[Indications for liver transplantation in Wilson's disease with a fulminant course]. / Indikation zur Lebertransplantation bei der fulminant verlaufenden Wilsonschen Krankheit.

In two 19-year-old girls with Wilson's disease the condition took a fulminant course, including a poor general state, marked haemolysis and ascites. In the first patient the diagnosis was histologically confirmed only after three weeks, and onset of treatment with penicillamine was therefore delayed. With this medication the concentrations of alkaline phosphatase, cholinesterase and total bilirubin returned to normal, but again became abnormal after about seven weeks. Despite substitution of clotting factors thromboplastin time remained reduced. She died 82 days after the onset of symptoms. In the second patient, treatment with penicillamine was started at once, without waiting for histological confirmation. All laboratory values became normal and remained so. It is concluded from these observations that liver transplantation is indicated if the abnormal values for cholinesterase, thromboplastin time and bilirubin do not remain normal after six weeks and if the initial suppression of alkaline phosphatase continues or occurs again.

Determination of proinsulin intermediates by means of an immunoradiometric method using polyclonal antibodies.

In our endeavour to develop a method for proinsulin determination, an immunoradiometric method was developed. Thereby guinea-pig antibodies to bovine insulin which were purified with an immunoadsorbent, were, in surplus, coupled to polyethylene tubes. These tubes were used to extract proinsulin and insulin from the sample and standard that or was to be determined. The proinsulin adsorbed onto the wall of the tube was distinguished from insulin by incubating, in a second step, a rabbit antibody to human C-peptide with the tubes. In order to render the proinsulin anti-C-peptide complex measurable, a donkey antibody to rabbit IgG was used, which had been purified via an immunoadsorbent and which was labelled with iodine-125. Since proinsulin extracted from human pancreata was available next to biosynthetic human proinsulin, it was striking to note that these substances were very differently recorded by the determination method applied. Thus biosynthetic human proinsulin dissolved in gelatin buffer could not be measured at all. After mild tryptic cleavage of the biosynthetic human proinsulin, a clear increase of the immunoreactivity was seen in this method. Therefore the claim could be made that partially cleaved proinsulin molecules with a retained C-peptide structure had come into existence. This could be verified by application of the proinsulin cleavage products 65/A1 and 32/33, which exhibited a behaviour very similar to that of pancreatic proinsulin in this method. In this way we could demonstrate that the originally planned immunoradiometric determination method for proinsulin, recorded partially hydrolized intermediates of the proinsulin, which represent a large part of the proinsulin immunoreactivity in the serum.

[The role of liver transplantation in the treatment of acute liver failure following Amanita phalloides poisoning]. / Die Rolle der Lebertransplantation im Behandlungskonzept des akuten Leberversagens nach Knollenblätterpilzvergiftung.

OBJECTIVE: To formulate the indications for liver transplantation in the treatment of acute liver failure after Amanita phalloides poisoning and to determine the results of this treatment. PATIENTS AND METHODS: In 1994 twelve patients with acute Amanita phalloides poisoning were treated in the intensive care unit of our hospital's toxicology department. Three of them developed irreversible signs of poisoning and were given orthotopic liver transplants. The findings and course of this group of patients were analysed retrospectively and prognostic criteria defined on the basis of this personal experience and published data. RESULTS: Amanita phalloides poisoning differs from other causes of acute liver failure in several respects. The following criteria make it possible reliably to distinguish a lethal from a non-lethal course: a Quick value < 20% over the course of several days, serum creatinine concentration > 1.4 mg%, even after correcting water and electrolyte abnormalities, serum bilirubin > 4.6 mg%, and progressive encephalopathy indicate a lethal course. Two of three patients survived severe poisoning by being given a liver transplant. Renal failure, pancreatitis and bone marrow suppression, in addition to liver failure, were signs relevant to treatment decisions. CONCLUSION: Liver transplantation is the procedure of choice in the treatment of acute Amanita phalloides poisoning, if the criteria for a probably lethal course under conservative treatment have been met. This should be taken into account when poisoned patients are to be transferred to a centre for treatment.

Kinetics of biosynthetic human proinsulin in patients with terminal renal insufficiency.

Eight volunteers with terminal renal insufficiency having consented to the investigation, were given an i.v. bolus administration of 40 pmol biosynthetic human proinsulin on their dialysis-free day. Intravenous blood for the determination of blood glucose proinsulin, insulin and C-peptide was collected in short intervals for 6 hours and thereafter in longer intervals for 24 hours. Proinsulin was determined by immunoradiometric assay with monoclonal antibodies. The proinsulin kinetics were compared with the kinetics of normal volunteers. The behaviour of proinsulin concentration-time is best described with a 3-compartment model. The dominant biological half-life in terminal renal insufficiency was 6.8 hours which signifies a 4.4-fold increase of the normal half-life. The distribution volumes (V1) in the central compartment do not differ in the two groups, whereas the distribution volume after complete distribution (Vss) is significantly increased in renal insufficiency. The total metabolic clearance in renal insufficiency namely 0.63 ml/kg/min is 2.6 times lower compared to normal subjects with 1.67 ml/kg/min. The extra-renal clearance is 39% of the total metabolic clearance rate, whereas the renal clearance comprises 61%. Peripheral conversion from proinsulin to insulin and C-peptide does not occur in terminal renal insufficiency. The basal endogenous proinsulin secretion rate in renal insufficiency does not differ from that of normal volunteers. The following conclusions can be drawn: 1) Hyperinsulinism observed in renal insufficiency can be explained by circulating proinsulin. 2) In the potential therapeutic use of biosynthetic human proinsulin in diabetics with renal insufficiency dosis adjustment according to the remaining renal function would probably be required.

Pharmacokinetics of biosynthetic human proinsulin following intravenous and subcutaneous administration in metabolically healthy volunteers.

40 pmol of biosynthetic human proinsulin was administered to 8 healthy volunteers by intravenous and by subcutaneous route. Following proinsulin administration, venous blood was collected in regular intervals within which proinsulin was determined by a specific radioimmunometric assay with monoclonal antibodies. The proinsulin concentration was determined simultaneously with the insulin and C-peptide radioimmunoassay. Through this investigation the following kinetic parameters were found: The kinetics of the biosynthetic human proinsulin can be best described by the 3-compartment model. The dominant biological half-life was 92 minutes. In intravenous proinsulin administration a proinsulin mean transit time of 80 minutes was found, whereas in subcutaneous administration a proinsulin retention time of 225 minutes was measured. The mean resorption velocity of the subcutaneously applied proinsulin amounted to 145 minutes. Two lag times for subcutaneous resorption can be described, a short one with 9.4 minutes and a long one with 65 minutes. The initial distribution volume for proinsulin was 3.8 l, whereas the distribution volume after complete distribution was 9.3 l. The mean total metabolic clearance was determined with 120 ml/min. Since no difference for the proinsulin concentration was found using the 3 different determination methods a peripheral proinsulin conversion to insulin and C-peptide is not likely. The basal endogenous secretion rate for proinsulin is 68.7 pmol per hour.

Liver transplantation for the treatment of fulminant hepatic failure induced by the ingestion of ecstasy.

Methylenedimethoxymethamphetamine (MDMA), more commonly known as ecstasy, is a synthetic amphetamine derivative used by teenagers and young adults in the United States as well as in Western Europe as a "dance drug". Though a number of complications associated with this drug have been reported, there is little information pertaining to hepatoxity as a result of MDMA ingestion. This case report is about an 18-year-old female patient who regularly used ecstasy on weekends over a 2-month period. Within 2 days after accepting a "hit" of the substance at a party, she was admitted to the hospital because of lethargy, vomiting, abdominal pain, stool discoloration, icterus, and darkened urine. On day 7 she developed fulminant hepatic failure with reduced hepatic coagulation factors and grade IV encephalopathy. Orthotopic liver transplantation was carried out 10 days following the ingestion. The patient made a full recovery within 72 h and was released from the hospital 6 weeks later. Histopathological examination of the removed liver revealed a nutritive-toxic liver necrosis. This case demonstrates that the ingestion of ecstasy, even on an infrequent basis, can lead to acute fulminant liver necrosis, and that this life-threatening complication can be treated successfully by liver transplantation.