K Weigand

Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304).

Objective:Acute cholecystitis is a common disease, and laparoscopic surgery is the standard of care. Background:Optimal timing of surgery for acute cholecystitis remains controversial: either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics. Methods:The ACDC (“Acute Cholecystitis—early laparoscopic surgery versus antibiotic therapy and Delayed elective Cholecystectomy”) study is a randomized, prospective, open-label, parallel group trial. Patients were randomly assigned to receive immediate surgery within 24 hours of hospital admission (group ILC) or initial antibiotic treatment, followed by delayed laparoscopic cholecystectomy at days 7 to 45 (group DLC). For infection, all patients were treated with moxifloxacin for at least 48 hours. Primary endpoint was occurrence of predefined relevant morbidity within 75 days. Secondary endpoints were as follows: (1) 75-day morbidity using a scoring system; (2) conversion rate; (3) change of antibiotic therapy; (4) mortality; (5) costs; and (6) length of hospital stay. Results:Morbidity rate was significantly lower in group ILC (304 patients) than in group DLC (314 patients): 11.8% versus 34.4%. Conversion rate to open surgery and mortality did not differ significantly between groups. Mean length of hospital stay (5.4 days vs 10.0 days; P < 0.001) and total hospital costs (&OV0556;2919 vs &OV0556;4262; P < 0.001) were significantly lower in group ILC. Conclusions:In this large, randomized trial, laparoscopic cholecystectomy within 24 hours of hospital admission was shown to be superior to the conservative approach concerning morbidity and costs. Therefore, we believe that immediate laparoscopic cholecystectomy should become therapy of choice for acute cholecystitis in operable patients. (NCT00447304)

Ischemia/Reperfusion Injury in Liver Surgery and Transplantation: Pathophysiology

Liver ischemia/reperfusion (IR) injury is caused by a heavily toothed network of interactions of cells of the immune system, cytokine production, and reduced microcirculatory blood flow in the liver. These complex networks are further elaborated by multiple intracellular pathways activated by cytokines, chemokines, and danger-associated molecular patterns. Furthermore, intracellular ionic disturbances and especially mitochondrial disorders play an important role leading to apoptosis and necrosis of hepatocytes in IR injury. Overall, enhanced production of reactive oxygen species, found very early in IR injury, plays an important role in liver tissue damage at several points within these complex networks. Many contributors to IR injury are only incompletely understood so far. This paper tempts to give an overview of the different mechanisms involved in the formation of IR injury. Only by further elucidation of these complex mechanisms IR injury can be understood and possible therapeutic strategies can be improved or be developed.

Assembly and export determine the intracellular distribution of hepatitis B virus core protein subunits

Little is known about the parameters and factors that determine the intracellular distribution of the hepatitis B virus core protein (HBc). In order to study HBc in living cells, HBc was tagged with green fluorescent protein (GFP). Being assembly-incompetent, the GFP-fusion protein was distributed equally throughout the cell. Mutational inactivation of known serine-phosphorylation sites within the C-terminal region led to predominantly intranuclear localization. Phosphorylation of these targets, presumably by an SR domain protein kinase, resulted in a predominantly cytoplasmic localization, which suggests active cytoplasmic export or retention. The phosphoserine itself, and not its negative charge, appears essential for the underlying mechanism. In addition, the arginine-rich, protamine-like domain surrounding these phosphorylation sites does not function as the dominant nuclear-localization signal, as had been assumed previously, because neither deleting nor altering these sequences led to a change in intracellular HBc subunit distribution. Restoring the capability of the fusion protein to form capsids by co-assembly with assembly-competent, sterically uncompromised HBc subunits provided a second assay that gave insight into the effects resulting from capsid formation. Assembly was found to be the dominant factor in the cytoplasmic retention of the GFP-HBc fusion protein. Furthermore, the stability of these empty capsids was influenced by the cell-cycle inhibitor nocodazole. Thus, the intracellular distribution of HBc is dominated by cytoplasmic assembly, which is supported by the active nuclear export of HBc subunits, and modulated during the cell cycle by the instability of capsids.

Acute cholecystitis – early laparoskopic surgery versus antibiotic therapy and delayed elective cholecystectomy: ACDC-study

BackgroundAcute cholecystitis occurs frequently in the elderly and in patients with gall stones. Most cases of severe or recurrent cholecystitis eventually require surgery, usually laparoscopic cholecystectomy in the Western World. It is unclear whether an initial, conservative approach with antibiotic and symptomatic therapy followed by delayed elective surgery would result in better morbidity and outcome than immediate surgery. At present, treatment is generally determined by whether the patient first sees a surgeon or a gastroenterologist. We wish to investigate whether both approaches are equivalent. The primary endpoint is the morbidity until day 75 after inclusion into the study.DesignA multicenter, prospective, randomized non-blinded study to compare treatment outcome, complications and 75-day morbidity in patients with acute cholecystitis randomized to laparoscopic cholecystectomy within 24 hours of symptom onset or antibiotic treatment with moxifloxacin and subsequent elective cholecystectomy. For consistency in both arms moxifloxacin, a fluorquinolone with broad spectrum of activity and high bile concentration is used as antibiotic. Duration: October 2006 – November 2008Organisation/ResponsibilityThe trial was planned and is being conducted and analysed by the Departments of Gastroenterology and General Surgery at the University Hospital of Heidelberg according to the ethical, regulatory and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and the Good Clinical Practice guideline (GCP).Trial RegistrationClinicalTrials.gov NCT00447304

Immune tolerance against HBV can be overcome in HBV transgenic mice by immunization with dendritic cells pulsed by HBVsvp

In chronic Hepatitis B Virus (HBV) infection the function of dendritic cells (DC), T- and B-cells is impaired. DC vaccination is an option to overcome this. DC pulsed in vitro with HBV sub viral particles (HBVsvp) and used to immunize mice can activate HBV directed humoral and cellular immune responses. In the present study we vaccinated HBV transgenic mice as a model for chronic HBV infection and observed humoral and cellular immune responses. In these mice, the lacking immune response against HBV is mainly due to peripheral tolerance. HBVsvp, together with LPS as a co-activating molecule, were used for pulsing and in vitro activation of DC. HBV transgenic mice were injected with pulsed DC two times. Four weeks after DC vaccination humoral and cellular immune responses, viral antigen levels and liver histology were analyzed. DC vaccinated HBV-transgenic mice developed a strong HBV specific antibody and T-cell response after DC vaccination. Neither circulating HBV antigen levels nor viremia, however, were controlled. No liver damage was observed. These results demonstrate that in vitro activation of DC and loading with HBVsvp can overcome tolerance against HBV and reactivate B- and T-cell responses in HBV transgenic mice, but were not sufficient to lead to virus control in these mice. Vaccination using DC, the key players of cellular and humoral immunity, after in vitro reactivation promises to break tolerance against HBV and may help patients with chronic hepatitis B to clear the infection.

Prognostic Value of Standard Parameters as Predictors for Long-Term Renal Replacement Therapy after Liver Transplantation

Chronic kidney disease has become increasingly prevalent after liver transplantation (LTPL) because outcome and survival rates have improved. Chronic kidney insufficiency is most likely associated with increased morbidity and mortality. The challenge is to identify patients who will be in need of long-term renal replacement therapy (RRT) after LTPL. We analyzed 208 liver transplant recipients with respect to mortality, associated laboratory values, underlying liver disease, immunosuppressive protocol and the need for RRT. Long-term RRT was defined by the need for RRT 3 months after LTPL. Altogether, 5.8% of the surviving study patients remained in need of RRT 3 months after LTPL. All of these patients continued to need RRT throughout the study period (2 years). The need for RRT significantly increased the 2-year mortality rate 4.3-fold, from 15.4 to 66.7% (p = 0.004). Comparison of laboratory and clinical parameters at the time of LTPL revealed no significant differences for creatinine, albumin and MDRD between patients undergoing hemodialysis 3 months after LTPL and patients without RRT. Comparing mean urea, a difference was observed. However, multivariate regression analyses using easy-to-observe demographic or laboratory parameters failed to generate a model to predict the need for RRT after LTPL. In addition, a comparison of underlying liver disease and immunosuppressive regimes identified no significant differences. Taken together, patients who were on hemodialysis 3 months after LTPL were also on hemodialysis 2 years after LTPL or until death. RRT 3 months after LTPL may predict the risk for chronic renal insufficiency and is associated with significantly increased mortality.

Hepatitis E Seroprevalence and Genotyping in a Cohort of Wild Boars in Southern Germany and Eastern Alsace

In the last few years it has been realized that the hepatitis E virus (HEV) is endemic in most industrialized countries and that it is a zoonotic disease. Potential reservoirs for HEV have been identified to be wild boars and deers, but HEV has also been found in domestic pigs and other animals. Due to the probable spread of the virus via contaminated food or contact to infected animals, HEV antibodies are present in more than 16% of the German adult population and rates are increasing with age. We collected blood from 104 wild boars in southern Germany and the border region of Alsace. We found an anti-HEV seroprevalence of 11.5% in our cohort, using ELISA. Furthermore, we observed active infection in 3.85% of the animals by positive HEV PCR in the sera of the boars. In our cohort, no regional differences of seroprevalence or active infection were seen. Sequencing revealed rather close homology of some detected HEV sequences to genotypes isolated from patients in Germany. Hence wild boars are a potential source of HEV infection in Middle Europe and the rate of infectious animals is quite high.

Akutes Leberversagen durch Hitzschlag – Unterschätztes Risiko oder Rarität? Zwei Fallberichte

Wahrend kardiorespiratorische Symptome ein bekanntes Problem bei Patienten mit Hitzschlag darstellen ist das akute Leberversagen ein kaum beschriebenes Phanomen. Wir berichten hier uber zwei Patienten mit akutem Leberversagen durch Hyperthermie. Wahrend der erste Patient im Rahmen eines Halbmarathons kollabierte, erlitt der zweite einen klassischen Hitzschlag im uberhitzten Buro. Beide wurden mit deutlich erhohten Transaminasen und einer verlangerten International Normalisierten Ratio (INR) aufgenommen. Trotz weit reichender Diagnostik konnte auser der physischen Erschopfung keine Ursache fur das Leberversagen identifiziert werden. Als mogliche Ursache wird neben einem durch Hyperthermie modifizierten Immunsystem eine Storung des intrahepatischen Blutflusses diskutiert. Durch engmaschige Uberwachung und standardisierte symptomatische Therapie konnten die Gefahren eines akuten Leberversagens gemildert und eine Lebertransplantation, als letzte Therapieoption, verhindert werden. Literatur: [1] Lepape A, Sarron C, Grozel JM, Perdrix JP, Banssillon V A severe form of heat stroke in a long-distance runner. Ann Fr Anesth Reanim 1986;5(4):441-4 [2] Bruguera M Liver and sports. Med Clin (Barc) 2004 Jan 31;122(3):111-2 [3] Yeo TP Heat stroke: a comprehensive review. AACN Clin Issues 2004 Apr-Jun;15(2):280-93 [4] Varghese GM, John G, Thomas K, Abraham OC, Mathai D Predictors of multi-organ dysfunction in heatstroke. Emerg Med J. 2005 Mar;22(3):185-7 [5] Scobie BA Gastrointestinal emergencies with marathon-type running: omental infarction with pancreatitis amd liver failure with portal vein thrombosis. N Z Med J. 1998 Jun 12;111(1067):211-2 [6] Irie H, Mori W Fatal hepatic necrosis after shock. Acta Pathol Jpn 1986 Mar;36(3):363-74 [7] Takahashi K, Chin K, Ogawa K, Kasahara M, Sakaguchi T, Hasegawa S, Sumi K, Nakamura T, Tamaki A, Mishima M, Nakamura T, Tanaka K Living donor liver transplantation with non-invasive ventilation for exertional heat stroke and severe rhabdomyolysis. Liver Transpl 2005 May;11(5):570-2 [8] Lambert GP Role of gastrointestinal permeability in exertional heatstroke. Exerc Sport Sci Rev 2004 Oct;32(4):185-90 [9] Chen SH, Chang FM, Tsai YC, Huang KF, Lin MT Resuscitation from experimental heatstroke by transplantation of human umbilical cord blood cells. Crit Care Med 2005 Jun;33(6):1458-9