Giada Pietrosi

Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: A cochrane meta-analysis

BACKGROUND & AIMS Emergency sclerotherapy is used as a first-line therapy for variceal bleeding in cirrhosis, although pharmacologic treatment stops bleeding in most patients. We performed a meta-analysis comparing emergency sclerotherapy with pharmacologic treatment. METHODS MEDLINE (1968-2002), EMBASE (1986-2002), and the Cochrane Library (2002;4) were searched to retrieve randomized controlled trials comparing sclerotherapy with vasopressin (+/- nitroglycerin), terlipressin, somatostatin, or octreotide for variceal bleeding in cirrhosis. Outcome measures were failure to control bleeding, rebleeding, blood transfusions, adverse events, and mortality. RESULTS Fifteen trials were identified. Sclerotherapy was not superior to terlipressin, somatostatin, or octreotide for any outcome and to vasopressin for rebleeding, blood transfusions, death, and adverse events; it was superior to vasopressin for the control of bleeding in a single trial flawed by a potential detection bias. Sclerotherapy was associated with significantly more adverse events than somatostatin. In a predefined sensitivity analysis, combining all of the trials irrespective of the control treatment, risk differences (sclerotherapy minus control) and confidence intervals (CIs) were as follows: failure to control bleeding, -0.03 (-0.06 to 0.01); mortality, -0.035 (-0.07 to 0.008); adverse events, 0.08 (0.02 to 0.14). Mortality risk difference was -0.01 (-0.07 to 0.04) in good-quality trials and -0.08 (-0.14 to -0.02) in poor-quality trials. CONCLUSIONS Available evidence does not support emergency sclerotherapy as the first-line treatment of variceal bleeding in cirrhosis when compared with vasoactive drugs, which control bleeding in 83% of patients. Therefore, endoscopic therapy might be added only in pharmacologic treatment failures.

Efficient human fetal liver cell isolation protocol based on vascular perfusion for liver cell–based therapy and case report on cell transplantation

Although hepatic cell transplantation (CT) holds the promise of bridging patients with end‐stage chronic liver failure to whole liver transplantation, suitable cell populations are under debate. In addition to hepatic cells, mesenchymal stem cells (MSCs) and hematopoietic stem cells (HSCs) are being considered as alternative cell sources for initial clinical cell work. Fetal liver (FL) tissue contains potential progenitors for all these cell lineages. Based on the collagenase incubation of tissue fragments, traditional isolation techniques yield only a fraction of the number of available cells. We report a 5‐step method in which a portal vein in situ perfusion technique is used for tissue from the late second trimester. This method results in the high viabilities known for adult liver vascular perfusion, addresses the low cell yields of conventional digestion methods, and reduces the exposure of the tissue to collagenase 4‐fold. We used donated tissue from gestational weeks 18 to 22, which yielded 1.8 ± 0.7 × 109 cells with an average viability of 78%. Because HSC transplantation and MSC transplantation are of interest for the treatment of hepatic failure, we phenotypically confirmed that in addition to hepatic progenitors, the resulting cell preparation contained cells expressing typical MSC and HSC markers. The percentage of FL cells expressing proliferation markers was 45 times greater than the percentage of adult hepatocytes expressing these markers and was comparable to the percentage of immortalized HepG2 liver hepatocellular carcinoma cells; this indicated the strong proliferative capacity of fetal cells. We report a case of human FL CT with the described liver cell population for clinical end‐stage chronic liver failure. The patients Model for End‐Stage Liver Disease (MELD) score improved from 15 to 10 within the first 18 months of observation. In conclusion, this human FL cell isolation protocol may be of interest for further clinical translation work on the development of liver cell–based therapies. Liver Transpl 18:226–237, 2012.

Arterial chemoembolization/embolization and early complications after hepatocellular carcinoma treatment: a safe standardized protocol in selected patients with Child class A and B cirrhosis.

PURPOSE To assess the safety of transarterial treatments of hepatocellular carcinoma (HCC), and the statistical correlation of various patient factors with the frequency of complications, in selected patients with cirrhosis when adhering to well-standardized protocols. MATERIALS AND METHODS Three hundred twenty consecutive patients with unresectable HCC were treated with transarterial chemoembolization, oil chemoembolization, and embolization. A total of 712 treatments were performed, with an average of 2.3 treatments for each patient. The epirubicin dose was adjusted according to defined laboratory criteria. An early complication was defined as one that occurred within 4 weeks of treatment. Complications were classified as minor and major and assessed by using clinical and laboratory data. RESULTS Of the 712 procedures, 21 complications (2.9%) occurred in 17 of the 320 patients (5.3%). Major complications included acute liver failure (n = 1, 0.1%), variceal bleeding (n = 2, 0.3%), moderate-to-severe ascites (n = 4, 0.6%), sepsis (n = 3, 0.4%), cholecystitis (n = 1, 0.1%), and diverticulitis (n = 1, 0.1%). Minor complications were hepatic artery damage, including spontaneously resolved dissection (n = 3, 0.4%), mild encephalopathy (n = 1, 0.1%), and aspartate aminotransferase/alanine aminotransferase levels greater than 500 U/L (n = 5, 0.7%). The 30-day mortality rate was 0.003% (n = 1). Constitutional syndrome (P = .0001), Child-Pugh score (P = .0001), ascites (P = .037), and the Model for End-Stage Liver Disease score (P = .02) were found to have a statistically significant correlation with complications after univariate analysis. Child-Pugh score (P = .012) and constitutional syndrome (P = .003) were found to have a statistically significant correlation with complications after logistic regression analysis. CONCLUSIONS Transarterial treatments can be considered safe in patients with Child class A and B cirrhosis when an adjusted dose of epirubicin is used according to body surface, severity of liver disease, and white blood cell count. Accurate patient selection and procedure-related factors may reduce the frequency of complications and help preserve liver function.

Lamivudine monoprophylaxis for de novo HBV infection in HBsAg-negative recipients with HBcAb-positive liver grafts.

Vizzini G, Gruttadauria S, Volpes R, D’Antoni A, Pietrosi G, Filì D, Petridis I, Pagano D, Tuzzolino F, Maria Santonocito M, Gridelli B. Lamivudine monoprophylaxis for de novo HBV infection in HBsAg‐negative recipients with HBcAb‐positive liver grafts.
Clin Transplant 2011: 25: E77–E81.

Phases I-II Matched Case-Control Study of Human Fetal Liver Cell Transplantation for Treatment of Chronic Liver Disease:

Fetal hepatocytes have a high regenerative capacity. The aim of the study was to assess treatment safety and clinical efficacy of human fetal liver cell transplantation through splenic artery infusion. Patients with endstage chronic liver disease on the waiting list for liver transplantation were enrolled. A retrospectively selected contemporary matched-pair group served as control. Nonsorted raw fetal liver cell preparations were isolated from therapeutically aborted fetuses. The end points of the study were safety and improvement of the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores. Nine patients received a total of 13 intrasplenic infusions and were compared with 16 patients on standard therapy. There were no side effects related to the infusion procedure. At the end of follow-up, the MELD score (mean ± SD) in the treatment group remained stable from baseline (16.0 ± 2.9) to the last observation (15.7 ± 3.8), while it increased in the control group from 15.3 ± 2.5 to 19 ± 5.7 (p = 0.0437). The Child-Pugh score (mean ± SD) dropped from 10.1 ± 1.5 to 9.1 ± 1.4 in the treatment group and increased from 10.0 ± 1.2 to 11.1 ± 1.6 in the control group (p = 0.0076). All treated patients with history of recurrent portosystemic encephalopathy (PSE) had no further episodes during 1-year follow-up. No improvement was observed in the control group patients with PSE at study inclusion. Treatment was considered a failure in six of the nine patients (three deaths not liver related, one liver transplant, two MELD score increases) compared with 14 of the 16 patients in the control group (six deaths, five of which were caused by liver failure, four liver transplants, and four MELD score increases). Intrasplenic fetal liver cell infusion is a safe and well-tolerated procedure in patients with end-stage chronic liver disease. A positive effect on clinical scores and on encephalopathy emerged from this preliminary study.

Fulminant hepatic failure and autoimmune disorders in patient with multiple sclerosis on interferon beta 1a: A fatal combination?

We report the case of a 46-year-old woman admitted to our liver transplant unit for sudden onset of jaundice, elevated transaminases and coma. She had been diagnosed, ten years before, with progressive relapsing multiple sclerosis (MS) involving predominantly the left side of her body, and treated with steroids for 8 years. She was then switched to interferon (IFN)-beta 1a 30 lg/0.5 ml i.m. once weekly. She had never taken anti-inflammatory drugs or alcohol. Six months later IFN was initiated; a diagnosis of chronic thyroiditis was made on the basis of positive antiperoxidase antibodies (160 IU/l, normal value 0–35) and nodular goiter. The thyroid hormones and liver function were found within normal ranges a few months before liver decompensation. One year ago, after a two-and-a-half-year course of IFN-beta treatment, the patient had a relapse of MS requiring steroid treatment with clinical improvement. One-and-half months later, after receiving her weekly injection of IFN-beta, she became jaundiced and confused reaching comatose stage in 48 h requiring intubation. She was then transferred to our liver transplant unit and was treated with steroids, antibiotic prophylaxis and fluids. Upon admission, no signs of portal hypertension were present. The laboratory tests showed aspartate transaminase 505 (normal value = 10–42 IU/l), alanine transaminase 1232 (10–40 IU/l), gamma glutamyl transpeptidase 73 (2–30 IU/l), alkaline phosphatase 221 (39–92 IU/l), total bilirubin 15.2 (0.2–1.2 mg/dl), direct bilirubin 9.1 (0.0–0.3 mg/dl), prothrombin activity 28.6 (70–120%), prothrombine time (PT) 24.9 s, international normalized ratio (INR) 1.97, total protein 5.4 g/dl (6–8 g/dl), gammaglobulins 23.1 (12–22.5%), free tri-iodothyronine <1 (1.5–4.1 pg/ml), and free thyroxine 0.64 (0.80–1.9 ng/ml). Anti-smooth muscle antibodies (SMA) were positive 1:80 and antiperoxidase antibodies were 112 (normal value: 0–35 IU/ml). All other autoantibodies and serology screening were negative. The abdominal computerised tomography scan showed a normal liver with a patent enlarged portal vein and mild ascites. We then performed a transjugular liver biopsy, which showed severe acute hepatitis with sub-massive hepatic necrosis involving 80% of liver parenchyma. The inflammatory infiltrate was a mix consisting of lymphocyte and small clusters of plasma cells seen predominantly in centrilobular areas (Fig. 1). Trichrome stain highlighted the presence of mild portal fibrosis. The patient’s score for autoimmune hepatitis was 10. Three days after admission, the patient developed fulminant hepatic failure and, according to King’s College criteria, underwent uneventful cadaveric liver transplantation. She had a regular postoperative course on single immunosuppressant drug (tacrolimus) but has developed hypothyroidism. The autoantibodies repeated were negative except for antiperoxidase antibodies (73.8 IU/ ml). Multiple sclerosis is an organ-specific autoimmune disease thought to be mediated by type 1 helper T cells (Th1) that produce IFN-gamma that has been thought to induce the autoimmune process observed in Hashimoto’s disease. Moreover, the IFNs can contribute to the development of chronic inflammation by preventing activated T-cell apoptosis [1]. MS has also been found to be associ-

Characterization of Liver-Specific Functions of Human Fetal Hepatocytes in Culture.

This study was designed to assess liver-specific functions of human fetal liver cells proposed as a potential source for hepatocyte transplantation. Fetal liver cells were isolated from livers of different gestational ages (16-22 weeks), and the functions of cell preparations were evaluated by establishing primary cultures. We observed that 20- to 22-week-gestation fetal liver cell cultures contained a predominance of cells with hepatocytic traits that did not divide in vitro but were functionally competent. Fetal hepatocytes performed liver-specific functions at levels comparable to those of their adult counterpart. Moreover, exposure to dexamethasone in combination with oncostatin M promptly induced further maturation of the cells through the acquisition of additional functions (i.e., ability to store glycogen and uptake of indocyanine green). In some cases, particularly in cultures obtained from fetuses of earlier gestational ages (16-18 weeks gestation), cells with mature hepatocytic traits proved to be sporadic, and the primary cultures were mainly populated by clusters of proliferating cells. Consequently, the values of liver-specific functions detected in these cultures were low. We observed that a low cell density culture system rapidly prompted loss of the mature hepatocytic phenotype with downregulations of all the liver-specific functions. We found that human fetal liver cells can be cryopreserved without significant loss of viability and function and evaluated up to 1 year in storage in liquid nitrogen. They might, therefore, be suitable for cell banking and allow for the transplantation of large numbers of cells, thus improving clinical outcomes. Overall, our results indicate that fetal hepatocytes could be used as a cell source for hepatocyte transplantation. Fetal liver cells have been used so far to treat end-stage liver disease. Additional studies are needed to include these cells in cell-based therapies aimed to treat liver failure and inborn errors of metabolism.

Management of Liver Failure: From Transplantation to Cell-Based Therapy

The severe shortage of deceased donor organs has driven a search for alternative methods of treating liver failure. In this context, cell-based regenerative medicine is emerging as a promising interdisciplinary field of tissue repair and restoration, able to contribute to improving health in a minimally invasive fashion. Several cell types have allowed long-term survival in experimental models of liver injury, but their therapeutic potential in humans should be regarded with deep caution, because few clinical trials are currently available and the number of patients enrolled so far is too small to assess benefits versus risks. This review summarizes the current literature on the physiological role of endogenous stem cells in liver regeneration and on the therapeutic benefits of exogenous stem cell administration with specific emphasis on the potential clinical uses of mesenchymal stem cells. Moreover, critical points that still need clarification, such as the exact identity of the stem-like cell population exerting the beneficial effects, as well as the limitations of stem cell-based therapies, are discussed.

Is human fetal liver stem cell transplantation a panacea for alcohol-induced liver decompensation?

We read with great interest the article by Khan et al. (1), plantation cannot be considered proof of engraftment or definitive homing of cells, but can rule out extrahepatic who showed that patients with chronic liver disease due to alcohol consumption can significantly improve within shunting. We know that it is difficult to track infused cells and follow their long-term engraftment by radio a 6-month period after being treated with a single intrahepatic injection of EpCAM+ fetal liver cells. As we are labeling, yet we believe the most advisable approach to assessing liver regeneration after implantation is still involved in a clinical trial on fetal liver cell infusion in patients with chronic liver disease (http://clinicaltrials. liver histology through a transjugular liver biopsy in compromised patients. Regarding clinical improvement gov/ct2/show/NCT01013194?term=fetal+liver+trial+cir rhosis&rank=1), there are some observations we would soon after cellular infusion, it would be interesting to know if the patient treated in 2007, as shown in Figure like to share concerning this article. The fetuses used in Khan et al.’s study were between 5 of the article (1), experienced further general improvement or needed to undergo liver transplantation. the 16th and 20th weeks, and the total cellular yield reported was 8 × 109 (there are no data on the cellular Finally, we strongly believe that for confirmation of the therapeutic efficacy of fetal liver cell transplantation yield of each fetus). These data are surprisingly different from those reported by the same group in a previous in patients with chronic liver disease a randomized controlled trial should be conducted in order to avoid bias article, where the total number of cells obtained ranged between 140.0 ± 30.8 × 106 (15–20 weeks) and 193.4 ± and misinterpretation of published outcomes. 96.8 × 106 (21–25 weeks), depending on the gestational week (2). Based on our data, we can confirm that the REFERENCES cellular yield of fetuses between the 17th and 22nd 1. Khan, A. A.; Shaik, M. V.; Parveen, N.; Rajendraprasad, weeks can range between 3 × 108 and 3.3 × 109 (unpubA.; Aleem, M. A.; Habeeb, M. A.; Srinivas, G.; Raj, T. A.; lished data). Tiwari, S. K.; Kumaresan, K.; Venkateswarlu, J.; Pande, Patients with alcoholic liver disease can improve G.; Habibullah, C. M. Human fetal liver-derived stem cell transplantation as supportive modality in the management clinically over a 6-month period with abstention from of end-stage decompensated liver cirrhosis. Cell Transplant. alcohol. In order to confirm a correlation between cellu19(4):409–418; 2010. lar therapy and clinical improvement, the treated pa2. Rao, M. S.; Khan, A. A.; Parveen, N.; Habeeb, M. A.; tients the study by Dr. Habibullah and colleagues should Habibullah, C. M.; Pande, G. Characterization of hepatic have been randomized with untreated controls. progenitors from human fetal liver during second trimester. World J. Gastroenterol. 14(37):5730–5737; 2008. A positive hepatic scintigraphy after cellular trans-

Transplantation and Regeneration in the Heart of the Mediterranean

The second half of the 20th century witnessed the birth of organ transplantation, and failing organs can now be replaced with healthy ones procured from living or cadaveric donors, allowing their recipient to start, or return to, an active life. Major milestones in the field were set in the eighties and nineties at the University of Pittsburgh Medical Center (UPMC), an institution that made it a mission to spread its expertise internationally. A successful partnership between UPMC and the Region of Sicily gave rise to the Mediterranean Institute for Transplantation and Highly Specialized Therapies (ISMETT), the only Italian facility entirely dedicated to transplantation of all solid organs and therapies for the treatment of end-stage organ failure. In its first seven years of activity, ISMETT has become a major referral center for patients from the entire Mediterranean Basin and the Middle East. Despite the fact that organ transplantation is the current gold standard for end-stage organ failure, the field is facing a worldwide emergency represented by the chronic shortage of organ donors. Research aimed at understanding the molecular networks involved in organ-specific ageing and their relationship with maintenance networks and organ failure should be actively encouraged and supported as it could ultimately allow to control organ performance and lifespan, increasing the number of organs available for transplant.