Hepatitis B Antigen and Auto-antibodies in Chronic Liver Diseases in Hong Kong

Summary: The frequency of occurrence of hepatitis B antigen (HBAg) and certain tissue auto-antibodies [antinuclear antibody (ANA), smooth muscle antibody (SMA) and mitochondrial antibody (MIA)] were studied with the microtiter complement fixation and immunofluorescence techniques respectively in a group of patients suffering from chronic liver diseases. These were chronic hepatitis (30), cirrhosis of the liver (66) and hepatocellular carcinoma, mostly with underlying cirrhosis (100). A group of closely matched hospital in-patients served as controls. HBAg was found in high frequency in the patients with liver disease (60% in chronic hepatitis, 36·4% in cirrhosis and 49% in hepatocellular carcinoma) whereas tissue auto-antibodies were found in lower frequencies (16·7%, 10·6% and 13% in the three groups respectively). However, in both the frequency was significantly higher than that in the controls (9·2% for HBAg and 0·8% for auto-antibodies). There was a negative correlation between HBAg and tissue auto-antibodies in the group of patients with liver disease when taken as a whole (·²= 14·3, P < 0·001). These results suggest a possible aetiological role played by hepatitis virus B in hepatocellular carcinoma through chronic hepatitis and cirrhosis in Hong Kong while the mutual exclusion between HBAg and auto-antibodies supports the hypothesis of heterogeneity in the aetiology of chronic liver diseases. The patients with auto-antibodies may belong to the auto-immune category but no definite conclusion can be reached until the role played by hepatitis virus A in chronic liver diseases is clarified when more reliable techniques for its identification are available.     

Auto-immune features in patients with idiopathic chronic active hepatitis who are seronegative for conventional auto-antibodies

In patients with chronic active hepatitis (CAH), the absence of the conventional serum auto-antibodies (antinuclear, smooth muscle and liver-kidney microsomal) is often taken as evidence against an auto-immune aetiology and as indicative that the disease is unlikely to respond to immunosuppressive therapy. We report 12 British patients (11 female) who presented with histologically florid CAH (11 with cirrhosis or fibrosis and seven with ascites) but without significant titres of these antibodies or any other demonstrable aetiological feature (cryptogenic CAH), who have been followed up for a median of 5.25 years (range: 0.75-16 years). Ten had hypergammaglobulinaemia and/or specific elevations of serum IgG concentrations at presentation and five of 10 patients tested were found to have the HLA allotypes B8 and DR3. Remission was initially induced with prednisolone with or without azathioprine in all patients. Six patients subsequently relapsed on one or more occasions, either spontaneously while on maintenance therapy or during attempts to withdraw corticosteroids, and required increases or reintroduction of immunosuppressive therapy to regain disease control. Retrospective analysis of pretreatment samples from 11 of the patients revealed that all had been seropositive at presentation for auto-antibodies against the liver membrane lipoprotein preparation known as liver-specific membrane lipoprotein (LSP) and/or against the hepatic asialoglycoprotein receptor (ASGP-R), titres of which subsequently fluctuated in direct relation to response to treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chronic persistent hepatitis. A clinical, serological, and prognostic study.

The diagnosis of chronic persistent hepatitis is based on a combination of clinical and morphological data. During a 7-year period 26 cases were diagnosed in 3 medical departments in Copenhagen. In 22 patients the disease was considered to be a sequela to acute viral hepatitis, and 12 had Australia antigen in serum. Only few patients had circulating auto-antibodies. The clinical and biochemical activity at the time of diagnosis was usually slight. A morphological and clinical follow-up study revealed that the course of the disease was generally benign. However, in 3 patients the last repeat biopsy showed progression to cirrhosis, severe portal fibrosis, and chronic aggressive hepatitis. Such exceptions may represent a sampling error in the interpretation of the first needle biopsy, or the correct diagnosis may have been chronic aggressive (active) hepatitis at a stage with slight activity. Clinical and biochemical observation is recommended in chronic persistent hepatitis, and in some patients serial needle biopsies are necessary to reveal the few exceptional cases which progress to an active chronic liver disease.     

Measurement of the sus-hepatic pressure gradient in differential diagnosis of chronic persistent or active hepatitis

The value of the hepatic venous pressure gradient, measured during a transjugular liver biopsy procedure, was evaluated in the differential diagnosis of chronic persistent versus active hepatitis. The diagnosis of chronic persistent or active hepatitis was carried out according to classical clinical, biological, and above all pathological criteria. Patients with chronic active hepatitis were divided in to subgroups according to the degree of aggressivity and the presence of cirrhosis. Of the 70 patients studied, 13 had a gradient lower than 0.79 kPa, and all had chronic persistent hepatitis; 48 patients had a gradient higher than 0.93 kPa, they all had a chronic active hepatitis. For the 9 remaining patients, the gradient was between 0.79 and 0.93 kPa, 3 had persistent hepatitis, and 6 had active hepatitis. There was no significant variation of the gradient according to aggressivity in the subgroups of chronic active hepatitis. The gradient separated clearly chronic active hepatitis with or without cirrhosis. The measurement of the hepatic venous pressure gradient allows to differentiate between chronic persistent versus active hepatitis in 87 p. 100 of cases. This simple procedure offers a quick clue to diagnosis before obtaining histologic results.     

Clinical course and prognosis of one hundred and two patients with hepatic coma 1958 through 1975

The clinical course and prognosis of hepatic coma were examined in 102 patients treated in the period from 1958 to 1975. The diagnoses included 9 fulminant hepatitis, 7 subacute hepatitis, 53 liver cirrhosis without liver carcinoma (40 cases of the acute type, 10 cases of the chronic type and 3 cases of another type, according to Sherlock's classification of hepatic coma) and 33 liver cirrhosis with primary liver carcinoma. Four of 9 fulminant hepatitis patients gained consciousness within 1 week and recovered completely. Seven subacute hepatitis patients died within 2 weeks after onset of hepatic coma. In the period from 1958 to 1969, 20% of liver cirrhosis patients with the acute type of coma recovered from coma, and in the period from 1970 to 1975, 45% of patients recovered. Seven of 10 patients with the chronic type of coma died between 4 months and 9 years after the onset of coma. Three other patients are presently still alive. The median survival time was 2.5 years. Nine primary liver carcinoma patients with coma were hospitalized from 1958 to 1969 and 24 from 1970 to 1975. Hepatorenal syndrome was present in 31 of 71 examined patients. Twenty-three patients with hepatorenal syndrome were in the period from 1970 to 1975.     

Anticalmodulin autoantibody in liver diseases: a new antibody against a cytoskeleton-related protein

An ELISA has been developed for detection of auto-antibodies against calmodulin. There was a significantly increased frequency (63.1%) of autoantibodies against calmodulin in 103 patients with chronic liver diseases as compared to that (30%) of patients with systemic lupus erythematosus and to that (6.9%) of normal subjects (p less than 0.01). IgG autoantibodies against calmodulin were detected in the patients with acute hepatitis (37.9%), chronic liver disease (45.6%) and also in the patients with systemic lupus erythematosus (30%). IgM autoantibodies against calmodulin were frequently found in patients with liver cirrhosis (52.2%), primary biliary cirrhosis (50%) and autoimmune chronic active hepatitis (38.7%), but rarely in patients with acute hepatitis (13.8%), chronic persistent hepatitis (9.5%) and systemic lupus erythematosus (0%). IgA autoantibodies against calmodulin were frequently found in liver cirrhosis (33.3%), primary biliary cirrhosis (42.9%) and autoimmune chronic active hepatitis (53.6%), but rarely in chronic persistent hepatitis (15.8%), chronic active hepatitis (14.3%) and systemic lupus erythematosus (0%). The occurrences of autoantibodies against calmodulin correlated neither with those of antismooth muscle antibody, antinuclear antibody and antimitochondrial antibody, nor with serum IgG concentrations. Autoantibodies against calmodulin did not cross-react with troponin, myosin light chain, calf thymus DNA and actin. The titer of autoantibodies against calmodulin was decreased by absorption of serum with calmodulin and the liver plasma membrane fraction. The immunoblotting experiment revealed the binding of autoantibodies against calmodulin to calmodulin. IgG fraction from a patient with autoimmune chronic active hepatitis inhibited the activation of phosphodiesterase by calmodulin.(ABSTRACT TRUNCATED AT 250 WORDS)     

Elevated growth hormone levels in patients with non-alcoholic chronic liver disease

High serum concentrations of growth hormone (GH) were found in five patients with chronic liver diseases, including auto-immune chronic active hepatitis (two cases), Budd-Chiari syndrome, primary biliary cirrhosis and hepatitis B virus associated cirrhosis. Mean levels of GH were 27.8 units (normal up to 5). In three patients elevated prolactin levels were also found (mean 37.3 units for two females, normal up to 20), and 36 units in one male (normal up to 9). No other endocrine disorders were found. Although the association of raised GH levels in patients with alcoholic cirrhosis is well known, its occurrence in patients with non-alcoholic chronic liver disease is not fully established. We describe the effect of the disease course, and steroid treatment on GH levels in one patient with auto-immune chronic active hepatitis, and propose possible mechanisms for this elevation.     

Haemagglutinating anti-actin antibodies in acute and chronic liver disease

Anti-actin antibody was measured by the passive haemagglutination test in the serum of 118 patients with various forms of chronic cholestatic and non-cholestatic liver disease, and of 23 patients with acute hepatitis B or non-A, non-B. Tanned sheep erythrocytes and electrophoretically pure actin prepared from rabbit skeletal muscle were employed; absorption tests confirmed the specificity of positive reactions, defined from healthy controls as a titre of greater than 1/80. The presence of anti-actin activity in chronic liver disease corresponded generally to the immunofluorescent demonstration of smooth muscle antibody (P<0.01). However, in acute hepatitis, with one exception (later progressing to subacute disease) raised anti-actin titres were not found. Thus, the weak smooth muscle antibody occasionally demonstrable in this condition may be neither IgM in class, nor directed against actin. Anti-actin antibody was present in significantly high titre in 54% of 37 active chronic hepatitis patients and 79% of 24 ;mixed-form' cholestatic active chronic hepatitis, as compared with only 21% of 29 primary biliary cirrhosis patients, and 11% of alcoholic liver disease. Anti-actin antibody is therefore associated with chronic autoimmune parenchymal liver damage and its appearance may mark the transition from acute hepatitis. No raised anti-actin titres were seen in 10 primary biliary cirrhosis patients positive for mitochondrial antibody by indirect immunofluorescence, but negative by the complement fixation test. This result suggests that the cytoplasmic fluorescence observed is due to low titre mitochondrial antibody rather than cytoplasmic actin and that these patients do not represent a different disease entity. The generation of anti-actin antibody in chronic parenchymal liver disease, perhaps due to unmasking or schlepping of intracellular or SIg/HLA-associated actin, may characterise autoimmune events at hepatocyte level, point to prognosis, and aid in the differential diagnosis of individual patients.     

Alpha-SMA expression in hepatic stellate cells and quantitative analysis of hepatic fibrosis in cirrhosis and in recurrent chronic hepatitis after liver transplantation

BACKGROUND: The alpha isotype of actin expressed by hepatic stellate cells reflects their activation to myofibroblast-like cell and has been directly related to experimental liver fibrogenesis, and indirectly to human fibrosis in chronic liver disease. AIMS: To evaluate the changes in distribution and percentage of alpha-smooth muscle actin-positive hepatic stellate cells and the correlation with the degree of the fibrosis in cirrhotic livers, as well as in patients with recurrent HCV chronic hepatitis after liver transplantation. METHODS: Human liver biopsies were divided in four groups: (1) normal livers obtained from cadaveric liver donors (n=35), (2) cirrhosis post-HBV hepatitis (n=11), (3) cirrhosis post-HCV hepatitis (n=10), and (4) post-transplant recurrent HCV chronic hepatitis (n=13). Samples were stained with anti-alpha-smooth muscle actin antibody by immunoperoxidase method and semi-quantitatively evaluated. Liver fibrosis was assessed from specimens stained with Masson's trichrome and quantified by computer image analysis. RESULTS: The percentage of alpha-smooth muscle actin-positive hepatic stellate cells was significantly higher in the HBV cirrhosis, HCV cirrhosis and post-transplant HCV recurrent hepatitis groups (36.1+/-15.2, 23.8+/-19.7 and 27.8+/-16.4%, respectively) compared to the liver donor group (2.9+/-4.0%). The alpha-smooth muscle actin-positive hepatic stellate cells to fibrous tissue ratio were significantly higher in the post-transplant recurrent HCV hepatitis group (2.36+/-1.12) compared to both the donor livers and the HCV cirrhosis groups (0.74+/-1.09 and 1.03+/-0.91, respectively). The alpha-smooth muscle actin-positive hepatic stellate cell percentage and fibrosis correlated positively in the post-transplant recurrent HCV hepatitis group and negatively in the HCV cirrhosis group. No difference in the immunohistochemical and morphometrical variables was found between the HCV cirrhosis and HBV cirrhosis groups. CONCLUSIONS: These results indirectly confirm that, in vivo, alpha-smooth muscle actin expression is a reliable marker of hepatic stellate cells activation which precedes fibrous tissue deposition even in the setting of recurrent HCV chronic hepatitis after liver transplantation, and it could be useful to identify the earliest stages of hepatic fibrosis and monitoring the efficacy of the therapy. In the presence of advanced cirrhosis other factors, rather than alpha-smooth muscle actin-positive hepatic stellate cells, may sustain fibrosis deposition.     

The occurrence of orcein-positive hepatocellular material in various liver diseases.

Liver specimens from 103 patients with various hepatic diseases and from 297 consecutive liver biopsies examined routinely were stained with orcein after oxidation of the tissue sections with potassium permanganate. Orcein-positive dark brown cytoplasmic material could be demonstrated in 27 cases with long-standing cholestasis. These patients had either primary biliary cirrhosis, the cholestatic liver disease of ulcerative colitis or chronic active hepatitis, advanced alcoholic cirrhosis or secondary biliary cirrhosis due to extrahepatic biliary obstruction. Orcein-positive material could not be demonstrated in congenital disorders of bilirubin metabolism or in hemochromatosis. Similarly, it could not be found in acute, toxic, alcoholic or chronic persistent hepatitis.     

Low prevalence of hepatitis C antibodies in chronic liver disease in Finland.

High prevalence of hepatitis C antibodies (anti-HCV) have been found in the Middle- and Southern European countries in connection with chronic liver diseases. In a study of Finnish chronic liver disease patients no anti-HCV antibodies were found in 22 autoimmune chronic active hepatitis, in 5 chronic persistent hepatitis and in 38 alcoholic liver disease patients. 2/30 primary biliary cirrhosis patients were anti-HCV positive. As a comparison 3/9 patients with acute community acquired non-A non-B hepatitis and 28/48 i.v. drug addicts had anti-HCV antibodies. The results indicate that HCV infections in Finnish chronic hepatitis patients are rare.     

675例肝脏穿刺活检的肝细胞脂肪变性分析

目的通过对675例肝脏穿刺病理结果的回顾性研究,分析各种肝脏疾病的肝细胞脂肪变性情况。方法收集西京医院2008年7月-2011年9月进行的675例肝脏穿刺活检的病理结果,分析其病理诊断及脂肪变性的构成比,肝细胞脂肪变性的发生率,以及肝细胞脂肪变性与血清甘油三酯的相关性。结果 72.6%(490/675)的肝脏穿刺患者为肝肿瘤或瘤样变、自身免疫性肝病、慢性病毒性肝炎及肝硬化。15.7%(106/675)患者存在不同程度的肝细胞脂肪变性,其中49.1%(52/106)的患者为肝硬化、病毒性肝炎及肝损害,33.0%(35/106)患者为酒精性/非酒精性脂肪肝。肝硬化患者发生肝细胞脂肪变性的比率高达30.7%。结论肝细胞脂肪变性普遍存在于各种慢性肝脏损害性疾病,尤其是肝硬化合并肝细胞脂肪变性的比率高达30.7%,需要在临床诊治过程中高度重视。     

Long-term histologic follow-up study of alcoholic liver disease.

Forty Japanese patients with alcoholic liver disease (nonspecific change, 9; fatty liver, 5; hepatic fibrosis, 4; chronic hepatitis, 12; alcoholic hepatitis, 5; liver cirrhosis, 5) were followed for 3-17 yr (average 8 yr) with repeated liver biopsies (2-5 times; average 2.5 times) at intervals of more than 3 yr. All of the patients continued to consume alcohol during this observation period. Five out of 12 patients with chronic hepatitis and 2 of 5 patients with alcoholic hepatitis eventually progressed to cirrhosis, while none of the 4 patients with hepatic fibrosis became cirrhotic. Anti-hepatitis C virus antibody was positive in 2 patients with liver cirrhosis among 12 patients whose sera were available. Two patients with cirrhosis died of hepatic failure and one patient died of hepatocellular carcinoma. These data suggest that the long-term prognosis of alcoholic liver disease is not necessarily poor, but patients with chronic hepatitis or alcoholic hepatitis can be at risk of progression to cirrhosis.     

肝活检对82例肝病诊断的临床价值

本文对82例肝病患者做肝活检，并以病理诊断与临床诊断进行对比。结果临床与病理诊断符合者49例，占59．8％，不符合33例占40．2％，其中肝硬化患者临床与病理诊断符合率69．7％，慢性活动性肝炎诊断符合率60％，慢性迁延性肝炎符合率66．7％，肝脓疡及亚急性重症肝炎符合率50％。慢性无症状乙肝病毒携带者8例，病理确诊为慢性迁延性肝炎5例，慢性活动性肝炎1例，肝轻微病变2例。以上资料表明，对肝病患者做肝活检是非常必要的，既可明确诊断，又可早期预防和治疗。     

Lack of evidence for involvement of fetal microchimerism in pathogenesis of primary biliary cirrhosis

Microchimerism may be involved in the etiopathogenesis of autoimmune diseases such as scleroderma. Primary biliary cirrhosis (PBC) shares some features with scleroderma, including a female predominance and a histologic picture reminiscent of chronic graft-versus-host disease. Our aim was to detect Y-chromosome-specific sequences as a marker for microchimerism in liver tissue of female patients with PBC. Liver biopsies of 105 female patients were investigated (28 patients with primary biliary cirrhosis, 25 patients with chronic hepatitis C, 6 patients with chronic hepatitis B, 9 with autoimmune hepatitis, and 37 patients with other liver diseases) by a sensitive Y-chromosome-specific polymerase chain reaction and/or fluorescence in situ hybridization (FISH) technique for the detection of the Y chromosome on a single cell level. In the liver of 9 (8.6%) female patients Y-chromosome-specific sequences were detected by PCR. Five of the patients had PBC as underlying disease, 2 had chronic hepatitis C, and 2 other liver diseases. No significant difference in the positivity rate for Y-specific sequences in females with PBC and patients with other liver diseases was found (P > 0.05). By FISH, single cells with one Y chromosome were detected in liver specimens from 3 of 21 patients suffering from PBC and from 1 of 13 patients with other liver diseases. In summary, microchimerism can be detected in livers of patients with hepatic diseases. However, in our study we found no evidence for an increased prevalence of microchimerism in the livers of patients with primary biliary cirrhosis. Our data suggest that microchimerism does not play a significant role in the development of PBC.     

High prevalence of viral infection in adults with homozygous and heterozygous alpha 1-antitrypsin deficiency and chronic liver disease.

OBJECTIVE: To determine the prevalence of chronic liver disease in adults with homozygous (Pi ZZ) and heterozygous (Pi Z) alpha 1-antitrypsin deficiency and to assess the presence of other possible risk factors for the development of chronic active hepatitis and cirrhosis of the liver in these patients. DESIGN: Cross-sectional study. SETTING: A referral-based university hospital. PATIENTS: Consecutive patients (164) with the Pi ZZ and Pi Z phenotype with and without chronic liver disease. MEASUREMENTS: The presence of antibody to hepatitis C virus (anti-HCV) was determined using an assay incorporating synthetic peptide antigen from capsid protein (United Biomedical [UBI] assay) and a second-generation enzyme immunoassay (Abbott test); the presence of antibody to hepatitis B virus (anti-HBV) was determined using radioimmunoassays incorporating hepatitis B surface antigen (HBsAg) and hepatitis B core antigen (HBcAg); assays for antinuclear antibody and antimitochondrial antibody (M2 subtype) were also done, and alcohol abuse was assessed by history. RESULTS: Among patients with cirrhosis (32%), 62% were anti-HCV positive by the Abbott test (P = 0.006), and 41% were anti-HCV positive by the UBI assay (P = 0.007). Thirty-three percent of patients with cirrhosis had hepatitis B virus (HBV) infection (P = 0.01); 41% had a history of alcoholism; and 12% had features of autoimmune liver disease. Only five patients (9%) with cirrhosis had no other risk factor for chronic liver disease. Among patients with chronic active hepatitis (7%), 80% were anti-HCV positive by the Abbott test (P = 0.002), and 75% were anti-HCV positive by the UBI assay (P less than 0.001). Thirty percent of patients with chronic active hepatitis had HBV infection (P = 0.023); 18% had autoimmune hepatitis; and 8% abused alcohol. Only two patients (17%) had no additional risk factor for the development of chronic active hepatitis. Among patients with steatosis of the liver (48%), 5% were anti-HCV positive by the Abbott test, and none were anti-HCV positive by the UBI assay; 18% had serologic evidence of past HBV infection, and 28% abused alcohol. Among patients without chronic liver disease (13%), no viral infection could be found; 9% were alcoholics. CONCLUSIONS: Chronic liver disease in patients with alpha 1-antitrypsin deficiency is associated with a high prevalence of viral infection; this infection, rather than alpha 1-antitrypsin deficiency alone, may be the cause of the liver disease in such patients.     

慢性肝病患者髂骨病理变化的观察及意义

对１７例乙肝后肝经和１４例慢性活动性肝炎患者的髂骨病理组织学改变进行了观察,发现肝硬化组骨质疏松的发生率为８２．５３％,肝炎组为３５．７１％,两组比较差异显著。提示随肝脏病变程度加重,其相关骨病的发生率亦之增加。将髂骨病理改变分为三组,为诊断肝性骨病（ＨＢＤ）提供了依据。     

Chronic active hepatitis associated with liver-kidney microsomal antibody of an autoimmune type

We report the findings in two sisters with active cirrhosis and an anti-liver-kidney microsomal antibody (anti-LKM) of the autoimmune type. This unusual disease is characterized by the presence of high levels of antibodies that react with the smooth and rough endoplasmic reticulum of the liver and other tissues. Our patients had the usual features of chronic hepatitis associated with presence of antibodies: they were young girls, they had anti-LKM antibodies of autoimmune type persisting at a high titer during the whole course of the disease, but with no smooth muscle antibodies; one had a low level of IgA. The occurrence of two cases in the same family has not yet been reported and is probably not coincidental because of the rare occurrence of this disease.     

CASE REPORT: Primary hepatic lymphoma associated with chronic liver disease

We report on a case of primary hepatic lymphoma that developed in a patient with chronic hepatitis C. Given that Japan is an area endemic for both hepatitis B and C viruses, we reviewed 51 Japanese cases of primary hepatic lymphoma, addressing the question as to whether the Japanese cases have unique characteristics and whether there is a causal relationship to the presence of chronic liver disease. Primary hepatic lymphoma most commonly affected middle-aged males. Presenting symptoms and physical findings were non-specific. Aminotransferases tended to stay in the low range compared with marked increases in lactate dehydrogenase. Sixteen patients (31%) had chronic liver disease, eight had liver cirrhosis and eight had chronic hepatitis, suggesting that there is a possible aetiological link between chronic liver disease and primary hepatic lymphoma.     

Bridging hepatic necrosis

The probable etiology and outcome of bridging hepatic necrosis found on a liver biopsy performed within three months of the onset of clinical illness was evaluated in 42 consecutive patients with this finding. Eighteen of the patients (43%) had a probable drug etiology for their hepatitis. Ten patients had HB_sAG-positive acute hepatitis. Fourteen patients had neither drug-induced disease nor proven HB_sAg-positive hepatitis. One patient from the drug-induced group died, but the other 17 had complete clinical recovery. Eight of ten in the hepatitis B antigen-positive group cleared their antigen and had complete clinical recovery. Chronic hepatitis developed in two who remained persistently HB_sAg positive. Eight of the patients in the group with unknown etiology recovered, while six developed evidence of active chronic liver disease. This incidence of active chronic liver disease is significantly greater than that found in the drug-induced group (P<0.02). We conclude that drug-induced hepatitis accounts for a significant proportion of patients of acute hepatitis who have bridging hepatic necrosis on liver biopsy. However, in these drug-induced cases the finding of bridging hepatic necrosis does not appear to be associated with an increased risk of development of active chronic liver disease.