Pathophysiology and Pharmacologic

Modulation of Hepatic Fibrosis

Cynthia R. Leveille, DVM, and Irwin M. Arias, MD

Most chronic liver disorders are accompanied morphologically by the deposition of fibrous tissue within
the hepatic parenchyma. This fibrotic tissue compromises hepatic function and contributes significantly
to hepatic failure. Fibrosis is a dynamic process associated with the continual deposition and resorption
of connective tissue. Therapeutic strategies are emerging whereby this dynamic process can be modu-
lated. Since collagen is the major component of the extracellular matrix deposited in hepatic fibrosis,
most anti-fibrotic therapies have been directed toward the control of collagen metabolism. After collagen
genes are transcribed and translated into precursor procollagen proteins, a number of post-translational
modifications that ensure the deposition of structurally sound collagen within the extracellular matrix
occur. A number of drugs can specifically modulate collagen biosynthesis at the transcriptional level or at
various post-translational stages. These anti-fibrotic drugs include corticosteroids, azathioprine, penicil-
lamine, colchicine, zinc, prostaglandins, cyclosporine, and interferons. The pharmacologic action of
these drugs and the clinical role in veterinary and human fibrotic hepatopathies will be discussed.
(Journal of Veterinary Internal Medicine 1993; 7:73-84)

HEPATIC FIBROSIS is an important feature of chronic
liver disease. The replacement of normal hepatic paren-
chymal tissue by connective tissue compromises the
functional capacity of the liver and disrupts the normal
architectural relationships of the liver. An important
consequence of liver fibrosis is the deposition of connec-
tive tissue around the hepatic sinusoids so that vascular
diffusion barriers are disrupted and sinusoidal blood
flow tracts are narrowed. The resultant portal hyperten-
sion and impaired clearance of endogenous and exoge-
nous metabolites contribute to hepatic dysfunction (Fig.
l).’ Portal hypertension also leads to pooling of blood in
the splanchnic circulation, decreasing effective arterial
blood volume and activating volume receptors so that
sodium and water is avidly retained and eventually
ascites ensues.’ Hepatic fibrogenesis ultimately results in
cirrhosis, a condition marked by diffuse lobular fibrosis
and conversion of normal liver architecture into struc-
turally abnormal nodules.
The liver has a remarkable regenerative capability and
studies have shown that early hepatic fibrotic changes
From Tufts University School of Veterinary Medicine, North Grafton,
and Tufts University School of Medicine, Boston, Massachusetts.
Accepted for publication October 9, 199 I .
Reprint requests: Cynthia R. Leveille, DVM, Tufts University
School of Veterinary Medicine, 200 Westboro Road, North Grafton,
MA 01536.
are rever~ible.~,~Therefore, if the fibrogenic processes as-
sociated with chronic liver injury could be detected early
and curtailed, the development of end-stage hepatic fail-
ure might be prevented. Hepatic anti-fibrotic drugs are
rapidly emerging as potentially important therapeutic
modalities for chronic hepatopathies in human beings.
Anti-fibrotic therapy in human medicine has been di-
rected toward four major hepatic disorders: 1) Schistoso-
miasis, a parasitic disease known to affect more than 200
million people, is associated with the development of
periportal hepatic fibrosis. Schistosoma eggs are depos-
ited in the mesenteric veins and blood flow cames them
to the liver via the portal vein where parasitic antigens
trigger the development of periportal hepatic granulo-
mas. The granuloma formation is primarily mediated by
T-lymphocyte ~ytokines.~ 2) Acute hepatitis B virus in-
fection often progresses to chronic active hepatitis and
ultimately to cirrhosis. Currently, there are more than
200 million people with chronic hepatitis B infection.63)
Chronic alcohol ingestion causes a spectrum of patho-
logic changes in the liver starting with lipidosis and lead-
ing to alcoholic hepatitis and finally cirrhosis.’ 4) Pri-
mary biliary cirrhosis is an immune-mediated disease
characterized by granulomatous bile duct destruction
and subsequent cholestasis. Inflammatory and fibrotic
changes in the intrahepatic bile ducts involve a number
of immune reactions many of which are mediated by T
lymphocytes.*

13
 19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
74 LEVEILLE AND ARIAS Internal Medicine

I MAJOR CONSEQUENCES OF F I B R 0 S I S 1 usually accompanies either form. The nonsuppurative

form of the syndrome may represent the later stage in a
I perisinusoidal fibtosis I continuum of inflarnrnati~n.~~ It is associated with
marked periductal fibrosis and the development of
bridging fibrosis, i.e., the deposition of connecting bands
of fibrous tissue between portal tracts.25Biliary cirrhosis
is the final sequela of chronic cholangiohepatitis in
which severe diffuse fibrotic changes are commonly as-
~UomorCu*.l hpaocsC1.r
POaJclS I
rnalnutrRim
01 hspatccylea
deledive clearance
01 toxc umpamnja
eaoph.geal
varues
sociated with end-stage liver disease.26The etiology of
1 1 1 1 1 1 this syndrome in cats is unknown although a relation-
~ m i ~ l uocdcldblpfmms1
n l rrmtatnhc psrwtent endotoxmaemu ship with pancreatic disease has been suggested. Its histo-
OumI wnrnpdshs1 ha~mnerry ~ m c ~
hepltccoma Wmp
Mnutdropnt nocross pathologic similarity to primary biliary cirrhosis in hu-
EClF t
man beings suggests a role for immune mechanisms.
FIG. 1. Biochemical and clinical consequences of perisinusoidal fibro-
sis. (Modified and reprinted with permission from Semin Liver Dis
1990; 10:31.
Extracellular Matrix
The extracellular matrix (ECM) of the liver consists of
the insoluble portion of the extracellular environment
Hepatic fibrosis plays an important role in the develop- and is composed of four major substances: collagen, pro-
ment of end-stage liver failure in many hepatobiliary dis- teoglycans, elastin, and glycoproteins including fibronec-
eases in veterinary medicine. The etiology of these hepa- tin and laminin. Hepatic parenchymal cells, sinusoidal
topathies varies. Doberman pinschers develop a familial endothelial cells, hepatic macrophages (Kupffer cells),
hepatopathy characterized by chronic active hepatitis and hepatic lipocytes (Ito cells) are all capable of synthe-
that eventually progresses to ~irrhosis.~-'~ Similar syn- sizing components of the E C M . ' TThe ~ ~ ECM provides
dromes occur in West Highland White Temers13 and not only a structural framework for those cells to exist in
Skye Terrier~.'~ Some controversy exists as to whether but also acts a determinant of cell function by regulating
copper accumulation within the hepatocytes in these gene expression and r e g u l a t i ~ n .Normally
~ ~ , ~ ~ the ECM
breeds of dogs is a consequence or a cause of their liver surrounding differentiated cells or tissues is regionally
disease. Copper balance is normally regulated by biliary specialized, but during hepatic injury, a histologic redis-
excretion. Increased hepatic copper concentrations, tribution of the constituents of the ECM occurs. In he-
therefore, often accompany hepatobiliary diseases asso- patic fibrosis, the production of each of the components
ciated with cholesta~is.'~ Such cholestasis is often a fea- of the ECM is increased. In pathologic conditions, the
ture of the hepatopathies in these breeds of dogs. In Bed- hepatic lipocyte is stimulated to proliferate and trans-
lington Temers, however, there is an inherited disorder form into a myofibroblast-likecell capable of producing
in hepatic copper metabolism that leads to copper accu- large quantities of ECM. This activation occurs in re-
mulation in the liver independent of c h o l e ~ t a s i s . ~ ~ * ~ ~ to cytokines released from Kupffer cells, plate-
sponse
Eventually chronic hepatocellular copper overload re- lets, and other inflammatory cells as well as in response
sults in hepatic necrosis and inflammation, which pro- to changes in ECM c o r n p ~ s i t i o n . ~ ~
gresses to chronic active hepatitis and cirrhosis. Lepto-
sporosis" and infectious canine hepatitis virus19 have Collagen Metabolism
been incriminated as infectious causes of chronic active
Structure
hepatitis. A transmissible agent, as yet unidentified, has
been associated with canine chronic active hepatitis in Because collagen is the major component of the ECM,
Scotland." Fibrotic hepatopathies have occurred with anti-fibrotic strategies have centered on attempts to alter
chronic anticonvulsant therapy2' and have also been as- hepatic collagen metabolism. In chronic liver disease,
sociated with the use of the daily heartworm preventa- hepatic collagen content increases significantly. Cir-
tive combination diethylcarbamazine-o~ibendazole.~~~~~ rhotic liver contains up to seven times as much collagen
Fibrosis may also be a component of the feline cholan- as does normal liver.30
giohepatitis syndrome. This syndrome encompasses he- Collagens are proteins composed of three polypeptide
patobiliary disorders marked by inflammation of the in- chains folded into a triple helix. The polypeptide chains,
trahepatic bile ducts and portal triads. It has been classi- which are called alpha chains, contain the repetitive
fied histologically according to the predominant amino-acid sequences, glycine-X-Y. Unique to collagen
inflammatory cell infiltrate. A neutrophilic infiltrate is the frequent presence of the amino-acid proline in the
characterizes the suppurative form24and a lymphocytic, X position and hydroxyproline in the Y position. Varia-
plasmacytic cell infiltrate is present in the nonsuppura- tion in amino-acid chain length and amino-acid compo-
tive form.25 Varying degrees of pericholangial fibrosis sition allow for at least 13 types of ~ o l l a g e n . ~ Hepatic
.~',~~

Vol. 7 . NO.2, 1993 HEPATIC FIBROSIS
tissue contains eight types of ~ o l l a g e n .In
~ . some
~ ~ types
of collagen, the triple helix molecules are longitudinally
aligned into fibrils that are subsequently strengthened by
interchain covalent bonds.” This is true of the most
abundant collagens in liver, types I and 111, the so-called
interstitial collagen^.^.'^ Type I and 111 collagens com-
prise 80% of the total liver collagen. Type I collagen
forms the thick dense connective tissue networks located
primarily in the liver capsule, portal triads, and around
venules. Type 111 collagen forms the fine, thin networks
of connective tissue associated with type I collagen in the
portal triads, centrolobular regions and around venules,
and is responsible for the fine, reticulum network that
supports the liver lobules. Type IV collagen, which does
not form fibrils, represents about 10%of the total liver
collagen. It is localized primarily to sinusoidal basement
membrane~.~,~~,~~,’~
Biosynthesis
The synthesis of all types of liver collagen is increased in
chronic liver diseases; however, increases in type I and
111 collagens pred~minate.’,~,~’.’~ Early fibrotic changes
are primarily due to increases in type 111 collagen. Type I
collagen deposition predominates in advanced fibrotic
disease.’ Although quantitatively less important, the in-
creased deposition of the type IV basement membrane
collagen within the space of Disse with subsequent
disruption of sinusoidal endothelial cell function may
play an important role in initiating hepatic dysfunc-
tion.’*
The biosynthesis of collagen occurs in several steps,
many of which are unique to collagen metabolism. Col-
lagen genes are transcripted and translated as long pro-
collagen molecules that contain additional amino and
carboxy terminal amino-acid sequences (Fig. 2).31The
procollagen molecules then undergo a series of intracel-
lular and extracellular post-translational modifications
(Table 1).31,33.36 The first step in the intracellular post-
PROCOLLAGEN MOLECULE
I collagen fiber with its tensile strength. Improperly cross-
FIG. 2. Schematic representation of the structure of the procollagen
molecule. Glc, glucose; Gal, galactose: Man, mannose; and GlcNac,
N-acetylglucosamine. (Reprinted with permission from N Engl J Med
1979; 301:16.
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
75
translational modification is the hydroxylation of pro-
line and lysine residues. These reactions are catalyzed by
three enzymes, prolyl-4-hydroxylase, prolyl-3-hydroxy-
lase, and lysylhydroxylase. All three enzymes require
iron, 2-oxoglutarate, ascorbic acid, and molecular oxy-
gen as cofactors. These hydroxylations are necessary for
the spontaneous formation of a stable triple helix by the
procollagen alpha chains. The triple helix formation, in
turn, is necessary for resistance to intracellular and ex-
tracellular degradation and for optimal secretion of the
procollagen molecules into the extracellular ma-
tri~.”.’~,’~ The second step in the intracellular processing
of the procollagen molecule is the addition of sugar moi-
eties to the hydroxylysyl residues. This reaction requires
glucose and galactose sugars and specific glucosyl and
galactosyl transferases. Manganese serves as a cofactor
for these enzyme^.^'.^'.^^ After hydroxylation and addi-
tion of the sugars are complete, the procollagen alpha
chains spontaneously fold into a triple helix and intra-
chain and interchain disulfide bonds form to stabilize
the molecule (step 3). The fourth step in the intracellular
processing is the secretion of the procollagen molecule
into the extracellular m a t ~ i x . ” . ~ This
’ . ~ ~ secretory pro-
cess is similar to that of any protein synthesized for ex-
port.
Once within the extracellular environment type I and
type 111 collagen undergo extracellular modifications re-
sulting in the formation of fibrils (Table 1).31.33.36 In the
first step, the amino terminal and carboxy terminal pro-
peptide sequences in the type I and type 111 procollagen
molecules are enzymatically cleaved. These reactions are
catalyzed by procollagen amino proteinase and carboxy
proteinase. Both enzymes require calcium as a co-factor.
After cleavage of these propeptides, the collagen triple
helices spontaneously assemble into fibrils. These fibrils
lack tensile strength until they are crosslinked by a series
of covalent bonds. The second extracellular modifica-
tion prepares the collagen molecule for the formation of
these bonds. It is the oxidative deamination of lysine and
hydroxylysine residues. This reaction is catalyzed by the
copper-containing enzyme, lysyl oxidase, and requires
molecular oxygen. The reactive aldehydes generated by
the action of lysyl oxidase can then participate in the
formation of covalent crosslinks (step 3) that confer the
linked collagen molecules are subject to increased degra-
dation by extracellular pro tease^.^^.'^
Type IV procollagen molecules do not undergo exten-
sive extracellular modification and do not form collagen
fibrils. The terminal propeptides are not removed but
remain to crosslink the molecule into a three-dimen-
sional n e t ~ o r k . ’ ~
Degradation
Because native collagen is resistant to proteolysis by
most tissue proteases, collagen degradation requires the
 19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
76 LEVEILLE AND ARIAS Internal Medicine

TABLE
I . Post-translational Events in Collagen Biosynthesis

Mechanisms

Event Enzymes Co-Factors Functional Significance

Intracellular modifications
1 . Hydroxylation of proline
and lysine
2. Addition of sugar
moieties
3. Triple helix formation
4. Secretion procollagen
into extracellular
environment
Extracellular modifications
1. Cleavage of amino- and
carboxy-terminal
propeptides
2. Oxidative deamination of
lysine and hydroxylysine
3. Fibril assembly and cross
link formation
Prol yl-4-hydroxylase Fe+2 Requiring for folding of (Y
Prol yl-3-hydroxylase 2-oxoglutarate, Ascorbic chains into triple helix
Lysyl hydroxylase acid, O2
Glucosyltransferase galactosyl Manganese May influence cross link
transferase formation
Spontaneous disulfide bond Necessary for procollagen
formation secretion
Requires microtubular Secretion necessary for
assembly extracellular collagen
deposition
Amino proteinase Calcium Necessary for assembly
Carboxy proteinase into fibrils
Lysyl oxidase Necessary for
stabilization of fibrils
by covalent cross links
Reactive aldehydes from Stable collagen fibers
previous reaction

presence of specific collagenases. Two types of neutral are chemotactic for fibroblasts. PDGF is also a potent
proteinases are involved in collagen d e g r a d a t i ~ n . ~ ' . ~ fibroblast
~ m i t ~ g e n . ' . TGFP,
~ ~ . ~ ~an important profibro-
One is an interstitial collagenase capable of degrading genic factor, stimulates collagen synthesis. Hepatic
1727*32

type I and type 111 collagen and the other is a type IV
collagenase. The cellular origin of these enzymes in the
liver has not been accurately determined but evidence
suggests that the transformed hepatic lipocyte may be
the major source.37All of the collagenases are synthe-
sized as latent proenzymes and must undergo activation.
Once specific collegenates unfold the collagen helix, the
molecule becomes susceptible to a number of broad
spectrum proteinases.
Anti-fibrotic Therapy
Modulation of Inflammation
One approach to antifibrotic therapy is to alter the stimu-
lus for connective tissue deposition. There is ample evi-
dence that soluble factors released during hepatocyte in-
jury and the subsequent inflammatory response provide
this s t i m ~ l u s . ~Inflammatory
~ , ~ ~ . ~ ~ cell infiltrates com-
posed of neutrophils, platelets, macrophages, and lym-
phocytes usually accompany hepatic fibrosis. Mediators
released from these inflammatory cells are involved in
the activation and transformation of the hepatic lipocyte
into the connective tissue producing myofibroblast and
subsequent stimulation of their synthetic activity.
Early in the inflammatory cascade, platelets release al-
pha granule contents. These contents include fibronec-
tin, platelet- derived growth factor (PDGF), and trans-
forming growth factor P (TGFP). PDGF and fibronectin
macrophages are an additional source of TGFP. Acti-
vated macrophages also release additional cytokines in-
cluding tumor necrosis factor, fibronectin, macrophage-
derived growth factor, fibroblast activating factor, and
interleukin- 1, that are chemotactic and/or mitogenic for
fibroblast^.',^^,^^ T lymphocytes are also important medi-
ators of connective tissue deposition. Lymphokines such
as lymphocyte-derivedfibroblast growth factor, collagen
activating factor, and fibroblast activating factor attract
fibroblasts and stimulate their proliferation and produc-
tion of collagen.38Inflammatory reactions play a pivotal
role in initiating fibrogenesis. Therefore, anti-inflamma-
tory agents that alter cytokine production or :he subse-
quent response of target cells should modulate collagen
deposition. Corticosteroids, azathioprine, cyclosporine,
and colchicine have been used in fibrotic hepatopathies
to modulate inflammatory responses.
Modulation of Collagen Synthesis
There are a number of unique events that can be pharma-
cologically modified so as to disrupt collagen synthesis in
the post-translation processing of the collagen molecule
1927,32(Table 2). Inhibition of proline and lysine hydroxylation
results in underhydroxylated procollagens that do not
form stable triple helix molecules. Divalent cations, such
as zinc, interfere with hydrolase activity by competing
with the enzymes ferric ion ~ o - f a c t o rInhibitors
.~~ of 2-
 19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VOl. 7 . NO.2, 1993 HEPATIC FIBROSIS 77

TABLE
2. Pharmacologic Modulation of Collagen Metabolism

Event Pharmacologic Agent Mechanism of Action

Transcription of collagen DNA Corticosteroids Inhibit mRNA transcription

Gamma interferons
Hydroxylation of proline and lysine Zinc Competes with Fe+*co-factor
Pyridine 2,4 dicarboxylate Inhibitors of 2-oxoglutarate
3,4-dihydroxybenzoate
3,4-dehydroproline Proline analogues preferentially
Cis-4-hydroxyproline incorporated but not hydroxylated
L-azetidine-2-carboxylate
Corticosteriods Inhibit prolyl-4-hydroxylase
Secretion into extracellular Colchicine Inhibits microtubular assembly necessary
environment for secretory process.
Cleavage of carboxy-terminal Amino acids Inhibit carboxy-proteinase activity
propeptides Polyamines
Oxidative deamination of lysine Penicillamine Inhibits lysyl oxidase by chelating copper
and hydroxylysine
Complexes with products of lysyl oxidase
reaction
Zinc Inhibits lysyl oxidase by chelating copper
Collagen degradation Tumor necrosis factor a Increase collagenase activity
Interleukin I
Colchicine
PDGF

oxoglutarate, another hydrolase co-factor, have been de-
veloped, and preliminary work indicates that they sup-
press collagen hydro~ylation.”~~~ Proline analogues,
such as 3,4-dehydroproline, cis-4-hydroxyproline, and
L-azetidine-2-carboxylate, are preferentially incorpo-
rated into procollagen. Since these analogues will not
undergo hydroxylation, the formation of the stable triple
helix is prevented. If given before experimental injury,
these analogues effectively delay fibrotic changes in a rat
model of carbon tetrachloride induced hepatic fibrosi~.~’
No clinical trials with these analogues have been con-
ducted.
Interference with secretion of procollagen molecules
into the extracellular environment disrupts collagen de-
position. Vinca alkaloids, such as vinblastine, vincris-
tine, and colchicine, inhibit protein secretion by interfer-
ing with polymerization of microtubules, a process re-
quired for secretory a ~ t i v i t y . ~ ~ , ~ ~
Once within the extracellular environment, cleavage
of the amino and carboxy terminal procollagen peptides
is necessary for proper alignment of collagen molecules
into fibrils.” The carboxy proteinase and amino protein-
ase which catalyze these reactions have not been well
characterized biochemically. Several amino acids, poly-
amines and their analogues inhibit carboxy proteinase
activity in vitro and decrease collagen synthesis in cell
culture^.^'*^* Because these proteinases are extracellular,
drugs which modulate their activity may have a therapeu-
tic advantage in that they do not have to penetrate the
cell to be active. No clinical work has been done with
these compounds.
A major focus in anti-collagen therapy centers on inhi-
bition of the extracellular cross link formation between
the collagen triple helical molecules. Without the forma-
tion of cross links, the unstable collagen molecule lacks
tensile strength and is more sensitive to degradation. Sev-
eral inhibitors of lysyl oxidase are effective in decreasing
collagen deposition in animal models of hepatic fibro-
sis.” Penicillamine at high concentrations inhibits lysyl
oxidase by chelating copper, a necessary co-factor for the
enzyme. Penicillamine also disrupts cross link formation
by interfering with the product of the lysyl oxidase reac-
tion, the lysine derived aldehydes, rendering them un-
available for cross link~.”*~’
Modulation of Collagen Degradation
Collagenase activity is increased in early hepatic fibrosis
but is often low to normal in late fibrosis and cirrhosis.
The lack of collagenase activity in advanced fibrosis may
be an important reason why the ability to remodel is lost
and may contribute significantly to irreversible fibrosis.
Several compounds including colchicine, interleukin- 1,
tumor necrosis factor a , and PDGF stimulate procolla-
genase activity in vitro.34.37,40,43Retinoids, corticoste-
roids, and TGFP decrease collagenase a~tivity.’~,~’
Anti-fibrotic Agents
Corticosteroids
Corticosteroidshave anti-inflammatory, immune-modu-
lating, and anti-fibrotic effects in liver d i ~ e a s e . ~Corti-
~.~’

78 LEVEILLE AND ARIAS
costeroids inhibit the movement of monocytes and neu-
trophils into sites of inflammation ar 1 interfere with
leukocyte adherence to blood vessel walls. Mononuclear
phagocytosis is depressed. The major effect on mono-
cytes, however, is to suppress responsiveness to lympho-
kines which accounts for suppression of cell mediated
immune (CMI) responses. CMI reactivity is also ad-
versely affected by a corticosteroid-induced decrease in
T lymphocyte numbers and impairment of T cell cyto-
t o x i activity. Humeral antibody responses are indirectly
reduced by corticosteroids due to a steroid mediated sup-
pression of T lymphocyte effector activity and subse-
quent decreases in antigen presentation to B lympho-
c y t e ~Corticosteroids
.~~ also inhibit phospholipase A, ac-
tivity and therefore decrease the enzyme's conversion of
membrane arachidonic acid to prostaglandins and leu-
kotrienes. These arachidonic acid metabolites are potent
mediators of inflammation. By suppressing immune re-
sponses and inflammatory activity in hepatic tissue, cor-
ticosteroids control a major stimulus for ongoing fibro-
genesis.
A direct anti-fibrotic effect of corticosteroid therapy
relates to their ability to inhibit proline hydroxylaseactiv-
ity.44 Corticosteroids also work at the transcriptional
level to decrease procollagen mRNA ~ y n t h e s i s . ~ ~ , ~ ~ chronic hepatobiliary disease has not been well docu-
Several human studies have shown that the use of
prednisone improves survival, slows progression of dis-
ease, and improves biochemical tests and quality of life
in some fibrotic he pa top at hie^.^^-^' These beneficial ef-
fects are seen only with chronic, noninfectious liver dis-
ease accompanied by moderate histologic activity char-
acterized by inflammation and/or necrosis with fibrotic
changes. The use of corticosteroids is detrimental, how-
ever, when ascites or hepatic encephalopathy is pres-
ent.44 Corticosteroid-induced sodium retention poten-
tiates fluid accumulation, and an increase in protein ca-
tabolism potentiates encephalopathy.
Prednisone is the corticosteroid of choice in human
beings with hepatic d i ~ e a s e .Prednisone
~.~~ itself, how-
ever, has little glucocorticoid activity and requires he-
patic conversion to the active form, prednisolone. Al-
though in severe liver disease some impairment of this
conversion occurs, a concurrent reduction in elimina-
tion and further metabolism offsets this d e f i ~ i e n c y . ~ ~ is
Similar studies comparing the two forms of the drug in
animals with hepatic disease have not been conducted.
The therapeutic benefit of corticosteroids in human
beings is most profound in individuals with documented
autoimmune chronic hepatitis (AIH).55 Patients with
this diagnosishave a number of immunologic abnormali-
ties, which although not specificfor chronic active hepati-
tis, suggest immunologic imbalances. Hypergammaglo-
bulinemia associated with a polyclonal increase in serum
immunoglobulins is found in 80% of human patients
with AIH.56,57 Numerous non-organ specific antibodies
including anti-nuclear, anti-smooth muscle, and anti-
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
Internal Medicine
mitochondria1 antibodies have been demonstrated in the
serum of AIH patient^.^^,^^ These autoantibodies may be
more important as serologic markers of the autoimmune
disease process rather than as mediators of hepatocyte
injury. These antibodies are most likely present second-
ary to hepatocellular destruction or due to primary de-
fects in immunoregulation. The demonstration of anti-
bodies against liver-specific cell membrane antigens may
be of more importance in causing hepatocyte lysis. Anti-
bodies to liver-specificlipoprotein, liver membrane anti-
gen and liver microsomal antigen are present in the sera
of many patients with AIH.57Lymphocytes sensitized to
these antigens have also been demonstrated in the sera of
AIH patients57implicating a role for cell-mediated im-
mune processes in hepatocellular damage. Additional ev-
idence incriminating this arm of the immune system in
AIH is the consistent decrease in suppressor T-cell activ-
ity found in these patient^.^^.^^ Corticosteroids by virtue
of their ability to suppress immune responsiveness are
able to control the stimulus for ongoing hepatocyte de-
struction. Although there are occasional reports of hy-
pergammaglobulinemia or positive antinuclear anti-
body titers in dogs with chronic active he pa ti ti^,",'^ the
immunologic status of most veterinary patients with
mented.
A recent retrospective study evaluated the use of corti-
costeroids in 151 dogs with chronic he pa ti ti^.^' In dogs
that survived for more than 1 week from the time of
diagnosis,prednisone significantly increased survival. Al-
though inherently biased, this retrospective study sug-
gests that prospective trials of corticosteroid therapy are
warranted in canine chronic hepatopathies. One factor
that was statistically related to a shorter survival time in
the dogs was the degree of bridging fibrosis in a liver
biopsy specimen, which emphasizes both the need for
anti-fibrotic therapy and the importance of early diagno-
sis in management of canine hepatic disease.
The ideal dose of prednisone in canine hepatopathies
is unknown. In human beings, prednisone is started at
high doses, 60 mg daily, to induce clinical remission and
is then tapered in 10-mg increments usually over a 6-
week period until a maintenance dose of 10-20 mg a day
. ~r~e a ~ h e d . ~Clinical
~ , ~ ' , ~remission
~ is defined by normal-
ization of histologic and biochemical parameters and res-
olution of clinical signs. The most commonly reported
prednisone doses in dogs are 1-2 mg/kg a day tapered
gradually to 0.5 mg/kg a day.'0,58,59 Alternate day ther-
apy is preferred to avoid side effects. In human beings,
alternate day therapy has been shown to be effective in
maintaining clinical and biochemical remission but does
not induce histologic remi~sion.~' No such data is avail-
able in canine hepatopathies.
In human beings, steroid therapy is continued well
beyond clinical remission. If medication is prematurely
discontinued, 50% of those with severe liver disease re-

VOl. 7 . NO. 2, 1993 HEPATIC FIBROSIS
lapse within 6 months of remission, whereas only 8%
relapse if treatment is continued more than 6 months
beyond r e m i ~ s i o n . ~Comparable
~.~’ studies in canine hep-
atopathies have not been conducted.
Evaluation of response to corticosteroids in canine
hepatopathies is complicated by corticosteroid induc-
tion of hepatic enzyme Since increases in
serum alanine aminotransferase and serum alkaline
phosphatase accompany the administration ofcorticoste-
roids in dogs, these important biochemical indicators of
hepatobiliary disease cannot be reliably used to monitor
therapeutic response. Histopathology of serial liver
biopsy samples must remain the standard for judging the
response to therapy although normalization of serum al-
bumin and bilirubin values as well as resolution of clini-
cal signs can be used as indicators of remission in dogs.
In human beings, hepatic biopsy is recommended at 6-
month intervals, but due to the inherent difficulties in
monitoring dogs biochemically, more frequent biopsies
would seem appropriate.
Because hepatic biopsy is an invasive and expensive
procedure, a reliable serum marker of hepatic fibrogene-
sis is needed for people and dogs. Such a marker would
allow for frequent, inexpensive, noninvasive assessment
of the benefit of corticosteroid and other antifibrotic
agents in hepatic fibrosis. In human patients, prelimi-
nary clinical studies indicate that the serum concentra-
tions of the amino terminal type I11 procollagen peptide
released during the extracellular processing of the type
I11 procollagen molecule may serve as such a marker.
Elevated concentrations of this peptide have been found
in chronic active hepatitis and cirrhosis in human beings
and correlations with histologic degree of fibrosis have
been d e m o n ~ t r a t e d . ~Other
~ - ~ ~ investigations suggest
that serum concentrations of the 7s fragment of type IV
collagen may also be a useful marker of hepatic fibrogen-
esis.66Clinical studies of these markers have not been
conducted in veterinary medicine.
Corticosteroid therapy has been recommended in fe-
line nonsuppurative cholangiohepatitis.26Although no
large-scale clinical trials have been reported, prednisone
given at an initial dose of 2.2 mg/kg daily tapered gradu-
ally to 1.O mg/kg every other day has been beneficial in
some cats.25
Corticosteroids can be associated with significant ad-
verse effects in humans and animals. Suppression of the
pituitary-adrenal axis occurs with glucocorticoid ther-
apy, and long-term administration can result in adrenal
atrophy and iatrogenic Cushing’s syndrome marked by
polyuria, polydipsia, polyphagia, muscle wasting, weight
gain, hepatomegaly, alopecia, and thin skin.60-62*67,68 Al-
ternate day therapy with short-acting corticosteroids
such as prednisone minimizes axis suppre~sion.~~ Other
associated adverse effects of corticosteroid therapy are
gastrointestinal ulceration, diabetes mellitus, pancreati-
tis, and secondary infection^."".^^.^^
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
79
Azathioprine
Azathioprine is an anti-metabolite that has immune-
modulating effects. It is metabolized in the liver to its
active form, 6 mercaptopurine. Mercaptopurine com-
petes with purines in the synthesis of nucleic acids, and
thus, disrupts nucleic acid synthesis. It also inhibits
coenzyme formation and disrupts mitosis. The net effect
is to inhibit proliferation of rapidly dividing cells. Azathi-
oprine also modifies T-lymphocyte functions, such as
cell-mediated immunity and T-cell-dependent antibody
synthesis.69
Azathioprine has proven to be a valuable adjunct to
prednisone therapy in treating chronic active hepatitis in
human beings primarily because it allows steroid doses
to be decreased thereby avoiding troublesome adverse
effect^.^^,^' In clinical trials in human beings a combina-
tion of prednisone, 10 mg/day, and azathioprine, 50 mg/
day, was shown to be comparable to prednisone alone at
20 mg/day in improving biochemical parameters and
histologic lesions in patients with chronic active hepati-
ti^.^^ The prednisone/azathioprine combination was as-
sociated with only a 13% incidence of serious adverse
effects while 67% of those on the higher prednisone dose
alone had serious adverse effects. In human beings, some
advocate the rapid induction of remission with high
doses of prednisone (60 mg/day) and subsequently add-
ing azathioprine ( 1.25 mg/kg/day) so that prednisone
can be eliminated quickly.7o
Combination therapy has been recommended for use
in dogs at a prednisone dose of 0.5 to 1.O mg/kg/day and
an azathioprine dose of 1 m g / k g / d a ~ If
. ~possible,
~ both
drugs should be tapered to an every other day dosage to
avoid toxicoses.
The role of hepatic insufficiency in decreasing conver-
sion of azathioprine to its active form mercaptopurine
has not been investigated clinically but should be kept in
mind in evaluating response to therapy.
The major adverse reaction associated with azathio-
prine use is bone marrow suppression. Other adverse ef-
fects include gastrointestinal disturbances and hepato-
Although controversial, a major concern with
the long-term use of azathioprine is its oncogenic poten-
tial. An increase in the incidence of malignant neo-
plasms occurred in human beings with chronic active
hepatitis during a 9 1-month clinical trial.” Another
study contends that concerns over the drugs oncogeni-
city are ~nfounded.’~ Because carcinogenicityassociated
with antimetabolitc use develops slowly, the shorter life
span of animals may preclude concerns over azathio-
prines oncogenicity.
Colchicine
Colchicine, an alkaloid derived from Colchicum autum-
nale, has a number of beneficial effects in liver disease.
Colchicine binds to tubulin and thereby inhibits func-

80 LEVEILLE AND ARIAS
tions requiring microtubular assembly. It has been used
for years in humans to control inflammation associated
with gout. Anti-inflammatory effects are mediated by
the drug's inhibition of neutrophil and mononuclear cell
m i g r a t i ~ n . ~The
~ . ~anti-fibrotic
' effects of colchicine are a
result of the ability of the drug to block the microtubular-
mediated transcellular movement of proteins and, thus,
inhibit the secretion of the procollagen molecules into
the extracellular matrix.40 This same action also sup-
presses release of various mediators of fibrogenesis from
macrophages such as fibronectin and macrophage-de-
rived growth factor.73Colchicine also increases collage-
nase activity in vitro and may play a role in increasing
collagen degradation in Colchicine may exert a
direct hepatoprotective effect by stabilizing hepatocyte
plasma membranes and, thereby, restoring important
enzyme a ~ t i v i t i e s . ~ ~
Colchicine is effective in decreasing hepatic fibrosis in
people. The drug has been investigated in a number of
double-blind prospective trials in patients with cirrho-
sis74.75and patients with primary biliary c i r r h o s i ~ . ~In~ * ~ ' hibit chemotaxis of neutrophils and to interfere with T-
a trial involving 100 patients observed over a 14-year
period, cirrhotics given colchicine at 1 mg/day once a
day for 5 days a week showed improvement in survival
and hepatic histopathology compared with the placebo
group.75These findings were independent of the cause of
cirrhosis. In three controlled trials of patients with pri-
mary biliary cirrhosis, patients treated with 0.5-0.6 mg
of colchicine twice a day showed biochemical improve-
ment manifested as increases in serum albumin and de-
creases in bilirubin.78Albumin and bilirubin concentra-
tions are particularly important predictors of survival in
assessing human patients with
There are limited reports ofcolchicine use in dogs.80-82 tients. More serious adverse effects include: renal pro-
Colchicine was given at 0.03 mg/kg daily to a dog with
chronic active hepatitis. The dog showed clinical remis-
sion for 7 months and repeat liver biopsies at 7 weeks
post-colchicine therapy showed histologic improve-
ment." A Cocker Spaniel with a fibrotic hepatopathy
accompanied by multiple portal systemic shunts was
successfully managed with combination therapy that in-
cluded colchicine.8' Colchicine, 0.025 mg/kg, was in-
cluded in the therapeutic regime for a 2-year-old English
Setter with evidence of hepatoportal fibrosis during liver
biopsy.82The dog survived for 30 months after diagnosis
during which time there was gradual improvement in
clinical signs and biochemical tests of liver function. At
the time of death from nonhepatic causes, histopatho-
logic assessment of the liver indicated no progression of
hepatic fibrosis.
Colchicine has a long tract record of safety in treating
gout in people. Many patients have been treated without
serious complications for long periods at doses similar to
those found to be useful in controlling hepatic fibrosis.
Because of interference with the rapidly dividing cells of
the gastrointestinal tract, adverse effects of colchicine in-
clude nausea, vomiting, diarrhea, and abdominal pain.
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
Internal Medicine
Often these signs abate and do not require discontinua-
tion of therapy. Rare toxic reactions have been reported
and include agranulocytosis, aplastic anemia, myopa-
thy, and ne~ropathy.~"~' No adverse effects have been
noted in dogs treated with c ~ l c h i c i n e . ~ ~ - ~ ~
PenicillaminP
Penicillamine, a derivative of penicillin, was first iso-
lated from the urine of a patient who had liver disease
and was taking penicillin. It has anti-fibrotic and im-
mune-modulating e f f e c t ~ . ~By ~ .forming
~ ~ , ~ ~complexes
with the reactive aldehydes generated by the action of
lysyl oxidase on the hydroxylysine residues in the colla-
gen molecule, penicillamine inhibits collagen crosslink-
ing, rendering the collagen molecule more susceptible to
degradation by nonspecific proteinases. Penicillamine
also chelates copper and promotes cupriuresis. It inhibits
the activity of the copper-containing enzyme, lysyl oxi-
dase. Immunornodulating effects relate to the ability to
decrease circulating immunoglobulin concentrations, in-
lymphocyte function.42
The use of penicillamine as an anti-fibrotic agent in
human medicine has been disappointing. Seven prospec-
tive, controlled studies of penicillamine use in primary
biliary cirrhosis have not demonstrated drug efficacy at
doses ranging from 600- 1000 m g / d a ~ Similar . ~ ~ results
have been seen with penicillamine therapy in a limited
number of Doberman Pinschers with chronic active hep-
atiti~.~.'~
There is a increased incidence of adverse reactions to
penicillamine therapy in human beings. Cutaneous al-
lergic reactions are seen in about one-third of the pa-
teinuria and hematuria that may progress to a nephrotic
syndrome associated with a membranous glomerulo-
pathy; hematologic alterations such as leukopenia,
aplastic anemia, and agranulocytosis; and pulmonary
complications manifested as acute dyspnea due to bron-
c h o a l ~ e o l i t i sAnorexia
.~~ and vomiting are the major ad-
verse effects observed in dog^.'^,^^ Penicillamine given to
one cat with chronic nonsuppurative cholangiohepatitis
caused significant n e ~ t r o p e n i a . ~ ~
Penicillamine is used to treat patients with chronic
hepatic disease primarily for its copper-chelating ability
in diseases associated with excessive copper accumula-
tion. Wilson's disease is a familial human disorder of
hepatic copper excretion that is similar to the copper
hepatopathy seen in Bedlington Penicilla-
mine at 750-2000 mg daily retards the development of
hepatic pathology in Wilson's disease patients. 15,83 Peni-
cillamine ( 10- 15 mg/kg BID) has been used to treat af-
fected Bedlington T e m e r ~ . ' ~Penicillamine
,~~ works
slowly and it can take years before appreciable copper
detoxification is realized. Other copper chelators such as
2,3,2 tetramine have also shown efficacy in Bedlingtons
with this ~yndrome.'~

VOl. 7 . NO. 2. 1993 HEPATIC FIBROSIS
Zinc
Zinc is an essential co-factor in a broad range of biologi-
cal reactions. An important therapeutic action of zinc in
hepatic disease relates to its ability to inhibit the intes-
tinal absorption of copper.” It has therefore been used in
copper-associated hepatopathies. Zinc also inhibits pro-
lyl hydroxylase activity in vitro by competing with its
femc ion ~ o - f a c t o r .In
~ ~an
. ~experimental
~ model of fi-
brotic liver disease using carbon tetrachloride induced
lesions in rats, concurrent dietary zinc supplementation
decreased hepatic collagen a c c u m ~ l a t i o n . In
~ ~addi-
.~~
tion to its anti-fibrotic and cupruretic actions, zinc may
have a direct hepatoprotective effect by inhibiting lipid
peroxidation and stabilizing lysosomal membrane^.'^,^^
Interestingly, serum and hepatic zinc concentrations are
significantly decreased in a variety of chronic liver dis-
orders in human being^.'^*^^-^^ Although the clinical sig-
nificance of this finding is unknown, some advocate the
administration of zinc, 3 mg zinc gluconate/kg/day or 2
mg zinc sulfate/kg/day, to dogs with chronic he pa ti ti^.'^
This recommendation is also based on the finding of
high hepatic copper concentrations in canine hepatopa-
thies associated with chole~tasis.~-l~~~’
Zinc therapy is not associated with significant adverse
effects except at very high doses when iron deficiency
and hemolytic anemia are possible.89
Cyclosporine
Cyclosporine is a complex cyclic peptide produced by
the fungus, Tolypocladium inflaturn. It is a powerful im-
mune-modulating drug exerting its primary effects on
cell-mediated i r n m ~ n i t y . ~Its
~ *actions
~’ are affected by
its ability to block the production of lymphokines pro-
duced by T lymphocytes particularly interleukin 11. It
also inhibits precursor cytotoxic T cells from acquiring
responsiveness to interleukin I1 possibly by inhibition of
interleukin I1 receptor formation. The net result of these
actions is to suppress differentiation and clonal expan-
sion of cytotoxic T cells involved in specific target cell
lysis and graft rejection and to suppress lymphokine-in-
duced delayed-type hypersensitivity responses. For max-
imal effectiveness cyclosporine must be given before the
onset of T-cell activation. Cyclosporine has no effect on
suppressor T-cell f u n ~ t i o n . ’ ~ . ~ ~
Cyclosporine has been used in three preliminary hu-
man clinical trials in primary biliary ~ i r r h o s i sa, disease
~~
believed to be mediated by T-lymphocyte activity di-
rected against antigenic determinants in the biliary epi-
thelium. Improvement in clinical signs and biochemical
parameters including decreases in bilirubin and in-
creases in albumin have been noted. In an experimental
model of schistosomiasis, hepatic granulomas induced
by the injection of streptococcal wall antigens into rats
were inhibited by pretreatment with cycl~sporine.~~
Nephrotoxicosis is a major adverse effect of cyclospor-
ine use in human patients. In addition, gastrointestinal
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
81
upset, cholestatic hepatopathy, hypertension, and neuro-
logic adverse effects have been reported.” In addition to
these adverse effects, the unpalatibility of the oral prepa-
ration may preclude long-term dosage in some animals;
the highly variable intestinal absorption of the oral solu-
tion makes monitoring of blood or plasma concentra-
tions of the drug essential to maintain therapeutic con-
centrations; and the use of cyclosporine in animals is
limited because of the high cost of therapy.93
Miscellaneous Agents
Prostaglandins increase the rate of degradation of intra-
cellular collagen and thus decrease the rate of extracellu-
lar collagen deposition in fibroblast culture^.^^.^^ In a rat
model of nutritional liver disease in which the animals
were fed a high fat, lipotrope-deficient diet, the adminis-
tration of prostaglandin E, significantly decreased colla-
gen formation and deposition.” Prostaglandin E, may
also have cytoprotective effects on the liver protecting
against hepatocyte necrosis and subsequent inflamma-
tory reactions that may be an important stimulus for
connective tissue deposition. In several animal models
of liver disease, these prostaglandins have suppressed the
development of hepatic necrosis if administered concur-
rent with the inciting e ~ e n t . ~Prostaglandins
~-~’ may also
exert some of their beneficial effects by decreasing the
release of macrophage c y t o k i n e ~or~by
~ promoting he-
patic arterial va~odilation.~~
Investigation into a potential role of interferons in the
modulation of collagen synthesis has been prompted by
the close association of lymphocytes and collagen-pro-
ducing cells. Although both alpha and gamma interfer-
ons have potent anti-proliferative effects on fibroblasts,
most of the work in fibrotic diseases has been done with
gamma i n t e r f e r ~ nGamma
.~~ interferon, a lymphokine,
decreases collagen synthesis in human fibroblast cell cul-
turesIm and prevents collagen deposition in in vivo mod-
els of hepatic fibrosis.’O’ This effect apparently involves
modulation at the transcriptional level as decreases in
collagen mRNA levels have been demonstrated in experi-
mental systems.lo2Clinical trials with gamma interferon
have not been conducted in human or veterinary medi-
cine.
Alpha interferons are produced by many cell types
during viral infection. Several clinical trials involving pa-
tients with chronic hepatitis B virus infection have dem-
onstrated the efficacy of alpha interferons in reversing
viremia and achieving biochemical and histologic remis-
sion.Io3The drug was administered subcutaneously daily
and adverse effects included bone marrow suppression
and flu-like symptoms such as myalgia, fever, fatigue,
and headache.Io3 Although experimental infection of
Beagles with the canine infectious hepatitis adenovirus
has been associated with the development ofchronic hep-
atitis,’’ the importance of this virus in clinical cases of
chronic hepatitis remains unknown. A newly discovered

82 LEVEILLE AND ARIAS
TABLE
3. Anti-fibrotic Agents in Canine Fibrotic Hepatopathies
Drug Dosage
Prednisone 1-2 mg/kg/day gradually tapered to
0.5 mg/kg/day or alternate day
therapy
Colchicine 0.025-0.03 mg/kg/day
Azathioprine I mg/kg/day or alternate day therapy
Penicillamine 10-15 mg/kg/twice a day
Zinc Zn Gluconate: 3 mg/kg/day
Zn Sulfate: 2 mg/kg/day
transmissible agent involved in cases of chronic hepatitis
in Scotland may be viral.20Until the role of viruses in
chronic hepatopathies is better investigated, alpha inter-
ferons will have limited clinical applicability in animals.
Summary
Fibrosis accompanies most chronic liver disorders and
its presence is a major factor contributing to hepatic fail-
ure. Therapeutic strategies are emerging whereby he-
patic fibrogenesis can be modulated. Some anti-fibrotic
drugs, in particular, corticosteroids, azathioprine, peni-
cillamine, colchicine, and zinc have been evaluated on a
limited basis in veterinary populations (Table 3). Im-
proved histologic, biochemical, and etiologic character-
ization of the various veterinary hepatopathies will allow
the clinical use of these and other anti-fibrotic drugs to
be further clarified and expanded in veterinary medi-
cine.
In suspected autoimmune hepatopathies, immune-
modulating drugs such as prednisone and azathioprine
are the therapeutic agents of choice. High dose predni-
sone therapy at 1-2 mg/kg/day should be initiated until
clinical and biochemical signs of remission are evident at
which time the dosage can be tapered to 0.5 mg/kg/day.
As in human AIH, dose reduction will most likely be
possible within the first few weeks of therapy. Because
prednisone induces increases in canine liver enzymes,
remission of clinical signs and improvement in other bio-
chemical parameters such as bilirubin and albumin have
to be used to judge when dose reduction is possible in
dogs. Histologic re-evaluation of liver biopsy samples
from veterinary patients is best performed within 2 to 3
months after initiating therapy. If histologic remission or
stabilization is demonstrated, therapy can be continued
at the present dose or, if necessary, further dose reduc-
tions can be made. Although alternate-day therapy with
prednisone is preferred to minimize pituitary-adrenal
axis suppression, such therapy in human patients is less
effective in maintaining histologic remi~sion.~' It re-
mains to be determined if this is true in animals.
If significant adverse effects occur with prednisone
therapy, substitution of or combination therapy with aza-
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
Internal Medicine
Major Adverse Effects
Polyuria, pol ydipsia Iatrogenic hyperadrenocorticism
Gastrointestinal ulceration
Diarrhea
Vomiting/diarrhea
Neutropenia, vomiting, diarrhea, hepatopathy
Vomiting, diarrhea, cutaneous hypersensitivity, renal
proteinuria
Iron deficiency
Hemolytic anemia
thioprine would be an appropriate a l t e r n a t i ~ e . ~Ini- ~?~'.~~
tial doses of 1 mg/kg/day can be tapered to alternate day
therapy. Azathoprine does not induce hepatic enzyme
activity thus simplifying biochemical monitoring.
The anti-fibrotic and possible hepatoprotective ac-
tions of colchicine will most likely be beneficial in a vari-
ety of veterinary fibrotic hepatopathies regardlessof etiol-
ogy. In human clinical trials, the effectiveness of this
drug was independent of the initiating cause of cirrho-
s ~ sAnother
. ~ ~ advantage of colchicine treatment in peo-
ple is its low incidence of toxic adverse effects. Hopefully
this same safety profile will occur.in animals.
In cases of copper-associated hepatotoxicosis, penicil-
lamine is the preferred drug. In these cases, penicilla-
mine is used primarily for its copper-chelating ability
and not for its anti-fibrotic actions. The effectiveness of
penicillamine in delaying fibrotic changes in liver disease
in animals remains to be demonstrated. The drug has
been shown to have limited benefit in human clinical
trials.78At the same time the drug has also been asso-
ciated with significant
Zinc by virtue of its actions in blocking intestinal ab-
sorption of copper may also have a role in copper-asso-
ciated hepatotoxicosis and possibly in managing choles-
tatic hepatic d i s ~ r d e r s . ' ~ ~
The
' ' , ~anti-fibrotic
~ and hepa-
toprotective effects of zinc remain to be demonstrated in
human and veterinary clinical trials.
References
I . Gressner AM, Bachem MG. Cellular sources of noncollagenous
matrix proteins: role of fat storing cells in fibrogenesis. Semin
Liver Dis 1990; 10:30-46.
2. Epstein M. The kidney in liver disease. In: Arias IM, Jacoby WB,
Popper H et al eds. The Liver: Biology and Pathobiology. New
York: Raven Press, LTD. 1988; 1043-1062.
3. Rojkind M, Perez-Tamayo R. Liver fibrosis. Int Rev Connect
Tissue Res 1988; 10:333-393.
4. Biagini G, Ballardini G. Liver fibrosis and extracellular matrix. J
Hepatol 1989; 8: I 15- 124.
5. Takiya C, Grimaud JA. Hepatic schistosomiasis. In: Testa 9, ed.
Liver drugs: Experimental pharmacology to therapeutic ap-
plication. Florida: CRC Press, Inc. 1989; 146-160.
6. Immunization Practices Advisory Committee (ACIP). Recom-
mendations of the immunization practices advisory commit-
tee (ACIP): inactivated hepatitis B virus vaccine. Morbid
Mortal Weekly Rep 1982; 31:317-328.
7. Morgan M. Drug treatment of alcohol-related liver injury. In:

Vol. 7 . NO.2, 1993 HEPATIC FIBROSIS
Testa B, ed. Liver drugs: Experimental pharmacology to thera-
peutic application. Florida: CRC Press Inc, 1989; 1 12- I 14.
8. James SP, Vierling JM, Strober W. The role of the immune re- 35.
sponse in the pathogenesis of primary biliary cirrhosis. Semin
Liver Dis 1981: 1:322-335. 36.
9. Johnson GF, Zawie DA, Gilbertson SR et al. Chronic active hepa-
titis in Doberman Pinschers. J Am Vet Med Assoc 1980;
180:1438-1442. 37.
10. Crawford MA, Schall WD, Jensen RK, et al. Chronic active hepa-
titis in 26 Doberman Pinschers. J Am Vet Med Assoc 1985; 38.
187:1343-1 349.
I I . Franklin JE, Saunders GK. Chronic active hepatitis in Dober-
man Pinschers. Comp Cont Educ 1988; 10:1247-1254. 39.
12. Van Den Ingh TSGAM. Rothuzen J, Ruurdje C. Chronic active
hepatitis with cirrhosis in the Doberman Pinscher. Vet Quar-
terly 1988; 10234-89. 40.
13. Thornburg LP, Shaw D, Dolan M, et al. Hereditary copper toxi-
cosis in West Highland White Temers. Vet Pathol 1986: 41.
23:166-172.
14. Rugers C, Haywood S, Christian MK. Liver disease in Skye
Terriers. Vet Rec 1987: 118576. 42.
15. Sternlieb 1. Copper and zinc. In: Arias IM. Jakoby WB, Popper H
et al, eds. The Liver: Biology and Pathobiology. New York:
Raven Press, Ltd. 1988; 525-533.
16. Twedt DC. Sternlieb I. Gilbertson SR. Clinical, morphologic and 43.
chemical studies on copper toxicosis of Bedlington Temers. J
Am Vet Med Assoc 1979; 175:269-275.
17. Hardy RM. Chronic hepatitis in dogs: a syndrome. Comp Cont 44.
Educ 1986; 8:904-9 13.
18. Bishop L, Standberg JD. Adam RJ. et al. Chronic active hepatitis
in dogs associated with leptospires. Am J Vet Res 1979; 45.
40339-844.
19. Gocke AJ, Presig R. Moms TD. et al. Experimental viral hepati-
tis in the dog: production of persistent disease in partially 46.
immune animals. J Clin Invest 1975; 46:1506-1517.
20. Jarrett WFM, O'Neil BW. A new transmissible agent causing
acute hepatitis, chronic hepatitis and cirrhosis in dogs. Vet
Rec 1985; I16:629-635. 47.
2 I . Bunch SE, Castleman WL, Hornbuckle WE, et al. Hepatic cirrho-
sis associated with long-term anticonvulsant drug therapy in
dogs. J Am Vet Med Assoc 1982; 181:357-362. 48.
22. Vaden SL, Bunch SE. Duncan DE. et al. Hepatotoxicosis asso-
ciated with heartworm/hookworm preventive medication in
a dog. J Am Vet Med Assoc 1988; 192:651-654. 49.
23. Hardy RM, OBrien T, Adams LG, et al. Periportal hepatitis as-
sociated with the use of a heartworm/hookworm preventative
(diethylcarbamazine-oxibendazole) in I3 dogs. J Am Anim
Hosp Assoc 1989; 25:4 19-429. 50.
24. Hirsch VM, Doige CE. Suppurative cholangitis in cats. J Am Vet
Med Assoc 1983; 182:1223-1226.
25. Prasse KW, Mahaffey EA, DeNovo R, et al. Chronic lymphocytic 5 I.
cholangitis in three cats. Vet Pathol 1982; 19:99-108.88.
26. Center SC. Feline liver disorders and their management. Comp
Cont Educ 1986; I2:889-90 I .
27. Friedman SL. Cellular sources ofcollagen and regulation of colla- 52.
gen production in liver. Semin Liver Dis 1990; 10:20-29.
28. Friedman SL. Roll FJ, Boyles J, et al. Maintainance of differen- 53.
tiated phenotype of cultured rat hepatic lipocytes by base-
ment membrane matrix. J Biol Chem 1989; 264:10756-
10762. 54.
29. Liau G, Chan LM. Regulation ofextracellular matrix RNA levels
in cultured smooth muscle cells. J Biol Chem 1989;
264: I03 15-10320.
30. Rojkind M, Giambrone MA, Biemdica L. Collagen types in nor- 55.
mal and cirrhotic liver. Gastroenterology 1979; 76:7 10-7 19.
31. Prockop DJ, Kivirikko KI, Tuderman L. The biosynthesis ofcol-
lagen and its disorders. N Engl J Med 1979; 301: 13-23. 56.
32. Bissell DM, Friedman SL, Maher JJ, et al. Connective tissue biol-
ogy and hepatic fibrosis: report of a conference. Hepatology 57.
1990; I I :488-498.
33. Kivirikko KI, Savolainen ER. Hepatic collagen metabolism. In:
Testa B, ed. Liver drugs: Experimental Pharmacology to Ther- 58.
apeutic Application. Florida: CRC Press Inc., 1989; 42-53.
34. Rojkind M, Kershenobich D. The extracellular matrix, fibrosis
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
83
and cirrhosis. In: Arias IM, Frenkel M. Wilson JHP. eds. The
Liver Annual 6. 1987; 302-333.
Brennar DA. Alcorn JM. Therapy for hepatic fibrosis. Semin
Liver Dis 1990; 10:75-83.
Schuppan D. Structure of the extracellular matrix in normal and
fibrotic liver: collagens and glycoproteins. Semin Liver Dis
1990; 10: 1-9.
Arthur MJ. Matrix degradation in the liver. Semin Liver Dis
1990; 10:47-55.
Wahl SM. Host immune factors regulating fibrosis. In: Ciba
Foundation Symposium on Fibrosis. London: Pitman 1985:
175- 195.
Grotendorst GR, Drolia L, McIvor C, et al. Chemoattractants in
fibrotic disorders. In: Ciba Foundation Symposium on Fibro-
sis. London: Pitman 1985: 150- 163.
Chojkier M, Brenner DA. Therapeutic strategies for hepatic fi-
brosis. Hepatology 1989; 8: 176- 182.
Rojkind M. Inhibition of liver fibrosis by L-azetidine-2-carbox-
ylic acid in rats treated with carbon tetrachloride. J Clin Invest
1973; 52:2451-2454.
Uitto J, Tan EML, Ryhanen L. Inhibition ofcollagen accumula-
tion in fibrotic processes: review of armacologic agents and
new approaches with amino acids aLidtheir analogues. J In-
vest Dermatol 1982; 79: 1 13s- 120s.
Kivirikko KL, Majamaha K. Synthesisofcollagen: chemical regu-
lation of post-translational events. In: Ciba Foundation Sym-
posium on Fibrosis. London, Pitman 1985; 34-59.
Tygstrop N. Use ofcorticosteroids in liver disease. In: Testa B, ed.
Liver Drugs: Experimental Pharmacology to Therapeutic Ap-
plication. Florida: CRC Press Inc. 1989; 162-173.
Tanner A, Powell L. Corticosteroids in liver disease: possible
mechanisms of action, pharmacology and rational use. Gut
1979; 20: 1 109- 1 124.
Weiner FR, Czaja MJ, Ciambrone MA, et al. Transcriptional and
post transcriptional effects of dexamethasone on albumin and
procollagen messenger RNAs in murine schistosomiasis. Bio-
chemistry 1986; 26: 1557-1 562.
Weiner FR, Czaja MJ, Jefferson DM, et al. The effects of dexa-
methasone on in vitro collagen gene expression. J Biol Chem
1987; 262x6955-6958.
Copenhagen Study Group for Liver Disease: Effect of prednisone
on the survival of patients with cirrhosis of the liver. Lancet
1969; 1:119-121.
Soloway RD, Summerskill DM, Baggenstoss AH. Clinical, bio-
chemical and histological remission of severe chronic active
liver disease: a controlled study of treatments and early prog-
nosis. Gastroenterology 1972; 63320-833.
Murray-Lyon IM, Stem RB, Williams R. Controlled trial of pred-
nisone and azathioprine in active chronic hepatitis. Lancet
1973; 735-737.
Summerskill WHJ, Korman MG, Ammon HV, et al. Prednisone
for chronic active liver disease: dose titration, standard dose,
and combination with azathioprine compared. Gut 1975;
16:876-883.
Wright EC, Seeff LB, Berk PD, et al. Treatment of chronic active
hepatitis. Gastroenterology 1977; 73: 1422-1430.
Schalm SW, Summerskill WHJ, Go VLW. Prednisone for
chronic active liver disease: Pharmacokinetics including con-
version to prednisolone. Gastroenterology 1977; 72:9 10-9 13.
Uribe M, Summerskill WHJ, Go VLW. Comparative serum
prednisone and prednisolone concentration following admin-
istration to patients with chronic active liver disease. Clin
Pharmacokinet 1982; 7:452-459.
Thomas H. Immunologic aspects of liver disease. In: Schiff L,
Schiff E, eds. Diseases of Liver, 6th edition. Philadelphia: JB
Lippincott 1987; 163-186.
Czaja AJ. Natural history, clinical features, and treatment of au-
toimmune hepatitis. Semin Liver Dis 1984; 4:l-12.
Thomas HC, Lok AS. The immunopathology of autoimmune
and hepatitis B virus-induced chronic hepatitis. Semin Liver
Dis 1984; 4:36-44.
Strombeck DR, Miller LM, Harrold D. Effects of corticosteroids
on survival time in dogs with chronic hepat'tis: 151 cases
(1977-1985). J Am Vet Med Assoc 1988; 193:1109-1I13.

84 LEVEILLE AND ARIAS
59. Maone ML, Chiapella AM. Medical management of canine
chronic hepatitis. Comp Cont Educ 1986; 8:9 15-920.
60. Rogers WA, Ruebner BH. A retrospective study of probable glu-
cocorticoid hepatopathy in dogs. J Am Vet Med Assoc 1977;
170603-606.
61. Badylak SF, VanVleet JF. Sequential morphologic and clinico-
pathologic alterations in dogs with experimentally induced
glucocorticoid hepatopathy. Am J Vet Res I98 1; 42: I3 10-
1318.
62. DeNovo RC, Prasse KW. Comparison of serum biochemical and
hepatic functional alterations in dogs treated with corticoste-
roids and hepatic duct ligation. Am J Vet Res 1983; 44: 1703-
1709.
63. Rohde H, Varoas L, Hahn E, et al. Radioimmunoassay for type
111procollagen peptide and its application to human liver dis-
ease. Eur J Clin Invest 1979; 9:455-459.
64. Weigand K, Zaugg PY, Frei A, Zimmerman A. Long term fol-
low-up of serum N-terminal propeptide of collagen type 111
levels in patients with chronic liver disease. Hepatology 1984;
4:835-838.
65. Frei A, Zimmerman A, Weigand K. The N-terminal propeptide
of collagen type Ill in serum reflects activity and degree of
fibrosis in patients with chronic liver disease. Hepatology
1984; 418304334.
66. Bentsen KD, Horn T, Risteli J, et al. Serum aminoterminal type
I11 procollagen peptide and the 7 s domain of type IV collagen
in patients with alcohol abuse. Liver 1987; 7:339-346.
67. Feldman EC, Nelson RW. Glucocorticoid therapy. In: Canine
and Feline Endocrinology and Reproduction. Philadelphia:
WB Saunders Co. 1987; 218-228.
68. Uribe M, Wolf AM, Summerskill WMJ. Steroid side effects dur-
ing therapy of chronic active liver disease (CALD): what to
expect. Gastroenterology 1976; 7 1:932.
69. Calabresi P, Parks RE. Chemotherapy of neoplastic diseases. In:
Goodman and Gilman, eds. Pharmacologic Basis of Thera-
peutics. New York: MacMillian Publishing Co. 1980; 1249-
1313.
70. Tassoni JP, Kaplan MM. Rapidly progressive liver failure in a
65-year-old woman. Gastroenterology 1991; 100:1462-1468.
71. Tage-Jensen U, Schlichting P, Thomsen HF, et al. Malignancies
following long-term azathioprine treatment in chronic liver
disease. Liver 1987; 7:81-83.
72. Schaffner F. The oncogenicity of azathioprine? Hepatology 1988;
8:693.
73. Rennard SI, Bitterman PB, Ozaki T, et al. Colchicine suppresses
the release of fibroblast growth factors from alveolar macro-
phages in virro. Am Rev Respir Dis 1988; 137:181-185.
74. Kershenobich D, Uribe M, Suarez GI, et al. Treatment of cirrho-
sis with colchicine: a double-blind randomized trial. Gastroen-
terology 1979; 77:532-536.
75. Kerschenobich D, Vargas F, Garcia-Tsao G, et al. Colchicine in
the treatment of cirrhosis of the liver. N Engl J Med 1988;
318: 1709-17 13.
76. Bodenheimer H, Schaffner F, Pezzullo J. Evaluation of colchi-
cine therapy in primary biliary cirrhosis. Gastroenterology
1988; 95~124-129.
17. Warnes TW, Smith A, Lee FI, et al. A controlled trial of colchi-
cine in primary biliary cirrhosis. J Hepatol 1987; 5:l-7.
78. Kaplan MM. Medical treatment of primary biliary cirrhosis. Se-
min Liver Dis 1989; 9:138-142.
79. Roll J, Boyer JH, Barry D, et al. The prognostic importance
of clinical and histologic features in asymptomatic and
symptomatic primary biliary cirrhosis. N Engl J Med 1983;
308: 1-7.
80. Boer HH, Nelson RW, Long GG. Colchicine therapy for hepatic
fibrosis in a dog. J Am Vet Med Assoc 1984; 185:303-305.
8 I . LaFlamme DP. Hepatoencephalopathy associated with multiple
portal systemic shunts in a dog. J Am Anim Hosp Assoc.
1989; 25~199-202.
82. Rutgers HC, Haywood S, Batt RM. Colchicine treatment in a dog
19391676, 1993, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.1993.tb03173.x by Cochrane Peru, Wiley Online Library on [29/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Veterinary
Internal Medicine
with hepatoportal fibrosis. J Small Anim Pract 1990; 31:97-
101.
83. Brewer GJ, Yuzbasiyan-Gurkan V. Wilson’s disease: an update,
with emphasis on new approaches to treatment. Dig Dis 1989;
7: 178-193.
84. Twedt DC,Hunsaker MS, Alleid KGD. Use of 2,3,2-tetramine as
a hepatic copper chelating agent for the treatment of copper
hepatotoxicosis in Bedlington terriers. J Am Vet Med Assoc
1988; 192x52-56.
85. Chvapil M, Ryan JN, Elias SL, et al. Protective effect of zinc on
carbon tetrachloride-induced liver injury in rats. Exp Mol
Pathol 1973; 19:186-196.
86. Annttinen H, Ryhanen L, Puistula V, et al. Decrease in liver
collagen accumulation in carbon tetrachloride-injured and
normal growing rats upon administration ofzinc. Gastroenter-
ology 1984; 861532-539.
87. Schilsky M, Blank R, Stockert R, et al. Copper hepatotoxicity
attenuated by zinc. Hepatology 1988; 8:2240.
88. Sullivan JF, Burch RE. Potential role of zinc in liver disease. In:
Prasad AS, ed. Trace Elements in Human Health and Dis-
ease. New York: Academic, 1976; 67-85.
89. Prasad AS. Clinical, biochemical and pharmacological role of
zinc. Ann Rev Pharmacol Toxicol 1979; 20:393-426.
90. Hess AD, Esa AH, Colombani PM. Mechanisms of action of
cyclosporine: effect on cells of the immune system and on
subcellular events in T cell activation. Transplant Proc 1988;
20:29-40.
91. Cates JA, Wood AJJ. Cyclosporine. N Engl J Med 1989;
321:1725-1737.
92. Yocum DE, Allen JB, Wahl SM, et al. Inhibition by cyclosponn
A of streptococcal cell wall-induced arthritis and hepatic gran-
ulomas in rats. Arthrit Rheum 1986; 29:262-272.
93. Gregory CR. Cyclosporine. In: Kirk RW, ed. Current Veterinary
Therapy X. Philadelphia: WB Saunders Co 1989; 5 13-5 14.
94. Steinman BU, Abe S, Martin GR. Modulation of type 1 and type
111 collagen production in normal and mutant human skin
fibroblasts by cell density, prostaglandin E, and epidermal
growth factor. Collagen Re1 Res 1982; 2:185-195.
95. Ruwart MJ, Rush BD, Snyder KF, et al. 16,16-dimethyl prosta-
glandin E, delays collagen formation in nutritional injury in
rat liver. Hepatology 1988; 8:61-64.
96. Stachura J, Tarnawski A, h e y KJ, et al. Prostaglandin protection
in carbon-tetrachloride-induced liver cell necrosis in the rat.
Gastroenterology 1981; 81:211-217.
97. Abecassis M, Falk JA, Makowha L, et al. 16,16-dimethyI prosta-
glandin E, prevents the development of fulminant hepatitis
and blocks the induction of monocyte/macrophage procoagu-
lant activity after murine hepatitis virus strain 3 infection. J
Clin Invest 1987; 80881-889.
98. Richardson PDI, Withrington PG. The vasodilator actions of iso-
prenaline, histamine, prostaglandin E,, glucagon and secretin
on hepatic arterial vascular bed of the dog. Br J Pharmacol
1976; 57:581-588.
99. Baouty-Boye D. Inhibitory effects of interferons on cell multipli-
cation. Lymphokine Rep 1980; I :99- I 12.
100. Jimenez SA, Freundlich B, Rosenbloom J. Selective inhibition of
human diploid fibroblast collagen synthesis by interferons. J
Clin Invest 1984; 74:1112-1I16.
101. Czaja MJ, Weiner FR, Takahashi S, et al. Gamma-interferon
treatment inhibits collagen deposition in murine schistoso-
miasis. Hepatology 1989; 10:795-800.
102. Rosenbloom J, Feldman G, Freundlich B, et al. Transcriptional
control of human diploid fibroblast collagen synthesis by
gamma-interferon. Biochem Biophy Res Commun 1984;
123~365-372.
103. Perillo RP, Schiff ER, Davis GL, et al. A randomized controlled
trial of interferon ALPHA-2b alone and after prednisone with-
drawal for the treatment of chronic hepatitis B. N Engl J Med
1990; 323:295-30 I.