Endotoxin Metabolism Reflects Hepatic Functional Reserve in End-Stage Liver Disease.

BACKGROUND: The hepatic clearance of endotoxin (Et) may reflect hepatic functional reserve and ischemic injury to hepatocytes. Therefore, we examined the relationships between Et activity (EA) and the metrics Pediatric End-Stage Liver Disease (PELD)/Model of End-Stage Liver Disease (MELD) score and alanine transaminase (ALT) levels in the postoperative period. METHODS: We performed 8 living-donor liver transplantations (LDLTs) for biliary atresia at our center from April 2012 to December 2012. EA was measured by means of an Et activity assay (EAA) in samples collected from a vein 1 day before LDLT, from the portal vein during the intraoperative anhepatic phase, from an artery 1 hour after reperfusion, from an artery on postoperative day (POD) 1, and from an artery or vein at PODs 7 and 14. RESULTS: EAs generally remained at low levels. EA at the reperfusion period was significantly lowest. The correlation coefficient for the preoperative MELD/PELD score and the EAA was 0.837, and the corresponding P value was .009; thus, there was a significant relationship between the preoperative MELD/PELD score and the EAA. The correlation coefficients for ALT at POD 1 and EA during the anhepatic phase, at 1 hour after reperfusion, and at POD 1 were 0.64, 0.43, and 0.38, respectively, and the P values for these correlations were .08, .67, and .34. Thus, we observed that ALT and EA generally tended to be somewhat directly correlated, but no significant relationships between these 2 metrics were observed. CONCLUSIONS: Endotoxin metabolism reflects the hepatic functional reserve capacity of end-stage liver disease.

Antibody Drug Treatment for Steroid-Resistant Rejection After Pediatric Living Donor Liver Transplantation: A Single-Center Experience.

BACKGROUND: Antibody drugs have been used to treat steroid-resistant rejection (SRR) after liver transplantation. Although anti-thymocyte globulin has been used for SRR after liver transplantation in place of muromonab-CD3 since 2011 in Japan, the effectiveness of anti-thymocyte globulin after pediatric living-donor liver transplantation (LDLT) has not yet been reported. The aim of this study was to evaluate the effectiveness of antibody drug treatment for SRR after pediatric LDLT in our single center. METHODS: Between May 2001 and December 2013, 220 pediatric LDLTs were performed. Initial immunosuppression after LDLT included tacrolimus and methylprednisolone therapy. Acute rejection was diagnosed by use of a liver biopsy and the administration of steroid pulse treatment, and SRR was defined as acute rejection refractory to the steroid pulse treatment. RESULTS: Acute rejection and SRR occurred in 74 (33.6%) and 16 patients (7.3%), respectively. The graft survival rates of non-SRR and SRR were 92.4% and 87.5%, respectively (P = .464). The median concentration of alanine aminotransferase before and after the administration of antibody drug was 193.5 mU/mL (range, 8-508) and 78 mU/mL (range, 9-655), respectively (P = .012). The median rejection activity index before and after the administration of antibody drugs was 5 (range, 2-9) and 1 (range, 0-9), respectively (P = .004). After antibody drug treatment, 12 patients had cytomegalovirus infections, 2 patients had Epstein-Barr virus infections, 3 patients had respiratory infections, and 1 patient had encephalitis. The cause of death in 1 patient with SRR was recurrence of infant fulminant hepatic failure. CONCLUSIONS: Antibody drug treatment for SRR after pediatric LDLT is safe and effective.

Relationship Between Graft Liver Function and the Change of Graft Liver and Spleen Volumes After Technical Variant Liver Transplantation.

BACKGROUND: Although there have been a few reports describing the changes of graft liver and spleen volumes after liver transplantation (LT), little is known about the relationship between graft liver function and the changes of these volumes after technical variant liver transplantation (TVLT). We therefore performed a retrospective study to investigate the relationship between graft liver function and these volumes after TVLT. METHODS: We retrospectively investigated the cases of 140 TVLT procedures that were performed in our department between July 1987 and October 2012 and in which follow-up was conducted at our department. We calculated the graft liver volume to standard liver volume (GV/SLV) ratio, the spleen volume to standard spleen volume (SV/SSV) ratio, and the spleen volume to graft liver volume (S/L) ratio by CT volumetry. We clarified the relationship between graft liver function (according to the pathological findings) and the graft liver and spleen volumes at 2, 5, and 10 years after TVLT. RESULTS: In the normal liver function group, the GV/SLV, SV/SSV, and S/L ratios decreased until 6 months after TVLT and then converged at 10 years after TVLT to 0.95, 1.27, and 0.27, respectively. In the graft liver failure group, the GV/SLV, SV/SSV, and S/L ratios at 10 years after TVLT were 0.67, 5.01, and 1.55, respectively. A significant correlation was observed between the GV/SLV ratio and the presence of mild liver fibrosis at 2 and 5 years after TVLT (P = .03 and P = .04, respectively). CONCLUSIONS: Post-transplant CT-volumetry is a noninvasive and effective means of evaluating graft liver status.

Prediction of acute cellular rejection by peripheral blood eosinophilia in pediatric living donor liver transplantation.

BACKGROUND: Acute cellular rejection (ACR) is a common cause of morbidity following liver transplantation. Several reports have evaluated the predictive value of peripheral blood eosinophilia as a simple noninvasive diagnostic marker for ACR. This study examined whether the relative eosinophil counts (REC) predicted ACR in pediatric living donor liver transplantation (LDLT). METHODS: One hundred three patients underwent LDLT between May 2001 and December 2007. ACR were diagnosed based on the pathological findings. RESULTS: The incidence of ACR was 46.6% (48/103); ACR was diagnosed an average of 13.5 days after LDLT. The average REC at 4 and 2 days before the onset ACR (n = 39) within 30 postoperative day (POD) was 4.3% and 7.3%, respectively, and 9.0% at the onset. Patients with ACR showed significantly higher levels of REC compared with those free of ACR (P = .039). REC thresholds of 10% at POD 7 displayed a sensitivity and specificity of ACR detection of 80% and 75%, respectively. Moreover, the accumulated morbidity ratio of ACR within 30 POD was significantly higher with REC >10% at POD 7 (P = .007). CONCLUSION: ACR within POD 30 should be considered when REC is >10% at POD 7 after LDLT.

Hepatic arterial buffer response after pediatric living donor liver transplantation: report of a case.

BACKGROUND: Excessive portal pressure at an early stage after living-donor liver transplantation (LDLT) can damage sinusoidal endothelial cells and hepatocytes through shear stress leading to graft failure, or hepatic arterial complications due to low hepatic artery flow from a hepatic arterial buffer response. We encountered a case in which excessive portal vein flow was observed from an early stage after pediatric LDLT. The hepatic artery flow decreased due to a hepatic arterial buffer response. CASE REPORT: A 6-month-old boy with biliary atresia showed excessive portal vein flow early after LDLT with a decreasing hepatic artery flow without anastomotic stenosis from postoperative day 3. The PV flow gradually exhibited a decrease at approximately postoperative day 8 and, similtaneously, hepatic artery flow exhibited improvement. CONCLUSION: Because excessive portal pressure after LDLT is reversible, it has been suggested that it may be possible to prevent the progress of hepatic arterial complications if temporary portal pressure modulation can be performed for cases among the high-risk group for hepatic arterial complications.

Management of intra-abdominal drain after living donor liver transplantation.

BACKGROUND: There have been few reports on the management of intra-abdominal drains after living donor liver transplantation (LDLT). We retrospectively investigated changes in ascitic data related to management of an intra-abdominal drain. PATIENTS AND METHODS: Between March 2008 and June 2009, we performed 28 LDLT. On the first and the fifth postoperative day (POD) after LDLT, we examined the number of ascites cells and cell fractions as well as performed biochemical examination and cultures. RESULTS: The day of removal of the drain for massive ascites (10 mL/kg/d or more) was 14.2 ± 5.4 POD; for less than 10 mL/kg/d it was 8.7 ± 1.9 POD (P < .001). Nine patients were ascites culture positive; long-term placement of the drain caused an infection in two patients. CONCLUSIONS: When the amount of ascitic fluid on the fifth POD after LDLT was small, it was important to assess the properties of the ascitic fluid because of the possibility of a drain infection or of poor drainage. If the ascitic neutrophil count is less than 250/mm(3) or the examined ascites is normal, intra-abdominal drains should be removed.

The Parker Flex-Tip tracheal tube makes endotracheal intubation with the Bullard laryngoscope easier and faster.

BACKGROUND: The Bullard laryngoscope can be useful in management of difficult airway. When the endotracheal tube is advanced over the original Bullard laryngoscope stylet, the endotracheal tube sometimes makes contact with structures around the vocal cords, especially the right arytenoids. A similar problem also occurs with flexible fibreoptic intubation and it has been shown that use of the Parker Flex-Tip tube usually resolves the problem. In this study we tested our hypothesis that use of the Parker Flex-Tip tube might improve endotracheal tube passage with the Bullard laryngoscope. METHODS: Forty patients scheduled for elective anaesthesia were randomly assigned into group ST (standard tube) or Group PT (Parker Flex-Tip tube). The time taken to achieve successful endotracheal tube placement after obtaining the best laryngeal view, the number of attempts at intubation and the incidences of successful intubation at first attempt and of re-direction of the Bullard laryngoscope during intubation were recorded. Unpaired t-test and chi2-test were employed and P < 0.05 was considered significant. RESULTS: Use of the Parker Flex-Tip tube reduced the time required for successful endotracheal tube placement after the best laryngeal view was obtained from 14 +/- 6 to 6 +/- 2 s (P < 0.01). It also reduced the incidence of requirement for re-direction of the Bullard laryngoscope during intubation from 10/19 to 1/19 (P < 0.01). The incidence of successful intubation at the first attempt (18/19 vs. 15/19) was higher in the PT group but the difference was not statistically significant. CONCLUSIONS: During intubation with the Bullard laryngoscope, use of the Parker Flex-Tip tube is associated with more rapid success and a lower incidence of re-direction of the Bullard laryngoscope during endotracheal intubation when compared to a standard endotracheal tube.

Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube.

Following surgery requiring the use of a double-lumen endobronchial tube, a patient immediately complained of persistent severe hoarseness. On the third day after the operation, fibreoptic laryngoscopy revealed posterolateral dislocation of the left arytenoid cartilage. By the sixth day of the operation, a slight improvement was observed in the hoarseness without treatment and a spontaneous recovery of arytenoid cartilage dislocation was expected. The patient did not consent to surgical treatment, and therefore a conservative therapy was selected. Ten weeks after the operation, it was found that the dislocated left arytenoid cartilage had spontaneously repositioned and the patient regained his normal voice. The causes and treatment options are discussed.

[A case with cerebral subcortical hemorrhage following the administration of phenylpropanolamine].

A 21-year-old woman experienced severe headache and nausea one hour after taking pills containing 160 mg of phenylpropanolamine for common cold. She had no previous history of drug abuse or hypertension. Physical examination revealed slight left-sided hemiparesis. Her blood pressure was 100/52 mmHg. Subcortical hemorrhage was noted in the right frontal lobe with a cranial computed tomography. On the seventh hospital day, cerebral angiography demonstrated with segmental narrowing of a branch of the right anterior cerebral artery, indicating the presence of focal angitis. This finding disappeared on the 35th hospital day. In the majority of the reported cases of the intracerebal hemorrhage associated with the ingestion of phenylpropanolamine, focal angitis rather than induced hypertension is considered to be a causative factor for hemorrhage. Thus, we would like to emphasize that the administration of phenylpropanolamine should be avoided, even to the patients without hypertention or past history of intracerebral hemorrhage.

Decreased body temperature dependent appearance of behavioral despair in the forced swimming test in mice.

Effects of body temperature on the immobile response and brain glucose metabolism were examined in the forced swimming test in mice. The first experiment was performed to study behavior, after initial periods of vigorous activity, a characteristic immobile posture occurred when the water was 25 and 35 degrees C. However, several minutes after forced swimming at 25 degrees C, significantly decreased spontaneous motility occurred in a time-dependent manner, but no changes was observed at 35 degrees C. Our interpretation was that mechanisms of acquisition and retention of the forced swim-induced immobile response differed. Body temperature was also significantly decreased at 25 degrees C but not at 35 degrees C in the forced swimming test. This lowering of body temperature almost paralleled the immobile response. The second experiment was a biochemical study in which the uptake of [(14)C] 2-deoxy-d-glucose into the brain significantly decreased after forced swimming at 25 degrees C but did not change in the forced swim loaded mice when the water was 35 degrees C. These results suggested two types of immobile mechanisms in the forced swimming test: (1) an early phase acquisition of the immobile response which might be related to adaptive response and (2) a late phase to retain the immobile response which might be related to the decrease in brain glucose metabolism.

Occurrence and distribution of substance P receptors in the cerebral blood vessels of the rat.

The distribution of immunoreactivity to the receptor for substance P was examined in the cerebral blood vessels of the rat. Substance P immunoreactivity has been demonstrated in the nerve fibers of the cerebral blood vessels. Recently, the production of substance P receptor specific antibody has enabled the detection of localization of the substance P receptor in the central nervous system. In this study, we examined the existence of nerve fibers with substance P receptor immunoreactivity in the cerebral blood vessels and the cranial ganglia innervating the cerebral blood vessels. Sprague-Dawley rats were perfused with fixative and the pial arteries and the cranial ganglia known to innervate the cerebral blood vessels, i.e., trigeminal, sphenopalatine, internal carotid, otic and superior cervical ganglia, were dissected. All specimens were incubated with anti-substance P receptor IgG, then stained by the avidin-biotin-peroxidase complex method. Numerous nerve fibers with varicosities forming plexuses, with substance P receptor immunoreactivity were observed on the walls of the major extracerebral arteries forming the circle of Willis and its branches. Substance P receptor immunoreactivity was also detected in the endothelium of the cerebral arteries. Substance P receptor immunoreactivity was positive in many neurons of the sphenopalatine ganglion, otic ganglion, trigeminal ganglion, superior cervical ganglion and internal carotid ganglion. The present study demonstrated the existence of nerve fibers with substance P receptor immunoreactivity in the cerebral blood vessels and the cranial ganglia that innervate the cerebral blood vessels. These findings are important in understanding the responsiveness of the cerebral blood vessels to substance P.

Partial characterization of binding sites of VA-045, a novel apovincaminic acid derivative, in rat brain membranes.

1. We characterized the binding sites of VA-045 [(+)-eburunamenine-14- carboxylic acid (2-nitroxyethyl)ester] in the rat brain. 2. VA-045 showed no affinity for various types of well-known neurotransmitter-related receptors or channels. However, radiolabeled VA-045 ([3H]VA-045) bound to rat brain membranes in a saturable and reversible manner. The Kd and Bmax values of [3H]VA-045 binding were 58.2 nM and 2685 fmol/mg of protein, respectively. 3. The largest specific binding of [3H]VA-045 was observed in the cerebellum, among seven brain regions, and in subcellular synaptosomes. 4. Specific binding of [3H]VA-045 was inhibited by VA-045 (Ki = 0.06 microM), a levorotatory enantiomer of VA-045 (VA-213) and its structural analog, vinpocentine. Moreover, compounds with calmodulin antagonistic activity inhibited the [3H]VA-045 binding. 5. These results suggest that VA-045 binds to specific sites, which may resemble calmodulin, on synaptic membranes in the brain.

A novel antitumor compound, NC-190, induces topoisomerase II-dependent DNA cleavage and DNA fragmentation.

A novel benzophenazine derivative, NC-190, is a potent antitumor compound. NC-190 has been shown to inhibit the DNA strand-passing activity of DNA topoisomerase II. We investigated further the mode of action of NC-190 against DNA topoisomerase II and DNA fragmentation. NC-190 inhibited the decatenation activity of purified topoisomerase II, but had only a weak inhibitory effect against topoisomerase I. A topoisomerase II-dependent DNA cleavage assay showed that NC-190 inhibited the enzyme activity by stabilizing a topoisomerase II-DNA cleavable complex. NC-190 induced growth inhibition, protein-linked DNA breaks, and DNA fragmentation in cultured HL-60 cells in a dose-dependent manner. These activities of NC-190 in HL-60 cells were comparable to those of etoposide (VP-16). These results demonstrate a good correlation among growth inhibition, topoisomerase II-dependent DNA cleavage, and DNA fragmentation induced by NC-190. A DNA unwinding assay showed that NC-190 had intercalating activity, but its activity appeared to be weaker than those of ethidium bromide and adriamycin. These results indicate that the mechanism by which NC-190 exhibits antitumor activity may be the inhibition of topoisomerase II.

Prostacyclin analogue TTC-909 reduces memory impairment in rats with cerebral embolism.

The effects of the stable prostacyclin analogue TTC-909 on memory impairment in the water maze task and on neuronal damage were studied in rats with cerebral embolism induced by injecting polyvinyl acetate (PVA) into the right internal carotid artery and the ensuing embolism extending out into the right middle cerebral artery. Areas supplied by the lenticulostriate artery were most markedly damaged. In the water maze test, the PVA-embolized rats took longer to reach the platform than did the nontreated control rats. To some extent, repeated administrations of TTC-909 (200 ng/kg, IV) overcame this impairment in water maze learning in the rats. We assume that the vasodilating effects of TTC-909 maintain this blood supply to the ischemic area and that TTC-909 prevents the development of thrombosis around the PVA particles in the arterial capillaries, as a result of antiplatelet aggregative effects. These two mechanisms are likely to be involved in memory improvement. TTC-909 may prove effective for treating subjects with stroke and other cerebrovascular disorders.

Depolarization and hypoxia-induced cell damage in serum-free cultures of the rat cortex, and related extracellular glutamate changes.

Experiments were carried out to clarify the influence of K+-induced chronic membrane depolarization on cytotoxicity and changes in extracellular glutamate, as induced by hypoxia in serum-free cortical cultures. Excitotoxic cell death was examined by measuring lactic dehydrogenase (LDH) activity released into the culture medium. In culture grown in the presence of 25 mM K+, morphological injury occurred during a 4 h exposure to hypoxia, together with a substantial efflux of LDH. In hypoxic cultures, extracellular glutamate concentrations were elevated and these responses were absent in cultures grown in physiological medium (K+ = 5.4 mM), even with 16 h of hypoxia. In cultures at 25 mM K+, the cytotoxicity induced by hypoxia was attenuated by NMDA receptor antagonists, in a concentration dependent manner. We also examined the effects of excitatory amino acids, agonists of the main glutamate receptor classes (glutamate, NMDA, kainate, and AMPA). In both 5.4 nM and 25 mM K+ cultures, a dose dependent release of LDH was induced by a long exposure to glutamate receptor agonists, although the release of LDH in the 5.4 mM K+ was less than that in the 25 mM K+ cultures. Despite of the expression of the glutamate receptor in the 5.4 mM K+ cultures, hypoxic neuronal damage did not occur. These results suggest that when cultures grown in a chronically depolarizing environment are exposed to hypoxia, they are damaged by an excitotoxic mechanism in which the main cause seems to be the glutamate released into the medium at high extracellular levels.

Expression of prostaglandin H synthase-2 in endotoxic shock induced in rats.

We investigated the expression of prostaglandin H synthase-2 in rats subjected to endotoxic shock. The prostaglandin H synthase activities were assessed by measuring the plasma prostaglandins (PGE2 and 6-keto-PGF1 alpha) after arachidonic acid administration (3 mg/kg, i.v.). The plasma prostaglandin concentrations increased immediately after administration of arachidonic acid, reached a peak at 30-60 seconds, and then rapidly decreased. Lipopolysaccharide (1 mg/kg, i.v.) also increased the plasma prostaglandin concentrations, reached a peak 1 hour after administration, and then gradually decreased to normal levels. The production of plasma prostaglandin, induced by administration of arachidonic acid, was markedly enhanced in the lipopolysaccharide-treated rats. A low dose of acetylsalicylic acid (3 mg/kg, i.v.) blocked the prostaglandin production in the nontreated rats but not in the lipopolysaccharide-treated rats. In the latter group of rats, a high dose of acetylsalicylic acid (30 mg/kg, i.v.), given 10 to 30 minutes before administration of arachidonic acid, completely blocked the prostaglandin production, but recovery of this production was seen with acetylsalicylic acid (30 mg/kg) treatment at 1 to 2 hours before administration of arachidonic acid. These data suggest that pretreatment with lipopolysaccharide enhances the prostaglandin production by forming newly synthesized prostaglandin H synthase. Immunoblots of the levels of enzyme protein from rat aorta endothelial cells were analyzed. The enzyme protein cross-reacting with antibody against prostaglandin H synthase-2 was increased by lipopolysaccharide treatment in endothelial cells, and was constitutively expressed in the stomach, kidney and liver, but not in the lung and the intestine. The induction of prostaglandin H synthase-2 by lipopolysaccharide treatment was observed only in endothelial cells. The enhancement of the prostaglandin production in lipopolysaccharide-treated rats was blocked by pretreatment with dexamethasone, prior to administration of lipopolysaccharide, this suppression is apparently the result of a decrease of the prostaglandin H synthase-2 protein in endothelial cells, as determined by Western blotting. The enhanced production of prostaglandin, induced by lipopolysaccharide, seems to be due to the in vivo expression of prostaglandin H synthase-2.

Prolonged inhibition of an antigen-specific IgE response in vivo by monoclonal antibody against lymphocyte function-associated antigen-1.

Intraperitoneal injection of ovalbumin (OVA) into BALB/c mice caused the induction of OVA-specific IgE production in vivo. However, administration of monoclonal antibody against lymphocyte function-associated antigen-1 (anti-LFA-1 mAb) at days 0 and 1 after OVA immunization resulted in an inhibition of OVA-specific primary and secondary IgE production in a dose-dependent manner. The inhibition of the antigen-specific IgE response due to anti-LFA-1 mAb was seen up to 8 weeks after anti-LFA-1 mAb administration. The OVA-specific IgG1 response was also blocked by anti-LFA-1 mAb. The spleen cells obtained from OVA-immunized mice showed enhanced proliferation against secondary stimulation with OVA in vitro. However, the spleen cells obtained from the mice treated with both OVA and anti-LFA-1 mAb revealed a markedly decreased proliferative responses to OVA, while they showed no reduced responses against keyhole limpet hemocyanin stimulation, indicating that anti-LFA-1 mAb might induce antigen-specific anergy in vivo. It was also demonstrated that treatment of the mice with anti-LFA-1 mAb significantly inhibited the interleukin-4-producing ability of OVA-immunized mouse spleen cells. These results demonstrated that LFA-1-dependent cell-cell interaction is essential for the production of IgE in vivo and may be important in IgE-dependent allergic disease.

Establishment of a T cell-dependent nude mouse liver injury model induced by Propionibacterium acnes and LPS.

Normal ICR mice developed severe liver injury when they were given intravenous injections of Propionibacterium acnes and lipopolysaccharide (LPS) with a 7 day interval. In contrast, T cell-deficient ICR nude mice were resistant to P. acnes and LPS-induced liver injury. However, athymic ICR nude mice, which were treated with cell transfer of normal ICR mouse spleen cells (10(8) cells) or ICR mouse nylon-wool passed splenic T-enriched cells (over 10(7) cells), showed severe liver injury as assessed by elevation of serum transaminase activities. Histological analyses also demonstrated that the transferred cells migrated into the liver of nude mice to induce liver injury. However, depletion of both CD4+ T cells and CD8+ T cells from transferred cell populations caused a marked decrease in the elevation of serum transaminase, indicating the actual involvement of T cells in liver injury. Moreover, in vivo administration of anti-LFA-1 mAb blocked P. acnes and LPS-induced liver injury in nude mice following T cell transfer. Thus, this model will provide a new strategy to investigate T cell-dependent cell-cell interaction during the induction of liver damage.