may exist that selectively affect one subclass. This possibility prompted us to investigate the distribution of IgA1 and IgA2 subclasses in the serum of 25 heavy alcohol drinkers (alcohol: 80 to 200 g per day) without clinical disorders, in comparison with 35 patients affected by alcoholic liver cirrhosis, 29 viral hepatitis patients and 33 social drinkers as a control group. Mean (+/- SD) IgA2 concentration (0.56 +/- 0.31 g/l) was significantly increased (p < 0.01) in heavy alcohol drinkers, with an IgA2/IgA1 ratio of 0.33 +/- 0.12, while the mean total IgA concentration was similar to the control group. Mean IgA1 and IgA2 concentrations were significantly increased (p < 0.001) in alcoholic liver cirrhosis patients (6.13 +/- 4.52 g/l and 1.83 +/- 1.93 g/l respectively, with an IgA2/IgA1 ratio of 0.32 +/- 0.19) and viral hepatitis patients (3.66 +/- 2.59 g/l and 0.69 +/- 0.67 g/l respectively, with an IgA2/IgA1 ratio of 0.21 +/- 0.14) High serum IL-6 concentrations (34 +/- 33 ng/l) were correlated with elevated IgA1 and IgA2 concentrations only in patients with alcoholic liver cirrhosis. IgA2 subclass and IgA2/IgA1 ratio could therefore be used as markers of chronic alcohol abuse directly related to the extent and duration of the alcohol abuse and the effectiveness of alcohol withdrawal.

Alcohol inhibits lipopolysaccharide-induced tumor necrosis factor alpha gene expression by peripheral blood mononuclear cells as measured by reverse transcriptase PCR in situ hybridization

We recently showed that alcohol significantly suppressed lipopolysaccharide (LPS)-induced tumor necrosis factor alpha (TNF-alpha) production by whole blood and total mononuclear cells from healthy subjects as measured by bioassay. In the current study, we further examined the effect of alcohol on LPS-induced TNF-alpha gene expression by semiquantitative solution PCR and in situ reverse transcriptase PCR (RT-PCR) hybridization methods. Peripheral blood mononuclear cells were cultured with LPS (10 micrograms/ml) for 4 to 8 h with or without different concentrations of ethanol (0.1, 0.2, and 0.3% [vol/vol]). Total RNA from treated and untreated cultures was extracted and used for solution PCR analysis. Treated and untreated cells were subjected to both conventional in situ hybridization and RT-PCR in situ hybridization. In solution RT-PCR in vitro analysis, alcohol significantly suppressed TNF-specific message. In conventional in situ hybridization, the effect of alcohol on TNF-alpha gene expression was poorly detected. However, when cells were subjected to RT-PCR prior to in situ hybridization, cells treated with alcohol significantly suppressed expression of the message for TNF-alpha. These studies confirm our earlier finding that alcohol suppressed the production of TNF-alpha by LPS-induced whole blood cells and peripheral blood mononuclear cells. Furthermore, these studies also demonstrate that the RT-PCR in situ technique is a powerful tool for detecting and amplifying specific genes in whole cells when limited numbers of cells are available for RNA extraction.

Selective inhibition by alcohol and cortisol of natural killer cell activity of lymphocytes from cord blood

1. The immunosuppressive effects of drugs such as alcohol or hormones such as cortisol may be age-related. To test this hypothesis, the authors investigated the in vitro effects of ethanol (EtOH) and cortisol on Natural Killer (NK) cell activity of lymphocytes from normal cord blood in comparison with that of lymphocytes from normal adult peripheral blood. 2. K562, an erythroleukemia cell line, was used as a target in a 4 hr 51Cr release assay. 3. Ethanol at 0.3% (V/V) and cortisol at 0.05, 0.1 and 0.2 microgram/ml concentrations, added directly to a mixture of effector and target cells significantly suppressed the NK activity of cord blood lymphocytes in a dose dependent fashion, whereas similar concentrations of either EtOH or cortisol did not manifest significant immunoregulatory effects on NK cell activity of normal adult lymphocytes. 4. Pre-treatment of the target with either EtOH or cortisol for 4 hours did not affect cytotoxicity. Inhibition of cytotoxicity was also not due to direct toxicity of effector cells because lymphocytes treated with either EtOH or cortisol showed normal 51Cr release and their viability was comparable to that of untreated control cells. 5. This suggests a selective inhibitory effect of EtOH and cortisol on NK activity of neonatal lymphocytes that may be of clinical significance.

Suppression of tumor necrosis factor production by alcohol in lipopolysaccharide-stimulated culture

Many studies have shown that alcohol consumption is associated with alteration in immune responses and increased incidence of infection in the host. Tumor necrosis factor (TNF) is a potent soluble mediator of immunoregulation and inflammation, and plays a very important role in host's defenses against infection and tumor. We propose that one of the mechanisms of alcohol-mediated immunosuppression may be due to a defect in the synthesis and release of the TNF. To determine this, we studied the direct effect of alcohol on lipopolysaccharide (LPS)-induced TNF production by whole blood and total mononuclear cell from normal subjects. Aliquots of blood samples (1 ml) or ficoll-hypaque separated total mononuclear cells (1 x 10(6)/ml) were cultured with different concentrations of either ethanol or acetaldehyde in the presence or absence of LPS for 4 hr at 37 degrees C. Plasma samples and culture supernatants were assayed for TNF levels in a bioassay using a TNF-sensitive WEHI 164 subclone 13 cell line. LPS at 10 micrograms/ml produced a maximal level of TNF compared with lower (1 micrograms/ml) or higher concentration (50 micrograms/ml) of LPS. Kinetics studies showed that an incubation time of 4 hr with LPS produced a maximum level of TNF production by blood. Alcohol, as low as 0.1% concentration, produced significant suppression of LPS-induced TNF production by whole blood, whereas alcohol at 0.2 and 0.3% concentrations were required to produce a significant suppression of TNF production by separated mononuclear cells. Anti-TNF-alpha antibodies significantly neutralized the LPS-induced TNF that suggests that blood monocytes may be the primary source of TNF production.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective effect of alcohol on cellular immune responses of lymphocytes from AIDS patients

In this study we examined the in vitro effects of alcohol on the proliferative responses of lymphocytes from healthy donors and AIDS patients to a recombinant fusion peptide, env-gag, corresponding to portions of the gp41 envelope (env) and internal core (gag) proteins of HIV. The effects of alcohol (ETOH) on the natural killer (NK) cell activities of lymphocytes from healthy donors and patients with AIDS were also investigated. Peripheral blood mononuclear cells from both normal donors and AIDS patients produced significant levels of lymphocyte proliferative responses to the HIV env-gag peptide; however, these responses were significantly higher in patients with AIDS, showing the specificity of the response. The env-gag-induced proliferative responses of lymphocytes from normal subjects were significantly suppressed when cultures contained only higher levels of ETOH (0.2% and 0.3%), whereas ETOH even at a lower level (0.1%) produced significant suppression of the env-gag-induced proliferation of lymphocytes only from AIDS patients. Direct addition of ETOH at concentrations of 0.1%, 0.2%, and 0.3% to cultures of lymphocytes from normal donors and NK target cells did not produce significant suppression of NK cell activities. However, ETOH at concentrations of 0.2% and 0.3% significantly suppressed the NK activities of lymphocytes from AIDS patients, and the suppressive effect was observed at all E:T cell ratios examined. Control peptide from the Escherichia coli expression vector did not produce any significant effect on lymphocyte proliferative responses or NK activity of both normal donors and AIDS patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Aetiology and pathogenesis of alcoholic liver disease

Until the 1960s, liver disease of the alcoholic patient was attributed exclusively to dietary deficiencies. Since then, however, our understanding of the impact of alcoholism on nutritional status has undergone a progressive evolution. Alcohol, because of its high energy content, was at first perceived to act exclusively as 'empty calories' displacing other nutrients in the diet, and causing primary malnutrition through decreased intake of essential nutrients. With improvement in the overall nutrition of the population, the role of primary malnutrition waned and secondary malnutrition was emphasized as a result of a better understanding of maldigestion and malabsorption caused by chronic alcohol consumption and various diseases associated with chronic alcoholism. At the same time, the concept of the direct toxicity of alcohol came to the forefront as an explanation for the widespread cellular injury. Some of the hepatotoxicity was found to result from the metabolic disturbances associated with the oxidation of ethanol via the liver alcohol dehydrogenase (ADH) pathway and the redox changes produced by the generated NADH, which in turn affects the metabolism of lipids, carbohydrates, proteins and purines. Exaggeration of the redox change by the relative hypoxia which prevails physiologically in the perivenular zone contributes to the exacerbation of the ethanol-induced lesions in zone 3. In addition to ADH, ethanol can be oxidized by liver microsomes: studies over the last twenty years have culminated in the molecular elucidation of the ethanol-inducible cytochrome P450IIE1 (CYP2E1) which contributes not only to ethanol metabolism and tolerance, but also to the selective hepatic perivenular toxicity of various xenobiotics. Their activation by CYP2E1 now provides an understanding for the increased susceptibility of the heavy drinker to the toxicity of industrial solvents, anaesthetic agents, commonly prescribed drugs, 'over the counter' analgesics, chemical carcinogens and even nutritional factors such as vitamin A. Ethanol causes not only vitamin A depletion but it also enhances its hepatotoxicity. Furthermore, induction of the microsomal pathway contributes to increased acetaldehyde generation, with formation of protein adducts, resulting in antibody production, enzyme inactivation and decreased DNA repair; it is also associated with a striking impairment of the capacity of the liver to utilize oxygen. Moreover, acetaldehyde promotes glutathione depletion, free-radical mediated toxicity and lipid peroxidation. In addition, acetaldehyde affects hepatic collagen synthesis: both in vivo and in vitro (in cultured myofibroblasts and lipocytes), ethanol and its metabolite acetaldehyde were found to increase collagen accumulation and mRNA levels for collagen. This new understanding of the pathogenesis of alcoholic liver disease may eventually improve therapy with drugs and nutrients.

Immunosuppression in adult female B6C3F1 mice by chronic exposure to ethanol in a liquid diet

The overall objective of these studies was to characterize the effects of ethanol on the immunocompetence of adult female B6C3F1 mice. To obtain a significant suppression in the antibody response to SRBC, splenocytes from untreated mice had to be directly exposed to concentrations of ethanol from 0.3% to 3.0%, or to acetaldehyde at concentrations greater than 0.03%. We do not believe that these results are consistent with a role by a direct effect by either ethanol or its primary metabolite because these concentrations are higher than what could be obtained as reasonable blood levels. For in vivo exposure, we employed a pair-feeding regimen which was based on a liquid diet containing 5% ethanol (v/v) that provided 36% of the caloric intake as ethanol. Our results indicated that there was a definite temporal relationship to the consequent suppression of the antibody response to SRBC in that no effect was observed after 14 days exposure, and that the magnitude of the suppression increased from 18% after 21 days to 70% after 42 days. We also monitored the liver for histopathology and observed that the ethanol-induced liver damage was restricted to steatosis (fatty liver), which was also manifested with time and which was most pronounced after 42 days exposure. In contrast to our results with the in vivo antibody response, we saw no effect on mitogen-induced proliferation by splenocytes from ethanol-treated mice. These results prompted us to measure in vitro antibody responses by splenocytes from ethanol-treated mice. We saw no suppression of the in vitro antibody responses to SRBC, DNP-Ficoll or LPS after any length of exposure to ethanol, and speculated that the basis for the suppression of the in vivo antibody response was an indirect consequence of exposure. We subsequently determined that when normal splenocytes were cultured in 5% serum from ethanol-exposed mice (42-day group), there was a > 80% suppression relative to the serum from the pair-fed controls. As important controls for these studies, we have demonstrated that there was no difference between the responses of normal lymphocytes cultured in 5% normal mouse serum and in 5% serum taken from the pair-fed restricted controls. A determination of the ethanol content in the serum from ethanol-exposed mice (42-day group) indicated that the amount of ethanol present in these cultures was < 0.003%.(ABSTRACT TRUNCATED AT 400 WORDS)

Increased spontaneous and lymphokine-conditioned IgA and IgG synthesis by B cells from alcoholic cirrhotic patients

Immunoglobulin secretion by B lymphocytes is a complex process in which lymphokines secreted by T lymphocytes play an important regulatory role. Increased serum levels of IgA and IgG have been characteristically detected in patients with alcoholic cirrhosis. We have studied the functional alterations of T and B lymphocytes implicated in the physiopathology of this common immunoglobulin abnormality. After activation with phytohemagglutinin, purified T cells from alcoholic cirrhotic patients showed significantly enhanced secretion of B-cell differentiation factors for IgG and IgA with respect to those secreted by T cells from healthy controls (p less than 0.05). Simultaneously, normal secretion of B-cell differentiation factor for IgM was demonstrated in T lymphocytes from these patients. The pattern of secretion of the lymphokines involved in the regulation of the B-cell differentiation pathway found in alcoholic cirrhotic patients was different from that of the primary biliary cirrhotic patients studied. Purified B cells from patients with alcoholic cirrhosis secreted significantly higher amounts of IgA and IgG than did those found in healthy controls, both spontaneously (p less than 0.05) and after sequential activation with immunoglobulin ligands (Staphylococcus aureus Cowan I) and a standard B-cell differentiation factor preparation (p less than 0.05). By contrast, the IgM secretion and regulatory pathway were normal in alcoholic cirrhotic patients. These results support a physiopathological explanation for the characteristic hyperimmunoglobulinemia found in patients with alcoholic cirrhosis.

Effects of alcohol and nicotine on cytotoxic functions of human lymphocytes

The in vitro effects of the recreational drugs, ethanol (EtOH) and nicotine, on natural killer (NK) antibody-dependent cellular cytotoxic (ADCC) and lymphokine-activated killer (LAK) cell activities on normal lymphocytes were investigated. Lymphocytes precultured with EtOH at concentrations of 0.4 and 0.6% (v/v) produced significant suppression of NK and ADCC activities. In target-binding assays, EtOH decreased the target-binding capacity of effector cells. EtOH also inhibited the activities of Percoll-separated, NK-enriched large granular lymphocytes. EtOH-induced inhibition of NK activity could be reversed by incubating lymphocytes for 1 hr with interferon. The generation and lytic capacity of LAK cells was also significantly depressed by EtOH when added at the initiation of culture. Nicotine at concentrations of 5 and 10 micrograms/ml, when added directly to mixtures of effector and target cells, produced significant inhibition of NK activity. Nicotine (2 micrograms/ml) and EtOH (0.01, 0.1, and 0.2%) at noninhibitory concentrations when added separately, showed significant suppression of NK activity when used in combination. Pretreatment of target cells with either EtOH or nicotine for 4 hr did not affect cytotoxic activity. Inhibition of cytotoxicity was also not due to direct toxicity of effector cells because lymphocytes treated with either EtOH or nicotine showed normal 51Cr release and their viability was comparable to that of untreated control cells. These studies demonstrate that EtOH and nicotine have significant immunomodulatory effects on the cytotoxic activities of human lymphocytes which may be of clinical relevance.

Early onset of nonalcoholic cirrhosis in patients with familial alcoholism

The etiology of many forms of liver disease is largely unknown. Recent research has identified certain immunogenetic factors which may play a role in the progression of alcoholic cirrhosis as well as autoimmune forms of cirrhosis. In this study we examined the role of familial alcoholism and HLA status in determining age of liver disease onset. Patients with biopsy-proven nonalcoholic autoimmune cirrhosis and having a history of familial alcoholism experience an earlier age of onset of liver disease than patients without a family history of alcoholism. The same result was true for patients with alcoholic liver disease. This effect may be more prominent in females. Subjects with HLA B-8 also had a younger age of onset of nonalcoholic autoimmune liver disease. The presence of a family history of alcoholism in conjunction with the presence of HLA B-8 and DR-3 also was related to an earlier age of disease onset. These findings suggest that the susceptibility to develop alcoholism and nonalcoholic autoimmune liver disease may be transmitted conjointly and point to potential fruitful areas of research for identifying individuals at risk for developing cirrhosis as well as detecting genetic markers for alcoholism.

Mechanism of ethanol induced hepatic injury

Ethanol is hepatotoxic through redox changes produced by the NADH generated in its oxidation via the alcohol dehydrogenase pathway, which in turn affects the metabolism of lipids, carbohydrates, proteins and purines. Ethanol is also oxidized in liver microsomes by an ethanol-inducible cytochrome P-450 (P-450IIE1) which contributes to ethanol metabolism and tolerance, and activates xenobiotics to toxic radicals thereby explaining increased vulnerability of the heavy drinker to industrial solvents, anesthetic agents, commonly prescribed drugs, over-the-counter analgesics, chemical carcinogens and even nutritional factors such as vitamin A. Induction also results in energy wastage and increased production of acetaldehyde. Acetaldehyde, in turn, causes injury through the formation of protein adducts, resulting in antibody production, enzyme inactivation, decreased DNA repair, and alterations in microtubules, plasma membranes and mitochondria with a striking impairment of oxygen utilization. Acetaldehyde also causes glutathione depletion and lipid peroxidation, and stimulates hepatic collagen synthesis, thereby promoting fibrosis.

Differences in the nature and kinetics of the ethanol-related circulating cytotoxic proteins in normal subjects and patients with alcohol-induced cirrhosis

The kinetics and nature of the nondialyzable cytotoxic activity which appeared in the serum after the consumption of 1.2 g ethyl alcohol per kilogram body weight over 45 min was studied in six healthy volunteers and eight patients with histologically proven alcohol-related cirrhosis of the liver. Whereas the cytotoxic activity in the dialyzed serum showed a single peak with a maximum value 8 hr after the start of ethanol consumption in the healthy volunteers, it showed two peaks with maximum values at 2 and 8 hr in the patients with cirrhosis. Studies of the fractions obtained by Sephacryl-S-300 gel filtration of the 2-hr postalcohol serum samples revealed substantial cytotoxic activity in the fractions containing both the albumin peak and the IgG peak in the patients with cirrhosis and only in the fractions containing the albumin peak in the healthy volunteers. Experiments with pure IgG preparations obtained from prealcohol and 2-hr postalcohol sera by chromatography on Q-Sepharose Fast Flow anion-exchange resin showed considerable cytotoxic activity in the preparations from the patients with cirrhosis and little or no cytotoxic activity in those from the healthy volunteers. Thus, the early peak of the biphasic serum cytotoxicity curve seen after ethanol consumption by patients with cirrhosis appeared to be caused by the development of a substantial cytotoxic activity in the IgG molecules during the first 2 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

Histocompatibility antigens: markers of susceptibility to and protection from alcoholic liver disease in a Portuguese population

The distribution of six HLA antigens in a population of 88 Portuguese chronic alcohol abusers with biopsy-proven liver disease was compared to that in 66 Portuguese normal controls. Among the group of 88 alcohol abusers, the presence of HLA antigens A1, A9, A28 and Bw35 marked a significant 2.5- to 3-fold increased estimated risk for the development of alcohol-induced cirrhosis, while the presence of HLA B5 was found to be associated with a significantly decreased risk of alcohol-induced cirrhosis. Further, compared to controls, the estimated risk of any stage of alcohol-induced liver disease was significantly increased in alcoholic individuals with HLA A28 and Bw35, and the protective effect of HLA B5 was again observed. The findings of this study suggest that at least in a relatively homogeneous population group such as the Portuguese, the presence of HLA B5 may confer protection against alcohol-induced liver disease, including cirrhosis. The presence of HLA Bw35 and A28 appear to mark susceptibility to all histologic manifestations of alcohol-induced liver disease, while in addition to Bw35 and A28, A1 and A9 may mark increased risk for cirrhosis in particular.

Histocompatibility antigens in patients with alcoholic liver disease in Scotland and northeastern England: failure to show an association

A study of HLA-A and B antigens in 248 patients with biopsy diagnosed alcoholic liver disease was conducted to examine for a genetic predisposition to alcohol related liver injury. No statistically significant differences were established for 8 HLA-A and 16 HLA-B antigens between normal healthy controls (n = 342) and patients with alcoholic fatty liver (n = 86), alcoholic hepatitis (n = 63), active alcoholic cirrhosis (n = 64) and inactive alcoholic cirrhosis (n = 35). It is concluded that no HLA-A or B locus genetic susceptibility to alcoholic related injury could be shown.

Immunoglobulin A in the diagnosis of alcoholic liver disease

The diagnostic relevance of the serum immunoglobulin A (IgA) concentration and liver deposition of IgA for chronic excessive alcohol consumption was evaluated in 164 patients with biochemical liver abnormalities. A relationship was demonstrated between the amount of daily alcohol consumption and the two IgA parameters and serum gamma-glutamyl transpeptidase. A continuous pattern of IgA deposition along hepatic sinusoids proved to be the best diagnostic feature, combining a specificity of 0.91 with a sensitivity of 0.75. Although serum IgA has a specificity of 0.78, its diagnostic value is restricted by a sensitivity of 0.50, making it not superior to serum gamma-glutamyl transpeptidase. Furthermore, serum IgA proved to be related to liver histopathology. High levels of serum IgA are found in hepatitis and cirrhosis, without significant differences between alcoholic and nonalcoholic patients. However, in the case of mild histopathologic changes in the liver, such as steatosis and fibrosis, significantly higher serum IgA concentrations are found in alcoholic than in nonalcoholic liver disease.

Blood markers of alcoholic liver disease

Not all heavy drinkers develop severe alcoholic liver disease. Genetic factors are probably involved, but no corresponding useful markers have been developed thus far. Of greater practical applicability is the recognition of early changes in the liver that may indicate that the process of scarring or fibrosis has been initiated. Measurement of breakdown products of collagen, the protein of the fibrotic tissue, have been found to be useful for detecting these early stages. Assessment of glutamic dehydrogenase activity in the serum also provides some indication of the degree of inflammation and necrosis present in the liver, but not of the alcohol intake. The severity of the latter can be assessed with a variety of biological markers, to which circulating antibodies against acetaldehyde adducts have recently been added.

Antibodies against acetaldehyde-modified protein epitopes in human alcoholics

Acetaldehyde, the primary metabolite of ethanol, binds covalently to proteins forming condensation products which have been recently shown to be immunogenic. To assess whether an antibody response against acetaldehyde-modified protein epitopes is associated with alcoholic liver disease, the serum immunoreactivity against proteins modified in vitro by acetaldehyde and against the corresponding unmodified proteins was measured by an enzyme-linked immunosorbent assay in 58 alcoholics with varying degrees of liver damage. Alcoholics showed significantly higher titers against protein-acetaldehyde conjugates than against the unmodified protein, independent of the nature of the carrier protein. The highest titers occurred in alcoholic hepatitis patients. Sera of patients with chronic hepatitis of nonalcoholic origin and of healthy controls also reacted with acetaldehyde conjugates, but their titers were significantly lower than those in alcoholic hepatitis patients. Our data support the idea that binding of acetaldehyde to proteins in humans generates antigenic determinants which trigger a corresponding immune response against such epitopes and suggest that this humoral immune response may be implicated in autoantibody formation and liver damage associated with excessive alcohol consumption.

Functional analysis of T-cell subsets in chronic experimental alcoholism

In order to obtain a better understanding of immune system function in chronic alcoholism, we have assessed primary B-cell responses to helper T-cell independent (TI) and dependent (TD) antigens in chronic alcoholic Sprague-Dawley male rats fed totally liquid diet containing ethanol. Pair-fed littermates received the same diet except that carbohydrates isocalorically replaced ethanol, which accounted for 36% of the total calories. The ability of alcoholic animals to mount primary in vivo splenic plaque-forming cell (PFC) responses to TI pneumococcal polysaccharide type III (SIII) was elevated throughout 50 days of observation when compared to pair-fed controls; serum antibody responses to SIII paralleled the enhanced PFC responses. Primary in vivo B-cell responses to antigen sheep red blood cells (SRBC), a TD antigen, were initially elevated but were found to be significantly suppressed 30 days after chronic ethanol consumption. The degree of immunosuppression increased with length of chronic ethanol consumption. The elevated primary splenic PFC responses to TI (SIII) may be attributed to loss of T-suppressor cell control, since alcoholic rat spleen cells did not respond to low-dose priming with SIII. We suggest that either loss of function and/or actual depletion of accessory and regulatory cells (T-suppressor and T-helper) may be responsible for irregularities in B-cell function observed during chronic alcoholism. T-cell subset enumeration using fluorescein-labelled monoclonal antibodies revealed that a sequential T-helper and T-suppressor loss occurred several days following dysfunction of these T-cell subsets in splenic populations, suggesting that a combination of numerical and dysfunctional changes in lymphocyte subpopulations may be responsible for the immunological alterations observed in chronic alcoholics.

Characteristics of serum IgA and liver IgA deposits in alcoholic liver disease

Patients with alcoholic liver disease frequently reveal an increase in IgA serum concentration and IgA deposits in a continuous pattern along hepatic sinusoids. We investigated whether the hepatic IgA deposits are a passive reflection of changes in concentration or composition of IgA in the circulation, or represent a distinct effect of alcohol on the liver. Forty-one patients with alcoholic liver disease (daily alcohol intake at least 50 gm for more than five consecutive years) were compared with 41 patients with nonalcoholic liver disease. Patients in both groups were matched for serum IgA and histopathological changes in the liver biopsy. IgA deposits in the liver were found in 78% of the alcoholic patients and in 12% of the nonalcoholic patients. The presence of deposits was not related to histopathological changes in the liver or to the serum IgA concentration. In serum IgA subclass distribution, alcoholic patients differed from nonalcoholic patients by a slight but significant shift to IgA2; in contrast, the hepatic IgA deposits in alcoholic patients were almost of the IgA1 subclass. Serum secretory component (which is an equivalent of serum secretory IgA) was elevated in both alcoholic and nonalcoholic patients; patients with a liver biopsy revealing hepatitis showed the highest level. In contrast, the hepatic deposits did not contain secretory component. We conclude that the continuous deposits of IgA along liver sinusoids are not a passive reflection of changes in concentration or composition of circulating IgA, but may represent a distinct effect of alcohol on the liver related to the role of this organ in IgA metabolism.

IgA deposition in alcoholic liver disease

Immunoglobulin deposition in alcoholic and non-alcoholic liver disease was studied using an indirect immunoperoxidase technique. A continuous pattern of IgA deposition, with IgA outlining the sinusoids, was shown to be a specific and sensitive marker for liver disease caused by alcohol in both cirrhotic and non-cirrhotic livers. The sensitivity was lowest in cases of alcoholic disease showing fatty change alone. In one case it was possible to show the absence of IgA in liver disease caused by a drug, which was histologically indistinguishable from alcoholic hepatitis.

Relationships between 34 HLA-A, HLA-B and HLA-DR antigens and three serological markers of viral infections in alcoholic cirrhosis

In order to study the genetic risk of alcoholic cirrhosis, the frequency of 26 HLA-A and -B antigens was compared in 184 normal controls, 175 alcoholic cirrhotic patients and 83 alcoholic patients with hepatic steatosis of carefully selected ethnic origin. Eight HLA-DR antigens were also determined in 95 subjects of the normal control group and 63 patients of the alcoholic cirrhosis group. The incidence of hepatitis B virus antibodies (anti-HBc and anti-HBs) was defined in 74 patients of the alcoholic steatosis group, 170 patients of the alcoholic cirrhosis group and 111 normal controls different from the previously mentioned normal control group. The incidence and the titers of cytomegalovirus and rubella antibodies were also determined in 93 patients of the alcoholic cirrhosis group and the 111 normal controls. Serum immunoglobulin concentrations were measured in the same 93 cirrhotic patients. Compared with the controls, the alcoholic cirrhosis group revealed a significantly higher frequency of HLA-B15 (21.7 vs. 9.8%, p less than 0.00025, corrected p less than 0.050) and HLA-DR4 (38.1 vs. 17.9%, p less than 0.005, corrected p less than 0.050) and a significantly lower frequency of HLA-B13 (2.9 vs. 11.4%, p less than 0.025, corrected p less than 0.050). As for the frequency of all other HLA antigens, there was no significant difference between the three groups (normal controls, alcoholic cirrhosis and alcoholic steatosis).(ABSTRACT TRUNCATED AT 250 WORDS)

Frequencies of glyoxalase I phenotypes as biological markers in chronic alcoholism

Biological markers for alcoholism would be a valuable tool for early diagnosis. We have studied the phenotype frequencies of genetically determined erythrocyte enzymes in 397 alcoholics, including two populations with liver disease: steatosis (n = 86) and cirrhosis (n = 128) and a population of alcoholics without apparent liver disease (n = 183) compared to a well selected control population (n = 177). Only for Glyoxalase I (GLO) phenotypes (1,2 and 2-1) were significant differences found between the male controls and the male alcoholics. In the total male alcoholic population the frequency of phenotype 1 was significantly increased (23.2% vs. 11%, p less than 0.02), and the frequency of phenotype 2 was significantly decreased (32.3% vs. 46.3 p less than 0.02) compared to the male control population. For normal women the frequency of phenotype 1 and 2 was significantly different from normal men. (1: +177% p less than 0.001, 2: -45% p less than 0.01), but no significant differences were found between alcoholic and normal women. Our results suggest that in male subjects Glyoxalase I phenotype 1 may provide a marker for predisposition to alcoholism.

Helper and suppressor T lymphocyte function in severe alcoholic liver disease

The immune regulatory T cell status of patients with severe alcoholic liver disease (ALD) was investigated. Using monoclonal antibodies to identify lymphocyte subsets in 22 patients, a significant decrease in the percentage of T suppressor/cytotoxic cells (P less than 0.01) and increase in the percentage T helper/inducer population (P less than 0.05) was observed when the results were compared with 20 normal controls. However, when absolute numbers of these lymphocyte subsets were calculated the patient group did not differ significantly from the controls. Further studies revealed T immunoregulatory cell function to be normal. Concanavalin A induced suppressor cells resulted in equivalent inhibition of autologous cell mitogen responsiveness in the patient and control groups. In addition, purified patient T lymphocytes were demonstrated to provide normal help to and manifest normal suppression of IgG, IgA and IgM synthesis by allogeneic B cells. When spontaneous immunoglobulin synthesis by circulating mononuclear cells was investigated, a significant increase in IgA synthesis was found in the ALD patients (P less than 0.05). These results suggest that T cell immunoregulation is normal in patients with ALD and a defect in this system is not responsible for the increased synthesis of immunoglobulin observed in ALD.

Oxidation phenotyping in alcoholics with liver disease of varying severity

The propensity to develop alcoholic cirrhosis is probably, at least in part, genetically determined. A striking similarity exists histologically between perhexiline and alcohol-related hepatitis and both are potentially precirrhotic lesions. Liver damage due to perhexiline is associated with impaired drug oxidation capacity which is genetically determined and tested by use of debrisoquine. Oxidation phenotyping might be used to predict susceptibility to perhexiline liver damage; it might also predict the potential to develop alcoholic cirrhosis. Oxidation phenotyping was therefore undertaken, using debrisoquine in 100 alcoholic patients, 30 of whom had only fatty liver despite prolonged alcohol abuse, while the remaining 70 had alcoholic hepatitis and/or cirrhosis. One hundred patients with nonalcoholic chronic liver disease served as controls. The number of patients with severely impaired drug oxidation capacity (poor metabolizer phenotype) was similar in the alcoholic group (8%) and the nonalcoholic control group (7%). In particular, the incidence of the poor metabolizer phenotype was similar in alcoholics with severe liver disease (10%) and in those with only fatty change (3%). There appears to be no association between the susceptibility to develop alcoholic cirrhosis and drug oxidizing capacity.

Polyclonal B cell activation in alcoholic patients with no evidence of liver dysfunction

Unstimulated and pokeweed mitogen (PWM) stimulated immunoglobulin (Ig) synthesis by peripheral blood mononuclear cells (PBMC) in vitro and plasma Ig concentrations were measured in three groups of alcoholic patients: (i) with clinical or biochemical signs of liver disease, (ii) with evidence of an alcohol related disease but no overt signs of liver damage and (iii) with no evidence of any alcohol related disease. The concentrations of IgG and IgA were significantly raised in the supernatants of unstimulated cultures of PBMC from the patients, while the stimulation of Ig synthesis by PWM, measured as a stimulation index, was significantly reduced. The ratio of the concentration of IgG to IgA was reduced in the unstimulated cultures of PBMC from the alcoholics, indicating a greater relative increase in IgA synthesis compared to IgG synthesis. Comparing the alcoholics to the controls, it was found that the concentration of IgA in the plasma of the alcoholics was increased, but that the concentration of IgG was not altered. Comparing the different groups of patients, it was found that the concentration of IgG in the plasma was higher in the alcoholics with evidence of liver damage compared to alcoholics with alcohol related disease but no evidence of liver damage, and that the concentration of IgA in the plasma was higher in alcoholics with liver damage than those without. Otherwise there were no differences between the alcoholics with respect to the synthesis of IgG or IgA or the plasma Ig concentrations. These results indicate that IgG synthesis by PBMC in vitro, and serum Ig concentration in vivo, are abnormal in all alcoholics, not just those with overt clinical or biochemical signs of liver damage.

Importance of markers of hepatitis B virus in alcoholic liver disease

To determine the importance of the presence of serological markers of hepatitis B virus infection in patients with alcohol related liver disease we compared cumulative alcohol intake and clinical and histological features in patients with markers of hepatitis B virus infection and in those without. Hepatitis B surface antigen (HBsAg) was detected in five (2%) out of 285 patients studied and antibody to HBsAg (anti-HBs) in 41 (14%); one patient had antibody to hepatitis B core antigen alone. The combined prevalence of markers of hepatitis B virus infection was similar in patients with alcoholic cirrhosis (18%) and precirrhotic liver disease (13%). Two patients positive for HBsAg had histological features of both alcoholic liver disease and chronic active hepatitis, with stainable HBsAg. Patients with anti-HBs were, however, histologically indistinguishable from patients without markers, and the mean cumulative alcohol intake of patients with anti-HBs was similar to or even higher than that of patients with liver disease of comparable severity who had no evidence of previous infection. The presence of markers of hepatitis B virus infection was related to former residence in countries with a high prevalence of the infection and to previous parenteral treatment and blood transfusions. Infection with hepatitis B virus does not enhance the development of chronic liver disease in heavy drinkers, except in the small number who remain positive for HBsAg.

Detection of immunoglobulins G and A on the cell membrane of hepatocytes from patients with alcoholic liver disease

The presence of immunoglobulins (Ig) G, A, and M and of complement fractions (C3-C4) on the liver cell surface was investigated by direct immunofluorescence in 40 patients with alcoholic liver disease. IgG was detected on the liver cell membrane with a linear staining pattern in 29 patients. The percentage of IgG-positive hepatocytes correlated with transaminase activities, independently of the histological findings. IgA was demonstrable with a coarse granular staining pattern in 11 of the 14 cases with established cirrhosis. The finding of IgG bound to the hepatocyte surface in patients with alcohol-induced liver damage suggests that alcohol could be responsible for antigenic modifications of hepatocyte membrane with consequent triggering of a humoral immune response.

Association between HLA-B40 and acute alcoholic hepatitis with cirrhosis and the lack of relation between carcinoembryonic antigen and HLA antigens in alcoholic liver disease

The frequency of HLA-B40 was significantly increased in 30 patients with acute alcoholic hepatitis with cirrhosis (63%) and in 60 patients with alcoholic cirrhosis with or without acute alcoholic hepatitis (48%) compared with its frequency in 234 healthy blood donors (18%). The HLA-B40 frequency was not increased in 20 patients with acute alcoholic hepatitis without cirrhosis (0%), in 41 patients with fatty liver infiltration (12%), or in 67 alcoholics with moderate biochemical abnormalities (19%). The association between HLA-B40 and alcoholic liver cirrhosis and acute alcoholic hepatitis with cirrhosis favors the idea that these disorders might be genetically determined. There was, however, no difference in the distribution of the HLA antigens in 54 patients with different degrees of alcoholic liver disease and an elevated carcinoembryonic antigen (CEA) value of greater than or equal to 5.0 micrograms/l compared with 61 alcoholics with different degrees of liver disease and a normal CEA value. Thus, the results of HLA-A and -B typing gave no evidence of genetic susceptibility to develop a CEA elevation in patients with alcoholic liver disease.

Association of primary sclerosing cholangitis with HLA-B8

The frequency of HLA antigens was studied in 25 patients with primary sclerosing cholangitis and compared with a control group of 562 kidney donors. Fourteen patients also had ulcerative colitis. A significant increase in the frequency of HLA-B8 (60%) was found in the primary sclerosing cholangitis patients compared with controls (25%) (p less than 0.001). HLA-B8 was found in eight patients with ulcerative colitis. The frequency of HLA-B12 was significantly decreased (8%) compared with controls (30%) (p less than 0.02). Piecemeal necrosis was observed on liver histology in 66% of HLA-B8 positive and 50% of HLA-B8 negative patients. Low titres of serum autoantibodies were frequently found in the primary sclerosing cholangitis group but did not correspond to the presence of HLA-B8. Raised serum concentrations of IgM and IgG were not related to HLA-B8. This study has shown that in patients with primary sclerosing cholangitis there exists a disease susceptibility gene closely associated with the B locus of the major histocompatibility complex which may be modified by other factors such as ulcerative colitis. Patients with ulcerative colitis and HLA-B8 may be particularly liable to develop primary sclerosing cholangitis.

Accelerated development of alcoholic cirrhosis in patients with HLA-B8

To test whether the increased prevalence of HLA-B8 reported in patients with alcoholic cirrhosis is due to the antigen being a genetic marker of susceptibility to liver damage from alcohol, patients who had cirrhosis of comparable clinical and histological severity were investigated for HLA-B8 status and cumulative alcohol intake. Both male and female cirrhotics with HLA-B8 had been drinking greater than 40 g alcohol/day for a shorter period of time (16.6 +/- 1.4 men, and 9.4 +/- 2.0 years, women) than their counterparts without this antigen (23.7 +/- 1.7, p less than 0.005, and 15.8 +/- 2.0 years, p less than 0.05, respectively), but the mean daily alcohol intake was similar whether patients had HLA-B8 or not. These results suggest that genetic determinants linked to HLA-B8 enhance the rate of development of liver damage in those who drink potentially hepatotoxic amounts of alcohol.

Histocompatibility types and antiviral antibodies in a diverse group of individuals

A study was made of the possible relationship between histocompatibility (HLA) antigens of the A and B loci and antibodies to cytomegalovirus, influenza A (victoria strain), measles, rotavirus, vaccinia, and varicella/zoster. A large and diverse group of unselected individuals was studied. A possible relationship was detected between the presence of the antigen B15 and a lack of circulating measles antibodies. The study group was divided into three sections: (a) healthy individuals, (b) "renal disease" patients awaiting renal transplantation, and (c) patients with various types of "other disease," mainly of an immunological nature. Significantly elevated titers to cytomegalovirus and varicella/zoster were found in the two diseased groups, but these elevated titers could not be linked with the presence or absence of any particular HLA A or B antigen.

A comparative study of the biliary secretion of human dimeric and monomeric IgA in the rat and in man

In the rat, dimeric immunoglobulin A (dIgA) is cleared rapidly from the systemic circulation into bile by vesicular transport through the hepatocyte. Whether such transfer of dIgA occurs in man is controversial. The fate of dIgA and monomeric IgA (mIgA) was studied in rats with biliary drainage, and in parallel in 4 patients, 3 of whom had biliary drainage. Human dIgA and mIgA were prepared from myeloma sera and labeled with radioisotopes of iodine. Ten microcuries each of 125I-dIgA and 131I-mIgA (2 to 4 microgram protein) were given i.v. simultaneously. In the four patients, 125I-dIgA disappeared more rapidly from the serum than did 131I-mIgA. Biliary recovery of 125I-dIgA (expressed as per cent total dose given) was only 0.2 to 0.9% in 8 8 hr while that of 131I-mIgA was 0.1 to 0.2%. In contrast, biliary recovery over the same period in rats was 21 to 32% for 125I-dIgA and 3.0 to 4.6% for 131I-mIgA. The data show that in man after injection of a trace amount of human myeloma IgA, rapid transport of dIgA into bile, as observed in the rat, was not seen. Although selective transport of dIgA over mIgA into bile occurred in man, the total amount of dIgA transported was small, and it is suggested that under physiological conditions, the major part of human biliary IgA is derived from local synthesis.

Liver membrane antibodies in alcoholic liver disease: 1. prevalence and immunoglobulin class

Using an indirect immunofluorescence technique liver membrane antibodies of IgG and IgA class have been demonstrated in a statistically significant proportion of sera from patients with alcoholic hepatitis and alcoholic cirrhosis. IgG and IgA class antibodies were found respectively in 23 and 25% of 48 patients with alcoholic hepatitis, in 27 and 33% of 84 with active cirrhosis, and 67 and 58% of 12 with inactive cirrhosis. These results provide evidence of a humoral immune response in alcoholic liver disease which is directed against, as yet undefined, liver-cell membrane antigens.

T cell subsets in patients with acute and chronic HBV infection, primary biliary cirrhosis and alcohol induced liver disease

The proportions of inducer and cytotoxic/suppressor T cells and their concentration in peripheral blood have been determined in patients with acute and chronic type B hepatitis, hepatitis B virus (HBV) carriers with normal hepatic histology, patients with alcohol-induced liver disease (ALD), primary biliary cirrhosis (PBC) and chronic extrahepatic cholestasis. During acute type B hepatitis the inducer/suppressor ratio was decreased due to an increase in suppressor cell concentrations. When this ratio returned to normal the HBs antigen was cleared and HBs antibody was detectable. Similar abnormalities were found in patients with HBs + ve chronic hepatitis. In HBs antigen-positive patients with normal histology, normal T cell subsets were found. In some patients with primary biliary cirrhosis the ratio of inducer to suppressor cells was low due to a reduction in the concentration of inducer cells and in others high due to a reduction in suppressor cells. Administration of cyclosporin A to the latter group produced an increase in the concentration of suppressor cells and there was an improvement in liver biochemistry. In alcohol-induced hepatitis and cirrhosis the ratio of inducer/suppressor cells was normal. Whether these imbalances of the regulatory cells of the immune system in patients with chronic HBV-induced hepatitis and PBC are of primary or secondary importance is uncertain. The relationship of the depressed ratio to persistence of the hepatitis B virus is worthy of further study.