1117
6. Crawford
P, Ghadiali E, Lane R, Blumhardt L, Chadwick
Gabapentin as an antiepileptic drug Psychiatry 1987; 50: 682-86.
in
man.
J
Neural
D.
Neurosurg 11.
of gabapentin in plasma and urine by high performance liquid chromatography and precolumn labelling for ultraviolet detection. J Chromatogr 1984; 341: 473-78. 8. Vollmer K-O, Von Hodenberg A, Kolle E-U. Pharmamkinetics and metabolism of gabapentin in rat, dog and man. Arzneimittellforschung 7. Hengy H, Kolle E-U. Determination
1986; 36: 830-39. E, Jawad B, Wroe S, Richens A. Does the anticonvulsant
12.
13.
14.
9. Allen
gabapentin
lack
enzyme-inducing
properties?
17th
Epilepsy
International Congress, Jerusalem, 1987 (abstr). 10. Anhut H, Leppik I, Schmidt B, Thomann P. Drug interaction study of
15.
the new anticonvulsant gabapentin with phenytoin in epileptic patients. Naunyn Schmiedebergs Arch Pharmacol 1988; 337 (suppl): 507 (abstr). Hills M, Armitage P. The two-period cross-over clinical trial. Br J Clin Pharmacol 1979; 8: 7-20. Mumford JP. A profile of vigabatrin. Br J Clin Pract 1988; 42 (suppl 61): 7-9. Schmidt D. Two antiepileptic drugs for intractable epilepsy with complex-partial seizures. J Neurol Neurosurg Psychiatry 1982; 45: 1119-24. Temkin NR, Wilensky AJ. New AEDs: are the compounds or the studies ineffective?. Epilepsia 1986; 27: 644-45. Crawford P, Chadwick D. A comparative study of progabide, valproate and placebo as add-on therapy in patients with refractory epilepsy. J Neurol Neurosurg Psychiatry 1986; 49: 1251-57.
Hepatitis C antibody and chronic liver disease in haemophilia
A
radioimmunoassay was used to detect antibodies to hepatitis C virus (anti-HCV) in 154 patients with haemophilia. Prevalence of antiHCV was associated with exposure to clotting factor concentrates. 76 of 129 (59%) who had received factor VIII or IX had anti-HCV: 42 of 55 (76%) who required over 10 000 units of concentrate annually had anti-HCV, compared with 34 of 74 (46%) who required less, and 0 of 25 patients who had never received concentrates. Anti-HCV were significantly more common in patients seropositive for antibodies against human immunodeficiency virus (anti-HIV) or with markers of previous hepatitis B infection than in those without anti-HIV or hepatitis B markers (88% vs 39% and 75% vs 46%, respectively). 5 of 23 (22%) haemophiliacs treated only with heated concentrates had anti-HCV compared with 71 of 106 (67%) patients who received unmodified products. 35 patients with chronic liver disease underwent liver biopsy: histological examination showed features associated with post-transfusion hepatitis in 24, all of whom were anti-HCVpositive; of the other 11 patients with no histological features of non-A, non-B hepatitis, 5 were anti-HCV-positive. HCV appears to be the major predisposing factor for most non-A, non-B hepatitis and chronic liver disease in haemophilia. Lancet 1990; 335: 1117-19.
Introduction Before heat treatment of clotting factor concentrates, almost all patients who were treated with factor VIII for the first time
acquired non-A, non-B (NANB) hepatitis,l of whom
70 % would show chronic liver enzyme abnormalities2 and at least 20% would develop cirrhosis.3 End-stage liver failure is now recognised to be a major cause of morbidity and mortality in haemophilia 4 Although it has been widely assumed that such liver disease is caused by a virus or viruses, in the absence of a serological marker it has been impossible to identify the agent or agents responsible. We report serological evaluation of a novel marker for hepatitis C5,6 in relation to clinical, biochemical, and histological changes in a population of haemophilia patients.
Patients and methods Sera from 154 adults (aged 17-91 years) with coagulation disorders who attended the Sheffield Haemophilia Centre were tested for the presence of antibody to hepatitis C virus (anti-HCV). All 46 patients with severe haemophilia (less than 2 IU/dl factor VIII or IX plasma concentrations) were included, as were a randomly selected group of patients with less severe haemophilia, 18 with von Willebrand’s disease, and 9 with other familial coagulation disorders. 129 (84%) of the patients had received either factor VIII or IX concentrate. All samples were kept frozen at - 20°C until tested. The presence of chronic liver disease was defined biochemically as a raised serum alanine aminotransferase (ALT; above 45 U/1) for more than 6 months. ALT concentrations were considered persistently raised when all 3 most recent measurements were high, intermittently raised when 1 or 2 of the last 3 values were
ADDRESSES Departments of Haematology (M. Makris, MRCP, Prof F E. Preston, MD), Medicine (D. R. Triger, FRCP), and Pathology (J. C. E. Underwood, MD), Royal Hallamshire Hospital, Sheffield, UK; and Chiron Corporation, Emeryville, California, USA (Q. L. Choo, PhD, G Kuo, PhD, M. Houghton, PhD) Correspondence to Prof F E. Preston, Department of Haematology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
1118
TABLE I-DEMOGRAPHIC DATA
*Factor X deficiency (1 factor XI carner for haemophilia B (6)
deficiency (1); carrier for haemophilia A (1 ); and
high, or normal when none of the last three estimations was above the normal range. The average annual concentrate usage was calculated for the period 1986-88. 4 patients received cryoprecipitate only and are grouped here with 21 patients who had never been given factor VIII or IX concentrates. 23 patients had received heat-treated factor concentrates only. 35 patients with persistently abnormal liver function underwent liver biopsy. Specimens were examined by a histopathologist (J. C. E. U.), who did not know the results of the HCV assays, and were considered to show evidence of NANB hepatitis if at least 2 of 3 features were observed:7-10 focally dense lymphocytic portal tract infiltrates adjacent to or surrounding interlobular ducts, rarely associated with ductal epithelial damage; fatty change, often microvesicular, without other features (eg, Mallory’s hyalin) to indicate an alternative explanation; and sinusoidal infiltrates of lymphoid cells without a proportionate degree of liver necrosis. Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc) were used as markers of hepatitis B infection, and measured by standard radioimmunoassay and enzyme-linked immunoassay techniques. Neither of the HBsAgpositive patients underwent liver biopsy. For anti-HCV assay all samples were coded and shipped to the assay laboratory (Chiron) on dry ice. Anti-HCV was detected by a radioimmunoassay in which a recombinant HCV polypeptide was used to coat the wells, as previously described.6 Values greater than 3 SD above the mean result for uninfected controls were considered to be positive .6 In most patients who underwent liver biopsy, anti-HCV was measured in blood taken the day before biopsy, and in all within 10 weeks of the procedure. Fisher’s exact test and the X2 test were used to compare frequencies between groups.
Results
patients had received clotting factor concentrates, 76 (59%) of whom had anti-HCV ; there was no significant difference in prevalence of anti-HCV between patients with haemophilia A or B (61% vs 58%). Anti-HCV positivity 129
associated with greater exposure to factor concentrates: (76%) patients who required more than 10 000 units annually had anti-HCV compared with 34 of 74 (46%) who required less (table II; p < 0-001). All 25 patients who had never received concentrates were anti-HCV-negative.
was
42 of 55
TABLE II-PREVALENCE OF ANTI-HCV IN RELATION TO CLOTTING FACTOR CONCENTRATES
The prevalence of anti-HCV in the 23 patients who had received heat-treated concentrates only was significantly less than that in those who had received non-heat-treated concentrates (22% vs 67%, p < 0-001; table II). The groups are not directly comparable in that only 1 of the patients who received heat-treated factor only had severe haemophilia compared with 45 of 96 who were given non-heat-treated concentrates, but the difference remains statistically significant when only patients who required less than 10 000 units annually are compared (5 of 22 [23%] heat-treated vs 29 of 52 [54%] non-heat-treated; p < 0-05). 8 of the 18 patients with von Willebrand’s disease had received factor VIIIconcentrate (all less than 10 000 IU annually). In all but 1 patient, the concentrate was not heat-treated. 4 of the treated patients had abnormal liver function tests and these alone were anti-HCV-positive. 47 of 60 (78%) patients with persistently raised serum ALT concentrations were anti-HCV-positive, and 19 of 29 with intermittently raised ALT were anti-HCV-positive, compared with 10 of 62 with normal ALT (p < 0-001); 3 patients were excluded because of insufficient data. TABLE III-RELATION OF HCV ANTIBODY STATUS TO OTHER VIRAL MARKERS
Table III shows the relation of anti-HCV seropositivity to other viral markers. 27 of 36 (75%) patients with evidence of previous exposure to hepatitis B were anti-HCV-positive, compared with 38 of 82 (46%) anti-HBc-negative patients (p < 0-01). We also found a significantly higher prevalence of anti-HCV in patients who were HIV-positive compared with HIV-negative patients (28 of 32 [88%] vs 48 of 122
[39%]; p < 0-001). Histological examination of 35 liver biopsy specimens showed chronic persistent hepatitis in 17, chronic active hepatitis in 8, cirrhosis in 6, and other changes in 4. Anti-HCV were found in the serum of all 24 patients whose biopsies showed histological features of NANB hepatitis. 5 of 11 specimens (45%) without histological evidence of NANB hepatitis were also anti-HCV-positive (3 had chronic persistent hepatitis, 1 had chronic active hepatitis, and I had cirrhosis). Of the other patients with no histological features of NANB hepatitis and who were anti-HCVnegative, 2 had alcoholic liver disease, 1 had cirrhosis,1 had chronic persistent hepatitis, 1 had fatty change with portal fibrosis, and 1 had a mild portal infiltration with TABLE IV-HCV, HBV, AND HIV MARKERS IN RELATION TO LIVER HISTOLOGY
1119
mononuclear cells. In the 29 anti-HCV-positive patients who underwent liver biopsy, the presence of anti-HIV or markers of previous hepatitis B infection was not associated with increased severity of liver disease (table IV).
Discussion Our findings show hepatitis C to be a major cause of chronic NANB hepatitis in UK patients with haemophilia. The overall incidence of anti-HCV in our patients treated with factor VIII or IX concentrates is 59%-which is lower than that reported from Spain (71%)," France (66%)," and West Germany (78%).13 The incidence of anti-HIV in treated patients also differs (25% vs 56%, 60%, and 51 %, respectively). These differences might reflect different usage of concentrates. The absence of anti-HCV from any of our 25 untreated patients reflects a low prevalence in a healthy UK population,14,15 and indicates that this test could be used as a specific marker of HCV infection in our
if antiviral therapy is contemplated in with suspected chronic liver damage. We haemophiliacs found no evidence to indicate that coexistence of markers of HIV infection accelerates the progression of HCVassociated liver disease, which contrasts with a preliminary report by Martin et al,19 who found rapid deterioration in liver function of patients with AIDS who had NANB
taken into
account
hepatitis. In conclusion, hepatitis C appears to be the major, if not the sole, cause of non-hepatitis-B viral liver disease in haemophiliacs. There is an urgent need to eliminate HCV from clotting factor concentrates by screening and other means; only when this has been achieved will it be possible determine whether other agents disease in patients with haemophilia.
to
chronic liver
We thank Mrs Linda Westlake for help with statistical analysis.
patients.
REFERENCES
of clotting factor concentrates, anti-HIV seropositivity, and anti-HBc seropositivity were also associated with a higher incidence of anti-HCV. Patients with haemophilia B treated almost exclusively with National Health Service (NHS) factor IX derived from volunteer donors had a similar incidence of anti-HCV to haemophilia A patients who received a mixture of commercially obtained (paid donor) and NHS (volunteer donor) factor VIII concentrate (60% vs 69%): this may reflect Fletcher et al’s suggestion1 that although blood derived from volunteer as opposed to paid donors is associated with reduced viral transmission, this may be counterbalanced by the size of the donor pool. Only 22% of patients who received heated factor concentrate were anti-HCV-positive compared with 67% who were given non-heat-treated products: this observation is consistent with reports that heat treatment of the concentrate reduces, but does not abolish, the risk of NANB hepatitis.16-18 We found that patients with persistently raised ALT had a higher prevalence of anti-HCV than those with intermittently raised ALT. 10 of 62 (16%) patients with normal liver enzymes had circulating anti-HCV. We feel this finding may reflect quiescent chronic liver disease--6 of these 10 patients had had abnormal ALT concentrations and undergone liver biopsy during the previous 2-10 years; 4 of these had had histological evidence of chronic persistent hepatitis, 1 of chronic active hepatitis, and the other cirrhosis. Only 1 anti-HCV-positive patient had no previous evidence of abnormal ALT concentrations. Our study enabled the relation between HCV antibody status, serological markers for HBV and HIV, and liver histology in haemophiliacs to be examined. All 24 patients with histological features of NANB hepatitis7-10 were positive for anti-HCV, which indicates that HCV may have caused the liver abnormalities. The absence of these features in liver biopsy specimens from 5 anti-HCV-positive patients has several possible explanations: a sampling error is unlikely because NANB hepatitis is usually diffuse; more likely reasons are that the typical histology of NANB hepatitis does not occur throughout all phases of infection, or that other hitherto unidentified viruses may coexist with HCV and stimulate the liver inflammation. The observation of various histological abnormalities in 6 patients who were anti-HCV-negative indicates that persistent abnormalities of liver enzymes cannot always be equated with chronic virus-associated liver damage: this observation should be Increased
cause
use
1. Fletcher ML, Trowell JM, Craske J, Pavier K, Rizza CR. Non-A, non-B hepatitis after transfusion of factor VIII in infrequently treated patients. Br Med J 1983; 287: 1754-57. 2. Cederbaum AI, Blatt PM, Levine PH. Abnormal serum transminase levels in patients with haemophilia A. Arch Intern Med 1982; 142: 481-84. 3.
Hay CRM, Preston FE, Triger DR, Underwood JCE. Progressive liver disease in haemophilia: an understated problem? Lancet 1985; i: 1495-98.
Eyster ME, Whitehurst DA, Catalano PM, et al. Long-term follow-up of haemophiliacs with lymphocytopenia or thrombocytopenia. Blood 1985; 66: 1317-20. 5. Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 244: 359-62. 6. Kuo G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989;
4.
244: 362-64.
M, Murray AK, Weller IVD, et al. Clinical and histological features of a group of patients with sporadic non-A, non-B hepatitis. J Clin Pathol 1981; 34: 1175-80.
7. Bamber
8. Bamber M, Murray A, Arborgh BAM, et al. Short incubation non-A, non-B hepatitis transmitted by factor VIII concentrates in patients with congenital coagulation disorders. Gut 1981; 22: 854-59. 9. Dienes HP, Popper H, Arnold W, Lobeck H. Histological observations in human hepatitis non-A, non-B. Hepatology 1982; 2: 562-71.
M, Pirovino M, Altorfer J, Gudat F, Bianchi L. Acute hepatitis non-A, non-B; are there any specific light microscopic features? Liver 1982; 2: 61-67. 11. Esteban JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-97. 12. Noel L, Guerois C, Maisonneuve P, Verroust F, Laurian Y. Antibodies to hepatitis C virus in haemophilia. Lancet 1989; ii: 560. 13. Roggendorf M, Dienhardt F, Rasshofer R, et al. Antibodies to hepatitis C virus. Lancet 1989; ii: 324-25. 14. Contreras M, Barbara JAJ. Screening for hepatitis C virus antibody. Lancet 1989; ii: 505. 15. Mortimer PP, Cohen BJ, Litton PA, et al. Hepatitis C virus antibody. Lancet 1989; ii: 798. 16. Colombo M, Mannucci PM, Camelli V, et al. Transmission of non-A, non-B hepatitis by heat-treated factor VIII concentrate. Lancet 1985; ii: 10. Schmid
1-A. 17.
Kemoff PBA, Miller EJ, Savidge GF, Machin SJ, Dewar MS, Preston FE. Reduced risk of non-A, non-B hepatitis after a first exposure to "wet-heated" factor VIII concentrate. Br J Haematol 1987; 67: 207-11. 18. Preston FE, Hay CRM, Dewar MS, Greaves M, Triger DR. Non-A, non-B hepatitis and heat-treated factor VIII concentrates. Lancet 1985; ii: 213.
P, Di Bisceglie AM, Kassianides C, Lisker-Melman M, Hoofnagle JH. Non-A, non-B hepatitis leads to rapidly progressive liver disease in patients with human immunodeficiency virus infection. Gastroenterology 1989; 96: A627.
19. Martin
6. Crawford
P, Ghadiali E, Lane R, Blumhardt L, Chadwick
Gabapentin as an antiepileptic drug Psychiatry 1987; 50: 682-86.
in
man.
J
Neural
D.
Neurosurg 11.
of gabapentin in plasma and urine by high performance liquid chromatography and precolumn labelling for ultraviolet detection. J Chromatogr 1984; 341: 473-78. 8. Vollmer K-O, Von Hodenberg A, Kolle E-U. Pharmamkinetics and metabolism of gabapentin in rat, dog and man. Arzneimittellforschung 7. Hengy H, Kolle E-U. Determination
1986; 36: 830-39. E, Jawad B, Wroe S, Richens A. Does the anticonvulsant
12.
13.
14.
9. Allen
gabapentin
lack
enzyme-inducing
properties?
17th
Epilepsy
International Congress, Jerusalem, 1987 (abstr). 10. Anhut H, Leppik I, Schmidt B, Thomann P. Drug interaction study of
15.
the new anticonvulsant gabapentin with phenytoin in epileptic patients. Naunyn Schmiedebergs Arch Pharmacol 1988; 337 (suppl): 507 (abstr). Hills M, Armitage P. The two-period cross-over clinical trial. Br J Clin Pharmacol 1979; 8: 7-20. Mumford JP. A profile of vigabatrin. Br J Clin Pract 1988; 42 (suppl 61): 7-9. Schmidt D. Two antiepileptic drugs for intractable epilepsy with complex-partial seizures. J Neurol Neurosurg Psychiatry 1982; 45: 1119-24. Temkin NR, Wilensky AJ. New AEDs: are the compounds or the studies ineffective?. Epilepsia 1986; 27: 644-45. Crawford P, Chadwick D. A comparative study of progabide, valproate and placebo as add-on therapy in patients with refractory epilepsy. J Neurol Neurosurg Psychiatry 1986; 49: 1251-57.
Hepatitis C antibody and chronic liver disease in haemophilia
A
radioimmunoassay was used to detect antibodies to hepatitis C virus (anti-HCV) in 154 patients with haemophilia. Prevalence of antiHCV was associated with exposure to clotting factor concentrates. 76 of 129 (59%) who had received factor VIII or IX had anti-HCV: 42 of 55 (76%) who required over 10 000 units of concentrate annually had anti-HCV, compared with 34 of 74 (46%) who required less, and 0 of 25 patients who had never received concentrates. Anti-HCV were significantly more common in patients seropositive for antibodies against human immunodeficiency virus (anti-HIV) or with markers of previous hepatitis B infection than in those without anti-HIV or hepatitis B markers (88% vs 39% and 75% vs 46%, respectively). 5 of 23 (22%) haemophiliacs treated only with heated concentrates had anti-HCV compared with 71 of 106 (67%) patients who received unmodified products. 35 patients with chronic liver disease underwent liver biopsy: histological examination showed features associated with post-transfusion hepatitis in 24, all of whom were anti-HCVpositive; of the other 11 patients with no histological features of non-A, non-B hepatitis, 5 were anti-HCV-positive. HCV appears to be the major predisposing factor for most non-A, non-B hepatitis and chronic liver disease in haemophilia. Lancet 1990; 335: 1117-19.
Introduction Before heat treatment of clotting factor concentrates, almost all patients who were treated with factor VIII for the first time
acquired non-A, non-B (NANB) hepatitis,l of whom
70 % would show chronic liver enzyme abnormalities2 and at least 20% would develop cirrhosis.3 End-stage liver failure is now recognised to be a major cause of morbidity and mortality in haemophilia 4 Although it has been widely assumed that such liver disease is caused by a virus or viruses, in the absence of a serological marker it has been impossible to identify the agent or agents responsible. We report serological evaluation of a novel marker for hepatitis C5,6 in relation to clinical, biochemical, and histological changes in a population of haemophilia patients.
Patients and methods Sera from 154 adults (aged 17-91 years) with coagulation disorders who attended the Sheffield Haemophilia Centre were tested for the presence of antibody to hepatitis C virus (anti-HCV). All 46 patients with severe haemophilia (less than 2 IU/dl factor VIII or IX plasma concentrations) were included, as were a randomly selected group of patients with less severe haemophilia, 18 with von Willebrand’s disease, and 9 with other familial coagulation disorders. 129 (84%) of the patients had received either factor VIII or IX concentrate. All samples were kept frozen at - 20°C until tested. The presence of chronic liver disease was defined biochemically as a raised serum alanine aminotransferase (ALT; above 45 U/1) for more than 6 months. ALT concentrations were considered persistently raised when all 3 most recent measurements were high, intermittently raised when 1 or 2 of the last 3 values were
ADDRESSES Departments of Haematology (M. Makris, MRCP, Prof F E. Preston, MD), Medicine (D. R. Triger, FRCP), and Pathology (J. C. E. Underwood, MD), Royal Hallamshire Hospital, Sheffield, UK; and Chiron Corporation, Emeryville, California, USA (Q. L. Choo, PhD, G Kuo, PhD, M. Houghton, PhD) Correspondence to Prof F E. Preston, Department of Haematology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
1118
TABLE I-DEMOGRAPHIC DATA
*Factor X deficiency (1 factor XI carner for haemophilia B (6)
deficiency (1); carrier for haemophilia A (1 ); and
high, or normal when none of the last three estimations was above the normal range. The average annual concentrate usage was calculated for the period 1986-88. 4 patients received cryoprecipitate only and are grouped here with 21 patients who had never been given factor VIII or IX concentrates. 23 patients had received heat-treated factor concentrates only. 35 patients with persistently abnormal liver function underwent liver biopsy. Specimens were examined by a histopathologist (J. C. E. U.), who did not know the results of the HCV assays, and were considered to show evidence of NANB hepatitis if at least 2 of 3 features were observed:7-10 focally dense lymphocytic portal tract infiltrates adjacent to or surrounding interlobular ducts, rarely associated with ductal epithelial damage; fatty change, often microvesicular, without other features (eg, Mallory’s hyalin) to indicate an alternative explanation; and sinusoidal infiltrates of lymphoid cells without a proportionate degree of liver necrosis. Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc) were used as markers of hepatitis B infection, and measured by standard radioimmunoassay and enzyme-linked immunoassay techniques. Neither of the HBsAgpositive patients underwent liver biopsy. For anti-HCV assay all samples were coded and shipped to the assay laboratory (Chiron) on dry ice. Anti-HCV was detected by a radioimmunoassay in which a recombinant HCV polypeptide was used to coat the wells, as previously described.6 Values greater than 3 SD above the mean result for uninfected controls were considered to be positive .6 In most patients who underwent liver biopsy, anti-HCV was measured in blood taken the day before biopsy, and in all within 10 weeks of the procedure. Fisher’s exact test and the X2 test were used to compare frequencies between groups.
Results
patients had received clotting factor concentrates, 76 (59%) of whom had anti-HCV ; there was no significant difference in prevalence of anti-HCV between patients with haemophilia A or B (61% vs 58%). Anti-HCV positivity 129
associated with greater exposure to factor concentrates: (76%) patients who required more than 10 000 units annually had anti-HCV compared with 34 of 74 (46%) who required less (table II; p < 0-001). All 25 patients who had never received concentrates were anti-HCV-negative.
was
42 of 55
TABLE II-PREVALENCE OF ANTI-HCV IN RELATION TO CLOTTING FACTOR CONCENTRATES
The prevalence of anti-HCV in the 23 patients who had received heat-treated concentrates only was significantly less than that in those who had received non-heat-treated concentrates (22% vs 67%, p < 0-001; table II). The groups are not directly comparable in that only 1 of the patients who received heat-treated factor only had severe haemophilia compared with 45 of 96 who were given non-heat-treated concentrates, but the difference remains statistically significant when only patients who required less than 10 000 units annually are compared (5 of 22 [23%] heat-treated vs 29 of 52 [54%] non-heat-treated; p < 0-05). 8 of the 18 patients with von Willebrand’s disease had received factor VIIIconcentrate (all less than 10 000 IU annually). In all but 1 patient, the concentrate was not heat-treated. 4 of the treated patients had abnormal liver function tests and these alone were anti-HCV-positive. 47 of 60 (78%) patients with persistently raised serum ALT concentrations were anti-HCV-positive, and 19 of 29 with intermittently raised ALT were anti-HCV-positive, compared with 10 of 62 with normal ALT (p < 0-001); 3 patients were excluded because of insufficient data. TABLE III-RELATION OF HCV ANTIBODY STATUS TO OTHER VIRAL MARKERS
Table III shows the relation of anti-HCV seropositivity to other viral markers. 27 of 36 (75%) patients with evidence of previous exposure to hepatitis B were anti-HCV-positive, compared with 38 of 82 (46%) anti-HBc-negative patients (p < 0-01). We also found a significantly higher prevalence of anti-HCV in patients who were HIV-positive compared with HIV-negative patients (28 of 32 [88%] vs 48 of 122
[39%]; p < 0-001). Histological examination of 35 liver biopsy specimens showed chronic persistent hepatitis in 17, chronic active hepatitis in 8, cirrhosis in 6, and other changes in 4. Anti-HCV were found in the serum of all 24 patients whose biopsies showed histological features of NANB hepatitis. 5 of 11 specimens (45%) without histological evidence of NANB hepatitis were also anti-HCV-positive (3 had chronic persistent hepatitis, 1 had chronic active hepatitis, and I had cirrhosis). Of the other patients with no histological features of NANB hepatitis and who were anti-HCVnegative, 2 had alcoholic liver disease, 1 had cirrhosis,1 had chronic persistent hepatitis, 1 had fatty change with portal fibrosis, and 1 had a mild portal infiltration with TABLE IV-HCV, HBV, AND HIV MARKERS IN RELATION TO LIVER HISTOLOGY
1119
mononuclear cells. In the 29 anti-HCV-positive patients who underwent liver biopsy, the presence of anti-HIV or markers of previous hepatitis B infection was not associated with increased severity of liver disease (table IV).
Discussion Our findings show hepatitis C to be a major cause of chronic NANB hepatitis in UK patients with haemophilia. The overall incidence of anti-HCV in our patients treated with factor VIII or IX concentrates is 59%-which is lower than that reported from Spain (71%)," France (66%)," and West Germany (78%).13 The incidence of anti-HIV in treated patients also differs (25% vs 56%, 60%, and 51 %, respectively). These differences might reflect different usage of concentrates. The absence of anti-HCV from any of our 25 untreated patients reflects a low prevalence in a healthy UK population,14,15 and indicates that this test could be used as a specific marker of HCV infection in our
if antiviral therapy is contemplated in with suspected chronic liver damage. We haemophiliacs found no evidence to indicate that coexistence of markers of HIV infection accelerates the progression of HCVassociated liver disease, which contrasts with a preliminary report by Martin et al,19 who found rapid deterioration in liver function of patients with AIDS who had NANB
taken into
account
hepatitis. In conclusion, hepatitis C appears to be the major, if not the sole, cause of non-hepatitis-B viral liver disease in haemophiliacs. There is an urgent need to eliminate HCV from clotting factor concentrates by screening and other means; only when this has been achieved will it be possible determine whether other agents disease in patients with haemophilia.
to
chronic liver
We thank Mrs Linda Westlake for help with statistical analysis.
patients.
REFERENCES
of clotting factor concentrates, anti-HIV seropositivity, and anti-HBc seropositivity were also associated with a higher incidence of anti-HCV. Patients with haemophilia B treated almost exclusively with National Health Service (NHS) factor IX derived from volunteer donors had a similar incidence of anti-HCV to haemophilia A patients who received a mixture of commercially obtained (paid donor) and NHS (volunteer donor) factor VIII concentrate (60% vs 69%): this may reflect Fletcher et al’s suggestion1 that although blood derived from volunteer as opposed to paid donors is associated with reduced viral transmission, this may be counterbalanced by the size of the donor pool. Only 22% of patients who received heated factor concentrate were anti-HCV-positive compared with 67% who were given non-heat-treated products: this observation is consistent with reports that heat treatment of the concentrate reduces, but does not abolish, the risk of NANB hepatitis.16-18 We found that patients with persistently raised ALT had a higher prevalence of anti-HCV than those with intermittently raised ALT. 10 of 62 (16%) patients with normal liver enzymes had circulating anti-HCV. We feel this finding may reflect quiescent chronic liver disease--6 of these 10 patients had had abnormal ALT concentrations and undergone liver biopsy during the previous 2-10 years; 4 of these had had histological evidence of chronic persistent hepatitis, 1 of chronic active hepatitis, and the other cirrhosis. Only 1 anti-HCV-positive patient had no previous evidence of abnormal ALT concentrations. Our study enabled the relation between HCV antibody status, serological markers for HBV and HIV, and liver histology in haemophiliacs to be examined. All 24 patients with histological features of NANB hepatitis7-10 were positive for anti-HCV, which indicates that HCV may have caused the liver abnormalities. The absence of these features in liver biopsy specimens from 5 anti-HCV-positive patients has several possible explanations: a sampling error is unlikely because NANB hepatitis is usually diffuse; more likely reasons are that the typical histology of NANB hepatitis does not occur throughout all phases of infection, or that other hitherto unidentified viruses may coexist with HCV and stimulate the liver inflammation. The observation of various histological abnormalities in 6 patients who were anti-HCV-negative indicates that persistent abnormalities of liver enzymes cannot always be equated with chronic virus-associated liver damage: this observation should be Increased
cause
use
1. Fletcher ML, Trowell JM, Craske J, Pavier K, Rizza CR. Non-A, non-B hepatitis after transfusion of factor VIII in infrequently treated patients. Br Med J 1983; 287: 1754-57. 2. Cederbaum AI, Blatt PM, Levine PH. Abnormal serum transminase levels in patients with haemophilia A. Arch Intern Med 1982; 142: 481-84. 3.
Hay CRM, Preston FE, Triger DR, Underwood JCE. Progressive liver disease in haemophilia: an understated problem? Lancet 1985; i: 1495-98.
Eyster ME, Whitehurst DA, Catalano PM, et al. Long-term follow-up of haemophiliacs with lymphocytopenia or thrombocytopenia. Blood 1985; 66: 1317-20. 5. Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 244: 359-62. 6. Kuo G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989;
4.
244: 362-64.
M, Murray AK, Weller IVD, et al. Clinical and histological features of a group of patients with sporadic non-A, non-B hepatitis. J Clin Pathol 1981; 34: 1175-80.
7. Bamber
8. Bamber M, Murray A, Arborgh BAM, et al. Short incubation non-A, non-B hepatitis transmitted by factor VIII concentrates in patients with congenital coagulation disorders. Gut 1981; 22: 854-59. 9. Dienes HP, Popper H, Arnold W, Lobeck H. Histological observations in human hepatitis non-A, non-B. Hepatology 1982; 2: 562-71.
M, Pirovino M, Altorfer J, Gudat F, Bianchi L. Acute hepatitis non-A, non-B; are there any specific light microscopic features? Liver 1982; 2: 61-67. 11. Esteban JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989; ii: 294-97. 12. Noel L, Guerois C, Maisonneuve P, Verroust F, Laurian Y. Antibodies to hepatitis C virus in haemophilia. Lancet 1989; ii: 560. 13. Roggendorf M, Dienhardt F, Rasshofer R, et al. Antibodies to hepatitis C virus. Lancet 1989; ii: 324-25. 14. Contreras M, Barbara JAJ. Screening for hepatitis C virus antibody. Lancet 1989; ii: 505. 15. Mortimer PP, Cohen BJ, Litton PA, et al. Hepatitis C virus antibody. Lancet 1989; ii: 798. 16. Colombo M, Mannucci PM, Camelli V, et al. Transmission of non-A, non-B hepatitis by heat-treated factor VIII concentrate. Lancet 1985; ii: 10. Schmid
1-A. 17.
Kemoff PBA, Miller EJ, Savidge GF, Machin SJ, Dewar MS, Preston FE. Reduced risk of non-A, non-B hepatitis after a first exposure to "wet-heated" factor VIII concentrate. Br J Haematol 1987; 67: 207-11. 18. Preston FE, Hay CRM, Dewar MS, Greaves M, Triger DR. Non-A, non-B hepatitis and heat-treated factor VIII concentrates. Lancet 1985; ii: 213.
P, Di Bisceglie AM, Kassianides C, Lisker-Melman M, Hoofnagle JH. Non-A, non-B hepatitis leads to rapidly progressive liver disease in patients with human immunodeficiency virus infection. Gastroenterology 1989; 96: A627.
19. Martin
