Antonio Poyato

N-acetylcysteine, coenzyme Q10 and superoxide dismutase mimetic prevent mitochondrial cell dysfunction and cell death induced by D-galactosamine in primary culture of human hepatocytes

D-Galactosamine (D-GalN) induces reactive oxygen species (ROS) generation and cell death in cultured hepatocytes. The aim of the study was to evaluate the cytoprotective properties of N-acetylcysteine (NAC), coenzyme Q(10) (Q(10)) and the superoxide dismutase (SOD) mimetic against the mitochondrial dysfunction and cell death in D-GalN-treated hepatocytes. Hepatocytes were isolated from liver resections. NAC (0.5 mM), Q(10) (30 microM) or MnTBAP (Mn(III)tetrakis(4-benzoic acid) porphyrin chloride (1mg/mL) were co-administered with D-GalN (40 mM) in hepatocytes. Cell death, oxidative stress, mitochondrial transmembrane potential (MTP), ATP, mitochondrial oxidized/reduced glutathione (GSH) and Q(10) ratios, electronic transport chain (ETC) activity, and nuclear- and mitochondria-encoded expression of complex I subunits were determined in hepatocytes. d-GalN induced a transient increase of mitochondrial hyperpolarization and oxidative stress, followed by an increase of oxidized/reduced GSH and Q(10) ratios, mitochondrial dysfunction and cell death in hepatocytes. The cytoprotective properties of NAC supplementation were related to a reduction of ROS generation and oxidized/reduced GSH and Q(10) ratios, and a recovery of mitochondrial complexes I+III and II+III activities and cellular ATP content. The co-administration of Q(10) or MnTBAP recovered oxidized/reduced GSH ratio, and reduced ROS generation, ETC dysfunction and cell death induced by D-GalN. The cytoprotective properties of studied antioxidants were related to an increase of the protein expression of nuclear- and mitochondrial-encoded subunits of complex I. In conclusion, the co-administration of NAC, Q(10) and MnTBAP enhanced the expression of complex I subunits, and reduced ROS production, oxidized/reduced GSH ratio, mitochondrial dysfunction and cell death induced by D-GalN in cultured hepatocytes.

Acute liver failure in a patient with multiple sclerosis treated with interferon-β

Sir Acute liver failure (ALF) is a rare but frequently fatal disorder, defined by the onset of coagulopathy and encephalopathy within 1 26 weeks of presentation, without underlying liver disease [1]. The mortality rate reaches 60 90%, depending on the grade of encephalopathy, and urgent liver transplantation is recommended when criteria are fulfilled (King’s College and Clichy criteria). We report an uncommon case of ALF requiring liver transplant occurring five years after starting interferon-b treatment in a patient with multiple sclerosis (MS). A 39-year-old woman with jaundice and malaise was admitted to our unit. She had relapsing MS, diagnosed 10 years earlier and had been receiving interferon-b (Betaferon, Schering) for five years at a dose of 25 mcg subcutaneously every two days, without any serious adverse event so far. There was no history of alcohol or paracetamol abuse, and without concomitant medications during the last five years. At admission her mental status was normal, without signs of encephalopathy or fever. The liver function tests at presentation were as follows: AST 1609 U/L, ALT 1082 U/L, GGT 175 U/L, ALP 176 U/L, total bilirubin 10.4 mg/dL, prothrombin activity 26% and factor V 26%. The values of other parameters such as glucose, BUN, creatinin, sodium, potassium, amylase, total protein, albumin, ceruloplasmin, copper, a-1-antitrypsin and a-fetoprotein were normal. All serum viral markers of HCV, HBV, HAV and systemic viruses (CMV, Herpes, Epstein-Barr) were negative. Autoimmune profile demonstrated positivity for ANA and SMA antibodies with a titre of 1:1260 and 1:160, respectively. Abdominal ultrasound examination showed normal liver size and no features of portal hypertension. The administration of interferon-b was discontinued, and the patient started on steroid treatment (methyl prednisolone 1 mg/kg weight i.v.). After 10 days, liver function tests improved partially (AST 101 UI/L, ALT 214 UI/L, bilirubin 15.4 mg/dL, prothrombin activity 23.7%, factor V 23.6%), but abdominal ultrasound showed presence of ascites and hepatic atrophy. At day 13 after admission the patient developed decreased level of consciousness and asterixis. Liver transplant was performed 24 h later, and the explant showed massive hepatic necrosis without specific aetiological features. The outcome of the patient was satisfactory and she was discharged 20 days after OLT with normal graft function. An association between MS and other autoimmune disorders has already been reported (thyroiditis, myasthenia gravis and rheumatoid arthritis). Some authors have suggested that the prevalence of AIH in MS patients is nearly 10 times higher than in the general population through similar B-cellmediated mechanisms [2]. The treatment of AIH includes steroids and azathioprine. On the other hand, interferon-b is considered as the gold standard treatment for MS, but abnormal liver function tests are reported in up to 36% of patients, based on postmarketing studies [3]. Several cases of AIH [4,5] or acute liver injury requiring liver transplantation [6] have been recorded in patients with MS treated with interferon-b. Although interferon-b treatment is safe and generally well tolerated, patients should be frequently monitored in order to detect eventual deterioration of liver function.

Factores pronósticos de complicaciones postoperatorias en el trasplante hepático

OBJECTIVES the postoperative evolution of patients submitted to orthotopic liver transplant (OLT) is frequently associated with the appearance of different types of complications such as renal failure, graft rejection, infections, and neurological disorders. These complications are the most significant causes of early morbidity and mortality in patients undergoing OLT. The purpose of the present study was the identification of factors related to the different postoperative complications after OLT. EXPERIMENTAL DESIGN a prospective study was carried out. PATIENTS seventy-eight variables were analyzed in 32 consecutive patients undergoing OLT. The factors independently associated with the appearance of postoperative complications were identified using a stepwise logistic regression analysis. RESULTS the multivariate analysis showed that malondialdehyde and creatinine pretransplant serum levels were associated with the development of renal dysfunction. The pretransplant levels of haemoglobin and the units of platelets administered during surgery were prognostic factors of infections. Acute graft rejection was predicted by ?-glutamyl transpeptidase and total bilirubin serum levels. The pretransplant sodium and glutaredoxin levels in serum were associated with neurological complications. CONCLUSIONS we propose these markers for the identification of high-risk patients allowing an early surveillance and/or treatment to improve morbidity and survival in patients submitted to OLT.

Everolimus is safe within the first month after liver transplantation.

BACKGROUND & AIMS Sirolimus should not be started within the first month after liver transplantation (LT) because of an increased risk of adverse outcomes. The evidence regarding everolimus is lacking but the manufacturer transposed the same warning. We aimed to evaluate the safety of everolimus started within the first month after LT. METHODS A consecutive cohort 187 LT patients (2009-2013) with a tacrolimus-based immunosuppression was evaluated. Patients starting everolimus within the first month after LT (n = 33; 17.6%) were compared with those starting everolimus thereafter (n = 25; 13.4%) or not receiving everolimus (n = 129; 69%). The median follow-up after LT was 21 months (IQR 7-36). Prospective outcomes were evaluated by using Kaplan-Meier curves and Coxs regression. RESULTS The incidence of hepatic artery thrombosis was not significantly different in patients early treated with everolimus when compared with the remaining cohort (0% vs 9.1%; p = 0.12). Other vascular complications occurred in 9.1% of patients with early everolimus vs 7.3% in the remaining cohort (p = 0.72). No wound healing complications were detected with early everolimus. There were similar rates of incisional hernia (p = 0.31), infections (p = 0.15), renal impairment (p = 0.37), and histologically-proven acute rejection (p = 0.24) between groups. The rates of hyperlipidemia were increased with early everolimus (29.9% vs 16.5% at 3 years; p = 0.018). Graft loss and mortality rates were similar between groups (p = 0.34 and p = 0.94 respectively), after adjusting for possible confounding factors. CONCLUSIONS Everolimus combined with reduced tacrolimus proved to be safe within the first month after LT. Future trials may be allowed to implement everolimus early after LT.

Incidental hepatocellular carcinoma after liver transplantation: Prevalence, histopathological features and prognostic impact

Background Incidental hepatocellular carcinoma (iHCC) is a histological finding after liver transplantation (LT) which relevance has been scarcely studied. Aims to describe the histopathological features of iHCC and to determine its prognostic impact in terms of tumor recurrence and overall survival. Methods Observational study including 451 consecutive adult LT patients (2000–2013). Patients aged<18, retransplanted or with early postoperative death were excluded. Median follow-up after LT was 58 months. Multiple Cox’s regression was used to assess the prognostic impact of iHCC on tumor recurrence and mortality while controlling for potential confounders. Results 141 patients had known HCC before LT (31.3%). Among the remaining 310 patients, the prevalence of iHCC was 8.7% (n = 27). In the explanted liver, 36.2% of patients with known HCC and 25.9% of patients with iHCC trespassed Milan criteria (p = 0.30). Patients with known and iHCC had similar rates of multinodular disease (50.4% vs 55.6%; p = 0.62), macrovascular invasion (6.5% vs 3.7%; p = 0.58), microvascular invasion (12.9% vs 14.8%; p = 0.76) and moderate-poor tumor differentiation (53.9% vs 70.4%; p = 0.09). In the multivariate analysis, iHCC and known HCC had identical recurrence-free survival after controlling for histological features (RR = 1.06, 95%CI 0.36–3.14; p = 0.90). Cumulative 5-year overall survival rates were similar between patients with known and iHCC (65% vs 52.8% respectively; log rank p = 0.44), but significantly inferior as compared with patients without HCC (77.8%) (p = 0.002 and p = 0.007 respectively). Indeed, in the overall cohort, iHCC was an independent predictor of mortality (RR = 3.02; 95%CI 1.62–5.65; p = 0.001). Conclusion The risk of tumor recurrence after LT is similar in patients with iHCC and known HCC. A close imaging surveillance is strongly recommended for patients awaiting LT in order to detect HCC prior to LT, thus allowing for an adequate selection of candidates, prioritization and indication of bridging therapies.

Randomized clinical trial comparing high versus standard dose of ribavirin plus peginterferon alfa-2a in hepatitis C genotype 3 and high viral load. Dargen-3 study

INTRODUCTION Less than half of patients with chronic hepatitis C genotype 3 (G3) and high viral load (HVL) without a rapid virological response (RVR) achieve a sustained virological response (SVR) when treated with peginterferon plus ribavirin (RBV). OBJECTIVES To assess the impact of high doses of RBV on SVR in patients with G3 and HVL. METHODS Ninety-seven patients were randomized to receive peginterferon α-2a+RBV 800 mg/day (A; n=42) or peginterferon α-2a+RBV 1600 mg/day+epoetin β 400 IU/kg/week SC (B; n=55). Patients allocated to group B who achieved RVR continued on RBV (800mg/day) for a further 20 weeks (B1; n=42) while non-RVR patients received a higher dose of RBV (1600 mg/day)+epoetin β (B2; n=13). RESULTS RVR was observed in 64.3% of patients in A and in 76.4% in B (p=0.259). Intention-to-treat (ITT) analysis showed SVR rates of 64.3% (A) and 61.8% (B), with a reduction of -2.5% (-21.8% to 16.9%) (p=0.835). The SVR rate was 61.9% in arm B1 and 61.5% in arm B2. No serious adverse events were reported, and the rate of moderate adverse events was < 5%. CONCLUSIONS G3 patients with high viral load without RVR did not obtain a benefit from a higher dose of RBV. Higher doses of RBV plus epoetin β were safe and well tolerated (Clin Trials Gov NCT00830609).