Alpha-fetoprotein and tumour size are associated with microvascular invasion in explanted livers of patients undergoing transplantation with hepatocellular carcinoma.

BACKGROUND: To determine factors associated with outcomes and microvascular invasion (MVI) in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). METHODS: Between July 1996 and August 2008 at the Universities of Kentucky or Tennessee, LT recipients were retrospectively analysed. RESULTS: One hundred and one patients had HCC in the explanted liver; one patient was excluded because of fibrolamellar histology. Seventy-nine (79%) were male and 81 (81%) were older than 50. HCC was incidental in 32 patients (32%). Median follow-up was 31 months. Ten patients (10%) developed recurrence, which was associated with poor survival (P= 0.006). Overall 1-, 3-, and 5-year survival rates were 87%, 69% and 62%, respectively. Excluding patients with lymph node metastasis (LNM) or MVI yielded 91%, 81% and 75% survival at the same time points. MVI was independently associated with recurrence (OR 28.40, 95% CI 1.77-456.48, P= 0.018) and decreased survival (OR 4.70, 95% CI 1.24-17.80, P= 0.023), and LNM with decreased survival (OR 6.05, 95% CI 1.23-29.71, P= 0.027). Tumour size (OR 4.1, 95% CI 1.2-13.5, P= 0.013) and alpha-fetoprotein (AFP) > 100 (OR 5.0, 95% CI 1.4-18.1, P= 0.006) were associated with MVI. CONCLUSIONS: MVI greatly increases the risk of recurrence and death after LT for HCC, and is strongly associated with tumour size and AFP > 100.

Obesity, diabetes, and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients.

OBJECTIVE: To investigate independent contributions of obesity, diabetes, and smoking to resource utilization in patients following liver resection. SUMMARY BACKGROUND DATA: Despite being highly resource-intensive, liver resections are performed with increasing frequency. This study evaluates how potentially modifiable factors affect measures of resource utilization after hepatectomy. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) public-use database was queried for patients undergoing liver resection. Resource variables were operative time (OT), intraoperative transfusion, length of stay (LOS), ventilator support at 48 hours, and reoperation. Bivariable and multivariable linear and logistic regressions were performed. RESULTS: There were 1029 patients identified. Most resections involved less than a hemiliver (599 patients, 58.2%). Mean BMI was 28.0 +/- 6.0. Mean OT was 253 +/- 122 minutes (range, 27 to 794) but varied by procedure (P < 0.001). Mean LOS was 8.7 +/- 10.7 days (range, 0 to 202). Morbid obesity added 48 minutes to OT (P = 0.018), 1.1 units to transfusions (P = 0.049), 2.2 days to LOS (P < 0.001), and accounted for delayed ventilator weaning (odds ratio, 4.5; P = 0.022). Underweight patients had shorter OT, but stayed 3.3 days longer than normal weight patients (P < 0.001). Insulin-treated patients with diabetes had longer OT (P < 0.001), increased transfusions (P < 0.001), and delayed ventilator weaning (odds ratio, 6.7; P < 0.001), while orally-treated patients with diabetes showed opposite trends. Smokers stayed 1.9 days longer (P < 0.001), with increased risk of prolonged ventilation (odds ratio, 3.3; P = 0.002) and reoperation (odds ratio, 2.3; P = 0.015). CONCLUSION: Obesity, diabetes, and smoking are each associated with important components of healthcare expenditure. Education and prevention programs are needed to limit their impact on overall resource utilization.

An in vitro study of liposomal curcumin: stability, toxicity and biological activity in human lymphocytes and Epstein-Barr virus-transformed human B-cells.

Curcumin is a multi-functional and pharmacologically safe natural agent. Used as a food additive for centuries, it also has anti-inflammatory, anti-virus and anti-tumor properties. We previously found that it is a potent inhibitor of cyclosporin A (CsA)-resistant T-cell co-stimulation pathway. It inhibits mitogen-stimulated lymphocyte proliferation, NFkappaB activation and IL-2 signaling. In spite of its safety and efficacy, the in vivo bioavailability of curcumin is poor, and this may be a major obstacle to its utility as a therapeutic agent. Liposomes are known to be excellent carriers for drug delivery. In this in vitro study, we report the effects of different liposome formulations on curcumin stability in phosphate buffered saline (PBS), human blood, plasma and culture medium RPMI-1640+10% FBS (pH 7.4, 37 degrees C). Liposomal curcumin had higher stability than free curcumin in PBS. Liposomal and free curcumin had similar stability in human blood, plasma and RPMI-1640+10% FBS. We looked at the toxicity of non-drug-containing liposomes on (3)H-thymidine incorporation by concanavalin A (Con A)-stimulated human lymphocytes, splenocytes and Epstein-Barr virus (EBV)-transformed human B-cell lymphoblastoid cell line (LCL). We found that dimyristoylphosphatidylcholine (DMPC) and dimyristoylphosphatidylglycerol (DMPG) were toxic to the tested cells. However, addition of cholesterol to the lipids at DMPC:DMPG:cholesterol=7:1:8 (molar ratio) almost completely eliminated the lipid toxicity to these cells. Liposomal curcumin had similar or even stronger inhibitory effects on Con A-stimulated human lymphocyte, splenocyte and LCL proliferation. We conclude that liposomal curcumin may be useful for intravenous administration to improve the bioavailability and efficacy, facilitating in vivo studies that could ultimately lead to clinical application of curcumin.

Cyclosporin A up-regulates and activates protein kinase C-zeta in EBV-infected and EBV-transformed human B-cells.

BACKGROUND: Protein Kinase C (PKC) is a family of enzymes that plays a key role in cell signaling pathways leading to cellular activation and proliferation. Conventional PKC (cPKC) is dependent on calcium for activation. We have proposed that cyclosporin A (CsA), despite being a calcineurin inhibitor, will activate PKC in B cells, thus promoting Epstein-Barr virus (EBV)-induced transformation. Here we show that CsA promoted atypical PKC isoform PKC-zeta in B cells. MATERIALS AND METHODS: Western-blot was used to assay PKC-zeta protein level in EBV-B cells. Confocal microscopy was used to assay PKC-zeta translocation from cytosol to cell membrane, a known process of PKC activation. RESULTS: CsA (500 ng/mL) time dependently increased PKC-zeta from control of 7055 units to 7145, 10,805, 10,914, and 12,705 units, respectively, after 15 min, 1 h, 12 h, and 24 h of incubation in EBV-transformed human B-cell line (LCL). CsA increased PKC-zeta expression was inhibited 50% by Vit.E (40 microM) indicating that this effect may be due to oxidative stress induced by CsA. Indeed, after oxidant H(2)O(2) (0.1 mM) treatment, PKC-zeta protein level in LCL cells increased 124%, 257%, 349%, and 359% after 15 min, 1 h, 12 h, and 24 h of culture compared with control. Addition of Vit.E (40 microM) in H(2)O(2) (0.1 mM) treatment and then with Vit.E in the culture decreased PKC-zeta level in LCL cells 26%, 20%, 41%, and 60% after 15 min, 1 h, 12 h, and 24 h of culture. In confocal microscopy in Jurkat T cell line, phorbol 12-myristate 13-acetate (PMA) activated cPKC isoform PKCalpha after 30 min treatment and activated PKC-zeta after 60 min treatment. CsA inhibited PMA activation of PKC-alpha, but not PKC-zeta. CsA alone did not activate PKC-alpha or PKC-zeta in Jurkat T cells. In LCL and in EBV-infected human B-cells, PMA stimulated PKC-alpha activation after 30 min treatment and stimulated PKC-zeta activation after 60 min treatment. CsA inhibited PMA activation of PKC-alpha, but not PKC-zeta. In addition, CsA activated PKC-zeta in the EBV-transformed and EBV-infected human B cells. CONCLUSION: These experiments show that CsA-induced oxidative stress caused PKC-zeta up-regulation in LCL cells, and show the differential effect of CsA in the PKC signaling pathways in T cells versus B cells. CsA-induced PKC-zeta activation may be an important signaling step in EBV-induced post-transplant lymphoproliferative disorders.

Seatbelt injury resulting in functional loss of a transplanted kidney.

The transplanted kidney, lying heterotopically in the iliac fossa, is especially vulnerable to damage from blunt trauma, particularly compression by vehicle seatbelt. We present a case wherein a functioning renal allograft lying in the right iliac fossa was severely injured by seatbelt compression, resulting in significant functional compromise and eventual loss. The patient later underwent successful retransplantation with a second living donor kidney. Management of injured renal transplant recipients requires appreciation of mechanisms likely to cause damage to the graft, as well as familiarity with available treatment options, both surgical and nonsurgical. As functional life spans of renal allografts improve, this type of injury will most likely be encountered with increasing frequency.

Cyclosporin A-induced lipid and protein oxidation in human B-cells and in Epstein-Barr virus-infected B-cells is prevented by antioxidants.

The incidence of post-transplant lymphoproliferative disorder (PTLD) has increased since cyclosporin A (CsA) became the mainstay of transplant immunosuppression. We have previously shown that, in addition to its potent immunosuppressive property, CsA-induced oxidative stress plays an important role in Epstein-Barr virus (EBV)-related PTLD. Using lipid hydroperoxide and malondialdehyde as markers of lipid oxidation, and protein carbonyls as markers of protein oxidation, we further investigated the in vitro effect of CsA on human B cells and EBV-infected human B cells. We found that CsA at 500 ng/ml, a relatively safe and effective blood concentration in organ transplant recipients, induced the highest lipid hydroperoxide and malondialdehyde after 10 min of treatment in time- and concentration-related kinetic studies. We also found that treatment with CsA at 500 ng/ml for 10 min increased the EBV-infected B cell protein carbonyl formation as assayed by immunoblot method. CsA-induced lipid and protein oxidation could be inhibited by vitamin E, N-acetyl cysteine, and pyrollidine dithiocarbamate. CsA significantly promoted the EBV-B cell transformation as assayed by colony counting, cell counting, and (3)H-thymidine incorporation. Our recent study provides further evidence to support the hypothesis that CsA exerts direct oxidative stress in EBV-infected as well as non-EBV-infected human B cells. A greater understanding of these cellular and molecular mechanisms may benefit the clinical practice and prevention of PTLD.

Surgical treatment of a rare primary renal carcinoid tumor with liver metastasis.

BACKGROUND: Carcinoid tumors are characteristically low grade malignant neoplasms with neuroendocrine differentiation that arise in various body sites, most commonly the lung and gastrointestinal tract, but less frequently the kidneys, breasts, ovaries, testes, prostate and other locations. We report a case of a carcinoid of renal origin with synchronous single liver metastases on radiological studies. CASE PRESENTATION: A 45 year-old patient who presented with abdominal pain was found on CT scan to have lesions in the right ovary, right kidney, and left hepatic lobe. CA-125, CEA, and CA 19-9 were within normal limits, as were preoperative liver function tests and renal function. Biopsy of the liver mass demonstrated metastatic neuroendocrine tumor. At laparotomy, the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, radical right nephrectomy with lymphadenectomy, and left hepatectomy. Pathology evaluation reported a right ovarian borderline serous tumor, well-differentiated neuroendocrine carcinoma of the kidney (carcinoid) with 2 positive retroperitoneal lymph nodes, and a single liver metastasis. Immunohistochemistry revealed that this lesion was positive for synaptophysin and CD56, but negative for chromogranin as well as CD10, CD7, and CD20, consistent with a well-differentiated neuroendocrine tumor. She is doing well one year after her initial surgery, with no evidence of tumor recurrence. CONCLUSION: Early surgical intervention, together with careful surveillance and follow-up, can achieve successful long-term outcomes in patients with this rare malignancy.

Analysis of smoking in patients referred for liver transplantation and its adverse impact of short-term outcomes.

Smoking has been reported to adversely affect the outcome of patients undergoing liver transplantation (LT). We present a clinical and demographic analysis of smoking in patients from a rural Appalachian region referred to our center for LT. We reviewed 237 consecutive patients referred for LT between January 2002 and December 2003. We also reviewed charts of 65 patients that underwent LT at our center during this period and analyzed the length of stay (LOS), one-year survival post LT, and hospital charge information. The mean MELD score was similar between smokers and nonsmokers at the time of referral (12.3 vs. 12.1, respectively, p = 0.8). Smokers had a tendency towards a higher CPT score (8.2 vs. 7.9, p = 0.06). The incidence of difficult-to-manage ascites and encephalopathy was significantly higher in smokers (p < 0.O1 for both ascites and encephalopathy). Of the 65 patients that underwent LT, 69.2% were smokers. While one-year post LT survival was similar (approximately 90%) for both smokers and nonsmokers, the mean length of stay and hospital charge for smokers was significantly higher (13.4 vs. 7.9 days; P = .02 and $129,185 vs. $99,694; P = .02). In conclusion, smokers have a higher incidence of ascites and encephalopathy and thus may be disadvantaged by the MELD allocation scheme for liver transplantation. While post-transplant one-year survival is similar between smokers and nonsmokers, smokers have higher LOS and resource utilization.

ERCP in the management of early versus late biliary leaks after liver transplantation.

The role of endoscopy in the management of bile leaks following liver transplantation has been controversial. Bile leak after liver transplantation has an incidence of approximately 10% to 15%, and the choice of observation, laparotomy, or endoscopic retrograde pancreatography (ERCP), usually with sphincterotomy and/or placement of a bile duct stent, has depended on the transplant groups' experience and the availability of skilled endoscopists. We report our experience in the management of bile leaks following orthotopic liver transplantation. Between July 11, 1995, and January 22, 2003, there were 174 whole-liver-graft orthotopic liver transplant procedures performed at the University of Kentucky. In 158 of these, the initial bile duct management was by choledochocholedochostomy (duct-to-duct anastomosis) over a small-caliber T-tube. Bile leaks were diagnosed in 21 of 158 patients, with an incidence of 13.3%. Of the early leaks (<30 days post-transplantation), 2 were managed with observation alone, and 12 underwent ERCP. This revealed five anastomotic leaks requiring laparotomy. Of the seven leaks occurring later, six were managed by ERCP and one required laparotomy. With a median follow-up period of 18 months, 18 patients (85.7%) are alive with no further biliary tract problems. ERCP remains a useful adjunct in the management of post-liver transplant bile leaks. It is, however, less likely to be successful in the definitive management of early leaks.

Orthotopic liver transplantation in hepatocellular carcinoma: comparison of results in incidental and known hepatocellular carcinoma.

Liver transplantation (LTx) is known therapy for hepatocellular carcinoma (HCC). We undertook a retrospective chart review and analysis of our experience with 19 patients with HCC who had undergone LTx between June 1995 and January 2003. We compared the results of 12 patients with known HCC (group I) with that of 7 patients with incidental HCC (group II). We found that the incidence of multifocal disease, lymphatic involvement, and tumor-free survival was not significantly different between the two groups. One patient in group I died of tumor. Patient survival was better in group II (100%), with a median follow-up of 45 months, as 4 more patients in group I (with known HCC) died of reasons unrelated to tumors, with a median follow-up of 23 months. We conclude that LTx in patients with either incidental or known HCC results in excellent tumor-free survival.

Stimulation of Epstein-Barr virus-infected human B cell growth by physiological concentrations of 4-hydroxynonenal.

We had previously shown that cyclosporin A (CsA) directly promoted the immortalization of Epstein-Barr virus (EBV)-infected human B cells (EBV-B cells) via an oxidative stress mechanism. 4-Hydroxynonenal (HNE) is a reactive end-product of lipid peroxidation. We hypothesized that HNE may mediate a direct oxidative stress-promoting effect of CsA on EBV-B cells. HNE-protein adducts in CsA-treated EBV-B cell extracts were assayed immunochemically using a Slot-Blot method. Cell proliferation was assayed by [(3)H]-thymidine incorporation. EBV oncogene latent membrane protein-1 (LMP1) expression was assayed by using PE-conjugated anti-LMP1 antibody in flow cytometry. We found that CsA at 500 ng ml(-1) and 1000 ng ml(-1) significantly increased the level of HNE-protein adducts in EBV-B cells over the control (arbitrary units +/- SE) by 251.3 +/- 7.5 to 361.3 +/- 9.7 and 342.7 +/- 10.7, respectively (p < 0.05, n = 3). EBV-B cells treated with a physiological concentration of HNE (1 microM) for 0.5 and 1 h and cultured for 2 and 4 weeks showed significantly increased [(3)H]-thymidine incorporation. EBV-B cells treated with HNE (1 microM) for 1 h and subsequently cultured for 2 and 4 weeks had a significantly higher ( > 2.0 times) LMP1-positive cell population over the control. In conclusion, in accordance with our previous findings, we show that CsA treatment of EBV-B cells results in increased production of the lipid peroxidation reactive end-product HNE that directly promotes EBV-B cell proliferation and LMP1 expression. This observation provides evidence for further understanding the mechanism of CsA-induced oxidative stress on EBV-related post-transplant lymphoproliferative disorder (PTLD).

University of Kentucky experience with laparoscopic live donor nephrectomy using two different techniques.

Laparoscopic live donor nephrectomy (LDN) is becoming increasingly popular for its minimum donor morbidity and accelerated return to work. Hand-assisted laparoscopic donor nephrectomy (HALDN) may be more acceptable if the modified technique would offer easier performance. We compared our experience with HALDN and conventional LDN. From November 1998 to June 2004, two groups of patients underwent conventional LDN (n = 71) or HALDN (n = 12). Operative and extraction times, complications, and immediate graft function were compared. Mean operative and extraction times are significantly shorter in the HALDN group (206.7 versus 143.4 minutes and 225 versus 141 seconds). Two in the LDN group required open conversion (3%). Three in the LDN group showed delayed graft function (4%). Three in the LDN group developed graft renal artery thrombosis (4%). There was no ureteral complication in both groups. HALDN provides shorter operative and extraction times and better recipient surgeon satisfaction without increasing donor morbidity.

Recipient outcome following living donor kidney transplantation using kidneys procured laparoscopically.

BACKGROUND: Laparoscopic live donor nephrectomy is becoming increasingly popular as it has been shown to minimize donor morbidity, length of hospital stay and length of time to return to work. Initial experience suggested that kidneys procured laparoscopically had higher rates of delayed graft function and ureteric complications but with increasing experience, these complications have become less common. METHODS: Retrospective chart review of all patients who underwent living donor kidney transplant using kidneys procured laparoscopically at our centre was performed. From the initiation of the laparoscopic donor nephrectomy programme at our institution in November 1998 until February 2002, we performed 71 living donor kidney transplants (69 kidneys procured laparoscopically and two procured by open donor nephrectomy after failed laparoscopic approach). Donor left kidney was used in all except in one patient. Mean duration of warm ischaemia time was 206 +/- 79 s. RESULTS: The mean age of the recipients was 42 +/- 15 years (range 1-68) including five paediatric recipients (age < 18 years). There were 48 males and 23 females. Nine (13%) were retransplants (seven second transplants and one each of third and fourth transplants). Two patients died with functioning grafts and four patients lost the graft (three thrombosis, one anastomotic rupture). No patient developed ureteric complications. The incidence of delayed graft function (need for dialysis in the first week post-transplant) was 4%. Patient and graft survival rates (actual) were 97% and 91%, respectively. Mean length of hospital stay was 9 +/- 7 days (median 7 days). CONCLUSIONS: Recipient outcome is not compromised and excellent results can be achieved with living donor kidney transplantation using laparoscopically procured kidneys.

Simultaneous kidney-pancreas transplantation in a patient with small lymphocytic lymphoma.

BACKGROUND: Experience with organ transplantation in patients with indolent lymphoma is limited, and it is unknown how the natural history of the disease is altered by chronic immunosuppressive therapy. METHODS: A patient with type 1 diabetes and renal failure who underwent simultaneous kidney-pancreas transplantation was found to have stage IV small lymphocytic lymphoma at the time of transplantation. He received quadruple immunosuppressive therapy using interleukin (IL)-2 receptor antibody, tacrolimus, mycophenolate mofetil, and prednisone. RESULTS: Patient is doing well 3 years posttransplant with excellent graft function of both the kidney and pancreas without any evidence of progression of the disease. CONCLUSION: Indolent lymphoma should not be considered an absolute contraindication to organ transplantation.

Transjugular intrahepatic portosystemic shunt migration in patients undergoing liver transplantation.

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful procedure for patients with variceal bleeding and refractory ascites. Migration of TIPS can potentially complicate the subsequent transplant procedure. The aim of this study was to compare survival, operating time, and blood transfusion requirements in patients with migrated and nonmigrated TIPS undergoing liver transplantation. Of 152 patients, 21 received TIPS; stent migration was noted in seven patients-six distally and one proximally. Mean age of the patients was 54 +/- 11 years (range, 27-65 years), and there were 12 men and 9 women. The etiology of liver disease included the following: hepatitis C virus, six patients; cryptogenic cirrhosis, seven patients; alcoholic cirrhosis, four patients; primary biliary cirrhosis, three patients; and autoimmune hepatitis, one patient. The mean Child-Pugh-Turcotte score was 10 +/- 2. Mean length of hospital stay for patients with migrated TIPS was 22.2 days and for nonmigrated TIPS was 23.5 days. Patient and graft survival (actual) was 81% in both groups with a mean follow-up of 27.9 months. Migration of TIPS is not rare, and in our study it did not affect survival, length of surgery, or blood transfusion requirements compared with patients in whom TIPS had not migrated.