Significant Hepatic Inflammation Research Articles

Risk factors related to significant hepatic inflammation in patients with acute drug-induced liver injury

BackgroundCurrently, research on biopsy-proven acute drug-induced liver injury (DILI) remains limited. This study aimed to identify clinical characteristics and risk factors for significant hepatic inflammation in patients with acute DILI. MethodsAn ambispective cohort study was conducted on biopsy-proven acute DILI patients admitted to our hospital from 2012 to 2018. Using the Scheuer scoring system, patients were categorized into G0-2 or G3-4 groups and followed up for 12 months after first admission. Clinical characteristics and outcomes were retrieved from medical records. ResultsThe median age of the 157 enrolled patients (65.6% female) was 40.4 (interquartile range (IQR), 31.9–49.1) years. The median latency and length of hospitalization were 30.0 (IQR, 5.0–60.0) and 18.0 (IQR, 12.0–26.0) days. The proportions of patients in the G0-2 and G3-4 groups were 54.8% and 45.2%, respectively. Logistic regression analysis revealed that females (odds ratio (OR): 2.623, 95% confidence interval (CI): 1.169–5.887, p ​= ​0.019), higher body mass index (OR: 1.168, 95% CI: 1.029–1.325, p ​= ​0.016), higher total bilirubin (OR: 1.004, 95% CI: 1.000–1.007, p ​= ​0.047), and lower prothrombin activity (OR: 0.976, 95% CI: 0,957–0.995, p ​= ​0.013) were associated with significant hepatic inflammation. The predominance of the hepatocellular injury pattern (60.5%) at admission transformed into a predominance of the cholestatic pattern (60.5%) at discharge. During follow-up, 23 patients (14.6%) developed chronic DILI, with nine patients (5.7%) progressing to cirrhosis. Moreover, 15 female patients (9.6%) developed autoimmunity (3cases in the G0-2 group vs 12 cases in the G3-4 group, p ​< ​0.05). ConclusionsAcute DILI patients with high-risk factors were more likely to develop significant hepatic inflammation, and females with significant inflammation were at a higher risk of developing autoimmunity during follow-up.

Shear wave elastography: How well does it perform in chronic hepatitis D virus infection?

Hepatitis delta virus (HDV) infection is associated with accelerated progression of liver disease to cirrhosis. Shear wave elastography (SWE) is a non-invasive evaluation method of liver fibrosis. Its performance in accurately characterizing HDV fibrosis compared to other noninvasive markers remains unknown. We assessed the performance of SWE in patients with chronic HDV, Hepatitis B (HBV) and Hepatitis C (HCV) infection. Cirrhosis was determined by histology or clinical data. Area under receiver operator characteristics (AUROC) was used to assess diagnostic performance in identifying cirrhosis by SWE in comparison with Fibroscan® (VCTE) and serologic tests of fibrosis. 158 patients with chronic hepatitis (HDV:44%, HBV: 46% and HCV: 29%) were evaluated. Cirrhosis was diagnosed in 28 (17.7%) patients. Mean noninvasive fibrosis measurements for the HBV/HCV and HDV groups, respectively, were as follows: APRI: 0.73 ± 1.08 and 1.3 ± 1.38; FIB-4: 1.90 ± 2.24 and 2.33 ± 2.24; VCTE: 8.9 ± 6.7kPa vs 10.4 ± 5.3kPa; SWE: 1.5 ± 0.2m/s and 1.6 ± 0.2m/s. The performance of SWE in detecting HDV-induced cirrhosis (AUROC 0.84, 95% CI 0.71-0.97) was slightly lower than in HBV/HCV induced disease (AUROC 0.88, 95% CI 0.81-0.96). For HDV patients, the performance of SWE was comparable to VCTE and slightly better than APRI and FIB-4 especially in APRI and FIB-4 indeterminate zones. The overall less accurate performance of noninvasive markers in HDV in comparison with HBV and HCV may be a result of significant hepatic inflammation in HDV.

Serum qAnti-HBc combined with ALT and HBsAg predicts significant hepatic inflammation in HBeAg-positive immune active patients.

Quantitative hepatitis B core antibody (qAnti-HBc) level has been reported to predict significant liver inflammation in treatment-naïve chronic hepatitis B patients. However, little evidence has been revealed that qAnti-HBc alone or with other serum parameters in predicting moderate to severe hepatic inflammation in HBeAg-positive immune active patients treated with entecavir (ETV). A total of 142 patients with HBeAg-positive immune active hepatitis were recruited in our study. Serum liver biochemistry, qAnti-HBc, hepatitis B virus markers, and liver inflammation were evaluated during 48-week ETV treatment. The association between liver inflammation grades and serum markers was systematically analyzed. The patients with moderate to severe inflammation (≥G2) had a significantly higher level of qAnti-HBc compared with those with no to mild liver inflammation patients (<G2). The levels of qAnti-HBc and alanine transaminase (ALT) were positively correlated with hepatic inflammation grades, and qAnti-HBc had a better correlation than ALT, whereas HBsAg was negatively correlated with hepatic inflammation grades before treatment. After 48-week ETV treatment, no correlation was observed between hepatic inflammation grades and qAnti-HBc, ALT, or HBsAg. The combination of qAnti-HBc, ALT, and HBsAg had better performance in predicting significant liver inflammation (≥G2) than qAnti-HBc alone or its combination with ALT. Serum qAnti-HBc levels were positively correlated with hepatic inflammation grades before treatment, but no positive correlation between them was observed after 48-week treatment. The level of qAnti-HBc combined with ALT and HBsAg may serve as a more reliable marker for identifying significant liver inflammation before treatment in HBeAg-positive immune active patients.

Vibration-controlled transient elastography for the detection of cirrhosis in chronic hepatitis D infection.

Noninvasive detection of cirrhosis via vibration-controlled transient elastography (VCTE) has revolutionized the management of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. However, VCTE has not been studied in chronic hepatitis D virus (HDV) infection and accuracy remains in question due to the significant hepatic inflammation associated with this infection. Consecutive HBV, HCV and HDV patients who underwent VCTE (2006-2019) were evaluated. Diagnosis of cirrhosis was made via liver biopsy or clinical findings. VCTE was compared with other noninvasive serum fibrosis tests using AUROC curves. The performance of VCTE in HBV/HCV/HDV was also compared. We evaluated 319 patients (HBV-112; HCV-132; HDV-75), 278(87%) patients had histology for evaluation. HDV patients had evidence of higher hepatic inflammation as evidence by aspartate aminotransferase, alanine aminotransferase and histology activity index. Cirrhotic HDV patients had higher mean liver stiffness measurements compared with noncirrhotic patients (29.0 vs 8.3kPa, P<.0001). VCTE demonstrated excellent diagnostic accuracy for the detection of cirrhosis with an AUROC of 0.90 compared with APRI (0.83), FIB-4 (0.88), AAR (0.73) and RPR (0.85). Performance of VCTE in HDV was comparable with HBV (0.93) and HCV (0.94). At the optimized cut-off value of ≥14.0kPa for determining cirrhosis in HDV, VCTE had a sensitivity of 0.78, specificity of 0.86, NPV of 0.93 and PPV of 0.64. Hence, VCTE is a useful noninvasive test in HDV for determining cirrhosis despite the presence of significant hepatic inflammation.

Management of individuals with chronic hepatitis B virus infection and persistent normal or mildly elevated aminotransferase levels.

No consensus exists with respect to positive hepatitis B virus (HBV) DNA results and persistent normal or mildly elevated alanine aminotransferase (ALT). The aim of this study is to investigate the appropriate management and prognosis of these populations with chronic hepatitis B (CHB). A total of 235 subjects with positive HBV DNA results and persistent normal or mildly elevated ALT were enrolled in this study. Liver biopsy and liver stiffness measurements (LSM) were performed in all participants at baseline. Antiviral therapy was initiated in patients with significant hepatic inflammation (G ≥ 2) and/or fibrosis (S ≥ 2). The patients were divided into entecavir and adefovir groups based on HBV DNA load (>2000 IU/mL vs <2000 IU/mL). The liver biopsies were repeated at 72 weeks for the patients received antiviral therapy. We found that 112 subjects were hepatitis B e antigen (HBeAg) positive, and 123 subjects were negative. The corresponding median ALTs were 46 (39.5-52.5) and 48 (41.5-57.0) U/mL, respectively. G ≥ 2 and/or S ≥ 2 diseases were present in 48.8% (82/168) of the HBeAg-positive and 51.2% (86/168) of HBeAg-negative patients, respectively. In addition, 96 HBeAg-positive and 72 HBeAg-negative patients were divided into entecavir and adefovir groups. Meanwhile, liver biopsies had greater diagnostic accuracy for determining cirrhosis than LSM (0.711 vs 1.0, P < 0.0001). At the end of the study period, undetectable HBV DNA levels and normal ALT levels were observed in CHB-infected patients. Furthermore, the patients showed histologic improvement at 72 weeks compared with baseline measurements (G, 1.72 ± 1.00 vs 0.73 ± 0.88, P = 0.0002; S, 1.484 ± 0.90 vs 0.99 ± 1.13, P < 0.0001). Collectively, liver biopsy enhanced diagnostic accuracy for CHB-infected individuals with persistent normal or mildly elevated aminotransferase levels. Moreover, antiviral therapy can improve or regress the hepatic fibrosis and cirrhosis.

Long-Term, Low-Dose Exposure to Microcystin-LR Does not Cause or Increase the Severity of Liver Disease in Rodents

BackgroundAcute exposure to high concentrations of microcystin-LR (MC-LR) can cause significant hepatocyte injury. Aim. To document the effects of long-term, low-dose MC-LR exposure on hepatic inflammation and fibrosis in mice with healthy and diseased livers. Material and methodsMale CD1 mice (N = 20/group) were exposed to 1.0 μg/L of MC-LR in drinking water; 1.0 μg/L MC-LR plus 300 mg/L of the hepatotoxin thioacetamide (MC-LR/TAA); or 300 mg/L TAA alone for 28 weeks. Liver biochemistry and histology were documented at the end of the study period. In addition, hepatic stellate cells (HSCs), were exposed in vitro to MC-LR (0.1-10,000 μg/L) and monitored for changes in cell metabolism, proliferation and activation. ResultsLiver biochemistry and histology were essentially normal in MC-LR alone exposed mice. MC-LR/TAA and TAA alone exposed mice had significant hepatic inflammation and fibrosis but the extent of the changes were similar in the two groups. In vitro, MC-LR had no effect on HSC metabolism, proliferation or activation. ConclusionLong-term, low-dose exposure to MC-LR is unlikely to lead to chronic liver disease in the setting of a normal liver or exacerbate existing liver disease in the setting of ongoing hepatitis.

Olive Oil Attenuates the Cholesterol-induced Development of Nonalcoholic Steatohepatitis Despite Increased Insulin Resistance in a Rodent Model

It is indefinite whether nonalcoholic steatohepatitis (NASH) results as by-product from general metabolic perturbations and adipokine dysregulations or whether defined dietary factors also play a pathogenetic role. Here, we examine the effects of a modification of dietary lipids in a NASH inducing diet on metabolic changes as well as hepatic steatosis, inflammation, and fibrosis in rats. Male Wistar rats were fed with variations of the atherogenic diet (AD), which induces pathophysiological changes resembling human NASH. Dietary variants (AD without cholesterol, cholate, or choline; change of neutral fat to olive oil or coconut oil) were fed for 8 weeks. Insulin resistance, adipokine profile, liver histology, and lipid content as well as expression of proinflammatory and profibrogenic genes were examined. AD led to clear signs of hepatic steatosis and inflammation together with an increase in TNF and collagen type 1 expression. AD without cholesterol showed markedly less liver damage without changes of insulin action and adipokine profile. AD with olive oil and AD without cholate clearly attenuated hepatic inflammation, whereas fat deposition and features of the metabolic syndrome were increased in these animals. Insulin resistance and hepatic fat deposition per se do not cause significant hepatic inflammation in this rodent model. However, dietary cholesterol is an important causal agent for the development of NASH. Olive oil plays a protective role in this respect, which might be due to the high content of monounsaturated fatty acids.

Laboratory‐based scoring system for prediction of hepatic inflammatory activity in patients with autoimmune hepatitis

In autoimmune hepatitis (AIH), inflammation is closely related to fibrosis. Although transaminase levels are commonly used to assess hepatic inflammation, they may not relate directly to the histology. We developed a noninvasive diagnostic score as an alternative to liver biopsy to help optimize treatment for AIH and monitor disease progress. Eighty-two participants with type 1 AIH who had undergone liver biopsy were included (44 in training and 38 in validation sets). Liver histology was assessed according to the histologic activity index (HAI; score 0-18) and Ishak's histologic fibrosis index (HFI; score 0-6). High inflammation was defined as HAI>4, and advanced fibrosis was defined as HFI>2. Routine laboratory test findings and stepwise linear regression were used to develop the best models predicting HAI and HFI. The best cut-off value to predict high inflammation and advanced fibrosis for these formulas was then calculated based on receiver-operating characteristic analysis. The cut-off value for a model predicting high inflammation was ≥3.57 (AUROC=0.93; 95% CI: 0.86-1.00), with 100% sensitivity and 85% specificity. High inflammation was confirmed with an 81% positive predictive value and excluded with a 100% negative predictive value. In the validation set, the sensitivity, specificity, positive predictive value and negative predictive values were 100, 56, 88 and 100% respectively. The diagnostic yield of the fibrosis score was unsatisfactory. The noninvasive inflammatory score based on four routine laboratory parameters discriminated patients with and without significant hepatic inflammation and may facilitate follow-up of type 1 AIH patients.

Influence of Age and HBeAg Status on the Correlation Between HBV DNA and Hepatic Inflammation and Fibrosis in Chronic Hepatitis B Patients

The purpose of this study was to examine the correlation between serum HBV DNA level and the severity of hepatic inflammation and fibrosis in patients with chronic hepatitis B. Liver function, serological markers of HBV and serum HBV DNA quantification were assayed in 215 CHB patients who also underwent liver biopsy. Liver pathology was regarded as the evaluation criteria to evaluate the correlation between serum HBV DNA level and the severity of liver inflammation and fibrosis. Of the 215 patients, 136 were HBeAg-positive and 79 were HBeAg-negative; 134 patients had mild hepatic inflammation and fibrosis and 81 had significant hepatic inflammation and fibrosis in pathological diagnosis. We found that positive correlation between the severity of hepatic inflammation and fibrosis and serum HBV DNA level was only present in HBeAg-negative patients but not HBeAg-positive patients (P < 0.001). Patients' age was a key factor influencing the correlation between serum HBV DNA level and the severity of hepatic inflammation and fibrosis. the cutoff values to predict the severity of hepatic inflammation and fibrosis were 33.5 and 36 years, respectively. Using 35 years as the cutoff value, positive correlation between serum HBV DNA level and hepatic inflammation and fibrosis was observed in both HBeAg-positive and HBeAg-negative patients aged ≥ 35 years (P < 0.05), however no correlation was observed in HBeAg-positive patients aged <35 years. There was positive correlation between serum HBV DNA level and hepatic inflammation and fibrosis in both HBeAg-positive and HBeAg-negative patients' aged ≥ 35 years, but in patients aged <35 years, positive correlation was only observed in HBeAg-negative patients.

Significant hepatic histopathology in chronic hepatitis B patients with serum ALT less than twice ULN and high HBV‐DNA levels in Indonesia

To study the prevalence of significant hepatic histopathology in chronic hepatitis B (CHB) patients with alanine aminotransferase (ALT) ≤ twice upper limit of normal (ULN) and its association with age, HBeAg status, hepatitis B virus (HBV)-DNA level and viral genotype. A prospective study was conducted over a 3-year period in treatment-naive CHB patients with ALT ≤ twice ULN. Patients with a history of acute flare hepatitis, use of alcohol and hepatotoxic drugs, hepatitis C, hepatitis D and human immunodeficiency virus (HIV) co-infection were excluded from the study. Hepatic histopathology was assessed according to the METAVIR scoring system. A total of 145 patients were recruited, 81 (55.9%) of whom were male. The patients' mean age was 41.50 ± 10.74 years (range 16-70 years). Significant hepatic inflammation was found in 59.3% of these patients, and significant hepatic fibrosis was found in 62.1%, the latter being associated with hepatitis B e antigen status, ALT levels and serum HBV-DNA, but not with their age group or viral genotype. Significant hepatic fibrosis was found in 24 of 35 CHB patients (68.6%) who were previously considered in an immunotolerance phase. The prevalence of significant hepatic histopathology in CHB patients with serum ALT levels ≤ twice ULN is high. Delayed antiviral treatment can be harmful.

Elevated systemic monocyte chemoattractrant protein-1 in hepatic steatosis without significant hepatic inflammation

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with obesity and the metabolic syndrome. It encompasses a clinico-pathologic spectrum of conditions ranging from simple steatosis to nonalcoholic steatohepatitis (NASH). The latter develops upon pro-inflammatory cell infiltration and is widely considered as the first relevant pathophysiological step in NAFLD-progression. The chemokine monocyte chemoattractant protein 1 (MCP-1) plays an important role in the progression of hepatic inflammation and fibrosis, and both increased hepatic expression and circulating serum levels have been described in NASH. Here, we aimed to investigate MCP-1 expression in simple hepatic steatosis. Upon feeding a high-fat diet mice developed hepatic steatosis in the absence of significant hepatic inflammation, but elevated hepatic MCP-1 expression compared to control mice fed a standard chow. Interestingly, high-fat diet fed mice had significantly higher MCP-1 serum levels, and MCP-1 mRNA expression was significantly increased in visceral adipose tissue. Furthermore, MCP-1 serum levels were also elevated in patients with ultrasound-diagnosed NAFLD and correlated with the body-mass index and fasting glucose. In conclusion, our data indicate both the liver and adipose tissue as cellular sources of elevated circulating MCP-1 levels already in the early phase of hepatic steatosis. Since MCP-1 derived from visceral adipose tissue reaches the liver via portal circulation at high concentrations it may significantly contribute to the progression of simple steatosis to NASH.

Elevated systemic monocyte chemoattractrant protein-1 levels in hepatic steatosis without significant hepatic inflammation

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with obesity and diabetes mellitus. It encompasses a clinico-pathologic spectrum of conditions ranging from simple steatosis to nonalcoholic steatohepatitis (NASH). The latter develops upon pro-inflammatory cell infiltration and is widely considered as the first relevant pathophysiological step in NAFLD-progression. The chemokine monocyte chemoattractant proteins (MCP-1) plays an important role in the progression of hepatic inflammation and fibrosis and increased hepatic expression has been described in NASH. The aim of the present study was to investigate MCP-1 expression simple hepatic steatosis. Methods and Results: A high-fat diet (HFD; 30% lard) was fed to male BALB/c mice for 20 weeks leading to a significant increase of body weight and fasting glucose serum levels. Further, HFD-fed mice revealed marked hepatic lipid accumulation in the absence of significant hepatic inflammation as evidenced by unaltered serum transaminases and hepatic TNF expression. However, HFD-fed mice had elevated hepatic MCP-1 expression and significantly higher MCP-1 serum levels compared to control mice fed standard chow. Moreover, we detected markedly increased MCP-1 expression in visceral adipose tissue of HFD-fed mice. In addition, we assessed MCP-1 in a cohort of patients with bland steatosis and observed significantly increased serum levels, which correlated with the body-mass index and serum glucose levels. Conclusion: Our data indicate both the liver and adipose tissue as cellular sources of elevated circulating MCP-1 levels already in the early phase of hepatic steatosis. Since MCP-1 derived from visceral adipose tissue reaches the liver via portal circulation at high concentrations it may significantly contribute to the progression of simple steatosis to NASH.

A novel in vitro model of alcohol-induced hepatic fibrogenesis

Chronic alcohol consumption is one of the main etiological factors for liver disease worldwide, however, only a fraction of drinkers develops significant hepatic inflammation, and even less progresses to significant hepatic fibrosis and cirrhosis. Still, there are no experimental models that lead to relevant hepatic fibrosis, and there is a high need to unravel the mechanisms and factors promoting hepatic injury in alcoholic liver disease (ALD).The aim of this study was to establish an in vitro model to study the hepatocyte mediated effects of alcohol on hepatic stellate cells (HSCs), the central mediators of liver fibrogenesis. Methods and Results: HepG2 hepatoma cells and primary human hepatocytes (PHH) were incubated with different concentrations of alcohol (0.1–1%) for 48h, which did not affect cell viability or mitochondrial activity but led to dose-dependent hepatocellular lipid accumulation as assessed by analysis of triglyceride content and free fatty acid levels, and as visualized by oil red o staining. Subsequently, human HSC were incubated with conditioned media (CM) from alcohol stimulated (Alc) or control hepatocytes. Further controls included control medium with and without alcohol (at concentrations determined in the CM from Alc-treated cells). Noteworthy, incubation of HSC with CM from Alc-treated hepatocytes significantly induced proliferation as well as pro-fibrogenic (TGF-beta) and NFkapaB-mediated pro-inflammatory gene (IL-8, RANTES) expression compared to the control groups. Conclusion: Our in vitro data indicate release of soluble factors as a potential mechanism for development and progression of fibrogenesis in alcoholic liver disease, the identification of which may lead to novel prognostic markers. Thus, this study provides an attractive in vitro model to study molecular mechanisms of alcohol-induced fibrogenesis, and to identify and test novel targets for anti-fibrotic therapies in alcoholic liver disease.

PD1 expression inhibits hepoatic inflammation and fibrosis in non-alcoholic steatohepatitis

PD-L1 is a B7-family member that binds to programmed death-1 (PD-1). PD-1 is involved in the negative regulation of immune responses. Recently, we have shown that PD-L1 is expressed on hepatocytes, and that hepatocytes induce apoptosis in T-cells via PD-L1. The aim of this study was to analyzed the expression and function of PD-1 in non-alcoholic steatohepatitis (NASH) in which T-cells play an important pathophysiological role according to most recent studies. Methods and Results: Two different NASH-models were applied to (i) PD-1 deficient (PD1-ko), (ii) PD-1 transgenic (PD1-trg), and (iii) wildtype (wt) control mice. Both models led to significant hepatic inflammation, and also PD-L1 and PD-1 upregulated in wt-mice. Noteworthy, hepatocellular inflammation and apoptosis were significantly lower in PD1-trg mice, but significantly higher in PD1-ko mice. Histopathological analysis confirmed extended hepatocellular damage and fibrosis in PD1-ko mice compared to wt-mice, while the damage in PD1-trg mice was less pronounced. Analysis of human hepatic specimens confirmed increased expression of PD-L1 and PD-1 in NASH-patients. Moreover, we observed increased PD-L1 expression in primary human hepatocytes in an in vitro model of hepatocellular lipid accumulation. Conclusion: Our findings indicate that increased hepatic PD-L1 expression in steatotic livers exhibits a protective effect via PD1. The control of this interaction appears as a promising strategy to inhibit NASH development and progression. Further, hepatic PD-L1/PD-1 expression may serve as prognostic marker.

Clinical use of liver biopsy for the diagnosis and management of inactive and asymptomatic hepatitis B virus carriers in Bangladesh

Patients with inactive chronic hepatitis B virus (HBV) infection are assumed to be free from liver disease. Accordingly, antiviral drug treatment is not recommended for these patients. However, the extent of liver damage in these patients has not been evaluated fully. The aim of this study was to evaluate the extent of liver damage in patients with inactive HBV. Liver biopsy was conducted in 141 inactive HBV carriers [HBeAg-negative, low levels of HBV DNA (<or=10,000 copies/ml) and normal levels of serum alanine aminotransferase (ALT)]. The extent of hepatic inflammation and fibrosis was evaluated in these patients by examining liver biopsy specimens. Although the patients were inactive HBV carriers, mild to moderate levels of necroinflammation (HAI necroinflammation score HAI-N1 >or= 7) were detected in 36 of 141 (26%) patients. Seventeen patients had a severe degree of hepatic fibrosis (HAI fibrosis score HAI-F >or= 3). A total of 10 patients had both considerable necroinflammation (HAI-N1>or=7) and severe fibrosis (HAI-F >or=3). All 10 patients with significant hepatic inflammation and fibrosis were male and older than 25 years. However, all were HBeAg-negative and expressed low levels of HBV DNA and normal ALT levels. The study demonstrates that features of liver damage were present in a considerable number of the patients. Assessment of liver biopsy specimens in a larger cohort of inactive HBV carriers is necessary to establish management guidelines for such patients.

Hepatic steatosis induces induction of the chemokine RANTES in the absence of significant hepatic inflammation

Hepatic steatosis induces induction of the chemokine RANTES in the absence of significant hepatic inflammation

Author reply

We appreciate the comments by Basso et al. concerning our article,1 in which we investigated the characteristics of patients with chronic hepatitis C virus (HCV) infection who developed hepatocellular carcinoma (HCC) after a sustained biochemical response (BR) to interferon (IFN) monotherapy. Basso et al. agreed with our belief that the persistence of serum HCV without significant hepatic inflammation does not play a significant role in the development of HCC, but they were interested in whether the HCV replication is associated with hepatocarcinogenesis. They then suggested that we clarify whether HCV persistence was noted among those patients who were sustained responders (SRs) and who developed HCC. Of the 27 SRs who developed HCC, 26 patients were sustained viral responders (SVRs) and only 1 patient had persistent viremia. A total of 1370 patients who were treated at the hospitals of Kyoto Prefectural University of Medicine and its affiliated hospitals were followed for 5.6 years on average and were examined regarding their serum HCV RNA status after IFN therapy. A total of 426 patients were SRs, 375 of whom were negative for serum HCV RNA (SVRs) and 51 of whom were positive for serum HCV RNA (BRs). Four SVRs developed HCC during the follow-up period and HCC was not noted in any of the 51 BRs.2 In our clinic, we also have followed 129 HCV carriers with persistently normal alanine aminotransferase (ALT) levels (≤ 30 IU/L), and HCC was not reported to have developed in any of these patients during a mean follow-up period of 7.3 years. Considering these data, we conclude that HCV replication without significant hepatic inflammation does not contribute to the development of HCC in HCV carriers. Therefore, we suggest that BR patients can be followed in the same manner as HCV carriers with persistently normal ALT levels. Although, as Basso et al. pointed out, there is a discrepancy with regard to the frequency of HCC developing in SVR patients between Japan1, 3, 4 and Europe,5 we must consider the baseline status of the subjects, especially with regard to their age, gender, and the stage of liver fibrosis. The majority of HCC cases develop in elderly male patients with advanced stage hepatic fibrosis with significant elevation of serum ALT. In our experience, the mean tumor dimension in the 114 patients who developed HCC after IFN therapy was 21 mm2; however, to our knowledge, there were no descriptions concerning the tumor dimensions in HCC patients provided in other studies. We suspect that careful follow-up might result in an increase in the number of HCC cases reported, even in Europe. Yoshito Itoh M.D.*, Akiko Makiyama M.D.*, Takeshi Okanoue M.D.*, * Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan.

Hepatic inflammation in rats with experimental small intestinal bacterial overgrowth

Hepatobiliary inflammation and other extraintestinal manifestations accompany certain intestinal disorders, perhaps because of proliferation or enhanced transport of luminal bacteria or their phlogistic cell-wall components. Using jejunal self-filling blind loops to create small bowel bacterial overgrowth, we compared biochemical and histological evidence of hepatic inflammation in 3 rat strains chosen for their variable inflammatory responses to bacterial cell wall polymers. Lewis and Wistar rats developed weight loss, hepatomegaly, and hepatic inflammation 4 and 12 wk, respectively, after creation of SFBL. Plasma aspartate aminotransferase levels in Lewis rats 4 wk (578 ± 77 U/L) and Wistar rats 12 wk (220 ± 35 U/L) after self-filling blind loops were significantly greater than in rats with self-emptying blind loops (112 ± 24 U/L, p < 0.001; 104 ± 22, p < 0.05) or sham-operated Lewis (84 ± 24, p < 0.001) or Wistar (78 ± 10, p < 0.001) rats. Randomized comparison using a histology grading score showed abnormalities that parallelled aminotransferase values. Lewis and Wistar rats with self-filling blind loops had hepatic injury with bile duct proliferation, fibrosis and acute and chronic periportal and focal parenchymal inflammation. Lewis and Wistar rats with self-emptying blind loops developed occasional mild histologic lesions. 50% of Lewis rats with self-filling blind loops for 4 wk died compared with only 15% in other groups. However, Buffalo rats with self-filling blind loops developed no weight loss, hepatomegaly, or hepatic injury. Anaerobic cultures of blood, peritoneum and liver were negative in all strains. Diet-restricted, sham-operated Wistar rats with weights similar to the Wistar rats with self-filling blind loops did not develop histologic abnormalities or elevated aminotransferase levels (76 ± 31 U/L). These results show that experimental small bowel bacterial overgrowth causes significant hepatic inflammation leading to fibrosis in susceptible rat strains. Caloric deprivation and hepatic bacterial invasion are not etiologically responsible. We suggest that bacterial cell wall polymers or other bacterial toxins from the blind loop cause hepatic lesions in genetically susceptible hosts.