Serum Gc-globulin in the early course of multiple trauma

OBJECTIVES

In patients with multiple trauma, actin released from damaged cells may cause severe circulatory disturbance due to thrombi formation. The aim of this study was to evaluate serum concentrations of the actin scavenger, Gc-globulin, in relation to the severity of injury and outcome.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Trauma center at a university hospital.

PATIENTS

Twelve patients with multiple trauma, consecutively included, according to defined criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serum Gc-globulin concentrations were measured at the time of admission and daily thereafter for 1 wk or until death. In all patients, the Gc-globulin concentration was significantly low (p < .0001), and the proportion of Gc-globulin bound to actin was already increased compared with normal values (p < .0001) by the time of hospital arrival. There was an inverse correlation between the mean concentration of serum Gc-globulin in the first week after trauma and the Injury Severity Score (r = -0.72, p < .05). Surviving patients had a significantly (p < .05) higher concentration of serum Gc-globulin in the first week after trauma compared with nonsurvivors.

CONCLUSIONS

Serum concentrations of Gc-globulin were significantly low in trauma patients. The reduction took place within 60 mins after injury. Because the normal half-life of Gc-globulin is almost 48 hrs, our observations suggest a marked consumption of Gc-globulin immediately after the trauma. This finding could be the first clinical evidence that Gc-globulin plays a role in the systemic inflammatory response syndrome after trauma. This result is supported by the finding that lack of Gc-globulin was related to nonsurvival and the severity of the trauma.

Reduced serum Gc-globulin concentrations in patients with fulminant hepatic failure: association with multiple organ failure

OBJECTIVE

To evaluate the association between admission serum concentrations of the actin-scavenger, Gc-globulin, and the subsequent development of multiple organ failure in patients with fulminant hepatic failure.

DESIGN

Retrospective study.

SETTING

A hepatologic intensive care unit.

PATIENTS

Seventy-nine patients with hepatic encephalopathy grade 3 or 4.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serum admission concentrations of both total and nonactin-complexed (free) Gc-globulin were determined. The development of cardiovascular failure, renal failure, pulmonary failure, intracranial hypertension, and infections were recorded in each patient. Both total and free Gc-globulin values were significantly lower in the patients, compared with normal controls. The Gc-globulin values were significantly reduced in patients who subsequently developed cardiovascular failure (p < .01), intracranial hypertension (p < .001), and infections (p < .001), compared with those patients who did not. No differences were found between patients with and without pulmonary or renal failure. Patients with total Gc-globulin values in the lowest quintile had on average 2.6 organ failures, whereas patients with Gc-globulin concentrations in the highest quintile had 0.9 organ failures. The corresponding figures for the lowest and highest quintiles of free Gc-globulin were 3.0 and 1.1 organ failures, respectively. Both total and free Gc-globulin were inversely correlated to the number of organ failures (p < .005 in both cases). Patients with multiple organ failure (> or = 2 organ failures) had significantly reduced Gc-globulin values compared with patients without multiple organ failure (p < .0001).

CONCLUSIONS

In patients with fulminant hepatic failure, the lowest admission Gc-globulin concentrations were associated with the subsequent development of cardiovascular failure, intracranial hypertension, and infections. Lack of Gc-globulin correlated significantly with the development of multiple organ failure and may be pathogenetically involved in this condition.

Expression of liver functions following sub-lethal and non-lethal doses of allyl alcohol and acetaminophen in the rat

BACKGROUND/AIMS

To relate severity of intoxication with allyl alcohol and acetaminophen to modulated hepatic gene expression of liver functions and regeneration.

METHODS

Rats fasted for 12 h received acetaminophen 3.5 or 5.6 g per kg body weight, or allyl alcohol 100 or 125 microl by gastric tube, doses producing no and about 30% mortality, respectively, within 2 days. In the morning 2, 6, 12, 24, and 36 h after intoxication, RNA was extracted from liver tissue. By slot blot hybridization mRNA levels were determined for acute phase proteins, enzymes involved in ammonia elimination and urea synthesis, and for proteins related to liver regeneration.

RESULTS

After allyl alcohol, mRNA of "positive" acute phase proteins was higher than after acetaminophen and increased with the dose, whereas after acetaminophen it decreased with the dose. The mRNA of the urea cycle enzymes and glutamine synthetase was uniformly reduced by allyl alcohol, whereas that of most urea cycle enzymes was above the controls after the non-lethal, but not after the sub-lethal, dose of acetaminophen. The mRNA of glutamine synthetase was significantly more reduced by acetaminophen than by allyl alcohol. The mRNA of cell-cycle dependent proteins was greatly reduced after both toxins, more after the higher dose.

CONCLUSIONS

The study shows that acetaminophen intoxication inhibits or fails to induce the expression of acute phase proteins in contrast to allyl alcohol intoxication. Allyl alcohol suppressed the expression of urea cycle enzymes, whereas that of the rate limiting enzymes carbamoylphosphate synthase and argininosuccinate synthetase was increased by the non-lethal but not by the sub-lethal dose of acetaminophen. The expression of the cell-cycle dependent proteins was more suppressed after the sub-lethal than after the non-lethal dose of both toxins. The data support the view that a fatal outcome of the intoxications depends more on the ability to regenerate than on the maintenance of liver-specific functions.

Effects of growth hormone and insulin-like growth factor-I singly and in combination on in vivo capacity of urea synthesis, gene expression of urea cycle enzymes, and organ nitrogen contents in rats

Improvement of nitrogen balance is desirable in patients with acute or chronic illness. Both growth hormone (GH) and insulin-like growth factor-I (IGF-I) are promising anabolic agents, and their combined administration has been shown to reverse catabolism more efficiently than each of the peptides alone. This is believed to be mediated primarily through increased peripheral protein synthesis, whereas little attention has focused on a possible participation of amino acid metabolism in the liver. Four groups of rats were given: 1) placebo; 2) GH (200 micrograms/d); 3) IGF-I (300 micrograms/d); and 4) both GH and IGF-I. After 3 days, the maximum capacity of urea-nitrogen synthesis was determined by saturating infusion of alanine (n = 8 in each group), together with measurements of liver messenger RNA (mRNA) levels for urea cycle enzymes (n = 5 in each group) and N-contents of muscles, heart, and kidney. Basal plasma alpha-amino acid concentrations were similar in all groups. The capacity of urea-N synthesis [mumol/(min x 100 g body weight)] was reduced in a stepwise manner (placebo: 8.25 +/- 1.2; GH treatment: 6.52 +/- 0.8; IGF-I treatment: 5.5 +/- 0.6; and GH/IGF-I: 4.22 +/- 1.6 [P < .001 by ANOVA]), each step being lower than the former. Serum IGF-I increased stepwise from placebo (699 +/- 40 to 1,579 +/- 96 micrograms/L in the combined GH/IGF-I group), and was correlated negatively with the capacity of urea-nitrogen synthesis (P < .01). mRNA levels for urea cycle enzymes in the liver decreased after GH and IGF-I treatment, and the effect was more pronounced after the combined treatment in which the rate-limiting enzyme, argininosuccinate synthetase, was halved. Nitrogen contents of organs increased after both GH and IGF-I treatment, and even more so after the combination treatment, reaching an increase of 30% (P < .05). Data suggest that GH and IGF-I singly and, even more so in combination, additively inhibit urea synthesis. This is supposed to favor protein buildup in organs. We speculate that this inhibitory effect on the capacity of urea synthesis is caused by a decreased translation rate of the urea cycle enzymes caused by GH and IGF-I's down-regulatory effect on urea cycle enzyme gene transcription. The findings may indicate a novel mechanism of the protein anabolic action of GH and IGF-I.

[Gc-globulin in paracetamol poisoning]

Gc-globulin scavenges actin liberated from necrotic cells. We measured serum Gc-globulin and the degree of complexing with monomeric actin (complex ratio) in the initial phase of paracetamol (acetaminophen) intoxication and related this to the severity of liver necrosis and the clinical course. In eighteen patients with paracetamol intoxication serial measurements of serum Gc-globulin and complex ratio were determined from admission and every three hours thereafter. Eight patients developed hepatic encephalopathy (HE) and two of them died. On admission all patients had significantly reduced serum Gc-globulin levels compared to normal individuals, and patients with HE had significantly lower values than patients without HE. All patients with HE had at least three samples, where Gc-globulin was below 120 mg/l (35% of normal). Complex ratio on admission did not differ significantly in the patients with and those without HE. The peak complex ratio was higher in patients with HE than in patients without HE, and three of four patients with peak complex ratio above 75% had HE. In conclusion, Gc-globulin levels were found to be decreased in patients with paracetamol intoxication; this decrease correlated with the most severe sign of liver dysfunction, HE. Serum Gc-globulin below 120 mg/l and peak complex ratios above 75% may be critical values.

Expression of liver-specific functions in rat hepatocytes following sublethal and lethal acetaminophen poisoning

AIM

In order to study the short-term effect of moderate and severe reduction of liver function by acetaminophen poisoning of different severity on gene expression for liver-specific functions, rats were given 3.75 and 7.5 g per kg body weight acetaminophen intragastrically. The lower dose is associated with low mortality; after the higher dose, most rats die at between 12 and 24 h.

METHODS

In the morning, 1 1/2, 3, 6, 9, and 12 h after the injection, the rats were killed and RNA was extracted from liver tissue. By slot-blot hybridization mRNA steady-state levels were determined for enzymes involved in metabolic liver functions, i.e. ureagenesis, gluconeogenesis, and drug metabolism, for acute phase proteins, "house-keeping" proteins, and for proteins related to liver regeneration. Results were expressed as per cent of the level in similarly fasted, untreated rats of the same stock

RESULTS

After the smaller dose of acetaminophen, most of the examined mRNA levels were increasing during the experimental period, being two- to four-fold elevated in relation to control after 6 to 12 h. Rats receiving the lethal dose either showed no or a later and smaller increase, and in several cases a fall towards the end of the experiment. The greatest differences were seen for mRNA of arginase, beta-fibrinogen, alpha 1-acid glycoprotein, alpha-tubulin, histone 3, TGF beta, and cyclin d, i.e. proteins associated with acute phase response and liver cell replication and maintenance.

CONCLUSIONS

It is concluded that reversible intoxication with acetaminophen induces an adaptive modulation of mRNA expression of liver functions and regeneration which is lacking after severe intoxication. This adaptation, with emphasis on acute phase response and regeneration, may be crucial for recovery after acetaminophen intoxication. If this also applies to the intoxication in man, estimates of the corresponding variables may be clues to the prognosis of acetaminophen-induced fulminant hepatic failure.

Expression of messenger RNA for liver functions following 70% and 90% hepatectomy

AIMS/METHODS

The effect of moderate and severe reduction of the functional liver mass on gene expression for liver functions was studied in rats following 70% and 90% hepatectomy. At intervals up to 24 h after operation rats were killed and RNA was extracted from the remaining liver tissue. By slot-blot hybridization mRNA steady-state levels were determined for enzymes involved in metabolic 'liver-specific' functions, acute phase proteins, 'house-keeping', and growth-related proteins. Results were expressed as per cent of levels in a pool from fed control rats of the same gender and age.

RESULTS

Among 'liver-specific' metabolic functions only expression of gluconeogenesis, represented by phosphoenol carboxykinase mRNA, was augmented initially, followed by a fall to very low values after 90% hepatectomy. The drug metabolizing system represented by CYP2B1/2 mRNA was reduced to half of the control values. Expression of urea synthesis, as reflected by carbamoylphosphate synthetase mRNA, showed a gradual decline after 90% hepatectomy, in contrast to rising levels of argininosuccinate lyase and arginase mRNA, possibly serving polyamine rather than urea synthesis. The mRNA level of the acute phase protein alpha 1-acid glycoprotein showed a smaller and later rise in 90% than in 70% hepatectomized rats, whereas that of alpha 2-macroglobulin only increased after 90% hepatectomy like the 'house-keeping' beta-actin mRNA. A rise in histone 3, which coincides with mitosis, was only seen after 70% hepatectomy, indicating that after 90% hepatectomy the response to growth-stimulating factors is weak or delayed, supported by a delayed rise in cyclin d and low levels of growth hormone receptor mRNA.

CONCLUSIONS

It is concluded that attempts by gene regulation to adapt liver functions to a reduction of the liver mass depend on the amount of liver tissue lost. When the loss is nearly fatal, compensation for normal metabolic functions may be abandoned for efforts to regenerate, which, however, may be delayed or after all be too weak.

Admission levels of serum Gc-globulin: predictive value in fulminant hepatic failure

Gc-globulin scavenges actin released from necrotic hepatocytes to the extracellular space. In 77 patients with fulminant hepatic failure (FHF) (excluding patients treated with liver transplantation), admission levels of serum Gc-globulin and degree of complexing with monomeric actin (complex ratio) were determined to evaluate their predictive values in relation to survival/nonsurvival. Gc-globulin levels were significantly reduced in 47 nonsurvivors, compared with 30 survivors (96 +/- 71 mg/L vs. 169 +/- 101 mg/L, P < .001), whereas the complex ratio in nonsurvivors did not differ significantly from that of survivors. Gc-globulin levels were significantly lower in 59 patients with non-acetaminophen-induced FHF, compared with 18 patients with acetaminophen-induced FHF (P < .01). Using a cutoff level of serum Gc-globulin of 100 mg/L, a lesser value correctly predicted nonsurvival in 79 percent of patients with non-acetaminophen-induced FHF, whereas a higher value predicted survival in 60 percent. In patients with acetaminophen-induced FHF, nonsurvival was correctly predicted in 100 percent of patients and survival in 53 percent. In comparison, the King's College Hospital (KCH) criteria correctly predicted nonsurvival and survival in 69 percent and 57 percent, respectively, of the same non-acetaminophen-induced FHF patients and in 60 percent and 38 percent, respectively, of the acetaminophen-induced FHF patients. Thus, in our study population, the predictive properties of Gc-globulin were in the same range as the KCH criteria. An advantage of Gc-globulin is that it gives an estimate of the outcome already on admission. Acute liver transplantation should be considered in FHF patients with Gc-globulin less than 100 mg/L.

Cerebral blood flow, oxygen metabolism and transcranial Doppler sonography during high-volume plasmapheresis in fulminant hepatic failure

OBJECTIVE

The effect of high-volume plasmapheresis on hepatic encephalopathy, cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRO2) was investigated in patients with fulminant hepatic failure (FHF).

METHODS

Twelve consecutive patients (8 women, 4 men, median age 34 years (range 19-51), were studied before and after high-volume plasmapheresis with 10-16 litres fresh frozen plasma, while PaCO2 and body temperature were maintained at 30 (23-34) mmHg and 37.6 degrees C (36.6-38.4), respectively. Blood samples from the internal jugular vein and a radial artery allowed calculation of the cerebral arteriovenous oxygen difference (AVDO2) and oxygen extraction (AVDO2 divided by arterial oxygen content). CBF was determined by a xenon-133 clearance method in eight patients and CMRO2 calculated as AVDO2 times CBF. Cerebral perfusion pressure (CPP) was determined as the difference between mean arterial and subdural pressures in eight patients.

RESULTS

High-volume plasmapheresis was initiated 22 (6-168) h after the development of hepatic encephalopathy and 11 patients had grade 4 encephalopathy. Following high-volume plasmapheresis the grade of encephalopathy improved in four patients. The CBF increased from a median of 31 (16-86) to 45 (18-97) ml/100 g/min and as oxygen extraction remained unchanged (32 (9-41) vs. 29 (7-39)%), CMRO2 increased from 1.24 (0.96-1.82) to 1.86 (1.00-2.07) ml/100 g/min (P < 0.05). The CPP increased from 62 (19-76) to 92 (50-105) mmHg (P < 0.01), whereas the intracranial pressure remained unchanged (19 (3-45) vs. 11 (5-33) mmHg). No statistical difference was found between the relative changes in the above parameters in survivors compared to non-survivors.

CONCLUSION

Although the clinical status did not improve in all patients, both CBF and CMRO2 increased after high-volume plasmapheresis. The alleviation of brain oxygen metabolism by high-volume plasmapheresis may reflect partial removal of neuroinhibitory plasma factors.

Systemic vascular resistance during high-volume plasmapheresis in patients with fulminant hepatic failure: relationship with oxygen consumption

BACKGROUND

In patients with fulminant hepatic failure, systemic vascular resistance and blood pressure are often reduced.

OBJECTIVE

To determine whether systemic vascular resistance increases during high-volume plasmapheresis, which is assumed to eliminate endogenous vasodilatory substances from the bloodstream.

DESIGN

A prospective study.

PATIENTS AND METHODS

Ten patients [median age 48 (range 21-53) years] were admitted for liver transplantation. Systemic haemodynamic variables were determined using a catheter in a radial artery and a thermodilution catheter placed in a pulmonary artery. Ten (range 8-15) litres of fresh frozen plasma were exchanged, while body temperature [37.6 (range 36.6-38.4) degrees C], blood partial pressure of carbon dioxide [3.75 (range 3.30-4.50) kPa] and peak inspiratory ventilatory pressure [24 (range 20-26) mmHg] were kept constant.

RESULTS

Mean arterial pressure increased from 74 (range 61-110) to 96 (range 68-103) mmHg and cardiac index decreased from 5.2 (range 3.6-7.5) to 4.2 (range 3.4-6.6) l/min/m2. The systemic vascular resistance index increased from 662 (range 430-1270) to 1060 (range 621-1520) dyn s/cm5/m2. In contrast, the pulmonary vascular resistance index [42 (range 20-110) dyn s/cm5/m2) remained constant. As cardiac index decreased, oxygen delivery decreased from 939 (range 680-1496) to 745 (range 601-1189) ml/min/m2 with no effect on oxygen consumption [171 (87-231) ml/min/m2], as the arteriovenous oxygen extraction ratio increased from 17 (range 9-22) to 25 (range 8-31)% (P < 0.02).

CONCLUSION

In patients with fulminant hepatic failure, cardiac output, systemic vascular resistance and arterial blood pressure improved during high-volume plasmapheresis.

Functional loss of cerebral blood flow autoregulation in patients with fulminant hepatic failure

In management of patients with fulminant hepatic failure, it is recommended that mean arterial pressure should be raised if cerebral perfusion pressure is lower than 50 mmHg, but the influence of such therapy on cerebral blood flow is unknown. We examined cerebral blood flow autoregulation in seven consecutive patients with fulminant hepatic failure during treatment of imminent insufficient cerebral perfusion pressure. Cerebral perfusion was evaluated by transcranial Doppler assessed mean flow velocity in the middle cerebral artery and by the arterio-venous difference for oxygen. Intracranial pressure was recorded by a subdural transducer and cerebral perfusion pressure calculated as the difference between mean arterial pressure and intracranial pressure. After 20 (range 10 to 43) min, mean arterial pressure was raised from 74 (43-80) to 94 (76-114) mmHg by i.v. noradrenaline, cerebral perfusion pressure increased from 49 (26-75) to 82 (50-108) mmHg (p < 0.01) as the intracranial pressure remained unchanged at 26 (3-35) mmHg. The mean flow veolocity increased from 68 (30-134) to 108 (48-168) cm s-1 and the arterio-venous difference for oxygen by 46 (10-82)% (p < 0.05). Both mean flow velocity (r = 0.63) and arterio-venous difference for oxygen (r = 0.71) were correlated to mean arterial pressure (p < 0.001), and a lower blood pressure limit of autoregulation could not be identified in any of the patients. These data suggest that the cerebral blood flow is not autoregulated in patients with fulminant hepatic failure and therefore cerebral blood flow should be "clamped" within the normal physiologic range by manipulation of arterial blood pressure in order to avoid cerebral hypoxia and/or hypertensive induced cerebral oedema.

Serial measurements of serum Gc-globulin in acetaminophen intoxication

OBJECTIVES

To describe serum Gc-globulin and the extent to which it complexes with monomeric actin in the initial phase of acetaminophen (Paracetamol) intoxication and to relate this to the severity of liver necrosis and the clinical course.

PATIENTS AND METHODS

Serial measurements of Gc-globulin and the proportion of Gc-globulin complexed to G-actin (complex ratio) were made on admission and every 3 h thereafter in eighteen consecutive patients with acetaminophen intoxication. Eight patients developed hepatic encephalopathy (HE) and two died.

RESULTS

On admission, all patients had significantly reduced serum Gc-globulin levels compared with normal individuals (P < 0.0001); patients with HE had significantly lower values than patients without HE (P < 0.001). Gc-globulin levels in the two patients who died did not differ from those in patients who survived hepatic encephalopathy. Fourty-four of 52 serum samples with Gc-globulin levels below 120 mg/l were from patients with encephalopathy (all eight of these patients provided at least three samples). The complex ratio on admission did not differ significantly between patients with and those without HE and fluctuated considerably during the observation period. The peak complex ratio was, however, higher in patients with HE than in patients without HE (P < 0.01), and three of four patients with peak complex ratios above 75% had HE. In addition, the mean complex ratio was greater in the two patients who died than in those who survived HE (P < 0.05).

CONCLUSION

Gc-globulin levels were decreased in individuals suffering from acetaminophen intoxication; this decrease correlated with the most severe sign of liver dysfunction, HE. Serum Gc-globulin levels below 120 mg/l and peak complex ratios above 75% may be critical values. However, as a result of considerable fluctuations in the complex ratio, serial measurements are needed to evaluate the Gc-globulin complexing capacity.

Gene expression of urea cycle enzymes following two-thirds partial hepatectomy in the rat

The effect of reduction of functional liver mass on the expression of enzyme systems for hepatic urea synthesis was assessed in rats following two-thirds partial hepatectomy. Results were related to normal, fed rats and to sham-operated rats, with identical timing for surgery and feeding. Among the five urea cycle enzymes the mRNA steady-state level was higher in hepatectomized than in sham-operated rats for carbamoyl phosphate synthetase and arginino-succinate lyase. The level for albumin mRNA remained close to that of the controls. Relative transcription rates were found to be increased for carbamoyl phosphate synthetase, arginino-succinate synthase and arginase. For albumin the transcription rate was drastically reduced initially, but recovered gradually during the experimental period. The data indicate that the expression of urea cycle enzymes, in particular that of carbamoyl phosphate synthetase which is the rate-limiting step, is up-regulated by partial hepatectomy. This helps to maintain urea synthesis rate at a normal or near normal level during the period of reduced liver mass, confirming metabolic studies. In contrast, the transcription for albumin was reduced. The immediate increase in urea cycle enzyme expression during the period of acute hepatocyte loss is consistent with the view that it is vitally important that urea synthesis, in contrast to e.g. albumin synthesis, remains intact when the metabolic capacity of the liver is reduced.

A liver factor increasing glucose uptake in rat hindquarters

The effect of the liver on glucose uptake in muscle was studied in the isolated rat hindquarter, perfused with and without an isolated rat liver included in a recirculating system. Glucose uptake in the hindquarter was 0.75 +/- 0.10 mumol.min-1 x 100 g bw-1 (mean and SEM), and increased to 1.30 +/- 0.12 during the period when the liver was included in the perfusion (N = 17; p = 0.0001). In experiments where tissue extracts were added to the perfusate during the second period, raw liver extracts increased the glucose uptake from 0.87 +/- 0.11 to 1.25 +/- 0.10 (N = 6; p = 0.003). Deproteinized liver and kidney extracts increased glucose uptake similarly. When the liver and hindquarter were perfused together during the first period, the glucose uptake in the hindquarter was 1.55 +/- 0.16 mumol.min-1 x 100 g bw-1 and decreased gradually during the period of isolated perfusion to 1.27 +/- 0.16 (N = 4; p = 0.15). In control experiments where tissue free extract fluid was added to the perfusate during the second period, or where the hindquarter was perfused either alone or with the liver during both periods, glucose uptake decreased slightly from 0.87 +/- 0.18 to 0.80 +/- 0.13 (N = 9; p = 0.2). In conclusion, a factor from the liver may increase the glucose uptake in muscle tissues. This factor is present in extracts from the liver and kidney, it is probably not a protein, but its nature is not known. It is speculated that glucose intolerance in patients with liver disease may be related to a lack of this factor.

Updating prognosis in primary biliary cirrhosis using a time-dependent Cox regression model. PBC1 and PBC2 trial groups

BACKGROUND

The precision of current prognostic models in primary biliary cirrhosis (PBC) is rather low, partly because they are based on data from just one time during the course of the disease. The aim of this study was to design a new, more precise prognostic model by incorporating follow-up data in the development of the model.

METHODS

We have performed Cox regression analyses with time-dependent variables in 237 PBC patients followed up regularly for up to 11 years. The validity of the obtained models was tested by comparing predicted and observed survival in 147 independent PBC patients followed for up to 6 years.

RESULTS

In the obtained model the following time-dependent variables independently indicated a poor prognosis: high bilirubin, low albumin, ascites, gastrointestinal bleeding, and old age. When including histological variables, cirrhosis, central cholestasis, and low immunoglobulin (Ig)M also indicated a poor prognosis. The survival predicted by the models agreed well with the survival observed in the independent PBC patients. The time-dependent models predicted better than our previously published time-fixed model.

CONCLUSIONS

Using the time-dependent Cox models, one can estimate a more precise probability of surviving the next 1, 3, or 6 months for any given patient at any time during the course of the disease. This may improve monitoring of PBC patients.

The effect of hyperosmotic solutions on the hepatic blood flow

The present study was undertaken in order to measure the effect of hyperosmotic solutions on portal and hepatic blood flow. In five anaesthetized pigs without arterial blood supply to the liver, portal blood flow rate was measured (electromagnetic flowmeter) during 5 min lasting intravenous infusions of hyperosmotic galactose (50%, 84-100 ml) and mannitol (25%, 100 ml), with physiological saline (100 ml) as control. Portal blood flow increased to a peak value of (39% [P = 0.06] galactose and 37%, [P = 0.06], mannitol) soon after stop of the hyperosmotic infusion. For galactose the change ended somewhat earlier than for mannitol. Saline induced a minor increase (15%). Similarly, increments of, on average, 144% of the hepatic blood flow rate was seen in six patients with cirrhosis, following infusion of hyperosmotic galactose, the increase being more pronounced than in the pigs. The causes for these osmotic effects are not known, but they have to be taken into consideration in studies of the portal and hepatic blood flow.

Hepatic, renal, and total body galactose elimination in the pig

Galactose elimination capacity is used as a quantitative measure of liver function on the assumption that galactose elimination outside the liver is negligible or easily corrected for. The relationship between hepatic and extrahepatic removal of galactose was studied in anesthetized pigs during quasi-steady-state conditions by continuous infusion of galactose. The hepatic removal approximated a constant [maximal velocity = 585 +/- 41 mumol/min, Michaelis constant (Km) = 0.24 +/- 0.07 mmol/l, mean +/- SE, n = 20]. The renal removal was less than the amount filtered, showing maximal tubular reabsorption (Tm 178 +/- 3.0 mumol/min, Km 3.8 +/- 0.9 mmol/l, n = 20). Metabolic conversion of galactose in the kidney was not demonstrable. At all concentrations studied (0.4-5.8 mmol/l), total galactose elimination from the body exceeded the sum of hepatic and renal elimination by approximately 100 mumol/min, independent of the concentration. At blood concentrations usually used for clinical estimation of the galactose elimination capacity (approximately 4 mmol/l), hepatic removal in the pig accounted for 55% and renal removal for 30% of total removal; 15% of removal occurred in other organs. We conclude that estimation of the hepatic galactose elimination capacity from whole body elimination curves requires correction for renal removal of galactose.

High volume plasma exchange in fulminant hepatic failure

We investigated the effect of repeated high volume plasma exchange with fresh donor plasma in 11 patients with fulminant hepatic failure, all initially in stage 3 or 4 encephalopathy. A daily exchange of a volume equal to the extracellular volume (20% of body weight) on three consecutive days was intended. We obtained an average of 2.6 exchanges each with a mean volume equal to 16% of the body weight. Five patients (46%, 95% confidence limits 17%-77%) survived, all with acetaminophen induced liver failure. Four of the 6 non-survivors showed a temporary improvement in cerebral function. Two of the patients woke up completely. The 6 non-survivors maintained a stable condition with a systolic blood pressure > 110 mm Hg for a mean of 6.9 days after initiating plasma exchange. Plasma exchange may be considered in acute liver failure in patients with residual liver function before transplantation is finally decided. In addition, plasmapheresis may be used to keep patients with definite liver failure clinically stable until a transplant can be performed.

Cyclosporin A treatment in primary biliary cirrhosis: results of a long-term placebo controlled trial

BACKGROUND

Effective treatment for primary biliary cirrhosis (PBC) resulting in slower progression and improved survival remains elusive. Cyclosporin A (CyA), which has been so effective in preventing human allograft rejection, has shown promise in small numbers of patients in early studies.

METHODS

Three hundred forty-nine patients with PBC were randomized to receive CyA, 3 mg.kg-1.day-1, or placebo in a multicenter study with follow-up for 6 years. The end point was death or liver transplantation.

RESULTS

Cox multivariate analysis showed time from entry to death or transplantation was significantly prolonged (by up to 50%) in the CyA-treated group. Liver-related mortality was also significantly lower. However, a univariate analysis of survival showed no statistical differences between the two groups. Biochemical liver indices deteriorated more slowly in the CyA-treated group, but serum creatinine concentration was elevated > 150 mumol/L in 9%, necessitating permanent discontinuation in half of these. A reduction in the dose of CyA was required in 11% because of hypertension.

CONCLUSIONS

CyA has some therapeutic potential in primary biliary cirrhosis, providing blood pressure and renal function are closely monitored.

Who benefits from endoscopic sclerotherapy of bleeding oesophageal varices? Proposal for differential indications. The Copenhagen Esophageal Varices Sclerotherapy Project

The value of early sclerotherapy for variceal haemorrhage remains unsettled, possibly because the treatment may be beneficial to some patients and harmful to others. On the basis of a randomized clinical trial of sclerotherapy in 187 patients presenting with their first variceal haemorrhage, we examined the relationship between clinical, endoscopic and biochemical characteristics at admission and the treatment effect on mortality. As previously published, sclerotherapy had no overall effect on the very high mortality during the first 6 weeks (47%), but thereafter the mortality and risk of rebleeding were reduced. The analysis showed that in the 48% of the patients with disturbed consciousness and/or elevated plasma creatinine, sclerotherapy considerably increased short-term mortality, and this was not compensated for by increased long-term survival. Among patients without these characteristics, sclerotherapy reduced mortality in the 25% with ascites, but did not affect short-term mortality in the 27% without. Sclerotherapy significantly improved the long-term survival of these patients. The results suggest that sclerotherapy should not be used in patients with disturbed cerebral or renal function, whereas it may be beneficial in patients without these characteristics.

Effect of dietary protein on the capacity of urea synthesis in rats

The in vivo capacity of urea nitrogen synthesis (CUNS) during alanine stimulation was measured within the blood amino acid concentration interval 7.3-11.6 mmol/l, where urea synthesis is at maximum and independent of substrate concentration. Three groups of rats were fed for 14 days, either a low protein diet (8%), a normal diet (17%), or a high protein diet (53%). Diet protein modified both CUNS and plasma glucagon concentration. CUNS was 5.86 +/- 2.93, 7.43 +/- 2.16, and 19.31 +/- 4.32 mumol/(min.100 g BW) (mean +/- SD, N = 6), respectively. The corresponding plasma glucagon concentrations after alanine stimulation were 222 +/- 400, 633 +/- 229, and 1700 +/- 627 ng/l, respectively. The in vivo kinetics of urea production is regulated by dietary protein, possibly via glucagon. This implies that the liver plays an active part in adaptation of whole body nitrogen homeostasis to dietary changes.