Moritz Kleine

Incidence and long‐term risk of de novo malignancies after liver transplantation with implications for prevention and detection

The goal of this study was the characterization of long‐term cancer risks after liver transplantation (LT) with implications for prevention and detection. Site‐specific cancer incidence rates and characteristics were compared retrospectively for 2000 LT patients from a single institution (January 1, 1983 to December 31, 2010) and the general German population with standardized incidence ratios (SIRs); the total follow‐up at December 31, 2011 was 14,490 person‐years. The cancer incidence rates for the LT recipients were almost twice as high as those for the age‐ and sex‐matched general population (SIR = 1.94, 95% CI = 1.63‐2.31). Significantly increased SIRs were observed for vulvar carcinoma (SIR = 23.80), posttransplant lymphoproliferative disorder/non‐Hodgkin lymphoma (SIR = 10.95), renal cell carcinoma (SIR = 2.65), lung cancer (SIR = 1.85), and colorectal cancer (SIR = 1.41). The mean time between transplantation and diagnosis was 6.8 years. The mean age at the time of diagnosis was significantly lower for the cohort versus the general population with similar malignancies [50 years (both sexes) versus 69 and 68 years (males and females), P ≤ 0.006]. Tumors were diagnosed at more advanced stages, and there was a trend of higher grading, which suggested more aggressive tumor growth. Tumor treatment was performed according to accepted guidelines. Surprisingly, 5‐year survival was slightly better in the study cohort versus the general population for renal cell carcinoma, lung cancer, colorectal cancer, and thyroid cancer. Long‐term immunosuppression with different protocols did not lead to significantly different SIRs, although patients treated with mycophenolate mofetil had the lowest SIR for de novo cancers (1.65, 95% CI = 1.2‐2.4). Alcoholic liver disease (SIR = 2.30) and primary sclerosing cholangitis (SIR = 3.40) as indications for LT were associated with an increased risk of de novo malignancies. In conclusion, risk‐adapted cancer surveillance is proposed. Tumor treatment performed according to accepted guidelines appears adequate. Mycophenolate may lead to lower long‐term risks for de novo cancers. Liver Transpl 19:1252–1261, 2013.

The Donor-Risk-Index, ECD-Score and D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable sensitivity and specificity

BACKGROUND Expansion of the donor pool by the use of grafts with extended donor criteria reduces waiting list mortality with an increased risk for graft and patient survival after liver transplantation. This study investigates the ability of the Donor-Risk-Index (DRI), the Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-score to predict early outcome after liver transplantation. MATERIAL/METHODS 291 consecutive adult liver transplants (01.01.2007-31.12.2010) were analysed in a single centre study with ongoing data collection. Primary study endpoints were 30-day mortality, 3-month mortality, 3-month patient and graft survival and the necessity of acute retransplantation within 30 days. For the primary study endpoints ROC-curve analysis was performed to calculate the sensitivity, specificity, and overall model correctness of the Donor-Risk-Index (DRI), Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-Score as predictive models. Cut-off values were selected with the best Youden index. RESULTS ROC-curve analysis showed areas under the curve (AUROCs) <0.7 for the DRI, the ECD-Score and the D-MELD-Score as models for the prediction of 30-day mortality, 3-month mortality, 3-month patient survival, 3-month graft survival as well as the necessity of acute retransplantation within 30 days after transplantation with unacceptable low levels of overall model correctness (<62%) and specificity (<56%). CONCLUSIONS The DRI, the ECD-Score and the D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable overall model correctness in a current European transplant setting.

A multicentre, randomized clinical trial comparing the Veriset™ haemostatic patch with fibrin sealant for the management of bleeding during hepatic surgery

BACKGROUND Bleeding during hepatic surgery is associated with prolonged hospitalization and increased morbidity and mortality. The Veriset™ haemostatic patch is a topical haemostat comprised of an absorbable backing made of oxidized cellulose and self-adhesive hydrogel components. It is designed to achieve haemostasis quickly and adhere to tissues without fixation. METHODS A prospective, randomized, multicentre, single-blinded study (n = 50) was performed to compare the use of a Veriset™ haemostatic patch with a fibrin sealant patch (TachoSil(®) ) (control) in the management of diffuse bleeding after hepatic surgery. Patients were randomized following the confirmation of diffuse bleeding requiring the use of a topical haemostat. Time to haemostasis was assessed at preset intervals until haemostasis was achieved. RESULTS Both groups were similar in comorbidities and procedural techniques. The median time to haemostasis in the group using the Veriset™ haemostatic patch was 1.0 min compared with 3.0 min in the control group (P < 0.001; 3-min minimum application time for the control patch). This result was independent of bleeding severity and surface area. Both products had similar safety profiles and no statistical differences were observed in the occurrence of adverse or device-related events. CONCLUSIONS Regardless of bleeding severity or surface area, the Veriset™ haemostatic patch achieved haemostasis in this setting significantly faster than the control device in patients undergoing hepatic resection. It was safe and easy to handle in open hepatic surgery.

Inhibition of Autophagic Flux by Salinomycin Results in Anti-Cancer Effect in Hepatocellular Carcinoma Cells

Salinomycin raised hope to be effective in anti-cancer therapies due to its capability to overcome apoptosis-resistance in several types of cancer cells. Recently, its effectiveness against human hepatocellular carcinoma (HCC) cells both in vitro and in vivo was demonstrated. However, the mechanism of action remained unclear. Latest studies implicated interference with the degradation pathway of autophagy. This study aimed to determine the impact of Salinomycin on HCC-autophagy and whether primary human hepatocytes (PHH) likewise are affected. Following exposure of HCC cell lines HepG2 and Huh7 to varying concentrations of Salinomycin (0–10 µM), comprehensive analysis of autophagic activity using western-blotting and flow-cytometry was performed. Drug effects were analyzed in the settings of autophagy stimulation by starvation or PP242-treatment and correlated with cell viability, proliferation, apoptosis induction, mitochondrial mass accumulation and reactive oxygen species (ROS) formation. Impact on apoptosis induction and cell function of PHH was analyzed. Constitutive and stimulated autophagic activities both were effectively suppressed in HCC by Salinomycin. This inhibition was associated with dysfunctional mitochondria accumulation, increased apoptosis and decreased proliferation and cell viability. Effects of Salinomycin were dose and time dependent and could readily be replicated by pharmacological and genetic inhibition of HCC-autophagy alone. Salinomycin exposure to PHH resulted in transient impairment of synthesis function and cell viability without apoptosis induction. In conclusion, our data suggest that Salinomycin suppresses late stages of HCC-autophagy, leading to impaired recycling and accumulation of dysfunctional mitochondria with increased ROS-production all of which are associated with induction of apoptosis.

Explanted Diseased Livers – A Possible Source of Metabolic Competent Primary Human Hepatocytes

Being an integral part of basic, translational and clinical research, the demand for primary human hepatocytes (PHH) is continuously growing while the availability of tissue resection material for the isolation of metabolically competent PHH remains limited. To overcome current shortcomings, this study evaluated the use of explanted diseased organs from liver transplantation patients as a potential source of PHH. Therefore, PHH were isolated from resected surgical specimens (Rx-group; n = 60) and explanted diseased livers obtained from graft recipients with low labMELD-score (Ex-group; n = 5). Using established protocols PHH were subsequently cultured for a period of 7 days. The viability and metabolic competence of cultured PHH was assessed by the following parameters: morphology and cell count (CyQuant assay), albumin synthesis, urea production, AST-leakage, and phase I and II metabolism. Both groups were compared in terms of cell yield and metabolic function, and results were correlated with clinical parameters of tissue donors. Notably, cellular yields and viabilities were comparable between the Rx- and Ex-group and were 5.3±0.5 and 2.9±0.7×106 cells/g liver tissue with 84.3±1.3 and 76.0±8.6% viability, respectively. Moreover, PHH isolated from the Rx- or Ex-group did not differ in regards to loss of cell number in culture, albumin synthesis, urea production, AST-leakage, and phase I and II metabolism (measured by the 7-ethoxycoumarin-O-deethylase and uracil-5′-diphosphate-glucuronyltransferase activity). Likewise, basal transcript expressions of the CYP monooxygenases 1A1, 2C8 and 3A4 were comparable as was their induction when treated with a cocktail that consisted of 3-methylcholantren, rifampicin and phenobarbital, with increased expression of CYP 1A1 and 3A4 mRNA while transcript expression of CYP 2C8 was only marginally changed. In conclusion, the use of explanted diseased livers obtained from recipients with low labMELD-score might represent a valuable source of metabolically competent PHH which are comparable in viability and function to cells obtained from specimens following partial liver resection.

Clinical versatility of porcine hepatocytes in the light of interspecies differences in cytochrome P450 regulation and expression

Abstract:  Background and aims:  In fulminant hepatic failure, the clinical use of bioartifical liver support with porcine hepatocytes is the subject of a controversial debate. Cytochrome P450 (CYP) metabolic functions have relevant implications for drug metabolism and detoxification. In this study, we investigate interspecies differences in CYP gene expression between human and porcine primary hepatocytes and the impact of interleukin 6 (IL‐6) and tumor necrosis factor alpha (TNF‐α) exposition mimicking cytokine release in fulminant hepatic failure.

Surgical treatment for intrahepatic cholangiocarcinoma in Europe : a single center experience

Intrahepatic cholangiocarcinoma is the second most common primary liver tumor. The aim of this study was to analyze retrospectively the outcome of surgical treatment and prognostic factors. Clinical, histopathological and treatment data of 221 patients treated from 1995 to 2010 at our institution were investigated. Univariate and multivariate analysis of the patients data was performed. Patients after R0 and R1 resection presented an overall survival of 67% and 54.5% after 1 year and 40% and 36.4% after 3 years, respectively. The survival of patients without resection of the tumor was dismal with 26% and 3.4% after 1 and 3 years, respectively. Survival after resection was not statistically different in cases with R0 versus R1 resection (P = 0.639, log rank). Univariate Cox regression revealed that higher T stages are a significant hazard for survival (P = 0.048, hazard ratio (HR): 1.211, 95% confidence interval (CI): 1.002–2.465). Patients with tumor recurrence had a significantly inferior long‐term survival when compared to patients without recurrence (P < 0.001, log rank). Presence of lymph node metastasis (N1) was an independent prognostic factor for survival after resection in risk‐adjusted multivariate Cox regression (P < 0.001, HR: 2.577, 95% CI: 1.742–3.813). Adjuvant chemotherapy did not improve patient survival significantly (P = 0.550, log rank). Surgical resection is still the best treatment option for intrahepatic cholangiocarcinoma regarding the patients long‐term survival. R0 and R1 resection enable both better survival rates when compared to surgical exploration without resection. T status, N status, and tumor recurrence seem to be the most important prognostic factors after resection.

Risk Factors for Short- and Long-Term Mortality in Liver Transplant Recipients with MELD Score ≥30

BACKGROUND After introduction of MELD-based allocation in Germany, decreased waiting list mortality and increased mortality after transplantation have been reported. MATERIAL AND METHODS This study compares relevant outcome parameters in patients with high MELD ≥30 versus lower MELD scores in a retrospective analysis including 454 consecutively performed liver transplantations in adults (age >16 years) at Hannover Medical School between 01/01/2007 and 31/12/2012 and a follow-up until 31/12/2013. Multivariable risk-adjusted models were applied to identify independent risk factors for 90-day and long-term mortality. RESULTS MELD score ≥30 (n=117; 26.1%) was an independent risk factor for 90-day mortality (p=0.004, odds ratio: 3.045, 95% CI 1.439-6.498) and long-term mortality (p=0.016, hazard ratio: 1.620, 95% CI 1.095-2.396) and was associated with significantly longer hospital and intensive care unit stays (p<0.001), and death occurred in more cases earlier after transplantation (90-day mortality 21.6% vs. 13.0%; p=0.029). Portal vein thrombosis at transplantation was significantly associated with 90-day mortality after transplantation in patients with MELD scores ≥30 (p=0.041), but this was not the case for patients with MELD scores <30, although portal vein thrombosis was equally frequent in individuals of both groups (3.0% vs. 3.4%, p=0.824). CONCLUSIONS Results of this study suggest that liver transplant recipients with portal vein thrombosis at transplantation should be transplanted before reaching a MELD score ≥30.

Value of the preoperative SOFT-score, P-SOFT-score, SALT-score and labMELD-score for the prediction of short-term patient and graft survival of high-risk liver transplant recipients with a pre-transplant labMELD-score ≥30

BACKGROUND The SOFT-score, P-SOFT-score, SALT-score and labMELD-score have been applied for the prediction of survival of liver transplant recipients after transplantation. We analysed the value of these scores for the prediction of short-term survival in high-risk liver transplant recipients with a labMELD-score ≥30. MATERIAL/METHODS Retrospective single-centre analysis including 88 consecutive liver transplants in adults between 01.01.2007 and 31.12.2010 with a pretransplant labMELD-score ≥30 and follow-up until the 31.12.2011. Combined and living-related liver transplants were excluded. ROC-curve analysis was used to calculate sensitivity, specificity and overall model correctness of prognostic models. RESULTS The P-SOFT-score demonstrated a significant influence on 1-year patient survival (p=0.045, Mann-Whitney-U test). Multivariate Cox regression analysis showed a significant influence of the P-SOFT-score on patient (p=0.013; Exp(B)=1.050; 95%CI: 1.010-1.091) and on graft survival (p=0.023; Exp(B)=1.042; 95%CI: 1.006-1.080). ROC-curve analysis showed areas under the curve (AUROCs) <0.5 for the SOFT-score, P-SOFT-score, SALT-score and the labMELD-score ≥30 for the prediction of 3-month patient and graft survival as well as 1-year patient and graft survival. CONCLUSIONS Our results imply that the SOFT-score, P-SOFT-score, SALT-score and labMELD-score ≥30 all have a sensitivity, specificity and overall model correctness that is unable to discriminate short-term survivors from non-survivors in a collective of high-risk liver transplant recipients sufficiently in order to guide clinical decision making in the current German transplant situation with decreasing numbers of deceased liver donors, decreasing donor organ quality and increasingly sick transplant candidates.

Adult Kasabach-Merritt Syndrome due to Hepatic Giant Hemangioma

Cavernous hemangiomas are the most common benign tumors of the liver. They can reach enormous sizes and cause various complications. Kasabach-Merritt syndrome is a rare but serious complication characterized by consumptive coagulopathy caused by the hemangioma; mortality rate ranges between 10 and 37%. More than 80% of cases occur within the first year of life. Goals of the treatment are to control the coagulopathyand thrombocytopenia as well as to eradicate the hemangioma. Different nonsurgical treatment regimens are performed, includingsystemic corticosteroids, irradiation and various chemicals. Surgery should be limited to symptomatic or complicated cases. Although difficult, resection of the tumor is usually curative. Here we present a 44-year-old woman with giant hepatic hemangioma causing Kasabach-Merritt syndrome managed by enucleation.