C.C Wang

Propofol pretreatment attenuates LPS-induced granulocyte–macrophage colony-stimulating factor production in cultured hepatocytes by suppressing MAPK/ERK activity and NF-κB translocation

Propofol (PPF), a widely used intravenous anesthetic for induction and maintenance of anesthesia during surgeries, was found to possess suppressive effect on host immunity. This study aimed at investigating whether PPF plays a modulatory role in the lipopolysaccharide (LPS)-induced inflammatory cytokine expression in a cell line of rat hepatocytes. Morphological observation and viability assay showed that PPF exhibits no cytotoxicity at concentrations up to 300 microM after 48 h incubation. Pretreatment with 100 microM PPF for 24 h prior to LPS stimulation was performed to investigate the modulatory effect on LPS-induced inflammatory gene production. The results of semi-quantitative RT-PCR demonstrated that PPF pretreatment significantly suppressed the LPS-induced toll-like receptor (TLR)-4, CD14, tumor necrosis factor (TNF)-alpha, and granulocyte-macrophage colony-stimulating factor (GM-CSF) gene expression. Western blotting analysis showed that PPF pretreatment potentiated the LPS-induced TLR-4 downregulation. Flow cytometrical analysis revealed that PPF pretreatment showed no modulatory effect on the LPS-upregulated CD14 expression on hepatocytes. In addition, PPF pretreatment attenuated the phosphorylation of mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK) and IkappaBalpha, as well as the nuclear translocation of NF-kappaB primed by LPS. Moreover, addition of PD98059, a MAPK kinase inhibitor, significantly suppressed the LPS-induced NF-kappaB nuclear translocation and GM-CSF production, suggesting that the PPF-attenuated GM-CSF production in hepatocytes may be attributed to its suppressive effect on MAPK/ERK signaling pathway. In conclusion, PPF as an anesthetic may clinically benefit those patients who are vulnerable to sepsis by alleviating sepsis-related inflammatory response in livers.

Preoperative Imaging Evaluation of Potential Living Liver Donors: Reasons for Exclusion From Donation in Adult Living Donor Liver Transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (< 30%) is the crucial point for the adult LDLT decision.

Outcome of living donor liver transplantation for glycogen storage disease.

GLYCOGEN storage diseases (GSD) are inherited disorders in which the amount and/or structure of glycogen in body tissues are abnormal. GSD I (von Gierke disease) is caused by a deficiency of glucose 6-phosphatase activity in the liver, kidney, and intestinal mucosa with glycogen overloading in these organs. The clinical manifestations are seizures, systemic acidosis, hyperlipidemia, hyperuricemia, and growth retardation. Without effective treatment, long-term complications occur, including gout, osteoporosis, short stature, and hepatic adenomas. GSD III (Cori disease) is caused by a deficiency of glycogen debranching enzyme activity and characterized with limit dextrin-like glycogen accumulated in both liver and muscle in most patients. Hepatomegaly, hypoglycemia, hyperlipidemia, and growth retardation are the main manifestations in children; while liver cirrhosis and /or hepatocellular carcinoma may occur later. Great progress in the management of GSD I and III has been made recently. For patients affected with GSD I, nocturnal nasogastric feeding of glucose or orally administered uncooked cornstarch is effective. With early diagnosis and initiation of treatment, normal growth and development may be expected. Some patients are free of long-term complications. Treatment of GSD III consists of highprotein diet, and frequent high carbohydrate meals for patients with hypoglycemia. Nocturnal gastric feeding or cornstarch supplements comprise effective therapy. However, some patients with GSD do not respond to diet therapy and may need frequent intravenous glucose infusions and even parenteral nutrition to maintain metabolic homeostasis. Liver transplantation (LT) is considered to correct the metabolic defects and the deleterious complications of GSD. LT for GSD I and III was first reported, respectively, by Malatack et al in 198 and by Superina et al in 1989. We present five cases of GSD (four GSD Ia; one GSD III), which were treated by living donor liver transplantation (LDLT) in our institution. These patients were unresponsive to medical therapy or developed serious complications of GSD. In this study we investigate the outcome of these children after LDLT for GSD. PATIENTS AND METHODS

Doppler Ultrasound Evaluation of Postoperative Portal Vein Stenosis in Adult Living Donor Liver Transplantation

AIM To evaluate the postoperative portal vein stenosis (PVS) and the diagnostic efficiency of Doppler ultrasound (DUS) in adult living donor liver transplantation (ALDLT). MATERIALS AND METHOD From January 2007 to December 2008, 103 ALDLTs were performed and postoperatively followed by routine DUS. The morphologic narrowing at the anastomotic site (AS) of the PVS was analyzed. We calculated the PV stenotic ratio (SR) using the following formula: SR (%)=PRE-AS/PRE (PRE=pre-stenotic caliber). An SR>50% was defined as the critical point for PVS. We also calculated the velocity ratio (VR) between the AS and PRE, and set the significant VR as >3:1. Statistical analyses were carried out to determine clinical significance. RESULTS Using the definition of morphologic PVS by DUS, there were total 20 cases (19.4%) in this series with SR>50%, which included 17 cases with VR>3:1. Eight cases of severe PVS had a stenotic AS>5 mm and subsequently underwent interventional management. Doppler criteria of SR and VR values were elevated up to 75.8% and 7.5:1, respectively, in these treated cases. Two cases of severe PVS subsequently developed PV thrombosis. Intervention by balloon dilation and/or stenting was performed successfully in this PVS case. CONCLUSION DUS is the most convenient and efficient imaging modality to detect and follow postoperative PVS in ALDLT. The Doppler criteria of SR and VR are both sensitive but less specific. Cases of AS<5 mm require interventional management for good long-term graft survival.

Bispectral Index Monitoring in Healthy, Cirrhotic, and End-Stage Liver Disease Patients Undergoing Hepatic Operation

The purpose of this study was to assess factors influencing the end-tidal concentrations of isoflurane within a bispectral index (BIS) range of 45-55 among healthy live liver donors (n = 11), chronic hepatitis B patients undergoing hepatectomy hepatocellular carcinoma (n = 10), and end-stage liver disease patients undergoing liver transplantation (n = 7). Patients data collected prospectively were compared among the groups using one-way analysis of variance as well as univariate and multivariate techniques. The results showed that end-stage liver disease patients required the least end-tidal isoflurane concentration. Patients with hepatocellular carcinoma with cirrhosis required intermediate end-tidal isoflurane concentrations; healthy live liver donors required the highest end-tidal isoflurane concentrations to provide sufficient anesthetic depth, as monitored by a target BIS (range, 45-55). Upon multivariate analysis, liver function was the only significant factor influencing the likelihood of lowering the end-tidal isoflurane concentration by 4 hours after anesthesia induction (P = .026). In conclusion, we recommend a preset target BIS within the range of 45-55 to monitor the depth of anesthesia during partial hepatectomy and liver transplantation because end-tidal isoflurane concentration requirements are different for patients with various liver status. This strategy may protect the patients from intraoperative recall or anesthesia over-depth as a consequence of insufficient or overdose of anesthesia, respectively.

Correlation Between Hepatic Steatosis, Hepatic Volume, and Spleen Volume in Live Liver Donors

INTRODUCTION The purpose of this study was to evaluate the changes in liver fatty content and the volumes of liver and spleen after body weight reduction in potential living liver donors. MATERIALS AND METHODS Twenty-three potential living donors had fatty livers at pretransplantation sonography and computed tomography (CT). All were advised to undergo body weight reduction by exercise and diet control. A percutaneous core liver biopsy was performed in segment 5 of the liver in 22 donors to evaluate the hepatic fat content before and after body weight reduction. We compared the changes in the liver CT attenuation values and volume changes in the left and right lobes of the liver and the spleen before and after body weight reduction. RESULTS The mean (SD) body weight, body mass index, and fatty content of the liver biopsy specimens were 73 (17) kg, 26.8 (4.4), and 16.9% (12.7%), respectively, before body weight reduction and 70 (15) kg, 25.3 (3.8), and 6.6% (3.7%), respectively, thereafter. These changes were significant. The CT attenuation values of the left and right lobes of the liver and spleen were 54 (11), 51 (11), and 52 (5) HU, respectively, before body weight reduction and 60 (8), 58 (6), and 53 (5) HU, respectively, thereafter. The mean CT attenuation value of the left lateral segment was greater than that of the right lobe both before and after body weight reduction. The volume of the left and right lobes and spleen changed from 497 (129) cm3 to 452 (99) cm3, 927 (237) cm3 to 846 (173) cm3, and 185 (65) cm3 to 186 (63) cm3, respectively, thereafter. The right and left lobe volume change ratios were 7.0% (10.6%) and 7.6% (11.1%), respectively, but showed no significant difference. Twenty of the 23 candidates were able to donate part of their liver. CONCLUSION Body weight reduction by exercise and diet control in potential living liver donors is effective to reduce the fatty content of the liver. Reversed percentage of the fatty content and volume of the liver was observed in these donors. The volumes of the right and left lobes of liver decreased significantly after body weight reduction. The volume changes were proportional.

High concentration of magnolol induces hepatotoxicity under serum-reduced conditions

Although magnolol is cytoprotective against warm ischemia/reperfusion injury, its effect on cold preservation has not been fully investigated. This study aimed at examining whether magnolol maintains the liver graft integrity after cold preservation and elucidating the underlying mechanisms in terms of apoptotic signaling under both normothermic and hypothermic conditions. After being preserved in Ringers lactate (RL) at 4 degrees C for 6h ex vivo, the magnolol-treated grafts demonstrated significantly higher AST, ALT, and LDH levels in perfusates than those from negative controls. TUNEL staining showed no difference in the number of apoptotic nuclei in both groups, whereas a more intense apoptotic signal in magnolol-treated grafts was shown as compared with the controls. In vitro data showed no significant difference in viability of RL-preserved clone-9 hepatocytes between the magnolol-treated and control groups, while magnolol pretreatment at 30min before cold preservation prominently induced hepatocyte cell death. RT-PCR and Western blotting analyses revealed a suppression in Bcl-2, but an up-regulation in Bax expression in clone-9 cells after magnolol treatment. Magnolol suppressed the ratios of NF-kappaB to I-kappaBalpha protein contents and I-kappaBalpha phosphorylation induced by TNF-alpha, and potentiated mitochondrial cytochrome c release and subsequent caspase-3 cleavage. Conversely, caspase-3 inhibitor attenuated magnolol-induced hepatotoxicity. We concluded that magnolol could not protect liver grafts from cold ischemia/reperfusion injury. High concentration of magnolol under serum-reduced conditions attenuates NF-kappaB-mediated signaling and induces intrinsic apoptotic pathway, thereby inducing in vitro hepatotoxicity.

Soluble thrombomodulin antigen as a marker for endothelial damage during liver transplantation.

RTHOTOPIC liver transplantation (OLT) is now being performed with improved survival rates in a high number of patients suffering from different liver diseases. Despite better control of blood loss, hemorrhages still occur, particularly after reperfusion. Problems arising from defective hemostasis during major abdominal surgery are a major risk for patients with terminal chronic liver disease. 1 Liver transplantation, most often performed in such patients, differs from operations because the recipients start with a diseased liver and end up with a healthy liver, the function of which, however, is compromised by preservation damage. Thrombomodulin (TM), an integral glycoprotein on the surface of endothelial cells, serves as a receptor for thrombin. Thrombin bound to TM greatly reduces procoagulatory and platelet-stimulating effects but activates the zymogen, protein C. 2 Activated protein C together with protein S inactivates two blood coagulation cofactors, factor Va and factor VIIIa, and indirectly stimulates fibrinolysis. Thus, TM plays an important role as an anticoagulant protein on the blood vessel wall. Immunohistochemically, TM has been found to be mainly present on endothelial cell surfaces of blood and lymphatic vessels in all organs except the brain. 3,4 A smaller from of TM, the soluble thrombomodulin (sTM), has been isolated from human blood and urine. 5 The structure of sTM is not known but is thought to be similar to the soluble protein obtained after proteolytic modification of TM with elastase 6 —a cleaved form of tissue TM with loss of part of the transmembrane domain, and the cytoplasmatic tail. 7 Therefore, sTM in plasma appears to be derived from injured endothelial cells or to be proteolytically cleaved from TM by proteases. In vitro, sTM has been shown to be a marker of endothelial damage 8 and several previous clinical studies have shown that plasma levels of sTM are increased in various diseases associated with endothelial cell damage or proteolytic activity on the endothelial cell surface, including DIC, 9,10 adult respiratory distress syndrome (ARDS), 10 thromboembolic disease, 9,10 thrombotic thrombocytopenic purpura, 11,12 diabetes mellitus with microangiopathy, 9,13 systemic lupus erythematosus (SLE), 14 and chronic myelogenous leukemia. 15 Because they are usually associated with vascular endothelium alterations, 10,16 TM plays an important role as an anticoagulant protein on the blood vessel wall. However, in the context of liver transplantation, the understanding of pathophysiology of TM in the coagulation-fibrinolysis equilibrium is still in its infancy. There are only few reports 17,18 on sTM in liver transplantation. In orthotopic liver transplantation, both platelet and leukocyte activation as well as prothrombin activation are suspected of being caused by damaged endothelial cells in the grafted liver. In this study, plasma sTM levels as an endothelial marker were measured in the course of 11 consecutive liver transplantation. Samples were taken at nine different time points perioperatively as well as the perfusate released from the graft outflow vein during the flushing procedure.

Liver and spleen change in the living related liver donation

DUE TO the difficulty of obtaining organs from cadavers, living-related liver transplantation (LRLT) has been utilized for compatible children and adults with endstage liver disease. The operation involves removal of left lateral segments (S2, S3), extend left lateral segment (S2, S3, and medial part of S4), left lobe (S2, S3, and S4), or right lobe of the liver without endangering the function of the remaining liver. After partial hepatectomy, liver regeneration leads to restoration of liver function. On follow-up computed abdominal tomography (CT), we noted spleen volume changes in the donors after operation, a finding which has not been mentioned in the previous literature. The purpose of this study was to evaluate liver regeneration and spleen volume changes in donors after LRLT using CT volumetry.

Hemodynamics of portal venous stenosis before and after treatment in pediatric liver transplantation: evaluation with Doppler ultrasound.

AIM The aim of this study was to evaluate portal vein stenosis (PVS) in pediatric liver transplantation (PLT) using Doppler ultrasound (DUS) before and after interventional management for hemodynamic changes. MATERIALS AND METHODS From 2000 to 2010, we encountered 11 PVS cases among 180 PLT that were evaluated using DUS and computed tomography (CT) angiography (CTA); all underwent portal stenting. DUS was used to monitor portal hemodynamics. For the diagnosis of PVS, we investigated multiple parameters including stenotic size (SS), stenotic ratio (SR) (SR [%]=PRE-SS/PRE [PRE=stenotic size]), portal flow velocity ratio (VR) (VR=VS/PRE [PRE=velocity at prestenotic site; VS=peak velocity at stenotic site]), spleen size, and platelet count. RESULTS The incidence of PVS was 5.6% (11/180). The PV was 2.5 mm using DUS and 2.7 mm using CTA. The average SR was 65% fitting the criterion. Low prestenotic portal flow<12 cm/sec and high peak velocity in the stenotic segment (up to 147 cm/sec) were observed in 6 cases. The VR value was high at 7.5:1 and there was splenomegaly with thrombocytopenia. After portal vein stenting, hyperperfusion occurred might after reopening the stenosis: the flow increased to an average of 34 cm/sec and then flow decreased slowly to a stable level 2 weeks later. The size of the spleen decreased from 17 to 12 cm and the thrombocytopenia also improved with platelet counts increasing from 67×10(3) to 178×10(3)/μl at 2 months follow-up. The changes in portal flow, portal vein size, spleen size, and platelet count were significant (P<.05). CONCLUSION PVS is diagnosed using DUS by increased intrahepatic PV dilatation, peak flow at the stenotic site, discrepant VR. Early portal stenting showed a better prognosis. DUS is essential and effective for hemodynamic monitoring and management of PVS.