Gian Luca Grazi

Cyclin G1 Is a Target of miR-122a, a MicroRNA Frequently Down-regulated in Human Hepatocellular Carcinoma

We investigated the role of microRNAs (miRNAs) in the pathogenesis of human hepatocellular carcinoma (HCC). A genome-wide miRNA microarray was used to identify differentially expressed miRNAs in HCCs arisen on cirrhotic livers. Thirty-five miRNAs were identified. Several of these miRNAs were previously found deregulated in other human cancers, such as members of the let-7 family, mir-221, and mir-145. In addition, the hepato-specific miR-122a was found down-regulated in approximately 70% of HCCs and in all HCC-derived cell lines. Microarray data for let-7a, mir-221, and mir-122a were validated by Northern blot and real-time PCR analysis. Understanding the contribution of deregulated miRNAs to cancer requires the identification of gene targets. Here, we show that miR-122a can modulate cyclin G1 expression in HCC-derived cell lines and an inverse correlation between miR-122a and cyclin G1 expression exists in primary liver carcinomas. These results indicate that cyclin G1 is a target of miR-122a and expand our knowledge of the molecular alterations involved in HCC pathogenesis and of the role of miRNAs in human cancer.

Can Antiplatelet Prophylaxis Reduce the Incidence of Hepatic Artery Thrombosis After Liver Transplantation

To ascertain whether postoperative antiplatelet therapy could reduce the incidence of hepatic artery thrombosis (HAT) after liver transplantation (LT), 838 consecutive adult whole‐graft LTs performed from April 1986 to August 2005 that survived beyond the first postoperative month were reviewed. Antiplatelet prophylaxis with aspirin (100 mg per day) was given following 236 LTs; the median starting time was 8 postoperative days (range, 1 to 29 days). Early HAT was observed in 29 cases. The median time of presentation was 5 postoperative days (range, 1‐28 days), and the effect of aspirin on this type of complication was therefore not assessable. A total of 14 cases of late HAT were observed (1.67 %). The median time of presentation was 500.5 days (range, 50–2,405 days). Late HAT occurred in 1 out of 236 (0.4 %) patients who were maintained under antiplatelet prophylaxis and in 13 out of 592 (2.2 %) who did not receive prophylaxis (P = 0.049). Risk factors for late HAT (grafts retrieved from donors who died of cerebrovascular accident and/or use of iliac conduit at transplantation) were present in 498 LTs: in this group the incidence of late HAT was significantly higher among cases who did not receive prophylaxis (12/338 vs 1/160; p = 0.037). There were no hemorrhagic complications associated with the use of aspirin. In conclusion,antiplatelet prophylaxis can effectively reduce the incidence of late HAT after LT, particularly in those patients at risk for this complication. Liver Transpl 13:651–654, 2007.

Aberrant Notch3 and Notch4 expression in human hepatocellular carcinoma

Background: Notch signalling is altered in several solid tumours and it plays a role in growth inhibition and apoptosis of hepatocellular carcinoma (HCC)‐derived cell lines, bile duct development and hepatocyte regeneration.

A new priority policy for patients with hepatocellular carcinoma awaiting liver transplantation within the model for end-stage liver disease system

The best prioritization of patients with hepatocellular carcinoma (HCC) waiting for liver transplantation under the model for end‐stage liver disease (MELD) allocation system is still being debated. We analyzed the impact of a MELD adjustment for HCC, which consisted of the addition of an extra score (based on the HCC stage and waiting time) to the native MELD score. The outcome was analyzed for 301 patients with chronic liver disease listed for liver transplantation between March 1, 2001 and February 28, 2003 [United Network for Organ Sharing (UNOS)‐Child‐Turcotte‐Pugh (CTP) era, 163 patients, 28.8% with HCC] and between March 1, 2003 and February 28, 2004 (HCC‐MELD era, 138 patients, 29.7% with HCC). In the HCC‐MELD era, the cumulative dropout risk at 6 months was 17.6% for patients with HCC versus 22.3% for those patients without HCC (P = NS), similar to that in the UNOS‐CTP era. The cumulative probability of transplantation at 6 months was 70.3% versus 39.0% (P = 0.005), being higher than that in the UNOS‐CTP era for patients with HCC (P = 0.02). At the end of the HCC‐MELD era, 12 patients with HCC (29.3%) versus 57 without HCC (58.8%) were still on the list (P = 0.001). Both native and adjusted MELD scores were higher (P < 0.05) and progressed more in patients with HCC who dropped out than in those who underwent transplantation or remained on the list (the initial‐final native MELD scores were 17.3‐23.1, 15.5‐15.6, and 12.8‐14.1, respectively). The patients without HCC remaining on the list showed stable MELD scores (initial‐final: 15.1‐15.4). In conclusion, the present data support the strategy of including the native MELD scores in the allocation system for HCC. This model allows the timely transplantation of patients with HCC without severely affecting the outcome of patients without HCC. Liver Transpl 13:857–866, 2007.

Use of Vascular Clamping in Hepatic Surgery Lessons Learned From 1260 Liver Resections

HYPOTHESISnSeveral techniques have been introduced to minimize intraoperative bleeding in hepatic surgery. Ischemia-reperfusion injuries and intestinal congestion are the main drawbacks of vascular clamping. We hypothesized possible negative effects on early postoperative outcomes associated with different types of vascular clamping during liver resections and evaluated how attitudes have changed in the past 20 years.nnnDESIGNnRetrospective review.nnnSETTINGnAcademic research institute.nnnPATIENTSnPatients who underwent 1260 consecutive liver resections, 338 of them (26.8%) in patients with cirrhosis.nnnMAIN OUTCOME MEASURESnPostoperative complications and mortality were analyzed relative to liver disease, blood transfusion, vascular clamping, and type of liver resection.nnnRESULTSnVascular clamping was applied in 594 patients (47.1%). Operative mortality was 4.4% in the vascular clamping group and 2.9% in the nonclamped group, a statistically nonsignificant difference. On multivariate analysis, blood transfusion, major hepatectomies, and the presence of cirrhosis were statistically significantly associated with postoperative complications. Among the overall cohort and among patients with cirrhosis, there was statistically significantly reduced use of vascular clamping and of blood transfusion during the past 20 years. The lowest incidences of severe complications occurred among cases of continuous or hemihepatic clamping. Among 338 patients with cirrhosis, 155 (45.9%) received some type of vascular control; morbidity and mortality rates were similar in the groups with vs those without vascular control. On multivariate analysis, only blood transfusion was statistically significantly associated with postoperative morbidity. Postoperative complications were statistically significantly reduced among patients receiving intermittent compared with continuous clamping.nnnCONCLUSIONSnVascular clamping can be applied without additional risk during partial hepatectomy. Intermittent or hemihepatic clamping is preferable in patients with cirrhosis.

Laboratory test variability and model for end-stage liver disease score calculation: effect on liver allocation and proposal for adjustment.

Background. The use of the Model for End-Stage Liver Disease (MELD) score to prioritize patients on liver waiting lists must take the bias of different laboratories into account. Methods. We evaluated the outcome of 418 patients listed during 1 year whose MELD score was computed by two laboratories (lab 1 and lab 2). The two labs had different normality ranges for bilirubin (maximal normal value [Vmax]: 1.1 for lab 1 and 1.2 for lab 2) and creatinine (Vmax: 1.2 for lab 1 and 1.4 for lab 2). The outcome during the waiting time was evaluated by considering the liver transplantations and the dropouts, which included deaths on the list, tumor progression, and patients who were too sick. Results. Although the clinical features of patients were similar between the two laboratories, 36 (13.1%) out of 275 were dropped from the list in lab 1, compared to 5 (3.5%) out of 143 in lab 2 (P<0.01). The differences were mainly due to the deaths on the list (8% lab 1 vs. 2.1% lab 2, P<0.05). The competing risk analysis confirmed the different risk of dropout between the two labs independently of the MELD score, blood group, and preoperative diagnosis. The bias on MELD calculation was considered and bilirubin and creatinine values were “normalized” to Vmax of lab 1 (corrected value=measured value×Vmax lab 1/Vmax lab 2). By comparing receiver operating characteristic curves, the ability of MELD to predict the 6-month dropouts significantly increased from an area under the curve of 0.703 to 0.716 after “normalization” (P<0.05). Conclusions. Normalization of MELD is a correct and good compromise to avoid systematic bias due to different laboratory methods.

Modification of Acid-Base Balance in Cirrhotic Patients Undergoing Liver Resection for Hepatocellular Carcinoma

Objective:To examine modifications of acid-base balance of cirrhotic patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Summary Background Data:Acid-base disorders are frequently observed in cirrhotics; however, modifications during hepatectomy and their impact on prognosis have never been investigated. Methods:Two hundred and two hepatectomies for HCC on cirrhosis were reviewed. Arterial blood samples were collected immediately before and at the end of resection. Preresection and postresection acid-base parameters were compared and related to patient characteristics and postoperative course. The accuracy of acid-base parameters in predicting postoperative liver failure, defined as an impairment of liver function after surgery that led to patient death or required transplantation, was assessed using receiver operating characteristic analysis (ROC). Results:All patients showed a significant reduction in pH, bicarbonate, and base excess at the end of hepatectomy (P < 0.001 in all cases), worsened by intraoperative blood loss (P < 0.010) and preoperative Model for end-stage liver disease score ≥11 (P < 0.010). ROC curve analysis identifies patients with postresection bicarbonate <19.4 mmol/L at high risk for liver failure (50.0%) whereas levels >22.1 mmol/L did not lead to the event (0%; P < 0.001). Postoperative prolongation of prothrombin time and increases in bilirubin, creatinine, and morbidity were also more frequent in patients with lower postresection bicarbonate, resulting in a longer in-hospital stay. Conclusion:In cirrhotic patients, a trend toward a relative acidosis can be expected during surgery and is worsened by the severity of the underlying liver disease and intraoperative blood loss. Postresection bicarbonate level lower than 19.4 mmol/L is an adverse prognostic factor.

Liver and partial atrium transplantation for chronic Budd-Chiari syndrome.

A 22-year-old man was admitted to our hospital for progressive liver failure with ascites, jaundice, and bleeding from esophagogastric varices due to chronic Budd-Chiari syndrome and antiphospholipid syndrome. Nine years before, a transjugular intrahepatic portosystemic shunt (TIPS) had been placed between the right hepatic vein and the portal vein at another hospital. The patient subsequently developed acute obstruction of the hepatic veins followed by the progressive upward extension of the thrombus, requiring positioning of a second TIPS in the vena cava. Because of complete occlusion of both shunts, the patient developed the symptoms of chronic Budd-Chiari syndrome despite collateral circulation. At our hospital, a computed tomography scan confirmed the presence of a thrombus in the vena cava from the renal veins to the right atrium (Fig. 1). The patient was scheduled for liver and partial right atrium transplantation with cardiopulmonary bypass. The abdominal incision started when the ascending aorta, the superior vena cava, and the right femoral vein had been cannulated and normothermic cardiopulmonary bypass had been instituted. This strategy helped us to decompress the portal vein and the collateral circulation and permitted an easier approach to the right atrium. The recipient hepatectomy was performed with the resection of the vena cava from the renal veins to the right atrium and with the opening of the diaphragm through the central fibrous body (Fig. 2). Occlusion of the caval lumen up to the right atrium was confirmed (Fig. 3A,B). The graft was retrieved from a 66-year-old woman considered to be not suitable for heart donation; this allowed us to harvest the liver with the right atrium en bloc (Fig. 4A). In the recipient, the donor atrium was brought into the chest through the diaphragm for the atriumatrium anastomosis (white circle in Fig. 4B). The anastomosis of the inferior vena cava, portal vein, hepatic artery, and bile duct was performed in a standard fashion. During the procedure, hemodynamic parameters remained stable, the cold ischemia time was 7 hours, and 12 units of packed red blood cells were required. The postoperative course was uneventful, and the patient was discharged after 4 weeks. We believe that the key point for the success of this procedure was the planning of liver and partial atrium transplantation with cardiopulmonary bypass. The use of the donor atrium ensured enough tissue to remove the recipient vena cava together with the portion of the atrium affected by the thrombus and easy accomplishment of the atrium-atrium anastomosis. The cardiopulmonary bypass and the partial atrium transplantation due to the atrium being affected by the thrombus, reported in other cases, permitted optimal management of the intraoperative hemodynamic conditions, counterbalancing the need for heparin infusion during extracorporeal circulation.

Successful Liver Transplantation from a 95-Year-Old Donor to a Patient with MELD Score 36 and Delayed Graft Arterialization

A 55-year-old woman with hepatitis C-related cirrhosis, UNOS status 2A and MELD score 36 (1) underwent liver transplantation (LT) on April 2006. The donor was a 95-yearold woman deceased due to cerebral hemorrhage, with stable hemodynamics under 4 lg/kg/min dopamine infusion. The liver function was normal and the graft biopsy basically showed mild periportal fibrosis and macrovescicular steatosis of up to 20% of the hepatocytes (Figure 1). A definitive reticulin staining was made, confirming a mild portal fibrosis.

Associated benign liver tumors in idiopathic granulomatous hepatitis: A case report

We report a unique association of ruptured hepatocellular adenoma, focal nodular hyperplasia and granulomatous hepatitis in a young woman taking oral contraceptives. Diffuse granulomatous hepatitis was found in the liver parenchyma, which was associated with a large granulomatous mass of the left lobe and loco‐regional granulomatous lymphadenitis. We cannot give a full explanation of the situation, which represented a challenge in the diagnosis and in the treatment of this patient.