Lymphocytotoxicity against autologous hepatocytes and membrane-bound IgG in viral and autoimmune chronic active hepatitis

ABSTRACT— Membrane-bound IgG and lymphocytotoxic activity of total, T-enriched and T-depleted lymphocytes, using autologous hepatocytes have been evaluated in: (a) 31 patients with chronic active hepatitis (CAH) (six autoimmune and 25 hepatitis B virus - HBV-related); (b) five patients with inactive alcoholic cirrhosis; and (c) nine subjects with normal hepatic histology. Lymphocytotoxicity was positive in 83% of autoimmune CAH and 68% of HBV-related cases; it was confined to the T-depleted subpopulation in the first group, while it was present in both the T-enriched and T-depleted subpopulations in 81% of HBV-related cases. Membrane-bound IgG was present in 58% of group (a) and in none of the other groups. A linear pattern was found in four out of five autoimmune CAH patients with positive lymphocytotoxic activity. The autoimmune patient with lymphocytotoxic activity within the normal range did not show any membrane fluorescence. Among HBV-related CAH patients, 13 presented a granular pattern, two an associated granular and linear pattern and ten were negative. These data suggest that different lymphocytotoxic mechanisms are involved in the two forms of CAH studied.     

Lymphocyte cytotoxicity to autologous liver cells in chronic active hepatitis.

Lymphocyte function in vitro was evaluated in patients with chronic active hepatitis and compared to normal controls. Circulating lymphocytes of patients were spontaneously cytotoxic to 51Cr-labeled human Chang liver cells and to suspensions of autologous liver cells obtained at the time of liver biopsy when tested at a lymphocyte target cell ratio of 200:1. Prednisone treatment of patients with chronic active hepatitis inhibited both spontaneous and concanavalin A-stimulated lymphocyte cytotoxicity to human Chang liver cells. Similarly, chronic prednisone administration substantially reduced lymphocyte cytotoxicity towards the patients' own liver cells in vitro, which correlated with a clinical, biochemical, and histological response to such therapy. Thus, patients with chronic hepatitis have circulating lymphocytes that are capable of causing destruction of their own liver cells in vitro. The beneficial effect of prednisone therapy in such patients may be related to this inhibition of lymphocyte cytotoxicity.     

Spontaneous reactivation of hepatitis B in Chinese patients with HBsAg-positive chronic active hepatitis

Eleven patients of Chinese origin experienced spontaneous reactivation of chronic active hepatitis B. Eight HBsAg-positive patients were followed for an average of 15 months prior to, while three others presented during reactivation. Fatigue, hepatomegaly and jaundice were frequent findings. Elevation of both serum ALT (average = 1,212 units per liter) and hepatitis B virus DNA levels were noted in all patients, and reactivation lasted an average of 4.4 months. During resolution, clinical symptoms abated, serum ALT levels reverted toward normal, and in nine patients, the hepatitis B virus DNA values became undetectable. All patients lacked evidence for acute hepatitis A, Epstein-Barr Virus, cytomegalovirus or hepatitis delta virus infection. Histologic findings of liver tissue from eight patients showed piecemeal necrosis and fibrosis. Within the parenchyma, varying degrees of hepatocytolysis with cuffing, perivenular necrosis and acidophilic bodies were noted. Ground-glass cells and regenerative changes also were observed. Cirrhosis was not present in any of the liver biopsies. These findings suggest that spontaneous reactivation of hepatitis B occurs in heterosexual patients with chronic active hepatitis B and contributes to chronic inflammation and to the progression of their liver disease.     

Treatment of HBsAg-positive chronic active hepatitis with human fibroblast interferon

Two patients with HBsAg positive chronic active hepatitis have been treated with human fibroblast interferon 10(7) units daily for two weeks. Before treatment, both patients had high levels of hepatitis B surface antigen, core antibody, and DNA-binding antibody in the blood and one patient had a fourfold rise in serum AST. During treatment there was a striking fall in the core antibody titre and also in the DNA-binding antibody, which has been maintained for several months subsequently; in one patient the initially high AST level fell to normal. No significant adverse effects occurred, and these observations should encourage further trials of fibroblasts interferon in hepatitis B.     

Hepatitis B virus replication in steroid-treated severe HBsAg-positive chronic active hepatitis

To determine the effect of corticosteroids on the replication of hepatitis B virus and to assess the relationship between virus replication and prognosis, the behavior of serum and tissue HB_cAg was evaluated in 16 patients with severe HB_sAg-positive chronic active hepatitis who were treated with prednisone and followed for up to 10 years (mean±Sem, 66±9 months). Hepatitis B virus replication was assessed in serum by a solid-phase radioimmunoassay of Dane particle-associated HB_cAg and in liver tissue by indirect immunoperoxidase staining for HB_cAg. Despite the presence of severe inflammatory activity, only low levels of hepatitis B virus replication were demonstrated. Mean serum HB_cAg levels were low at accession and remained essentially unchanged or gradually decreased during corticosteroid therapy. Serum HB_cAg appeared in only one patient in whom no virus replication was detected prior to therapy. HB_eAg was frequently detected at low titers by radioimmunoassay when serum HB_cAg was undetectable. Loss of HB_cAg preceded loss of HB_eAg by radioimmunoassay, and disappearance of both markers was a prerequisite for sustained histologic remission. In eight patients, inflammation was present despite absence of serum or tissue HB_cAg; in three of these, disease activity continued after loss of HB_eAg. We conclude that low levels of hepatitis B virus replication may be associated with severe inflammatory activity, and these levels are not increased by long-term corticosteroid therapy. Inflammation can continue despite loss of HB_eAg and absence of detectable virus replication.Presented in part at the National Meeting of the American Federation for Clinical Research, May 7, 1982, Washington, D.C.     

Immunological abnormalities in autoimmune chronic active hepatitis

Autoimmune chronic active hepatitis is often associated with clinical and laboratory features that resemble those observed in systemic lupus erythematosus (SLE). We describe a 24-year-old woman with autoimmune chronic active hepatitis who was studied for serologic markers of autoimmunity and for immune clearance in terms of in vivo Fc receptor function. A markedly depressed immune clearance and splenic uptake of radiolabelled and IgG coated autologous erythrocytes was observed. The magnitude of this defect equaled or exceeded the most severe defects seen in a group of patients with SLE. This phenomenon was associated with markedly depressed serum C4 levels, a variably positive Sm antibody, and normal circulating immune complex concentrations. In addition, many clinical extrahepatic manifestations meeting criteria for classifying SLE were present. These findings further support the concept of autoimmune chronic active hepatitis and SLE being part of spectrum of overlapping autoimmune diseases.     

Cyclosporine treatment of autoimmune chronic active hepatitis

A 14-yr-old boy with a 5-yr history of autoimmune chronic active hepatitis refractory to corticosteroid therapy was given cyclosporin A (5 mg/kg X day). Before cyclosporine therapy, serum aminotransferase levels were 20 times normal and immunoglobulin G was 4 g/dl. Within 2 wk of starting cyclosporine therapy, aminotransferase levels decreased; by 2 mo they were almost normal, and at 1 yr into therapy they were normal. A decrease in cyclosporine dosage was associated with an increase in aminotransferase levels, which then again decreased as the dose was increased. Severe growth failure observed during previous corticosteroid therapy reversed during cyclosporine treatment and the patient displayed "catch-up" growth. No significant side effects were noted after 1 yr of cyclosporine therapy. Further evaluation of cyclosporine in the treatment of corticosteroid-unresponsive autoimmune chronic active hepatitis appears warranted.     

Kayser-Fleischer like ring in autoimmune chronic active hepatitis

Kayser-Fleischer ring is considered an important diagnostic sign of Wilson's disease. We report a 9 year old boy with autoimmune chronic active hepatitis who exhibited Kayser-Fleischer like ring.     

Nature of immune complexes in autoimmune chronic active hepatitis

Immune complexes containing antinuclear antibodies have been observed in autoimmune chronic active hepatitis. Using a library of nuclear constituents (deoxyribonucleic acid, small nuclear ribonucleoproteins, and histones), we analyzed the antigens involved in formation of immune complexes. Immune complexes were defined in dissociation experiments, and after separation under dissociating conditions. Immune complexes composed of histones and immunoglobulin G were observed in four of nine immune complex-positive autoimmune chronic active hepatitis sera. Immune complexes containing the small nuclear ribonucleoprotein U1-RNP and immunoglobulin G were observed in two additional samples. Kidney eluates obtained from 2 patients with autoimmune chronic active hepatitis and membranous glomerulonephritis revealed enrichment of anti-U1-RNP, suggesting specific deposition of this antibody in complexed form. Circulating immune complexes containing histones were observed only in patients with autoimmune chronic active hepatitis-associated sicca syndrome; those containing U1-RNP were restricted to patients with autoimmune chronic active hepatitis associated with kidney disease.     

Antibody to liver cytosol (anti-LC1) in patients with autoimmune chronic active hepatitis type 2

A new autoantibody was detected by immunoprecipitation in the serum of 21 patients with chronic active hepatitis. The antibody reacted against a soluble cytosolic antigen in liver. The antibody was organ specific but not species specific and was therefore called anti-liver cytosol antibody Type 1 (anti-LC1). In seven of 21 cases, no other autoantibody was found; the remaining 14 cases had anti-liver/kidney microsome antibody Type 1 (anti-LKM1). With indirect immunofluorescence, a distinctive staining pattern was observed with the seven sera with anti-LC1 and without anti-LKM1. The antibody stained the cytoplasm of hepatocytes from four different animal species and spared the cellular layer around the central veins of mouse and rat liver that we have called juxtavenous hepatocytes. The immunofluorescence pattern disappeared after absorption of sera by a liver cytosol fraction. The 14 sera with both antibodies displayed anti-LC1 immunofluorescent pattern after absorption of anti-LKM1 by the liver microsomal fraction. The anti-LC1 was found in the serum only in patients with chronic active hepatitis of unknown cause. Anti-LC1 antibody was not found in sera from 100 patients with chronic active hepatitis associated with anti-actin antibody classic chronic active hepatitis Type 1, 100 patients with primary biliary cirrhosis, 157 patients with drug-induced hepatitis and a large number of patients with liver and nonliver diseases. This new antibody was considered a second marker of chronic active hepatitis associated with anti-LKM1 (anti-LKM1 chronic active hepatitis) or autoimmune chronic active hepatitis Type 2.     

Lack of in vivo activation of the interferon system in HBsAg-positive chronic active hepatitis

The in vivo activation state of the interferon system was biochemically evaluated in patients with HBsAg-positive liver disease by assaying the interferon-induced enzyme, 2'5'-oligoadenylate synthetase, in peripheral blood mononuclear cells. All patients with chronic active hepatitis had normal levels of enzyme activity. Increased values were found in 77% of patients with acute hepatitis, 50% of those with chronic persistent hepatitis and 54% chronic healthy carriers. These results provide evidence for lack of activation of the interferon system in HBsAg-positive chronic active hepatitis and support the hypothesis that an in vivo defective interferon response may aid in development of chronic active hepatitis.