- Email: [email protected]
Anti-GOR and hepatitis C virus in autoimmune liver diseases
267
2. Monges H, Honcy A. Emotional disorders of the esophagus. In: Vantrappen G, Hellemans J, eds. Diseases of the esophagus. New York: Springer-Verlag, 1974: 410-14. 3. Vantrappen G, Janssens J, Coremans G, Jian R. Gastrointestinal motility disorders. Dig Dis Sci 1986; 31 (suppl): 5S-25S. 4. Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The interdigestive motor complex of normal subjects and patients with bacterial
overgrowth of the small intestine. J Clin Invest 1977; 59: 1158-66. 5. Leeuwenhoek A, cited by Phillips JR, Eldridge FL. Respiratory myoclonus (Leeuwenhoek’s disease). N Engl J Med 1973; 289: 1390-95. 6. Porter WB. Diaphragmatic flutter with symptoms of angina pectoris. JAMA 1963; 106: 992-94. 7. Davis JW. An experimental study of hiccup. Brain 1970; 93: 851-72.
Anti-GOR and hepatitis C virus in autoimmune liver diseases
Anti-GOR is an autoantibody found in hepatitis C virus (HCV) infection. We have studied the specificity of this antibody for HCV infection in various groups of autoimmune liver diseases. Anti-HCV was detected by a second generation HCV enzyme-linked immunosorbent assay in 14 of 29 patients with liver-kidney-microsomal (LKM-1) -antibody-positive autoimmune hepatitis type 2 and in all 6 control patients with HCV-RNApositive chronic hepatitis C. Anti-HCV was not found in those with antinuclear-antibody-positive autoimmune hepatitis type 1 (10 patients), with soluble-liver-protein-antibody-positive autoimmune hepatitis type 3 (8), with primary biliary cirrhosis (9), with systemic lupus erythematosus (SLE) (10), or in healthy controls (13). Anti-GOR was detected in 11 of 14 patients with autoimmune hepatitis type 2 who were all positive for anti-HCV but only in 1 of 15 LKM-1 patients who were negative for anti-HCV. We did not find anti-GOR in any other group of autoimmune liver disease, SLE, or control sera, but this antibody was detected in 3 of 6 patients with chronic hepatitis C. Autoimmune hepatitis type 2 patients who were anti-GOR positive and anti-HCV positive were less likely to be female, were older (p<0·001), and had lower LKM-1 antibody titres (p<0·001), lower disease activity, and responded less effectively to immuno- suppression than did those who were anti-HCV negative/anti-GOR
negative. The findings show that anti-GOR reflects HCVspecific autoimmunity. HCV seems to induce autoimmunity to both GOR (an HCV-specific autoepitope) and LKM-1 (an epitope that is also recognised by autoimmune hepatitis sera of a different cause). Anti-GOR and LKM-1 antibodies better differentiation of chronic hepatitis, a finding that has therapeutic implications.
contribute to
a
Introduction Mishiro et al’ have described antibodies against a fusion cDNA clone (GOR 47-1) derived
protein expressed by a
from a chimpanzee infected with non-A, non-B hepatitis. The frequency of these anti-GOR antibodies was 81 % in patients with chronic non-A, non-B hepatitis, less than 10% in patients with chronic hepatitis B virus infection or alcohol misuse, and only 2% in healthy blood donors. Circulating hepatitis C virus (HCV) RNA was detectable in most anti-GOR-positive individuals even if they were anti-HCV negative. However, HCV antibodies have been found in various autoimmune liver diseases.2-4 Although positive anti-HCV results obtained with first generation tests were non-specific in most cases of autoimmune liver disease3 anti-HCV was detected in some patients with autoimmune hepatitis type 2,4,8 which is characterised by liver-kidneymicrosomal (LKM-1) antibodies that recognise cytochrome P450 IID6.’9 We have studied the specificity of anti-GOR for HCV infection and its prevalence in various groups of autoimmune liver disease. We have also assessed whether anti-GOR is specifically associated with exposure to HCV and whether measurement of anti-GOR throws light on the role of HCV in liver diseases of unknown cause such as autoimmune hepatitis.
Patients and methods We assessed sera from 29 patients with LKM-1-antibodypositive autoimmune hepatitis type 2, 10 patients with antinuclearantibody (ANA)-positive autoimmune hepatitis type 1, 8 patients with soluble-liver-protein-antibody (SLA)-positive autoimmune hepatitis type 3, 9 patients with primary biliary cirrhosis who were positive for antimitochondrial antibodies (AMA), 10 patients with systemic lupus erythematosus (SLE) who were positive for ANA, 13 confirmed anti-HCV-negative healthy blood donors, and 6 patients with chronic hepatitis C infection as evidenced by detection of anti-HCV and HCV-RNA in
serum.
From the 29 LKM-1
patients with autoimmune hepatitis type 2,23 were from Germany, 2 from Canada,1 from England,1 from Poland,1 from Austria, and 1 from Saudi-Arabia. All other patients were German. Autoantibodies (ANA, LKM-1, SLA, and AMA) were measured by conventional techniques, as previously described.7 ADDRESSES: Abbott Laboratories, European Research and Development, Wiesbaden (G. Michel, PhD, A. Ritter, MSc, R Decker, PhD), Department of Medicine I, Johannes Gutenberg Universität Mainz, Mainz (G. Gerken, MD, K-H Meyer zum Buschenfelde, MD), and Department of Gastroenterology and Hepatology, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Konstanty-Gutschow-Str 8, 3000 Hannover 61 (Prof M. P. Manns, MD), Germany. Correspondence to Prof Michael P Manns.
268
HETEROGENEITY OF AUTOIMMUNE HEPATITIS TYPE 2
Values expressed as median (range) AST aspartate aminotransferase. *p<0 001
anti-HCV negative. The anti-GOR OD value for this anti-HCV-negative LKM-1 serum, however, was only marginally above the normal range (figure). Anti-GOR was not found in any other patient group. ELISA OD values for anti-GOR were significantly higher in LKM-1/anti-HCVpositive autoimmune hepatitis type 2 patients than in patients with chronic hepatitis C (0-954 [SD 0.660] vs 0 360 Furthermore, anti-GOR-positive/anti[0-242], p<005). HCV-positive LKM-1patients were less likely to be female, and had a higher age at onset, lower LKM-1titres, and less severe disease activity as evidenced by serum aspartate aminotransferase (AST) concentrations (table). When analysed retrospectively, response by LKM-1 patients to immunosuppressive treatment was less effective for those who were anti-GOR positive/anti-HCV positive
were
Anti-GOR reactivity in patients with LKM-1-antibody-positive autoimmune hepatitis type 2.
(A) LKM-1 positive sera that are also positive for anti-HCV. (B) LKM-1 positive sera that are anti-HCV negative. There were no significant associations (Spearman-Rank correlation) between anti-GOR OD values and AST or age in anti-HCV-positive (r=0 333, -0 028) or anti-HCVnegative (r=0226, 0310) patients. Anti-LKM-1 tltres were weakly correlated with anti-GOR OD values (r=-0402, p<0025, data not shown) when data from all 29 anti-LKM-1 positive patients were analysed. There was no such correlation, however, when patients were divided on the basis of anti-HCV reactivity (anti-HCV negative r=0 064: anti-HCV positive, r=0 071).). Antibodies against HCV-encoded antigens (C100-3,33c, c22) were assessed by the second generation Abbott enzyme-linked immunosorbent assay (ELISA) according to the manufacturer’s instructions. Anti-GOR was measured by a microtitre ELISA with synthetic GOR-2 peptide1 covalently bound to the solid phase. Antibodies that specifically bound to the peptide were detected by use of polyclonal goat anti-human IgG coupled to horseradish peroxidase. All sera were diluted 1/1000. Sera were regarded as anti-GOR-2 positive when optical density (OD) values were above the mean of 18 anti-HCV-negative controls plus 2 SDs-ie, if OD values exceeded 0243. The OD values obtained in negative controls were normally distributed. Student’s unpaired t test was used for comparative statistics. Normal distribution was achieved by logarithmic transformation of all patients data before analysis.
than for those who were anti-GOR negative/anti-HCV negative. All HCV-negative LKM-1 patients were treated with immunosuppressive drugs and responded well. Patients were treated either with prednisolone alone or with prednisolone and azathioprine. Prednisolone was started with up to 100 mg/day, and then the dose was reduced after a week. Maximum azathioprine dose was 2 mg/kg per day. Of the anti-HCV-positive LKM-1-positive cases, 9 had not received immunosuppressive treatment because of a low disease activity. The other 5 patients had received immunosuppressive treatment, in 4 of whom immunosuppression was unsuccessful (AST was not reduced in 2 patients, hepatocellular carcinoma was diagnosed during treatment in 1 patient, and severe cholestasis associated with azathioprine occurred in another). The fifth patient had a reduction in AST, from 250 U/1 before to 35 U/1 during treatment. Of the 14 anti-HCV-positive LKM-1 patients, 6 reported risk factors for viral hepatitis (2 previous intravenous drug use, 1 working as a nurse, and 3 previous blood transfusions). None of the 15 anti-HCV-negative LKM-1 patients reported risk factors for acquiring viral hepatitis infection. 4 of the 29 LKM-1patients have died-2 anti-HCV-negative cases due to acute exacerbation of their chronic liver disease, 1 anti-HCV-positive case due to hepatocellular carcinoma, and in another anti-HCV-positive patient death was unrelated to liver disease.
Discussion Results Anti-HCV was detected in 14 of 29 LKM-1patients with autoimmune hepatitis type 2 and in all 6 patients with HCV-RNA-positive chronic hepatitis C but not in any of the other patient groups, nor in the 18 healthy controls. Anti-GOR was detected in 11 of the 14 LKM-1patients who were anti-HCV positive, in 3 of the 6 patients with chronic hepatitis C, but in only 1 of 15 LKM-1patients who
Anti-GOR
is said to reflect HCV-induced On the other anti-HCV antibodies hand, autoimmunity.l have been found in autoimmune liver diseases, though results have been conflicting.2-4 Fusconi et al4 found anti-HCV in some patients with autoimmune hepatitis type 2, but prevalence seems to vary geographically;8 whereas 78% of Italian patients were anti-HCV positive, almost no LKM-1 sera from England were confirmed as anti-HCV
269
positive by new generation anti-HCV assays. In our series, 48% of LKM-1-positive autoimmune hepatitis type 2 patients were anti-HCV positive as judged by a second generation test that specifically detects antibodies against 3 HCV-encoded peptides (C100-3, 33c, and c22). Since anti-GOR was found in most of these 48%, might there be an association with autoimmune hepatitis via HCV? Apart from patients with HCV-RNA-positive chronic hepatitis C, anti-GOR was almost exclusively detected in a subgroup of autoimmune hepatitis type 2 patients who were also anti-HCV positive. These data support our proposal that autoimmune hepatitis type 2 consists of two distinct patient populations. One group (autoimmune hepatitis type 2a), with neither anti-HCV nor anti-GOR, consists of the more typical type 2 patient-ie, young age at onset, likely to be female, and high anti-LKM-1 titres. These patients responded well when treated by immunosuppression. A second group, type 2b (about 80% of autoimmune hepatitis type 2 in Italy, and presumably less than 10% in England8), is associated with HCV infection. This patient population is older, has fewer females, LKM-1 titres are lower, disease activity is less severe, and immunosuppressive treatment seems to be less effective compared with the type 2a group. Usually, HCV seems to induce antibodies to GOR, the function of which is unknown. In addition to this HCVspecific autoimmunity, HCV may rarely induce LKM-1I antibodies, which are markers for autoimmune hepatitis type 2.1These LKM-1autoantibodies are directed against cytochrome P450 IID6,7,8 which is a drug metabolising enzyme underlying a well-defined genetic polymorphism. Recently, it has been reported that sera from both antiHCV-positive and anti-HCV-negative patients with autoimmune hepatitis type 2 recognise the same core epitope on P450 IID6.10 This linear epitope sequence has extensive homology with the immediate early 175 protein (IE175) of herpes simplex virus type 1 (HSV-1).10 HSV-1 possibly has a role in anti-HCV-negative autoimmune hepatitis type 2 (ie, type 2a). Anti-GOR, LKM-1autoantibodies, and anti-HCV will probably contribute to a better differentiation of chronic hepatitis, and thus lead to a more specific treatment of this syndrome. Whether to treat patients by immunosuppression or interferon is an important decision since immunosuppression prolongs survival in autoimmune hepatitis whereas interferons may be harmful." Interferon therapy can be evaluated in anti-HCV and anti-GORpositive patients with autoimmune hepatitis type 2b who fail to
respond to immunosuppression.
This work was supported by the Deutsche Forschungsgemeinschaft SFB 311 Al. We thank Ms U. Dang for technical assistance and the following outside colleagues for clinical data of their patients: Prof M. Burdelski, Hannover; Dr G. Burk, Datteln; Prof R. Eckhard, Koln; Dr E. Elias, Birmingham; Prof T. Granditsch, Wien; Dr H. Hartmann, Goltingen; Dr H. Heidemann, Kiel; Dr S. Koletzko, Dusseldorf; Prof G. R. Pape, Munchen; Dr E. Roberts, Toronto; Prof E. Seifert, Koblenz; Prof H. Thaler, Wien; Dr T. Warnes, Manchester; and Dr G. Waurich, Koln.
4. Fusconi 5.
6.
M, Lenzi M, Ballardini G, et al. Anti-HCV in autoimmune hepatitis and primary biliary cirrhosis. Lancet 1990; 336: 823. Manns M. Autoantibodies and antigens in liver diseases: updated. J Hepatol 1989; 9: 272-80. Zanger UM, Hauri HP, Loeper J, et al. Antibodies against human cytochrome P450 db in autoimmune hepatitis type II. Proc Natl Acad
Sci USA 1988; 27: 8256-60. 7. Manns M, Johnson EF, Griffin KJ, et al. The major target of liver kidney microsomal autoantibodies in idiopathic autoimmune hepatitis is cytochrome P450 dbl. J Clin Invest 1989; 83: 1066-72. 8. Lenzi M, Johnson PJ, McFarlane IG, et al. Antibodies to hepatitis C virus in autoimmune liver disease: evidence for geographical heterogeneity. Lancet 1991; 338: 277-80. 9. Homberg JC, Abuaf N, Benard O, et al. Chronic active hepatitis associated with antiliver/kidney microsome antibody type 1: a second type of "autoimmune" hepatitis. Hepatology 1987; 7: 1333-39. 10. Manns M, Griffin KJ, Sullivan KF, et al. LKM-1 autoantibodies recognize a short linear sequence in P450 IID6. J Clin Invest 1991; 88:
1370-78. 11. Vento S, Di Perri G, Garofano T, et al. Hazards of interferon therapy for HBV-seronegative chronic hepatitis. Lancet 1989; ii: 926.
SHORT REPORTS Indomethacin and
postprandial gallbladder emptying
Patients with
gallstone disease commonly have impaired gallbladder emptying. To see whether non-steroidal anti-inflammatory drugs (NSAIDs) prevent gallstone formation by improving gallbladder emptying, we assessed the effect of indomethacin on postprandial emptying in healthy subjects and in patients with gallstone disease. Subjects received indomethacin 25 mg three times a day for a week and matching placebo for another week. Compared with placebo, indomethacin improved postprandial gallbladder emptying in all 7 patients with gallstone disease. This finding was not recorded in healthy subjects with normal gallbladders. The prevention of gallstone formation associated with ingestion of NSAIDs may be due mainly to a prokinetic effect on the gallbladder since there is no evidence to suggest that these drugs affect cholesterol crystal nucleation at ordinary therapeutic doses in
man or
animals.
REFERENCES 1. Mishiro
S, Hoshi Y, Takeda K, et al. Non-A, non-B hepatitis specific antibodies directed at host-derived epitope: implication for an autoimmune process. Lancet 1990; 336: 1400-03. 2. Esteban JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-97. 3. McFarlane IG, Smith HM, Johnson PJ, Bray GP, Vergani D, Williams R. Hepatitis C virus antibodies in chronic active hepatitis: pathogenetic factor or false-positive result? Lancet 1990; 335: 754-57.
Gallstone recurrence after successful dissolution with oral bile acids can be prevented by non-steroidal antiinflammatory drugs (NSAIDs).’ This effect has been attributed to a decreased production of gallbladder mucin caused by alterations to eicosanoid metabolism because in a study of cholesterol-fed prairie dogs,2 high-dose aspirin
2. Monges H, Honcy A. Emotional disorders of the esophagus. In: Vantrappen G, Hellemans J, eds. Diseases of the esophagus. New York: Springer-Verlag, 1974: 410-14. 3. Vantrappen G, Janssens J, Coremans G, Jian R. Gastrointestinal motility disorders. Dig Dis Sci 1986; 31 (suppl): 5S-25S. 4. Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The interdigestive motor complex of normal subjects and patients with bacterial
overgrowth of the small intestine. J Clin Invest 1977; 59: 1158-66. 5. Leeuwenhoek A, cited by Phillips JR, Eldridge FL. Respiratory myoclonus (Leeuwenhoek’s disease). N Engl J Med 1973; 289: 1390-95. 6. Porter WB. Diaphragmatic flutter with symptoms of angina pectoris. JAMA 1963; 106: 992-94. 7. Davis JW. An experimental study of hiccup. Brain 1970; 93: 851-72.
Anti-GOR and hepatitis C virus in autoimmune liver diseases
Anti-GOR is an autoantibody found in hepatitis C virus (HCV) infection. We have studied the specificity of this antibody for HCV infection in various groups of autoimmune liver diseases. Anti-HCV was detected by a second generation HCV enzyme-linked immunosorbent assay in 14 of 29 patients with liver-kidney-microsomal (LKM-1) -antibody-positive autoimmune hepatitis type 2 and in all 6 control patients with HCV-RNApositive chronic hepatitis C. Anti-HCV was not found in those with antinuclear-antibody-positive autoimmune hepatitis type 1 (10 patients), with soluble-liver-protein-antibody-positive autoimmune hepatitis type 3 (8), with primary biliary cirrhosis (9), with systemic lupus erythematosus (SLE) (10), or in healthy controls (13). Anti-GOR was detected in 11 of 14 patients with autoimmune hepatitis type 2 who were all positive for anti-HCV but only in 1 of 15 LKM-1 patients who were negative for anti-HCV. We did not find anti-GOR in any other group of autoimmune liver disease, SLE, or control sera, but this antibody was detected in 3 of 6 patients with chronic hepatitis C. Autoimmune hepatitis type 2 patients who were anti-GOR positive and anti-HCV positive were less likely to be female, were older (p<0·001), and had lower LKM-1 antibody titres (p<0·001), lower disease activity, and responded less effectively to immuno- suppression than did those who were anti-HCV negative/anti-GOR
negative. The findings show that anti-GOR reflects HCVspecific autoimmunity. HCV seems to induce autoimmunity to both GOR (an HCV-specific autoepitope) and LKM-1 (an epitope that is also recognised by autoimmune hepatitis sera of a different cause). Anti-GOR and LKM-1 antibodies better differentiation of chronic hepatitis, a finding that has therapeutic implications.
contribute to
a
Introduction Mishiro et al’ have described antibodies against a fusion cDNA clone (GOR 47-1) derived
protein expressed by a
from a chimpanzee infected with non-A, non-B hepatitis. The frequency of these anti-GOR antibodies was 81 % in patients with chronic non-A, non-B hepatitis, less than 10% in patients with chronic hepatitis B virus infection or alcohol misuse, and only 2% in healthy blood donors. Circulating hepatitis C virus (HCV) RNA was detectable in most anti-GOR-positive individuals even if they were anti-HCV negative. However, HCV antibodies have been found in various autoimmune liver diseases.2-4 Although positive anti-HCV results obtained with first generation tests were non-specific in most cases of autoimmune liver disease3 anti-HCV was detected in some patients with autoimmune hepatitis type 2,4,8 which is characterised by liver-kidneymicrosomal (LKM-1) antibodies that recognise cytochrome P450 IID6.’9 We have studied the specificity of anti-GOR for HCV infection and its prevalence in various groups of autoimmune liver disease. We have also assessed whether anti-GOR is specifically associated with exposure to HCV and whether measurement of anti-GOR throws light on the role of HCV in liver diseases of unknown cause such as autoimmune hepatitis.
Patients and methods We assessed sera from 29 patients with LKM-1-antibodypositive autoimmune hepatitis type 2, 10 patients with antinuclearantibody (ANA)-positive autoimmune hepatitis type 1, 8 patients with soluble-liver-protein-antibody (SLA)-positive autoimmune hepatitis type 3, 9 patients with primary biliary cirrhosis who were positive for antimitochondrial antibodies (AMA), 10 patients with systemic lupus erythematosus (SLE) who were positive for ANA, 13 confirmed anti-HCV-negative healthy blood donors, and 6 patients with chronic hepatitis C infection as evidenced by detection of anti-HCV and HCV-RNA in
serum.
From the 29 LKM-1
patients with autoimmune hepatitis type 2,23 were from Germany, 2 from Canada,1 from England,1 from Poland,1 from Austria, and 1 from Saudi-Arabia. All other patients were German. Autoantibodies (ANA, LKM-1, SLA, and AMA) were measured by conventional techniques, as previously described.7 ADDRESSES: Abbott Laboratories, European Research and Development, Wiesbaden (G. Michel, PhD, A. Ritter, MSc, R Decker, PhD), Department of Medicine I, Johannes Gutenberg Universität Mainz, Mainz (G. Gerken, MD, K-H Meyer zum Buschenfelde, MD), and Department of Gastroenterology and Hepatology, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Konstanty-Gutschow-Str 8, 3000 Hannover 61 (Prof M. P. Manns, MD), Germany. Correspondence to Prof Michael P Manns.
268
HETEROGENEITY OF AUTOIMMUNE HEPATITIS TYPE 2
Values expressed as median (range) AST aspartate aminotransferase. *p<0 001
anti-HCV negative. The anti-GOR OD value for this anti-HCV-negative LKM-1 serum, however, was only marginally above the normal range (figure). Anti-GOR was not found in any other patient group. ELISA OD values for anti-GOR were significantly higher in LKM-1/anti-HCVpositive autoimmune hepatitis type 2 patients than in patients with chronic hepatitis C (0-954 [SD 0.660] vs 0 360 Furthermore, anti-GOR-positive/anti[0-242], p<005). HCV-positive LKM-1patients were less likely to be female, and had a higher age at onset, lower LKM-1titres, and less severe disease activity as evidenced by serum aspartate aminotransferase (AST) concentrations (table). When analysed retrospectively, response by LKM-1 patients to immunosuppressive treatment was less effective for those who were anti-GOR positive/anti-HCV positive
were
Anti-GOR reactivity in patients with LKM-1-antibody-positive autoimmune hepatitis type 2.
(A) LKM-1 positive sera that are also positive for anti-HCV. (B) LKM-1 positive sera that are anti-HCV negative. There were no significant associations (Spearman-Rank correlation) between anti-GOR OD values and AST or age in anti-HCV-positive (r=0 333, -0 028) or anti-HCVnegative (r=0226, 0310) patients. Anti-LKM-1 tltres were weakly correlated with anti-GOR OD values (r=-0402, p<0025, data not shown) when data from all 29 anti-LKM-1 positive patients were analysed. There was no such correlation, however, when patients were divided on the basis of anti-HCV reactivity (anti-HCV negative r=0 064: anti-HCV positive, r=0 071).). Antibodies against HCV-encoded antigens (C100-3,33c, c22) were assessed by the second generation Abbott enzyme-linked immunosorbent assay (ELISA) according to the manufacturer’s instructions. Anti-GOR was measured by a microtitre ELISA with synthetic GOR-2 peptide1 covalently bound to the solid phase. Antibodies that specifically bound to the peptide were detected by use of polyclonal goat anti-human IgG coupled to horseradish peroxidase. All sera were diluted 1/1000. Sera were regarded as anti-GOR-2 positive when optical density (OD) values were above the mean of 18 anti-HCV-negative controls plus 2 SDs-ie, if OD values exceeded 0243. The OD values obtained in negative controls were normally distributed. Student’s unpaired t test was used for comparative statistics. Normal distribution was achieved by logarithmic transformation of all patients data before analysis.
than for those who were anti-GOR negative/anti-HCV negative. All HCV-negative LKM-1 patients were treated with immunosuppressive drugs and responded well. Patients were treated either with prednisolone alone or with prednisolone and azathioprine. Prednisolone was started with up to 100 mg/day, and then the dose was reduced after a week. Maximum azathioprine dose was 2 mg/kg per day. Of the anti-HCV-positive LKM-1-positive cases, 9 had not received immunosuppressive treatment because of a low disease activity. The other 5 patients had received immunosuppressive treatment, in 4 of whom immunosuppression was unsuccessful (AST was not reduced in 2 patients, hepatocellular carcinoma was diagnosed during treatment in 1 patient, and severe cholestasis associated with azathioprine occurred in another). The fifth patient had a reduction in AST, from 250 U/1 before to 35 U/1 during treatment. Of the 14 anti-HCV-positive LKM-1 patients, 6 reported risk factors for viral hepatitis (2 previous intravenous drug use, 1 working as a nurse, and 3 previous blood transfusions). None of the 15 anti-HCV-negative LKM-1 patients reported risk factors for acquiring viral hepatitis infection. 4 of the 29 LKM-1patients have died-2 anti-HCV-negative cases due to acute exacerbation of their chronic liver disease, 1 anti-HCV-positive case due to hepatocellular carcinoma, and in another anti-HCV-positive patient death was unrelated to liver disease.
Discussion Results Anti-HCV was detected in 14 of 29 LKM-1patients with autoimmune hepatitis type 2 and in all 6 patients with HCV-RNA-positive chronic hepatitis C but not in any of the other patient groups, nor in the 18 healthy controls. Anti-GOR was detected in 11 of the 14 LKM-1patients who were anti-HCV positive, in 3 of the 6 patients with chronic hepatitis C, but in only 1 of 15 LKM-1patients who
Anti-GOR
is said to reflect HCV-induced On the other anti-HCV antibodies hand, autoimmunity.l have been found in autoimmune liver diseases, though results have been conflicting.2-4 Fusconi et al4 found anti-HCV in some patients with autoimmune hepatitis type 2, but prevalence seems to vary geographically;8 whereas 78% of Italian patients were anti-HCV positive, almost no LKM-1 sera from England were confirmed as anti-HCV
269
positive by new generation anti-HCV assays. In our series, 48% of LKM-1-positive autoimmune hepatitis type 2 patients were anti-HCV positive as judged by a second generation test that specifically detects antibodies against 3 HCV-encoded peptides (C100-3, 33c, and c22). Since anti-GOR was found in most of these 48%, might there be an association with autoimmune hepatitis via HCV? Apart from patients with HCV-RNA-positive chronic hepatitis C, anti-GOR was almost exclusively detected in a subgroup of autoimmune hepatitis type 2 patients who were also anti-HCV positive. These data support our proposal that autoimmune hepatitis type 2 consists of two distinct patient populations. One group (autoimmune hepatitis type 2a), with neither anti-HCV nor anti-GOR, consists of the more typical type 2 patient-ie, young age at onset, likely to be female, and high anti-LKM-1 titres. These patients responded well when treated by immunosuppression. A second group, type 2b (about 80% of autoimmune hepatitis type 2 in Italy, and presumably less than 10% in England8), is associated with HCV infection. This patient population is older, has fewer females, LKM-1 titres are lower, disease activity is less severe, and immunosuppressive treatment seems to be less effective compared with the type 2a group. Usually, HCV seems to induce antibodies to GOR, the function of which is unknown. In addition to this HCVspecific autoimmunity, HCV may rarely induce LKM-1I antibodies, which are markers for autoimmune hepatitis type 2.1These LKM-1autoantibodies are directed against cytochrome P450 IID6,7,8 which is a drug metabolising enzyme underlying a well-defined genetic polymorphism. Recently, it has been reported that sera from both antiHCV-positive and anti-HCV-negative patients with autoimmune hepatitis type 2 recognise the same core epitope on P450 IID6.10 This linear epitope sequence has extensive homology with the immediate early 175 protein (IE175) of herpes simplex virus type 1 (HSV-1).10 HSV-1 possibly has a role in anti-HCV-negative autoimmune hepatitis type 2 (ie, type 2a). Anti-GOR, LKM-1autoantibodies, and anti-HCV will probably contribute to a better differentiation of chronic hepatitis, and thus lead to a more specific treatment of this syndrome. Whether to treat patients by immunosuppression or interferon is an important decision since immunosuppression prolongs survival in autoimmune hepatitis whereas interferons may be harmful." Interferon therapy can be evaluated in anti-HCV and anti-GORpositive patients with autoimmune hepatitis type 2b who fail to
respond to immunosuppression.
This work was supported by the Deutsche Forschungsgemeinschaft SFB 311 Al. We thank Ms U. Dang for technical assistance and the following outside colleagues for clinical data of their patients: Prof M. Burdelski, Hannover; Dr G. Burk, Datteln; Prof R. Eckhard, Koln; Dr E. Elias, Birmingham; Prof T. Granditsch, Wien; Dr H. Hartmann, Goltingen; Dr H. Heidemann, Kiel; Dr S. Koletzko, Dusseldorf; Prof G. R. Pape, Munchen; Dr E. Roberts, Toronto; Prof E. Seifert, Koblenz; Prof H. Thaler, Wien; Dr T. Warnes, Manchester; and Dr G. Waurich, Koln.
4. Fusconi 5.
6.
M, Lenzi M, Ballardini G, et al. Anti-HCV in autoimmune hepatitis and primary biliary cirrhosis. Lancet 1990; 336: 823. Manns M. Autoantibodies and antigens in liver diseases: updated. J Hepatol 1989; 9: 272-80. Zanger UM, Hauri HP, Loeper J, et al. Antibodies against human cytochrome P450 db in autoimmune hepatitis type II. Proc Natl Acad
Sci USA 1988; 27: 8256-60. 7. Manns M, Johnson EF, Griffin KJ, et al. The major target of liver kidney microsomal autoantibodies in idiopathic autoimmune hepatitis is cytochrome P450 dbl. J Clin Invest 1989; 83: 1066-72. 8. Lenzi M, Johnson PJ, McFarlane IG, et al. Antibodies to hepatitis C virus in autoimmune liver disease: evidence for geographical heterogeneity. Lancet 1991; 338: 277-80. 9. Homberg JC, Abuaf N, Benard O, et al. Chronic active hepatitis associated with antiliver/kidney microsome antibody type 1: a second type of "autoimmune" hepatitis. Hepatology 1987; 7: 1333-39. 10. Manns M, Griffin KJ, Sullivan KF, et al. LKM-1 autoantibodies recognize a short linear sequence in P450 IID6. J Clin Invest 1991; 88:
1370-78. 11. Vento S, Di Perri G, Garofano T, et al. Hazards of interferon therapy for HBV-seronegative chronic hepatitis. Lancet 1989; ii: 926.
SHORT REPORTS Indomethacin and
postprandial gallbladder emptying
Patients with
gallstone disease commonly have impaired gallbladder emptying. To see whether non-steroidal anti-inflammatory drugs (NSAIDs) prevent gallstone formation by improving gallbladder emptying, we assessed the effect of indomethacin on postprandial emptying in healthy subjects and in patients with gallstone disease. Subjects received indomethacin 25 mg three times a day for a week and matching placebo for another week. Compared with placebo, indomethacin improved postprandial gallbladder emptying in all 7 patients with gallstone disease. This finding was not recorded in healthy subjects with normal gallbladders. The prevention of gallstone formation associated with ingestion of NSAIDs may be due mainly to a prokinetic effect on the gallbladder since there is no evidence to suggest that these drugs affect cholesterol crystal nucleation at ordinary therapeutic doses in
man or
animals.
REFERENCES 1. Mishiro
S, Hoshi Y, Takeda K, et al. Non-A, non-B hepatitis specific antibodies directed at host-derived epitope: implication for an autoimmune process. Lancet 1990; 336: 1400-03. 2. Esteban JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-97. 3. McFarlane IG, Smith HM, Johnson PJ, Bray GP, Vergani D, Williams R. Hepatitis C virus antibodies in chronic active hepatitis: pathogenetic factor or false-positive result? Lancet 1990; 335: 754-57.
Gallstone recurrence after successful dissolution with oral bile acids can be prevented by non-steroidal antiinflammatory drugs (NSAIDs).’ This effect has been attributed to a decreased production of gallbladder mucin caused by alterations to eicosanoid metabolism because in a study of cholesterol-fed prairie dogs,2 high-dose aspirin