Filomena Conti

Production of Infectious Hepatitis C Virus in Primary Cultures of Human Adult Hepatocytes

BACKGROUND & AIMSnAlthough hepatitis C virus (HCV) can be grown in the hepatocarcinoma-derived cell line Huh-7, a cell-culture model is needed that supports its complete, productive infection cycle in normal, quiescent, highly differentiated human hepatocytes. We sought to develop such a system.nnnMETHODSnPrimary cultures of human adult hepatocytes were inoculated with HCV derived from Huh-7 cell culture (HCVcc) and monitored for expression of hepatocyte differentiation markers and replication of HCV. Culture supernatants were assayed for HCV RNA, core antigen, and infectivity titer. The buoyant densities of input and progeny virus were compared in iodixanol gradients.nnnRESULTSnWhile retaining expression of differentiation markers, primary hepatocytes supported the complete infectious cycle of HCV, including production of significant titers of new infectious progeny virus, which was called primary-culture-derived virus (HCVpc). Compared with HCVcc, HCVpc had lower average buoyant density and higher specific infectivity; this was similar to the characteristics of virus particles associated with the very-low-density lipoproteins that are produced during in vivo infection. These properties were lost after re-culture of HCVpc in poorly differentiated Huh-7 cells, suggesting that authentic virions can be produced only by normal hepatocytes that secrete authentic very-low-density lipoproteins.nnnCONCLUSIONSnWe have established a cell-culture-based system that allows production of infectious HCV in physiologically relevant human hepatocytes. This provides a useful tool for the study of HCV interactions with its natural host cell and for the development of antiviral therapies.

Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study

BACKGROUNDnManagement of anastomotic biliary strictures after liver transplantation deserves optimization.nnnOBJECTIVEnTo evaluate placement and removal of partially covered self-expandable metal stents (PCSEMSs) in this setting.nnnDESIGNnProspective, multicenter, uncontrolled study.nnnSETTINGnThree French academic hospitals with liver transplantation units and tertiary referral endoscopy centers.nnnPATIENTSnTwenty-two patients (18 men, 4 women, aged 49.7 ± 12 years) with anastomotic biliary stricture. Seventeen (77.3%) presented stricture recurrence after plastic stenting.nnnINTERVENTIONSnPCSEMSs were placed across the stricture for 2 months and then removed. Patients were followed by clinical examination and liver function tests 1, 3, 6, 9, and 12 months after PCSEMS removal.nnnMAIN OUTCOME MEASUREMENTnThe ability to remove PCSEMS.nnnRESULTSnPCSEMS placement was successful in all patients, after sphincterotomy in 21 patients. Stent-related complications included minor pancreatitis (3 patients), transient pain (1 patient), and cholangitis (1 patient). Stent removal was achieved in all patients but 2 whose stents had migrated distally. Partial stent dislocation was noted in 5 patients (upward in 4, downward in 1). Complications associated with stent removal were minor, including self-contained hemorrhage (1 patient) and fever (1 patient). The stricture persisted at the end of treatment in 3 patients (13.6%), all of whom had stent migration or dislocation. Recurrence of anastomotic stricture after initial success occurred in 9 of 19 patients (47.4%) within 3.5 ± 2.1 months. Sustained stricture resolution was observed in 10 of 19 patients (52.6%), 45.6% from an intent-to-treat perspective.nnnLIMITATIONSnUncontrolled study with limited follow-up.nnnCONCLUSIONSnTemporary placement and removal of PCSEMSs in anastomotic biliary strictures after liver transplantation is feasible, although sometimes demanding. Stent migration may impair final outcome.

Hepatocellular carcinoma developed on compensated cirrhosis: Resection as a selection tool for liver transplantation

The objective of this study was to evaluate the histological profile obtained from primary resection of hepatocellular carcinoma (HCC) as a selection tool for liver transplantation (LT). The natural history of HCC depends on its histological features. The clinical effectiveness of resection as a selection tool for salvage or de principe LT has been previously advocated. Between 1987 and 2006, 20 patients underwent a resection prior to LT. Long‐term survival of these 20 patients was compared to that of 73 patients who underwent primary LT. Histological features of the resected specimen were compared to those of the recurrences. Feasibility, morbidity, and mortality of LT following primary resection were also analyzed. Mean follow‐up was 3.8 ± 4.4 and 2.7 ± 4.5 years from resection and LT, respectively; 6 patients died. The mean 1‐, 3‐, 5‐, and 10‐year overall survival rates were 71%, 61%, 55%, and 45% and 74%, 66%, 66%, and 40% after primary transplantation and primary resection, respectively (not significant). At LT, 14 patients had a recurrence, but histological study of the recurrence was not possible in 2 (complete necrosis). For 9 patients (75%), histological features of both primary and recurrent tumors were exactly the same. Four patients had recurrence following LT; in each case, primary and recurrent nodules shared the same histological markers of poor prognosis. De principe transplantation was proposed to 6 patients because of poor prognosis histological features on the resected specimen. All these patients are alive without recurrence with a mean follow‐up of 55 months. In conclusion, the natural history of HCC can be predicted on the basis of the histological profile of the resected specimen, which may be used as a selection tool for LT. De principe LT in patients within Milan criteria with poor prognosis histological features may be an optimal strategy. Liver Transpl 14:779–788, 2008.

Long-term Outcomes Following Aggressive Management of Recurrent Hepatocellular Carcinoma After Upfront Liver Resection

BackgroundLong-term outcomes of patients who experience recurrence after liver resection (LR) of hepatocellular carcinoma (HCC) are uncertain.MethodsThe characteristics of 58 patients were obtained from a retrospective database at two time points: primary resection and recurrence. Patterns of recurrence, treatment strategies, and long-term survival rates were analyzed.ResultsThe recurrence was inside the Milan criteria (Milan+) in 19 patients (32.7xa0%), 11 of whom were already eligible for a liver transplant (LT) at the time of primary liver resection (LR). Treatment of the recurrence included the following procedures: salvage LT (nxa0=xa06; 10.3xa0%), repeat LR (nxa0=xa07; 12.1xa0%), percutaneous radiofrequency ablation (RFA) and/or transarterial chemoembolization (TACE) (nxa0=xa024; 41.3xa0%), systemic chemotherapy (nxa0=xa015; 25.8xa0%), and best supportive care (nxa0=xa012; 20.7xa0%). With a mean follow-up of 26.9xa0±xa027.9xa0months, the overall 1-, 3-, and 5-year survival rates of the 58 patients with HCC recurrence after primary LR were 57.3, 42.5, and 35.3xa0%, respectively. In the multivariate analysis the presence of esophageal varices (pxa0=xa00.001), an AFP level >200xa0μg/L (pxa0=xa00.03) and a Milan− recurrence pattern (pxa0=xa00.05) were independent predictors of decreased survival. The overall 5-year survival of patients who experienced Milan+ recurrence was comparable to that of Milan+ patients who underwent primary LR (62.5xa0% vs. 66.3xa0%, pxa0=xa00.48).ConclusionsAggressive management of recurrent HCC after upfront LR improves patient survival. The pattern of recurrence is an independent predictor of survival which can be used as a selection criterion for salvage LT.

Might physicians be restricting access to liver transplantation for patients with alcoholic liver disease

BACKGROUND/AIMSnIn France, the most common cause of cirrhosis is excessive alcohol consumption. Post-transplant survival rates in patients with alcoholic liver disease (ALD) are at least as good as those seen with other indications. However, fewer of these patients are found on the waiting list. To understand the reasons for this discrepancy, it was decided to examine physicians attitudes concerning the allocation of deceased donor liver allografts.nnnMETHODSnUsing a standardized postal questionnaire, 1739 physicians were asked to allocate 100 liver transplants to two competing groups of patients who were equivalent except for the cause of their cirrhosis (i.e. alcohol-related or primary biliary cirrhosis). A composite score was then used to assess their attitude regarding the behavior of alcoholics and their responsibility for their illness.nnnRESULTSnAmong the 475 respondents (response rate: 27.3%), 55.2% allocated fewer than 50 transplants to ALD patients. This lower rate was independently associated with factors such as being a general practitioner (odds ratio [OR]=3.2, 95% confidence interval [95%CI]=1.8-5.9), a misinterpretation of ALD patients being equivalent to others (OR=1.8, 95%CI=1.1-3.0) or unfavorable attitudes regarding alcoholics (OR=4.0, 95%CI=1.7-9.5, to OR=126.8, 95%CI=34.0-472.1).nnnCONCLUSIONSnGreater information and education of physicians may improve access to liver transplantation for ALD patients.

Prospective assessment of renal histopathological lesions in patients with end-stage liver disease: Effects on long-term renal function after liver transplantation

BACKGROUND & AIMSnThe incidence of organic renal lesions in patients with end-stage liver disease is unknown. The goal of this study was to make a prospective evaluation of renal histological lesions in a group of unselected patients awaiting liver transplantation.nnnMETHODSnSixty cirrhotic patients underwent a renal biopsy via the transjugular route. The potential effect of renal lesions on renal function was evaluated five years after transplantation.nnnRESULTSnThe yield of biopsies enabling satisfactory analysis was 77%, and no major complications occurred. Proteinuria>0.5 g/day was observed in only 8.7% of these patients, microscopic haematuria in 4.3%, creatinine levels>133 mmol/L (1.5mg/dl) in 10.9%, and Modification of the Diet in Renal Disease (MDRD) clearance<60 ml/min in 13.0%. Twenty-five patients (55.3%) had a morphological diagnosis of renal disease, 15 displayed IgA nephropathy and immunofluorescence testing showed that 12 had specific diabetic linear staining for IgG and albumin, of whom seven had associated histological lesions of diabetic nephropathy. Five years after liver transplantation, renal function had significantly deteriorated more in patients with initial diabetic lesions than in those with normal histology or IgA nephropathy alone.nnnCONCLUSIONSnIn patients with end-stage liver disease, IgA nephropathy and diabetic lesions were frequently found despite the absence of renal impairment and/or urinalysis anomalies. Our results strongly suggest that severe renal failure develops preferentially in liver transplant recipients with diabetes or carbohydrate intolerance, and that pre-existing arterial lesions may favour the nephrotoxicity of calcineurin inhibitors. Diabetes prior to transplantation needs to be strictly managed and requires a renal sparing immunosuppressive regimen after transplantation.

Split liver transplantation using extended right grafts: the natural history of segment 4 and its impact on early postoperative outcomes.

Split liver transplantation (SLT) using extended right grafts is associated with complications related to ischemia of hepatic segment 4 (S4), and these complications are associated with poor outcomes. We retrospectively analyzed 36 SLT recipients so that we could assess the association of radiological, biological, and clinical features with S4 ischemia. The overall survival rates were 84.2%, 84.2%, and 77.7% at 1, 3, and 5 years, respectively. The recipients were mostly male (24/36 or 67%) and had a median age of 52 years (range = 13‐63 years), a median body mass index of 22.9 kg/m2 (range = 17.3‐29.8 kg/m2), and a median graft‐to‐recipient weight ratio of 1.3% (range = 0.9%‐1.9%). S4‐related complications were diagnosed in 22% of the patients (8/36) with a median delay of 22 days (range = 10‐30 days). Secondary arterial complications were seen in 3 of these patients and led to significantly decreased graft survival in comparison with the graft survival of patients without complications (50.0% versus 85.6%, P = 0.017). Patients developing S4‐related complications had significantly elevated aspartate aminotransferase (AST) levels (>1000 IU/L) on postoperative day (POD) 1 and elevated gamma‐glutamyl transpeptidase (GGT) levels (>300 IU/L) on PODs 7 and 10 (P < 0.05). These AST and GGT elevations conferred a significantly high risk of developing these complications (odds ratio = 42, 95% confidence interval = 4‐475, P < 0.05). The ischemic volume of S4 was extremely variable (0%‐95%) and did not correlate with S4‐related complications. In conclusion, our results suggest that S4‐related complications are risk factors for worse graft survival, and the development of these complications can be anticipated by the early identification of a specific biological profile and a routine radiological examination. Liver Transpl 18:413–422, 2012.

Subjective parameters markedly limit the referral of transplantation candidates to liver transplant centres

Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End‐stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step.