Evaluation of a novel non-invasive (13) C-glucose breath test for the identification of diabetes mellitus in cirrhotic patients.

AIM: Diabetes mellitus (DM) has been reported to worsen the long-term prognosis of cirrhotic patients, and many studies have reported that DM is an independent risk factor for hepatocellular carcinoma. However, an accurate diagnosis of DM is sometimes difficult in cirrhotic patients. Recently, a novel non-invasive (13) C-glucose breath test has been reported to be useful for diagnosing insulin resistance in non-cirrhotic patients. The aim of this study was to evaluate the efficacy of this tool for the identification of DM in cirrhotic patients. METHODS: Thirty eight cirrhotic patients with normal fasting serum glucose and hemoglobin A1c levels underwent the (13) C-glucose breath test and the oral glucose tolerance test. Blood and breath samples were collected at baseline and at 30, 60 and 120 min after ingestion of 100 mg (13) C-labeled glucose and 75 g glucose. RESULTS: There was a strong correlation between the change in the concentrations at 2 h for the measured (13) C-glucose breath test (2h-BT) and the 2 h plasma glucose level (r = -0.60, P < 0.0001). In a receiver-operator curve analysis using the 2h-BT, the area under the curve was determined to be 0.88, with a sensitivity and specificity (cut-off value of 3.5‰) of 82% and 85%, respectively, for the detection of DM. Multivariate analysis showed the 2h-BT to be an independent parameter to identify DM. CONCLUSION: The (13) C-glucose breath test is a useful tool and has the potential to become a routine outpatient examination for the screening of DM in cirrhotic patients.

Timeline for development of autologous bone marrow infusion (ABMi) therapy and perspective for future stem cell therapy.

Liver cirrhosis patients generally progress to liver failure. To cure this progressive disease, we developed a novel cell therapy using bone marrow cells; autologous bone marrow cell infusion (ABMi) therapy. We previously described the possible action mechanism of ABMi therapy in the cirrhotic liver, and showed the timeline and results of clinical studies of ABMi therapy. We have also carried out other clinical studies using bone marrow cells and granulocyte colony-stimulating factor. Here, we report a new randomized clinical trial to evaluate the effects of ABMi therapy. However, ABMi therapy may not be possible in patients who are unable to undergo general anesthesia; therefore, we have started to develop a next-generation stem cell therapy using cultured mesenchymal stem cells.

[Sensitivity surveillance of Haemophilus influenzae isolates for several antibiotics in Gifu Prefecture (2006)].

We investigated the susceptibility to antibacterials of 194 strains of Haemophilus influenzae isolated from medical facilities in Gifu prefecture between 2005 and 2006, and compared these results with those of 280 strains of H. influenzae isolated between 1999 and 2000. Additionally, the strains that had been separated between 2005 and 2006 were examined for beta-lactamase (BL) production, the mutation of ftsI gene coding for PBP3, the bla gene coding for TEM type of BL and the serotype. Referring to the CLSI breakpoint, H. influenzae strains were classified into the following categories: (1) beta-lactamase-negative ampicillin-susceptible (BLNAS) strains, which showed BL negative, ampicillin (ABPC) and ampicillin/sulbactam (ABPC/SBT)-MIC < or = microg/ml, (2) beta-lactamase producing ampicillin-resistant (BLPAR) strains, which showed BL producing and ABPC/SBT-MIC < or =2 microg/ml, (3) beta-lactamase-negative ampicillin-resistant (BLNAR) strains, which showed BL negative, ABPC and ABPC/SBT-MIC > or =2 microg/ml, (4) beta-lactamase-producing amoxicillin/clavulanic acid-resistant (BLPACR) strains, which showed BL producing and ABPC/SBT-MIC > or =4 microg/ml. The prevalence of each resistance class were 71.8% for BLNAS, 7.9% for BLPAR, 19.6% for BLNAR and 0.7% for BLPACR in strains isolated between 1999 and 2000. But they were 38.1% for BLNAS, 4.6% for BLPAR, 54.6% for BLNAR and 2.6% for BLPACR in strains isolated between 2005 and 2006, indicating that the percentage of BLNAS and BLPAR decreased and that of BLNAR and BLPACR increased from 1999-2000 to 2005-2006. On the basis of ftsI substitutions and having bla gene, the strains isolated between 2005 and 2006 were classified into the following distribution: 24.2% for gBLNAS, 4.1% for gBLPAR, 10.8% for gLow-BLNAR, 57.7% for gBLNAR, and 3.1% for gBLPACR-II. Ratio of BLNAR belonging to gBLNAR and gLow-BLNAR based on the ftsI substitutions and having bla gene was higher than that based on the susceptibility pattern. The MIC50 and MIC90 for those strains isolated between 2005 and 2006 were as follows; 0.0039, 0.0156 microg/ml for garenoxacin, 0.0078, 0.0156 microg/ml for tosufloxacin and ciprofloxacin, 0.0156, 0.0313 microg/ml for levofloxacin, 0.0313, 0.0625 microg/ml for norfloxacin, 0.0625, 0.25 microg/ml for piperacillin/ tazobactam, 0.0625, 0.5 microg/ml for piperacillin, 0.125, 0.25 microg/ml for ceftriaxone and cefditoren, 0.5, 1 microg/ml for cefteram, chloramphenicol and tetracycline, 0.5, 2 microg/ml for cefotaxime, 2, 8 microg/ml for ampicillin, ampicillin/sulbactam and cefdinir. In comparison with the values for the strains isolated between 1999 and 2000, the MIC50s of beta-lactam for the strains isolated between 2005 and 2006 increased over 4 times.

[Complete response to treatment with hepatic arterial infusion of cisplatin powder (IA-call) in a case of hepatocellular carcinoma with multiple lung metastases].

A 74-year-old woman was admitted to our hospital to treat her hepatocellular carcinoma (stage IVB) with multiple lung metastases. She was treated with 3 times of hepatic arterial infusion of cisplatin powder (IA-call). After the treatment, liver mass and lung tumors were disappeared and high levels of tumor markers (AFP and PIVKA-II) were markedly decreased. These data revealed that a complete response (CR) was obtained for her. She has still been maintained in CR for 2 years since the first treatment.

Effect of a late evening snack on outpatients with liver cirrhosis.

AIMS: We have reported that one-week administration of a late evening snack (LES) improved not only malnutrition but also glucose intolerance in hospitalized patients with liver cirrhosis. Thus, we investigated whether long-term LES administration to outpatients for 3 months could reproduce the results obtained from hospitalized patients, especially improved glucose intolerance. If this treatment aggravated glucose intolerance, we tried to find any marker predicting this aggravation before the treatment. METHODS: Outpatients were prescribed one pack of oral supplementation of a branched-chain amino acid (BCAA)-enriched nutrient, Aminoleban EN (210 kCal) as a LES without dietician supervision. Both before LES administration and after 3 months, glucose tolerance and liver function were examined using a 75 g oral glucose tolerance test (OGTT), biochemical parameters in blood and the relationship between glucose tolerance (area under the curve (AUC)) and the following serum markers. RESULTS: Branched-chain amino acid/tyrosine ratio (BTR), the number of red blood cells (RBC), and hematocrit (Ht) significantly increased, with significant reduction of blood NH(3) level in patients with a blood glucose level less than 200 mg/dL 2 h after 75 g OGTT. However, the increase of AUC was seen after 3 months of LES administration in patients who had blood glucose higher than 200 mg/dL 2 h after 75 g OGTT. AUC weakly correlated positively with serum 7S collagen and negatively with choline esterase (ChE) and albumin (Alb). CONCLUSION: 75 g OGTT is a useful marker to predict the worst outcome and avoid the adverse effect of LES treatment in liver cirrhosis patients if performed without adequate nutrient conduct by a dietician.

Herbal medicine Rhei rhizome prevents liver fibrosis in rat liver cirrhosis induced by a choline-deficient L-amino acid-defined diet.

The aim of this study was to investigate whether herbal medicine Rhei rhizome, extract powder from herbs, has influences on the development of liver fibrosis. In in vivo studies the effects of Rhei rhizome were examined using the choline-deficient L-amino acid-defined (CDAA) diet-induced liver fibrosis model. In In vitro studies the effects of Rhei rhizome on type I procollagen mRNA expression, alpha-smooth muscle actin (alpha-SMA), metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) of isolated hepatic stellate cell were examined. In vivo Rhei rhizome prevented fibrosis in a dose-dependent manner up to 1.0% (w/w) with a reduced number of activated stellate cells. In vitro the Rhei rhizome prevented stellate cell activation resulting in reduced type I procollagen mRNA, alpha-SMA and TIMP-1, 2 expression. These results indicate that Rhei rhizome significantly reduces liver fibrosis by the direct inhibition of stellate cell activation without reducing hepatocyte cell death.

Percutaneous radiofrequency ablation with cooled electrodes combined with hepatic arterial balloon occlusion in hepatocellular carcinoma.

BACKGROUND: We have reported that percutaneous radiofrequency ablation (RFA) with balloon occlusion of the hepatic artery (balloon-occluded RFA), using an expandable electrode, increases the coagulation area. In this study, we investigated the efficacy of balloon-occluded RFA and balloon-microcatheter-occluded RFA, using a cool RF single electrode. METHODS: We studies 41 patients with 47 hepatocellular carcinoma (HCC) lesions. We treated 28 patients (32 nodules) with balloon-occluded RFA, 5 patients (6 nodules) with balloon-microcatheter-occluded RFA, and 8 patients (9 nodules) with standard RFA. Initial therapeutic efficacy was evaluated with dynamic computed tomography performed 1 week after one session of treatment. RESULTS: One session of treatment was done for 20 nodules (62.5%) in the balloon-occluded RFA group and for 4 nodules (66.7%) in the balloon-microcatheter-occluded RFA group. We compared the coagulation diameter for balloon-occluded RFA (7 nodules), balloon-microcatheter-occluded RFA (6 nodules), and standard RFA (9 nodules) after one application cycle (12 min). The greatest dimension of the area coagulated by balloon-occluded RFA was significantly larger (greatest long-axis dimension, 47.6 +/- 7.8 mm; greatest short-axis dimension, 33.4 +/- 7.5 mm) than that coagulated by standard RFA (greatest long-axis dimension, 35.3 +/- 4.7 mm; greatest short-axis dimension, 25.9 +/- 3.7 mm; P = 0.002 for greatest long-axis dimension; P = 0.041 for greatest short-axis dimension). However, there was significant difference only in the greatest short-axis dimension of the area coagulated comparing balloon-microcatheter-occluded RFA and standard RFA. CONCLUSIONS: We consider balloon-occluded RFA using a cool RF electrode to be superior to standard RFA for the treatment of HCC, especially when larger coagulation volumes are required.

Prognostic factors in patients with advanced hepatocellular carcinoma receiving hepatic arterial infusion chemotherapy.

BACKGROUND: The prognosis of patients with advanced hepatocellular carcinoma (HCC) is poor. We aimed to clarify the prognostic factors in patients with advanced HCC receiving hepatic arterial infusion chemotherapy (HAIC). METHODS: Forty-four HCC patients were treated with HAIC, using low-dose cisplatin (CDDP) and 5-fluorouracil (5-FU) with/without leucovorin (or isovorin). Of these 44 patients, 15 received low-dose CDDP and 5-FU, and 29 received low-dose CDDP, 5-FU, and leucovorin or isovorin. Prognostic factors were evaluated by univariate and multivariate analyses of patient and disease characteristics. RESULTS: Of all patients, 5 and 12 patients respectively, exhibited a complete response (CR) and a partial response (PR) (response rate, 38%). The response rate (48.3%) in the low-dose CDDP and 5-FU with leucovorin/isovorin group was significantly better than that (20%) in the low-dose CDDP and 5-FU group (P = 0.002). The 1-, 2-, 3-, and 5-year cumulative survival rates of the 44 patients were 39%, 18%, 12%, and 9%, respectively. The regimen using low-dose CDDP and 5-FU with leucovorin/isovorin tended to improve survival rates (P = 0.097). Univariate and multivariate analyses showed the same variables--the Child-Pugh score (P = 0.013, P = 0.018), alpha-fetoprotein (AFP) level (P = 0.010, P = 0.009), and therapeutic effect after HAIC (P = 0.003, P = 0.01), respectively, to be significant prognostic factors. CONCLUSIONS: Patients who had advanced HCC with favorable hepatic reserve capacity and a lower AFP level were suitable candidates for HAIC. Moreover, the regimen using low-dose CDDP and 5-FU with leucovorin/isovorin may be suitable for advanced HCC patients, because of the improvement in the response rate and survival compared with the low-dose CDDP and 5-FU regimen without leucovorin/isovorin.

The effect of a late evening snack in patients with liver cirrhosis.

OBJECTIVES: : As an intervention for energy malnutrition, frequent meals or a late evening snack (LES) has been recently recommended. On the other hand, it has been reported that glucose intolerance is found in approximately 70% of patients with liver cirrhosis. Thus, we investigated which would be better for the improvement of energy malnutrition and glucose intolerance, treatment with LES alone or LES plus divided meals. METHODS: : One group of oral supplementation with one pack of a branched-chain amino acid (BCAA)-enriched nutrient, Aminoleban EN (210kcal), at 10 p.m. LES and the other group with two packs of Aminoleban EN (one pack at 10 p.m. as LES and another pack during the day, i.e. at sometime from 10 a.m. to 3 p.m.) were examined to determine the influence of LES on the blood glucose level, biochemical parameters, and energy metabolism. Twenty-six patients participated in this study. The administration period was 7 days. Metabolic measurements were performed using an indirect calorimeter. RESULTS: : The fat oxidation rate was significantly decreased and the carbohydrate oxidation rate significantly increased in both groups. As a result, respiratory quotient (RQ) was significantly improved. In many cases, the increase of the glucose level after meals seemed to be reduced after LES administration for 1 week. LES could improve energy malnutrition, and correct amino acid imbalance. There was also a significant correlation between non-protein respiratory quotient (npRQ) and the creatinine height index. CONCLUSION: : LES alone improved the energy malnutrition state and glucose intolerance equivalent to LES plus divided meals. Thus, LES may improve glucose intolerance in patients with liver cirrhosis.

Late evening snack and the change of blood glucose level in patients with liver cirrhosis.

It has been reported that patients with liver cirrhosis suffer from energy malnutrition and late evening snacks (LES) can be effective for this malnutrition. On the other hand, it is also known that some patients with liver cirrhosis have glucose intolerance as a complication. We have shown that 1 week LES treatment using as an oral supplement with branched chain amino acids significantly reduced an increase of blood glucose level after meals. Fat oxidation rate was significantly decreased with an increased carbohydrate oxidation rate. LES may improve glucose intolerance in patients with liver cirrhosis, at least hospitalized patients.

Pioglitazone prevents hepatic steatosis, fibrosis, and enzyme-altered lesions in rat liver cirrhosis induced by a choline-deficient L-amino acid-defined diet.

Non-alcoholic steatohepatitis (NASH) may progress to liver cirrhosis, and NASH patients with liver cirrhosis have a risk of development of hepatocellular carcinoma. Peroxisome proliferator-activated receptor (PPAR) gamma ligand has recently been reported to have improved the condition of patients with NASH. The aim of this study was to investigate whether pioglitazone, a PPARgamma ligand, has any influence on the animal model of NASH as well as isolated hepatic stellate cells. In vivo, the effects of pioglitazone were examined using the choline-deficient L-amino acid-defined (CDAA)-diet liver fibrosis model. After two weeks, pioglitazone improved hepatic steatosis, prevented liver fibrosis, and reduced preneoplastic lesions in the liver after 10 weeks. Pioglitazone reduced the expression of TIMP-1 and TIMP-2 mRNA without changing MMP-13 mRNA expression compared to the liver fed a CDAA diet alone. In vitro, pioglitazone prevented the activation of hepatic stellate cells resulting in reducing the expression of type I procollagen, MMP-2, TIMP-1, and TIMP-2 mRNA with increased MMP-13 mRNA expression. These results indicate that pioglitazone may be one of the candidates for the benefit drugs for the liver disease of patients with NASH.

Arterial infusion chemotherapy using cisplatin, 5-fluorouracil, and isovorin for patients with advanced hepatocellular carcinoma, pilot study: Is a high dose of the biochemical modulator effective?

The authors report the efficacy of arterial infusion chemotherapy using cisplatin (CDDP), 5-fluorouracil (5-FU), and leucovorin (LV) for patients with advanced hepatocellular carcinoma (HCC). In this study, we evaluated the efficacy of our regimen with high-dose LV, using isovorin (IV) (high dose group), comparing the previous regimen (low-dose LV; low dose group). This is a retrospective, historical, and non-controlled trial. In the high dose group (n=15), one course of chemotherapy consisted of the daily administration of CDDP (10 mg/1 h, for 5 days) and IV (12.5 mg/10 min, for 5 days) followed by 5-FU (250 mg/5 h, for 5 days). In the low dose group (n=9), changing to the administration of LV (12 mg/day), the same regimen was employed. In principle, we did this 20 times. In the high dose group, complete response (CR) was found in two patients, and partial response (PR) in six patients. Thus, the response rate was 53%. In the low dose group, CR was found in two patients, and PR in three patients. Thus, the response rate was 56%. There were no significant differences in the response rate (P=0.71), the survival rate (P=0.29) and the toxicity between the two groups. We considered the recommended dose of LV to be 12 mg/day in our regimen, although this is a preliminary study.

Effect of a late evening snack on the blood glucose level and energy metabolism in patients with liver cirrhosis.

BACKGROUND/AIM: Patients with liver cirrhosis suffer from energy malnutrition. Late evening snacks (LESs) have been recently reported to be effective for this. However, it is known that a significant proportion of patients with liver cirrhosis have glucose intolerance as a complication. For this reason, the influence of LES on the blood glucose level should be examined. SUBJECTS/METHOD: We administered an oral supplement with branched-chain amino acids (Aminoleban EN) to patients with liver cirrhosis at 10 P.M. to investigate the changes of the blood glucose level and energy metabolism with an indirect calorimeter. Ten patients (average age, 70; Child A/B/C, 5/4/1) participated in this study. The administration period was 7 days. Blood glucose levels were examined before and after breakfast, lunch, supper and at 10 P.M. RESULTS: (1) The fat oxidation rate was significantly decreased and the carbohydrate oxidation rate significantly increased. As a result, RQ was significantly improved. (2) With many cases, an increase of glucose level after meals seemed to reduce with LES administration for 1 week. (3) BTR was significantly improved. CONCLUSIONS: LES could improve energy malnutrition, correct amino acid imbalance, and ultimately may improve glucose intolerance in patients with liver cirrhosis.

Herbal medicine Inchin-ko-to (TJ-135) prevents liver fibrosis and enzyme-altered lesions in rat liver cirrhosis induced by a choline-deficient L-amino acid-defined diet.

BACKGROUND/AIMS: The herbal medicine Inchin-ko-to (TJ-135), extract power from three herbs, has recently been reported possessing anti-apoptotic activity. The aim of this study was to investigate whether TJ-135 has any influence on the development of preneoplastic lesions as well as liver fibrosis. METHODS: The effects of the TJ-135 were examined using the choline-deficient L-amino acid-defined diet-induced liver fibrosis model. In addition, the effect of TJ-135 on mitogen-activated protein (MAP) kinase, type III procollagen mRNA expression and the medium N-terminal procollagen III propeptide (PIIINP) concentration in a hepatic stellate cell line (LI90) were examined. RESULTS: TJ-135 prevented fibrosis in a dose-dependent manner up to 1.5% (w/w). TJ-135 also reduced the expression of type III procollagen mRNA in the liver, as well as the number of activated stellate cells. Furthermore, TJ-135 reduced the area of preneoplastic lesions in the liver. With LI90 cells, TJ-135 reduced MAP kinase (ERK and JNK but not P38) activities resulting in reduced type III procollagen mRNA and PIIINP concentrations in the medium in a dose-dependent manner. CONCLUSIONS: These results indicate that although TJ-135 has anti-apoptotic activity, TJ-135 does not increase preneoplastic lesions but significantly reduces liver fibrosis through the inhibition of stellate cell activation without a reduction of hepatocyte cell death.

Two novel transcripts for human endothelin B receptor produced by RNA editing/alternative splicing from a single gene.

Hirschsprung disease is a heterogeneous genetic disorder, causative genes of which include the endothelin B receptor (ETB). To investigate the mutations of ETB in Hirschsprung disease, expression of the ETB gene in lymphoblastoid cells from patients and normal healthy adults was examined, and novel mutant transcripts were found. The mutant ETB gene transcripts lacked a 134-bp nucleotide sequence corresponding to exon 5, and some also contained a substitution from A to G at position 950 in exon 4, resulting in an amino acid substitution from glutamine (Q) to arginine (R). This substitution was suspected to be the result of RNA editing because it was not present in the genomic sequence. Transfection experiments using ETB minigenes containing the editing site with or without the gene for double-strand RNA deaminases (ADAR1 and ADAR2) revealed that the deaminases were involved in RNA editing. Furthermore, a c-Myc-tagged mutant ETB protein was not detected by Western blot analysis. The present results show that the mutant ETB transcripts were novel splice variants, which might not be translated, or that the products translated from splice variants might be quickly degraded, presumably because of their instability. The preferential production of this null function ETB by RNA editing/splicing could be involved in the etiology of some cases of Hirschsprung disease.