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Interferon treatment for chronic hepatitis C virus infection in uremic patients
Kidney International, Vol. 45 (1994), pp. 1507—1509
Interferon treatment for chronic hepatitis C virus infection in uremic patients PAUL KOENIG, WOLFGANG VOGEL, FLORIAN UMLAUFT, KATHARINA WEYRER, RUPERT PROMMEGGER, KARL LHOTTA, ULRICH NEYER, HANS-KRISTER STUMMVOLL, and KURT GRUENEWALD Department of Internal Medicine, Innsbruck University, District Hospitals Linz and Feldkirch, Austria
Hepatitis C virus infection has been identified as the major during treatment, RNA testing was done until two consecutive cause of parenterally transmitted hepatitis [1]. Chronic hepatitis evaluations were negative. Alter the end of treatment ( week C is a major problem in patients on maintenance hemodialysis 16), at week 18 and week 36, further RNA testing was carried awaiting kidney transplantation [21. Whereas uremia seems to out. HCV-RNA was extracted from serum with the single-step predispose to chronic viral carrier status with little inflamma- acid guanidium thiocyanate-phenol-chloroform method essen-
tory activity in the liver, the change in immune status after kidney transplantation modified by immunosuppressive drugs causes acceleration of inflammatory liver disease often leading to death from liver failure [3]. For the first time an effective therapy became available with the advent of interferon treatment for chronic hepatitis virus infection. A bulk of evidence has accumulated during the last decade showing that this therapy is of benefit in nonuremic patients with chronic hepatitis C [4, 5]. However, little information has been presented so far on chronically hepatitis C virus-infected uremic patients treated with interferon. Therefore, we conducted a study of interferon treatment in patients on maintenance dialysis with regard to its efficacy in suppressing viremia and tolerability of side effects. We report the result of an open multicenter trial of interferon treatment in patients on maintenance hemodialysis suffering from chronic hepatitis C virus infection. The trial was conducted by the Austrian Association of Nephrology.
tially described by Chomczynski and Sacchi [7]. Sequences specific for the 5'-non-coding region of HCV genome were detected after reverse transcription of HCV-RNA and amplification of cDNA with the nested PCR technique and confirmation by Southern blot. Primers were designed according to sequences published by Ulrich et alES]. PCR was run for 30 cycles for outers and inners each. A sensitivity limit of 1000 to 10,000 copies per ml serum was determined by amplification of a diluted synthetic HCV-RNA standard. Precautions according
to Kwok and Higushi [9] were taken to avoid false positive results. Each sample was tested at least twice. In addition, a complete laboratory work-up was done at the same time. Thirty-seven patients (15 women and 22 men; mean age 54
years) entered the trial. Time of dialysis treatment ranged from three to 228 months (mean 84.16 64.03 months). For renal diagnosis see Table 1. In the six-month pretrial period 23 patients had nonnal transaminases. Of 14 patients with initially slightly elevated ALT levels (less than threefold the upper normal limit), seven returned to normal ALT levels at the end of Methods therapy, three experienced a drop in ALT without reaching Alter informed consent was obtained, the patients received 5 normal levels and four had invariably elevated ALT values. million IU interferon-a three times weekly given subcutane- One patient of the 23 with normal pretherapeutic ALT levels ously after hemodialysis for a four month period. This period of had elevated levels during and at the end of therapy, which time was chosen because of the evidence in the literature that returned to normal after therapy had ended. None of the responders do indeed respond within the first two months of patients showed evidence of advanced stage liver disease as treatment [6]. Thereafter the patients were followed further for judged by clinical, laboratory, ultrasonographic or endoscopic five months. A negative result was only accepted when PCR investigation. Generally, no correlation between ALT and HCV-RNA was found. remained negative in three independent tests. All patients were known to be positive for anti-HCV (second generation ELISA, Abbot Laboratories) for at least six months Results and for HCV-RNA (tested before treatment commencement) as Twenty-three patients completed the study and 14 were shown in Table 1. Before entering and then every two weeks withdrawn for the following reasons: septicemia without preexisting leukocytopenia (N 3); grade III interferon toxicity (N = 6: fever, malaise, leukocytopenia, diarrhea or stupor); one Received for publication December 6, 1993 patient received a cadaveric kidney graft and had an uneventful and in revised form February•, 1994 Accepted for publication February 14, 1994 postoperative course. Four patients refused further therapy for less severe IFN side-effects. © 1994 by the International Society of Nephrology 14
1507
1508
Koenig et a!: Interferon treatment for chronic HCV
Table 1. Patient characteristics and PCR results HCV-PCR results
Sex
Age
years
week
Reasons for withdrawal
16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16
I I I I I I I I I I I I I I I I I I I I I I I
+ + + + + + +
12
septicemia IFN toxicity septicemia septicemia IFN toxicity
+ + + + + + + + +
Therapy Nephrologic diagnosis
Therapy completed (N = 23) f 47 chronic GN m 67 nephrosclerosis m 70 chronic ON f 58 analgesic nephropathy m 49 reflux nephropathy m 56 chronic ON m 33 chronic UN f 59 polycystic kidney disease f 67 polycystic kidney disease f 55 polycystic kidney disease f 27 chronic GN m 43 Alport syndrome m 55 polycystic kidney disease m 48 rapid progressive ON m 33 chronic ON m 61 nephrosclerosis f 68 chronic GN m 65 rapid progressive GN m 56 chronic GN f 62 polycystic kidney disease m 54 chronic ON f 31 reflux nephropathy m 46 diabetic nephropathy Withdrawn from therapy (N = 14) f 29 chronic pylelonephritis f 73 chronic ON m 45 chronic GN f 64 chronic pylelonephritis f 81 polycystic kidney disease m 54 nephrosclerosis m 52 chronic GN m 40 Alport syndrome m 32 chronic ON f 25 chronic ON m 49 chronic ON m 64 chronic GN f 72 analgesic nephropathy m 29 chronic ON
2 4 9 5 2
2 2 12 1
12
10
I
4
IFN toxicity IFN toxicity IFN toxicity IFN toxicity
pre
4-
+ + + + 4-
+ + + + + + + + + +
Tx
+
IFN toxicity IFN toxicity IFN toxicity IFN toxicity
4-
+ + +
neg since week 2 2 2 2 2 2 2 2 14 2 2 2 6 8 10
week 16 ÷ 18
week
— — —
— —
— — —
36
— — —
— — — — — — —
()a
— —
+ +
— —
+ + 4-
I I
+ +
I I I I I I
-I-
4
— — —
— —
+ + + +
+ + +
2
6 I I I I I I I I I I I
+ + + + 4-
4-
+ ND ND ND ND ND
4-
+ + + + + + +
+
4-
+ + + + + +
ND
Abbreviations are: f, female; m, male; ON, glomerulonephritis; Tx, kidney transplantation; pre, before therapy; neg, negative; +, HCV-PCR positive; —, HCV-PCR negative; nd, not done. a Lost for follow-up after week 28.
Discussion During the entire treatment period 15 patients (41% of study population or 65% of patients completing treatment) lost HCVRNA and remained negative until the end of treatment and two Pathogenesis of chronic hepatitis virus infection in uremic weeks thereafter. Eleven were already negative after week 2; patients is still poorly understood. There is evidence to suggest the remaining four patients became negative after weeks 6, 8, 10 a complex immune defect [10, 11] in these patients. The and 14, respectively. Eight of the 23 patients showed either no antiviral effect of interferon includes the induction of antiviral
proteins in infected cells and the enhancement of cellular immune response by class I expression as well as a direct immunostimulatory effect on effector lymphocytes. The observed response rate of 65% of patients completing therapy (41% of study population) and the relapse rate of 36% are
response (N = 3) to interferon treatment or their HCV-RNA results fluctuated during the time of observation. In the dropout group (N = 14) three further patients became sustained negative for HCV-RNA after an average of four weeks of therapy; two of them remained negative throughout the observation period. Elevated levels of transaminases fell during
comparable to results in non-uremic patients [12]. This stresses
treatment to normal levels; no flare-up of liver AST or ALT was
the importance of the direct antiviral effect of the drug in
noticed. In the follow-up period of five months, five of the 15 immunocompromised patients. responders relapsed. One patient was sustained negative until The other noteworthy finding was the high rate of side effects week 28, when she was lost for follow-up (Table 1). observed in the treated patients with a drop-out rate of 37%. Six
Koenig et a!: Interferon treatment for chronic HCV
patients experienced grade III IFN toxicity, but four patients withdrew consent for further treatment because of less severe side-effects; three patients were lost due to shunt septicemia, a side-effect not usually encountered with JFN. This could be caused by "priming" by the release of endogenous cytokines induced by membrane contact of mononuclear cells during dialysis treatment or to the chronic state of disease in these patients.
On the basis of our experience IFN therapy seems to be
similarly efficacious in uremic and non-uremic patients, but side effects seem to be more severe and less well tolerated. Acknowledgments This work was supported by the grant p 9148 of the Fonds zur Forderung der wissenschaftlichen Forschung. We acknowledge the technical assistance of Miss M. Haun and Mrs. A. Schlogl.
Reprint requests to Dr. P. Koenig, Department of Nephrology,
Innsbruck University, Anichstr. 35, A-6020 Innsbruck, Austria.
1509
as the cause of death in kidney transplant patients: An analysis of 689 autopsy cases. Zentraib! Aug Pathol 133:447-452, 1987 4. DAVIS GL, BALART LA, SCHIFF ER, LINDSAY K, BODENHEIMER HC, PERILLO RP, CAREY W, JACOBSON IM, PAYNE J, DIENSTAG JL, VANTHIEL DH, TAMBURRO A, LEFKOWITCH J, ALBRECHT J, MESCHIVITZ C, ORTEGO J, GIBAS A, AND THE HEPATITIS INTER-
VENTIONAL THERAPY GROUP: Treatment of chronic hepatitis C with recombinant interferon alpha: A multicenter randomized controlled trial. N Engl I Med 321:1501—1506, 1989 5. TINE F, MAGRIN S, CRAxI A, PAGLIARO L: Interferon for non-A,
non-B chronic hepatitis: A meta-analysis of randomized clinical trials. JHepatol 13:192—199, 1991 6. HAGIWARA H, HAYASHI N, MITA E, UEDA K, TAKEHARA T, KASAHARA A, FUSAMOTO H, KAMADA T: Detection of hepatitis C
virus RNA in serum of patients with chronic hepatitis C treated with interferon-a. Hepatology 15:37—41, 1991 7. CHOMCZYNSKI P, SACCHI N: Single step method of RNA isolation
by acid guanidinium thiocyanate phenol chlotoform extraction. Anal Biochem 162:156—157, 1987
8. ULRICH PP, ROMEO JM, DANIEL U, VYAS GN: An improved
method for the detection of hepatitis C virus RNA in plasma utilizing heminested primers and internal control RNA. PCR Meth Applic 2:241—249, 1993
9. KWOK KS, HiousnI HR: Avoiding false positives with PCR. References 1. ESTEBAN ii, GONZALEZ A, HERNANDEZ JM, VILADOMIU L, SANCHEZ C, LOPEZ-TALAVERA JC, LUCEA D, MARTIN-VEGA C,
VIDAL X, ESTEBAN R, GUARDIA J: Evaluation of antibodies to hepatitis C virus in a study of transfusion-associated hepatitis. N EnglJ Med 323:1107—1112, 1990 2. CHAN TM, L0K ASF, CHENG IKP, CHAN RT: Prevalence of hepatitis C virus infection in hemodialysis patients: A longitudinal
study comparing the results of RNA and antibody assays. Hepatology 17:5—8, 1993
3. REINKE P, DAVID H, SCHOLZ D: The significance of liver changes
Nature 339:237—238, 1989
10. Kuaz P, KOHLER H, MEUER SC, HUTTEROTH T, MEYER ZUM BUSCHENFELDE KH: Impaired cellular immune response in chronic renal failure: Evidence for a T-cell defect. Kidney In! 29:1209—1214, 1986
11. LANGHOFF E, HOFMANN B, ODUM N, LADEFOGED J, PLATZ P,
RYDER UP, SVEJGAARD A: Kinetic and analysis of interleukin (IL-2) production and IL-2 receptors by uremic and normal lymphocytes. Scand J Immunol 25:29—36, 1987 12. SHINDO M, DI BISCEGLIE AM, HOOFNAGLE J: Long-term follow-up of patients with chronic hepatitis C treated with a-Interferon. Hepatology 15:1013—1016, 1992
Interferon treatment for chronic hepatitis C virus infection in uremic patients PAUL KOENIG, WOLFGANG VOGEL, FLORIAN UMLAUFT, KATHARINA WEYRER, RUPERT PROMMEGGER, KARL LHOTTA, ULRICH NEYER, HANS-KRISTER STUMMVOLL, and KURT GRUENEWALD Department of Internal Medicine, Innsbruck University, District Hospitals Linz and Feldkirch, Austria
Hepatitis C virus infection has been identified as the major during treatment, RNA testing was done until two consecutive cause of parenterally transmitted hepatitis [1]. Chronic hepatitis evaluations were negative. Alter the end of treatment ( week C is a major problem in patients on maintenance hemodialysis 16), at week 18 and week 36, further RNA testing was carried awaiting kidney transplantation [21. Whereas uremia seems to out. HCV-RNA was extracted from serum with the single-step predispose to chronic viral carrier status with little inflamma- acid guanidium thiocyanate-phenol-chloroform method essen-
tory activity in the liver, the change in immune status after kidney transplantation modified by immunosuppressive drugs causes acceleration of inflammatory liver disease often leading to death from liver failure [3]. For the first time an effective therapy became available with the advent of interferon treatment for chronic hepatitis virus infection. A bulk of evidence has accumulated during the last decade showing that this therapy is of benefit in nonuremic patients with chronic hepatitis C [4, 5]. However, little information has been presented so far on chronically hepatitis C virus-infected uremic patients treated with interferon. Therefore, we conducted a study of interferon treatment in patients on maintenance dialysis with regard to its efficacy in suppressing viremia and tolerability of side effects. We report the result of an open multicenter trial of interferon treatment in patients on maintenance hemodialysis suffering from chronic hepatitis C virus infection. The trial was conducted by the Austrian Association of Nephrology.
tially described by Chomczynski and Sacchi [7]. Sequences specific for the 5'-non-coding region of HCV genome were detected after reverse transcription of HCV-RNA and amplification of cDNA with the nested PCR technique and confirmation by Southern blot. Primers were designed according to sequences published by Ulrich et alES]. PCR was run for 30 cycles for outers and inners each. A sensitivity limit of 1000 to 10,000 copies per ml serum was determined by amplification of a diluted synthetic HCV-RNA standard. Precautions according
to Kwok and Higushi [9] were taken to avoid false positive results. Each sample was tested at least twice. In addition, a complete laboratory work-up was done at the same time. Thirty-seven patients (15 women and 22 men; mean age 54
years) entered the trial. Time of dialysis treatment ranged from three to 228 months (mean 84.16 64.03 months). For renal diagnosis see Table 1. In the six-month pretrial period 23 patients had nonnal transaminases. Of 14 patients with initially slightly elevated ALT levels (less than threefold the upper normal limit), seven returned to normal ALT levels at the end of Methods therapy, three experienced a drop in ALT without reaching Alter informed consent was obtained, the patients received 5 normal levels and four had invariably elevated ALT values. million IU interferon-a three times weekly given subcutane- One patient of the 23 with normal pretherapeutic ALT levels ously after hemodialysis for a four month period. This period of had elevated levels during and at the end of therapy, which time was chosen because of the evidence in the literature that returned to normal after therapy had ended. None of the responders do indeed respond within the first two months of patients showed evidence of advanced stage liver disease as treatment [6]. Thereafter the patients were followed further for judged by clinical, laboratory, ultrasonographic or endoscopic five months. A negative result was only accepted when PCR investigation. Generally, no correlation between ALT and HCV-RNA was found. remained negative in three independent tests. All patients were known to be positive for anti-HCV (second generation ELISA, Abbot Laboratories) for at least six months Results and for HCV-RNA (tested before treatment commencement) as Twenty-three patients completed the study and 14 were shown in Table 1. Before entering and then every two weeks withdrawn for the following reasons: septicemia without preexisting leukocytopenia (N 3); grade III interferon toxicity (N = 6: fever, malaise, leukocytopenia, diarrhea or stupor); one Received for publication December 6, 1993 patient received a cadaveric kidney graft and had an uneventful and in revised form February•, 1994 Accepted for publication February 14, 1994 postoperative course. Four patients refused further therapy for less severe IFN side-effects. © 1994 by the International Society of Nephrology 14
1507
1508
Koenig et a!: Interferon treatment for chronic HCV
Table 1. Patient characteristics and PCR results HCV-PCR results
Sex
Age
years
week
Reasons for withdrawal
16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16
I I I I I I I I I I I I I I I I I I I I I I I
+ + + + + + +
12
septicemia IFN toxicity septicemia septicemia IFN toxicity
+ + + + + + + + +
Therapy Nephrologic diagnosis
Therapy completed (N = 23) f 47 chronic GN m 67 nephrosclerosis m 70 chronic ON f 58 analgesic nephropathy m 49 reflux nephropathy m 56 chronic ON m 33 chronic UN f 59 polycystic kidney disease f 67 polycystic kidney disease f 55 polycystic kidney disease f 27 chronic GN m 43 Alport syndrome m 55 polycystic kidney disease m 48 rapid progressive ON m 33 chronic ON m 61 nephrosclerosis f 68 chronic GN m 65 rapid progressive GN m 56 chronic GN f 62 polycystic kidney disease m 54 chronic ON f 31 reflux nephropathy m 46 diabetic nephropathy Withdrawn from therapy (N = 14) f 29 chronic pylelonephritis f 73 chronic ON m 45 chronic GN f 64 chronic pylelonephritis f 81 polycystic kidney disease m 54 nephrosclerosis m 52 chronic GN m 40 Alport syndrome m 32 chronic ON f 25 chronic ON m 49 chronic ON m 64 chronic GN f 72 analgesic nephropathy m 29 chronic ON
2 4 9 5 2
2 2 12 1
12
10
I
4
IFN toxicity IFN toxicity IFN toxicity IFN toxicity
pre
4-
+ + + + 4-
+ + + + + + + + + +
Tx
+
IFN toxicity IFN toxicity IFN toxicity IFN toxicity
4-
+ + +
neg since week 2 2 2 2 2 2 2 2 14 2 2 2 6 8 10
week 16 ÷ 18
week
— — —
— —
— — —
36
— — —
— — — — — — —
()a
— —
+ +
— —
+ + 4-
I I
+ +
I I I I I I
-I-
4
— — —
— —
+ + + +
+ + +
2
6 I I I I I I I I I I I
+ + + + 4-
4-
+ ND ND ND ND ND
4-
+ + + + + + +
+
4-
+ + + + + +
ND
Abbreviations are: f, female; m, male; ON, glomerulonephritis; Tx, kidney transplantation; pre, before therapy; neg, negative; +, HCV-PCR positive; —, HCV-PCR negative; nd, not done. a Lost for follow-up after week 28.
Discussion During the entire treatment period 15 patients (41% of study population or 65% of patients completing treatment) lost HCVRNA and remained negative until the end of treatment and two Pathogenesis of chronic hepatitis virus infection in uremic weeks thereafter. Eleven were already negative after week 2; patients is still poorly understood. There is evidence to suggest the remaining four patients became negative after weeks 6, 8, 10 a complex immune defect [10, 11] in these patients. The and 14, respectively. Eight of the 23 patients showed either no antiviral effect of interferon includes the induction of antiviral
proteins in infected cells and the enhancement of cellular immune response by class I expression as well as a direct immunostimulatory effect on effector lymphocytes. The observed response rate of 65% of patients completing therapy (41% of study population) and the relapse rate of 36% are
response (N = 3) to interferon treatment or their HCV-RNA results fluctuated during the time of observation. In the dropout group (N = 14) three further patients became sustained negative for HCV-RNA after an average of four weeks of therapy; two of them remained negative throughout the observation period. Elevated levels of transaminases fell during
comparable to results in non-uremic patients [12]. This stresses
treatment to normal levels; no flare-up of liver AST or ALT was
the importance of the direct antiviral effect of the drug in
noticed. In the follow-up period of five months, five of the 15 immunocompromised patients. responders relapsed. One patient was sustained negative until The other noteworthy finding was the high rate of side effects week 28, when she was lost for follow-up (Table 1). observed in the treated patients with a drop-out rate of 37%. Six
Koenig et a!: Interferon treatment for chronic HCV
patients experienced grade III IFN toxicity, but four patients withdrew consent for further treatment because of less severe side-effects; three patients were lost due to shunt septicemia, a side-effect not usually encountered with JFN. This could be caused by "priming" by the release of endogenous cytokines induced by membrane contact of mononuclear cells during dialysis treatment or to the chronic state of disease in these patients.
On the basis of our experience IFN therapy seems to be
similarly efficacious in uremic and non-uremic patients, but side effects seem to be more severe and less well tolerated. Acknowledgments This work was supported by the grant p 9148 of the Fonds zur Forderung der wissenschaftlichen Forschung. We acknowledge the technical assistance of Miss M. Haun and Mrs. A. Schlogl.
Reprint requests to Dr. P. Koenig, Department of Nephrology,
Innsbruck University, Anichstr. 35, A-6020 Innsbruck, Austria.
1509
as the cause of death in kidney transplant patients: An analysis of 689 autopsy cases. Zentraib! Aug Pathol 133:447-452, 1987 4. DAVIS GL, BALART LA, SCHIFF ER, LINDSAY K, BODENHEIMER HC, PERILLO RP, CAREY W, JACOBSON IM, PAYNE J, DIENSTAG JL, VANTHIEL DH, TAMBURRO A, LEFKOWITCH J, ALBRECHT J, MESCHIVITZ C, ORTEGO J, GIBAS A, AND THE HEPATITIS INTER-
VENTIONAL THERAPY GROUP: Treatment of chronic hepatitis C with recombinant interferon alpha: A multicenter randomized controlled trial. N Engl I Med 321:1501—1506, 1989 5. TINE F, MAGRIN S, CRAxI A, PAGLIARO L: Interferon for non-A,
non-B chronic hepatitis: A meta-analysis of randomized clinical trials. JHepatol 13:192—199, 1991 6. HAGIWARA H, HAYASHI N, MITA E, UEDA K, TAKEHARA T, KASAHARA A, FUSAMOTO H, KAMADA T: Detection of hepatitis C
virus RNA in serum of patients with chronic hepatitis C treated with interferon-a. Hepatology 15:37—41, 1991 7. CHOMCZYNSKI P, SACCHI N: Single step method of RNA isolation
by acid guanidinium thiocyanate phenol chlotoform extraction. Anal Biochem 162:156—157, 1987
8. ULRICH PP, ROMEO JM, DANIEL U, VYAS GN: An improved
method for the detection of hepatitis C virus RNA in plasma utilizing heminested primers and internal control RNA. PCR Meth Applic 2:241—249, 1993
9. KWOK KS, HiousnI HR: Avoiding false positives with PCR. References 1. ESTEBAN ii, GONZALEZ A, HERNANDEZ JM, VILADOMIU L, SANCHEZ C, LOPEZ-TALAVERA JC, LUCEA D, MARTIN-VEGA C,
VIDAL X, ESTEBAN R, GUARDIA J: Evaluation of antibodies to hepatitis C virus in a study of transfusion-associated hepatitis. N EnglJ Med 323:1107—1112, 1990 2. CHAN TM, L0K ASF, CHENG IKP, CHAN RT: Prevalence of hepatitis C virus infection in hemodialysis patients: A longitudinal
study comparing the results of RNA and antibody assays. Hepatology 17:5—8, 1993
3. REINKE P, DAVID H, SCHOLZ D: The significance of liver changes
Nature 339:237—238, 1989
10. Kuaz P, KOHLER H, MEUER SC, HUTTEROTH T, MEYER ZUM BUSCHENFELDE KH: Impaired cellular immune response in chronic renal failure: Evidence for a T-cell defect. Kidney In! 29:1209—1214, 1986
11. LANGHOFF E, HOFMANN B, ODUM N, LADEFOGED J, PLATZ P,
RYDER UP, SVEJGAARD A: Kinetic and analysis of interleukin (IL-2) production and IL-2 receptors by uremic and normal lymphocytes. Scand J Immunol 25:29—36, 1987 12. SHINDO M, DI BISCEGLIE AM, HOOFNAGLE J: Long-term follow-up of patients with chronic hepatitis C treated with a-Interferon. Hepatology 15:1013—1016, 1992