Chronic hepatitis C infection in patients with end stage renal disease: characterization of liver histology and viral load in patients awaiting renal transplantation

OBJECTIVES: Hepatitis C virus (HCV) is common in patients with end stage renal disease (ESRD) awaiting renal transplantation (RT). However, few data are available on the liver histology and viral titer in these patients relative to patients with HCV and normal renal function. The aims of this study were to assess liver histology, quantitative HCV-RNA titer, and alanine aminotransferase (ALT) levels in patients with ESRD awaiting RT, and to identify clinical predictors of histological progression to advanced bridging fibrosis and/or cirrhosis. METHODS: A total of 50 consecutive patients (mean age 42 yr, 62% male) with ESRD and HCV, who were awaiting RT, underwent liver biopsy. Two HCV populations, one with persistently normal ALT and another with elevated ALT, both with normal renal function, served as controls. HCV-RNA titer was assessed by quantitative PCR. RESULTS: Of the patients with ESRD, 94% had normal ALT. Log HCV RNA titer was significantly higher in patients with ESRD (5.8+/-0.3) than in either normal ALT (5.4+/-0.1) or elevated ALT (5.3+/-0.1) controls (p < 0.05). Knodell Histological Activity Index (HAI) in patients with ESRD was similar to that observed in control patients with normal ALT (4.8+/-0.4 vs 4.9+/-0.4) but significantly less (p < 0.05) than that observed in control patients with elevated ALT (8.4+/-0.5). The percentage of patients with bridging fibrosis or cirrhosis was similar in patients with ESRD and controls with persistently normal ALT (22% vs 13%) but significantly less (p < 0.001) than that observed in control patients with elevated ALT (48%). No significant differences in ALT, HCV-RNA titer, duration on hemodialysis, or time from first possible exposure was observed between ESRD patients with advance fibrosis (n = 11) and those with mild disease (n = 39). CONCLUSIONS: Our data suggest that liver biopsy is necessary to exclude significant liver pathology in patients with HCV and ESRD, and to help define those patients in whom interferon treatment might be helpful.     

Left ventricular pseudoaneurysm after mitral valve replacement

Development of left ventricular pseudoaneurysm is a rare complication of mitral valve surgery and requires urgent surgical intervention. We describe a case of pseudoaneurysm of membranous septum following repeat mitral valve replacement with the use of multimodality imaging.     

Disposition of Misoprostol and Its Active Metabolite in Impaired Hepatic Function

The pharmacokinetics of misoprostol and its active metabolite, misoprostol acid, was assessed in 17 healthy subjects and 17 subjects with various degrees of hepatic impairment. Before misoprostol administration, subjects underwent antipyrine and indocyanine green clearance studies to assess hepatic functional capacity. Subjects were administered 400 mcg of oral misoprostol in an open-label design. There was a lower antipyrine clearance in the group with hepatic disease as compared to normal volunteers (0.56 versus 0.80 ml min(minus sign1) kg(minus sign1), respectively, p = 0.022). There was no difference in indocyanine green clearance values between groups. The C(max), t(1/2)&bgr, and [Formula: see text] tended to be larger in the hepatic group; however, there was no statistical difference. Adverse events, mostly gastrointestinal in nature, occurred more often in the subjects with hepatic disease. These data suggest the pharmacokinetics of misoprostol may be altered in the presence of hepatic disease. However, because of significant interpatient variability, definitive dosing recommendations cannot be made. Further study in this area is needed.     

Gated MR imaging of left atrial myxomas

Two cases of left atrial myxoma were evaluated with magnetic resonance (MR) imaging. In both cases, the myxoma was clearly defined as to its location, origin, and size. In one case, the myxoma prolapsed through the mitral valve. Our study indicates that MR imaging is valuable in the diagnosis of myxomas.     

Effects of colchicine on intestinal mucosal dehydrogenases

Summary Histochemical methods have shown that colchicine has an apparent rapid inhibitory effect on LDH, SDH, GL-6-PDH, NADH dehydrogenase, and NADPH dehydrogenase in the mucosa of the small intestine of mice. This colchicine effect is qualitatively similar regardless of the dose of the drug given, although a single large dose (1.5 mg./kg.) did produce arrest of the mitosis in metaphase, while a single small dose (0.24 mg./kg.) did not produce abnormal histologic changes in any of the tissues examined.The importance of this effect of colchicine is discussed and related to the inhibition of other enzyme systems, functional activities and turn-over rate of intestinal mucosa, and the fate of colchicine in the body. In contrast to observations of the effect of irradiation on dehydrogenases, colchicine decreases dehydrogenase activity almost instantly.Since the site of primary action of colchicine is not known, a single explanation for the antimitotic effect of large doses and the therapeutic effect of small doses given to patients with gout is still elusive.Supported by grants CA-04980 and 2A-5286 from the U. S. Public Health Service.Trainee under Gastroenterology Training Grant TI AM 5286 from the U. S. Public Health Service. Service;     

Early fiberscope endoscopy for upper gastrointestinal bleeding

Conclusions and summary 245 patients (29 postgastrectomy and 216 with intact stomachs) were examined with the gastroduodenal fiberscope within 14 days of bleeding, 91 of these within 24 hr. Direct visualization of lesions was possible in 50%, and in a further 40% the diagnosis could be made by inference or exclusion. Only 4 wrong diagnoses were made. Sites of bleeding were roughly 60% duodenal, 40% stomach; acute erosions accounted for 33% of the total.This procedure, which is safe and well tolerated by the patient is easily learned and should if possible be performed in every patient with acute upper gastrointestinal hemorrhage. In the first 24 hr. it may be an important guide to therapy or aid to surgery.This study was supported by Grants AM 4978 and 2A-5286 from the U. S. Public Health Service, National Institutes of Arthritis and Metabolic Diseases.We acknowledge the assistance of the following Fellows and Residents who examined many of the patients reported in this study: Drs. Jerome G. Ippolito, C. Birnie Johnson, T. A. Farmer, P. W. Morris, J. B. Douglas, Ali M. Fahkro, B. S. Tynes, S. R. Furst, G. E. Ennis, J. W. Trigg Jr., Robert Ryan, Emmett T. Brunson, John Henderson, Omer Baker, B. P. Edmunds, E. Jack Green, and George G. B. Bilsten.