Light and electron microscopic analysis of liver biopsy samples from rheumatoid arthritis patients receiving long-term methotrexate therapy

OBJECTIVE: We study liver damage in forty-two patients with rheumatoid arthritis (RA) using light (LM) and electron microscopy (EM) and assess histological changes after four years of treatment with methotrexate (MTX). PATIENTS AND METHODS: liver biopsies (LB) were taken before and after four years of treatment. Patients received weekly doses of between 7.5-15 mg of MTX. RESULTS: Fourteen per cent of the baseline LB presented mild perisinusoidal fibrosis (Roenigk IIIA) and the rest a lower Roenigk grade; EM identified an increase in collagen fibers in the Disse spaces in 50% of baseline LB. Neither microscopy technique revealed histological progression in any of the sequential LB. Variables that correlated with histological abnormalities were patient's age, length of evolution of the disease, alcohol consumption and biochemical data (gammaglutamate transferase and albumin); the cumulative dose of MTX was not correlated with worse histological findings. Correlation between the two microscopy techniques was good, though EM was more sensitive than LM for the detection of fibrosis. CONCLUSIONS: RA patients present with liver damage before treatment with MTX. The alterations are mild. At low doses MTX treatment is safe. In addition to the recommendations of the American College of Rheumatology, other factors associated with liver impairment are patient's age and length of evolution of the RA.     

Light and electron microscopic analysis of sequential liver biopsy samples from rheumatoid arthritis patients receiving long-term methotrexate therapy followup over long treatment intervals and correlation with clinical and laboratory variables

Objective. To describe liver histopathologic features and ultrastructural changes in a prospectively studied cohort of rheumatoid arthritis (RA) patients receiving long-term methotrexate (MTX) therapy, and to seek correlations between these changes and simultaneously measured laboratory indices of liver function. Methods. This was a long-term, prospective, open observational study. Twenty-seven outpatients with RA who began therapy with MTX and continued treatment for extended periods underwent baseline and followup liver biopsies. One hundred seventy liver biopsy specimens were analyzed by light microscopy (LM) and assessed according to a modified Roenigk score and a newly devised numerical grading system. Ninety-three biopsy specimens were also analyzed by electron microscopy (EM). Blood samples were obtained at 4–6-week intervals for determination of bilirubin, alkaline phosphatase, aspartate aminotransferase (AST), and albumin levels, and the weekly dosage of MTX was adjusted if there were abnormalities in the AST or albumin level. A mean of 6.3 liver biopsies per patient were obtained over a mean followup period of 8.2 years (range 2–13 years). Results. The modified Roenigk score was significantly different from baseline at year 3, when it increased from a mean of 1.8 to 2.3 (P = 0.05) and at year 6, when it increased to 2.4 (P = 0.04), but this was not considered clinically meaningful. No other significant changes from baseline were observed by either LM grading system. No significant progression was observed by EM over the course of the investigation. Increases in serial measurements of AST correlated with both the modified Roenigk score (r = 0.21, P = 0.016) and the numerical rating score (r = 0.19, P = 0.027). Conclusion. Patients with RA who are receiving weekly single-dose oral MTX therapy exhibit little deterioration in hepatic architecture by LM or EM when the dosage of the drug is adjusted for abnormalities in AST and serum albumin, monitored at frequent intervals.     

Liver histology in rheumatoid arthritis patients receiving long-term methotrexate therapy. A prospective study with baseline and sequential biopsy samples

Twenty-nine patients with active rheumatoid arthritis receiving long-term oral weekly methotrexate (MTX) therapy were studied to determine the extent of their hepatic architectural changes. Liver biopsies (n = 101) were performed in all patients before the initiation of MTX therapy, after 2 years, and annually thereafter (mean duration of therapy 53 months). The hepatic histologic grade (5-point scale) in 25 patients increased (worsened) (mean +/- SEM change 0.84 +/- 1.02; P = 0.001). Fibrosis, confirmed by trichrome staining, developed in 14 of 27 patients (52%). A history of alcohol consumption prior to starting MTX correlated significantly with subsequent worsening of the liver biopsy grade (r = 0.55, P = 0.0054). Alcohol intake prior to study entry, elevated weight at MTX initiation, and dose and duration of MTX were significantly associated with the development of fibrosis. Elevations in serum aspartate aminotransferase levels at 29-53 months of therapy correlated with the increase in hepatic histologic grade at the 3-year biopsy (r = 0.50, P = 0.04) and 4-year biopsy (r = 0.58, P = 0.03). We conclude that long-term MTX therapy in rheumatoid arthritis patients results in a statistically significant worsening in hepatic histologic grade, with common development of mild fibrosis. We do not consider these changes to be clinically significant at present.     

Liver biopsy findings in patients with rheumatoid arthritis undergoing longterm treatment with methotrexate

Ten histological criteria were evaluated semiquantitatively in the liver biopsies of 60 patients with rheumatoid arthritis (RA) before initiation of methotrexate (MTX) and were compared with 40 biopsies taken during MTX treatment (mean cumulative dose 1.322 mg). Mesenchymal changes (Kupffer cell proliferation, portal tract infiltration) and parenchymal alterations (nuclear variability, ballooning, fatty infiltration) were very common without statistically significant difference between the 2 groups. Slight periportal and/or portal fibrosis was present in 25% of patients without statistical difference between groups. Central fibrosis occurred in 13.5-12.5%. We conclude that liver abnormalities in RA are not related to MTX treatment.     

The cost-effectiveness of liver biopsy in rheumatoid arthritis patients treated with methotrexate

Objective. To assess the cost-effectiveness of liver biopsy in monitoring rheumatoid arthritis (RA) patients for methotrexate (MTX)–induced cirrhosis. Methods. A decision analytic model was used to compare a strategy of no biopsy versus strategies of biopsy after 5 years or 10 years of MTX treatment. Results. Biopsy after 5 years of MTX treatment had a cost-effectiveness ratio of $1,891,830 per year of life saved, while biopsy after 10 years of treatment had a cost-effectiveness ratio of $52,374 per year of life saved. Sensitivity analyses revealed that the cost-effectiveness of biopsy was most dependent on the probability of cirrhosis. Conclusion. Liver biopsy to monitor for MTX-induced cirrhosis in RA patients is not cost effective after 5 years of treatment, and even biopsy after 10 years has a high cost.     

Electron microscopic studies of the cartilage-pannus junction in rheumatoid arthritis.

The junction between pannus and cartilage was examined in the rheumatoid joint. Three types of cartilage-pannus junction were observed. In one, proliferating small blood vessels, surrounded by highly cellular infiltrates, penetrated deeply into the cartilage. Degeneration of the cartilage was observed around the cellular accumulations. In the second, phagocytic and fibroblastic cells invaded the cartilage. In the third, fibrous pannus overlay the cartilage. Lysis of cartilage by infiltrating cells appeared to be a major cause of cartilage erosion in rheumatoid arthritis.     

Juvenile rheumatoid arthritis with rice bodies: light and electron microscopic studies.

Rice bodies obtained from a young man with juvenile rheumatoid arthritis were found by light and electron microscopy to contain cells that appeared viable. The majority of these cells closely resembled type B synovial lining cells. Type A-like cells were also seen. The cells contained few mitochondria but often much lipid and glycogen, observations which suggested a dependence on anaerobic metabolic pathways in the avascular synovial fluid environment. Cells within the rice bodies lay in a matrix of collagen fibres, fibrin, and amorphous material. The source of the collagen appeared to be the cells themselves. The relatively normal appearance of the cells suggested that they were protected from many of the inflammatory stimuli present in rheumatoid synovia. This 'reversion' towards a normal appearance suggested that the stimuli inducing chronic rheumatoid inflammation might not originate in the synovial lining.     

Electron microscopic studies of the cartilage-pannus junction in rheumatoid arthritis

The junction between pannus and cartilage was examined in the rheumatoid joint. Three types of cartilage-pannus junction were observed. In one, proliferating small blood vessels, surrounded by highly cellular infiltrates, penetrated deeply into the cartilage. Degeneration of the cartilage was observed around the cellular accumulations. In the second, phagocytic and fibroblastic cells invaded the cartilage. In the third, fibrous pannus overlay the cartilage. Lysis of cartilage by infiltrating cells appeared to be a major cause of cartilage erosion in rheumatoid arthritis.     

Renal biopsy findings and followup of renal function in rheumatoid arthritis patients treated with cyclosporin A. An update from the international kidney biopsy registry

Objective. To review data from the International Kidney Biopsy Registry, which describes the occurrence of cyclosporin A (CSA)–induced nephropathy, and to discuss the potential risk factors for its development. Methods. The report examines data on a total of 60 first and 14 second renal biopsies performed in rheumatoid arthritis (RA) patients treated with CSA for up to 87 months. Results. Five of the 60 patients with RA included in the Biopsy Registry had findings consistent with CSA-induced nephropathy at first biopsy. One further patient had such findings at second biopsy. Of the 22 patients who started CSA at dosages < 4 mg/kg/day and subsequently received dosages no higher than 5 mg/kg/day, none developed CSA-induced nephropathy. Continuous assessment of renal function did not show any evidence of deterioration over time in patients maintained on low-dose CSA. Conclusion. The data indicate that in RA patients being treated according to current dosing recommendations, the risk of developing CSA-induced nephropathy is low.     

Oxidant/antioxidant status of plasma samples from patients with rheumatoid arthritis

This study aims to elucidate plasma oxidant/antioxidant status in patients with rheumatoid arthritis (RA). Fasting blood samples were obtained from 24 patients with RA and 20 control subjects. Antioxidant potential (AOP) value, nonenzymatic superoxide radical scavenger activity (NSSA), and malondialdehyde (MDA) levels were measured to establish plasma oxidant/antioxidant status in the patient and control groups. Patients with RA had lower AOP and NSSA but higher MDA levels than those of the control subjects, which was an indication of reduced antioxidant capacity and oxidant stress in these patients. Results suggest that the antioxidant system is impaired and peroxidation reactions are accelerated in patients with RA. We suppose that therapeutic use of some antioxidants may be beneficial in this regard. Received: 26 April 1999 / Accepted: 2 August 1999     

Histopathologic findings in the liver of rheumatoid arthritis patients treated with long-term bolus methotrexate

Twenty-three patients with severe rheumatoid arthritis were treated with oral methotrexate (MTX) for more than 10 years. MTX was given as a bolus of 5-15 mg/week; the total cumulative dose ranged from 4,690 mg to 10,230 mg. Liver biopsies were performed on 21 of the patients to assess possible fibrosis and cirrhosis. Grade I histopathologic changes were found in 13 of the 21 biopsy samples, grade II changes were found in 3, and grade IIIA changes (mild fibrosis) were found in 5 specimens. None of the biopsy samples showed cirrhosis. Repeat biopsies were performed on the 5 patients with grade IIIA changes while they were still taking MTX. No progression of the fibrosis was noted. Two of the 5 samples, however, were graded IIIB because of portal and perilobular inflammation. Our findings support the premise that prolonged administration of oral MTX, when given as a weekly bolus at a low dose, does not cause cirrhosis or severe fibrosis in the rheumatoid arthritis patient who does not abuse alcohol.     

Renal involvement in rheumatoid arthritis: analysis of renal biopsy specimens from 100 patients

 We analyzed renal biopsy specimens from 100 patients to evaluate the characteristics of renal involvement in patients with rheumatoid arthritis (RA). Membranous nephropathy (MN) was the most common renal histological pattern (31%). Mesangial proliferative glomerulonephritis (GN) was found in 21% of cases (IgA nephropathy 12%, non-IgA GN 9%), minor changes in 17%, renal amyloidosis in 11%, interstitial nephritis in 9%, sclerotic GN in 4%, and crescentic GN in 2%. MN was relatively more frequent in men than in women, and most developed nephrotic syndrome, while a few developed renal failure. Disease-modifying antirheumatic drugs (DMARDs) correlated with MN in 26 of 31 cases. Mesangial proliferative GN showed high-grade hematuria. Amyloidosis correlated with long duration of RA; approximately half of the cases with amyloidosis also had nephrotic syndrome, and 82% developed renal failure. Of the 100 patients, 82% showed some tubulo-interstitial changes, which might be related to non-steroidal anti-inflammatory drugs. Because renal lesions in RA are very diverse, and early stage cases of MN and amyloidosis can be detected only by histological examinations, renal biopsy should be performed in cases with continuous urinary abnormalities or progressive renal failure. Received: May 14, 2001 / Accepted: November 17, 2001     

Electron microscopic investigation of endomyocardial biopsy samples in hypertrophy and cardiomyopathy. A semiquantitative study in 48 patients

Electron microscopic and statistical analyses of 66 right ventricular biopsies from 48 patients were undertaken to investigate whether quantitative differences exist between those patients with "ordinary" myocardial hypertrophy and those suffering from a form of cardiomyopathy. The electron microscopic changes were scored and correlated with hemodynamic variables such as ejection fraction (EF), left ventricular end-diastolic pressure (LVEDP) and length of history. The patients were followed for an average of 22.5 months, permitting an assessment of prognosis. The results show that the three diagnostic groups--"ordinary" hypertrophy, hypertrophic cardiomyopathy (HOCM) and congestive cardiomyopathy (COCM)--overlap, but crossover of sarcomeres is more frequent in patients in whom HOCM is diagnosed. Except for a tenuous relationship between EF, and the electron microscopy (EM) (r = -0.46, p less than 0.1) and between LVEDP and EM score (r = 0.61, p less than 0.01), in the COCM group, no correlation could be established between EF, LVEDP and length of history when the patients were grouped according to histologic or clinical diagnosis. This study shows that the various claims regarding relationships between morphologic changes and the functional status of patients or prognosis cannot be confirmed.     

Correlation of clinical and serological findings in patients with rheumatoid arthritis treated for one year with interferon-gamma

Results of a large therapeutic trial of interferon-gamma in patients with rheumatoid arthritis (RA) are described. Of 110 RA-patients enrolled in this clinical trial, 46 were treated with interferon-gamma for 12 months. During the treatment period, dosage was reduced on an individual basis. There was a correlation between the improvement of clinical parameters, such as pain or morning stiffness, and the improvement of laboratory parameters such as erythrocyte sedimentation rate, anemia, leucocytosis or thrombocytosis. Interferon-gamma was well tolerated, and no organ toxicity was detected.     

Phenotypic analysis of peripheral blood monocytes isolated from patients with rheumatoid arthritis.

The expression of CD14, Fc gamma receptor I (Fc gamma RI), Fc gamma RII, and HLA-DR on peripheral blood monocytes from patients with rheumatoid arthritis (RA) was studied to investigate their nature and their role in the pathogenesis of rheumatoid synovitis. Peripheral blood mononuclear cells obtained from 9 patients with active RA, 8 patients with RA in complete remission, and 14 healthy individuals, were stained with various monoclonal antibodies and analyzed on a fluorescence activated cell sorter. The expression of CD14 as well as Fc gamma RI and Fc gamma RII was upregulated on peripheral blood monocytes from patients with active RA, although the expression of HLA-DR was not increased. In addition, the expression of Fc gamma RI and Fc gamma RII on monocytes was still upregulated in patients with RA in complete remission, whereas the expression of CD14 on monocytes was normalized in these patients. These results indicate that peripheral blood monocytes in patients with active RA are already activated to express higher densities of CD14. In addition, our observation that CD14 density was increased on a subset of circulating blood monocytes in active RA, that HLA-DR was not significantly altered and that Fc gamma RI and Fc gamma RII were increased in both active and inactive RA is not compatible with the expected actions of interferon gamma. Finally, it is suggested that peripheral blood monocytes in patients with RA may have intrinsic abnormalities as evidenced by the enhanced expression of Fc gamma R, which is repeatedly observed regardless of the disease activity of RA.