Impaired intention-to-treat survival after listing for liver transplantation in children with biliary atresia compared to other chronic liver diseases: 20 years' experience from the Nordic countries.

Biliary atresia (BA) is the most common indication for LT in children. We investigated whether this diagnosis per se, compared to other chronic liver diseases (OCLD), had an influence on patient survival. Data from 421 Scandinavian children, 194 with BA and 227 with OCLD, listed for LT between 1990 and 2010 were analyzed. The intention-to-treat survival and influencing risk factors were studied. Patients with BA had higher risk of death after listing than patients with OCLD. The youngest (<1 year) and smallest (<10 kg) children with the highest bilirubin (>510 µmol/L), highest INR (>1.6), and highest PELD score (>20) listed during 1990s had the worst outcome. Given the same PELD score, patients with BA had higher risk of death than patients with OCLD. For adolescents, low weight/BMI was the only prognostic marker. Impaired intention-to-treat survival in patients with BA was mainly explained by more advanced liver disease in younger ages and higher proportion of young children in the BA group rather than diagnosis per se. PELD score predicted death, but seemed to underestimate the severity of liver disease in patients with BA. Poor nutritional status and severe cholestasis had negative impact on survival, supporting the "sickest children first" allocation policy and correction of malnutrition before surgery.

Erythropoietin and uremic toxicity during continuous ambulatory peritoneal dialysis.

This study examined the effect of continuous ambulatory peritoneal dialysis (CAPD) on erythropoiesis and macrophage function. The parameters evaluated were hemoglobin, erythropoiesis-stimulating factor(s) (ESF), and the inhibitory effect of patients' plasma and peritoneal dialysate on erythropoiesis in vitro and on the function of macrophages from normal humans cultured in vitro. ESF was determined by a cell culture assay using hepatic erythroid colony forming cells (CFUE) from newborn mice. The uremic inhibitory effect on macrophages cultured in vitro was expressed as macrophage survival in percentage of controls. Five patients were studied, one of whom was anephric. Hemoglobin increased, without blood transfusions during CAPD treatment, suggesting improved erythropoiesis. Plasma ESF increased in all patients; dialysate ESF increased in all but one patient. Survival of macrophage in vitro, incubated with plasma or dialysate, also improved. In two patients, the inhibitory effect of plasma samples on erythropoiesis in vitro decreased during CAPD treatment. These observations indicate that CAPD removes inhibitors of erythropoiesis and human macrophage function in vitro, and are consistent with transport of inhibitory substances of high molecular weight into the peritoneal cavity. The anephric patient showed improvement of erythropoiesis similar to that of the nephric patients, indicating that the kidney may not be the main producer of erythropoietin (Ep) in patients undergoing CAPD. Peritoneal macrophages may be a site of extrarenal Ep production in this situation. With regard to the parameters studied, CAPD treatment is superior to conventional hemodialysis.

Evidence that Alpers-Huttenlocher syndrome could be a mitochondrial disease.

We report an 11-year-old boy with a slight developmental delay and epilepsy. After he was placed on valproate, he developed hepatic failure and increasing neurologic symptoms, including epilepsia partialis continua, and died. Autopsy findings in liver and cerebrum were consistent with progressive neuronal degeneration of childhood with liver disease, also called Alpers-Huttenlocher syndrome. Ragged red fibers and cytochrome c oxidase negative fibers were present in muscle. These results suggest that Alpers-Huttenlocher syndrome, at least in some patients, is a mitochondrial disease.

Regulation of erythropoiesis during rapid growth.

High levels of plasma erythropoiesis stimulating factor(s) (ESF) have been found in neonatal WLO-mice during the period of rapid growth. If the high ESF activity is due to the concomitant physiological anaemia of infancy alone, it should be possible to block erythropoiesis by hypertransfusion. Mice were hypertransfused starting on day 14, and killed on day 20. Although hypertransfusion reduced the ESF levels by approximately 55% (P less than 0.001), ESF levels were still detectable in the cell culture assay used (P less than 0.001). Moreover, hypertransfused mice showed active erythropoiesis in the bone marrow, and none had a reticulocyte count below 2%. No correlation was found between PCV and ESF in the hypertransfused animals (r = 0.07, P greater than 0.5), nor was there any difference in weight gain between control and hypertransfused mice (P greater than 0.5). These results show that hypertransfusion did not totally supress erythropoiesis in neonatal WLO-mice, which is different from hypertransfused adult mice. The data indicate that the high plasma ESF found in neonatal WLO-mice during the growth period are not due to the anaemia alone. These findings support studies indicating that regulation of erythropoiesis in the neonate differs from the adult. Factors related to growth per se could be responsible for this difference.

Plasma erythropoiesis stimulating factor(s) in neonatal mice: in vitro dose response and chromatography studies.

High levels of plasma erythropoiesis stimulating factor(s) (ESF) have been found in neonatal WLO-mice during rapid growth. A previous study on hypertransfused neonatal animals indicated that the high ESF could not be due to the concomitant postnatal anemia alone. The present investigation was performed to answer the question: Is the high plasma ESF in neonatal WLO-mice erythropoietin (Ep) alone, or Ep in combination with other factors? The ESF of plasma from 20-day-old animals and standard Ep were compared in a cell culture assay for ESF based on erythroid colony formation, and also by means of gel filtration chromatography and affinity chromatography. Nonfractionated plasma and standard Ep showed parallel dose response curves and additive activity in the ESF assay. After gel filtration the detectable ESF of plasma was eluted in the same position as that of standard Ep, corresponding to an estimated molecular weight range of 34-65,000 daltons. The ESF of intact plasma, fractionated plasma, and standard Ep were identically bound to and eluted from the affinity chromatography column. These results show that the ESF of plasma from 20-day-old animals can neither be separated into several factors, nor distinguished from that of standard Ep by the methods used. It is therefore concluded that the high plasma ESF found in neonatal WLO-mice probably consists of Ep alone.

Erythropoietic factors in plasma from neonatal mice. In vivo studies by the exhypoxic polycythaemic mice assay for erythropoietin.

The erythropoiesis stimulating factor(s) (ESF) in plasma from 20-day-old WLO-mice have previously been studied by a cell culture assay, and also by means of gel filtration chromatography and affinity chromatography. It was concluded that the high levels of ESF found in the neonatal mouse plasma probably consisted of erythropoietin (Ep) alone. The objective of the present investigation was to obtain further information of whether this high ESF found in vitro is Ep alone, or Ep in combination with other factors. To accomplish this plasma from 20-day-old WLO mice and a standard Ep were studied in vivo by the exhypoxic polycythaemic mice assay for Ep, with and without preincubation with rabbit anti-Ep serum (AS). Aliquots of some samples were also studied in vitro by the exhypoxic polycythaemic mice assay for Ep, with and without pre- in both assays (P less than 0.001). However, incubation with AS significantly reduced (P less than 0.001) but did not totally block either the in vivo or the in vitro activity of the plasma (P less than 0.005). This also was the case regarding the in vivo activity of the standard Ep (P less than 0.001), while the in vitro activity of this Ep preparation was totally blocked by incubation with AS (P greater than 0.3). These results indicate that a considerable part of the high erythropoietic stimulatory activity found in plasma from 20-day-old mice, with both assays, is Ep. This supports the previous in vitro studies. However, the present results also support the conclusion that part of the activity is due to non-Ep stimulatory factors.

Variations in erythropoiesis throughout a lifetime. Studies in a high-leukaemic mouse strain, the AKR/O strain, and a non-leukaemic strain, the WLO strain.

We have studied the development of some haematological variables: erythropoiesis stimulating factor(s) (ESF), investigated with an in vitro cell culture assay; and the content of bone marrow and spleen erythroid colony forming unit(s) (CFU-E) and erythroid burst forming unit(s) (BFU-E) throughout the lifetime of 2 different mouse strains: the high-leukaemic, retrovirus infected AKR/O strain, and the non-leukaemic WLO strain. During the recovery phase of the postnatal anaemia, a peak in plasma ESF occurs in both strains. In young adult mice of both strains another peak in plasma ESF occurs at 70-110 days of age, associated with an increased number of bone marrow CFU-E, in a period when packed cell volume (PCV) remains stable. As the animals grow older PCV decreases, whereas plasma ESF and bone marrow CFU-E concentration increase. These results, together with in vitro dose-response studies, suggest reduced sensitivity to erythropoietin (Epo) of the ageing erythron. Throughout, the AKR/O strain has higher levels of plasma ESF and bone marrow CFU-E concentrations than the WLO strain, indicating both a reduced Epo responsiveness and some degree of ineffective erythropoiesis in the AKR/O strain. At all ages the AKR/O strain has a high concentration of Epo independent bone marrow CFU-E, possibly caused by the virus infection of precursor cells.

Regulation of erythropoiesis in suckling rabbits with and without postnatal anemia: partial suppression of production/release of erythropoiesis stimulating factor(s) by iron supplements.

The postnatal anemia in rabbits is accompanied by a marked rise in the plasma erythropoiesis stimulating factor(s) (ESF). The purpose of this study was to establish whether the increase in plasma ESF is only related to the anemia, or whether other mechanisms also are involved. Two matched groups of rabbits were studied from the 15th to the 36th day after birth. One group received iron parenterally and had no postnatal fall in hemoglobin concentration (Hb), the other developed the usual anemia. In both groups plasma ESF was undetectable on the 15th day, and also on the 22nd day, despite a marked fall in Hb in the untreated group and rise in the iron-treated group. Thereafter plasma ESF showed a slight, continuous rise in the nonanemic rabbits, in contrast to a marked, transient rise with maximum on the 29th day in the untreated group. On the 36th day there was no difference between the groups. In the iron-treated group the reticulocyte production rate remained unchanged, while the Hb mass rose continuously. In the untreated animals there was an initial decline in reticulocyte production rate, while Hb mass showed a slight increase. From the 29th day, however, reticulocyte production rate rose to the same level as in the iron-treated group and Hb mass rose markedly. In conclusion, the rise in plasma ESF during the postnatal anemia in rabbits is only in part related to the low Hb. Hypoxia-independent mechanisms, probably related to the growth and maturation per se also are involved. The lack of erythropoietic response to the rise in plasma ESF is due to lack of available iron.

Erythropoiesis-stimulating factor(s), erythropoiesis and erythrocyte 2,3-diphosphoglycerate in young rabbits with marked post-natal fall in haemoglobin.

The erythropoietic activity and erythrocyte 2,3-diphosphoglycerate (2,3-DPG) were studied during and after the nadir of the post-natal anaemia in normal, rapidly growing rabbits, from the 12th to the 35th day after birth. Whole blood haemoglobin (Hb) decreased from 9.3 g dl-1 on the 12th to 4.9 g dl-1 on the 25th day, while erythropoiesis-stimulating factor(s) (ESF) in plasma (determined by a cell culture assay) concomitantly rose from undetectable to high levels. In spite of marked rise in body weight, from 250 to 480 g, estimated haemoglobin mass (Hb mass) and reticulocyte mass production rate (Rt prod) remained essentially the same, about 1.8 g and 0.3 ml day-1. From the 25th to the 35th day, ESF decreased to a lower level, while Hb increased to 10.8 g dl-1 and Hb mass and Rt prod rose sharply, to 6.9 and 1.2 ml day-1. The 2,3-DPG rose markedly during the observation period, but showed a transient decline on the 29th day, simultaneously with the peak in reticulocyte counts (Rt) (24%) and release of young erythrocytes with low 2,3-DPG. The data indicate that the regions governing the erythropoietin production/release became increasingly sensitive to hypoxia during the observation period. The possibility also exists that the increase in ESF was due only in part to hypoxic stimulation. It could be related to the maturation of the animal in other ways, such as shift from extra-renal to renal erythropoietin production and the growth. The lack of response to increasing stimulation indicates that the erythropoiesis was restricted by the availability of iron and/or other factors necessary for erythrocyte and haemoglobin production.

Immunoreactive erythropoietin and erythropoiesis stimulating factor(s) in plasma from hypertransfused neonatal and adult mice. Studies with a radioimmunoassay and a cell culture assay for erythropoietin.

The objective was to study whether the high erythropoietic stimulatory activity found in plasma from neonatal mice during the growth period is erythropoietin (Ep) alone, or Ep in combination with other factors. Plasma from hypertransfused neonatal (20 d) and adult (13-20 weeks) mice were compared with a radioimmunoassay (RIA) and a cell culture assay for Ep. The RIA determines immunoreactive Ep (iEp) while the cell culture assay reflects erythropoiesis stimulating factor(s) (ESF). Compared to control values, hypertransfusion resulting in PCVs of 55% and higher reduced the mean iEp levels in neonatal and adult mice by 82% and 38%, respectively (P less than 0.01). There was no detectable difference between the mean iEp levels of hypertransfused neonatal and adult animals (P greater than 0.3). The parallel ESF data showed a reduction in mean plasma ESF levels by 68% in hypertransfused neonatal and 72% in hypertransfused adult animals (P less than 0.001). And notably, in contrast to the iEp data, the mean ESF level found in hypertransfused neonatal mice with PCVs of 55% and higher was significantly above that of hypertransfused adult animals (P less than 0.001). No correlation was found between PCV and iEp (r less than 0.4, P greater than 0.1) or ESF (r less than 0.2, P greater than 0.2) in hypertransfused animals. The parallel data from the two Ep assays show that plasma from hypertransfused 20-d-old mice contain one or more erythropoietic stimulatory factors not detected by the RIA. It is concluded that part of the high erythropoietic stimulatory activity found in plasma from neonatal mice is due to non-Ep factors.

Correlation of plasma erythropoiesis stimulating factor(s) and immunoreactive erythropoietin levels during rapid growth in the mouse.

During the early neonatal period of rapid growth in the mouse, increased plasma levels of erythropoiesis stimulating factor(s) (ESF) have been found when measured by an in-vitro bioassay technique. It is unclear whether these increased ESF levels represent increased levels of circulating erythropoietin (Ep) alone or Ep in combination with other less-defined erythropoietic stimulatory factors. To examine this issue, plasma from neonatal mice of varying post-natal ages and from normoxic and hypoxic adult mice was studied. We found that plasma Ep levels measured by radioimmunoassay (RIA) correlated significantly with in-vitro bioassayed ESF levels (r = 0.84, P less than 0.0001, n = 21). Although an in-vivo bioassay for plasma Ep proved too insensitive for rigorous correlation with data from the RIA and in-vitro bioassay, the in-vivo data were in qualitative agreement with the other two, more sensitive, assays. In all three assays the highest plasma levels were observed in the 20-day-old mice and in adult mice which had been subjected to hypobaric hypoxia for 8 h. Based on the strong agreement of the results obtained with the RIA and the in-vitro bioassay in both neonatal and adult mouse plasma, we conclude that the high plasma ESF levels of 20-day-old mice measured with the in-vitro bioassay are largely immunochemically identifiable Ep. However, the data also suggest the presence of non-Ep factors in neonatal plasma which stimulate the in-vitro bioassay.

The effects of biosynthetic insulin-like growth factor-1 supplementation on somatic growth, maturation, and erythropoiesis on the neonatal rat.

Somatomedins are anabolic hormones that may stimulate growth during the perinatal period. To test this hypothesis, neonatal rats were injected with a biosynthetic somatomedin, insulin-like growth factor 1 (IGF-1) twice daily for the first 2 wk of life. Two biosynthetic IGF-1 preparations of different potency were tested as well as a preparation of human growth hormone in five litters of rats. When compared to saline-injected rats, IGF-1 injected rats had increased body weight and tail length as well as specific increases in weights of liver, brain, heart, and testes. In addition, significant increases in bone marrow erythropoietic cell precursors were apparent after IGF-1 injection. IGF-1-treated neonatal rats also exhibited precocious eye opening as a sign of epithelial cell differentiation. Five additional litters of rats received similar injections but were exposed to postnatal nutritional deprivation via artificially increasing litter size. Although IGF-1 caused stimulation of bone marrow erythropoiesis and precocious eye opening, no effects of IGF-1 on somatic or organ growth could be documented. This represents the first demonstration in vivo of the anabolic effects of IGF-1 in rapidly growing neonatal rats but suggests that nutritional sufficiency may also be necessary for the full expression of somatomedin effects.

[Liver transplantation in Norway. Results after 10 years and 114 transplantations]. / Levertransplantasjon i Norge. Resultater etter ti års aktivitet og 114 transplantasjoner.

A total of 114 liver transplantations were performed in 106 patients in Norway during 1984-1994. Survival after one year was 65% and after three years 57%. The most frequent causes of death were infections and rejections. The survival rate improved considerably during the period, and after 1990 the 1 year survival was 70%. Approximately 2/3 of the patients return to work or education. Very few patients die later than 12 months after the transplantation. The most frequent indications were primary biliary cirrhosis, metabolic liver disease, primary sclerosing cholangitis, autoimmune cirrhosis and fulminant liver failure. The number of liver transplantations (approximately 4 per million inhabitants) is lower in Norway than in the other Nordic countries. The number should be increased to 7-8 per million inhabitants.