Digestion 14: 304-310 (1976)
Passive Immunotherapy in HBs A g Fulminant Hepatitis Results on Antigenaemia and Survival Ph. Gateau, P. Opolon, V. Nusinovici, C. Ropars and J . Caroli Gastroenterological Unit, CH U Saint-Antoine and C D T S, Paris
Key Words. Anti australia antigen • Australia antigen • Hepatic coma • Hepatitis infec tious • Immunotherapy • Liver failure • Liver function tests • Liver regeneration
Abstract. 19 patients with HBs Ag-positive fulminant hepatitis underwent exchange transfusions and anti-HBs-rich plasma infusions. Circulating HBs Ag disappeared in 17 cases. Circulating anti-HBs detected by RIA was higher in cases with liver regeneration. There was no correlation between circulating anti-HBs level and the amount o f anti-HBs-rich plasma administered. Recovery was observed in 36 % o f the cases and liver regeneration in 47 %. As the beneficial effect o f such a treatment is not yet evident, a controlled trial should require pairing o f patients with respect to the number o f exchange transfusions and amount o f real or placebo anti-HBs.
In 1971, Gocke (5) described a disappearance o f circulating HBs Ag in patients with fulminant hepatitis after exchange transfusion and administration o f plasma-containing HBs antibody. 5 of 8 patients survived after such therapy. In September 1972, the Acute Hepatic Failure Study Group began a co operative double-blind evaluation o f HBs antibody administration on survival in this disease. Using the same amount o f anti-HBs immunoglobulin for each patient without any preliminary exchange transfusion, antigenaemia was not abolished nor was survival improved (1). The aim o f this study was to determine the number of exchange transfu sions and the amount o f anti-HBs plasma required to obtain circulating HBs Ag disappearance. As these two parameters may differ for each patient, this prelimi nary study should provide information for the management o f a controlled trial following the original procedure described by Gocke (5).
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Received: October 29, 1976; accepted: February 18, 1976.
Gateau /Opoton/Nusinovici/Ropars/Caroli
305
Fig. 1. Clotting factor values in treated group at the onset o f treatment (mean ± SD). • = Death with no liver regeneration; * = death with liver regeneration; a. = complete re covery.
Material From March 1972 to July 1974, 19 patients with MBs Ag-positive fulminant hepatitis were treated. They were 13 females and six males (mean age: 33.4 years; range; 17-52). Mean value for interval between the onset o f jaundice and coma was 5.2 days (range: 1 1 3 days). All patients were treated in intensive care unit with routine hourly monitoring and the following examinations; (a) every 8 h: neurological examination; (b) twice daily: serum electrolytes, BUN, blood glucose; (c) once daily: clotting factors by modified Owrcn’s one stage procedure: factor II (normal level: 6 0 -1 0 0 % ), factor V (normal level: 6 0 -1 0 0 % ), factor V II + X (normal level: 6 0 -1 0 0 %); blood ammonia by Berthelot colorimetric method modified for Technicon analyzer (normal value: 6 5 -1 0 0 /ag%); blood volume measured with 51C'r labelled red cells; blood creatinine, calcium, phosphorus; blood gases (if necessary); proteinuria; FECI recording. All the patients, but three, were in coma grade IV when treatment started. In two cases only, coma did not exceed grade III during the course o f the illness. Blood ammonia level at the time o f admission in the intensive care unit was 223 ± 60 n%%. Factor II averaged 9 ± 6 %, factor V = 19 t 15 %, factor VII + X = 6 ± 4 %; for statistical studies 5 % was taken to represent values o f less than 10% (fig. 1). Liver regeneration was assessed by survival or increase in hepatocyte volume fraction estimated by stereological counting on serial liver biopsies (7).
Method
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General management. This included: 4-hourly intragastric administration o f antacids and lactulose (300 ml/day) through a nasogastric tube; 5 % glucose infusion with correction o f fluid and electrolyte balance as necessary; blood volume compensation with packed red cells, frozen plasma or fresh blood. Convulsions, cerebral oedema, hyperventilation were treated by infusion o f diazepam or methyl-4-fl-chlorcthyl-5-thiazol-ethane-disulphonate (Hemineurine®).
Gateau /Opolon /Nusinovici/Ropars /Caroli
306
Passive immunotherapy. Within 3 h o f admission, each patient’s plasma was tested by electroimmunodiffusion (E1D) for the presence o f HBs Ag or anti-HBs. Every HBs Ag-positive patient underwent an exchange transfusion with HBs Ag and anti-HBs radioimmunoassay (RIA)-negative fresh blood (less than 2 days old) conserved on citrate phosphate dextrose. This exchange transfusion was equal to the measured blood volume. 2 h later, anti-HBs containing frozen plasma (500 700 ml) was infused curing a period o f 4 h. As a large number o f donors (i.e. > 100) were not available for such a preliminary study, the anti-HBs containing plasma ('/8 - ‘/i* titer by EID) was not pooled, each sample from a donor being frozen separately. The best donor was selected by in vitro testing o f the patient’s serum against serial dilutions ('/, - '/ » ) o f a sample from each donor. The patient’s serum was tested by EID for HBs Ag or anti-HBs 2 It after the exchange transfusion, then 2 and 8 h after the anti-HBs infusion. If HBs Ag became negative, anti-HBs plasma was administered daily until recovery o f consciousness, or evidence o f excess circulating anti-HBs (by EID) or until death occurred. If HBs Ag was still positive after the first exchange transfusion and anti-HBs plasma in fusion, a new exchange transfusion was performed and then anti-HBs infusions continued as described above. Purposefully, one patient received a single dose o f anti-HBs containing plasma. Frozen plasma samples were stored (for all patients but two) for R1A detection o f HBs Ag and anti-HBs.
Results
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Side Effects One patient, 2 h after the third anti-HBs plasma infusion (on the third day o f treatment) had urticarial type rash on the face and upper trunk, raised blood pressure (260—100 mm Hg), anuria, focal convulsion (right arm and face), and supraventricular tachycardia. All these symptoms ceased within 30 min after administration o f hydrocortisone, furosemide and thiazol-ethane-disulphonate. An identical episode occurred 10 h later without any plasma infusion. There were no cases of proteinuria and only 2 o f the 19 patients had severe renal failure. Hence it is unlikely that the renal failure was related to immunotherapy. HBs antigenaemia. Plasma HBs Ag became negative in all patients but two: one o f these was previously treated for monocytic leukaemia and the other died within the first 24 h o f admission. HBs Ag became spontaneously negative in one case between admission and coma, so the management o f this patient included only anti-HBs plasma infusion without any exchange transfusion. R ole o f exchange transfusion. In three cases exchange transfusion alone negativated HBs Ag. In ten patients, exchange transfusion plus one dose of anti-HBs plasma negativated circulating HBs Ag. In three patients a second ex change transfusion was needed as HBs Ag was still positive after the first ex change transfusion and anti-HBs plasma infusion. However, in one o f these cases the first anti-HBs infusion was performed with an in vitro non-reacting anti-HBs plasma. After negativation, HBs Ag was never detected again in any patient, even by the sensitive technique o f RIA.
307
Passive Immunotherapy in Viral Hepatitis
Table l. Number o f exchange transfusions (ET) and anti-HBs plasma infusions required to obtain R IA detectable circulating anti-HBs level in 15 patients ET, n
0 1 2
Anti-HBs plasma infusions, n 0
1
3
1 5
2
3
4 1
1
Table II. Recovery and liver regeneration Number
Recovery
Liver regeneration
Survival < 72 h Survival > 72 h
4 15
0 (0 %) 6 (40 %)
1 (25 %) 8 (53 %)
Total
19
6 (36 %)
9 (47 %)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
Antibody. In all 17 tested patients but one (death within the first 24 h of admission), anti-HBs was positive by R IA. In the patient with monocytic leu kaemia anti-HBs appeared despite the persistence of HBs Ag. In three patients, anti-HBs was present before any treatment with, respectively, 12, 30 and 65 % titers. In the one case who purposefully received only one dose, anti-HBs appeared on the third day after treatment at a low level (11 % R IA titer). In the other cases, circulating anti-HBs appeared after one dose o f anti-HBs containing plasma (400-500 ml) in six cases, after two doses (800-1,000 ml) in three cases and only after three doses (1,200—2,000 ml) in three cases (table I). The anti-HBs disappearance curve shows three different shapes (results of follow-up study in twelve cases): (i) in three cases, an immediate high level (> 80%) was obtained with a slow and progressive fall (fig. 2 a); (ii) in six cases, anti-HBs titer rose more progressively with a plateau (< 50 %) (fig. 2b); (iii) in three cases, an immediate high level was obtained with a rapid fall after anti-HBs infusions (fig. 2 c). Survival (table II). 6 o f 19 patients recovered (36 %). If patients surviving less than 72 h are excluded, results are not changed: six recoveries out o f 15 patients (40 %). Liver regeneration (table II). Six patients survived and three others died with liver regeneration (for the latter hepatocyte volume rose, respectively, from 0% , 7,5% , and 15% to 25%, 46% , and 49%). So 9 o f 19 patients (47%)
Gateau/Opolon/Nusinovici/Ropars/Caroli
308
H B A g 4— R IA
C
Fig. 2. Disappearance curves o f circulating anti-HBs after treatment in three patients. a Immediate high level and progressive disappearance, b Progressive rise and plateau. c Immediate high level and rapid fall. HB Ab = Infusion o f anti-HBs plasma in millilitres.
showed evidence o f liver regeneration (table II). Maximal circulating anti-HBs titer is higher in patients with liver regneration: 71 ± 24 versus 37 ± 24% (R1A titer) (fig. 3). However, statistical analysis (Student’s t test) shows no significant difference (0.15 < p < 0.20). Maximal circulating anti-HBs titer after treatment did not correlate with the amount o f anti-HBs plasma administered (fig. 4).
Comments
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
In 19 treated patients, there were no major side-effects, particularly no renal involvement. In contrast with the Acute Hepatic Failure Study Group’s report (1), circulating HBs Ag disappeared in all but two patients. In three cases, HBs Ag became negative after exchange transfusion only. On the other hand, two
309
Passive Immunotherapy in Viral Hepatitis
100 -i
100 -i
a ,
A A Û
L
80 -
* A
80 -J •
Passive Immunotherapy in HBs A g Fulminant Hepatitis Results on Antigenaemia and Survival Ph. Gateau, P. Opolon, V. Nusinovici, C. Ropars and J . Caroli Gastroenterological Unit, CH U Saint-Antoine and C D T S, Paris
Key Words. Anti australia antigen • Australia antigen • Hepatic coma • Hepatitis infec tious • Immunotherapy • Liver failure • Liver function tests • Liver regeneration
Abstract. 19 patients with HBs Ag-positive fulminant hepatitis underwent exchange transfusions and anti-HBs-rich plasma infusions. Circulating HBs Ag disappeared in 17 cases. Circulating anti-HBs detected by RIA was higher in cases with liver regeneration. There was no correlation between circulating anti-HBs level and the amount o f anti-HBs-rich plasma administered. Recovery was observed in 36 % o f the cases and liver regeneration in 47 %. As the beneficial effect o f such a treatment is not yet evident, a controlled trial should require pairing o f patients with respect to the number o f exchange transfusions and amount o f real or placebo anti-HBs.
In 1971, Gocke (5) described a disappearance o f circulating HBs Ag in patients with fulminant hepatitis after exchange transfusion and administration o f plasma-containing HBs antibody. 5 of 8 patients survived after such therapy. In September 1972, the Acute Hepatic Failure Study Group began a co operative double-blind evaluation o f HBs antibody administration on survival in this disease. Using the same amount o f anti-HBs immunoglobulin for each patient without any preliminary exchange transfusion, antigenaemia was not abolished nor was survival improved (1). The aim o f this study was to determine the number of exchange transfu sions and the amount o f anti-HBs plasma required to obtain circulating HBs Ag disappearance. As these two parameters may differ for each patient, this prelimi nary study should provide information for the management o f a controlled trial following the original procedure described by Gocke (5).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
Received: October 29, 1976; accepted: February 18, 1976.
Gateau /Opoton/Nusinovici/Ropars/Caroli
305
Fig. 1. Clotting factor values in treated group at the onset o f treatment (mean ± SD). • = Death with no liver regeneration; * = death with liver regeneration; a. = complete re covery.
Material From March 1972 to July 1974, 19 patients with MBs Ag-positive fulminant hepatitis were treated. They were 13 females and six males (mean age: 33.4 years; range; 17-52). Mean value for interval between the onset o f jaundice and coma was 5.2 days (range: 1 1 3 days). All patients were treated in intensive care unit with routine hourly monitoring and the following examinations; (a) every 8 h: neurological examination; (b) twice daily: serum electrolytes, BUN, blood glucose; (c) once daily: clotting factors by modified Owrcn’s one stage procedure: factor II (normal level: 6 0 -1 0 0 % ), factor V (normal level: 6 0 -1 0 0 % ), factor V II + X (normal level: 6 0 -1 0 0 %); blood ammonia by Berthelot colorimetric method modified for Technicon analyzer (normal value: 6 5 -1 0 0 /ag%); blood volume measured with 51C'r labelled red cells; blood creatinine, calcium, phosphorus; blood gases (if necessary); proteinuria; FECI recording. All the patients, but three, were in coma grade IV when treatment started. In two cases only, coma did not exceed grade III during the course o f the illness. Blood ammonia level at the time o f admission in the intensive care unit was 223 ± 60 n%%. Factor II averaged 9 ± 6 %, factor V = 19 t 15 %, factor VII + X = 6 ± 4 %; for statistical studies 5 % was taken to represent values o f less than 10% (fig. 1). Liver regeneration was assessed by survival or increase in hepatocyte volume fraction estimated by stereological counting on serial liver biopsies (7).
Method
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
General management. This included: 4-hourly intragastric administration o f antacids and lactulose (300 ml/day) through a nasogastric tube; 5 % glucose infusion with correction o f fluid and electrolyte balance as necessary; blood volume compensation with packed red cells, frozen plasma or fresh blood. Convulsions, cerebral oedema, hyperventilation were treated by infusion o f diazepam or methyl-4-fl-chlorcthyl-5-thiazol-ethane-disulphonate (Hemineurine®).
Gateau /Opolon /Nusinovici/Ropars /Caroli
306
Passive immunotherapy. Within 3 h o f admission, each patient’s plasma was tested by electroimmunodiffusion (E1D) for the presence o f HBs Ag or anti-HBs. Every HBs Ag-positive patient underwent an exchange transfusion with HBs Ag and anti-HBs radioimmunoassay (RIA)-negative fresh blood (less than 2 days old) conserved on citrate phosphate dextrose. This exchange transfusion was equal to the measured blood volume. 2 h later, anti-HBs containing frozen plasma (500 700 ml) was infused curing a period o f 4 h. As a large number o f donors (i.e. > 100) were not available for such a preliminary study, the anti-HBs containing plasma ('/8 - ‘/i* titer by EID) was not pooled, each sample from a donor being frozen separately. The best donor was selected by in vitro testing o f the patient’s serum against serial dilutions ('/, - '/ » ) o f a sample from each donor. The patient’s serum was tested by EID for HBs Ag or anti-HBs 2 It after the exchange transfusion, then 2 and 8 h after the anti-HBs infusion. If HBs Ag became negative, anti-HBs plasma was administered daily until recovery o f consciousness, or evidence o f excess circulating anti-HBs (by EID) or until death occurred. If HBs Ag was still positive after the first exchange transfusion and anti-HBs plasma in fusion, a new exchange transfusion was performed and then anti-HBs infusions continued as described above. Purposefully, one patient received a single dose o f anti-HBs containing plasma. Frozen plasma samples were stored (for all patients but two) for R1A detection o f HBs Ag and anti-HBs.
Results
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
Side Effects One patient, 2 h after the third anti-HBs plasma infusion (on the third day o f treatment) had urticarial type rash on the face and upper trunk, raised blood pressure (260—100 mm Hg), anuria, focal convulsion (right arm and face), and supraventricular tachycardia. All these symptoms ceased within 30 min after administration o f hydrocortisone, furosemide and thiazol-ethane-disulphonate. An identical episode occurred 10 h later without any plasma infusion. There were no cases of proteinuria and only 2 o f the 19 patients had severe renal failure. Hence it is unlikely that the renal failure was related to immunotherapy. HBs antigenaemia. Plasma HBs Ag became negative in all patients but two: one o f these was previously treated for monocytic leukaemia and the other died within the first 24 h o f admission. HBs Ag became spontaneously negative in one case between admission and coma, so the management o f this patient included only anti-HBs plasma infusion without any exchange transfusion. R ole o f exchange transfusion. In three cases exchange transfusion alone negativated HBs Ag. In ten patients, exchange transfusion plus one dose of anti-HBs plasma negativated circulating HBs Ag. In three patients a second ex change transfusion was needed as HBs Ag was still positive after the first ex change transfusion and anti-HBs plasma infusion. However, in one o f these cases the first anti-HBs infusion was performed with an in vitro non-reacting anti-HBs plasma. After negativation, HBs Ag was never detected again in any patient, even by the sensitive technique o f RIA.
307
Passive Immunotherapy in Viral Hepatitis
Table l. Number o f exchange transfusions (ET) and anti-HBs plasma infusions required to obtain R IA detectable circulating anti-HBs level in 15 patients ET, n
0 1 2
Anti-HBs plasma infusions, n 0
1
3
1 5
2
3
4 1
1
Table II. Recovery and liver regeneration Number
Recovery
Liver regeneration
Survival < 72 h Survival > 72 h
4 15
0 (0 %) 6 (40 %)
1 (25 %) 8 (53 %)
Total
19
6 (36 %)
9 (47 %)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
Antibody. In all 17 tested patients but one (death within the first 24 h of admission), anti-HBs was positive by R IA. In the patient with monocytic leu kaemia anti-HBs appeared despite the persistence of HBs Ag. In three patients, anti-HBs was present before any treatment with, respectively, 12, 30 and 65 % titers. In the one case who purposefully received only one dose, anti-HBs appeared on the third day after treatment at a low level (11 % R IA titer). In the other cases, circulating anti-HBs appeared after one dose o f anti-HBs containing plasma (400-500 ml) in six cases, after two doses (800-1,000 ml) in three cases and only after three doses (1,200—2,000 ml) in three cases (table I). The anti-HBs disappearance curve shows three different shapes (results of follow-up study in twelve cases): (i) in three cases, an immediate high level (> 80%) was obtained with a slow and progressive fall (fig. 2 a); (ii) in six cases, anti-HBs titer rose more progressively with a plateau (< 50 %) (fig. 2b); (iii) in three cases, an immediate high level was obtained with a rapid fall after anti-HBs infusions (fig. 2 c). Survival (table II). 6 o f 19 patients recovered (36 %). If patients surviving less than 72 h are excluded, results are not changed: six recoveries out o f 15 patients (40 %). Liver regeneration (table II). Six patients survived and three others died with liver regeneration (for the latter hepatocyte volume rose, respectively, from 0% , 7,5% , and 15% to 25%, 46% , and 49%). So 9 o f 19 patients (47%)
Gateau/Opolon/Nusinovici/Ropars/Caroli
308
H B A g 4— R IA
C
Fig. 2. Disappearance curves o f circulating anti-HBs after treatment in three patients. a Immediate high level and progressive disappearance, b Progressive rise and plateau. c Immediate high level and rapid fall. HB Ab = Infusion o f anti-HBs plasma in millilitres.
showed evidence o f liver regeneration (table II). Maximal circulating anti-HBs titer is higher in patients with liver regneration: 71 ± 24 versus 37 ± 24% (R1A titer) (fig. 3). However, statistical analysis (Student’s t test) shows no significant difference (0.15 < p < 0.20). Maximal circulating anti-HBs titer after treatment did not correlate with the amount o f anti-HBs plasma administered (fig. 4).
Comments
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 7:44:15 AM
In 19 treated patients, there were no major side-effects, particularly no renal involvement. In contrast with the Acute Hepatic Failure Study Group’s report (1), circulating HBs Ag disappeared in all but two patients. In three cases, HBs Ag became negative after exchange transfusion only. On the other hand, two
309
Passive Immunotherapy in Viral Hepatitis
100 -i
100 -i
a ,
A A Û
L
80 -
* A
80 -J •
