Preoperative Alfa-Fetoprotein and Fibrinogen Predict Hepatocellular Carcinoma Recurrence After Liver Transplantation Regardless of the Milan Criteria: Model Development with External Validation.

BACKGROUND/AIMS: Patient selection is critically important in improving the outcomes of liver transplantation for hepatocellular carcinoma. The aim of the current study was to identify biochemical measures that could affect patient prognosis after liver transplantation. METHODS: A total of 119 patients receiving liver transplantation for hepatocellular carcinoma were used to construct a model for predicting recurrence. The results were validated using an independent sample of 109 patients from independent hospitals. All subjects in both cohorts met the Hangzhou criteria. RESULTS: Analysis of the discovery cohort revealed an association of recurrence with preoperative fibrinogen and AFP levels. A mathematical model was developed for predicting probability of recurrence within 5 years: Y = logit(P) = -4.595 + 0.824 ×fibrinogen concentration (g/L) + 0.641 × AFP score (1 for AFP<=20ng/ml, 2 for 20 400ng/ml). At a cutoff score of -0.85, the area under the curve (AUC) was 0.819 in predicting recurrence (vs. 0.655 when using the Milan criteria). In the validation cohort, this model had reasonable performance in predicting 5-year overall survival (68.8% vs. 28.1% in using the -0.85 cutoff, p< 0.001) and disease-free survival (65.7% vs. 25.9%, p< 0.001). The sensitivity and specificity were 77.0% and 62.5%, respectively. The AUC of this newly developed model was similar to that with the Milan criteria (0.698 vs. 0.678). Surprisingly, the DFS in patients with score <= -0.85 under this model but not meeting the Milan criteria was similar to that in patients meeting the Milan criteria (53.8% vs. 60.0%, p=0.380). CONCLUSIONS: Preoperative AFP and fibrinogen are useful in predicting recurrence of hepatocellular carcinoma after liver transplantation.

Therapeutic potentials of umbilical cord-derived mesenchymal stromal cells for ischemic-type biliary lesions following liver transplantation.

BACKGROUND AIMS: Ischemic-type biliary lesions are severe, graft-threatening complications after orthotopic liver transplantation, and a novel and efficient therapeutic strategy is urgently needed. Due to the immunosuppressive and regenerative properties, mesenchymal stromal cells (MSCs) could be an interesting candidate. METHODS: We initiated safety and efficacy of human umbilical cord-derived MSC (UC-MSC) transfusions for patients with ischemic-type biliary lesions after liver transplantation. From January 2013 to June 2014, 12 ischemic-type biliary lesions patients were recruited as the MSCs group in this phase I, prospective, single-center clinical study. Patients in this group received six doses of UC-MSCs (about 1.0 × 106 MSCs per kilogram body weight through peripheral intravenous infusion). The traditional therapeutic protocol was applied during October 2003 to December 2012 in 70 ischemic-type biliary lesions patients who were treated as the control group. Liver function tests, the need for interventional therapies and graft survival rate were chosen to evaluate the therapeutic efficacy of MSC treatment. Adverse events were closely monitored up to 2 years after MSC transfusions. RESULTS: No significant MSC-related adverse events were observed during the trial. Compared with baseline, the levels of total bilirubin, γ-glutamyl transferase and alkaline phosphatase were decreased after UC-MSC treatment at week 20 and week 48. Interventional therapies were performed in 64.3% (45/70) of patients in the control group and 33.3% (4/12) of patients in the MSCs groups. MSC therapy significantly decreased the need for interventional therapies (P = 0.046). The 1- and 2-year graft survival rates were higher in the MSCs group (100% and 83.3%, respectively) than in the control group (72.9% and 68.6%, respectively). CONCLUSIONS: The UC-MSC transfusions are clinically safe and short-term favorable, which may become a novel treatment for patients with ischemic-type biliary lesions after liver transplantation.

Pretransplant Elevated Plasma Fibrinogen Level is a Novel Prognostic Predictor for Hepatocellular Carcinoma Recurrence and Patient Survival Following Liver Transplantation.

BACKGROUND: Elevated plasma fibrinogen is associated with tumour progression and poor outcomes in several cancers. The present study investigated the prognostic value of preoperative fibrinogen in hepatocellular carcinoma (HCC) patients after liver transplantation (LT). MATERIAL AND METHODS: We analyzed the preoperative plasma fibrinogen levels of 41 patients who underwent LT for HCC. The cut-off value for elevated level of fibrinogen was determined by using a receiver operating characteristic (ROC) curve analysis. Cox regression analysis was performed to analyze the relationship between elevated fibrinogen level and HCC recurrence. The disease-free survival (DFS) and overall survival (OS) rate after transplantation were calculated by Kaplan-Meier method and compared by log-rank test. RESULTS: The fibrinogen levels were significantly higher in patients with tumor recurrence (3.31±0.98 g/L) compared with those in patients without recurrence (2.39±0.89 g/L) (P<0.01). A cut-off value for elevated fibrinogen level of 2.675 g/L was defined. Cox regression analysis showed that the relative risk for tumor recurrence increased by 6.871 times for patients with elevated fibrinogen. Eleven patients in the elevated fibrinogen group (21 cases) developed recurrence, while only 2 in the normal fibrinogen group (20 cases) developed recurrence. There were significant differences in DFS and OS between the elevated fibrinogen group and normal fibrinogen group (5-year DFS and OS of 44.0% and 42.9% vs. 89.2% and 80.0%, respectively, P<0.05). Vascular invasion and fibrinogen level ≥2.675 g/L were the independent prognostic predictors of tumor recurrence and poor outcome. CONCLUSIONS: Pretransplant elevated fibrinogen levels are associated with tumor recurrence and poor prognosis in hepatocellular carcinoma patients after liver transplantation.

A three-factor preoperative scoring model predicts risk of recurrence after liver resection or transplantation in hepatocellular carcinoma patients with preserved liver function.

BACKGROUND: No staging systems of hepatocellular carcinoma (HCC) are tailored for assessing recurrence risk. We sought to establish a recurrence risk scoring system to predict recurrence of HCC patients receiving surgical curative treatment (liver resection or transplantation). METHODS: We retrospectively studied 286 HCC patients with preserved liver function receiving liver resection (n=184) or transplantation (n=102). Independent risk factors were identified to construct the recurrence risk scoring model. The recurrence free survival and discriminatory ability of the model were analyzed. RESULTS: Total tumor volume, HBsAg status, plasma fibrinogen level were included as independent prognostic factors for recurrence-free survival and used for constructing a 3-factor recurrence risk scoring model. The scoring model was as follows: 0.758 x HBsAg status (negative: 0; positive: 1) + 0.387 x plasma fibrinogen level (≤ 3.24 g/L: 0; >3.24 g/L: 1) + 0.633 x total tumor volume (≤ 107.5 cm3: 0; > 107.5 cm3: 1). The cut-off value was set to 1.02, and we defined the patients with the score ≤ 1.02 as a low risk group and those with the score > 1.02 as a high risk group. The 3-year recurrence-free survival rate was significantly higher in the low risk group compared with that in the high risk group (67.9% vs 41.3%, P < 0.001). In the subgroup analysis, liver transplantation patients had a better 3-year recurrence-free survival rate than the liver resection patients in the low risk group (80.0% vs 64.0%, P < 0.01). Additionally for patients underwent liver transplantation, we compared the recurrence risk model with the Milan criteria in the prediction of recurrence, and the 3-year recurrence survival rates were similar (80.0% vs 79.3%, P = 0.906). CONCLUSION: Our recurrence risk scoring model is effective in categorizing recurrence risks and in predicting recurrence-free survival of HCC before potential surgical curative treatment.

Aberrantly regulated dysadherin and B-cell lymphoma 2/B-cell lymphoma 2-associated X enhances tumorigenesis and DNA targeting drug resistance of liver cancer stem cells.

Cancer stem cells (CSCs) in hepatocellular carcinoma (HCC) are frequently resistant to current therapeutic regimens and therefore responsible for tumor recurrence. Previous studies have reported that expression levels of dysadherin in CSCs may be used as a prognostic indicator, which is also responsible for treatment failure and poor survival rates. The present study analyzed the association of enhanced dysadherin levels with drug resistance and evasion of apoptosis in human HCC SP cells. An SP of 3.7% was isolated from human HCC cells using fluorescence­activated cell sorting. These SP cells displayed elevated levels of dysadherin and stemness proteins as well as high resistance to chemotherapeutic drugs and apoptosis. In order to reveal the possible link between dysadherin levels and tumorigenesis of SP cells, small interfering RNA technology was used to knockdown the expression of dysadherin in SP cells. Of note, the siRNA­transfected SP cells showed significantly reduced levels of stemness proteins, and were more sensitive to DNA­targeting drugs and apoptotic cell death as compared to non­transfected cells. Furthermore, in vivo experiments in NON/SCID mice indicated that dysadherin­expressing SP cells were highly tumorigenic, as they were able to induce tumor growth. The SP cell­derived tumor tissues in turn showed elevated dysadherin levels. The results of the present study therefore suggested that knockdown of dysadherin suppressed the tumorigenic properties of cancer stem-like SP cells. Hence, dysadherin is a valuable potential target for the development of novel anti-cancer drugs.

miR-630 overexpression in hepatocellular carcinoma tissues is positively correlated with alpha-fetoprotein.

BACKGROUND: MicroRNA-630 (miR-630) has been shown to be involved in various human malignancies. However, its role in hepatocellular carcinoma (HCC) remains unknown. MATERIAL AND METHODS: TaqMan qRT-PCR assay was performed to detect the expression of miR-630 in 42 pairs of HCC tissues and corresponding noncancerous hepatocellular tissues, and its correlations with clinicopathologic features and serum alpha-fetoprotein (AFP) level of patients were analyzed. RESULTS: The present study found that miR-630 expression was significantly increased in HCC tissues and cells compared with their normal counterparts. miR-630 expression level did not significantly chang at stage I but was markedly increased at advanced TNM stage (stage II~III). In addition, the increased expression of miR-630 in tissues of HCC appeared in patients who exhibited elevated serum levels of AFP (>25 ng/ml), but not in those with normal AFP levels (≤25 ng/ml). The miR-630 expression in carcinoma tissues revealed a positive correlation with the levels of serum alpha-fetoprotein (AFP; R2=0.768). CONCLUSIONS: These results suggest that miR-630 is associated with tumor progression of hepatocellular carcinoma and may be a potential prognosis indicator.

Prostate tumor overexpressed 1 is a novel prognostic marker for hepatocellular carcinoma progression and overall patient survival.

The gene prostate tumor overexpressed 1 (PTOV1) was first found to be upregulated in prostate cancer. This upregulation increased tumor cell proliferation, retinoic acid resistance, and migration. This study investigated the expression and prognostic significance of PTOV1 in hepatocellular carcinoma (HCC). Real-time Polymerase Chain Reaction and western blot analysis were performed to examine PTOV1 expression in 11 HCC cell lines and 2 normal hepatic cell lines. PTOV1 expression levels were also determined in 8 pairs of tissue samples taken from primary HCC tumors and the matched adjacent noncancerous liver tissue from the same patient. Immunohistochemistry assays assessed PTOV1 protein expression in paraffin-embedded clinical samples taken from 215 HCC patients. The correlation of PTOV1 expression with the clinicopathological parameters was evaluated along with the prognostic impact of PTOV1 expression in these HCC patients. PTOV1 mRNA and protein were overexpressed in HCC cell lines compared with normal liver cell lines and were overexpressed in primary HCC samples compared with the matched noncancerous liver tissue samples. In the paraffin-embedded tissue samples from 215 HCC patients, PTOV1 protein expression was significantly correlated with T classification, N classification, clinical stage, and serum α-fetoprotein. HCC patients with higher PTOV1 expression had shorter survival times than patients with lower PTOV1 expression. Our study demonstrated that PTOV1 overexpression is correlated with increased aggressiveness of HCC and could be a prognostic biomarker for patients with HCC.

Downregulation of miR-610 promotes proliferation and tumorigenicity and activates Wnt/ß-catenin signaling in human hepatocellular carcinoma.

BACKGROUND: Wnt/ß-catenin signaling pathway plays important roles in human cancer progression. Better understanding the mechanism underlying regulation of Wnt/ß-catenin signaling pathway might provide novel therapeutic targets for cancer treatment. METHODS: miR-610 expression levels in hepatocellular carcinoma (HCC) cell lines, HCC tissues and 76 archived HCC specimens were determined using real-time PCR. Cell viability was measured by 3-[4, 5-dimethylthiazol-2-yl]-2, 5-diphenyltetrazolium bromide (MTT) assay. The level of DNA synthesis was determined by BrdU incorporation assay. Flow cytometry analysis was used to analyze cell cycle progression. The cells proliferation and tumorigenesis were determined by colony formation and anchorage-independent growth assays in vitro, and by xenograft tumors in vivo. Luciferase assay and micro-ribonucleoprotein complex immunoprecipitation assay were used to confirm the association of the targeted mRNAs with miR-610. RESULTS: miR-610 was downregulated in human HCC cells and tissues, and correlated with HCC progression and patient survival. Inhibition of miR-610 promoted, but overexpression of miR-610 reduced, HCC cell proliferation and tumorigenicity both in vitro and in vivo. Furthermore, we found that inhibiting miR-610 activated, but overexpressing miR-610 decreased, the Wnt/ß-catenin activity through directly suppressing lipoprotein receptor-related protein 6 (LRP6) and transducin ß-like protein 1 (TBL1X). The in vitro analysis was consistent with the inverse correlation detected between miR-610 levels with expression of LRP6 and TBL1X in a cohort of human HCC samples. CONCLUSIONS: Our results indicate that miR-610 downregulation plays essential roles in HCC progression and reduced miR-610 is correlated with Wnt/ß-catenin signaling pathway.

Long-term results of liver transplantation for over 60 years old patients with hepatitis B virus-related end-stage liver disease.

BACKGROUND: Hepatitis B virus (HBV)-related end-stage liver disease is the leading indication for liver transplantation in China, but long-term results of liver transplantation in patients aged over 60 years are not clear. The present study was to reveal the natural history of liver recipients with hepatitis B older than 60 years. METHODS: The recipients who had received liver transplantation between December 2003 and December 2005 were divided into two groups: those equal or older than 60 years (older group, n=60) and those younger than 60 years (younger group, n=305). Risk factors for poor long-term outcome in patients aged over 60 years were also analyzed. RESULTS: Except for age and preexisting chronic disease (P<0.05), no significant differences were observed in perioperative characteristics between the two groups. There was also no significant difference in HBV and hepatocellular carcinoma recurrence (P>0.05). The actuarial 1-, 3-, 5- and 8-year survival rates were 81.6%, 71.6%, 66.7% and 63.3% respectively for the older group vs 84.9%, 77.7%, 70.8% and 65.6% for the younger group (P>0.05). Multivariate analyses showed that pre-liver transplant renal insufficiency was a risk factor for poor outcome in the older group (odds ratio=3.615, P=0.014). CONCLUSIONS: Liver transplantation is safe and feasible for patients with HBV-related end-stage liver disease aged over 60 years. Older patients with renal insufficiency should undergo transplantation earlier than younger patients.

[Preoperative neutrophil-lymphocyte ratio as a prognostic predictor after liver transplantation for hepatocellular carcinoma].

OBJECTIVE: To analyze the negative impact of preoperative neutrophil-lymphocyte ratio (NLR) on the tumor recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation. METHODS: The clinical data of HBV (hepatitis B virus)-associated HCC patients undergoing liver transplantation were retrospectively analyzed. Their clinical and pathological risk factors for tumor-free survival were evaluated by univariate analysis. The analysis of Cox multiple regression was performed to determine the parameters of predicting the HCC recurrence. NLR ≥ 2.5 was considered to be elevated. RESULTS: A total of 76 patients were identified. Among them, 37 had an elevated NLR. The 1, 3 and 5-year tumor-free survival rates were 69.2%, 52.7% and 50.9% respectively. The disease-free survival for patients with high NLR was significantly worse than that for those with normal NLR (1, 3, and 5 year survivals at 56.3%, 37.6% and 37.6% vs 81.1%, 66.9% and 63.3% respectively; P = 0.011). Univariate analysis of factors revealed that tumor size > 5 cm, tumor number > 3, vascular invasion, serum α-fetoprotein level ≥ 400 µg/L and NLR ≥ 2.5 were preoperative predictors of disease-free survival. Cox regression analysis showed that the presence of vascular invasion, tumor number > 3 and NLR ≥ 2.5 were independent prognostic factors of worse disease-free survival. CONCLUSION: An elevated NLR significantly increases the risk for tumor recurrence in HCC patients undergoing liver transplantation.

[The relationship between hepatocellular carcinoma recurrence and hepatitis B virus recurrence after liver transplantation].

OBJECTIVE: To investigate the relationship between hepatocellular carcinoma (HCC) recurrence and hepatitis B virus (HBV) recurrence. METHODS: The clinical data of 340 patients underwent liver transplantation due to HBV related end-stage liver disease and received long-term follow up in our hospital from Jan 2004 to Dec 2008 were retrospectively analyzed. All patients received nucleoside analogues therapy formally before entering into the waiting list and nucleoside analogues combined low-dose HBIG therapy during and after transplantation. Patients were regularly followed up at the outpatient, monitoring the HBV recurrence and survival. Multivariate Cox regression analysis was used to evaluate the risk factors for hepatitis recurrence. RESULTS: 33 patients suffered from HBV recurrence post transplantation. The 1-, 3- and 5- year recurrence rates were 7.0%, 10% and 13% respectively. The median HBV recurrence time was 5 months (1-21 months). COX regression analysis revealed that risk factors for HBV recurrence were HCC (HR = 2.98; 95% CI 1.08-8.25; P < 0.05) and pre-transplantation HBV-DNA load over 5 log10 copies/ml (HR = 3.99; 95% CI 1.85-8.62; P < 0.01). Further stratified analysis showed that patients who suffered from carcinoma recurrence had a higher incidence of HBV recurrence than those who did not, which were 27.9% and 8.7% (HR = 4.58;95% CI 1.88-11.12; P < 0.01) respectively. 12 patients suffered from both HCC and HBV recurrence. Spearman correlation analysis demonstrated a strong correlation between HBV and HCC recurrence times (r = 0.583, P < 0.05). CONCLUSIONS: Post transplantation HCC recurrence is a risk factor for HBV recurrence.

Prognostic factors for late mortality after liver transplantation for benign end-stage liver disease.

BACKGROUND: There are increasing numbers of patients who survive more than one year after liver transplantation. Many studies have focused on the early mortality of these patients. However, the factors affecting long-term survival are not fully understood. This study aims to evaluate prognostic factors predicting long-term survival and to explore measures for improving the survival outcomes of patients who underwent liver transplantation for benign end-stage liver diseases. METHODS: The causes of late death after liver transplantation and potential prognostic factors were retrospectively analyzed for 221 consecutive patients who underwent liver transplantation from October 2003 to June 2008. Twenty-seven variables were assessed using the Kaplan-Meier method, and those variables found to be univariately significant at P < 0.10 were entered into a backward step-down Cox proportional hazard regression analysis to identify the independent prognostic factors influencing the recipients' long-term survival. RESULTS: Twenty-eight recipients died one year after liver transplantation. The major causes of late mortality were infectious complications, biliary complications, and Hepatitis B virus recurrence/reinfection. After Cox analysis, the five remaining co-variables were: age, ABO blood group, cold ischemia time, post-infection region, and biliary complications. CONCLUSIONS: The major causes of late mortality were infection, biliary complications and Hepatitis B virus recurrence/reinfection. Five variables (Age, ABO blood group, cold ischemia time, infection, and biliary complications) had significant impacts on patient survival.

[Risk factors predicting late mortality after liver transplantation for benign end-stage liver disease].

OBJECTIVES: To find out the risk factors predicting long-term survival, and to explore the measures for further improving the survival outcome of whom underwent liver transplantation (LT) for benign end-stage liver disease. METHODS: The common causes of late death after LT and risk factors were retrospectively analyzed in 221 consecutive patients, who underwent LT from October 2003 to June 2007 and survived more than one year. Twenty-six potential risk factors were assessed by the Kaplan-Meier method, and those variables found to be univariately significant at P < 0.10 were entered into a backward step down Cox proportional hazard regression analysis to screen the independent risk factors influencing the recipient's long-term survival. RESULTS: There were 28 recipients died one year later after LT during the follow-up period. The major causes of late mortality were related to infectious complications 5.0% (11/221), biliary complications 3.6% (8/221) and HBV recurrence/reinfection 1.4% (3/221). After Cox proportional hazard regression analysis, 5 covariables finally retained in the formula were: age (RR = 2.325, P = 0.009), ABO blood group (RR = 2.206, P = 0.015), cold ischemia time (RR = 3.001, P = 0.000), post-infection region (RR = 1.665, P = 0.007) and biliary complications (RR = 2.655, P = 0.004). CONCLUSION: Age (≥ 60 years), ABO blood group (incompatible), cold ischemia time (> 12 h), infectious complications (lung infection) and biliary complications (diffuse biliary stricture) significantly impact patient's survival time.

Liver transplantation for end-stage alcoholic liver disease: a single-center experience from mainland China.

There has been a gradual increase in the number of patients with end-stage alcoholic liver disease (ALD) undergoing liver transplantation (LT) in mainland China. However, few studies have focused on the post-transplant outcomes of this population. The aim of this study was to evaluate the efficacy of LT in patients with ALD, mainly focusing on survival rates, complications, and alcohol recidivism. The results were retrospectively analyzed from 20 patients, who underwent LT for ALD from December 2003 to September 2007 at Liver Transplant Center of Third Affiliated Hospital of Sun Yat-sen University. The 1-, 2-, and 3-year survival rates of the ALD group and non-ALD group were 90.0, 80.0, 80.0% and 90.3, 84.7, 79.8%, respectively. There was no significant difference in 1-, 2-, and 3-year survival rates between these two groups (P=.909). No significant difference was observed in complications such as pulmonary infection (50.0 vs. 31.9%, P=.137), biliary complications (15.0 vs. 27.4%, P=.297), hepatic arterial complications (10.0 vs. 6.9%, P=.641), and rejection (15.0 vs. 8.1%, P=.394) after LT between the ALD group and non-ALD group. There was only one person who resumed mild, intermittent drinking after LT. End-stage ALD is a good indication for LT, with similar results in non-ALD patients. The major cause of death in ALD patients after LT was infectious complications. More attention is needed for the prophylaxis of infectious complications after LT.

[Effect of artificial liver support system on the survival rate of high risk patients after liver transplantation].

OBJECTIVE: To observe the effect of artificial liver support system (ALSS) after liver transplantation on the survival rate of severe hepatitis patients. METHODS: Patients with severe hepatitis with model for end stage liver disease (MELD) score above 35 were divided into two groups according to whether pre-transplantation ALSS was instituted (n=23) or not (n=41). Evaluation was performed on the day when the patient entered into the waiting list and 1 day pre-transplantation. Survival rates and survival curves were estimated with Kaplan-Meier method. Log-Rank test for trends was used when comparing curves. RESULTS: There was no significant difference between two groups when comparing the parameters including prothrombin time, fibrinogen, total bilirubin, blood ammonia, creatinine, MELD score on the day of entering into the waiting list (all P>0.05). After the therapy of ALSS, the parameters of ALSS group were significantly improved comparing to those of the control group (all P<0.01). MELD score of ALSS group on the day pre-transplant was decreased significantly comparing to that on the day entering into the waiting list (37.6+/-2.0 vs. 41.4+/-2.2, P<0.01), with the difference in MELD score (DeltaMELD) of -3.8. MELD score of control group on the day entering into the waiting list and 1 day pre-transplant was 40.6+/-1.7 and 41.0+/-1.6 respectively, with DeltaMELD of +0.4 ( P>0.05). The blood loss and operation time in ALSS group was significantly less than the control group [(4 070.0+/-688.1) ml vs. (4 905.9+/-1 142.1) ml, (9.4+/-1.1) hours vs. (10.5+/-1.0) hours, P<0.05 and P<0.01). Thirty days and 1 year survival rate of ALSS group was 91% and 82%, and that of control group was 76% and 59% respectively (P=0.044). CONCLUSION: ALSS can improve the survival rate of patients with severe hepatitis undergoing liver transplantation through ameliorating physiological status, lessening blood loss during operation and operation time.

Prospective evaluation of postoperative outcome after liver transplantation in hepatopulmonary syndrome patients.

BACKGROUND: Only a few reviews of small case series and individual case reports including a relatively small number of adult patients undergoing liver transplantation for hepatopulmonary syndrome (HPS) are available, and there has been no prospective evaluation of the long-term outcome of HPS patients after orthotopic liver transplantation (OLT). The aim of this study was to determine the frequency of HPS in OLT patients with chronic end-stage liver-disease, and the short-term and long-term postoperative outcome of HPS patients after OLT. METHODS: This prospective study included 31 HPS and 30 control, non-HPS patients. The preoperative conditions were similar between the two groups. Twenty-six of 31 HPS patients and all of the non-HPS patients underwent OLT. Standardized methods, such as arterial blood gas at room air and 99m-technetium macroaggregated albumin ((99m)Tc MAA) lung and brain perfusion scanning were performed for the diagnosis of HPS. Patients were followed after OLT. RESULTS: The incidence of HPS in OLT patients was 9.3% (26/279). Hypoxemia in HPS was obviously improved with a normalized shunt of (99m)Tc MAA in the lungs after OLT. The immediate postoperative survival rate (within 28 days after OLT) of HPS was 76.9% (20/26). The one year survival was 61.5% (16/26) and four-year survival was 57.7% (15/26); much higher than HPS patients without OLT (0). But high postoperative morbidity and mortality were observed in HPS patients whose death occurred within 3 months of OLT due to complications summarized in this study. CONCLUSIONS: Liver transplantation was an effective treatment for HPS. But the postoperative mortality rate following OLT in HPS patients was still much higher than that of patients without HPS.

[Significance of lipopolysaccharides, toll-like receptor and inducible nitric oxide synthase in hepatopulmonary syndrome].

OBJECTIVE: To investigate the role of lipopolysaccharides (LPS), toll-like receptor 2 (TLR2) and inducible nitric oxide synthase (iNOS) in the development of hepatopulmonary syndrome (HPS). METHODS: Seventy-one patients were divided into 3 groups: end-stage liver disease with HPS (HPS group, n = 31), end-stage liver disease without HPS (non-HPS group, n = 30) and healthy volunteers (n = 10). Blood was collected at pre-OLT and Days 3, 7, 14, 21 and 28 post-OLT to detect the plasma LPS level, TLR2mRNA and iNOSmRNA in peripheral blood monocytes. RESULTS: The LPS, TLR2mRNA and iNOSmRNA at pre-OLT in HPS group were 4.31 +/- 3.267 ng/L, 336,594.10 +/- 366,901.14 and 63,982.24 +/- 74,127.47 copies/microg RNA respectively; 1.62 +/- 1.34 ng/L, 336,321.53 +/- 222,317.17 and 44,169.9 +/- 24,993.00 copies/microg RNA respectively in non-HPS group and 0.94 +/- .69 ng/L, 10,338.28 +/- 3,814.64 and 19,168.49 +/- 2,417.35 copies/microg RNA in normal control group. LPS, TLR2mRNA and iNOSmRNA at pre-OLT in HPS group were higher than those in non-HPS group without significance (P > 0.05), but significantly higher than those in control group (P < 0.05). The TLR2mRNA decreased in all end-stage liver disease patients at post-OLT with the improvement of liver function and oxygenation. CONCLUSION: The dysfunction of intestinal barrier and intestinal endotoxemia may be the important mechanisms of HPS through the elevation of LPS level and the expressions of TLR2mRNA and iNOSmRNA.

[Immunization with dendritic cells infected with mTERT adenovirus vector effectively elicits immunity against mouse H22 hepatoma in vivo].

OBJECTIVE: To investigate the effects of dendritic cells (DCs) infected with adenovirus vector encoding mTERT on induction of mTERT antigen specific immunity against H22 hepatoma in vivo. METHODS: Forty Bal B/c mice were subcutaneously immunized with Ad-mTERT infected DC. Cytotoxicity of mTERT specific CTL was determined by 51Cr release assay. IL-2 and IFN-gamma were tested by ELISA. IFN-gamma ELISPOT assays were performed for measuring antigen specific IFN-gamma production by T cells. Tumor size and survival of the immunized mice were recorded and evaluated whether preexisting hepatoma metastases could be supressed after immunization with mTERT-expressing DCs. RESULTS: The lytic activity of CTL, IL-2 (871.25 pg/ml), IFN-gamma (169.15 ng/ml) and IFN-gamma secreting cells (378/10(6) spleen cells) elicited by the Ad-mTERT infected DCs were much stronger and higher than that by Ad-GFP group (131.6 pg/ml, 15.4 ng/ml, 36/10(6) spleen cells, P<0.05), DC group (71.3 pg/ml, 10.5 ng/ml, 21/10(6) spleen cells, P<0.05), PBS group (65.8 pg/ml, 7.4 ng/ml, 18/10(6) spleen cells, P<0.05). In prophylaxis and treatment experiment the Ad-mTERT/DCs immunized mice lived significantly longer than other groups, demonstrating that primary DCs were genetically modified to express the mTERT antigen and could suppress the tumor growth. CONCLUSION: Adenovirus vector mediated mTERT infected DCs can effectively induce mTERT antigen specific antitumor activity, and can induce protective and therapeutic antitumor immunity.

[Changes of systemic and pulmonary hemodynamics and plasma levels of inducible nitric oxide synthase and endothelin-1 in patients with hepatopulmonary syndrome].

OBJECTIVE: To observe the changes of systemic and pulmonary hemodynamics and the plasma levels of inducible nitric oxide synthase (iNOS) and endothelin-1 (ET-1) and investigate their association in patients with hepatopulmonary syndrome (HPS). METHODS: Twenty-six patients with HPS undergoing orthotopic liver transplantation (OLT) were enrolled in this study with 20 patients without hypoxemia as the control group. Blood samples were taken one day before OLT to measure the plasma levels of iNOS and ET-1 using fluorescence quantitative polymerase chain reaction (FQ-PCR) and radioimmunoassay, respectively, with 10 healthy volunteers serving as the healthy control group. Before the operation for OLT, the parameters of systemic and pulmonary hemodynamics were monitored after anesthesia induction. RESULTS: The systemic and pulmonary hemodynamics in patients without hypoxemia was characterized by high cardiac output and low resistance, and by comparison, the patients with HPS showed even higher cardiac output and lower mean pulmonary artery pressure, pulmonary artery wedge pressure, systemic vascular resistance and pulmonary vascular resistance. The two patient groups had comparable plasma iNOS and ET-1 levels, which were both higher than those in the healthy control group. CONCLUSION: The hemodynamics in patients with end-stage liver disease exhibit a pattern of high cardiac output and low resistance, which is more obvious in HPS patients possibly in association with elevated plasma levels of iNOS and ET-1.