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Recombinant interferon-alfa therapy in children with chronic hepatitis C
Original Articles Recombinant Interferon-Alfa Therapy in Children With Chronic Hepatitis C FLAVIA BORTOLOTTI, 1 RAFFAELLA GIACCHINO, 2 P I E T R O VAJRO, 3 CRISTIANA BARBERA, 4 CARLO CRIVELLARO, 5 ALFREDO ALBERTI, ~ GABRIELLA N E B B I A , 6 L U C I A ZANCAN, 7 LORENA D E M O L I N E R , ~ ADALBERTO BERTOLINI, 1 FIORELLA BALLI, s AND FRANCESCO CALLEA 9
The efficacy o f r e c o m b i n a n t interferon-alfa t h e r a p y in c h i l d r e n w i t h c h r o n i c hepatitis C h a s b e e n e v a l u a t e d in a r a n d o m i z e d , c o n t r o l l e d pilot study i n c l u d i n g 27 patients, a g e d 2 to 14 years, w i t h o u t u n d e r l y i n g s y s t e m i c diseases. On entry, all p a t i e n t s h a d a b n o r m a l a l a n i n e tran~qmirtase (ALT) levels, 22 w e r e hepatitis C virus (HCV) R N A positive, 19 h a d mild c h r o n i c active hepatitis, a n d 8 h a d c h r o n i c p e r s i s t e n t hepatitis o n liver biopsy. F o u r t e e n c h i l d r e n r e c e i v e d 5 M V / m 2 o f recombin a n t interferon-alfa2b thrice w e e k l y for 4 m o n t h s . If at this t i m e ALT h a d b e e n r e d u c e d to at least 50% t h e baseline level, t r e a t m e n t w a s c o n t i n u e d up to 12 m o n t h s . T h e o t h e r 13 c h i l d r e n r e m a i n e d untreated. The w h o l e followup period lasted 24 m o n t h s . I n t e r f e r o n w a s s t o p p e d at 4 m o n t h s in 4 c h i l d r e n b e c a u s e o f a n ALT i n c r e a s e (2 cases), u n c h a n g e d ALT a n d febrile c o n v u l s i o n s (1 case), a n d slight ALT d e c r e a s e (1 case). This latter patient, h o w e v e r , h a d n o r m a l ALT at 6 m o n t h s a n d t h r o u g h o u t f u r t h e r follow-up, a n d c l e a r e d HCV RNA, t h u s b e h a v i n g as a s u s t a i n e d r e s p o n d e r . All 10 c h i l d r e n treated for 12 m o n t h s h a d n o r m a l levels o f ALT, a n d 9 w e r e HCV R N A n e g a t i v e at the e n d o f treatment. Of t h e 9 c h i l d r e n w h o c o u l d be f o l l o w e d to 24 m o n t h s , 4 r e l a p s e d s o o n after t h e r a p y w i t h d r a w a l a n d 5 m a i n t a i n e d a s u s t a i n e d bioc h e m i c a l a n d virologic r e s p o n s e . Overall, 6 (43%) o f 14 treated c h i l d r e n h a d a s u s t a i n e d ALT n o r m a l i z a t i o n ass o c i a t e d w i t h HCV R N A c l e a r a n c e as c o m p a r e d w i t h o n l y 1 (7.5%) u n t r e a t e d child w h o h a d a s u s t a i n e d ALT n o r m a l i z a t i o n but did n o t clear HCV RNA. T h e s e results suggest that r e c o m b i n a n t i n t e r f e r o n therapy, at t h e regim e n u s e d in this study, m a y i n d u c e s u s t a i n e d ALT norm a l i z a t i o n a n d HCV c l e a r a n c e in a significant proportion o f c h i l d r e n w i t h c h r o n i c hepatitis C. (HEPATOLOGY 1995;22:1623-1627.)
Abbreviations: IFN, interferon; ALT, alanine transaminase; HCV, hepatitis C virus; anti-LKM, anti-liver-kidney microsomal autoantibodies; PCR, polymerase chain reaction. From the 'Clinica Medica 2, University of Padua; 2Department of Infectious Diseases, Gaslini Institute, Genoa; 3Department of Pediatrics, University of Naples; 4Pediatric Clinic, University of Turin; 5Department of Infectious Diseases, Padua Hospital, Padua; 6Pediatric Clinic De Marchi, Milan; 7Department of Pediatrics, University of Padua; SPediatric Clinic, University of Modena; 91° Servizio Anatomia Patologica, Brescia Hospital, Brescia, Italy. Received February 27, 1995; accepted July 21, 1995. Address reprint requests to: Flavia Bortolotti, MD, Clinica Medica 2, Via Giustiniani 2, 35100 Padova, Italy. Copyright © 1995 by the American Association for the Study of Liver Diseases. 0270-9139/95/2206-000153.00/0
Chronic hepatitis C is an insidious and slowly progressive disease that m a y lead to cirrhosis and hepatocellular carcinoma in a substantial proportion of patients in adult life. 1,2 Interferon alfa (IFN-~) is of proven efficacy in the treatment of chronic hepatitis C in adult patients. A number of trials have indeed demonstrated that IFN induces alanine transaminase (ALT) normalization in 40% to 70% of patients and that such effect is maintained after therapy withdrawal in 10% to 30%. 3.6 Hepatitis C is rare in childhood, and the natural history of the disease is poorly documented. In fact, most pediatric cases so far described belong to selected groups of multitransfused patients with underlying systemic diseases such as leukemia, hemophilia, thalassemia, or chronic uremia. In these patients, factors such as viral coinfections, hepatotoxic drugs, iron overload, or immunesuppression can modify the spontaneous course of the disease. Recently, we have retrospectively investigated the natural history of chronic hepatitis C in 77 otherwise healthy children and have demonstrated that the disease usually follows an asymptomatic course throughout childhood and adolescence, with mild and fluctuating ALT abnormalities and histological features ranging from nonspecific hepatitis to mild or moderate chronic active hepatitis. 7 Spontaneous biochemical remission and termination of virus replication are rare, and progression to more severe liver disease later in life may be expected. In this view, antiviral treatment of chronic hepatitis C in childhood should be considered, also taking into account that short duration of infection and a milder form of liver disease have been shown to be predictors of better response to therapy, at least in adult patients, s11 In addition, a recent uncontrolled trial in children with chronic hepatitis C has shown that a 6-month course of IFN can normalize ALT in a substantial proportion of cases, being well tolerated. 12 We have therefore conducted a randomized, controlled pilot study to evaluate the efficacy of a 12-month course of recombinant IFN in children with chronic hepatitis C. PATIENTS AND M E T H O D S Design of the Study. The study was started in 1991, after second-generation serological assays for antibody to hepatitis
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C virus (anti-HCV) became available. It was conducted over a period of 24 months in children aged 2 to 14 years, with persistent ALT abnormalities for more than 6 months, and histological evidence of chronic hepatitis in liver biopsy obtained within 1 year before entry. Criteria for exclusion were underlying systemic diseases, metabolic liver disorders such as al-antitrypsin deficiency or Wilson's disease, infection with hepatitis B virus or h u m a n immunodeficiency virus, history of febrile convulsions, immunosuppressive or antiviral therapy at any time before this study, and circulating non-organ-specific autoantibodies at titers lower than 1:20 for anti-liver-kidney microsomal autoantibodies (anti-LKM) and lower than 1:40 for antinuclear and anti-smooth muscle autoantibodies. When designing the study, we considered that (1) hepatitis C is rare in otherwise healthy children; (2) little was known about the rate of spontaneous remission of the disease in childhood; (3) nothing was known of the efficacy of IFN in children with hepatitis C. We therefore decided to conduct a pilot study of IFN treatment using a randomized comparison of treated and untreated patients. The study was approved by an ethical committee, and written informed consent was obtained from the children's parents. Children were randomly assigned to receive treatment with 5 MU/m 2 of recombinant IFN-~-2b (Intron-A, SheringPlough, Kenilworth, NJ) thrice weekly for 12 months, or no treatment. All patients who received treatment were hospitalized for 3 to 5 days after starting therapy and were then seen as outpatients at weeks 2 and 4 and monthly up to the fourth month. At this time, the following patients were considered as nonresponders and withdrawn from treatment: (1) children with increased ALT levels as compared with the baseline; (2) children with baseline ALT twice the normal or lower who had not normalized ALT; (3) children with baseline ALT greater than twice the normal whose ALT levels were not reduced at least 50%. Serial controls were performed at months 6, 9, and 12 and during off-therapy follow-up at months 15, 18, and 24. Untreated children were seen at months 4 and 6 and then every 3 months up to 24 months. At each visit physical examination was performed and serum samples were collected and stored at -20°C until use. Posttreatment biopsies were performed at 24 months only in long-term responders, to assess whether biochemical remission was associated with histological improvement. The criteria for response to treatment were established in advance. Patients were regarded as nonresponders if serum ALT had not decreased according to protocol at 4 months or were abnormal at the end of therapy. The short-term response group included all patients with normal ALT values at the end of therapy who experienced an increase of ALT beyond 1.5 times the upper normal value during subsequent follow-up. Long-term response was defined on the basis of sustained ALT normalization during the entire posttreatment follow-up. Methods. Liver biopsy specimens were reviewed by a pathologist not involved in the trial. Histology has been interpreted according to standard criteria, and the Knodell's index of histological activity has been calculated. Non-organ-specific autoantibodies, including antinuclear, anti-smooth muscle, and anti-LKM, were investigated by immunofluorescence on cryostatic sections of rat liver, kidney, and stomach at a screening dilution of 1:20. Hepatitis B virus markers were assayed by commercial immunoassays (Abbott Laboratories, Chicago, IL). Anti-HCV was investigated by
HEPATOLOGYDecember 1995 TABLE 1. C h a r a c t e r i s t i c s o f P a t i e n t s o n E n t r y Treated (n = 14)
Male/female Age (yr; mean _+ SD) ALT (mean _+ SD) (normal, <50 IU/L) Liver biopsy*: CAH CPH HCV RNA + HCV serotypes 1 1/2 2 3 Nonreactive
Untreated ( n = 13)
7/7 7.8 -+ 3.3
5/8 8.0 _+ 3.8
155 +_ 135 10 4 12
110 _+ 55 9 4 10
6 1 1 2 4
6 0 1 0 6
NOTE. Mean (_+ SD) Knodell's index was 4.8 _ 1.5 for treated and 4.0 _+ 1.1 for untreated children (P = NS). Abbreviations: CAH, chronic active hepatitis; CPH, chronic persistent hepatitis.
second-generation enzyme-linked immunosorbent assay (Ortho Diagnostic Systems, Raritan, NJ), and positive tests were confirmed by recombinant immunoblot assay (Chiron Corporation, Emeryville, CA). Serum HCV RNA was retrospectively investigated by nested polymerase chain reaction 13 in samples taken on entry and at months 12, 18, and 24. In patients that were HCV RNA negative on entry, one or two additional samples obtained during the 12 months preceding the study were also tested. HCV serotypes were investigated in basal serum samples by courtesy of Dr P. Simmonds (Edinburgh), using an enzyme-linked immunosorbent assay described in detail elsewhere.14 Statistical analysis of data was performed using the Fisher's exact test and the Student's t-test. For the comparison of Knodell's scores the Mann-Whitney U test for independent samples and the Wilcoxon matched pair test were used. RESULTS
P a t i e n t C h a r a c t e r i s t i c s . B e t w e e n April 1991 a n d J u n e 1992, 27 children w e r e enrolled b y t h e p e d i a t r i c a n d infectious d i s e a s e s d e p a r t m e n t s of P a d u a (4 cases), T u r i n (5 cases), N a p l e s (7 cases), G e n o a (6 cases), M i l a n (4 cases), a n d M o d e n a (1 case). All c h i l d r e n w e r e white. S e v e n t e e n h a d b e e n occasionally t r a n s f u s e d , m a i n l y in t h e p e r i n a t a l period for i n t e r c u r r e n t disorders; one h a d u n d e r g o n e s u r g e r y w i t h o u t blood t r a n s f u s i o n , 6 child r e n h a d a m o t h e r w i t h chronic H C V infection, a n d 3 h a d no h i s t o r y of exposure. T h e m e a n period of followu p before e n t e r i n g t h e s t u d y w a s 3.5 + 2.5 y e a r s . F o u r t e e n children w e r e t r e a t e d , a n d 13 w e r e unt r e a t e d controls. T a b l e 1 s h o w s t h e b a s e l i n e f e a t u r e s in t h e two groups. A L T levels r a n g e d b e t w e e n 1.2 a n d 12 t i m e s t h e u p p e r n o r m a l limit. Bilirubin, p r o t h r o m bin time, a l b u m i n , a n d globulins w e r e n o r m a l . N o n organ-specific a u t o a n t i b o d i e s w e r e n e g a t i v e in all cases. D i s e a s e activity w a s m i l d in all 19 c h i l d r e n w i t h histologic f e a t u r e s of active h e p a t i t i s . H C V R N A w a s d e t e c t e d in t h e b a s e l i n e s e r a of 22 p a t i e n t s , b u t 4 additional children w e r e H C V R N A positive in a t l e a s t one
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BORTOLOTTI ET AL
TABLE 2. B e h a v i o r o f A L T a n d H C V RNA D u r i n g F o l l o w - U p in Treated and Untreated Children Treated
At 12 mo ALT normal HCV RNAAt 24 mo$ ALT normal HCV RNA-
Total (n = 14)
Untreated (n = 13)
4 Mo (n = 4)
12 Mo (n = 10)
1 1
10 9
11 (78%)* 10 (71%)*
1 (7.6%)t 1 (7.6%)t
2 2
5/9 7/9
7/13 (54%)§ 9/13 (69%)*
2 (15%)[I 0t
$ One of the four children treated at 4 months (see text) had normal ALT at 18 and 24 months but was not considered a long-term responder. Of the two untreated children with normal ALT at 24 months, only one had a sustained ALT normalization. * P < .001 vs. t§P = .09 vs. II-
serum sample taken during the 12 months preceding the trial. The single patient who remained persistently HCV RNA negative was the child of an anti-HCV-positive mother. On entry she had ALT levels thrice the normal and evidence of infection with serotype 3 HCV. She was randomly assigned to the treatment group. The parameters considered did not differ significantly between the two study groups. Response t o t r e a t m e n t . Table 2 shows the behavior of ALT and HCV RNA in treated and untreated patients at 12 and 24 months of follow-up. Of the 14 treated patients, 4 stopped therapy after 4 months, and Fig. 1 shows the ALT profile during treatment and follow-up in this group of children. Case 1 was a 5-year-old, transfused, HCV RNA-positive girl with mild chronic active hepatitis who developed an asymptomatic ALT flare with appearance of low titers (1:20) of anti-LKM. After therapy withdrawal, ALT turned to baseline values within 15 months. The patient remained HCV RNA and antiLKM positive in serum. Case 2 was a 9-year-old, transfused, HCV RNA-positive girl with chronic persistent hepatitis who developed a fourfold ALT increase at the fourth month, without appearance of non-organ-specific autoantibodies. She never cleared HCV RNA during follow-up. Case 3 was a 6-year-old, HCV RNA-positive boy with unknown exposure and mild chronic active hepatitis who maintained stable ALT values and was withdrawn from treatment before the completion of the fourth month of therapy because of a febrile convulsion. He did not develop autoantibodies. This patient normalized ALT and cleared HCV RNA at 18 months. Case 4 was a 10-year-old transfused, HCV RNApositive boy with mild chronic active hepatitis who had only a slight ALT decrease during the first 4 months, and was therefore withdrawn from therapy according to protocol. He was negative for circulating autoantibodies. At 6 months, however, ALT had become normal and remained within the normal range up to the end of follow-up. HCV RNA also became negative during
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follow-up. This patient was considered to be a longterm responder. Ten children completed the 12-month treatment period, and all had normal ALT at the end of therapy. Normalization had occurred within the first 6 months of treatment in 8 cases and after the sixth month in 2 cases. Both patients in this group who were HCV RNA negative on entry remained negative at the 12th month, and 7 additional cases cleared HCV RNA during therapy. Non-organ-specific autoantibodies were not regularly checked in these patients, but retrospective investigation for anti-LKM in at least one serum sample taken during treatment or at 12 months yielded negative results. One patient was lost for follow-up after stopping therapy. Five of nine children who completed the follow-up maintained normal ALT and negative polymerase chain reaction (PCR) test, including the girl who had been always PCR negative, whereas four relapsed, including one child who had been PCR negative on entry and at the end of treatment and two who had become PCR negative during treatment. In two of the three cases, HCV RNA was again positive at 18 and 24 months, and in another patient PCR yielded positive results at 18 months but was negative again at 24 months. Figure 2 shows ALT profiles during treatment and follow-up in the five long-term and in the four shortterm responders. Liver histology was checked at 24 months in four of five children who completed the treatment schedule and had a sustained response to IFN and in the patient treated only for 4 months whose condition behaved like that of a long-term responder. In these cases, with initial biopsy showing active hepatitis, the histological pattern was consistent with persistent hepatitis (four cases) or inactive fibrosis (one case). The mean Knodell's score for necrosis was reduced from 1.4 +_0.6 to 0 (P < .04), and the mean score for inflammation from 1.8 _+ 0.9 to 0.2 + 0.3 (P < .06). Long-term response was observed in one of five (20%) children infected with type 1 HCV who completed the
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/~
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I~-~1 ~Pt21
700
4~
0 2
4
6
e
10
t2
14
16
18
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22
24
MONTHS
FiG. 1. ALT behavior during follow-up in the four children who interrupted therapy at 4 months. For details of the patients' histories see text. Normal ALT values, <50 IU/L.
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BORTOLOTTI ET AL
HEPATOLOGYDecember 1995
20o-
i 150i
STR
LTR
I
i
I
i
f
I
2
4
6
8
10
12
I 14
* 16
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20
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MONTHS
FIG. 2. Mean ALT values over time in five long-term responders (LTR) and in four short-term responders (STR) who completed the 24 months' follow-up. Normal ALT values, <50 IU/L.
follow-up, in the child with mixed infection, in both children with serotype 3, and in two of four cases with nonreactive sera. Age, gender, baseline ALT levels, initial HCV RNA status, and liver histology (Knodell's index) did not differ significantly between long-term responders and patients with no response or short-term response. Of the 13 control patients, 1 normalized ALT at the second month and went on with normal enzymes up to the end of follow-up while PCR was positive. During observation, HCV RNA was intermittently positive in 4 children, including 1 who had normal ALT at 18 and 24 months and 1 with transient ALT normalization at 15 and 18 months. All 4, however, were HCV RNA positive at 24 months. Side Effects. Therapy withdrawal soon before the end of the fourth month was required in a child who did not respond to IFN and had an episode of febrile convulsion. Another major event likely caused by IFN was the development of an ALT flare that was asymptomatic and associated with anti-LKM antibodies in a patient who had initially normalized ALT. A transient influenzalike syndrome, consisting of fever, myalgia, malaise, and headache, was observed in all treated children during the first few weeks of treatment. Hair loss was reported in one patient, pruritus in one further patient, and weight loss in one patient. Two children had moderate leukopenia (at the second and fourth months in one case and at the 10th month in the other), which required tapering of the dose to 3 MU/m 2 for 2 weeks. DISCUSSION
The results of this pilot study suggest that recombinant IFN-a at a dose of 5 MU/m 2 thrice weekly for 12 months m a y be beneficial in children with chronic hepatitis C. In fact, 10 (71%) of 14 children randomized for therapy could complete the treatment, and all were responders at the biochemical level, whereas 9 of them became negative for serum HCV RNA by a sensitive nested PCR assay. In addition, 1 of 4 patients treated only for 4 months because of trivial ALT changes nor-
malized ALT soon after therapy withdrawal and behaved like a long-term responder, suggesting that some patients could also benefit of shorter treatment schedules. Conversely, only 7.6% of untreated children had a sustained ALT normalization during a 12-month follow-up, and all remained HCV RNA positive. Overall biochemical remission, associated with HCV RNA clearance, was sustained in 6 (43%) of 14 treated cases who could be followed up to 24 months. Thus, HCV RNA was a sensitive marker of response to treatment and disappeared from serum in all initially positive patients who became long-term responders. As noted in adults, however, HCV RNA clearance did not prevent reactivation in individual cases. 15 In children with sustained response whose liver biopsy has been checked during follow-up, the Knodell's scores for inflammation and necrosis were significantly reduced. Both rates of primary and sustained response were higher in our study than previously observed in adults treated with standard schedules (3 MU of recombinant alpha IFN thrice weekly for 6 months). 3-6 Different explanations are possible: the duration of infection is obviously shorter in children, and most of them have a mild form of liver disease. Both of these conditions have been associated with a better response to IFN in adults, s-11 In addition, high doses of IFN have been used in our study and could have contributed to the maintenance of response. Recent studies have indeed shown that higher doses of IFN may increase the durability of the initial response by reducing early relapse. 16-~s It is difficult to compare our data with those of a previous noncontrolled study conducted in a series of Spanish children by Ruiz-Moreno et al, using lower doses of IFN for 6 months, because of a different selection of patients.12 Actually, 7 of 12 children with chronic hepatitis C in that study were HCV RNA positive but anti-HCV negative by second-generation tests: we have rarely observed such a pattern in children with chronic hepatitis C, ~9 and all patients enrolled in our study were anti-HCV positive. The rate of primary response in the Spanish series was much lower than in our study, and the kinetics of response was different. In our series, in fact, all but two responders normalized ALT during the first 6 months after starting therapy, and relapse occurred within 3 months after therapy withdrawal. Only in one patient, treated for 4 months, ALT normalization occurred several months after stopping therapy, as frequently observed in the Spanish children, but in this case the relationship between therapy and biochemical remission is questionable, especially if we consider that, as observed in our untreated patients, transient ALT normalization can occur in the spontaneous course of chronic hepatitis C in children. The small size of the sample did not allow a statistical analysis of factors predictive of long-term response to IFN. Neither ALT values, nor liver histology or HCV RNA status on entry, correlated with the outcome in the single patient. Both children with serotype 3 were long-term responders as compared with one of five chil-
HEPATOLOGYVol. 22, No. 6, 1995
BORTOLOTTI ET AL 1627
6. Causse X, Godinot H, Chevallier M, Chossegros P, Zoulim F, Ouzan D, Heyraud JP, et al. Comparison of I or 3 MU of interferon alpha-2b and placebo in patients with chronic non-A, nonB hepatitis. Gastroenterology 1991;101:497-502. 7. Bortolotti F, Jara P, Diaz C, Vajro P, Hierro L, Giacchino R, De la Vega A, et al. Posttransfusion and community-acquired hepatitis C in childhood. J Pediatr Gastroenterol Nutr 1994; 18:279-283. 8. Camma C, Craxi A, Tin~ F, Almasio P, Di Marco V, Lo Iacono O, Bruno R, et al. Predictors of response to alpha interferon (IFN) in chronic hepatitis C: a multivariate analysis on 361 treated patients [Abstract]. HEPATOLOGY1992;16:131A. 9. Yoshioka K, Kakumu S, Wakita T, Ishikawa T, Itoh Y, Takayanagi M, Higashi Y, et al. Detection of hepatitis C virus by polymerase chain reaction and response to interferon therapy: relationship to genotypes of hepatitis C virus. HEPATOLOGY 1992; 16:293-299. 10. Serfaty L, Giral P, Loria A, Andreani T, Legendre C, Poupon R. Factors predictive of the response to interferon in patients with chronic hepatitis C. J Hepatol 1994;21:12-17. 11. Chemello L, Cavalletto D, Noventa F, Bonetti P, Casarin C, Bernardinello E, Pontisso P, et al. Predictors of sustained response, relapse and no response in patients with chronic hepatitis C treated with alpha-interferon. J Viral Hepatitis 1995;2:9196. 12. Ruiz-MorenoM, Rua MJ, Castillo I, Garcia-NovoMD, Santos M, Navas S, Carreno V. Treatment of children with chronic hepatitis C with recombinant interferon alpha: a pilot study. HEPATOLOGY1992;16:882-885. 13. Tisminetzky S, Gerotto M, Pontisso P, Chemello L, Baralle F, Alberti A. Genotypes of hepatitis C virus in Italian patients with chronic hepatitis C. Int Hepatol Commun 1994;2:105-112. 14. Simmonds P, Rose KA, Graham S, Chan SW, McOmish F, Dow BC, Follet EAC, et al. 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Treatment of chronic hepatitis C interferon alpha-2b for 60 weeks. HEPATOLOGY1994; 19:280-285. with recombinant interferon alpha: a multicenter randomized, 19. Bortolotti F, Vajro P, Barbera C, Crivellaro C, Zancan L, Giaccontrolled trial. N Engl J Med 1989;321:1494-1500. chino R, Nebbia G, et al. Patterns of antibodies to hepatitis C 4. Di Bisceglie AM, Martin P, Kassianides C, Lisker-Melman M, virus and hepatitis C virus replication in children with chronic Murray L, Waggoner JG, Goodman Z, et al. Recombinant internon-A, non-B hepatitis. J Pediatr 1994;125:916-918. feron alpha therapy for chronic hepatitis C: a randomized double 20. Takada N, Tanase S, Enomoto N, Takada A, Date T. Clinical blind placebo controlled trial. N Engl J Med 1989;321:1506-1510. backgrounds of the patients having different types of hepatitis 5. Marcellin P, Boyer N, Giostra E, Degott C, Courouce AM, Degos C virus genomes. J Hepatol 1992;14:35-40. F, Coppere H, et al. Recombinant human alpha-interferon in 21. Tsubota A, Chayama K, Ikeda K, Yasuji A, Saitoh S, Hashimoto patients with chronic non-A, non-B hepatitis: a multicenter ranM, Iwasaki S, et al. Factors predictive of response to interferon domized controlled trial from France. HEPATOLOGY1991; 13:393alpha therapy in hepatitis C virus infection. HEPATOLOGY 397. 1994; 19:1088-1094.
d r e n w i t h serotype 1. B e c a u s e a good correlation h a s been f o u n d b e t w e e n serotype a n d genotype, 14 it is t e m p t i n g to s u g g e s t t h a t , as a l r e a d y s h o w n in adults, 9'2°'21 g e n o t y p e 1 m a y be a predictor of poorer r e s p o n s e to t h e r a p y in children. I F N t h e r a p y w a s g e n e r a l l y well tolerated. The m o s t i m p o r t a n t side effect observed in one p a t i e n t at the f o u r t h m o n t h of t r e a t m e n t was a n A L T flare associated with t h e a p p e a r a n c e of low a n t i - L K M titers. A similar flare, b u t w i t h o u t detectable a u t o i m m u n i t y , h a s been also r e p o r t e d by Ruiz-Moreno et al in one child d u r i n g t h e f o u r t h m o n t h of I F N t h e r a p y . 12 Therefore, t h e relationship b e t w e e n e x a c e r b a t i o n of liver d a m a g e a n d aut o i m m u n i t y in our p a t i e n t r e m a i n s speculative. Nevertheless, a careful m o n i t o r i n g of a u t o i m m u n i t y is m a n d a t o r y in children w i t h chronic h e p a t i t i s C t r e a t e d w i t h IFN. I n conclusion, t h e r e s u l t s of this s t u d y are e n c o u r a g ing a n d p r o m p t f u r t h e r investigation. Clearly the statistical significance of d a t a should be e v a l u a t e d on l a r g e r series of children, a n d t h e l o n g - t e r m effect of t h e r a p y , p a r t i c u l a r l y on viral replication, should be inv e s t i g a t e d over a l o n g e r follow-up period. I f a d d i t i o n a l i n v e s t i g a t i o n s on the n a t u r a l h i s t o r y of h e p a t i t i s C confirm t h e i n d o l e n t course of the disease d u r i n g childhood a n d adolescence, a n d I F N proves to be efficient in t h e s u s t a i n e d clearance of s e r u m H C V RNA, e r a d i c a t i o n of infection could be a c t u a l l y explored as t h e m a i n goal of I F N t h e r a p y in pediatric patients.
The efficacy o f r e c o m b i n a n t interferon-alfa t h e r a p y in c h i l d r e n w i t h c h r o n i c hepatitis C h a s b e e n e v a l u a t e d in a r a n d o m i z e d , c o n t r o l l e d pilot study i n c l u d i n g 27 patients, a g e d 2 to 14 years, w i t h o u t u n d e r l y i n g s y s t e m i c diseases. On entry, all p a t i e n t s h a d a b n o r m a l a l a n i n e tran~qmirtase (ALT) levels, 22 w e r e hepatitis C virus (HCV) R N A positive, 19 h a d mild c h r o n i c active hepatitis, a n d 8 h a d c h r o n i c p e r s i s t e n t hepatitis o n liver biopsy. F o u r t e e n c h i l d r e n r e c e i v e d 5 M V / m 2 o f recombin a n t interferon-alfa2b thrice w e e k l y for 4 m o n t h s . If at this t i m e ALT h a d b e e n r e d u c e d to at least 50% t h e baseline level, t r e a t m e n t w a s c o n t i n u e d up to 12 m o n t h s . T h e o t h e r 13 c h i l d r e n r e m a i n e d untreated. The w h o l e followup period lasted 24 m o n t h s . I n t e r f e r o n w a s s t o p p e d at 4 m o n t h s in 4 c h i l d r e n b e c a u s e o f a n ALT i n c r e a s e (2 cases), u n c h a n g e d ALT a n d febrile c o n v u l s i o n s (1 case), a n d slight ALT d e c r e a s e (1 case). This latter patient, h o w e v e r , h a d n o r m a l ALT at 6 m o n t h s a n d t h r o u g h o u t f u r t h e r follow-up, a n d c l e a r e d HCV RNA, t h u s b e h a v i n g as a s u s t a i n e d r e s p o n d e r . All 10 c h i l d r e n treated for 12 m o n t h s h a d n o r m a l levels o f ALT, a n d 9 w e r e HCV R N A n e g a t i v e at the e n d o f treatment. Of t h e 9 c h i l d r e n w h o c o u l d be f o l l o w e d to 24 m o n t h s , 4 r e l a p s e d s o o n after t h e r a p y w i t h d r a w a l a n d 5 m a i n t a i n e d a s u s t a i n e d bioc h e m i c a l a n d virologic r e s p o n s e . Overall, 6 (43%) o f 14 treated c h i l d r e n h a d a s u s t a i n e d ALT n o r m a l i z a t i o n ass o c i a t e d w i t h HCV R N A c l e a r a n c e as c o m p a r e d w i t h o n l y 1 (7.5%) u n t r e a t e d child w h o h a d a s u s t a i n e d ALT n o r m a l i z a t i o n but did n o t clear HCV RNA. T h e s e results suggest that r e c o m b i n a n t i n t e r f e r o n therapy, at t h e regim e n u s e d in this study, m a y i n d u c e s u s t a i n e d ALT norm a l i z a t i o n a n d HCV c l e a r a n c e in a significant proportion o f c h i l d r e n w i t h c h r o n i c hepatitis C. (HEPATOLOGY 1995;22:1623-1627.)
Abbreviations: IFN, interferon; ALT, alanine transaminase; HCV, hepatitis C virus; anti-LKM, anti-liver-kidney microsomal autoantibodies; PCR, polymerase chain reaction. From the 'Clinica Medica 2, University of Padua; 2Department of Infectious Diseases, Gaslini Institute, Genoa; 3Department of Pediatrics, University of Naples; 4Pediatric Clinic, University of Turin; 5Department of Infectious Diseases, Padua Hospital, Padua; 6Pediatric Clinic De Marchi, Milan; 7Department of Pediatrics, University of Padua; SPediatric Clinic, University of Modena; 91° Servizio Anatomia Patologica, Brescia Hospital, Brescia, Italy. Received February 27, 1995; accepted July 21, 1995. Address reprint requests to: Flavia Bortolotti, MD, Clinica Medica 2, Via Giustiniani 2, 35100 Padova, Italy. Copyright © 1995 by the American Association for the Study of Liver Diseases. 0270-9139/95/2206-000153.00/0
Chronic hepatitis C is an insidious and slowly progressive disease that m a y lead to cirrhosis and hepatocellular carcinoma in a substantial proportion of patients in adult life. 1,2 Interferon alfa (IFN-~) is of proven efficacy in the treatment of chronic hepatitis C in adult patients. A number of trials have indeed demonstrated that IFN induces alanine transaminase (ALT) normalization in 40% to 70% of patients and that such effect is maintained after therapy withdrawal in 10% to 30%. 3.6 Hepatitis C is rare in childhood, and the natural history of the disease is poorly documented. In fact, most pediatric cases so far described belong to selected groups of multitransfused patients with underlying systemic diseases such as leukemia, hemophilia, thalassemia, or chronic uremia. In these patients, factors such as viral coinfections, hepatotoxic drugs, iron overload, or immunesuppression can modify the spontaneous course of the disease. Recently, we have retrospectively investigated the natural history of chronic hepatitis C in 77 otherwise healthy children and have demonstrated that the disease usually follows an asymptomatic course throughout childhood and adolescence, with mild and fluctuating ALT abnormalities and histological features ranging from nonspecific hepatitis to mild or moderate chronic active hepatitis. 7 Spontaneous biochemical remission and termination of virus replication are rare, and progression to more severe liver disease later in life may be expected. In this view, antiviral treatment of chronic hepatitis C in childhood should be considered, also taking into account that short duration of infection and a milder form of liver disease have been shown to be predictors of better response to therapy, at least in adult patients, s11 In addition, a recent uncontrolled trial in children with chronic hepatitis C has shown that a 6-month course of IFN can normalize ALT in a substantial proportion of cases, being well tolerated. 12 We have therefore conducted a randomized, controlled pilot study to evaluate the efficacy of a 12-month course of recombinant IFN in children with chronic hepatitis C. PATIENTS AND M E T H O D S Design of the Study. The study was started in 1991, after second-generation serological assays for antibody to hepatitis
1623
1624
BORTOLOTTI ET AL
C virus (anti-HCV) became available. It was conducted over a period of 24 months in children aged 2 to 14 years, with persistent ALT abnormalities for more than 6 months, and histological evidence of chronic hepatitis in liver biopsy obtained within 1 year before entry. Criteria for exclusion were underlying systemic diseases, metabolic liver disorders such as al-antitrypsin deficiency or Wilson's disease, infection with hepatitis B virus or h u m a n immunodeficiency virus, history of febrile convulsions, immunosuppressive or antiviral therapy at any time before this study, and circulating non-organ-specific autoantibodies at titers lower than 1:20 for anti-liver-kidney microsomal autoantibodies (anti-LKM) and lower than 1:40 for antinuclear and anti-smooth muscle autoantibodies. When designing the study, we considered that (1) hepatitis C is rare in otherwise healthy children; (2) little was known about the rate of spontaneous remission of the disease in childhood; (3) nothing was known of the efficacy of IFN in children with hepatitis C. We therefore decided to conduct a pilot study of IFN treatment using a randomized comparison of treated and untreated patients. The study was approved by an ethical committee, and written informed consent was obtained from the children's parents. Children were randomly assigned to receive treatment with 5 MU/m 2 of recombinant IFN-~-2b (Intron-A, SheringPlough, Kenilworth, NJ) thrice weekly for 12 months, or no treatment. All patients who received treatment were hospitalized for 3 to 5 days after starting therapy and were then seen as outpatients at weeks 2 and 4 and monthly up to the fourth month. At this time, the following patients were considered as nonresponders and withdrawn from treatment: (1) children with increased ALT levels as compared with the baseline; (2) children with baseline ALT twice the normal or lower who had not normalized ALT; (3) children with baseline ALT greater than twice the normal whose ALT levels were not reduced at least 50%. Serial controls were performed at months 6, 9, and 12 and during off-therapy follow-up at months 15, 18, and 24. Untreated children were seen at months 4 and 6 and then every 3 months up to 24 months. At each visit physical examination was performed and serum samples were collected and stored at -20°C until use. Posttreatment biopsies were performed at 24 months only in long-term responders, to assess whether biochemical remission was associated with histological improvement. The criteria for response to treatment were established in advance. Patients were regarded as nonresponders if serum ALT had not decreased according to protocol at 4 months or were abnormal at the end of therapy. The short-term response group included all patients with normal ALT values at the end of therapy who experienced an increase of ALT beyond 1.5 times the upper normal value during subsequent follow-up. Long-term response was defined on the basis of sustained ALT normalization during the entire posttreatment follow-up. Methods. Liver biopsy specimens were reviewed by a pathologist not involved in the trial. Histology has been interpreted according to standard criteria, and the Knodell's index of histological activity has been calculated. Non-organ-specific autoantibodies, including antinuclear, anti-smooth muscle, and anti-LKM, were investigated by immunofluorescence on cryostatic sections of rat liver, kidney, and stomach at a screening dilution of 1:20. Hepatitis B virus markers were assayed by commercial immunoassays (Abbott Laboratories, Chicago, IL). Anti-HCV was investigated by
HEPATOLOGYDecember 1995 TABLE 1. C h a r a c t e r i s t i c s o f P a t i e n t s o n E n t r y Treated (n = 14)
Male/female Age (yr; mean _+ SD) ALT (mean _+ SD) (normal, <50 IU/L) Liver biopsy*: CAH CPH HCV RNA + HCV serotypes 1 1/2 2 3 Nonreactive
Untreated ( n = 13)
7/7 7.8 -+ 3.3
5/8 8.0 _+ 3.8
155 +_ 135 10 4 12
110 _+ 55 9 4 10
6 1 1 2 4
6 0 1 0 6
NOTE. Mean (_+ SD) Knodell's index was 4.8 _ 1.5 for treated and 4.0 _+ 1.1 for untreated children (P = NS). Abbreviations: CAH, chronic active hepatitis; CPH, chronic persistent hepatitis.
second-generation enzyme-linked immunosorbent assay (Ortho Diagnostic Systems, Raritan, NJ), and positive tests were confirmed by recombinant immunoblot assay (Chiron Corporation, Emeryville, CA). Serum HCV RNA was retrospectively investigated by nested polymerase chain reaction 13 in samples taken on entry and at months 12, 18, and 24. In patients that were HCV RNA negative on entry, one or two additional samples obtained during the 12 months preceding the study were also tested. HCV serotypes were investigated in basal serum samples by courtesy of Dr P. Simmonds (Edinburgh), using an enzyme-linked immunosorbent assay described in detail elsewhere.14 Statistical analysis of data was performed using the Fisher's exact test and the Student's t-test. For the comparison of Knodell's scores the Mann-Whitney U test for independent samples and the Wilcoxon matched pair test were used. RESULTS
P a t i e n t C h a r a c t e r i s t i c s . B e t w e e n April 1991 a n d J u n e 1992, 27 children w e r e enrolled b y t h e p e d i a t r i c a n d infectious d i s e a s e s d e p a r t m e n t s of P a d u a (4 cases), T u r i n (5 cases), N a p l e s (7 cases), G e n o a (6 cases), M i l a n (4 cases), a n d M o d e n a (1 case). All c h i l d r e n w e r e white. S e v e n t e e n h a d b e e n occasionally t r a n s f u s e d , m a i n l y in t h e p e r i n a t a l period for i n t e r c u r r e n t disorders; one h a d u n d e r g o n e s u r g e r y w i t h o u t blood t r a n s f u s i o n , 6 child r e n h a d a m o t h e r w i t h chronic H C V infection, a n d 3 h a d no h i s t o r y of exposure. T h e m e a n period of followu p before e n t e r i n g t h e s t u d y w a s 3.5 + 2.5 y e a r s . F o u r t e e n children w e r e t r e a t e d , a n d 13 w e r e unt r e a t e d controls. T a b l e 1 s h o w s t h e b a s e l i n e f e a t u r e s in t h e two groups. A L T levels r a n g e d b e t w e e n 1.2 a n d 12 t i m e s t h e u p p e r n o r m a l limit. Bilirubin, p r o t h r o m bin time, a l b u m i n , a n d globulins w e r e n o r m a l . N o n organ-specific a u t o a n t i b o d i e s w e r e n e g a t i v e in all cases. D i s e a s e activity w a s m i l d in all 19 c h i l d r e n w i t h histologic f e a t u r e s of active h e p a t i t i s . H C V R N A w a s d e t e c t e d in t h e b a s e l i n e s e r a of 22 p a t i e n t s , b u t 4 additional children w e r e H C V R N A positive in a t l e a s t one
HEPATOLOGY Vol. 22, No. 6, 1995
BORTOLOTTI ET AL
TABLE 2. B e h a v i o r o f A L T a n d H C V RNA D u r i n g F o l l o w - U p in Treated and Untreated Children Treated
At 12 mo ALT normal HCV RNAAt 24 mo$ ALT normal HCV RNA-
Total (n = 14)
Untreated (n = 13)
4 Mo (n = 4)
12 Mo (n = 10)
1 1
10 9
11 (78%)* 10 (71%)*
1 (7.6%)t 1 (7.6%)t
2 2
5/9 7/9
7/13 (54%)§ 9/13 (69%)*
2 (15%)[I 0t
$ One of the four children treated at 4 months (see text) had normal ALT at 18 and 24 months but was not considered a long-term responder. Of the two untreated children with normal ALT at 24 months, only one had a sustained ALT normalization. * P < .001 vs. t§P = .09 vs. II-
serum sample taken during the 12 months preceding the trial. The single patient who remained persistently HCV RNA negative was the child of an anti-HCV-positive mother. On entry she had ALT levels thrice the normal and evidence of infection with serotype 3 HCV. She was randomly assigned to the treatment group. The parameters considered did not differ significantly between the two study groups. Response t o t r e a t m e n t . Table 2 shows the behavior of ALT and HCV RNA in treated and untreated patients at 12 and 24 months of follow-up. Of the 14 treated patients, 4 stopped therapy after 4 months, and Fig. 1 shows the ALT profile during treatment and follow-up in this group of children. Case 1 was a 5-year-old, transfused, HCV RNA-positive girl with mild chronic active hepatitis who developed an asymptomatic ALT flare with appearance of low titers (1:20) of anti-LKM. After therapy withdrawal, ALT turned to baseline values within 15 months. The patient remained HCV RNA and antiLKM positive in serum. Case 2 was a 9-year-old, transfused, HCV RNA-positive girl with chronic persistent hepatitis who developed a fourfold ALT increase at the fourth month, without appearance of non-organ-specific autoantibodies. She never cleared HCV RNA during follow-up. Case 3 was a 6-year-old, HCV RNA-positive boy with unknown exposure and mild chronic active hepatitis who maintained stable ALT values and was withdrawn from treatment before the completion of the fourth month of therapy because of a febrile convulsion. He did not develop autoantibodies. This patient normalized ALT and cleared HCV RNA at 18 months. Case 4 was a 10-year-old transfused, HCV RNApositive boy with mild chronic active hepatitis who had only a slight ALT decrease during the first 4 months, and was therefore withdrawn from therapy according to protocol. He was negative for circulating autoantibodies. At 6 months, however, ALT had become normal and remained within the normal range up to the end of follow-up. HCV RNA also became negative during
1625
follow-up. This patient was considered to be a longterm responder. Ten children completed the 12-month treatment period, and all had normal ALT at the end of therapy. Normalization had occurred within the first 6 months of treatment in 8 cases and after the sixth month in 2 cases. Both patients in this group who were HCV RNA negative on entry remained negative at the 12th month, and 7 additional cases cleared HCV RNA during therapy. Non-organ-specific autoantibodies were not regularly checked in these patients, but retrospective investigation for anti-LKM in at least one serum sample taken during treatment or at 12 months yielded negative results. One patient was lost for follow-up after stopping therapy. Five of nine children who completed the follow-up maintained normal ALT and negative polymerase chain reaction (PCR) test, including the girl who had been always PCR negative, whereas four relapsed, including one child who had been PCR negative on entry and at the end of treatment and two who had become PCR negative during treatment. In two of the three cases, HCV RNA was again positive at 18 and 24 months, and in another patient PCR yielded positive results at 18 months but was negative again at 24 months. Figure 2 shows ALT profiles during treatment and follow-up in the five long-term and in the four shortterm responders. Liver histology was checked at 24 months in four of five children who completed the treatment schedule and had a sustained response to IFN and in the patient treated only for 4 months whose condition behaved like that of a long-term responder. In these cases, with initial biopsy showing active hepatitis, the histological pattern was consistent with persistent hepatitis (four cases) or inactive fibrosis (one case). The mean Knodell's score for necrosis was reduced from 1.4 +_0.6 to 0 (P < .04), and the mean score for inflammation from 1.8 _+ 0.9 to 0.2 + 0.3 (P < .06). Long-term response was observed in one of five (20%) children infected with type 1 HCV who completed the
lOOO
mmmmm
/~
8oo
I~-~1 ~Pt21
700
4~
0 2
4
6
e
10
t2
14
16
18
2O
22
24
MONTHS
FiG. 1. ALT behavior during follow-up in the four children who interrupted therapy at 4 months. For details of the patients' histories see text. Normal ALT values, <50 IU/L.
1626
BORTOLOTTI ET AL
HEPATOLOGYDecember 1995
20o-
i 150i
STR
LTR
I
i
I
i
f
I
2
4
6
8
10
12
I 14
* 16
I
I
I
18
20
,r~
*
MONTHS
FIG. 2. Mean ALT values over time in five long-term responders (LTR) and in four short-term responders (STR) who completed the 24 months' follow-up. Normal ALT values, <50 IU/L.
follow-up, in the child with mixed infection, in both children with serotype 3, and in two of four cases with nonreactive sera. Age, gender, baseline ALT levels, initial HCV RNA status, and liver histology (Knodell's index) did not differ significantly between long-term responders and patients with no response or short-term response. Of the 13 control patients, 1 normalized ALT at the second month and went on with normal enzymes up to the end of follow-up while PCR was positive. During observation, HCV RNA was intermittently positive in 4 children, including 1 who had normal ALT at 18 and 24 months and 1 with transient ALT normalization at 15 and 18 months. All 4, however, were HCV RNA positive at 24 months. Side Effects. Therapy withdrawal soon before the end of the fourth month was required in a child who did not respond to IFN and had an episode of febrile convulsion. Another major event likely caused by IFN was the development of an ALT flare that was asymptomatic and associated with anti-LKM antibodies in a patient who had initially normalized ALT. A transient influenzalike syndrome, consisting of fever, myalgia, malaise, and headache, was observed in all treated children during the first few weeks of treatment. Hair loss was reported in one patient, pruritus in one further patient, and weight loss in one patient. Two children had moderate leukopenia (at the second and fourth months in one case and at the 10th month in the other), which required tapering of the dose to 3 MU/m 2 for 2 weeks. DISCUSSION
The results of this pilot study suggest that recombinant IFN-a at a dose of 5 MU/m 2 thrice weekly for 12 months m a y be beneficial in children with chronic hepatitis C. In fact, 10 (71%) of 14 children randomized for therapy could complete the treatment, and all were responders at the biochemical level, whereas 9 of them became negative for serum HCV RNA by a sensitive nested PCR assay. In addition, 1 of 4 patients treated only for 4 months because of trivial ALT changes nor-
malized ALT soon after therapy withdrawal and behaved like a long-term responder, suggesting that some patients could also benefit of shorter treatment schedules. Conversely, only 7.6% of untreated children had a sustained ALT normalization during a 12-month follow-up, and all remained HCV RNA positive. Overall biochemical remission, associated with HCV RNA clearance, was sustained in 6 (43%) of 14 treated cases who could be followed up to 24 months. Thus, HCV RNA was a sensitive marker of response to treatment and disappeared from serum in all initially positive patients who became long-term responders. As noted in adults, however, HCV RNA clearance did not prevent reactivation in individual cases. 15 In children with sustained response whose liver biopsy has been checked during follow-up, the Knodell's scores for inflammation and necrosis were significantly reduced. Both rates of primary and sustained response were higher in our study than previously observed in adults treated with standard schedules (3 MU of recombinant alpha IFN thrice weekly for 6 months). 3-6 Different explanations are possible: the duration of infection is obviously shorter in children, and most of them have a mild form of liver disease. Both of these conditions have been associated with a better response to IFN in adults, s-11 In addition, high doses of IFN have been used in our study and could have contributed to the maintenance of response. Recent studies have indeed shown that higher doses of IFN may increase the durability of the initial response by reducing early relapse. 16-~s It is difficult to compare our data with those of a previous noncontrolled study conducted in a series of Spanish children by Ruiz-Moreno et al, using lower doses of IFN for 6 months, because of a different selection of patients.12 Actually, 7 of 12 children with chronic hepatitis C in that study were HCV RNA positive but anti-HCV negative by second-generation tests: we have rarely observed such a pattern in children with chronic hepatitis C, ~9 and all patients enrolled in our study were anti-HCV positive. The rate of primary response in the Spanish series was much lower than in our study, and the kinetics of response was different. In our series, in fact, all but two responders normalized ALT during the first 6 months after starting therapy, and relapse occurred within 3 months after therapy withdrawal. Only in one patient, treated for 4 months, ALT normalization occurred several months after stopping therapy, as frequently observed in the Spanish children, but in this case the relationship between therapy and biochemical remission is questionable, especially if we consider that, as observed in our untreated patients, transient ALT normalization can occur in the spontaneous course of chronic hepatitis C in children. The small size of the sample did not allow a statistical analysis of factors predictive of long-term response to IFN. Neither ALT values, nor liver histology or HCV RNA status on entry, correlated with the outcome in the single patient. Both children with serotype 3 were long-term responders as compared with one of five chil-
HEPATOLOGYVol. 22, No. 6, 1995
BORTOLOTTI ET AL 1627
6. Causse X, Godinot H, Chevallier M, Chossegros P, Zoulim F, Ouzan D, Heyraud JP, et al. Comparison of I or 3 MU of interferon alpha-2b and placebo in patients with chronic non-A, nonB hepatitis. Gastroenterology 1991;101:497-502. 7. Bortolotti F, Jara P, Diaz C, Vajro P, Hierro L, Giacchino R, De la Vega A, et al. Posttransfusion and community-acquired hepatitis C in childhood. J Pediatr Gastroenterol Nutr 1994; 18:279-283. 8. Camma C, Craxi A, Tin~ F, Almasio P, Di Marco V, Lo Iacono O, Bruno R, et al. Predictors of response to alpha interferon (IFN) in chronic hepatitis C: a multivariate analysis on 361 treated patients [Abstract]. HEPATOLOGY1992;16:131A. 9. Yoshioka K, Kakumu S, Wakita T, Ishikawa T, Itoh Y, Takayanagi M, Higashi Y, et al. Detection of hepatitis C virus by polymerase chain reaction and response to interferon therapy: relationship to genotypes of hepatitis C virus. HEPATOLOGY 1992; 16:293-299. 10. Serfaty L, Giral P, Loria A, Andreani T, Legendre C, Poupon R. Factors predictive of the response to interferon in patients with chronic hepatitis C. J Hepatol 1994;21:12-17. 11. Chemello L, Cavalletto D, Noventa F, Bonetti P, Casarin C, Bernardinello E, Pontisso P, et al. Predictors of sustained response, relapse and no response in patients with chronic hepatitis C treated with alpha-interferon. J Viral Hepatitis 1995;2:9196. 12. Ruiz-MorenoM, Rua MJ, Castillo I, Garcia-NovoMD, Santos M, Navas S, Carreno V. Treatment of children with chronic hepatitis C with recombinant interferon alpha: a pilot study. HEPATOLOGY1992;16:882-885. 13. Tisminetzky S, Gerotto M, Pontisso P, Chemello L, Baralle F, Alberti A. Genotypes of hepatitis C virus in Italian patients with chronic hepatitis C. Int Hepatol Commun 1994;2:105-112. 14. Simmonds P, Rose KA, Graham S, Chan SW, McOmish F, Dow BC, Follet EAC, et al. 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d r e n w i t h serotype 1. B e c a u s e a good correlation h a s been f o u n d b e t w e e n serotype a n d genotype, 14 it is t e m p t i n g to s u g g e s t t h a t , as a l r e a d y s h o w n in adults, 9'2°'21 g e n o t y p e 1 m a y be a predictor of poorer r e s p o n s e to t h e r a p y in children. I F N t h e r a p y w a s g e n e r a l l y well tolerated. The m o s t i m p o r t a n t side effect observed in one p a t i e n t at the f o u r t h m o n t h of t r e a t m e n t was a n A L T flare associated with t h e a p p e a r a n c e of low a n t i - L K M titers. A similar flare, b u t w i t h o u t detectable a u t o i m m u n i t y , h a s been also r e p o r t e d by Ruiz-Moreno et al in one child d u r i n g t h e f o u r t h m o n t h of I F N t h e r a p y . 12 Therefore, t h e relationship b e t w e e n e x a c e r b a t i o n of liver d a m a g e a n d aut o i m m u n i t y in our p a t i e n t r e m a i n s speculative. Nevertheless, a careful m o n i t o r i n g of a u t o i m m u n i t y is m a n d a t o r y in children w i t h chronic h e p a t i t i s C t r e a t e d w i t h IFN. I n conclusion, t h e r e s u l t s of this s t u d y are e n c o u r a g ing a n d p r o m p t f u r t h e r investigation. Clearly the statistical significance of d a t a should be e v a l u a t e d on l a r g e r series of children, a n d t h e l o n g - t e r m effect of t h e r a p y , p a r t i c u l a r l y on viral replication, should be inv e s t i g a t e d over a l o n g e r follow-up period. I f a d d i t i o n a l i n v e s t i g a t i o n s on the n a t u r a l h i s t o r y of h e p a t i t i s C confirm t h e i n d o l e n t course of the disease d u r i n g childhood a n d adolescence, a n d I F N proves to be efficient in t h e s u s t a i n e d clearance of s e r u m H C V RNA, e r a d i c a t i o n of infection could be a c t u a l l y explored as t h e m a i n goal of I F N t h e r a p y in pediatric patients.