BACTERIAL AND DIETARY ANTIBODIES IN LIVER DISEASE

A highly significant increase in antibody titres to Escherichia coli, Bacteroides, and rat-colon antigen is present in patients with liver disease, particularly chronic active hepatitis, when compared with controls; whereas antibody titres to Hœmophilus influenzœ are unremarkable. Serial sera from patients with acute viral hepatitis show an increased titre of E. coli antibodies, which reaches a peak two months after the onset, before returning to normal; whereas the titres to H. influenzœ are unchanged. These findings support the hypothesis that the diseased liver fails to sequester some antigens absorbed from the gut, and that they then become available for antibody formation elsewhere and hence contribute to the hyperglobulinæmia observed in liver disease.     

Immunological parameters, viral antibodies, and biochemical and histological findings in relatives of patients with chronic active hepatitis and primary biliary cirrhosis.

The familial occurrence of immunological, virological, biochemical and histopathological abnormalities has been studied in 39 first degree relatives of patients with primary biliary cirrhosis (PBC) and in 58 first degree relatives of patients with chronic active hepatitis (CAH). Tissue antibodies were more frequent in relatives than in age- and sex-matched controls. Abnormal immunoglobulin levels were demonstrated in about half of the relatives. Very high antibody titres to measles and rubella occurred only in the relatives of the patients with CAH. Moreover the raised titres tended to be clustered in a few families in which also the propositi had very high viral antibody titres. Liver biopsy was performed only on the relatives with biochemical abnormalities. Unspecific inflammatory changes were observed in 5 relatives of the patients with CAH and in 4 relatives of the patients with PBC. An active liver disease was detected in two relatives of the PBC-group and in one of the CAH-group. A marked accumulation of various immunological and histopathological abnormalities in four families was observed.     

Serum autoantibodies and immunoglobulins in hepatitis-associated antigen (HAA)-positive and -negative liver disease

Serum immunoglobulin G, A, and M and serum antinuclear, mitochondrial, and smooth muscle antibody have been measured in 223 patients with hepatitis-associated antigen (HAA)-positive and -negative acute and chronic liver disease. In patients with acute hepatitis, chronic persistent hepatitis, and primary liver cell carcinoma, these indices failed to show any significant differences. However, in the group with chronic aggressive hepatitis the patients who were HAA negative had significantly higher levels of serum IgG, much higher titres of smooth muscle antibody, and often antinuclear and mitochondrial antibodies which were not found in the HAA-positive patients from this group. This suggests that different pathogenic mechanisms may be operative in HAA-positive and -negative chronic aggressive hepatitis.     

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.     

Serum autoantibodies reacting with the hepatic asialoglycoprotein receptor protein (hepatic lectin) in acute and chronic liver disorders

Circulating autoantibodies reacting with affinity-purified, hepatic asialoglycoprotein receptor protein, hepatic lectin (HL), were detected by radioimmunoassay in 15 (83%) of 18 patients with autoimmune chronic active hepatitis (AI-CAH) who had active disease, at titres that showed a positive correlation (P less than 0.05) with severity of periportal inflammation assessed histologically. In contrast, 10 AI-CAH patients whose disease was in remission were all anti-HL seronegative. Anti-HL was also detected in 16 (73%) of 22 patients with hepatitis B virus-related CAH-a similar frequency to that in active AI-CAH but at significantly lower (P less than 0.005) titres. Only 1 of 8 patients with chronic active liver disease due to presumed non-A, non-B (NANB) viral infection and 5 (22%) of 23 with primary biliary cirrhosis were anti-HL seropositive (P less than 0.001 vs active AI-CAH and HBV-CAH) and there was no correlation with severity of periportal inflammation. Anti-HL antibodies were also found in sera from 7 (35%) of 20 patients with acute virus B hepatitis (AVH-B) but were not detected in 10 patients with AVH-A nor in 12 with AVH due to presumed NANB infection. Anti-HL was not found in sera of 12 patients with autoimmune thyroid disease. Hepatic lectin, a highly purifiable, liver-specific cell surface component, by analogy with the acetylcholine and thyrotropin receptors which are, respectively, targets of the pathogenetically-related autoimmune reactions in myasthenia gravis and autoimmune thyroid disease, may be an important target of autoreactions in liver disease.     

Raised levels of antibodies to human viruses at the clinical onset of autoimmune chronic active hepatitis

Summary. Patients with autoimmune chronic active hepatitis (AICAH) often have very high titres of antibodies to rubella and/or measles virus. In the present study a young girl at the clinical onset of AICAH exhibited very high titres of antibodies against influenza viruses A and B, parainfluenza viruses, rubella virus and varicella-zoster virus. The titres normalized over 2 months except for rubella and varicella-zoster antibodies. Strong reactivities were seen against the rubella structural proteins E1, E2 and C in Western blot but IgM antibodies were not demonstrated. Total IgG was increased with normal ratios of subclasses. The IgG1 was the dominant antibody to E1 and E2, while IgG4 dominated the anti-C response. There was no significant shift in subclass reactivities over one year from onset. The polymerase chain reaction (PCR), using a nested primer set, was negative for rubella virus RNA in a liver biopsy obtained at the clinical onset and in peripheral blood mononuclear cells (PBMC) 1 year later. Co-cultivation experiments using PBMC and permissive cell lines were also negative for rubella virus. Hence, in the very early phase of AICAH there may be a transiently enhanced antibody response to various unrelated viruses.     

Antibodies to double-stranded (native) DNA in active chronic hepatitis.

Sera from 36 patients with active chronic hepatitis were studied for the presence of antibodies to double-stranded (native) DNA. These antibodies are a specific antinuclear antibody previously shown to have a high degree of specificity for systemic lupus erythematosus. Fifteen of the 36 patients (42%) were found to have levels of antibody usually only reported in systemic lupus erythematosus and higher than those seen in a control population. Anti-DNA antibodies were not found in a group of 22 patients with other forms of liver disease.     

Autoantibodies in experimental autoimmune hepatitis.

Experimental autoimmune hepatitis (EAH) can be induced in mice by immunization with syngeneic soluble liver antigens in complete Freund's adjuvant. It has previously been shown that autoreactive T cells play an important role in this animal model of autoimmune hepatitis. We have studied the occurrence of liver autoantibodies in EAH. Characteristic autoantibodies appeared several weeks after disease induction and antibody titres continued to rise when histological and biochemical signs of disease activity had already regressed. Autoantibodies in EAH seemed to recognize autoantigens other than those present in autoimmune chronic active hepatitis patients. We conclude that autoantibodies arise in experimental autoimmune hepatitis but that these autoantibodies do not play a critical role in the pathogenesis of the disease.     

Liver membrane antibodies detected by immunoradiometric assay in acute and chronic virus-induced and autoimmune liver disease

In this study, we describe a radioimmunoassay to detect liver membrane binding antibodies. The assay was designed to exclude binding of aggregated IgG or immune complexes to Fc gamma receptors of hepatocytes. When this assay was applied to sera from 142 patients, antibodies were found in highest titer in patients with autoimmune chronic active hepatitis, rarely in patients with hepatitis B virus-induced chronic active liver disease, and in 32% of patients with primary biliary cirrhosis. IgM antibodies were found in 100% of patients with acute Type A but not B or non-A, non-B hepatitis. IgA class antibodies were found in the sera of 57% of patients with alcohol-induced hepatitis. All patient groups showing significant titers of liver membrane antibodies display the lesion of piecemeal necrosis except those with alcohol-induced hepatitis. Further studies are needed to determine whether this antibody is the cause of the lesion.     

Detection of anti-liver cell membrane antibody using a human hepatocellular carcinoma cell line

A radioimmunometric technique for the detection of autoantibodies to liver membrane antigens has been developed using Alexander cells, a human hepatocellular carcinoma cell line. After incubation of Alexander cells with serum, antimembrane antibodies were detected by addition of 125I-labeled Protein A. Binding ratios in 15 children with uncontrolled autoimmune chronic active hepatitis and in seven children with primary sclerosing cholangitis were significantly higher than in 18 age-matched normal controls. Nine patients with inactive autoimmune chronic active hepatitis, 13 with alpha 1-antitrypsin deficiency and five with fulminant hepatic failure had ratios similar to controls. In nine patients with Wilson's disease, there was a modest but significant increase in binding ratio. In four children with autoimmune chronic active hepatitis, binding ratios fell during effective immunosuppressive therapy. Sera from patients with systemic lupus erythematosus or rheumatoid arthritis gave normal results, excluding that binding derives from Fc-mediated immune complex capture. A positive correlation was found between Alexander cell binding values and anti-liver-specific protein antibody titers, suggesting that the two assays detect antibodies against shared antigenic determinants. The Alexander cell assay is a simple, rapid and sensitive technique to detect antibody to liver cell membrane antigens.     

High prevalence of hepatitis C in Egyptian patients with chronic liver disease.

The highest prevalence rates of hepatitis C virus infection in the world have been recently reported among Egyptian blood donors and frequent recipients of transfusions and other blood products. This is the first report, however, demonstrating hepatitis C as the most frequent association with chronic liver disease in Egypt. Of 1023 patients referred to the Liver Institute in Menoufia governorate for evaluation of chronic liver disease, 752 (73.5%) had antibodies to hepatitis C compared with 168 (16.4%) with hepatitis B surface antigen. Hepatitis C antibody was more common in patients with active schistosomiasis and patients without hepatitis B surface antigenaemia. Of 100 patients having liver biopsies, histological findings consistent with chronic viral hepatitis or its complications were found in 89 and antibody to hepatitis C was present in 75 (84.3%) of these patients with chronic hepatitis, active cirrhosis or hepatocellular carcinoma. These data pointing to the importance of hepatitis C as a cause of chronic liver disease in Egypt emphasise the necessity of studies delineating its routes of transmission in this country.     

Serum Amyloid P-Component as a Marker of Liver Involvement in Measles Infection

The P-component of amyloid (SAP) is a normal serum protein. Recent studies have pointed to the liver as the site of synthesis of SAP. Moreover, we have recently demonstrated a close correlation between serum level of SAP and the degree of liver impairment in patients with acute hepatitis, chronic active hepatitis, and cirrhosis. In the present study we have investigated liver involvement and serum SAP level during measles infection. Up to 80% of patients with measles had evidence of hepatic dysfunction. Serum SAP level was markedly decreased in patients with measles and correlated with the presence of liver involvement. Taken together, this finding suggests that serum SAP level might be a useful and sensitive indicator of liver disease.     

Endotoxin and liver diseases. High titres of enterobacterial common antigen antibodies in patients with alcoholic cirrhosis.

We have measured antibodies to the enterobacterial common antigen (ECA) in sera of 86 patients with various liver diseases. ECA is a component of the cell wall of all enteric bacteria, and ECA antibodies are a specific indication of the presence of enterobacterial components. Patients with alcoholic cirrhosis with or without signs of alcoholic hepatitis had significantly raised anti-ECA titres compared with healthy control subjects. Other groups of patients (alcoholic hepatitis and/or fatty liver, primary biliary cirrhosis, chronic active hepatitis, or liver metastases) did not differ significantly from controls in the height of their anti-ECA titres. The results support the concept that Gram-negative bacterial components may have some role in the pathophysiology of alcoholic cirrhosis.     

Frequency and significance of antibodies to liver/kidney microsome type 1 in adults with chronic active hepatitis.

To assess the frequency of antibodies to liver/kidney microsome type 1 (anti-LKM1) in patients with chronic active hepatitis, 131 such patients were tested by an indirect immunofluorescence assay. Of 62 patients with type 1 autoimmune hepatitis, none were seropositive. In contrast, 3 of 11 patients with autoimmune hepatitis and antimitochondrial antibodies (27%) were seropositive for anti-LKM1. Each had responded to corticosteroid therapy, and retesting of sera confirmed that each had been misclassified as antimitochondrial antibody positive. None of the patients with chronic active hepatitis B (14 patients) or C (24 patients) had anti-LKM1. Similarly, none of the 20 patients with cryptogenic disease had these antibodies. It is concluded that anti-LKM1 is specific for type 2 autoimmune hepatitis and is infrequent in adult patients seen at a referral center in the United States for chronic active hepatitis. Anti-LKM1 reactivity may be misinterpreted as antimitochondrial antibody reactivity by indirect immunofluorescence. Chronic hepatitis B and C virus infections are not important stimuli for the production of anti-LKM1, and testing for anti-LKM 1 is unlikely to clarify the nature of cryptogenic 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.     

Anti-actin antibodies of IgM and IgG class in chronic liver diseases detected by fluorometric immunoassay

Using a sensitive fluoroimmunoassay, anti-actin antibodies (AA) of the IgM and IgG classes were measured in 240 patients with various chronic liver diseases and in 211 patients with non-hepatic autoimmune muscle, heart, malignant and inflammatory bowel diseases. Thirty-two out of 40 patients (80%) with autoimmune chronic active hepatitis (CAH) had AA only of the IgG class (geom. mean X = 1.78, SEM +/- 0.07) and only three patients (8%) had both IgG and IgM AA, the latter in lower titres. In patients with primary biliary cirrhosis (PBC) and AMA-positive cholestatic CAH, AA of both IgM and IgG classes were equally represented (60% IgG and 64% IgM AA in PBC, 73% IgG and 51% IgM AA in cholestatic CAH) but the titres were very low (geom. mean IgG AA in PBC 1.035, SEM +/- 0.03, in cholestatic CAH 1.18, SEM +/- 0.02). In contrast to autoimmune (lupoid) CAH, AA were rare in HBsAg positive CAH (9/43, 21%) and only present in low titres. However, in six out of 21 patients with anti-HBs and anti-HBc-positive chronic active hepatitis, high AA of IgG class were found, suggesting the autoimmune type of liver disease. In NANB virus-induced chronic liver disease after blood transfusion, AA were only occasionally found (IgG antibodies 1/19, IgM antibodies 3/19) and none were found in the eight patients with sporadic NANB hepatitis. They were also rare in 30 patients with alcoholic liver disease (3/30, 10%).(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Longitudinal analysis of antibody response to immunization in paediatric survivors after allogeneic haematopoietic stem cell transplantation

The long-term antibody responses to re-immunization in recipients of allogeneic haematopoietic stem cell transplantation (allo-HSCT) have not been well studied. We prospectively and longitudinally evaluated the antibody responses to eight vaccine antigens (diphtheria, tetanus, pertussis, measles, mumps, rubella, hepatitis B, and poliovirus) and assessed the factors associated with negative titres in 210 allo-HSCT recipients at St. Jude Children's Research Hospital. Antibody responses lasting for more than 5 years after immunization were observed in most patients for tetanus (95.7%), rubella (92.3%), poliovirus (97.9%), and, in diphtheria-tetanus-acellular pertussis (DTaP) recipients, diphtheria (100%). However, responses to pertussis (25.0%), measles (66.7%), mumps (61.5%), hepatitis B (72.9%), and diphtheria in tetanus-diphtheria (Td) recipients (48.6%) were less favourable, with either only transient antibody responses or persistently negative titres. Factors associated with vaccine failure were older age at immunization; lower CD3, CD4 or CD19 counts; higher IgM concentrations; positive recipient cytomegalovirus serology; negative titres before immunization; acute or chronic graft-versus-host disease; and radiation during preconditioning. These response patterns and clinical factors can be used to formulate re-immunization and monitoring strategies. Patients at risk for vaccine failure should have long-term follow-up; those with loss of antibody response or no seroconversion should receive booster immunizations.     

Reovirus type 3 infection in patients with primary biliary cirrhosis and primary sclerosing cholangitis

Reovirus type 3 (Reo-3) infection has recently been implicated in the pathogenesis of certain idiopathic, cholestatic liver diseases of newborns. In the present study, antibody titres to Reo-3 virus (anti-Reo-3) were determined in sera from 43 adults with idiopathic cholestatic liver disease, including 34 patients with primary biliary cirrhosis (PBC) and 9 patients with primary sclerosing cholangitis (PSC). Seventy-four adults with various other causes of chronic liver disease and 16 healthy volunteers served as controls. Geometric mean titres of anti-Reo-3 were significantly higher in PBC and PSC sera than chronic liver disease and healthy controls (P less than 0.005). Mean antibody titres for all patient groups, however, were within the 95% confidence limits for normals. Seven of 34 (21%) PBC patients and 3/9 (33%) PSC patients had elevated titres of anti-Reo-3, as compared to only 4/74 (5%) chronic liver disease (P less than 0.05) and 0/16 (0%) healthy control subjects (P less than 0.05) (Fisher's Exact Test). Antibody titres to five other common viruses were normal in patients with high anti-Reo-3 titres when compared to age- and sex-matched controls with liver disease. Immunoperoxidase staining for Reo-3 viral markers and cultures of liver biopsy material for Reo-3 virus were negative in both patients and controls. The results of this study indicate that, although patients with PBC and PSC have higher anti-Reo-3 antibody titres than patients with other forms of chronic liver disease or healthy volunteers, only a minority of these patients have titres that exceed the 95% confidence limits for normals.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anti-actin antibodies of IgM and IgG class in chronic liver diseases detected by fluorometric immunoassay*

ABSTRACT— Using a sensitive fluoroimmunoassay, anti-actin antibodies (AA) of the IgM and IgG classes were measured in 240 patients with various chronic liver diseases and in 211 patients with non-hepatic autoimmune muscle, heart, malignant and inflammatory bowel diseases. Thirty-two out of 40 patients (80%) with autoimmune chronic active hepatitis (CAH) had AA only of the IgG class (geom. mean X = 1.78, SEM±0.07) and only three patients (8%) had both IgG and IgM AA, the latter in lower titres. In patients with primary biliary cirrhosis (PBC) and AMA-positive cholestatic CAH, AA of both IgM and IgG classes were equally represented (60% IgG and 64% IgM AA in PBC, 73% IgG and 51% IgM AA in cholestatic CAH) but the titres were very low (geom. mean IgG AA in PBC 1.035, SEM±0.03, in cholestatic CAH 1.18, SEM±0.02). In contrast to autoimmune (lupoid) CAH, AA were rare in HBsAg positive CAH (9/43, 21%) and only present in low titres. However, in six out of 21 patients with anti-HBs and anti-HBc-positive chronic active hepatitis, high AA of IgG class were found, suggesting the autoimmune type of liver disease. In NANB virus-induced chronic liver disease after blood transfusion, AA were only occasionally found (IgG antibodies 1/19, IgM antibodies 3/19) and none were found in the eight patients with sporadic NANB hepatitis. They were also rare in 30 patients with alcoholic liver disease (3/30, 10%). Of 211 patients with non-hepatic disorders, only 13 patients (6%) had AA (geom. mean of positive titres 0.076, SEM±0.01). We conclude therefore that high titre AA of the IgG class are reliable serological markers for the diagnosis of an autoimmune liver disease.