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Primary biliary cirrhosis (PBC) is sometimes diagnosed based on a positive antimitochondrial antibody in the appropriate clinical setting without a liver biopsy. Although a liver biopsy can assess the extent of liver fibrosis and provide prognostic information, serum fibrosis markers avoid biopsy complications and sampling error and provide results as a continuous variable, which may be more precise than categorical histological stages. The current study was undertaken to evaluate serum fibrosis markers as predictors of clinical progression in a large cohort of PBC patients. Serial liver biopsy specimens and serum samples were collected every 2 years in 161 PBC subjects for a median of 7.3 years. Clinical progression was defined as development of one or more of the following events: varices, variceal bleed, ascites, encephalopathy, liver transplantation, or liver-related death. Serum hyaluronic acid, tissue inhibitor of metalloproteinase 1, and procollagen III aminopeptide were measured and entered into the previously validated enhanced liver fibrosis (ELF) algorithm. The ability of ELF, histological fibrosis, bilirubin, Model for End-Stage Liver Disease (MELD), and Mayo Risk Score to differentiate between individuals who would experience a clinical event from those who would not was evaluated at different time points. Event-free survival was significantly lower in those with high baseline ELF. Each 1-point increase in ELF was associated with a threefold increase in future complications. The prognostic performance of all tests was similar when performed close to the time of the first event. However, at earlier times in the disease process (4 and 6 years before the first event), the prognostic performance of ELF was significantly better than MELD or Mayo R score. Conclusion: The ELF algorithm is a highly accurate noninvasive measure of PBC disease severity that provides useful long-term prognostic information. (HEPATOLOGY 2008;48:1549-1557.)

Primary biliary cirrhosis (PBC) is an uncommon chronic cholestatic liver disease that primarily afflicts young and middle-aged Caucasian women; there are limited data on the clinical presentation and disease severity among non-Caucasian patients with this disease. The goal of this study was to examine differences in the severity of liver disease between Caucasian and non-Caucasian patients with PBC screened for enrollment in a large national multicenter clinical trial. Demographic features, symptoms, physical findings, and laboratory tests obtained during screening were examined in 535 patients with PBC with respect to ethnicity, gender, and antimitochondrial antibody (AMA) status; 73 of 535 (13.6%) were non-Caucasian (21 were African American, and 42 were Hispanic). Non-Caucasians were more likely than Caucasians to be ineligible for participation in the clinical trial (46.5% versus 25.1%, P = 0.0001), primarily because of greater disease severity. African Americans and Hispanics were also more likely to have a lower activity level, more severe pruritus, and more advanced disease. However, the mean age, male-to-female ratio, and seroprevalence of AMA positivity were similar between the 2 groups. Conclusion: Liver disease severity at clinical presentation is higher among non-Caucasians than Caucasians with PBC, and this cannot be explained by demographic or serologic features alone. Possible mechanisms underlying this health discrepancy are not clear, but increased awareness of PBC as a cause of chronic cholestatic liver disease is critical in evaluating non-Caucasian patients in the United States. (HEPATOLOGY 2007.)

Background: CD40–CD154 is a receptor–ligand pair that provides key communication signals between cells of the adaptive immune system in states of inflammation and autoimmunity. The CD40 receptor is expressed constitutively on B lymphocytes, for which it provides important signals regulating clonal expansion and antibody production. CD154 is a member of the tumor necrosis factor superfamily, which is primarily expressed by activated T cells. Methods: Because many chronic liver diseases are characterized by lymphocytic infiltration of the liver and several have increased immunoglobulin (Ig) production, the role of CD40–CD154 in hepatic Ig production was investigated in patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis, autoimmune hepatitis (AIH), hepatitis C, hepatitis B, alcoholic and non-alcoholic steatohepatitis, as well as normal controls. Results: Soluble CD154 levels in the serum were found to be no different in chronic liver diseases vs normal controls. Likewise, CD154 mRNA levels in peripheral blood mononuclear cells did not differ. However, mRNA for CD154 was significantly increased in the liver of individuals with PBC and AIH as compared with the other groups. The quantity of CD154 mRNA in the liver correlated positively with the quantity of mRNA for secretory Ig. Conclusion: These findings suggest that CD40–CD154 signals may be involved in Ig production within the liver of autoimmune liver diseases.

Approximately 5% of patients with clinical and histological features suggestive of primary biliary cirrhosis do not have anti-mitochondrial antibodies that can be detected by current methodologies. Although the role of these autoantibodies in the pathogenesis of liver disease is uncertain, T lymphocytes within the portal tracts are felt to be important mediators of bile duct destruction. In order to investigate the hypothesis that a similar T-cell process may be involved in both antimitochondrial antibody-positive and -negative primary biliary cirrhosis, we characterized the oligoclonally expanded T cells in both types of patients by analysis of complementarity determining region 3 length in peripheral blood mononuclear cells. The distribution of oligoclonally expanded T cells was similar in both groups. This finding does not support a distinct T-cell-mediated pathogenesis for anti-mitochondrial antibody-positive and -negative primary biliary cirrhosis but rather suggests that similar processes may be involved in the immunopathogenesis of both.

In patients with primary biliary cirrhosis (PBC), ursodeoxycholic acid (ursodiol) improves laboratory test markers of cholestasis and hepatic inflammation as well as some hepatic histological features; it also delays histological progression in the early stages of PBC. Ursodiol is well tolerated and safe. Less well substantiated are that ursodiol either improves the quality of life or prevents liver transplantation or that it prolongs survival without transplantation. There are favorable trends for ursodiol in preventing transplantation and prolonging survival, but in the absence of randomized, placebo-controlled trials of sufficient duration, there remain impressions rather than statistically proved, strong conclusions.

Semiquantitative reverse-transcriptase polymerase chain reaction (RT-PCR) was used to study the T-cell receptor (TCR) beta-chain variable (Vbeta) region gene families expressed by T cells in 28 patients with primary biliary cirrhosis (PBC), 20 normal controls, and 9 patients with other chronic inflammatory hepatic diseases. We hypothesized that activation and clonal proliferation of T cells would lead to biases in the T-cell repertoire of patients with PBC. Freshly harvested T cells from both peripheral blood and liver tissue were examined for evidence of biased Vbeta utilization. Individuals varied considerably in their pattern of Vbeta expression, but several significant differences were noted in the PBC group. In peripheral blood, the mean level of Vbeta6.1,3 expression was greater in PBC patients than in normal controls. In the liver of PBC patients, the mean level of Vbeta6.1,3 expression was even higher than in the peripheral blood, indicating intrahepatic accumulation of these T cells. The mean level of Vbeta6.1,3 expression was not significantly different in the blood compared with liver in patients with other liver diseases. Expression of Vbeta7 and Vbeta13.1 was also significantly greater in the liver than in the blood of PBC patients, but similar trends were also seen in the control liver group. These data show that specific alterations in the TCR repertoire are present in the blood and liver of patients with PBC.

One hundred fifty-one patients with primary biliary cirrhosis (PBC) grouped into four strata based on entry serum bilirubin ( or +2 (strata 3 and 4). Histology was favorably affected by ursodiol in patients in strata 1 and 2 but not in strata 3 and 4. Ursodiol enrichment in fasting bile obtained at the conclusion of the trail was approximately 40% and comparable in all strata. Thus, differences in ursodiol enrichment of the bile acid pool do not explain better responses of laboratory tests and histology found in patients with less advanced PBC. Patients treated will ursodiol tended to develop a treatment failure less frequently that those who received placebo, particularly in strata 1 and 2 (ursodiol 42%, placebo 60%, P = .078). Development of severe symptoms (fatigue/pruritus) and doubling of serum bilirubin were reduced significantly in ursodiol-treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

This placebo-controlled, randomized, multicenter trial compared the effects of MTX plus UDCA to UDCA alone on the course of primary biliary cirrhosis (PBC). Two hundred and sixty five AMA positive patients without ascites, variceal bleeding, or encephalopathy; a serum bilirubin less than 3 mg/dL; serum albumin 3 g/dL or greater, who had taken UDCA 15 mg/kg daily for at least 6 months, were stratified by Ludwig's histological staging and then randomized to MTX 15 mg/m2 body surface area (maximum dose 20 mg) once a week while continuing on UDCA. The median time from randomization to closure of the study was 7.6 years (range: 4.6-8.8 years). Treatment failure was defined as death without liver transplantation; transplantation; variceal bleeding; development of ascites, encephalopathy, or varices; a doubling of serum bilirubin to 2.5 mg/dL or greater; a fall in serum albumin to 2.5 g/dL or less; histological progression by at least two stages or to cirrhosis. Patients were continued on treatment despite failure of treatment, unless transplantation ensued, drug toxicity necessitated withdrawal, or the patient developed a cancer. There were no significant differences in these parameters nor to the time of development of treatment failures observed for patients taking UDCA plus MTX, or UDCA plus placebo. The trial was conducted with a stopping rule, and was stopped early by the National Institutes of Health at the advice of our Data Safety Monitoring Board for reasons of futility. In conclusion, methotrexate when added to UDCA for a median period of 7.6 years had no effect on the course of PBC treated with UDCA alone.

Randomized, double-blind, placebo-controlled trials of ursodeoxycholic acid (UDCA) in patients with primary biliary cirrhosis (PBC) have not demonstrated improvement in survival during the placebo-controlled phases of these trials. Analyses purporting to demonstrate a survival advantage of UDCA are largely dependent on data obtained after the placebo phases were terminated, and placebo-treated patients were offered open-label UDCA. After completion of our 2-yr placebo-controlled trial of UDCA in which we observed no survival benefit for UDCA, we provided the patients with open-label UDCA to see if delay in providing UDCA for 2 yr had any effect on subsequent liver transplantation or death without liver transplantation.In our previously reported 2-yr placebo-controlled trial, 151 patients with PBC were randomized to receive either UDCA (n = 77) or placebo (n = 74). The number of patients who progressed to liver transplantation or death without transplantation were similar in both the groups, 12 (16%) in the UDCA-treated and 11 (15%) in placebo-treated patients. All the patients were then offered open-label UDCA, with 61 original UDCA and 56 original placebo-treated patients now taking UDCA in an extended open-label phase of the trial.No significant differences were observed in the number of patients who underwent liver transplantation or died without liver transplantation in the open-label phase of the trial. Moreover, no difference in the time to these endpoints was seen over the period of observation of as long as 6 yr from the time of initial randomization.Results of open-label extensions of previous conducted placebo-controlled trials of UDCA in PBC leave uncertain whether UDCA impacts significantly on liver transplantation and death without liver transplantation in patients with PBC.

Generalized pruritus is a common complication of cholestatic liver diseases, although its pathogenesis remains elusive. Current treatments are often inadequate and may be poorly tolerated, so the clinician is sometimes faced with a patient in misery and no good therapeutic options. Because, in our experience, several patients with primary biliary cirrhosis (PBC) claimed that sertraline had improved their pruritus, we sought to determine whether sertraline use was associated with changes in pruritus medications or self-reported severity of pruritus in a large cohort of patients with PBC.The self-reported severity of pruritus was followed prospectively in 40 patients with PBC for a mean of 7.5 +/- 1.3 yr. These data were then retrospectively examined to determine the effect of sertraline on pruritus in all subjects who had received sertraline at some time during the study.For 28 of 32 patients with pruritus, itching was stable or fluctuated slightly over the follow-up period. No patient experienced rapid progression of pruritus, and four patients experienced a sustained resolution of their pruritus. Ten subjects started sertraline and continued it long enough (6 months) to determine its lasting effect on pruritus. Three of these individuals did not have significant pruritus before or after sertraline. Of the seven patients with pruritus, six (86%) recorded a significant reduction or resolution of pruritus in their weekly diaries and also decreased or completely stopped other medications for pruritus.Sertraline use is associated with an improvement in cholestatic pruritus. This novel observation implies that serotonergic fibers are important in regulating the perception of itch.

Bile acid composition in fasting duodenal bile was assessed at entry and at 2 years in patients with primary biliary cirrhosis (PBC) enrolled in a randomized, double-blind, placebo-controlled trial of ursodeoxycholic acid (UDCA) (10-12 mg/kg/d) taken as a single bedtime dose. Specimens were analyzed by a high-pressure liquid chromatography method that had been validated against gas chromatography. Percent composition in bile (mean +/- SD) for 98 patients at entry for cholic (CA), chenodeoxycholic (CDCA), deoxycholic (DCA), lithocholic (LCA), and ursodeoxycholic (UDCA) acids, respectively, were 57.4 +/- 18.6, 31.5 +/- 15.5, 8.0 +/- 9.3, 0.3 +/- 1.0, and 0.6 +/- 0.9. Values for CA were increased, whereas those for CDCA, DCA, LCA, and UDCA were decreased when compared with values in normal persons. Bile acid composition of the major bile acids did not change after 2 years on placebo medication. By contrast, in patients receiving UDCA for 2 years, bile became enriched with UDCA on average to 40.1%, and significant decreases were noted for CA (to 32.2%) and CDCA (to 19.5%). No change in percent composition was observed for DCA and LCA. Percent composition at entry and changes in composition after 2 years on UDCA were similar in patients with varying severity of PBC. In patients whose bile was not enriched in UDCA (entry and placebo-treated specimens), CA, CDCA, DCA, and the small amount of UDCA found in some of these specimens were conjugated to a greater extent with glycine (52%-64%) than with taurine (36%-48%). Treatment with UDCA caused the proportion of all endogenous bile acids conjugated with glycine to increase to 69% to 78%, while the proportion conjugated with taurine (22%-31%) fell (P

Recent studies have demonstrated the presence of hepadnavirus-related nucleic acids in extrahepatic tissues in various animal models. The prevalence and biological significance of extrahepatic infection in humans remains undetermined. To characterize the tissue distribution and physical state of extrahepatic hepatitis B virus nucleic acids in acute hepatitis infection, we examined serum, liver and multiple extrahepatic tissues obtained at autopsy from two patients with fulminant hepatitis and one patient with resolving hepatitis who died of an unrelated cause. Southern-blot hybridization analysis was used to analyze the physical state of hepatitis B virus-related DNA. Hepatitis B virus-related RNA sequences were examined by slot-blotting total RNA extracted from corresponding tissues. Hepatitis B virus nucleic acids were demonstrated in lymph nodes, spleen, gonads, thyroid gland, kidneys, pancreas and adrenal glands. The most intense signal of hybridization was obtained with DNA extracted from lymph nodes. In general, the levels of hepatitis B virus RNA correlated with the amount of viral DNA. Fast-migrating DNA sequences resembling replicative intermediates and ranging in size from 1 to 3.2 kb were detected in EcoRI digests. Faint high-molecular-weight smears suggesting random integration also were observed. Remarkably, little or no hepatitis B virus nucleic acid was detected in the serum or liver. In control specimens obtained from hepatitis B virus carriers, most hybridizable hepatitis B virus nucleic acid was present in liver, but hepatitis B virus DNA was also detected in extrahepatic tissues. Finally, no specific histological changes were observed in extrahepatic tissues harboring hepatitis B virus.(ABSTRACT TRUNCATED AT 250 WORDS)

Introduction Primary biliary cirrhosis (PBC) is a chronic autoimmune cholestatic liver disease that causes progressive hepatic fibrosis, often leading to liver failure. The severity of PBC is typically determined by grading the extent of fibrosis in a liver biopsy using a 4-point histological scale: 0 = no fibrosis, 1 = non-bridging fibrosis, 2 = bridging fibrosis, and 3 = cirrhosis. However, liver biopsy is prone to sampling error, and it is sometimes a painful and dangerous procedure. The utility of serial liver biopsies to detect disease progression has not been studied, but it is a critical issue for clinical investigators and physicians. Null Hypothesis The average change of fibrosis in serial liver biopsies in patients with PBC is not a reliable indicator of clinical progression. Methods Serial liver biopsies were collected every 2 years on 265 subjects with PBC as part of a multicenter double-blind randomized controlled study, which demonstrated that methotrexate, when added to ursodiol treatment, had no effect on PBC. Mean follow-up was 7.4 years, and 935 samples were collected. Four pathologists, who were blinded to the sample order, graded each biopsy. A mean fibrosis score was calculated for each biopsy. Clinical decompensation was defined as development of one or more of the following: varices, ascites, encephalopathy, variceal bleed, liver transplant or liver death. The rate of change of fibrosis over time was compared between the patients who experienced clinical decompensation (n = 83) and those who did not (n = 162) using the Wilcoxon rank sum test. Results Fibrosis increased an average of 0.05 stages per year in the group who developed clinical decompensation and decreased 0.01 stages per year in the group who did not. This difference was statistically significant (p Conclusion In a large group of PBC patients, serial liver biopsies can detect a statistical difference in the change of fibrosis between patients who develop clinical decompensation versus patients who do not. However, the average rate of change in fibrosis associated with clinical decompensation is too small to be appreciated in an individual patient. Thus serial liver biopsies are not useful clinical tools to assess disease progression in individuals with PBC taking ursodiol.

Cholestyramine exerted a beneficial effect on the course of a patient with sclerosing cholangitis associated with ulcerative proctitis. Over a 6.5-yr period, discontinuation of cholestyramine resulted in episodes of RUQ pain and/or appearance of abnormalities in liver tests. Readministration of the resin was followed by disappearance of symptoms and normalization of test resuls. The mechanism of the beneficial effect of cholestyramine was not elucidated.

A prospective, double-blinded, randomized trial of corticosteroid therapy in patients with severe acute viral hepatitis has been conducted. At the same time, we have examined the prognostic significance of the presence of bridging necrosis in liver biopsies obtained from such patients as well as the predictive value of certain serologic markers. Forty-two of the 77 patients admitted to the trial were shown to have bridging necrosis on their initial biopsies. Two patients progressed to death with massive hepatic necrosis, while 5 patients developed chronic liver disease. A complicated course could not be predicted by the initial biopsy findings nor by any of the serologic markers assessed. We could not identify any clinical or epidemiologic features with prognostic impact. No advantage was demonstrated to be associated with the use of corticosteroids early in the course of severe viral hepatitis.

γ-Glutamyl transpeptidase (GGT) activity in serum was increased in the majority of women with viral hepatitis occurring in the first half of pregnancy. By contrast, GGT activity was abnormal less frequently and the mean value was relatively depressed, even though hepatitis was as severe, in the second half of gestation. Mean GGT activity was also lower, and abnormal values were less frequent, in nonpregnant women with viral hepatitis who were taking birth control pills (BCP). Depressed GGT is not attributable to an inhibitor in serum in women in late pregnancy or taking BCP. The data suggest that estrogen and/or progestational compounds affect liver such that less GGT is released into blood with acute hepatocellular injury. In addition, hyperbilirubinemia was found to be associated with depressed serum GGT activity, and bilirubin added to serum in vitro interfered with measured activity of the enzyme.

The apparent volume of the biliary tree (ABV) in the dog was determined by measuring the mean biliary transit time of injected [14C]taurocholate ([14C]TC). After bolus injection of [14C]TC, entry of bile salt into the lumen of the biliary tree is signaled by an increase in bile flow. The volume of bile collected at the common duct from onset of choleresis until maximal concentration of 14C radioactivity is reached in bile minus the calculated quantity of bile that contains radioactivity and the cannula volume yields a value for the volume of the biliary tree present just prior to injection of [14C]TC. The mean value for ABV in 19 dogs was 2.49 ± 0.65 μL/g liver (mean ± SD).

Low values for serum alkaline phosphatase activity were observed early in the course of two patients with Wilson's disease presenting with the combination of severe liver disease and Coombs' negative acute hemolytic anemia. A review of other cases of Wilson's disease revealed that 11 of 12 patients presenting with hemolytic anemia had values for serum alkaline phosphatase less than their respective sex- and age-adjusted mean values; in eight, serum alkaline phosphatase activity was less than the lower value for the normal range of the test. Low values for serum alkaline phosphatase were much less common in Wilson's disease patients with more chronic forms of presentation. Copper added in high concentration to serum in vitro did not have an important effect on serum alkaline phosphatase activity. The mechanism responsible for the decrease in serum alkaline phosphatase activity in patients is uncertain.

The effect of hepatic glutathione depletion on 14CO2 evolution from [14C]methyl-labeled aminopyrine was assessed in fed male Sprague-Dawley rats. Within 30 min of i.p. administration of either diethylmaleate or phorone, hepatic glutathione fell approximately 75 to 80% and remained depressed for the ensuing 120 min. [14C]Aminopyrine was i.p. administered 30 min after the glutathione-lowering agents (zero time) and exhaled 14CO2 was collected at 15-min intervals for the next 120 min. Parameters of 14CO2 exhalation including peak exhalation rate, cumulative exhalation from 0 to 120 min and the elimination rate constant were all impaired in glutathione-depleted rats. Metabolism of the [14C]methyl groups involves N-demethylation with formation of formaldehyde, oxidation to formate and conversion to 14CO2. Glutathione depletion did not affect CO2 evolution from i.p. administered formate or bicarbonate. The glutathione-dependent step presumably involves either or both generation of formaldehyde or its subsequent oxidation to formate.

Renal clearance of BSP compounds was investigated in dogs during infusion of sulfobromophthalein (BSP) or its glutathione conjugate (BSP-GSH). Conjugated BSP compounds are more readily excreted into urine than unconjugated BSP. Dye clearance into urine was much less than simultaneously measured inulin clearance. This suggests that protein binding of BSP compounds significantly retards the glomerular filtration of the dye. BSP was found to bind more avidly to albumin than BSP-GSH. The ratio of dye clearance to inulin clearance remained relatively constant over a broad range of plasma concentrations of dye. The data support but do not prove glomerular filtration of non-protein-bound dye as the major mechanism accounting of urinary elimination of BSP compounds in the dog.

SummaryThe increments in plasma triglyceride levels observed after administration of Triton were consistently and significantly lower in tetracycline-injected rats, when hepatic tetracycline concentration was high, than in Triton-injected controls. These data are interpreted as indicating impaired release of hepatic triglyceride in tetracycline-injected animals. Hepatic triglyceride increased in tetracycline-injected rats and most of this could be accounted for by impaired release of liver triglyceride. This mechanism, possibly due to impaired synthesis of hepatic lipid acceptor protein, appears to be the major cause of tetracycline-induced fatty liver.

SummaryHepatic disposition of DiBSP was studied in adult and newborn guinea pigs from days 2 through 16 of life after intravenous administration of DiBSP in doses sufficient to achieve maximal rates of dye excretion into bile. Neonatal guinea pigs showed a significant reduction in the maximal rate of dye excretion into bile when compared to adult animals. A minimal estimate of hepatic uptake of DiBSP showed that uptake was similar in neonatal and adult animals and was significantly greater than the maximal rates of excretion into bile. Hence hepatic uptake did not limit hepatic disposition of DiBSP. With aging, injected DiBSP was excreted at progressively more rapid rates reaching adult levels of excretion at the beginning of the second week of life. This study demonstrates the presence of a defect in the excretory process by which DiBSP is transported from liver cells into bile in the neonatal guinea pig.

The appearance of jaundice in patients with acute leukemia treated with mercaptopurine has been described in several reports and attributed to a toxic effect of the therapeutic agent on the liver.1-6A number of possible causes of jaundice unrelated to therapy exist in the leukemia patient, and it is difficult to be certain whether all reported instances are indeed produced by the drug. Nevertheless, it is generally accepted that mercaptopurine is potentially hepatotoxic. Recently, we have observed jaundice develop in two nonleukemic patients during therapy with mercaptopurine. Because of increasing current interest in the use of purine analogues for treatment of a variety of diseases, we are reporting our observations in order to direct attention to this important therapeutic complication. Patient Summaries Patient 1. —A 45-year-old man was admitted to Parkland Memorial Hospital on Dec 14, 1966, for evaluation of jaundice. He had been well until July 1964 when

The influence of serum from patients with a variety of liver abnormalities on the in vitro response of normal human peripheral blood lymphocytes to stimulation with phytohemagglutinin was studied. These experiments demonstrate that serum from patients with acute viral hepatitis, chronic Australia antigenemia, common bile duct obstruction, primary biliary cirrhosis, hepatic necrosis secondary to halothane, and alcoholic cirrhosis suppresses DNA synthesis by stimulated normal lymphocytes. Sera obtained from two patients 1 week after surgical correction of their common duct obstruction no longer demonstrated lymphocyte suppression. Dilution of normal serum with serum from either of three patients resulted in more rapid decrease of thymidine uptake by stimulated lymphocytes than when normal serum was diluted with culture medium. This indicates the presence of an inhibitory factor (s) in the patients' sera. No correlation was shown between the extent of thymidine uptake by stimulated lymphocytes and the bilirubin, transaminase, or alkaline phosphatase levels in the serum in which they were cultured. The addition of bile salts to stimulated lymphocyte cultures did result in suppression of the response but only at concentrations much higher than would be expected in serum of the patients studied. Cell death after 72-hr incubation was 42% in normal serum and only 50% in serum from a patient who had demonstrated prominent suppression of DNA synthesis.

SummaryPhenol 3,6-dibromphthalein disulfonate (diBSP) was shown to be excreted rapidly in the bile of rats as the unconjugated compound, confirming earlier observations of Javitt (6). In addition, it was demonstrated that diBSP and BSP share common hepatic transport systems. Finally, feeding a protein-free diet for 2 days did not affect the biliary excretion of diBSP, whereas the same diet was previously shown to result in decreased BSP excretion into bile accounted for by diminished excretion of conjugated BSP. The present findings support earlier conclusions that conjugation of BSP is an important determinant of the maximal rate of biliary excretion of BSP.

A patient with persistent Australia (Au) antigenaemia after post-transfusion hepatitis developed membranous glomerulonephritis. Immunofluorescent staining of kidney tissue revealed glomerular deposits of IgG, complement C 3 , and Au antigen in a pattern characteristic of immune complex deposition. These findings suggest that Au antigen was involved in the formation of immune complexes whose glomerular deposition initiated the pathologic process leading to the development of diffuse membranous glomerulonephritis.

Thirty-four pregnant patients with viral hepatitis form the basis of this prospective study. Of the 30 patients with adequate follow-up, 28 improved rapidly, 1 developed postnecrotic cirrhosis, and 1 died of massive hepatic necrosis. Fetal survival includes 22 full-term infants. There were eight premature labors (three resulting in twins, one induced), with six labors resulting in nine living infants. Two premature infants died. Two other pregnancies ended with spontaneous abortions. Neonatal hepatitis was not discovered. A favorable outcome may usually be anticipated for the mother with hepatitis. Fetal wastage attributable to hepatitis was no greater than the incidence observed in pregnant patients without this disease.

A micellar solution of sodium taurocholate has been shown to increase the solubility of cortisol and prednisolone crystals in vitro. That this enhanced solubility confers little physiological advantage to the rat has been demonstrated in in vivo studies on the intestinal absorption of these compounds. Tritiated crystals of cortisol and prednisolone were delivered intraduodenally to rats with complete biliary diversion receiving an intraduodenal infusion of either 37 mm taurocholate or normal saline. The excretion of the metabolic products of the steroids in bile and urine was used as a measure of the intestinal absorption of the parent compound. Excretion was greater in the first 2 hr after the administration of either cortisol or prednisolone in rats receiving bile salts than in bile salt-deficient animals. By 4 hr, however, no significant differences were found in the excretion values between the two groups of rats. More than 70% of the administered steroid was recovered in bile and urine within 4 hr in animals with a complete bile-salt deficit. Despite the demonstration, in vitro, that both steroid compounds are bound by cholestyramine, no significant decrease in the intestinal absorption of cortisol was observed when either cholestyramine or an antacid containing aluminum hydroxide were administered concomitantly.

A young black woman with the Dubin-Johnson syndrome developed acute Australia antigen-positive viral hepatitis. Histological studies have reaffirmed the previously described disappearance of the Dubin-Johnson pigment from her liver in the convalescent phase of the hepatitis. Prolonged Bromsulphalein studies at this time have demonstrated the persistence of the hepatic excretory defect for organic anions. This confirms the supposition that the pigment in the livers of patients with the Dubin-Johnson syndrome is the result of the excretory defect rather than its cause.

A review was conducted of 32 patients dying of massive hepatic necrosis and subject to complete autopsy examination. Sixteen of the 32 patients were found to have cerebral edema and 4 of these had evidence of cerebellar and/or uncal herniation. Those patients with cerebral edema were younger, had a more prolonged period of stage IV coma, and were less likely to have terminal azotemia and acidosis than the patients without cerebral edema. The pathogenesis of the cerebral edema in these patients is unknown but it does not appear to be related to secondary complications causing cerebral hypoxia nor to any specific form of therapy.

Isolated rat hepatocytes were exposed to CCl4 in doses commonly used in in vitro studies and for which we have provided biochemical evidence would induce solvent injury. Rapidly evolving morphologic alterations were observed in the plasma membrane, endoplasmic reticulum, and mitochondria. Swelling and fusion of surface microvilli with formation of blebs were particularly prominent and occurred within 2 min of exposure. Blebs regressed in some hepatocytes without evidence of cell death, when these cells were exposed to CCl4 under conditions promoting its evaporation. Disorganization of endoplasmic reticulum and mitochondrial injury were also prominent early findings. Rapid appearance of diffuse ultrastructural alterations in isolated hepatocytes exposed to CCl4 is consistent with nonspecific membrane injury induced by solvent effects.

CCl4 is proposed to induce cellular injury through its metabolites that are generated by a cytochrome P-450 dependent step. These free radical products can interact with membrane structures, thereby generating lipid peroxides. The latter process has been implicated as a major mechanism of CCl4 hepatoxicity, although this relationship has been difficult to demonstrate when using isolated hepatocyte preparations. This report demonstrates that there are at least two mechanisms by which CCl4 induces injury in isolated hepatocytes. One occurs within minutes of exposure to CCl4 and is characterized by modest malondialdehyde formation and no decline in cellular-reduced glutathione. SKF 525A, metyrapone and promethazine did not protect against this early damage. A second phase of damage, evident particularly after 3 hr, is characterized by a marked increase in malondialdehyde formation, a fall in cellular glutathione and substantial further cellular damage. These changes could be moderated by the cytochrome P-450 inhibitors and promethazine, and antioxidant. Further examination of the initial phase of damage reveals an immediate dose-related inhibition of O2 consumption. This could not be prevented by SKF 525A or metyrapone and was associated with loss of ability to stimulate mitochondrial respiration with dinitrophenol. Rapid recovery to initial O2 consumption rates occurred with time as CCl4 evaporated from the incubation system. This was associated with a partial return of dinitrophenol stimulation of mitochondrial O2 consumption despite significant glutamate dehydrogenase release. A portion of this recovery could be inhibited by SKF 525A, suggesting that some O2 consumption was due to CCl4 metabolism and ensuing lipid peroxidation. These data suggest that early CCl4 toxicity is a direct consequence of its solvent properties and is partially reversible; subsequent damage may be mediated by lipid peroxidation. This solvent injury has not been previously recognized and may have relevance not only to a reversible toxicity as demonstrated with isolated hepatocytes but also in vivo as well.