Significance of Viral Load, Core Promoter/Precore Mutations and Specific Sequences of Polymerase Gene in Hbv-Infected Patients on 3-Year Lamivudine Treatment

Background

Comprehensive study on viral factors predicting treatment responsiveness to lamivudine is lacking.

Aims

To define the significance of various viral factors and changes of viral population with lamivudine treatment.

Patients and methods

Hepatitis B virus (HBV) DNA levels at baseline, week 24, 52 and year 3 were measured in 80 patients on continuous lamivudine therapy for 3 years. Genotypes, core promoter/precore mutations, YMDD mutations, polymorphic sequence of polymerase gene (rt91I/L, rt256S/C) were determined at baseline, week 12, 24 and 52. YMDD mutations were also determined at year 3.

Results

High alanine aminotransferase levels and presence of core promoter/ precore mutations at baseline were associated with higher chance of achieving HBV DNA <1,000 copies/ml (good response) and higher rate of hepatitis Be antigen (HBeAg) seroconversion at week 52. Achieving HBV DNA levels <1,000 copies/ml at week 24 as well as baseline core promoter/precore mutations were associated with higher chance of achieving good response, higher rate of HBeAg seroconversion and lower rate of YMDD mutations at year 3. Lamivudine reversed core promoter mutations to wild type in 25% of patients. All 5 patients with rt256C had poor HBV DNA response, persistent HBeAg and YMDD mutations by year 3. There was no difference in treatment response between patients with genotype B and C.

Conclusions

Achieving HBV DNA levels <1,000 copies/ml at 24 week is the best target for short- and long-term treatment efficacy. Core promoter and precore mutations were associated with better treatment outcome, and rt256C polymorphism in the polymerase gene with poor response.

Tacrolimus for Primary Liver Transplantation: 12 to 15 Years Actual Follow-Up With Safety Profile

BACKGROUND

Tacrolimus has been increasingly used for liver transplantation during the last decade. The drug has immunological advantages in short- to medium-term follow-up. However, data on longitudinal follow-up are lacking.

AIM

The aim of the present report was to examine the impact of tacrolimus in primary adult and pediatric liver transplantation (LTx) patients.

MATERIAL AND METHOD

One thousand consecutive primary LTx patients were performed under tacrolimus between August 1989 and December 1992 were followed up until August 2004. Mean follow-up was 13.4 +/- 0.92 (range, 11.7-15) years. There were 600 males and 400 females with a mean age of 42.6 +/- 20.2 years. There were 166 children (age 18 years or younger) and 834 adults, of whom 204 were older than 60 years (seniors).

RESULTS

Four hundred ninety-seven (49.7%) patients died in the follow-up period. The overall 15-year actuarial patient survival rate was 51.4%. The survival rate for children was significantly better (81.3%) compared with adults (47.5%) and seniors (36.4%) (P = .0001). One hundred fifty-one patients received a second LTx, 22 patients received a third LTx, and 4 patients received a fourth LTx. Over all 15 years the actuarial graft survival rate was 46.1%. At last follow-up, 69.1% of patients were off steroids. The majority of late deaths were due to age-related complications, recurrence of disease, and De novo cancers.

CONCLUSION

The data on longitudinal follow-up have shown actuarial survival for children to be significantly better than in adults and seniors. Graft loss from immunological causes are rare even with long-term follow-up.

Livers Transplanted From Donors After Cardiac Death Occurring in the ICU or the Operating Room Have Excellent Outcomes

BACKGROUND

Increasing donor hospital cooperation with donation after cardiac death (DCD) requires the organ procurement organization (OPO) to use current withdrawal of life support (WLS) protocols. Hospital ICU nurses/physicians are comfortable performing the emotionally draining procedure of WLS in the ICU while OPOs are reluctant to accept these donors due to increased warm ischemia (WI). In our area, several hospitals will only allow WLS to occur in the ICU. This study compares liver outcomes from DCD donors where death occurred in the ICU (DCDICU) vs the OR (DCDOR).

METHODS

From March 2003 to June 2004, 34 DCD donors were recovered by our OPO. WLS occurred in the ICU for 26 donors (76%) and in the OR for 8 donors (24%). Thirteen of 26 DCDICU and 5 of 8 DCDOR livers were transplanted. Donor demographics, warm ischemic time, cold ischemic time, distance shipped, and recipient functions were analyzed.

RESULTS

Eighteen livers were transplanted both locally and at distant transplant centers. Results are outlined in the .

CONCLUSIONS

Although DCDICU donors averaged approximately 4 minutes longer WI than DCDOR donors, short-term results for both groups were equivalent. These findings support using DCDICU livers. DCDICU donors have the potential to significantly improve donor hospital cooperation.

A simple method to estimate force plate inertial components in a moving surface

Support surface perturbations are a common paradigm for the study of balance and postural control. Forces and moments acquired from force plates mounted on, or within, the moving surface will contain components resulting from the inertia of the force plate itself. These force plate inertial components must be removed in order to accurately estimate forces resulting from contact with the force plate. This is particularly important when these contact forces are to be used in further calculations, such as an inverse dynamics analysis of joint kinetics. An estimate of the FPIC can be derived using the kinematics of the moving surface and the inertial properties of the force plate. This technique allowed for a reduction of up to 85% of the peak and integrated FPIC acquired from AMTI (OR6-7) force plates during translations of 0.1m, and surface rotations of 10 degrees, using a ramp stimulus of 150 ms duration.

Review article: current status of liver transplantation in HIV-infected patients

The increases in survival of patients infected with human immunodeficiency virus is attributed to the introduction of combination human immunodeficiency virus antiviral therapy, better known as highly active anti-retroviral therapy. In fact, survival statistics have improved such that individuals often succumb to other disease entities, notably liver failure and not from acquired immunodeficiency syndrome complications. Liver transplantation has been introduction in this patient population in several centres around the world. This review will discuss the current clinical status of liver transplantation in individuals suffering from human immunodeficiency virus infection.

Endothelin receptor antagonist TAK-044 arrests and reverses the development of carbon tetrachloride induced cirrhosis in rats

BACKGROUND AND AIMS

Hepatic concentrations of the powerful vasoconstrictor and fibrogen endothelin 1 (ET-1) and its receptors increase in human and experimental cirrhosis, suggesting a major role for ET-1 in the pathology of chronic liver disease. We investigated whether ET-1 receptor antagonism, after the development of fibrosis and cirrhosis, arrests/reverses the progression of chronic liver disease.

METHODS

Chronic liver injury was induced in rats by carbon tetrachloride (CCl(4)) treatment (0.15 ml/kg intraperitoneally twice a week) in conjunction with phenobarbital in drinking water (0.4 g/l) for four (group 1: fibrosis) and eight (group 2: cirrhosis) weeks. Rat were then treated concurrently with the ET-1 receptor antagonist TAK-044 (10 mg/kg/day) and CCl(4)/phenobarbital for a further four weeks.

RESULTS

Histopathological examination revealed significant arrest of progression to cirrhosis in group 1 and reversal of cirrhosis in group 2 rats. TAK-044 treatment caused significant amelioration of portal hypertension, systemic hypotension, and liver injury (reduced activities of serum aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase), and improved hepatic synthetic capacity (increased serum albumin concentration) in both groups of rats relative to vehicle treated rats. TAK-044 treatment reduced collagen synthesis, as evidenced by decreased hepatic hydroxyproline content, mRNA expression of collagen-alpha type I, and tissue inhibitors of matrix metalloproteinases 1 and 2, and mRNA and protein expression of a potent fibrogenic cytokine, transforming growth factor beta1.

CONCLUSIONS

The results emphasise the role of ET-1 in the development of cirrhosis and strongly suggest that blockade of its actions can be a rational therapy for chronic liver disease and its complications.

A postural adaptation test for stroke patients

PURPOSE

To explore the interrater reliability of the Advanced Mobility and Balance Scale (AMBS) and to determine its discriminative capacity in stroke patients.

METHODS

Twelve hemiparetic patients and six healthy elderly volunteers were videotaped while: (1) executing rapid head motions during standing and walking; and (2) standing and walking on a slope. Five physical therapists viewed the videotapes to establish interrater reliability.

RESULTS

Interrater reliability: Intraclass correlation ratios ranged from 0.93-0.97 for the AMBS global as well as slope and head turn subscores. Construct validity: One-way ANOVAs and post-hoc pairwise comparisons were performed to determine whether there was a difference in scores between high (HFL) and low functional-level (LFL) stroke patients (based on gait speed) and healthy subjects. Mean (+/-SD) global scores were 45 +/- 3 for healthy subjects, 40 +/- 9 for HFL stroke patients and 25 +/- 1 for LFL stroke patients (p < 0.05 for HFL versus LFL patients and LFL patients versus healthy subjects). The AMBS slope subscores were 22 +/- 2, 19 +/- 5, 9 +/- 7 for healthy, HFL and LFL subjects respectively (p < 0.05 for HFL versus LFL patients and LFL patients versus healthy subjects).

CONCLUSION

The AMBS has excellent interrater reliability and good discriminative capacities.

A review of the adaptability and recovery of locomotion after spinal cord injury

Spinal cord injury (SCI) is associated with multiple motor problems leading to the alteration and limited adaptation in the walking and postural behavior. This review addresses recent findings on locomotor and postural adaptations after spinal cord injury. The adaptation of the locomotor behavior to behavioral goals and external constraints constitute important functional prerequisites in the recovery of locomotion after spinal cord injury. Functional prerequisites in locomotion include coping with changes in speed, slope obstacle, weight support, interaction with walking aids, energy consumption and attentional demands. Various treatment approaches such as locomotor training using body weight support (BWS) and functional electrical stimulation (FES) will be discussed, in the context of functional prerequisites necessary in the recovery of locomotion. Understanding locomotor and postural adaptations will lead to a better appreciation of the normal and dysfunctional mechanisms, and culminate eventually in the development of appropriate rehabilitation assessment and treatment strategies.

Cryptococcal meningitis: an analysis among 5,521 consecutive organ transplant recipients

Cryptococcal meningitis has been reported to be an important cause of morbidity and mortality in renal transplant recipients. However, additional studies of recipients of other organ transplants suggested that these patients might be at low risk for cryptococcal meningitis. We examined the incidence and clinical features of cryptococcal meningitis among different groups of organ transplant patients at the University of Pittsburgh Medical Center. From January 1989 through July 1999, 28 patients were diagnosed with cryptococcal meningitis among 5,521 transplant recipients. These included liver (11/2,539), heart (8/372), kidney (7/2,122), lung (1/432), and small bowel (1/56) recipients. The incidence of cryptococcal meningitis was higher in heart and small bowel recipients compared to other transplant populations (P = 0.005). The cryptococcal meningitis-related mortality in transplant recipients was 50% and was associated with altered mental status (P = 0.001), absence of headache (P = 0.02), and liver failure (P = 0.002). Multivariable analysis indicated that liver failure was the only independent risk factor for poor prognosis (P = 0.043). All cases of liver failure occurred among liver transplant recipients. Cryptococcal meningitis is associated with significant mortality among organ transplant recipients. The presence of allograft failure in liver transplant recipients with cryptococcal meningitis may be an indicator of poor prognosis in this patient population.

The pathogenesis and management of influenza virus infection in organ transplant recipients

Infection with influenza viruses poses specific problems in adult and pediatric organ transplant recipients, including a higher rate of pulmonary and extra-pulmonary complications. Also, data suggest that influenza is associated with acute cellular rejection and chronic allograft dysfunction. The main strategy of influenza prevention has been influenza immunization in order to stimulate local and systemic antibodies. However, studies have shown that antibody response to inactivated influenza vaccine is decreased in all groups of organ transplant recipients. A live attenuated influenza virus vaccine is nearing approval in the United States. However, studies are needed in organ transplant recipients to determine whether the live attenuated influenza virus vaccine can enable these patients to mount a protective immune response and what degree of protection or amelioration of illness is provided by such vaccine. It is also important to verify the safety of this vaccine in organ transplant recipients because live virus may cause severe disease in these patients. Therefore, other modalities of prevention against influenza, such as chemoprophylaxis with antiviral drugs, should be considered in this patient population. The current review provides an overview of the incidence, clinical manifestations, and strategies for the prevention and management of influenza in organ transplant recipients.

The role of rehabilitation in the recovery of walking in the neurological population

Recent studies demonstrate that neurological patients show great potential for recovery in both the early and late stages following injury. Enhancement of the recovery process could be achieved with new rehabilitation approaches alone or in combination with pharmacological intervention. These new approaches have evolved from fundamental advances in both animal and human studies. To date few randomized clinical trials have addressed the efficacy or effectiveness of these new approaches. In this paper, important quantitative studies will be reviewed and discussed in relation to the important mechanisms of locomotor control and plasticity that take place following lesions of the central nervous system.

Results of simultaneous and sequential pediatric liver and kidney transplantation

BACKGROUND

The indications for simultaneous and sequential pediatric liver (LTx) and kidney (KTx) transplantation have not been well defined. We herein report the results of our experience with these procedures in children with end-stage liver disease and/or subsequent end-stage renal disease.

PATIENTS AND METHODS

Between 1984 and 1995, 12 LTx recipients received 15 kidney allografts. Eight simultaneous and seven sequential LTx/KTx were performed. There were six males and six females, with a mean age of 10.9 years (1.5-23.7). One of the eight simultaneous LTx/KTx was part of a multivisceral allograft. Five KTx were performed at varied intervals after successful LTx, one KTx was performed after a previous simultaneous LTx/KTx, and one KTx was performed after previous sequential LTx/KTx. Immunosuppression was with tacrolimus or cyclosporine and steroids. Indications for LTx were oxalosis (four), congenital hepatic fibrosis (two), cystinosis (one), polycystic liver disease (one), A-1-A deficiency (one), Total Parenteral Nutrition (TPN)-related (one), cryptogenic cirrhosis (one), and hepatoblastoma (one). Indications for KTx were oxalosis (four), drug-induced (four), polycystic kidney disease (three), cystinosis (one), and glomerulonephritis (1).

RESULTS

With a mean follow-up of 58 months (0.9-130), the overall patient survival rate was 58% (7/12). One-year and 5-year actuarial patient survival rates were 66% and 58%, respectively. Patient survival rates at 1 year after KTx according to United Network of Organ Sharing (liver) status were 100% for status 3, 50% for status 2, and 0% for status 1. The overall renal allograft survival rate was 47%. Actuarial renal allograft survival rates were 53% at 1 and 5 years. The overall hepatic allograft survival rate was equivalent to the overall patient survival rate (58%). Six of seven surviving patients have normal renal allograft function, and one patient has moderate chronic allograft nephropathy. All surviving patients have normal hepatic allograft function. Six (86%) of seven sequentially transplanted kidneys developed acute cellular rejection compared with only two (25%) of eight simultaneously transplanted kidneys (P<0.04).

CONCLUSIONS

Simultaneously transplanted kidneys were less likely to develop rejection than sequentially transplanted kidneys in this series. This did not have any bearing on patient or graft survival rates. Mortality correlated directly with the severity of United Network of Organ Sharing status at the time of kidney transplantation. Candidates for simultaneous or sequential LTx/KTx should be prioritized based on medical stability to optimize distribution of scarce renal allografts.

Towards a full karyotype screening of interphase cells: 'FISH and chip' technology

Numerical chromosome aberrations are incompatible with normal human development. Our laboratories develop hybridization-based screening tools that generate a maximum of cytogenetic information for each polar body or blastomere analyzed. The methods are developed considering that the abnormality might require preparation of case-specific probes and that only one or two cells will be available for diagnosis, most of which might be in the interphase stage. Furthermore, assay efficiencies have to be high, since there is typically not enough time to repeat an experiment or reconfirm a result prior to fertilization or embryo transfer. Structural alterations are delineated with breakpoint-spanning probes. When screening for numerical abnormalities, we apply a Spectral Imaging-based approach to simultaneously score as many as ten different chromosome types in individual interphase cells. Finally, DNA micro-arrays are under development to score all of the human chromosomes in a single experiment and to increase the resolution with which micro-deletions can be delineated.

Clinical intestinal transplantation: a decade of experience at a single center

OBJECTIVE

To assess the long-term efficacy of intestinal transplantation under tacrolimus-based immunosuppression and the therapeutic benefit of newly developed adjunct immunosuppressants and management strategies.

SUMMARY BACKGROUND DATA

With the advent of tacrolimus in 1990, transplantation of the intestine began to emerge as therapy for intestinal failure. However, a high risk of rejection, with the consequent need for acute and chronic high-dose immunosuppression, has inhibited its widespread application.

METHODS

During an 11-year period, divided into two segments by a 1-year moratorium in 1994, 155 patients received 165 intestinal allografts under immunosuppression based on tacrolimus and prednisone: 65 intestine alone, 75 liver and intestine, and 25 multivisceral. For the transplantations since the moratorium (n = 99), an adjunct immunosuppressant (cyclophosphamide or daclizumab) was used for 74 transplantations, adjunct donor bone marrow was given in 39, and the intestine of 11 allografts was irradiated with a single dose of 750 cGy.

RESULTS

The actuarial survival rate for the total population was 75% at 1 year, 54% at 5 years, and 42% at 10 years. Recipients of liver plus intestine had the best long-term prognosis and the lowest risk of graft loss from rejection (P =.001). Since 1994, survival rates have improved. Techniques for early detection of Epstein-Barr and cytomegaloviral infections, bone marrow augmentation, the adjunct use of the interleukin-2 antagonist daclizumab, and most recently allograft irradiation may have contributed to the better results.

CONCLUSION

The survival rates after intestinal transplantation have cumulatively improved during the past decade. With the management strategies currently under evaluation, intestinal transplant procedures have the potential to become the standard of care for patients with end-stage intestinal failure.

Pulmonary Cyp1A1 and CYP1A2 levels and activities in adult male and female offspring of rats exposed during gestation and lactation to 2,3,7, 8-tetrachlorodibenzo-p-dioxin

The levels and activities of pulmonary microsomal CYP1A1 and CYP1A2 in 40-day-old male and female, and 120-day-old male offspring of pregnant rats treated with five weekly 0.1 microg/kg doses of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) during gestation and lactation were compared with those in age-matched offspring of untreated dams. The CYP1A1-preferential activity, ethoxyresorufin O-deethylase (EROD), was comparably induced 5.3- and 6.4-fold in 40-day-old male and female offspring, respectively, but was not induced in 120-day-old male offspring, of TCDD-treated dams. Similarly, CYP1A1 protein was induced in 40-day-old female or male offspring of untreated dams but was undetectable in 120-day-old offspring of untreated or treated dams. CYP1A2 activity, as measured by the bioactivation of 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ) to mutagens in the Ames assay, was elevated 11.1- and 5.5-fold in 40-day-old female and male offspring, respectively, of TCDD-treated dams, but was unaffected by TCDD exposure in 120-day-old offspring. CYP1A2 protein was undetectable in 40-day-old male or female offspring of untreated dams or in 120-day-old male offspring of treated or untreated dams; it was detected in 40-day-old offspring of treated dams, at a level that was higher in females than in males. The results show that gestational and lactational exposure to TCDD causes long-lasting and gender-preferential induction of CYP1A1 as well as CYPIA2 in the lungs of rat offspring.

Hepatocellular carcinomas in native livers from patients treated with orthotopic liver transplantation: biologic and therapeutic implications

The gross and histopathologic characteristics of 212 nonfibrolamellar hepatocellular carcinomas (HCCs) discovered in native livers removed at the time of liver transplantation were correlated with features of invasive growth and tumor-free survival. The results show that most HCCs begin as small well-differentiated tumors that have an increased proliferation rate and induce neovascularization, compared with the surrounding liver. But at this stage, they maintain a near-normal apoptosis/mitosis ratio and uncommonly show vascular invasion. As tumors enlarge, foci of dedifferentiation appear within the neoplastic nodules, which have a higher proliferation rate and show more pleomorphism than surrounding better-differentiated areas. Vascular invasion, which is the strongest predictor of disease recurrence, correlates significantly with tumor number and size, tumor giant cells and necrosis, the predominant and worst degree of differentiation, and the apoptosis/mitosis ratio. In the absence of macroscopic or large vessel invasion, largest tumor size (P <.006), apoptosis/mitosis ratio (P <.03), and number of tumors (P <.04) were independent predictors of tumor-free survival and none of 24 patients with tumors having an apoptosis/mitosis ratio greater than 7.2 had recurrence. A minority of HCCs (<15%) quickly develop aggressive features (moderate or poor differentiation, low apoptosis/mitosis ratio, and vascular invasion) while still small, similar to flat carcinomas of the bladder and colon. In conclusion, hepatic carcinogenesis in humans is a multistep and multifocal process. As in experimental animal studies, aggressive biologic behavior (vascular invasion and recurrence) correlates significantly with profound alterations in the apoptosis/mitosis ratio and with architectural and cytologic alterations that suggest a progressive accumulation of multiple genetic abnormalities.

Clinical significance of elevated alpha-fetoprotein in adults and children

The aim of the current study is to identify underlying pathology associated with elevated serum alpha-fetoprotein (AFP; >20 ng/ml) among patients referred to a tertiary-care academic medical center with emphasis in liver diseases, hepatobiliary surgery, and liver transplantation. From May 1992 to April 1997, 386 patients (320 adults and 66 children) with elevated AFP (>20 ng/ml) were identified from the Medical Archival System (MARS) database at the University of Pittsburgh Medical Center. The medical records from all these patients were retrospectively reviewed. Radiological, pathological, and biochemical profiles were obtained at the time of documented elevated AFP. These patients included: 218 adults with malignancies, 102 adults without malignancies, 18 children and infants with malignancies, and 48 children and infants without malignancies. Thirty-two percent of adults were found to have raised AFP with liver disease and without hepatocellular carcinoma and 78% had some type of malignancy, predominantly hepatocellular carcinoma. Seventy-three percent of infants and children had elevated AFP without malignancy. Based on our findings, we recommend that all patients (adults, infants and children) with raised AFP of >20 ng/ml should undergo thorough evaluation to rule out malignant disease.

Detection of structural and numerical chromosome abnormalities in interphase cells using spectral imaging

Chromosome abnormalities are common causes of congenital malformations and spontaneous abortions. They include structural abnormalities, polyploidy, trisomy, and mosaicism. In in vitro fertilization (IVF) programs, preimplantation genetic diagnosis (PGD) of oocytes and embryos has become the technique of choice to select against abnormal embryos before embryo transfer. For diagnosis of structural abnormalities, we developed case-specific breakpoint-spanning DNA probes. Screening of an in-house yeast artificial chromosome (YAC) library is facilitated by information from publicly available databases and published articles. Most numerical chromosome abnormalities, on the other hand, are detrimental to early embryonic development and increase with maternal age. We therefore developed a multichromosome screening technique based on spectral imaging to simultaneously detect and score as many as 10 different chromosome types. The probe set was chosen to detect more than 70% of all numerical chromosome aberrations responsible for spontaneous abortions. Detecting structural and numerical abnormalities in single interphase cells using spectral imaging is a powerful technique for multilocus genetic screening.

Monitoring signal transduction in cancer: from chips to fish

The microarray format of RNA transcript analysis should provide new clues to carcinogenic processes. Because of the complex and heterogeneous nature of most tumor samples, histochemical techniques, particularly RNA fluorescent in situ hybridization (FISH), are required to test the predictions from microarray expression experiments. Here we describe our approach to verify new microarray data by examining RNA expression levels of five to seven different transcripts in a very few cells via FISH. (J Histochem Cytochem 49:925-926, 2001)