Kenneth M. Klein

Ischemic preconditioning in deceased donor liver transplantation: A prospective randomized clinical trial of safety and efficacy

Ischemic preconditioning (IPC) has the potential to decrease graft injury and morbidity after liver transplantation. We prospectively investigated the safety and efficacy of 5 minutes of IPC induced by hilar clamping in local deceased donor livers randomized 1 : 1 to standard (STD) recovery (N = 28) or IPC (N = 34). Safety was assessed by measurement of heart rate, blood pressure, and visual inspection of abdominal organs during recovery, and efficacy by recipient aminotransferases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT], both measured in U/L), total bilirubin, and international normalized ratio of prothrombin time (INR) after transplantation. IPC performed soon after laparotomy did not cause hemodynamic instability or visceral congestion. Recipient median AST, median ALT, and mean INR, in STD vs. IPC were as follows: day 1 AST 696 vs. 841 U/L; day 3 AST 183 vs. 183 U/L; day 1 ALT 444 vs. 764 U/L; day 3 ALT 421 vs. 463 U/L; day 1 INR 1.7 ± .4 vs. 2.0 ± .8; and day 3 INR 1.3 ± .2 vs. 1.4 ± .3; all P > .05. No instances of nonfunction occurred. The 6‐month graft and patient survival STD vs. IPC were 82 vs. 91% and median hospital stay was 10 vs. 8 days; both P > .05. In conclusion, deceased donor livers tolerated 5 minutes of hilar clamping well, but IPC did not decrease graft injury. Further trials with longer periods of preconditioning such as 10 minutes are needed. (Liver Transpl 2005;11:196–206.)

The Ischemic Preconditioning Paradox in Deceased Donor Liver Transplantation—Evidence from a Prospective Randomized Single Blind Clinical Trial

While animal studies show that ischemic preconditioning (IPC) is beneficial in liver transplantation (LT), evidence from few smaller clinical trials is conflicting. From October 2003 to July 2006, 101 deceased donors (DD) were randomized to 10 min IPC (n = 50) or No IPC (n = 51). Primary objective was efficacy of IPC to decrease reperfusion (RP) injury. Both groups had similar donor risk index (DRI) (1.54 vs. 1.57). Aminotransferases on days 1 and 2 were significantly greater (p < 0.05) in IPC recipients. In multivariate analyses, IPC had an independent effect only on day 2 aspartate transferase. Prothrombin time, bilirubin and histological injury were similar in both groups. IPC had no significant effect on plasma TNF‐α, IL‐6 and IL‐10 in the donor and TNF‐α and IL‐6 in the recipient. In contrast, IPC recipients had a significant rise in systemic IL‐10 levels after RP (p < 0.05) and had fewer moderate/severe rejections within 30 days (p = 0.09). Hospital stay was similar in both groups. One‐year patient and graft survival in IPC versus No IPC were 88% versus 78% (p = 0.1) and 86 versus 76% (p = 0.25), respectively. IPC increases RP injury after DDLT, an ‘IPC paradox’. Other potential benefits of IPC are limited. IPC may be more effective in combination with other preconditioning regimens.

Recurrent familial prolonged intrahepatic cholestasis of pregnancy associated with chronic liver disease

Four Puerto Rican sisters had recurrent prolonged cholestasis of pregnancy without preexisting or intercurrent hepatic disorders. Available information was reviewed on the course, mechanism, and sequelae of prolonged recurrent cholestasis after 14 pregnancies in the 4 sisters. Etiologic, clinical, laboratory, radiological, and morphological studies of the liver and biliary tract were assessed. Each sister had contraceptive pill-induced pruritus. Prolonged recurrent cholestasis in the eldest sister was followed by cirrhosis and death. The second and third sisters had biopsy evidence of portal triaditis and fibrosis after five and three pregnancies, respectively. Intrahepatic cholestatic cirrhosis was present after three pregnancies in the youngest sister, necessitating an orthotopic liver transplantation; a posttransplantation pregnancy was also associated with prolonged cholestasis. Recurrent prolonged intrahepatic cholestasis of pregnancy was followed by periportal fibrosis or cirrhosis in 4 sisters. This finding suggests that patients with prolonged cholestasis after pregnancy should be followed up for evidence of ongoing liver disease, should be counseled on the potential of recurrence and disease progression in future pregnancies, and should alert family members at risk of possible occurrence of the syndrome.

Intraluminal radiation therapy for biliary tract malignancy--an endoscopic approach.

Carcinomas involving the biliary tract commonly lead to biliary tract obstruction. Most tumors are unresectable at the time of diagnosis, and palliative surgery for biliary decompression is associated with a mortality rate of 10% to 15% and a morbidity rate of 25% to 35%.1,2 Radiation therapy has been used for treating carcinoma involving the biliary tract with variable success.5 More recently, effective palliation has been accomplished by percutaneously or endoscopically placed biliary stents or prostheses. Intraluminal radiation therapy (ILRT) has been used to deliver radiation to the tumor site at several centers. However, to accomplish such intraluminal radiation therapy, an indwelling T-tube or percutaneously placed transhepatic catheter is necessary. We report a new technique for intraluminal hepatobiliary radiation therapy using an endoscopically placed nasobiliary catheter as the port for introducing the radiation source. This technique has a unique advantage of avoiding percutaneous puncture for placement of a catheter into the liver or a laparotomy for T -tube placement.

De Novo Diagnosis of Portopulmonary Hypertension Following Liver Transplantation

Portopulmonary hypertension occurs in 2–8% of liver recipients. However, new onset of pulmonary hypertension following liver transplantation has been reported only once. We report de novo occurrences of portopulmonary hypertension in two liver recipients following successful liver transplantation. Although both patients had recurrent hepatitis C after the transplant, both had excellent clinical graft function. In one patient, upper endoscopy and aortogram showed evidence of persistent venous collaterals in the abdomen. Both patients presented with shortness of breath. Portopulmonary hypertension was diagnosed late, thus contributing directly to their deaths. Autopsy in one patient confirmed the absence of significant liver pathology and failed to demonstrate any source of deep venous thrombosis. This, and our earlier case report, highlights the potential for the occurrence of pulmonary hypertension following liver transplantation. Further studies are needed to determine the scope of the problem and identify patients at risk for this complication.

Troglitazone-induced fulminant hepatitis: report of a case with autopsy findings.

Troglitazone is an insulin-sensitizing agent used to treat type 2 diabetes mellitus. Several cases have been reported of troglitazone-induced hepatic injury; some requiring transplantation, others resulting in death. We here present a case of troglitazone-induced fulminant hepatic necrosis that led to the death of the patient.

FUSE Binding Protein 1 Facilitates Persistent Hepatitis C Virus Replication in Hepatoma Cells by Regulating Tumor Suppressor p53

ABSTRACT Hepatitis C virus (HCV) is a leading cause of chronic hepatitis C (CHC), liver cirrhosis, and hepatocellular carcinoma (HCC). Immunohistochemistry of archived HCC tumors showed abundant FBP1 expression in HCC tumors with the CHC background. Oncomine data analysis of normal versus HCC tumors with the CHC background indicated a 4-fold increase in FBP1 expression with a concomitant 2.5-fold decrease in the expression of p53. We found that FBP1 promotes HCV replication by inhibiting p53 and regulating BCCIP and TCTP, which are positive and negative regulators of p53, respectively. The severe inhibition of HCV replication in FBP1-knockdown Huh7.5 cells was restored to a normal level by downregulation of either p53 or BCCIP. Although p53 in Huh7.5 cells is transcriptionally inactive as a result of Y220C mutation, we found that the activation and DNA binding ability of Y220C p53 were strongly suppressed by FBP1 but significantly activated upon knockdown of FBP1. Transient expression of FBP1 in FBP1 knockdown cells fully restored the control phenotype in which the DNA binding ability of p53 was strongly suppressed. Using electrophoretic mobility shift assay (EMSA) and isothermal titration calorimetry (ITC), we found no significant difference in in vitro target DNA binding affinity of recombinant wild-type p53 and its Y220C mutant p53. However, in the presence of recombinant FBP1, the DNA binding ability of p53 is strongly inhibited. We confirmed that FBP1 downregulates BCCIP, p21, and p53 and upregulates TCTP under radiation-induced stress. Since FBP1 is overexpressed in most HCC tumors with an HCV background, it may have a role in promoting persistent virus infection and tumorigenesis. IMPORTANCE It is our novel finding that FUSE binding protein 1 (FBP1) strongly inhibits the function of tumor suppressor p53 and is an essential host cell factor required for HCV replication. Oncomine data analysis of a large number of samples has revealed that overexpression of FBP1 in most HCC tumors with chronic hepatitis C is significantly linked with the decreased expression level of p53. The most significant finding is that FBP1 not only physically interacts with p53 and interferes with its binding to the target DNA but also functions as a negative regulator of p53 under cellular stress. FBP1 is barely detectable in normal differentiated cells; its overexpression in HCC tumors with the CHC background suggests that FBP1 has an important role in promoting HCV infection and HCC tumors by suppressing p53.

Rat hepatocyte culture model of macrosteatosis: Effect of macrosteatosis induction and reversal on viability and liver-specific function

BACKGROUND & AIMS A common cause of liver donor ineligibility is macrosteatosis. Recovery of such livers could enhance donor availability. Living donor studies have shown diet-induced reduction of macrosteatosis enables transplantation. However, cadaveric liver macrosteatotic reduction must be performed ex vivo within hours. Towards this goal, we investigated the effect of accelerated macrosteatosis reduction on hepatocyte viability and function using a novel system of macrosteatotic hepatocytes. METHODS Hepatocytes isolated from lean Zucker rats were cultured in a collagen sandwich, incubated for 6 days in fatty acid-supplemented medium to induce steatosis, and then switched for 2 days to medium supplemented with lipid metabolism promoting agents. Intracellular lipid droplet size distribution and triglyceride, viability, albumin and urea secretion, and bile canalicular function were measured. RESULTS Fatty acid-supplemented medium induced microsteatosis in 3 days and macrosteatosis in 6 days, the latter evidenced by large lipid droplets dislocating the nucleus to the cell periphery. Macrosteatosis significantly impaired all functions tested. Macrosteatosis decreased upon returning hepatocytes to standard medium, and the rate of decrease was 4-fold faster with supplemented agents, yielding 80% reduction in 2 days. Viability of macrosteatosis reduced hepatocytes was similar to control lean cells. Accelerated macrosteatotic reduction led to faster recovery of urea secretion and bile canalicular function, but not of albumin secretion. CONCLUSIONS Macrosteatosis reversibly decreases hepatocyte function and supplementary agents accelerate macrosteatosis reduction and some functional restoration with no effect on viability. This in vitro model may be useful to screen agents for macrosteatotic reduction in livers before transplantation.

Combination effect of carbaryl and malathion in rats

Pesticides remain in the environment for a varying length of time. These residues present a chronic hazard to man and animals consuming treated parts or contaminated drinking water. Carbamates and organophosphates were detected in well water, green peppers, and corn from areas in New Jersey. Hepatotoxicity by pesticides, especially carbamates and organophosphates, are of growing concern. Doses of 1–50 mg/kg of carbaryl and/or malathion were administered to Sprague-Dawley female rats as a single treatment, as well as daily treatments for a period of 21 days. Serum levels were monitored for serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvate transaminase (SGPT), glutamic dehydrogenase (GDH), β-glucuronidase (β-glu), leucine aminopeptidase (LAP) and glutathione (GSH). Liver β-glu and GSH levels were monitored. Serum β-glu levels showed a significant increase one hr after administration of 10 mg/kg carbaryl or 10/10 mg/kg carbaryl/malathion with both single and multiple administrations. However, the increase with the single administration was 20-fold greater compared to the multiple administrations. Malathion doses as high as 50 mg/kg had no effect on β-glu activity. Treatment with 50 mg/kg carbaryl or 50/50 mg/kg carbaryl/malathion for three weeks produced a 40% decrease in liver β-glu content. Blood GSH content increased significantly after multiple treatments with the high combination. Daily exposure to concentrations of 50 mg/kg carbaryl and/or malathion for 21 days produced a 20% decrease in hepatic GSH content. Histopathology revealed no necrosis after three weeks of treatment with these pesticides individually or in combination.

Cellular and molecular mechanisms in wound healing: selected concepts.

Abstract The interactions among cells, structural and other proteins, and large and small molecules in the dermis is an extremely complex, and largely unknown subject in normal skin, so that these interactions in wounded skin are incapable of complete comprehension at present. The problem is compounded by the further reaction and interaction of formed structures within the dermis, such as blood and lymphatic vessels and nerves of all types, and adnexal structures, as well as interactions with the epidermis, which are separately reviewed in the following chapter. In spite of all of this, there are several areas in which research has provided rather extensive insight into the wound healing process. These areas will now be reviewed. A separate review has been provided in this volume of the results obtained using in vitro systems for studies of the wound healing process (Chapter 6). Wound healing has been traditionally divided into three phases: (1) the inflammatory phase, also known as the exudative, lag, or substrate phase; (2) the fibroblastic phase, also known as the connective tissue or proliferative phase; and (3) the remodeling phase, also known as the resorptive or differentiating phase. Although these phases are somewhat arbitrary, we will use them to organize our approach to the problem, dividing our discussion into the inflammatory phase—to which we shall give emphasis—and later developments. Various aspects of the phases of wound healing overlap extensively.