Nutrition support with glutamine dipeptide in patients undergoing liver transplantation.

AIM: The effect of total parenteral nutrition (TPN) support supplemented with alanyl-glutamine (Ala-Gln) dipeptide was investigated in a randomized, controlled clinical trial. METHODS: Sixty-five patients with the diagnosis of end-stage liver disease or hepatic cellular carcinoma admitted for orthotopic liver transplantation were randomly divided into 3 groups: diet group (n = 21), TPN group (n = 22), and Gln group (n = 22). Patients in the TPN and Gln groups received isocaloric and isonitrogenous TPN for 7 days. Venous heparin blood samples were obtained for assay on days 2 and 9 after surgery; we performed routine pathologic tests. RESULTS: Compared with the results on day 9 in the TPN group, there was a significant increase in the prognostic nutrition index and in prealbumin among the Gln group. Aspartate aminotransferase improved significantly by Gln treatment compared with traditional TPN support (P < .05). The pathologic results also showed Gln supplementation to reduce hepatic cell injury. A significant decrease in postoperative hospital stay was observed in the Gln group. CONCLUSIONS: Posttransplant TPN support greatly improved protein metabolism and nutritional state of patients. TPN with Ala-Gln helped to improve synthetic function and to reduce the injury to a transplanted liver.

Growth factor-induced mobilization of dendritic cells in kidney and liver of rhesus macaques: implications for transplantation.

Hematopoietic growth factors (HGF) mobilize potential tolerogenic cells in transplant donors. Fms-like tyrosine kinase 3 ligand (Flt3L) mobilizes stem cells and dendritic cells (DCs) in human and nonhuman primate blood. Blood and renal and liver biopsies were obtained from untreated and Flt3L-mobilized rhesus macaques. Flt3L increased the number of myeloid CD11c(hi) and plasmacytoid CD123(hi) precursors in blood and both myeloid CD11c(+) HLA-DR(+) fascin(+) (CD45RA(-)) DCs and putative plasmacytoid CD11c(lo) CD45RA(hi) DC precursors in liver and kidneys, without affecting organ function. DC in Flt3L-treated monkeys were concentrated in the glomeruli and interstitium of kidneys, and in the portal triads and parenchyma of liver. These DCs exhibited the phenotype of immature antigen-presenting cells (APCs; CD83(-) CD86(lo) CCR5(+) CCR7(-)). HGF-induced changes reversed significantly within 7 days of Flt3L withdrawal. Therapeutic protocols that mobilize donor hematopoietic cells should consider the influence of HGF on the APC constituency of prospective organ allografts.

New photonic technologies for the treatment and diagnosis of hepatic diseases: an overview of the experimental work performed in collaboration, between Physics Institute of São Carlos and Ribeirão Preto Faculty of Medicine of the University of São Paulo.

Recent advances in optical techniques have created a great range of possibilities for diagnosis and therapeutics in liver related diseases. With the uses of efficient light sources like lasers and LEDs (Light Emitting Diodes) it is possible to employ the light-tissue interaction to promote hepatic tissue regeneration after partial hepatectomy, to detect hepatocarcinoma and steatosis by utilizing optical fluorescence, to evaluate the metabolism of the liver during hepatic transplantation as well as to treat liver tumors. We present here an overview of the technique presently in development at the Ribeirâo Preto Faculty of Medicine-USP in cooperation with the Physics Institute of São Carlos-USP. The results obtained so far have been the subject of a list of publications and are here presented as an overview. A new perspective for modern application of optical techniques in different medical practices related to the liver is presented.

New photonic technologies for the treatment and diagnosis of hepatic diseases: an overview of the experimental work performed in collaboration, between Physics Institute of São Carlos and Ribeirão Preto Faculty of Medicine of the University of São Paulo / Novas tecnologias fotônicas no tratamento e diagnóstico de doenças hepáticas: uma revisão dos trabalhos experimentais realizados em colaboração, entre o Instituto de Física de São Carlos e a Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo

Recent advances in optical techniques have created a great range of possibilities for diagnosis and therapeutics in liver related diseases. With the uses of efficient light sources like lasers and LEDs (Light Emitting Diodes) it is possible to employ the light-tissue interaction to promote hepatic tissue regeneration after partial hepatectomy, to detect hepatocarcinoma and steatosis by utilizing optical fluorescence, to evaluate the metabolism of the liver during hepatic transplantation as well as to treat liver tumors. We present here an overview of the technique presently in development at the Ribeirâo Preto Faculty of Medicine - USP in cooperation with the Physics Institute of São Carlos -USP. The results obtained so far have been the subject of a list of publications and are here presented as an overview. A new perspective for modern application of optical techniques in different medical practices related to the liver is presented.

Recentes avanços em técnicas ópticas têm propiciado vasto campo de possibilidades tanto para o diagnóstico quanto para a terapêutica de doenças hepáticas.Com o uso de eficientes fontes de luz como o laser e Light emitting diodes (LED) é possível utilizar a interação luz-tecido para promover a regeneração hepática após hepatectomias parciais,detectar hepatocarcinoma, esteatose e outras alterações do fígado pelo uso da fluorescência óptica,para avaliar o metabolismo hepático durante o transplante de fígado e na abordagem diagnóstica e terapêutica de alterações hepatocelulares. Os autores apresentam uma ampla revisão de técnicas atualmente em desenvolvimento na Divisão de Gastroenterologia Cirúrgica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo num trabalho cooperativo com o Instituto de Física de São Carlos da USP. Os resultados obtidos até agora têm sido motivo de lista de publicações que são aqui apresentados em forma de revisão. Uma nova perspectiva de moderna aplicação de técnicas ópticas em várias situações clínico-cirúrgicas relacionadas com o fígado é apresentada e amplamente discutida.

Panax notoginseng saponins preconditioning protects rat liver grafts from ischemia/reperfusion injury via an antiapoptotic pathway.

BACKGROUND: Ischemia/reperfusion (I/R) injury is a major cause of primary graft dysfunction and renders an allograft more immunogenic in orthotopic liver transplantation (OLT). Panax notoginseng saponins (PNS) has been reported to exert protective effects against I/R injury to various organs. The objective of this study is to investigate whether PNS preconditioning protects rat liver grafts from I/R injury via an antiapoptotic pathway. METHODS: Male Sprague-Dawley rats were used as donors and recipients of orthotopic liver transplantation (OLT) and were divided into PNS preconditioning group(group P) and normal saline control group (group N) randomly according to whether PNS (50 mg/kg) was injected intravenously 1 hour before liver grafts harvesting, and sham group (group S). The animals were separately killed 2, 6 and 24 hours after reperfusion. Plasma samples were collected for test of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Liver tissues were collected to detect histological changes, apoptosis and the expression of TNF-alpha, Bcl-2 and Caspase-3 mRNA. RESULTS: The serum levels of ALT and AST and the apoptosis index (AI) of liver tissue in group P were lower than in group N significantly 2, 6 and 24 hours after reperfusion. Compared with group N, the expression of TNF-alpha and Caspase-3 mRNA was reduced significantly in group P 2 and 6 hours after reperfusion and the expression of Bcl-2 mRNA was enhanced significantly in group P 6 and 24 hours after reperfusion. CONCLUSIONS: PNS preconditioning protects liver grafts from I/R injury effectively in rat OLT via an antiapoptotic pathway. The antiapoptotic mechanisms of PNS may include inhibiting the expression of TNF-alpha and Caspase-3 and enhancing the expression of Bcl-2.

Nephrotoxic effects of immunosuppressant therapy in pediatric liver transplant recipients.

Drugs used for immunosuppression have been implicated in causing numerous long-term side effects including nephrotoxicity, glucose intolerance, and hyperlipidemia. In this study, we reviewed our pediatric liver transplant recipients in terms of glomerular filtration rate (GFR) as well as fasting glucose and lipid profiles. To date, 79 pediatric liver transplantations have been performed at our center: 24 transplantations of at least 5 months to a maximum of 7.3 years posttransplant are reviewed herein. The mean time posttransplantation was 2.1 years. Nine boys and 15 girls showed a distribution of 19 mixed race, 3 black, and 2 white patients. The mean age at the time of transplantation was 6.6 years (0.8-13.3 years) with 8 cases under the age of 3 years. All recipients started with Cyclosporine Neoral (CSA) as first line, but, at the time of testing, immunosuppression included 5 children on CSA and 19 on Tacrolimus. Radionuclide 51 Cr-EDTA Glomerular Filtration Rates (GFR) showed a range from 21 to 220 mL/min/1.73 m2 (mean 96.1, median 89.8). Seven cases had a GFR less than 75 mL/min/1.73 m2. Twenty-one children were on antihypertensives agents: 15 children on 1 agent and 6 children on 2 agents. On full fasting lipid profiles, the total cholesterol ranged from 2 to 7.9 mmol/L (mean 4.4). Only 1 child is currently on statin therapy. Fasting glucose ranged from 3.2 to 5.9 mmol/L (mean 4.1) No difference was observed in glucose values between CsA and Tacrolimus. Thus, immunosuppressive therapies, such as the calcineurin inhibitors, are known to cause nephrotoxicity, which is of concern in pediatric liver transplant recipients. Almost all our patients currently require antihypertensive therapy. At present, the renal function is adequate in the majority of the group, but this study needs to be extended to other pediatric liver transplant recipients with particular emphasis on those who are more than 5 years posttransplantation.

Effect of 1,25-dihydroxyvitamin D3 on preventing allograft from acute rejection following rat orthotopic liver transplantation.

AIM: To study the mechanism and the preventive role of 1,25-dihydroxyvitamin D3 in acute rejection following orthotopic liver transplantation. METHODS: Rats were randomly divided as donors or recipients for orthotopic liver allotransplantation model. Four groups were designed in the study, Group I: syngenic control (Wistar to Wistar); Group II: acute rejection (SD to Wistar); Group III: acute rejection treated with cyclosporine A, and Group IV: acute rejection treated with 1,25-(OH)2D3. Liver function, rejection activity index and mRNA of IFN-gamma, IL-10 in intragraft in recipients were measured in on day 1, 5, 7, 15, 30 posttransplant for assessing graft function, severity of acute rejection and immune state of recipients. RESULTS: Survival time of recipients in Group VI was significantly prolonged (over 100 days) in comparison with other groups (vs Group II, P<0.001; vs Group III, P>0.05). After treatment with 1,25-(OH)2 D3, mean value of all the assay tested on each experimental time was compared, liver function in group IV was significantly improved (AST 127+/-41 U/L-360+/-104 U/L, BIL 13+/-5 mmol/l-38+/-11 mmol/l; vs Group II, P<0.05; vs Group III, P>0.05. Rejection activity index was significantly decreased (0-3.3+/-1.6; vs Group II, P<0.05; vs Group III, P>0.05). Level of hepatic IFN-gamma mRNA in group IV was decreased, while level of hepatic IL-10 mRNA was increased (vs Group II, P<0.05; vs Group III, P>0.05). CONCLUSION: Our results indicated that 1,25-(OH)2D3 induced the secretion of cytokine toward to Th2 type, which would alleviate acute rejection, protect liver function and prolong survival of recipient after orthotopic liver transplantation.

Auxiliary partial orthotopic living donor liver transplantation as an aid for small-for-size grafts in larger recipients.

BACKGROUND: In countries where living donors are the only source of liver grafts, restrictions on graft size are a serious obstacle for the expansion of indications for adult recipients. To overcome this problem, auxiliary partial orthotopic liver transplants (APOLT*) was performed on the basis of the concept that the residual native liver would support the graft function until the graft had grown enough to function by itself. METHODS: APOLT as an aid for small-for-size (SFS) grafts was reviewed retrospectively to evaluate its feasibility. Between April 1995 and March 1998, 20 recipients underwent APOLT, which was indicated because of a SFS graft in 15 of them. The indication was based on the estimated graft/recipient's body weight ratio (GRWR). If the ratio was <0.8%, APOLT was performed. The other 5 patients had a graft with a GRWR >0.8% and underwent APOLT on the basis of the residual native liver supporting the graft function temporarily, 4 for supplementation of the defective enzyme in metabolic liver diseases and one for leaving the potential of the regeneration of the native liver in fulminant hepatic failure. The recipients who underwent APOLT because of a SFS graft were categorized as the SFS group, and the others were the second group. RESULTS: In the SFS group, the age of the recipients ranged from 13 to 48 (median 23). The original indications of this group were fulminant hepatic failure in 2 recipients, acute deterioration of chronic liver diseases in 3, Wilson's disease in 2, biliary atresia in 4, primary biliary cirrhosis in 3, and primary sclerosing cholangitis (PSC) in one. The actual GRWR ranged from 0.45 to 0.72 (median 0.55). The graft was implanted after resection of the left lateral segment of the native liver. Except in the first two patients, the portal vein to the residual native liver was completely transected so that all of the portal blood drained into the graft liver. This procedure was successful in 9 patients. The cause of death in the other 6 was mainly infection. The mortality rate among the recipients with signs of advanced liver failure, such as massive ascites or hepatic coma, was higher, even though APOLT was used to support the SFS graft. In the second group, in the other five recipients who underwent APOLT for other indications, one recipient with fulminant hepatic failure died of sepsis caused by the dehiscence of bilio-enteric anastomosis. CONCLUSIONS: APOLT as an aid for a SFS graft is technically viable. This procedure can thus expand the indication of living donor liver transplants for adult recipients when the native liver retains some functional capability to support the grafted liver during the immediate postoperative period.

[Orthotopic liver transplantation from a living adult donor to an adult using the right hepatic lobe]. / Transplantation hépatique orthotopique à partir de donneur vivant d'adulte à adulte avec un foie droit.

STUDY AIM: In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult. PATIENTS AND METHODS: In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt. RESULTS: The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intra-operatively the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation. CONCLUSION: Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.

On the correlation between tissue hydration state and proton NMR relaxation rates in experimental liver transplantation.

As the tissue hydration state is one of the most important parameters to predict viability cold stored livers before transplantation, we investigated the correlation between the tissue inverse total water fraction, reflecting the hydration state, and proton relaxation times in cold stored rat liver and orthotopic liver transplantation in a pig model. In cold stored rat liver excellent linear correlations between relaxation rates R1 (= 1/T1) and R2 (= 1/T2) and inverse total water fraction 1/Pw were obtained. In pig liver transplants, the slope and intercept obtained from a linear regression model are twice as high for R1 and almost identical for R2; however, correlation coefficients are lower due to increased biological variation and a smaller range in storage conditions, reflected by the range of water content. Proton nuclear magnetic resonance relaxation times measured during the cold storage on the whole organ non-invasively show also linear correlation with the inverse total water fraction, but the method is presently not accurate enough to estimate the hydration state of the liver tissue with sufficient precision. NMR relaxation times obtained from liver biopsies have the potential to predict tissue viability in experimental liver transplantation independent of species, strain and gender, and thus may be useful in estimating the viability of human donor livers (or at least add a new complementary information to the information gained by standard liver selection and function test before and after transplantation).

Effect of cyclosporine on distribution of macrophage subpopulations in rat hepatic allograft.

Macrophage subpopulations infiltrating the grafts of ACI(RT1a) to LEW(RT1(1)) orthotopic rat liver transplants treated with or without immunosuppressive therapy were studied using immunohistochemical staining. LEW recipients of ACI liver transplants experienced severe acute graft rejection, with a mean survival of only 10.2 +/- 0.7 days. An indirect immunoperoxidase technique on cryostat sections of the liver grafts was used to determine the localization of macrophage subpopulations infiltrating the grafts, as defined by specific anti-rat macrophage monoclonal antibodies, designated TRPM-1 (pan-macrophage), TRPM-3 (activated macrophage) and Ki-M2R (tissue macrophage). TRPM-1+ or TRPM-3+ cells gradually increased on days 5 and 7 in the untreated hepatic allografts, whereas no significant changes in the number of these cells were observed in the isografts. Treatment with cyclosporine (CsA) greatly decreased the number of these two different types of cells infiltrating the hepatic allografts, compared to the untreated hepatic allografts or the isografts. The time course of the accumulation of these cells in the allografts treated with CsA showed a similar pattern; the cells increased gradually by day 5 and thereafter decreased. This pattern is different from that observed in the untreated allografts or in the isografts. There was no significant difference in the number of Ki-M2R+ cells between the untreated hepatic allografts and the isografts. However, the number of the Ki-M2R+ cells in the hepatic allografts treated with CsA was much less than that of either the untreated allografts or the isografts. These findings suggest that a progressive relative increase in host TRPM-3+ macrophage is a characteristic feature of ongoing first-set rejection in the rat hepatic allograft.2+ allograft, even when compared with the isografts.

Cryopreserved microencapsulated hepatocytes--transplantation studies in Gunn rats.

Hepatocyte transplantation has been shown to provide significant metabolic support in several animal models of liver diseases. However, for it to be a viable alternative for supplementation of liver function in disease, large quantities of isolated hepatocytes would be necessary. At the present time there are no inexpensive routine methods for cryopreservation of hepatocytes. Existing procedures are cumbersome and require expensive programmable freezers. Hepatocyte cultures are sensitive and easily damaged in handling. By utilizing techniques of microencapsulation and cryopreservation we have attempted to overcome these problems. We have developed a simple, convenient, and inexpensive technique for the long-term storage of hepatocytes. Biological activity of the nonfrozen isolated encapsulated hepatocytes (IEH) and cryopreserved IEH (cIEH) was assessed both in tissue culture and by transplantation in Gunn rats. Significant urea and protein syntheses were detectable during the 10-day culture period even in the 30-day cIEH. Additionally, transplanted IEH and cIEH significantly reduced hyperbilirubinemia in Gunn rats for up to 30 days posttransplantation. Control (empty) microcapsules did not lower serum bilirubin levels. Thus we conclude: (1) cryopreservation of IEH is a convenient and cost-effective method for preserving and storing hepatocytes; (2) cryopreserved IEH function as well as nonfrozen IEH both in vitro and in vivo; (3) microencapsulation may protect hepatocytes from the adverse effects of cryopreservation.

Adjuvant treatment with ursodeoxycholic acid reduces acute rejection after liver transplantation.

Acute rejection, occurring with a reported frequency of 50-70%, is still a dominating problem after liver transplantation. Medication with ursodeoxycholic acid (UDCA) has beneficial effects in different cholestatic conditions and has also been shown to reduce HLA class I antigen expression on hepatocytes in patients with PBC. Since August 1989 we have consecutively treated all patients with primary graft function with UDCA (n = 41). Patients transplanted in the first half of 1989 served as a control group (n = 8). All patients in this study were given sequential quadruple drug immunosuppression. The treatment group were given oral UDCA 10 mg/kg per day. During the first postoperative month, 17% of the UDCA-treated patients had an episode of acute rejection compared with 75% of the control patients (P < 0.01). Liver biochemistry tests 1 month postoperatively were significantly better in patients treated with UDCA. The results suggest that adjuvant treatment with UDCA reduces acute liver graft rejection.