Thrombotic microangiopathy after living-donor liver transplantation.

Thrombotic microangiopathy (TMA) is an infrequent but severe life-threatening disorder in solid organ transplant recipients. Few studies of TMA in living donor liver transplant (LDLT) recipients, however, have been reported. We investigated the clinical characteristics and prognostic factors of TMA after LDLT. Among 393 adult LDLT recipients, 30 patients (7.6%) were identified to have TMA. The 1-, 3- and 5-year survival rates of these patients were lower (60.6%, 52.5% and 47.7%, respectively) than those of patients without TMA (93.0%, 89.0% and 87.3%, respectively). Multivariate analysis confirmed that reduced administration of fresh frozen plasma and sensitization against HLA are closely related with TMA (odds ratio [OR]: 2.6 and 16.1, respectively). However, a review of the cases revealed that individual responses to treatment varied considerably and the main etiologies were difficult to determine. A comparison of the clinical factors suggested that late onset (>30 days), poor response to treatment and delayed diagnosis and/or treatment are associated with a poor outcome. Because the prevention of TMA in LDLT patients is difficult, early diagnosis and initiation of intensive therapies may be crucial to improve the prognosis.

Autocrine stimulatory mechanism by transforming growth factor beta in human hepatocellular carcinoma.

The serum concentration of transforming growth factor beta (TGF-beta) is elevated as tumors progress in hepatocellular carcinoma (HCC) patients. In this study, we examined whether modulation of tumor-derived TGF-beta signal transduction contributes to malignant progression. We investigated the production of TGF-beta1, the biological effects of TGF-beta and neutralizing antibody on HCC cells, activation of Smad 2, Smad 3, and Smad 4, induction of antagonistic Smads (Smad 6 and Smad 7), and promoter activities of two target genes, plasminogen activator inhibitor type 1 (PAI-1) and p15INK4B. In human cell lines HCC-M and HCC-T, TGF-beta accelerates their proliferation. Smad 2 was activated constitutively by an autocrine mechanism, because in the absence of exogenous TGF-beta, a high level of Smad 2 phosphorylation, induction of PAI-1 transcripts, and nuclear localization of Smad 2 were observed. This constitutive activation of Smad 2 was, at least in part, attributable to the lack of induction of antagonistic Smads by TGF-beta. However, Smads activated by tumor-derived TGF-beta constantly suppressed p151NK4B expression. In addition, 3 of 10 human HCC tissues showed nuclear localization of Smad 2 and low mRNA levels of p15INK4B and antagonistic Smads but a high level of PAI-1. Our observations suggest that this constant suppression of the p15INK4B gene could be involved in the malignant progression of HCC.

Clinicopathologic significance of protein induced vitamin K absence or antagonist II and alpha-fetoprotein in hepatocellular carcinoma.

Protein induced vitamin K absence or antagonist II (PIVKA-II) and alpha-fetoprotein (AFP) have been considered useful serum markers of hepatocellular carcinoma (HCC). In this study, we examined the clinicopathologic significance of these tumour markers in patients with HCCs by measuring their serum levels and performing immunohistochemistry. We studied 349 Japanese patients with HCCs. Their serum PIVKA-II and AFP levels were determined by enzyme immunoassay before treatment. We examined the correlations between serum PIVKA-II and AFP levels and tumour size, presence of satellite nodules, histologic HCC grade, and concomitant liver diseases and subjected tumour tissues to immunohistochemical staining to detect PIVKA-II and AFP expression. The serum PIVKA-II levels of patients with poorly differentiated HCCs were significantly higher than those of patients with well and moderately differentiated HCCs (p<0.05) and they were higher in HCC patients with than without satellite nodules. The serum AFP levels were influenced significantly by concomitant liver diseases, but not by the other factors. Immunohistochemical staining revealed the PIVKA-II expression levels of poorly differentiated HCCs were higher than those of well and moderately differentiated HCCs (p<0.05). Some HCC cells were PIVKA-II-positive, others were AFP-positive, and some expressed both. The serum PIVKA-II concentration was a better indicator of HCC than AFP, as it was not influenced by concomitant liver diseases. The presence of PIVKA-II in serum correlated with the presence of satellite nodules and the histologic HCC grade, a result concordant with the immunohistochemical findings.

Percutaneous injection of a low-concentration alkaline solution targeting hepatocellular carcinoma.

We developed a percutaneous low-concentration alkali injection therapy (PLAIT) targeting hepatocellular carcinoma (HCC), and compared the necrotic areas in the livers of rats that had received PLAIT [an alkaline solution of sodium hydroxide (NaOH)] with those that had received percutaneous ethanol injection therapy (PEIT) and percutaneous acetic acid injection therapy (PAIT). The necrotic area increased with increasing concentrations of NaOH solution. The survival rate of rats was 100% up to a concentration of 4 N; however, the rate dropped below 80% with concentrations over 5 N. Also, at a concentration of 2 N, the necrotic area increased with increasing quantities from 0.01 ml to 0.1 ml. PLAIT using 0.05 ml of 2 N NaOH was 1.56 times more effective than PEIT using 0.05 ml of 99.5% ethanol, and 63.33% less effective than PAIT using 0.05 ml of 50% acetic acid. However, the survival rate after PAIT was 50%, while that after PLAIT was 100%. Histopathological observation of normal rat livers after injection of 2 N NaOH at a volume of 0.05 ml showed that the tissue necrosis spread radially from the site immediately after injection by PLAIT, but necroses were not found in other organs. We conclude that PLAIT has promise as a new form of local therapy for HCC.

Usefulness of Lens culinaris agglutinin A-reactive fraction of alpha-fetoprotein (AFP-L3) as a marker of distant metastasis from hepatocellular carcinoma.

The objective of this study was to clarify the relationship between the serum level of the Lens culinaris agglutinin A-reactive fraction of alpha-fetoprotein (AFP-L3) and the clinical features including sex, age, Child's classification, virus markers, tumour size, tumour stage, distant metastasis, histopathologic findings, portal thrombus and outcome of hepatocellular carcinoma (HCC). We measured the AFP-L3 levels in 170 HCC cases at the time of diagnosis using lectin-affinity electrophoresis followed by antibody-affinity blotting. The patients were divided into two groups, those who were AFP-L3 positive (n=56; AFP-L3 >/=15% relative to the total alpha-fetoprotein (AFP) concentration) and those who were AFP-L3 negative (n=114; AFP-L3 <15%). Then we examined the association between the serum AFP-L3 level and the clinical features of HCC. No significant differences were found in age, sex, and virus markers between the AFP-L3-positive and -negative groups. However, patients in the positive group had worse liver function and larger tumours compared to the negative group. They also had more advanced cancer with poor tumour histology compared to the negative group. Distant metastasis was diagnosed significantly more often in the positive group than that in the negative group. There was no significant correlation between the AFP-L3 level and portal thrombus. Although the follow-up period was brief the prognosis for the positive group clearly was poor. These results suggest that AFP-L3 is a useful indicator of distant metastasis and a poor prognosis for HCC.

Change of temperature in mouse tumour tissue immersed in a water bath at 44 degrees C.

We investigated the change in temperature in tumour and normal tissues of mice when immersed in a water bath at 44.0 degrees C as part of a series of studies of hyperthermia. The right hind legs of the mice bearing the experimental tumour sarcoma 180 were immersed in the water bath, and measurements were performed using the multi-thermocouple thermosensor from a radiofrequency (RF) generator every 24 sec with a precision of 0.1 degrees C. The temperature in all tumour tissues exceeded 43.0 degrees C only at 1 min 24 sec after immersion of the limbs. The rise in temperature then reached a plateau phase, and was maintained around 44.0 degrees C. However, we found that the temperature of the normal tissue was about 0.6 degrees C lower than that of the tumour tissue or the tissue around the tumour at the plateau phase.

Preliminary investigation of resistance of plasmid DNA to neon ion beams using transformation into recipient Escherichia coli cells.

The sensitivity of the vector plasmid pKmK8 DNA to neon ion beams was studied under dry conditions. This plasmid contains the cloning vector pJKKmf(-) and a 3.6 kbp segment encoding the Escherichia coli crp gene that can be used in mutagenesis analysis. The survival curve of the plasmid indicated an exponential profile and a D10 value of about 16 kGy in the E. coli wild-type strain for DNA repair capability. This was similar to the D10 value for the shuttle vector plasmid pZ189 DNA. Therefore, it was assumed that the excision repair system in E. coli was not effective for repairing DNA lesions induced by irradiation with heavy ion beams.

Rapid progression of hepatocellular carcinoma after transcatheter arterial chemoembolization and percutaneous radiofrequency ablation in the primary tumour region.

We report one patient who showed rapid progression of hepatocellular carcinoma (HCC) after undergoing transcatheter arterial chemoembolization (TACE) and percutaneous radiofrequency ablation (PRFA) for a small HCC measuring 2.5 cm in diameter. Enhanced magnetic resonance imaging (MRI) following treatment showed complete tumour necrosis and did not reveal the presence of a tumour around the treated area. Furthermore, the serum alpha-fetoprotein (AFP) level decreased at the completion of therapy. However, the HCC advanced in a very short time. Numerous tumours around the treated area were observed on enhanced computed tomography (CT) 50 days after PRFA. It is strongly suspected that the tumour was disseminated through the portal system because of the presence pattern of tumours. We believe this to be the first case illustrating a hepatic cancer that progressed rapidly following TACE and PRFA.

Hepatic infarction following percutaneous ethanol injection therapy for hepatocellular carcinoma.

We report on two patients who developed hepatic infarction after undergoing percutaneous ethanol injection therapy (PEIT) for hepatocellular carcinoma (HCC). In both cases, liver function parameters deteriorated immediately after the ethanol injection, and enhanced computed tomography images showed a wedge-shaped avascular low-density area due to hepatic infarction. In one patient, PEIT was performed for a nodule treated with transcatheter arterial infusion (TAI) using a suspension of styrene maleic acid neocarzinostatin (SMANCS) 4 weeks before. In the other patient, TAI with SMANCS had been carried out 14 months previously for a different nodule in the same segment where the nodule treated with PEIT was located. When PEIT is used for patients with HCC who have previously undergone TAI, especially with SMANCS, PEIT may induce hepatic infarction.

Peristaltic squeezing of sperm bundles at the late stage of spermatogenesis in the silkworm, Bombyx mori.

Silkworm (Lepidoptera) males produce dimorphic sperm, nucleate eupyrene sperm, and anucleate apyrene sperm. The eupyrene sperm is the ordinary sperm fertilizing eggs, while the function of the apyrene sperm, which are about four times as numerous as the eupyrene sperm, is still uncertain. We found the peristaltic phenomenon at the very late stage of spermatogenesis. Peristalsis occurs in both eupyrene and apyrene sperm bundles. Through peristaltic action, cytoplasm of the eupyrene sperm and both cytoplasm and nuclei of the apyrene sperm are discarded from the posterior end of the sperm bundles. Peristaltic squeezing seems to be a process to eliminate the irregular nuclei of apyrene sperm while preserving the nuclei of eupyrene sperm.

Preservation injury patterns in liver transplantation associated with poor prognosis.

Preservation injury (PI) is defined as hepatic dysfunction that occurs within 10 days of liver transplantation (OLT) but spontaneously resolves. However, we noted two new patterns: one characterized by histologic evidence of preservation injury that occurs at later than 10 days post-OLT (late PI), and a second, of persistent charge in liver biopsies > 10 days post-OLT (persistent PI). To characterize these new patterns, we performed a retrospective study of patients who underwent liver biopsies for hepatic dysfunction post-OLT from September 1993 to March 1998. The outcome of the 61 patients with preservation injury on liver biopsy after OLT was followed until the last clinic visit or death. Thirty patients had early PI, 16 patients had persistent preservation injury and 15 patients, late onset preservation injury. There were no significant differences in the age (P =.28), sex (P =.77), follow-up time (P =.78), cold ischemia (P =.3), or warm ischemia time (P =.16) between these groups. There was also no significant association between early preservation injury or persistent preservation injury with the development of acute or chronic rejection (P =.19). The overall survival rates at 1, 3, and 5 years was 52%, 45%, and 45%, respectively. There was no significant difference in survival between early, persistent, and late PI patterns (P =.59), although there was a trend toward better survival for patients with early preservation injury. The survival of OLT patients with persistent or late preservation injury is poor and should prompt consideration for retransplantation.

Liver transplant for the septuagenarians: importance of patient selection.

With the increasing success of liver transplantation (OLT), more patients above 70 years of age are being considered for OLT. There is not enough data about the predictors for survival in this patient population. We retrospectively analyzed the medical records of 33 patients at least 70 years of age who received 34 OLT from July 1995 to July 2002. There were 16 women and 17 men of mean age 73.7 years. Etiologies of end-stage liver disease (ESLD) were: HCV (17/33, 52%), cryptogenic cirrhosis (8/33, 24%), PBC (3/33, 9%), Laennec's cirrhosis (2/33, 6%), and others (3/33, 9%). According to the UNOS classification, 15/34 (44%) were status 3, 16/34 (47%) status 2, and 3/34 (9%) status 1. Among 13/33 patients who died (39%), 1-year and 3-year survival rates were 78.79% and 71.43%, respectively. Based on UNOS criteria, 4/15 (26%) were status 3; 6/16 (37%), status 2; and 3/3 (100%), status 1 (P value = .04 for status 1 patients). There was no statistical differences between the scores using the Model for End-Stage Liver Disease (MELD) among those who died (MELD (19) versus MELD (17.35) respectively (P = .50). There was a statistically significant difference in cold ischemia time (CIT) and warm ischemia time (WIT) between those who died (P = .024 and.010, respectively). These results suggest that in this group of patients UNOS status classification, CIT and WIT correlate with survival. The sample size was too small to derive a conclusion about the association with the MELD score.

Model for end-stage liver disease and model for end-stage liver disease-Na scores predict both before-listing and wait-list mortality.

BACKGROUND: Due to the organ shortage, many patients die without transplantation, even before completing an evaluation for candidacy. We analyzed outcomes after patient referral and factors associated with mortality both before and after listing for cadaveric donor liver transplantation. METHODS: We analyzed 132 consecutive patients who were evaluated for candidacy for cadaveric donor liver transplantation between 2003 and 2010. RESULTS: The study included 69 men and 63 women of median age 49 years (range, 1-65). Etiologies of diseases were acute hepatic failure (n=19), liver cirrhosis due to hepatitis B or C (n=36), primary biliary cirrhosis (n=19), nonviral cirrhosis (n=14), hepatocellular carcinoma (n=13), or other causes (n=31). After evaluation for candidacy, we listed 68 (52%), subjects whereas 24 (18%) died before listing. Factors affecting death before listing were the levels of albumin (P<.001), bilirubin (P<.001), sodium (P<.001), international normalized ratio (INR; P<.001), Model for End-stage Liver Disease (MELD) score (P<.001), MELD-Na score (P<.001), and Child-Pugh-Turcotte (CPT) score (P<.001). Based on multivariate Cox regression analysis, MELD score (hazard ratio [HR] 1.201, P=.017), MELD-Na score (HR 1.244, P=.014), CPT score (HR 1.468, P=.033), and INR (HR 0.491, P=.027) were independently associated with death before listing. Among 68 listed candidates, 11 (16%) underwent transplantation, whereas 29 (43%) died without transplantation. Based on multivariate Cox regression analysis, MELD score (HR 1.102, P=.001), MELD-Na score (HR 1.128, P=.001), and CPT score (HR 1.282, P=.038) independently predicted wait-list mortality. All 11 patients who underwent cadaveric liver transplantation were alive at 29 months (range, 1-55) after transplantation. CONCLUSIONS: Patients with a higher MELD, higher MELD-Na, and higher CPT score at referral were at greater risk for death without transplantation, especially before listing. Evaluation for transplantation candidacy is a time-consuming process. Therefore, earlier referral is mandatory to achieve successful listing for transplantation.

Preemptive antiviral treatment for hepatitis C virus after living donor liver transplantation.

BACKGROUND: Recurrence following liver transplantation for hepatitis C virus (HCV), which is universal, affects long-term outcomes. Treatment with interferon (IFN) and ribavirin (RBV), the only widely available options at this time, have been faced with low tolerability and overall unsatisfactory results in deceased donor liver transplantation (DDLT). However, its place after living donor liver transplantation (LDLT) remains a matter of debate. Since most LDLT cases are performed in a planned manner at a lower Model for End-stage Liver Disease (MELD) score compared to DDLT, we have aggressively applied preemptive INF/RBV in our series. PATIENTS AND METHODS: We studied 122 adult recipients who underwent LDLT for HCV-related end-stage liver disease. The preemptive IFN/RBV protocol initiated treatment promptly after improvement in the patient's general condition with a low-dose IFN alpha2b and RBV (400 mg/d) followed by a gradual increase in the INFalpha2b dosage. Finally, we applied pegylated IFN (1.5 ug/kg/wk) and RBV (800 mg/d). The treatment was continued for 12 months after serum HCV-RNA became negative, which was defined as the end-of-treatment response (ETR). The response was considered to be a sustained viral response (SVR) if there were negative serologic results without antiviral treatment for another 6 months. Splenectomy was performed at the time of LDLT to improve tolerability to INF/RBV. The median age of the patients was 55 yrs (range = 23-66), with male dominance (87 males and 35 females). Median MELD score was 14 (range = 6-48). The series included 72 patients with hepatocellular carcinomas, and six with HIV coinfections. In 98 cases, HCV genotype was 1b. RESULTS: Overall survival at 5 years was 79%. Cumulative response rates under the protocol were ETR 56% and SVR 44% at 5 years. CONCLUSIONS: Preemptive IFN/RBV therapy after LDLT for HCV is feasible with acceptable outcomes.

Once-daily tacrolimus in living donor liver transplant recipients.

Once-daily tacrolimus (denoted here simply as OD) is a recently developed extended release drug formulation. The purpose of the present study was to pharmacokinetically evaluate tacrolimus exposure and determine the feasibility of its de novo use in liver transplant recipients in the perioperative period. This was an open-label, single center study. Eligible patients were 18 to 65 years of age in the perioperative period after a liver transplant. Patients were initially treated with intravenous tacrolimus and then converted to the 10× milligram-for-milligram daily dose of OD administered once daily. Twenty-four hour pharmacokinetic profiles were obtained on day 7 after the conversion. Laboratory and safety parameters were also evaluated. A total of 9 patients received OD, were successfully converted, and provided pharmacokinetic profiles. Intravenous tacrolimus and OD resulted in similar areas under the curve for 24 h (AUC0-24) of tacrolimus. OD was well tolerated with a safety profile comparable to that of intravenous tacrolimus. The AUC0-24 correlated with the minimum concentration of OD (R = 0.49). Renal and liver functions remained stable. None of the patients experienced acute rejection during the observation period. OD and intravenous tacrolimus provide equivalent drug exposure, allowing conversion of selected liver transplant recipients from intravenous tacrolimus to OD in the peri-operative period.

Simultaneous pancreas-kidney transplantation in the United States: an analysis of the UNOS registry.

The rate of chronic pancreas graft loss in simultaneous pancreas kidney transplantation has remained almost unchanged despite induction therapy. Since 1987, seven major immunosuppressive induction agents-basiliximab, daclizumab, ALG, eATG, OKT 3, alembuzumab, rATG-have been used as immunosuppressive induction agents. Those agents improved short-term survival by preventing acute rejection, but improvement of short-term survival has not translated into improved long-term graft survival. As with most solid organ transplants, there is a need for means to control chronic rejection to improve long-term graft survival.

Microdissection studies on the polarity of unequal division in grasshopper neuroblasts. I. Subsequent divisions in neuroblast-type cells produced against the polarity by micromanipulation.

Equal or unequal division against the polarity of normal division was induced in grasshopper neuroblasts by means of a microdissection technique. The subsequent cell divisions were traced in order to analyse the factors that determine the polarity. Daughter cells of two types (neuroblast-type and ganglion cell type) were produced by operations in which the mitotic apparatus was rotated or shifted. Cell types were classified by such characteristics as nuclear shape, mitotic activity, and inequality or equality of the subsequent cytokinesis. It became evident that the fate of daughter cells was determined simply by the cytoplasmic volume. In 27 cases out of 40 microdissecting operations, both sister cells were recognized as of neuroblast type. Mitosis of these neuroblast-type sister cells proceeded asynchronously. The time required for neuroblast-type cells to reach metaphase of the second division depended on their volume. It is considered that the polarity of unequal division in grasshopper neuroblasts may be maintained by a joint action of the cap cells attaching to one of the polar regions of the cell and the cortex differentiated in the previous cell division.

Behaviors of nucleus, basal bodies and microtubules during eupyrene and apyrene spermiogenesis in the silkworm, Bombyx mori (Lepidoptera).

Observations with immunostaining for tubulin and electron microscopy revealed that silkworm eupyrene spermiogenesis was characterized by an attachment of the basal body to the nucleus except in the period of movement for unidirectional arrangement. In young eupyrene sperm, a microtubule basket caught the nucleus, which thereafter was transformed elliptically. Microtubules were also observed along the elongated acrosome and mitochondrial derivatives. During apyrene spermiogenesis, however, the basal body was not attached to the nucleus and approached the head cyst cell after the completion of unidirectional arrangement, leaving the round nucleus in the middle of the cell. The presence or absence of the phenomenon in which the basal body attaches to the nucleus seems to be essential in the course of diverse spermatogenesis of the silkworm.