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Double-blind, randomized trial of IFN±colchicine in anti HCV-positive chronic active hepatitis (CAH)
HEPATOLOGY V o ] . 22, N o . 4, P t . 2, 1 9 9 5
1577
AASLD
HEPATITIS C VIRUS (HCV) ANTI-CORE IgM: A SEROLOGIC MARKER OF NECRO-INFLAMMATORY ACTIVITY IN LIVER BIOPSIES. A Tran 1, S Benzaken 2, JF Broussard I, P Rouqui61, J D u r a n t 1, ML Montoya 1, JL Nano 1, A Rampal 3, P Rampal 1. 1 D e p a r t m e n t o f H e p a t o - g a s t r o e n t e r o l o g y , 2 D e p a r t m e n t of Immunology, Archet Hospital Nice; 3 Department of Pathology, Pasteur Hospital, Nice, France.
ABSTRACTS
1578
WITH ACUTE HYPERINFLAMMATORYHEPATITISOF DIFFERENTORIGIN U Treichel'.N Tamol:maaos*.K-HMover zum Bf~Ich4mfold~',A HA~_'~ ~, G Pal~dheoddis*.C Stavrinos*.G Gerken*, *l.Dept.of Medicine, University of MalnT~Germanyand ~lestem Attica General Hospitalj~thens,Greece of Circulating autoantibodies contribute to the differential diagnosis chronic inflammatory liver diseases. However, the mechenims for their induction and the underlaying pathophysiology remains unclear. Therefore, coded sera from 257 patients (pts.) presenting with an hyperinflemmatory acute hepatitis served as a clinical model for severe Inter cell damage. The mean of levels for bilirubin ranged from 7-16.5 rng/dl, mean ALT-leveis from 1999-2993 Lift and y-globuUn levels from 716.5 .~1.. The diagnostic procedere identified 112 pts. with acute viral hepatitis A,B and C (AVH-A,n=50; AVH:B n=30 AVH-C n=32) 38 pts. with acute exacerbating chronic hepatitis B (ACH-B), 18 10ts. with autoimmune hepatitis 0MH), 25 10ts.with priman/biliary cirrhosis (PBC) and 64 pts. with NANBNC-hepatitis (AH-NANBNC). Circulating autoantibodies against intracellular epitopes (antinuclear~ANA, antimitochondrial "=AMA, smooth muscle~SMA, microsomal--'LKM, cytoke.mtin-'-SLA) and the asialoglycoprotein receptor (ASGPR) were de~ermined by appropriate immunolo[)ical assays. As a result ANA, SMA: AMA, .LKM ~ SLA were predom,nantly found in pts. with AIH but nearly comp~tely aDsent in pts. with AVH-A,-B or -C, ACH-B or AHNANBNC, respectively, except 16.7 percent SMA posith,es in AVH-B. In contrast, anti-ASGPR were detected in 48 up 1o 78 percent of all pts. .with acute hepatitis compared to 78 percent of lots. with autoimrnune nep~itis. The individual anti-ASGPRtiter had a wide range. No correlation was found between anti-ASGPR positivity and sex, age or laboratory tests. In the course of HBV-infection, 26 of 38 = 68 percent of anti2ASGPR pgsitive pts. showed HBsAg-elimination or absent HBV replicat~n, unly 1/4 pts. with hepatocellular carcinoma was anti-ASGPR positive. In HCV-infection however,11/16 lots. with disease progression r~tere anti-A.SGPR positive compared to 6/16 positive pts. with silent isease. Pinally, 10/12 pts. with AH-NANBNC demonstrated a p.rogression to chronic (presumable autoimmune) hepatitis and were a m i - A ~ H positive but ANA, AMA, SMA, LKM and SLA negative. In conclusion, autoantibodies against intracellular structures are not induced during he.[~.tocelluiar damage but disease-specifc. In contrast, in acute hepatitis anti-ASGPR are disease-unspecifc, but of ~linical prognostic significance.
DOUBLE-BLIND, RANDOMIZED TRIAL OF IFN5:COLCHICINE IN ANTI HCV-POSIT1VE CHRONIC ACTIVE HEPATITIS (CAll). P.Trande_P Esposito.S.Marchi*.A.GrottolaP.Buttafoco_A.Meri~hi P.Cieeoms si*~A-Ricchiuti*~S.Petruceelli*TA.Ferrari~R-Coseaza~F.Maneati,iLVilla ~ o enterology, University of Modena and Pisa, Italy, Fibrosis in patients with CAH is a frequent occurrence also in long term respenders to 1FN, as a consequence of repair of necrosis. We have therefore planned a double-blind, randomized trial of IFN with and without colchicine (IFN 18MU/weekly for 3 months then 9MU/weeHy for 3 months (Roferon,Roche) + colchicine (C) 1 mg for 5 days/week for one year) in the attempt of improving the overall outcome of IF'N alone. Ninety-two patients with antiHCV-positive CAH have been enrolled ; we report the preliminary results of 56 pts (IFN: 27 pts, 12 with mild CAH; ~N5:C: 29 pts, 6 with mild CAIO who have completed one year of follow-up. Results_.' the rate of sustained (IFN:7/27 vs IFNi-C 5/29) or short-term (IFN:13/27 vs IFN_+C:I0/29) response was not significantly different in the 2 treatment groups. ALTs decrease occurred morn rapidly in IFN than in IFNs:C-treated pts so that the difference at 3 months was significant (46 vs 83 UI/I) while at 6 months it was not. After stopping IFN, ALTs increased significantly more in IFN than in IFN_+C pts (month 10:251 vs 93 UI/I; month 12:213 vs 61 UI/I). Despite the presence in IFN-treated pts of more mild CAH than in IFN5:C, PIIll? levels at month 12 were significantly lower in IFNS:C treated pts than in IFN alone (p<.05). Viremia (endpoint dilutions+RT/PCR) decreased in both IFN and IFN_+C treated pts but after stopping IFN, the rebound was significantly less pronounced in FN5:C group. In conclusion: 1. the association IFN-colchicine is as effective as IFN alone m reducing ALTs levels, despite the higher number of severe CAll in IFNS:C group; 2. IFN_-~Cexerts a beneficial effect on the post-IFN ALTs rebound, possibly for a lesser rebound of viremia, which could be due to an immunemodulatory effect of colchicine; 3. the effect of the combination therapy may be especially relevant in diminishing the tendency toward fibrosis in severe CAH (Grant:40% Virus).
Following the report of a high prevalence of anti-HCV IgM in patients with chronic active hepatitis by Morisso et al. ( G a s t r o e n t e r o l o g y 1994;106:A945), the present study was designed to determine whether the presence of HCV anti-core IgM is correlated with the Knodell score. Patients and Methods: A total of 42 patients with chronic hepatitis C (23 men, 19 women, mean age 47.8+13.8 yr) were included in the study. A l l patients underwent transparietal liver aspiration biopsy (2 CPH, 23 C A H , 17 cirrhosis). HCV serology was confirmed in all cases by RIBA 2 or RIBA 3 tests. Anti-core IgM (Abbott) were sought in sera conserved at -20°C prior to treament with interferon from a blood bank. Anticore IgM results were expressed as the ratio between the optical density i n the sample and the cut-off optical density. Statistical analysis o f data was performed by the Chi-2 test, the Mann-Whitney test and the linear regression model. Results: (a) 15 patients (1 CPH, 5 CAH, 9 cirrhosis) had anti-core IgM; the remaining 27 patients (1 CPH, 18 CAH, 8 c i r r h o s i s ) did not. This d i f f e r e n c e is not statistically significant. (b) The mean Knodell score for the patients with anti-core IgM was 11.85:3.2 versus 9.1+3.1 for those without anti-core IgM. This difference is s i g n i f i c a n t (p = 0.01). (c) A positive correlation was observed between the Knodell score and the anti-core IgM ratio (r = 0.31, p = 0.05). Conclusion: The presence of anti-core lgM is associated with more severe liver histology while the anti-core IgM ratio is significantly correlated with the Knodell score.
1579 SIGNIFICANCE OF AUTOANTIBODIES IN 257 PATIENTS PRESENTING
501A
1580
QUANTITATION O F I t c v RNA IN P L A S M A AND P E R W H E R A L B L O O D M O N O N U C L E A R C E L L S OF PATIENTS WITH CHRONIC HEPATITLS C TREATED W I T H cc INTERFERON
P Trimoulet. L Rie~rd. p Bernard, MF ~ i ~ Marc Girard;-*, C S a y a d a ' , P CouziHu and H,IA Fleury Centre Hospitalier et Universitaire de Bordeaux, France *Roche France It is now admitted that HCV replicates in liver cells and in peripheral blood mononuclenr cells (PBMC). a interferon (o.-IFN) can be used for the treatment of a chronic hepatitis C ; in this case, a rapid decrease of the number of HCV RNA copies per ml of plasma is expectS. The aim of the present study was to compare the kinetics o f H C V RNA loads in plasma and PBMC of patients undergoing an ~-IFN therapy. 56 patients with a chronic hepatitis C were included in the study. All of them exhibited a positive qualitative PCR signal (Amplicor Roche) in the serum and the corresponding HCV RNAs were genotyped using the line probe assay (LIPA, hagen). No patient had rc~:eived Gc-IFN prior to the inclusion in the study. A treatment vms initiated with 6 millions units Roferon (Roche) three times a week for six months ; at days 0, 30, 60, 90,180 and 360 initiation of therapy, blood was punctured in EDTA vacutainers ; plasma was eollected and PBMC were isolated by demity gradient eentrifugation ; the PBMC were then washed three ttmes in phosphate buffered saline and kept frozen at -80°C. Total RNAs were extracted from the plasana, the PBMC and the last washing liquid ; HCV RNA was quantitatexl using the HCV monitor assay (Roche). The serum mmsammas¢ (ALT) levels were noted. Data from 18 patients analysed at days 0, 30, 60 and 90 are available at present time. The genotypes of the HCV isolates are as follows : la (2 patients), lb (2), 1 undetermined (3), 2a (2), 3 (7) and 4/5 (2). HCV RNA could be quantitated in the plasma and PBMC from all patients prior to therapy. After 90 days of IFN treatment three groups of patients could be described : - 8 patients with complete clearance of HCV RNA in plasma and PMBC plus ALT normalisation. - 2 patients with complete clearance of HCV RNA in both sites at d30 and d60 but with no sustained viral logs at d90 and abnormal ALT. - 8 patients with fluctuuting HCV RNA loads in both sites and variable ALT.
1577
AASLD
HEPATITIS C VIRUS (HCV) ANTI-CORE IgM: A SEROLOGIC MARKER OF NECRO-INFLAMMATORY ACTIVITY IN LIVER BIOPSIES. A Tran 1, S Benzaken 2, JF Broussard I, P Rouqui61, J D u r a n t 1, ML Montoya 1, JL Nano 1, A Rampal 3, P Rampal 1. 1 D e p a r t m e n t o f H e p a t o - g a s t r o e n t e r o l o g y , 2 D e p a r t m e n t of Immunology, Archet Hospital Nice; 3 Department of Pathology, Pasteur Hospital, Nice, France.
ABSTRACTS
1578
WITH ACUTE HYPERINFLAMMATORYHEPATITISOF DIFFERENTORIGIN U Treichel'.N Tamol:maaos*.K-HMover zum Bf~Ich4mfold~',A HA~_'~ ~, G Pal~dheoddis*.C Stavrinos*.G Gerken*, *l.Dept.of Medicine, University of MalnT~Germanyand ~lestem Attica General Hospitalj~thens,Greece of Circulating autoantibodies contribute to the differential diagnosis chronic inflammatory liver diseases. However, the mechenims for their induction and the underlaying pathophysiology remains unclear. Therefore, coded sera from 257 patients (pts.) presenting with an hyperinflemmatory acute hepatitis served as a clinical model for severe Inter cell damage. The mean of levels for bilirubin ranged from 7-16.5 rng/dl, mean ALT-leveis from 1999-2993 Lift and y-globuUn levels from 716.5 .~1.. The diagnostic procedere identified 112 pts. with acute viral hepatitis A,B and C (AVH-A,n=50; AVH:B n=30 AVH-C n=32) 38 pts. with acute exacerbating chronic hepatitis B (ACH-B), 18 10ts. with autoimmune hepatitis 0MH), 25 10ts.with priman/biliary cirrhosis (PBC) and 64 pts. with NANBNC-hepatitis (AH-NANBNC). Circulating autoantibodies against intracellular epitopes (antinuclear~ANA, antimitochondrial "=AMA, smooth muscle~SMA, microsomal--'LKM, cytoke.mtin-'-SLA) and the asialoglycoprotein receptor (ASGPR) were de~ermined by appropriate immunolo[)ical assays. As a result ANA, SMA: AMA, .LKM ~ SLA were predom,nantly found in pts. with AIH but nearly comp~tely aDsent in pts. with AVH-A,-B or -C, ACH-B or AHNANBNC, respectively, except 16.7 percent SMA posith,es in AVH-B. In contrast, anti-ASGPR were detected in 48 up 1o 78 percent of all pts. .with acute hepatitis compared to 78 percent of lots. with autoimrnune nep~itis. The individual anti-ASGPRtiter had a wide range. No correlation was found between anti-ASGPR positivity and sex, age or laboratory tests. In the course of HBV-infection, 26 of 38 = 68 percent of anti2ASGPR pgsitive pts. showed HBsAg-elimination or absent HBV replicat~n, unly 1/4 pts. with hepatocellular carcinoma was anti-ASGPR positive. In HCV-infection however,11/16 lots. with disease progression r~tere anti-A.SGPR positive compared to 6/16 positive pts. with silent isease. Pinally, 10/12 pts. with AH-NANBNC demonstrated a p.rogression to chronic (presumable autoimmune) hepatitis and were a m i - A ~ H positive but ANA, AMA, SMA, LKM and SLA negative. In conclusion, autoantibodies against intracellular structures are not induced during he.[~.tocelluiar damage but disease-specifc. In contrast, in acute hepatitis anti-ASGPR are disease-unspecifc, but of ~linical prognostic significance.
DOUBLE-BLIND, RANDOMIZED TRIAL OF IFN5:COLCHICINE IN ANTI HCV-POSIT1VE CHRONIC ACTIVE HEPATITIS (CAll). P.Trande_P Esposito.S.Marchi*.A.GrottolaP.Buttafoco_A.Meri~hi P.Cieeoms si*~A-Ricchiuti*~S.Petruceelli*TA.Ferrari~R-Coseaza~F.Maneati,iLVilla ~ o enterology, University of Modena and Pisa, Italy, Fibrosis in patients with CAH is a frequent occurrence also in long term respenders to 1FN, as a consequence of repair of necrosis. We have therefore planned a double-blind, randomized trial of IFN with and without colchicine (IFN 18MU/weekly for 3 months then 9MU/weeHy for 3 months (Roferon,Roche) + colchicine (C) 1 mg for 5 days/week for one year) in the attempt of improving the overall outcome of IF'N alone. Ninety-two patients with antiHCV-positive CAH have been enrolled ; we report the preliminary results of 56 pts (IFN: 27 pts, 12 with mild CAH; ~N5:C: 29 pts, 6 with mild CAIO who have completed one year of follow-up. Results_.' the rate of sustained (IFN:7/27 vs IFNi-C 5/29) or short-term (IFN:13/27 vs IFN_+C:I0/29) response was not significantly different in the 2 treatment groups. ALTs decrease occurred morn rapidly in IFN than in IFNs:C-treated pts so that the difference at 3 months was significant (46 vs 83 UI/I) while at 6 months it was not. After stopping IFN, ALTs increased significantly more in IFN than in IFN_+C pts (month 10:251 vs 93 UI/I; month 12:213 vs 61 UI/I). Despite the presence in IFN-treated pts of more mild CAH than in IFN5:C, PIIll? levels at month 12 were significantly lower in IFNS:C treated pts than in IFN alone (p<.05). Viremia (endpoint dilutions+RT/PCR) decreased in both IFN and IFN_+C treated pts but after stopping IFN, the rebound was significantly less pronounced in FN5:C group. In conclusion: 1. the association IFN-colchicine is as effective as IFN alone m reducing ALTs levels, despite the higher number of severe CAll in IFNS:C group; 2. IFN_-~Cexerts a beneficial effect on the post-IFN ALTs rebound, possibly for a lesser rebound of viremia, which could be due to an immunemodulatory effect of colchicine; 3. the effect of the combination therapy may be especially relevant in diminishing the tendency toward fibrosis in severe CAH (Grant:40% Virus).
Following the report of a high prevalence of anti-HCV IgM in patients with chronic active hepatitis by Morisso et al. ( G a s t r o e n t e r o l o g y 1994;106:A945), the present study was designed to determine whether the presence of HCV anti-core IgM is correlated with the Knodell score. Patients and Methods: A total of 42 patients with chronic hepatitis C (23 men, 19 women, mean age 47.8+13.8 yr) were included in the study. A l l patients underwent transparietal liver aspiration biopsy (2 CPH, 23 C A H , 17 cirrhosis). HCV serology was confirmed in all cases by RIBA 2 or RIBA 3 tests. Anti-core IgM (Abbott) were sought in sera conserved at -20°C prior to treament with interferon from a blood bank. Anticore IgM results were expressed as the ratio between the optical density i n the sample and the cut-off optical density. Statistical analysis o f data was performed by the Chi-2 test, the Mann-Whitney test and the linear regression model. Results: (a) 15 patients (1 CPH, 5 CAH, 9 cirrhosis) had anti-core IgM; the remaining 27 patients (1 CPH, 18 CAH, 8 c i r r h o s i s ) did not. This d i f f e r e n c e is not statistically significant. (b) The mean Knodell score for the patients with anti-core IgM was 11.85:3.2 versus 9.1+3.1 for those without anti-core IgM. This difference is s i g n i f i c a n t (p = 0.01). (c) A positive correlation was observed between the Knodell score and the anti-core IgM ratio (r = 0.31, p = 0.05). Conclusion: The presence of anti-core lgM is associated with more severe liver histology while the anti-core IgM ratio is significantly correlated with the Knodell score.
1579 SIGNIFICANCE OF AUTOANTIBODIES IN 257 PATIENTS PRESENTING
501A
1580
QUANTITATION O F I t c v RNA IN P L A S M A AND P E R W H E R A L B L O O D M O N O N U C L E A R C E L L S OF PATIENTS WITH CHRONIC HEPATITLS C TREATED W I T H cc INTERFERON
P Trimoulet. L Rie~rd. p Bernard, MF ~ i ~ Marc Girard;-*, C S a y a d a ' , P CouziHu and H,IA Fleury Centre Hospitalier et Universitaire de Bordeaux, France *Roche France It is now admitted that HCV replicates in liver cells and in peripheral blood mononuclenr cells (PBMC). a interferon (o.-IFN) can be used for the treatment of a chronic hepatitis C ; in this case, a rapid decrease of the number of HCV RNA copies per ml of plasma is expectS. The aim of the present study was to compare the kinetics o f H C V RNA loads in plasma and PBMC of patients undergoing an ~-IFN therapy. 56 patients with a chronic hepatitis C were included in the study. All of them exhibited a positive qualitative PCR signal (Amplicor Roche) in the serum and the corresponding HCV RNAs were genotyped using the line probe assay (LIPA, hagen). No patient had rc~:eived Gc-IFN prior to the inclusion in the study. A treatment vms initiated with 6 millions units Roferon (Roche) three times a week for six months ; at days 0, 30, 60, 90,180 and 360 initiation of therapy, blood was punctured in EDTA vacutainers ; plasma was eollected and PBMC were isolated by demity gradient eentrifugation ; the PBMC were then washed three ttmes in phosphate buffered saline and kept frozen at -80°C. Total RNAs were extracted from the plasana, the PBMC and the last washing liquid ; HCV RNA was quantitatexl using the HCV monitor assay (Roche). The serum mmsammas¢ (ALT) levels were noted. Data from 18 patients analysed at days 0, 30, 60 and 90 are available at present time. The genotypes of the HCV isolates are as follows : la (2 patients), lb (2), 1 undetermined (3), 2a (2), 3 (7) and 4/5 (2). HCV RNA could be quantitated in the plasma and PBMC from all patients prior to therapy. After 90 days of IFN treatment three groups of patients could be described : - 8 patients with complete clearance of HCV RNA in plasma and PMBC plus ALT normalisation. - 2 patients with complete clearance of HCV RNA in both sites at d30 and d60 but with no sustained viral logs at d90 and abnormal ALT. - 8 patients with fluctuuting HCV RNA loads in both sites and variable ALT.