Kinetics of hepatic bile acid handling in chronic liver diseases

April 1998 AASLD A1321 from 141 to 26.6. Nineteen of the 27 responders remained PCR negative for a mean follow-up of 612 days (range 180-1760), for a SR rate of 43%. Eight patients with ETR relapsed (29.6%) within a mean of 50.6 days (range 7-112). Viral relapse by PCR following cessation of therapy was associated with a rise in ALT in 6 of these 8 patients. Conclusion: A treatment regimen of 5 million units of interferon alpha three times a week for 1 year is considerably more effective than published results using 3 million units three times a week for 6 months, with a sustained response rate of 43%. This research was funded by the Mary Lea Johnson Richards Research Institute. L0502 KINETICS OF HEPATIC BILE ACID HANDLING IN CHRONIC LIVER DISEASES. P.PazzL R.Scagliarini, S. Gamberini, C.Rizzo, N.Prandini, L.Feggi, S.Gullini, Dept. of Gastroenterology and Nuclear Med., St. Anna Hospital, Ferrara, Italy. Bile acid metabolism is disturbed early in the course of liver diseases. It has been recently shown that the '/-labeled bile acid 75Se-homocholic acid taurine (7SSeHCAT) provides a tool for the direct measurement of hepatic bile acid handling, but it is not available for iv injection. 99mTc-BrHIDAis the only iv radiopharmaceutical available in Italy for hepatobiliary imaging. Therefore, the aim of the study was to compare the liver kinetics of 75SeHCAT with those of 99mTc-BrHIDA, measured by direct "/-camera scanning and by plasma disappearance rates, in 6 healthy controls (Ctr), in 6 patients with primary biliary cirrhosis stage I-II (PBC), and in 6 with chronic hepatitis C (CHC). Subjects were sex- and age-matched, and were not taking drugs. A homemade saline solution of 75SeHCAT (0.74Mbq) and 1.48 Mbq of 99mTc-BrHIDA were simultaneously injected. Plasma disappearance rates (early K t, and late K2) were determined from serial blood samples, and hepatic uptake and excretory rates directly from dynamic abdominal y-camera scanning. Both scanning and sampling were carried out over a 90-min period. In all groups, plasma disappearance rates were faster for 75SeHCAT than for 99mTc-BrHIDA (K~ ns, K2 p<0.05) and hepatic transit time (defined as time of first appearance of isotope activity over the gallbladder or gut area, whichever was first) of 75SeHCAT was significantly shorter (p<0.05). Uptake and excretion rates of the two compounds were similar. Overall, "/-camera counting of the two compounds showed a good correlation, as well as plasma activity. The initial phase of decline in plasma activity (K1) was independent of the second slower phase (K2), and correlated with hepatic uptake (99mTc-BrHIDA r=0.93, p=0.016; 75SeHCAT 1"=-0.89, p=0.033), but not with excretion, whereas K 2 tended to correlate with excretion, but not with uptake. Uptake rates and K 1 of the two compounds tended to be lower in CHC patients, but there was no significant difference between the three groups. Excretion rates were significantly lower in PBC (p<0.01) and in CHC (p<0.05) than in Ctr, and hepatic transit time was longer in PBC (p<0.05) and in CHC (p<0.01) compared to Ctr. In conclusion, 99mTc-BrHIDAis efficiently handled by the liver, similarly to 75SeHCAT, and it provides a tool for direct measurement of bile acid handling. Hepatic bile acid uptake and excretion appeared as independent processes; uptake is related to early, whereas excretion is related to late, plasma disappearance. CHC patients, as well as PBC ones, have an impairment in excretion rate and a delayed intrahepatic transit time, suggesting bile acid retention. L0503 NEW MARKERS OF OXIDANT STRESS IN CHRONIC LIVER DISEASE. P.Pemberton, S.Jain, A.Smith, T.W.Wames. Liver Unit, Manchester Royal Infirmary, Manchester, UK Oxidant stress, an imbalance between pro- and anti-oxidant processes, can play a significant role in progression of chronic liver disease. Methods for monitoring oxidant stress in human liver disease are limited and the present study examines novel markers. Patients & Methods:-Fasting serum and urine samples were obtained from 12 controls, 15 patients with hepatitis C (HCV) and 7 with alcoholic liver disease (ALD). Prooxidant processes were assessed using serum malondialdehyde (MDA; by TBARS or DETBARS), or 8-isoprostane (by EIA, Cayman kit). Total antioxidant levels were assayed in whole o r protein-free serum using a chemiluminescence method, and individual antioxidants by standard laboratory methods. Marker MDA (TBARS) MDA (DETBARS) 8-isoprostane (plasma) 8-isoprostane (urine) total antioxidant (whole serum) total antioxidant (protein-free) albumin vitamin E vitamin C bilirubin urate control 1.396 1.760 14.87 135.3 1364 468.9 56.77 11.91 13.78 15.00 0.280 HCV 1.687 2.141 35.72 603.4 917.4 a 450.6 50.20 e 10.10 12.00 14.00 0.310 ALD 2.837 b 4.868 b 74.84 944.1 " 962.4 446.8 44.04 b 13.83 10.95 59.00 b 0.270 Results are shown as medians. M D A in nmoles/1; 8-isoprostane in ng/l (serum) and ng/g creatinine (urine); antioxidants in tonoles/l trolox; albumin in g/l; vitamins in rag~l; bilirubin in pmoles/l and urate in mmoles/l, a = p < 0.05, b = p < 0.01, c = p < 0.001 compared to controls (Mann-Whitney) Results: High bilirubin levels in the ALD group indicate more severe liver disease which is reflected in higher MDA and 8-isoprostane in ALD than HCV. Unexpectedly, total serum antioxidants are more depleted in HCV than in ALD, but the high bilirubin in ALD may boost levels as bilirubin is itself an antioxidant. Protein-free antioxidant levels seem unaffected by liver disease, suggesting that protein-bound antioxidants are likely to play a more critical role. Conclusions: Although a wide range of markers of oxidant stress have been employed in cell culture and animal studies, human studies have in general been restricted to analysis of MDA (by TBARS and rarely by specific assay) and of individual antioxidants. The present study demonstrates that additional, valuable insights into the oxidative process may be gained by analysis of DETBARS, 8-isoprostanes and total antioxidant levels. • L0504 ASSOCIATION OF HEPATITIS C VIRUS IN CEREBROSPINAL FLUID WITH CRYOGLOBULINEMIA AND A SYNDROME OF CEREBRITIS. RG Perez, J Duffy, GW Petty, JJ Germer, P Rys, JB Gross Jr, DH Persing. Mayo Clinic and Foundation, Rochester, MN. HCV and other members of the flaviviradae family, have been shown to exist in the central nervous system (CNS). We report a p t with HCV RNA in cerebrospinal fluid (CSF) and a clinical syndrome of cerebritis. Case: A 74 yr old woman with cryoglobulinemia had stroke-like symptoms including slurred speech, gait abnormalities and dementia, in association with of a sensory peripheral neuropathy. A brain MRI demonstrated several infarcts. Electromyography was consistent with a sensory neuropathy and a nerve biopsy demonstrated necrotizing vasculitis of the nerve. A lumbar puncture was performed to search for other causes of her CNS symptoms. Serum tested positive for HCV by a second generation ELISA with confirmation by RIBA-2 (Chiron Corp.). Results: Serum and CSF were tested by RT/PCR with primers specific for the 5' UTR of the HCV genome. Both serum and CSF were positive for HCV RNA by both gel electrophoresis and confirmed by probe hybridization. Separate serum and CSF aliquots were also tested by the Amplicor Hepatitis C virus test (Roche) and both were positive for HCV. The serum and CSF were tested by the Quantiplex HCV RNA 2.0 assay (bDNA) (Chiron Corp.) method to quantitate the virus present. The serum demonstrated 9 Meq/ml and the CSF was below the detection limit of the test (<0.2 Meq/ml). The positive PCR products from the serum and the CSF were sequenced and the HCV genotype was found to be lb. The patient had been initially treated with prednisone and improved. After discovery of the cryoglobulinemia and HCV she was begun on alpha-Interferon and her prednisone is being tapered. Her neurologic symptoms have improved. Conclusions: 1. HCV RNA may be the only positive finding in CSF in some patients with a clinical syndrome of CNS vasculitis. 2. The association with mixed cryoglobulinemia strongly suggests HCV-associated vasculitis as the cause of this patient's CNS symptoms. 3. Patients with HCV-associated CNS vasculitis might benefit from antiviral therapy. L0505 ROLE OF HEPATITIS G IN SYMPTOMATIC CRYOGLOBULINEMIA. RG Perez, JB Gross Jr, J Duffy, DH Persing. Mayo Clinic and Foundation, Rochester, MN. Hepatitis G (HGV) is a recently discovered member of the flavivirus family that co-infects 10-20% of hepatitis C (HCV) infected patients. HCV is found in 80-90% of patients with essential mixed cryoglobulinemia and is thought to be the cause of this disease. No information exists regarding the prevalence of HGV infection in cryoglobulinemia. Aim: To assess the frequency of HGV in patients with symptomatic cryoglobulinemia. Methods: We tested all patients seen at the Mayo Clinic between 1994-96 with symptomatic type II mixed cryoglobulinemia, for HCV and HGV. HCV RNA was assessed using primers specific to the 5' UTR and HGV RNA using primers to the NS5 region of the viral genome. HCV genotypes were determined by amplifying and sequencing the NS5 region of the HCV gennme. Results: Twenty-one pts (llF, 1 0 M ) had symptomatic type II cryoglobulinemia. Twelve were HCV RNA positive by RT/PCR to the 5' UTR. HCV genotypes included four la, three lb, two 2b, and one 3a nd two were untypeable. HGV RNA was not detected in any of the HCV-associated cryoglobulinemia cases. HGV RNA was detected in two of the HCV- negative cryoglobulinemia patients. Both patients had received blood transfusions in the past. These two patients had significantly elevated cryocrits, 62% and 37%; both of these patients had significant renal disease and peripheral neuropathy. When comparing the HCV (-) and HCV (+) cryoglobulinemia pts the mean cryocrits were similar, 15% and 14%, respectively. The HCV (-) cryoglobulinemia pts were older, with a mean age of 51yrs versus 41yrs in the HCV (+) pts. Conclusions: 1. 55% (12/21) of symptomatic cryoglobulinemia pts were positive for HCV. 2. HCV genotype frequencies in symptomatic cryoglobulinemia pts were similar to previous frequencies reported for pts with hepatitis C in the U.S. (la and lb account for 58%). 3. HGV was not present in any of our HCV-associated cryoglobulinemia pts. 4. HGV was present in 2 of 9 HCV (-) cryoglobulinemia pts, both of whom had significant clinical manifestations, raising the possibility of HGV-induced cryoglobulinemia symptoms.