Autoantibodies and response to α-interferon in patients with chronic viral hepatitis

339

Autoantibodies

and response to a-interferon chronic viral hepatitis

in patients wirh

G. Saraccd, A. Tot~scoz’, M. Durazzo*, F. Rosina’. E. Donegani’, L. Chiandussi4, V. Gallo4, R. Petrinc#, A.G. De Micheli’, A. Wit&, A. Deplanes, A. Toccd, P.A. Cosst8, C. Pintt&, G. Vemte’ and M. Riuetto2

One hundred and fifteen patients with chronic type B, 0 and non-A, non-B hepatitis treated .rith recombinant a-interferon were tested for six different autoaatibodies prior to or during therapy, and the coarse of tre.ltmeat was comparedin autoaatikody-posit aad -negative patients. lltree oat of 25 (12%) hepatitis B pad&s, 14 out $4 30 (47%) hepatitis D patients and 19oat of 60 (32%) chmak non-A, non-B hepatitis carriers had baselineor posl-therq!y atttoaatibadics. Ilte rate.of respcmsebatweeo patients with aad without autoant;:-ties amoaS B, D aad arm-A, acm-B@eats was, raspertively, 67 vs. 79%,23 vs. 25%,70 vs. 61% @ = N.S.). NOadverse reaction was observed in the 36 patients who had or de. vekped nuclear, smooth musck, parietal cells and thyroid autoaatibcdks daring therapy. A patient with baseliae atttibodies against liver and kidney micmsomer developed aa ineric acute hepatitis at the fourth month of therapy, bat five other patients with this reactivity responded to therqy ut.eventfulIy.The presenceof autoantibodies before therapy or their iaduction followingtherapy is not a contraindicationto the use of interferon in patients with chmnk viral hpatitis.

Viral hepatitider may induce aberrant tissue autoantibodies, similar in immaaofhtoresceaccpatterns to those typically observed ia autoimatanc liver disease (1.2). In coatrast to aatoimmtmehepatitis, the autoantibodies elk. lted daring viral liver iafectkns are wttaUy of low titer. Akhough they are cons&red secondary epiphenomeaa without pathogenetk significaace to the liver disease (3,4), theii fittdiq caa creak pmbkms when tre.atinSpatients with iaterfamn. Although this cyiokiae is beaeficial ia several forms of viral hepatitis (S-S), it induces iamtuaomaduktory effects that caa eahaace autoamibady pmduction and thus incxase the risk of autoaggntiw ia pa tients with viral liver dimrderj with ktettt autoimmuae phenomena.

To detemtiae whet&r autoantibodies alter the responw of viral beprtitidcs to inkrfema, we examinedthe coarse of liver direax duriag treatment in patkats with chronic hepatitis type B, D and non-A, nor-B. These patients also had autoantibadks prior to. or &eloped durin& therapy. The resp0m.eof these patients to interferon wascomparedto the rqoase in patients without baseline ortherapy-iiKhlcedautoalttibodks.

0. SARACCO

340 exsmined for autoantibodies associated wth liver diseases. These patients were subjected to randomized tree& meut in efficacy trials for a-interferon (IFN) in chronic hepatitis 8, D and “on-A, “on-B. Autoantibodies against nucleus (ANA), smooth muscle (WA), mitochondrium (AMA), liver kidney microsome (LKM), pat&al cells (PCA) and thyroid (THAB) were first measured. ?be details and protocol for the IFN trials have bee” reported previously (6,9,10). Included in the 115patients were the following: (i) Twenty-five patients with chronic persistent (CPH) or active (CAH) hepatitis 9. Their serum was positive for the hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and HBVDNA. They were given Iymphoblastoid IFN (WELLFERON, Wellcome, U.K.) bttramuscularly for 6 months. T?.ey rcccixd 10 mega units (MU) daily during the first 4 weeks then thrice weekly for 5 months. (ii) Thirty HBsAg carriers with chronic hepatitis D virus (HDV) hepatitis. All had hepatitis D antigen (HD-Ag) in the liver and the antibody to hepatitis D (anti-HD) in their serum. Sixteen showed CAH, five CAH with cirrhosis and nine cirrhosis. These “atients were treated with a-2h IFN (INTRON. &he&g, Kenilworth, NJ) at doses of 5 MC/m2 of the body surface thrice weekly during the first 4 months then 3 MUlmz for the following 8 months. (iii) Sixty patients with chronic “on-A, non-B hepatitis. The diagnosis was made after the exclusion of other know” causes for liver disease. At histology, three of tbwe patients had CPH, seven had chronic lobular hepatitis. eight had chronic se”tel hepatitis, 20 had CAH and 22 had cirrhosis. Thirty patients received 3 MU of a-2b IFN (INTRON, Schering,

.

._

NJ) subcutaneously thrice weekly for 6 months, and 30 received 1 MU thrice wekly for 6 months. Testing for autoantibodies was performed in blood samples obtained before treatment, in the middle of therapy, at the end of therapy and 1 year following therapy.

HBV markers and anti-HD were measured by commercial RIAs (Abbott Laboratories. North Chicago, IL, U.S.A. and Soti”, Saluggia. Italy), HBV-DNA and HDV-RNA were detected by molecular hybtidllation techniques (12.13). sIarislica1 analysis Statistical analysis test.

was performed

,

identitled in the rat tissues; PCA and THAB were identified in the human tissues. SMA was also identified using HEp2 cells grow” in the presettce of colchicine. Colchicine pemtits development of actin cables. Fluoresceinated anti-human immunoglobulins were purchased from Dakopatts, Glostrup, Denmark.

with Fisher’s exact

Two of the 25 patients had ANA in their senmt before therapy. In one patient the baseline titer of the antibody was 1:40. This patient did not respond to IM but remained positive for HBeAg and HBV-DNA. The clittical course was uneventful. The ANA increased to a titn of I:80 during therapy, and was still detectable at a titer of 1:40 at 12 months after rherepy. The second patient had e baseline ANA et e titer of 1:lOO. He remanded to IFN bv e s-eroconversio” to anti-HBe and anti-HBs and a “orntalhation of ALT 5 months after the initiation of therapy. ANA has persisted without variatkms in titer thmughout the followup. A previously negative patient developed ShiA at a titer of 1:lO and ANA at e titer of 1:40 during treatment. He seroconverted to anti-HBs and anti-H& and normalized ALT. Both antibodies had disappeared at the end of the fouow-up. None of the other 22 patients had baseline or post-therapy autoantibodies. Two of them abandoned the study due to side effects from the cytokine. Of the remaining 20 patients, 14 cleared HBV-DNA and swxonverted to anti-HBe (70%) and five of them also semoonverted to anti-HBs (25%). No response weszee”

Seia were tested diluted 1:lO in 0.15 M of phosphate buffer solution (OH 7.3). on sections of the human stoma&, thyroid, liver, kidney, end tat liver and kidney eccording to standard indirect immunotluorescence methods (11). The titer wes established by increasing double dilutions until a” end-point (the loss of specific tluorescence) was reached. ANA, AMA, SMA and LKM were

et al.

in the other six.

The response rate among autoantibcdy~positive and -negative patients was similar (2/3 (67%) vs. 14i20 (70%), p = N.S.). Chronic hepetirir LI Eleven of the 30 patients had baseline autoantibodies. Five hsd LKM (titers ranging Tom 1:ZO to 1:40). four SMA (titers ranging from 1:lO to 1:40) and two ANA (tit. ers ranging from 1:lO to 1:40). Three previously negative patients developed autoantibodies during therapy: o”e hadSMA (titer of 1:20); one ANA (titer of 1:40); redone THAB (titer of 1:ZO). A patient who had baseline LKM et a titer of I:20 de. veloped e severe iaeric hepatitis during the fourth month

of therapy. Treatment was discontinued and the patient abandoned the study. ‘IIe level of LKM reached a peak (titer of 1:laO) during the acute episode. Following withdrawal from therapy, the titer decreasedto X20, ALT rehunal to the pie-therapy level and jawlice cleared. Of the other 13 patients with autoantibodies, three (one with LKM, one with ANA and one with WA) respondedto aIFN with a significant decrease in ALT levels and clearaoce of HDV-RNA that was maintained throughout ther-

apy. The remaining ten did rmt respond and their clinical course was uneventful; three had LKM two had ANA, four had SMA and one had THAR. Four of the 16 patkms without bawtim or tt.
342 tients responded to therapy compared to three of 12 auto. antibody-negative patients (23”s. 25%,p = N.S.). Chronicnon-A, non-B hepntiric Five of the 60 patients abandoned

the study due to

drug-related side effects. Two of them showed baseline ANA wilh a titer of 1:ZO and 1:80, respectively. A third patient developed SMA 1:20. They were dropped from the study due to the onset of severe fatigue. Eight patients showed pre-treatment autoantibodies: two had LKM (1:20), two had LKM and ANA (1:20), three had ANA (titer ranging from 1:20 to 1:80) and one patient had SMA (1:Bo). In all patients the titer of the autoantibodies increased during treatment (to a maximum ot I:100 in a patient with ANA), but returned to pre-ther. spy levek within l-12 months following therapy. In a patient who responded with a persistent ALT nomtalizaticc, SMA, present before therapy at a titer of 1:80, disappeared at the end of treatment. Eleven previoudy n&&e patients developed autoantibodies durine theraw. Six develooed ANA (titer of I:20 to 1:40). & PCAaccotttpanied by SMA (i&t), otte SMA (I:?$ one THAB and one ANA accompanied by SMA (1:20). The tissue autoantibody (ANA) persisted after 1 year of follow up in only two of these pat&is. No biochemical or clinical sign of autoimmune disease was observed. Among the 19 patients with autoantibodies, 15 (79%) were considered partial @SO% decrease of baseline ALT) or complete responders (ALT nortnalization). Twenty-two of 36 patients without autoantibodies (61%) normalized or sig. nifcantlvreduced the ALTlevels(79vs. 61%.0 = N&I.

of cell surface antigens and enhances the activity of cells committed to immune recognition and clearance (14.15), it may be potentially dangerous when given as a long-term therapy. In cancer patients treated with IFN. thyroid dysfunction has wcurred following an increase of antibodies against thyroglobulin and thyroid nticrosomes (l&17). No undesirable side effect was noted in patients with chronic type B hepatitis given recombinant a-iFN. Twenty-seven of 31 patients treated in Germany developed various autoantibodies (18) without variations in the expetted therapeutic response and without experiencing unwanted complications. In our study we found a lower percentage of a-IFN induced THAB than in the Getman study. This discrepancy is probably not due to the use of different methods, since the sensitivity of the immunofluo~esc~uce technique is comparable to the hemagglutiaatie: ‘est adopted by the Getman authors (19). However, the discrepancy is probably due to a difference in susceptibility to autoimmune thyroid disorders between North European and Mediterranean populations (19). The geegraphical prevaleuces of IFN-induced MALt vary in ICpatsfrom O-324 (17,18,20). Our nudy, conducted in patients with hepatitis 8. hep atitis D and non-A, non-B, confirms that aberrant autoantibodies do not affect the response of vital bepatitides 1o a-IFN. The frequency of baseline or a-IFN-induced au-

There was no evidence of autoimmune d&e in auy’of the patients with chronic hepatitis B, D or non-A, non-B who had baseline autoantibodies or developed autoantibodies after the initiation of IFN therapy. In particular, patients with the highest titers of ANA did nm show symptoms suggestive of any connective tissue syndrome.

toantibcdies ia the three diseases was 12.47 and 35%. respectively. In no ease was there clinical evidence of any autoimmune disorder. In patients whh chronic hepatitis B and D the rate of response did not differ among those with or without autoanlibodies, and in hepatitis non-A, non-B the response was better ia patients with autoantibodies. When the response rates 10 a-lFN for the three typs of hepatitis erc cumulated, the pcrccntagc of patients with baseline or a-IF%induced autoantibadies who responded to a-IPN WBSsimilar to that in the autoantibody-negative patients (20136 (55%) vs. 39/69 (57%). p = N.S.). Noun-

The two patients who developed

deskable

THAB had neither bio-

chemical nor clinical evidence of thyroid dysfunction and values of J-iodothyronine (T.?), thyroxine (T4) and thyroid stimulating hormone (TSH) remained within the normal ranges in both these patients. No significant variation in liver function term, or immunoglohulin levels was seen in any of the patients with au increase in autoantibodies or development of autoantibodies during therapy.

The antiviral properties of IFN make this cytokiue a suitable candidate for therapy of chronic viral liver infections (S-8). However, since IPN increaser the expression

side effect was observed

in patients

with base-

line autoantibodies whose autoaatilwdy titer ittcreased duting therapy. Generally the increase in titers remained within ranges well below the titets which characterize true autoimmune disorders. A number of patients with D and non-A, non-B hep aUs had LKM antibodies prior to treatment or developed them during therapy. Although these reactivltics reccgnlze mlaosomal antigens as targets both kt the liver and the kidney, they are associated with liver dysfutwiou Only. In patients with idiopathic liver disorders they identify a subset of autoimmune hepatitis but, interestingly, an association has also been recognized between LKM and chronic hepatitis D (21). A severe exacerbation of the underlying disease occurred in a patient with chronic hep

ALmO*NTlBODlES

IN INTERFERON-mEam

PmlENTs

atitis D who circulated LRM before therapy. However, no adverse effect oeeurred in the other eight patients with this antibody (four with chronic type D hepatitis and four with chronic non-A, non-B hepatitis). Five of these eight patients responded to treatment. It is therefore unlikely that the complication was linked to an intercurrent immunological event mediated by LKM and enhawed by ther-

343 spy. Since the presence of autoantibcdtes in tow titers has no clinical rekvarme when treatiq patients with cbnmic hepatitis 9, D and non-A, non-B, a4FN can be usedsafely both in those patiem who have baseline autoamitmdies and should not be diintinued in those who develop autoantibodies

during therapy.

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