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Treatment of acute hepatitis C with alpha interferon in hypogammaglobulinaemia - the UK gammagard outbreak
A1082
AASLD ABSTRACTS
• HEPATITIS C INFECTION AND ALPHA-INTERFERON T H E R A P Y I N PATIENTS W I T H N O R M A L TRANSAMINASES - A PILOT STUDY • CJ I-I~lev, S Read, J Kurtz, KA Fleming and RWG Chapman Dept of Gasti-~,' Oxford Regional PHI,S, J0h n Radcliffe Hospital, and Nuffield Dept. Of Pathology, University of Oxford, Oxford UK Introduction Many HCV cases have normal liver function (LPTS) but may have significant liver pathology. Infection can be confirmed by RTPCR for HCV RNA. Alpha-interferon (IFN) is the only therapy for HCV resulting in long term response; This pilot study used RT-PCR to identify chronic HCV infection and examine IFN response(standard dose) in patients with normal LPTs. Methods Patients w ~ ' w e r e anti-HCV +ve (2nd gen.ELISA) and HCV RNA +ve by RT-PC~ were offered liver biopsy. Histology was compared (stage and histological activity index, HAI) between patients with persistently n~rmal LF'I'S(NOR) and those with temporarily or permanently abnormal LPTs(AB). Persistently normal liver function was defined as at least 3x normal Lb-Ts(>lmo. apart). Cases with normal LFTS who had chronic persistant (CPH) or active hepatitis (CAH) were treated with IFN, 3.MU, 3x/week for 24wks. Nested RT-PCR was performed at 0, 12, 24, 36 and 48 wks.. Results ~arison of liver histolos~¢ between two 8re ~ps LFTs n m e a n HAI F/U HISTOLOGY* (range) Mo. Nor Min CPH I CAH I Cirr 'NOR 23 '3.7(0-8) 12.3 2 9 18 14 l0 ~AB 31 17.3(1-14) 14.4.1 0 5 ~7 16 ~3 Nor=Normal, Min=Minimal hepatitiS,Cirr=-Cirrhosis 14 patients with normal LFTs commenced IFN. 8 patients have completed 6/12, 2 patie~ats withdrew(2* to side effects) and 4 patients are yet to fifiish b) Response to IFN therapy in patients with normal LFTs Week 0 12 124 36 '] 48 Interferon Post therapy RNA+vetno. ofpts 14/14 17 / 1 2 2i8 5/8 2/3 % +ve 100 I ::~ [ 25, I 63 , 67 In 10 patients who have inished treatment (8 completed tdrawals), only 2 have remained HCV RNA negative (> 3mths post therapy). Conclusions Histological abnormality is common even in patients with normal LPTs. Response to interferon can be measured by RT-PCR in patients with normal LFTS. The majority of IFN treated patients have viraemic relapse within 6 months of therapy. Interferon does not appear in this pilot study to be more effective in patients with normal LPTs.
• COMBINED ANALYSIS OF FRENCH, AMERICAN AND CANADIAN RANDOMIZED CONTROLLED TRIALS OF URSODEOXYCHOLIC ACID THERAPY IN PRIMARY BILIARY CIRRHOSIS. E.J. Heathcote 1, K.D. Lindor2, R. Poupon3, K. Cauch-Dudek I . E.R. Dickson2, R. Trout4, R.E. Poupon5 IUniversity of Toronto. Toronto Canada, 2Mayo Clinic. Rochester MN. 3H6pital Saint-Antoine. Paris France. 4Rutgers University, New Brunswick N J, 5Inserm, Villejuif France.. Three large randomized controlled trials of ursodeoxycholic acid (UDCA) for the treatment of patients with primary biliary cirrhosis (PBC) have been published and all have shown the beneficial effect of treatment on biochemistry. However, a beneficial effect on survival free of transplant (defined as time to transplant or death without transplant) was observed in only 1 of these trials. To estimate the magnitude of this effect of UDCA at 4 years, the raw data from these 3 trials were combined and followup extended beyond that published. METHODS: All patients had biopsy-proven, antimitochondrial antibody positive PBC. and were randomized to receive UDCA (13-15 mg/kg/day) or identical placebo. In one study, blinded randomization continfied for 4 years; in 2 studies, open label UDCA was offered to all patients after 2 years. The endpoint of survival free of liver transplantation was compared between the UDCA and placebo using standard life table analyses• Analyses were done on an "intent-to-treat" basis, thereby potentially underestimating the effecl of UDCA. To indicate the size of benefit from UDCA therapy, the risk r~duetion was calculated. RESULTS: Between 1987 and 1992. 553 patients were randomized. 276 to UDCA and 277 to placebo. Baseline characteristics were comparable at entry viz median age 58 UDCA (range 30-84) vS' 56 placebo (2888). median bilirubin 1.0 mg/dL UDCA vs 1.1 placebo (0.2-26.9 vs 0.1-17.3), and number with cirrhosis 26.1% vs 24.5%. Median length.of followup was 4 yrs in the UDCA group, and 3.8 yrs in the original placebo group. Those placebo patients who went on to receive UDCA did so for a mean of 1 yr. There were 47 patients in the UDCA group and 68 in the placebo group who did not survive free of transplant. Survival free of transplantation was extended in patients originally randomized to UDCA when compared to those on placebo (mean of 3.66 vs 3.45 yrs, log rank 2-tailed p=0.014). In the UDCA group, the risk of dying or being transplanted was reduced by 32% (:k 11%) of that observed in the original placebo group. CONCLUSION: UDCA treatment of patients with PBC improved their survival free of transplant when compared to placebo.
GASTROENTEROLOGY,Vol. 108, No. 4
• TREATMENT OF ACUTE HEPATITIS C WITN ALPHA I N T E R F E R O N IN H Y P O G A M M A G L O B U L I N A E M I A - THE UK G A M M A G A R D O U T B R E A K CJ Healey, J Watson, M Durridge, N Snowdon, J Christie S Wong, S Read, J Kurtz, KA Fleming, H Chapel and RWG Chapman. Depts of Gastro.; Immunol., and Nuffield Dept. of Pathology, Oxford Regional pHLS, John Radcliffe Hospital, Oxford, UK for the UK Gammagard Users Introduction-Intravenous immunoglobulin (IVIG) is established therapy for antibody deficiencies. Despite anti-HCV screening, 36 UK patients were treated with a batch of IVIG containing HCV(Gammagard®-Withdrawn 23/2/94 by manufacturers). The majority of them have developed acute HCV (genotype la). Previous outbreaks of HCV in hypogammaglobulinic patients have suggested the infection can run a rapid severe course. Treatment of HCV With alpha-interferon (IFN) has been shown to be more effective both in the acute disease and at increased doses. Meth0ds-HCV infection was confirmed by RT=PCR in exposed individuals. Patients With documented HCV infection were offered treatment With IFN, if appropriate; Initial" therapy was planned as 6 Mega Units(MU), SC, 3x weekly for six months. As this was an open study, attending physicians were able to tailor the dose to each individual. Results-Treatment data from 9 UK centres i s available for 34/36 cases of contaminated IVIG exposure. 5 patients were PCR -ve, 3 declined therapy and 8 were considered inappropriate for treatment (5 malignancies 1 severi~ lung disease 1 Severe grali~10matous liver disease, 1 history of:depressi0n). One case had previous HCV cirrhosis, a biochemical flare at the second exposure, had a liver graft and now is well but with recurrent HCV. 17129(59%) HCV infected patients commenced treatment with IFN (13-6 MU 3x weekly, 4-at reduced doses) within 8 months of exposure (range 2-8 mths). 4 treated patients required dose reduction ( 2 thrombocytopaenia, 2 severe lethargy) and 4 failed to finish 6 months (2 intolerant to interferon, 2 concurrent illness). 3/17 patients are Still undergoing therapy and 4/17 patients who terminated therapy early are still HCV +ve. 10/17 patients have completed 6 months IFN, all had normal transaminases at cessation. However 1/6 tested was Still HCV PCR +vei 3/10 have relapsed within two months of completing (2 rapid and marked biochemical relapse, 1 viraemic only). Summary-IFN in acute HCV amongst hypogammaglobulinemic patients (prone to severe HCV) results in rapid biochemical improvement plus viral loss in the sera However side effects were marked and caused dosage reduction or termihation of therapy in many 8/17 (47%), 3 patients have relapsed rapidly despite normal LFFs and persistent clearence of viraemia during therapy though 3 patients are showing a sustained response.
QUANTITATIVE HEPATITIS-C-RNA-PCR AND DETECTION W I T H A DNA-ELISA T. Heintges, L. Mohr, C. Niederau, F. Scheiffele*, D.H~iussinger. Department of Gastroenterology, Heinrich-Heine-University, Dtisseldorf and *Albert-Ludwigs-University, Freiburg, Germany. Sensitive detection kits for PCR products could allow a quantitative PCR and therefore a quantification of viral replication. Due to the low cir8hlating levels of HCV-RNA direct hybridisation kits are not sensitive enough for detection. In a certain range of cycle numbers PCR amplifies viral RNA linearly. A DNA enzyme immunoassay (DEIA. Sorin Biornedica. Dtisseldorf. Germany) was tested for sensitivity and validity of HCV-RNA detection. Methods: PCR with 20 to 35 Cycles was performed using a pair of primers deduced from the 5"noncoding-Region of HCV. Parts of the HCV-RNA were cloned (pUC 18) and sequenzed. Detection of the amplified P(2R-products was done using an agarose gel (I,5%) or by DEIA. Microtiter plates were incubated with biotinylated antisense captureoligonueleotides (position 158-198. 41bp). Afterwards PCR-products were hybridised with the antisense oligonucleotides. Captured PCR-products were detected with an colorimetric antibody system specific for doublestranded DNA. Patients: The tests were done m serum of 30 consecutive patients with HCV-Ab positive, histologically proven active hepatitis. Results: The detection limit of PCR with DEIA or gel detection was dependent on the number of PCR cycles (DEIA: 25 cycles (e): 103 genomes/p-1 HCV-eDNA (G/p-l), 30 c: 103 g/p-l, 35 c: 10~ g/p.l; Gel 25 c: 2 2 I 10 g/p.l, 30 e: 10 g/p-l, 35 c: 10 g/p.l). The correlation of the OD with the HCV-cDNA concentration decreased with increasing numbers of PCR cycles (25 c: r=0,80; 30 c: r=0,67; 35 c: 1"=0,29). HCV-RNA was found in 19 of 30 sera of patients (47%) with gel detection and in 14 of 30 patients (63%) with DEIA using 35 PCR cycles. Discussion: The PCP,/DEIA technique allows a semiquantitative determination of HCV-cDNA concentrations of at least 103 G/gl by PCR and DEIA is possible. To obtain a reasonable sensitivity for HCV concentrations m serum of patients with hepatitis C the number of PCR cycles has to be increased however, to numbers that do not provide a reliable quantification anymore. Further studies have to evaluate whether the detection system can be improved to provide a sufficient sensitivity for quantitiative HCV PCR.
AASLD ABSTRACTS
• HEPATITIS C INFECTION AND ALPHA-INTERFERON T H E R A P Y I N PATIENTS W I T H N O R M A L TRANSAMINASES - A PILOT STUDY • CJ I-I~lev, S Read, J Kurtz, KA Fleming and RWG Chapman Dept of Gasti-~,' Oxford Regional PHI,S, J0h n Radcliffe Hospital, and Nuffield Dept. Of Pathology, University of Oxford, Oxford UK Introduction Many HCV cases have normal liver function (LPTS) but may have significant liver pathology. Infection can be confirmed by RTPCR for HCV RNA. Alpha-interferon (IFN) is the only therapy for HCV resulting in long term response; This pilot study used RT-PCR to identify chronic HCV infection and examine IFN response(standard dose) in patients with normal LPTs. Methods Patients w ~ ' w e r e anti-HCV +ve (2nd gen.ELISA) and HCV RNA +ve by RT-PC~ were offered liver biopsy. Histology was compared (stage and histological activity index, HAI) between patients with persistently n~rmal LF'I'S(NOR) and those with temporarily or permanently abnormal LPTs(AB). Persistently normal liver function was defined as at least 3x normal Lb-Ts(>lmo. apart). Cases with normal LFTS who had chronic persistant (CPH) or active hepatitis (CAH) were treated with IFN, 3.MU, 3x/week for 24wks. Nested RT-PCR was performed at 0, 12, 24, 36 and 48 wks.. Results ~arison of liver histolos~¢ between two 8re ~ps LFTs n m e a n HAI F/U HISTOLOGY* (range) Mo. Nor Min CPH I CAH I Cirr 'NOR 23 '3.7(0-8) 12.3 2 9 18 14 l0 ~AB 31 17.3(1-14) 14.4.1 0 5 ~7 16 ~3 Nor=Normal, Min=Minimal hepatitiS,Cirr=-Cirrhosis 14 patients with normal LFTs commenced IFN. 8 patients have completed 6/12, 2 patie~ats withdrew(2* to side effects) and 4 patients are yet to fifiish b) Response to IFN therapy in patients with normal LFTs Week 0 12 124 36 '] 48 Interferon Post therapy RNA+vetno. ofpts 14/14 17 / 1 2 2i8 5/8 2/3 % +ve 100 I ::~ [ 25, I 63 , 67 In 10 patients who have inished treatment (8 completed tdrawals), only 2 have remained HCV RNA negative (> 3mths post therapy). Conclusions Histological abnormality is common even in patients with normal LPTs. Response to interferon can be measured by RT-PCR in patients with normal LFTS. The majority of IFN treated patients have viraemic relapse within 6 months of therapy. Interferon does not appear in this pilot study to be more effective in patients with normal LPTs.
• COMBINED ANALYSIS OF FRENCH, AMERICAN AND CANADIAN RANDOMIZED CONTROLLED TRIALS OF URSODEOXYCHOLIC ACID THERAPY IN PRIMARY BILIARY CIRRHOSIS. E.J. Heathcote 1, K.D. Lindor2, R. Poupon3, K. Cauch-Dudek I . E.R. Dickson2, R. Trout4, R.E. Poupon5 IUniversity of Toronto. Toronto Canada, 2Mayo Clinic. Rochester MN. 3H6pital Saint-Antoine. Paris France. 4Rutgers University, New Brunswick N J, 5Inserm, Villejuif France.. Three large randomized controlled trials of ursodeoxycholic acid (UDCA) for the treatment of patients with primary biliary cirrhosis (PBC) have been published and all have shown the beneficial effect of treatment on biochemistry. However, a beneficial effect on survival free of transplant (defined as time to transplant or death without transplant) was observed in only 1 of these trials. To estimate the magnitude of this effect of UDCA at 4 years, the raw data from these 3 trials were combined and followup extended beyond that published. METHODS: All patients had biopsy-proven, antimitochondrial antibody positive PBC. and were randomized to receive UDCA (13-15 mg/kg/day) or identical placebo. In one study, blinded randomization continfied for 4 years; in 2 studies, open label UDCA was offered to all patients after 2 years. The endpoint of survival free of liver transplantation was compared between the UDCA and placebo using standard life table analyses• Analyses were done on an "intent-to-treat" basis, thereby potentially underestimating the effecl of UDCA. To indicate the size of benefit from UDCA therapy, the risk r~duetion was calculated. RESULTS: Between 1987 and 1992. 553 patients were randomized. 276 to UDCA and 277 to placebo. Baseline characteristics were comparable at entry viz median age 58 UDCA (range 30-84) vS' 56 placebo (2888). median bilirubin 1.0 mg/dL UDCA vs 1.1 placebo (0.2-26.9 vs 0.1-17.3), and number with cirrhosis 26.1% vs 24.5%. Median length.of followup was 4 yrs in the UDCA group, and 3.8 yrs in the original placebo group. Those placebo patients who went on to receive UDCA did so for a mean of 1 yr. There were 47 patients in the UDCA group and 68 in the placebo group who did not survive free of transplant. Survival free of transplantation was extended in patients originally randomized to UDCA when compared to those on placebo (mean of 3.66 vs 3.45 yrs, log rank 2-tailed p=0.014). In the UDCA group, the risk of dying or being transplanted was reduced by 32% (:k 11%) of that observed in the original placebo group. CONCLUSION: UDCA treatment of patients with PBC improved their survival free of transplant when compared to placebo.
GASTROENTEROLOGY,Vol. 108, No. 4
• TREATMENT OF ACUTE HEPATITIS C WITN ALPHA I N T E R F E R O N IN H Y P O G A M M A G L O B U L I N A E M I A - THE UK G A M M A G A R D O U T B R E A K CJ Healey, J Watson, M Durridge, N Snowdon, J Christie S Wong, S Read, J Kurtz, KA Fleming, H Chapel and RWG Chapman. Depts of Gastro.; Immunol., and Nuffield Dept. of Pathology, Oxford Regional pHLS, John Radcliffe Hospital, Oxford, UK for the UK Gammagard Users Introduction-Intravenous immunoglobulin (IVIG) is established therapy for antibody deficiencies. Despite anti-HCV screening, 36 UK patients were treated with a batch of IVIG containing HCV(Gammagard®-Withdrawn 23/2/94 by manufacturers). The majority of them have developed acute HCV (genotype la). Previous outbreaks of HCV in hypogammaglobulinic patients have suggested the infection can run a rapid severe course. Treatment of HCV With alpha-interferon (IFN) has been shown to be more effective both in the acute disease and at increased doses. Meth0ds-HCV infection was confirmed by RT=PCR in exposed individuals. Patients With documented HCV infection were offered treatment With IFN, if appropriate; Initial" therapy was planned as 6 Mega Units(MU), SC, 3x weekly for six months. As this was an open study, attending physicians were able to tailor the dose to each individual. Results-Treatment data from 9 UK centres i s available for 34/36 cases of contaminated IVIG exposure. 5 patients were PCR -ve, 3 declined therapy and 8 were considered inappropriate for treatment (5 malignancies 1 severi~ lung disease 1 Severe grali~10matous liver disease, 1 history of:depressi0n). One case had previous HCV cirrhosis, a biochemical flare at the second exposure, had a liver graft and now is well but with recurrent HCV. 17129(59%) HCV infected patients commenced treatment with IFN (13-6 MU 3x weekly, 4-at reduced doses) within 8 months of exposure (range 2-8 mths). 4 treated patients required dose reduction ( 2 thrombocytopaenia, 2 severe lethargy) and 4 failed to finish 6 months (2 intolerant to interferon, 2 concurrent illness). 3/17 patients are Still undergoing therapy and 4/17 patients who terminated therapy early are still HCV +ve. 10/17 patients have completed 6 months IFN, all had normal transaminases at cessation. However 1/6 tested was Still HCV PCR +vei 3/10 have relapsed within two months of completing (2 rapid and marked biochemical relapse, 1 viraemic only). Summary-IFN in acute HCV amongst hypogammaglobulinemic patients (prone to severe HCV) results in rapid biochemical improvement plus viral loss in the sera However side effects were marked and caused dosage reduction or termihation of therapy in many 8/17 (47%), 3 patients have relapsed rapidly despite normal LFFs and persistent clearence of viraemia during therapy though 3 patients are showing a sustained response.
QUANTITATIVE HEPATITIS-C-RNA-PCR AND DETECTION W I T H A DNA-ELISA T. Heintges, L. Mohr, C. Niederau, F. Scheiffele*, D.H~iussinger. Department of Gastroenterology, Heinrich-Heine-University, Dtisseldorf and *Albert-Ludwigs-University, Freiburg, Germany. Sensitive detection kits for PCR products could allow a quantitative PCR and therefore a quantification of viral replication. Due to the low cir8hlating levels of HCV-RNA direct hybridisation kits are not sensitive enough for detection. In a certain range of cycle numbers PCR amplifies viral RNA linearly. A DNA enzyme immunoassay (DEIA. Sorin Biornedica. Dtisseldorf. Germany) was tested for sensitivity and validity of HCV-RNA detection. Methods: PCR with 20 to 35 Cycles was performed using a pair of primers deduced from the 5"noncoding-Region of HCV. Parts of the HCV-RNA were cloned (pUC 18) and sequenzed. Detection of the amplified P(2R-products was done using an agarose gel (I,5%) or by DEIA. Microtiter plates were incubated with biotinylated antisense captureoligonueleotides (position 158-198. 41bp). Afterwards PCR-products were hybridised with the antisense oligonucleotides. Captured PCR-products were detected with an colorimetric antibody system specific for doublestranded DNA. Patients: The tests were done m serum of 30 consecutive patients with HCV-Ab positive, histologically proven active hepatitis. Results: The detection limit of PCR with DEIA or gel detection was dependent on the number of PCR cycles (DEIA: 25 cycles (e): 103 genomes/p-1 HCV-eDNA (G/p-l), 30 c: 103 g/p-l, 35 c: 10~ g/p.l; Gel 25 c: 2 2 I 10 g/p.l, 30 e: 10 g/p-l, 35 c: 10 g/p.l). The correlation of the OD with the HCV-cDNA concentration decreased with increasing numbers of PCR cycles (25 c: r=0,80; 30 c: r=0,67; 35 c: 1"=0,29). HCV-RNA was found in 19 of 30 sera of patients (47%) with gel detection and in 14 of 30 patients (63%) with DEIA using 35 PCR cycles. Discussion: The PCP,/DEIA technique allows a semiquantitative determination of HCV-cDNA concentrations of at least 103 G/gl by PCR and DEIA is possible. To obtain a reasonable sensitivity for HCV concentrations m serum of patients with hepatitis C the number of PCR cycles has to be increased however, to numbers that do not provide a reliable quantification anymore. Further studies have to evaluate whether the detection system can be improved to provide a sufficient sensitivity for quantitiative HCV PCR.