Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Factores de Coagulación Sanguínea/uso terapéutico , Factor VIIa/uso terapéutico , Hemofilia A/tratamiento farmacológico , Hemorragia/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Corticoesteroides/uso terapéutico , Anticuerpos Monoclonales de Origen Murino , Factores de Coagulación Sanguínea/administración & dosificación , Combinación de Medicamentos , Factor VIIa/administración & dosificación , Hemofilia A/terapia , Hemorragia/terapia , Humanos , Tolerancia Inmunológica , Técnicas de Inmunoadsorción , Masculino , Persona de Mediana Edad , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/uso terapéutico , RituximabRESUMEN
A 37-year-old female patient with systemic mastocytosis who was admitted with severe unexplained bleeding symptoms is studied. Laboratory procedures established the diagnosis of a patient-derived-heparin-like anticoagulant as a very rare hemostatic abnormality predisposing to bleeding. The patient died from refractory disease despite therapy with protamine, initiation of chemotherapy, and supportive measures. The case illustrates the clinical presentation and diagnosis of heparin-like anticoagulants. Etiology, pathophysiology, and therapeutic options are discussed.
Asunto(s)
Anticoagulantes/sangre , Hemorragia/sangre , Hemorragia/etiología , Heparina/sangre , Mastocitosis Sistémica/sangre , Mastocitosis Sistémica/complicaciones , Adulto , Médula Ósea/patología , Resultado Fatal , Femenino , Humanos , Mastocitos/patología , Mastocitosis Sistémica/patologíaRESUMEN
PURPOSE: To prospectively evaluate the effectiveness of portal vein embolization (PVE) and CD133(+) bone marrow stem cell (BMSC) administration to the liver, compared with PVE alone, to augment hepatic regeneration in patients with large hepatic malignancies. MATERIALS AND METHODS: The study was approved by the institutional ethics committee; informed consent was obtained. Thirteen patients underwent PVE of liver segments I and IV-VIII to stimulate hepatic regeneration prior to extended right hepatectomy. In six patients (three men, three women; mean age, 61 years; range, 46-72 years) with a future liver remnant volume (FLRV) below 25% and/or limited quality of hepatic parenchyma, PVE alone did not promise adequate proliferation. These patients underwent BMSC administration to segments II and III (group I). In seven patients (three men, four women; mean age, 69 years; range, 63-75 years) with an FLRV below 25%, PVE alone was performed (group II). Two radiologists blinded to patients' identity and each other's results measured liver and tumor volumes with helical computed tomography. Absolute, relative, and daily FLRV gains were compared by using the t test or the Wilcoxon test. RESULTS: The increase of the mean absolute FLRV in group I from 239.3 mL +/- 103.5 (standard deviation) to 417.1 mL +/- 150.4 was significantly higher than that from 286.3 mL +/- 77.1 to 395.9 mL +/- 94.1 in group II (P = .049). The relative gain of FLRV after PVE in group I (77.3% +/- 38.2) was significantly higher than that in group II (39.1% +/- 20.4) (P = .039). The daily hepatic growth rate in group I (9.5 mL/d +/- 4.3) was significantly superior to that in group II (4.1 mL/d +/- 1.9) (P = .03). Time to surgery was 27 days +/- 11 in group I and 45 days +/- 21 in group II (P = .057). CONCLUSION: In patients with malignant liver lesions, the combination of PVE with CD133(+) BMSC administration substantially increased hepatic regeneration compared with PVE alone.
Asunto(s)
Antígenos CD , Carcinoma Hepatocelular/terapia , Colangiocarcinoma/terapia , Embolización Terapéutica , Glicoproteínas , Trasplante de Células Madre Hematopoyéticas , Neoplasias Hepáticas/terapia , Hígado/fisiología , Péptidos , Regeneración , Antígeno AC133 , Anciano , Alanina Transaminasa/sangre , Aspartato Aminotransferasas/sangre , Bilirrubina/sangre , Carcinoma Hepatocelular/diagnóstico por imagen , Neoplasias Colorrectales/patología , Femenino , Células Madre Hematopoyéticas/inmunología , Humanos , Relación Normalizada Internacional , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Vena Porta , Cuidados Preoperatorios , Tomografía Computarizada por Rayos X , Trasplante AutólogoRESUMEN
The liver has a large capacity for regeneration after resection. However, below a critical level of future liver remnant volume (FLRV), partial hepatectomy is accompanied by a significant increase of postoperative liver failure. There is accumulating evidence for the contribution of bone marrow stem cells (BMSCs) to participate in liver regeneration. Here we report on three patients subjected to intraportal administration of autologous CD133(+) BMSCs subsequent to portal venous embolization of right liver segments, used to expand left lateral hepatic segments as FLRV. Computerized tomography scan volumetry revealed 2.5-fold increased mean proliferation rates of left lateral segments compared with a group of three consecutive patients treated without application of BMSCs. This early experience with portovenous application of CD133(+) BMSCs could suggest that this novel therapeutic approach bears the potential of enhancing and accelerating hepatic regeneration in a clinical setting.