Agreement between radial and femoral arterial blood pressure measurements during orthotopic liver transplantation

OBJECTIVE

To study agreement between radial and femoral arterial pressure measurements in orthotopic liver transplantation (OLTx) surgery to determine whether arterial cannulation sites are interchangeable.

DESIGN, SETTING AND PARTICIPANTS

Prospective observational study of 25 patients undergoing OLTx surgery.

METHODS

Radial and femoral arteries were cannulated with standardised arterial line kits. Radial and femoral mean arterial pressure (MAP), systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and pulse pressure (PP) were measured at four time points (30 minutes after induction of anaesthesia, 30 minutes after the start of the anhepatic phase, 30 minutes after liver graft reperfusion and 30 minutes after the start of bile duct anastomosis).

MAIN OUTCOME MEASURES

The bias, precision and limits of agreement between radial and femoral arterial pressures were calculated in accordance with Bland-Altman statistics.

RESULTS

Radial-femoral differences in MAP (mean difference, 4.8 mmHg [SD, 4.5 mmHg]), limits of agreement (- 13.6 and 8.8, P < 0.001) and DAP showed clinically acceptable agreement between measurement sites across all time points. However, clinically significant differences between radial and femoral SAPs (mean difference, - 14.9 mmHg [SD, 24.8 mmHg]) and limits of agreement (- 63.5 and 33.7, P < 0.001) occurred overall. This difference started after portal vein clamping and remained significant throughout the remainder of the operation.

CONCLUSION

Radial artery SAP underestimates femoral artery measurements significantly but unpredictably. As femoral measurement is more likely to reflect central arterial pressure, radial SAP measurement is not reliable in adults undergoing OLTx.

Characterization and treatment of persistent hepatocellular secretory failure

BACKGROUND & AIMS

Hepatocellular secretory failure induced by drugs, toxins or transient biliary obstruction may sometimes persist for months after removal of the initiating factor and may then be fatal without liver transplantation. We characterized patients with severe persistent hepatocellular secretory failure (PHSF) and treated them with the pregnane X receptor (PXR) agonist, rifampicin. We also studied the effect of rifampicin on PXR-dependent expression of genes involved in biotransformation and secretion in vitro.

METHODS

Thirteen patients (age 18-81 years, 6 male) with hepatocellular secretory failure that persisted after removal of the inducing factor (drugs/toxin: 9) or biliary obstruction (4) were identified over 6 years. Six of these patients were screened for ATP8B1 or ABCB11 mutations. All were treated with rifampicin (300 mg daily) for 1-10 weeks. Expression of genes involved in biotransformation and secretion was determined by rtPCR in human hepatocytes and intestinal cells incubated with rifampicin (10 μmol/L).

RESULTS

Serum bilirubin of patients with PHSF ranged from 264 to 755 μmol/L. Normal γGT was found in 10/13 patients of whom 3/6 tested positive for ATP8B1/ABCB11 mutations. Serum bilirubin declined to <33 μmol/L after 1-10 weeks of rifampicin treatment. In vitro, rifampicin PXR-dependently upregulated biotransformation phase 1 (CYP3A4), phase 2 (UGT1A1) and phase 3 (MRP2) enzymes/carriers as well as the basolateral bile salt exporter OSTβ.

CONCLUSION

Persistent hepatocellular secretory failure may develop in carriers of transporter gene mutations. In severe cases, rifampicin may represent an effective therapeutic option of PHSF. PXR-dependent induction of CYP3A4, UGT1A1, MRP2 and OSTβ could contribute to the anticholestatic effect of rifampicin in PHSF.

Usefulness of real-time elastography strain ratio in the assessment of bile duct ligation-induced liver injury and the hepatoprotective effect of chitosan: an experimental animal study

The purpose of the study described here was to evaluate the usefulness of the elastographic strain ratio in the assessment of liver changes in an experimental animal setting and the hepatoprotective effects of chitosan. Ultrasonography and Strain Ratio calculation were performed before and after bile duct ligation (BDL) in three groups of Wistar albino rats (n = 10 animals per group): (i) rats subjected to bile duct ligation only; (ii) rats subjected to bile duct ligation and administered chitosan for 14 d; (iii) rats subjected to bile duct ligation and administered chitosan for 7 d. The results were compared with the laboratory data and pathologic findings. Strain ratios revealed an increase in liver stiffness after bile duct ligation (p < 0.05), except in the group with chitosan administered for 7 d, and agreed with laboratory and pathology data. In conclusion, strain ratio can be used as an experimental research instrument in the assessment of liver response to injury. To the best of our knowledge, this is the first study reporting on the usefulness of the sonoelastographic liver-to-kidney strain ratio in assessing the effects of experimentally induced liver lesions.

Clinical trial with traditional Chinese medicine intervention ''tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment'' for chronic hepatitis B-associated liver failure

AIM: To study the clinical efficacy of traditional Chinese medicine (TCM) intervention “tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment” (“TTK”) for treating liver failure due to chronic hepatitis B.

METHODS: We designed the study as a randomized controlled clinical trial. Registration number of Chinese Clinical Trial Registry is ChiCTR-TRC-12002961. A total of 144 patients with liver failure due to infection with chronic hepatitis B virus were enrolled in this randomized controlled clinical study. Participants were randomly assigned to the following three groups: (1) a modern medicine control group (MMC group, 36 patients); (2) a “tonifying qi and detoxification” (“TQD”) group (72 patients); and (3) a “tonifying the kidney to promote liver regeneration and repair by affecting stem cells and their microenvironment” (“TTK”) group (36 patients). Patients in the MMC group received general internal medicine treatment; patients in the “TQD” group were given a TCM formula “tonifying qi and detoxification” and general internal medicine treatment; patients in the “TTK” group were given a TCM formula of “TTK” and general internal medicine treatment. All participants were treated for 8 wk and then followed at 48 wk following their final treatment. The primary efficacy end point was the patient fatality rate in each group. Measurements of various virological and biochemical indicators served as secondary endpoints. The one-way analysis of variance and the t-test were used to compare patient outcomes in the different treatment groups.

RESULTS: At the 48-wk post-treatment time point, the patient fatality rates in the MMC, “TQD”, and “TTK” groups were 51.61%, 35.38%, and 16.67%, respectively, and the differences between groups were statistically significant (P < 0.05). However, there were no significant differences in the levels of hepatitis B virus DNA or prothrombin activity among the three groups (P > 0.05). Patients in the “TTK” group had significantly higher levels of serum total bilirubin compared to MMC subjects (339.40 μmol/L ± 270.09 μmol/L vs 176.13 μmol/L ± 185.70 μmol/L, P = 0.014). Serum albumin levels were significantly increased in both the “TQD” group and “TTK” group as compared with the MMC group (31.30 g/L ± 4.77 g/L, 30.72 g/L ± 2.89 g/L vs 28.57 g/L ± 4.56 g/L, P < 0.05). There were no significant differences in levels of alanine transaminase among the three groups (P > 0.05). Safety data showed that there was one case of stomachache in the “TQD” group and one case of gastrointestinal side effect in the “TTK” group.

CONCLUSION: Treatment with “TTK” improved the survival rates of patients with liver failure due to chronic hepatitis B. Additionally, liver tissue was regenerated and liver function was restored.

Cytokine level modifications: molecular adsorbent recirculating system versus standard medical therapy

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is a systemic inflammatory reaction, which is characterized by a predominantly proinflammatory cytokine profile, causing the transition from stable cirrhosis to ACLF. The aim of the present study was to evaluate the changes in several cytokines associated with inflammatory liver disease and liver regeneration among 15 ACLF patients treated with the Molecular Adsorbent Recirculating System (MARS) compared with 15 patients treated with standard medical therapy (SMT). The subjects showed various disease etiologies but similar values for Model End-stage Liver Disease scores.

METHODS

In the MARS group, 15 (10 male and 5 female) patients were treated with MARS (Gambro). The number of MARS applications was nine; the length of applications was 8 hours. In the SMT group; 15 (10 male and 5 female) patients were treated with SMT. The patients were monitored for 30 days from inclusion with a survival follow-up at 3 months. Statistical results were calculated with SPSS14.0 (SPSS Inc, Chicago, Ill). A P < .07 was considered significant.

RESULTS

In the MARS group, we observed significant changes in the levels of Interleukin (IL)-6, IL-1, IL-10, and tumor necrosis factor (TNF)-alpha in association with improved hepatocyte growth factor. Patient survival at 3 months was 60%. The SMT group showed only a significant change in TNF-alpha (P = .03). Patient survival at 3 months was 30%.

CONCLUSION

The MARS liver support device corrected pathophysiologies of ALF and may be used to enhance spontaneous recovery or as a bridge to transplantation.

Little girl who conquered the "ALPPS''

An insufficient future liver remnant (FLR) is associated with post-hepatectomy liver failure. Associating liver partition and portal vein ligation for stage hepatectomy (ALPPS) has been shown to be effective for the induction of rapid FLR hypertrophy so as to improve the resectability in patients with insufficient FLR. We hereby report our experience of this novel approach for a 6-year-old patient with hepatoblastoma. Computed tomography showed a hepatoblastoma measuring 12.5 cm × 9.9 cm × 11.7 cm in the right liver (Couinaud segment IV, V and VIII). Volumetric assessment of the FLR i.e., left lateral section was 112.6 mL i.e., 21.2% of the estimated total liver volume. In view of the small-for-size FLR, ALPPS was contemplated. An anterior approach was adopted for the in-situ parenchymal split without mobilisation of the right liver. FLR volumetry on the seventh postoperative day was 160.7 mL, which represented a 46.1% gain in volume, and a FLR/ESLV ratio of 30.2%. A right trisectionectomy was performed on the eighth postoperative day. Postoperative recovery was uneventful. Patient was discharged on day 16 after the first operation. To our knowledge, this was the first report that showed the applicability of ALPPS to a paediatric patient.

Prognostic factors of hepatic decompensation and hepatocellular carcinoma in patients with transfusion-acquired HCV infection

AIMS

Aim of this study was to assess if host (immunogenetic traits, age, sex), exogenous (alcohol) or viral factors (viral type, past HBV infection) might affect the progression of chronic hepatitis C to liver decompensation or the development of HCC in a cohort of patients exposed to a single blood transfusion prior to the introduction of anti-HCV screening.

METHODS

Two hundred and forty-eight patients with a history of a single exposure to blood or blood products prior to 1990 were retrospectively considered. Patients were devoid of other risk factors of liver disease or immunosuppression and naïve to antiviral therapies. Eight baseline variables were assessed: age at transfusion, sex, HBV core antibody, immunogenetic profile (DRB1*11, DRB1*1104, DRB1*07), HCV genotype and alcohol consumption.

RESULTS

The follow-up was 22 (SD: 11) years. Sixty-eight patients (27%) progressed to hepatic decompensation over a median period of 22.5 years (IQR: 14-30) and 41 patients (16%) developed HCC over a median period of 31 years (IQR: 24-38). The cumulative incidence of liver failure was 0.4% (95% CI: 0.1-3.1), 4.9% (95% CI: 2.6-9.3) and 16.2% (95% CI: 10.4-24.7) at 10, 20 and 30 years after blood transfusion respectively. By univariate analysis, only age at transfusion was correlated with the risk of decompensation. Stratifying the age of transfusion by tertiles, the incidence of hepatic decompensation was 0.7% per year in patients transfused at ≤24 years of age as compared to 1.2% and 1.9% per year in those transfused at 25-35 and >36 years of age respectively (HR: 5.5, 95% CI: 2.78-10.7, P<0.001). The risk of HCC development was correlated by univariate analysis with age at transfusion (as continuous variable, HR: 1.12, 95% CI: 1.08-1.16 per year of age, P<0.001, >36 compared to ≤24 years, HR: 10.3, 95% CI: 3.9-26.9, P<0.001) and male sex (HR: 4.2, 95% CI: 1.7-10, P=0.001). Multivariate analysis confirmed age at transfusion and male sex as independent predictors of HCC development [HR: 1.12 per year (95% CI: 1.08-1.16), P<0.001 and HR: 5.4 (95% CI: 2.2-13.2), P<0.001 respectively].

CONCLUSIONS

In patients with transfusion-acquired HCV infection, age at transfusion affects the risk for hepatic decompensation. Age at transfusion and male sex are independent risk factors for HCC development.

Improvement in the nutritional status and clinical conditions of patients with liver failure using a liver diet combined with a branched chain amino acids-enriched elemental diet

BACKGROUND/AIMS

This study was performed to evaluate any improvement in the nutritional state and clinical symptoms in patients with liver failure and advanced cirrhosis after consumption of a liver diet with restricted energy and protein, in combination with a branched chain amino acids (BCAA)-enriched elemental diet.

METHODOLOGY

A BCAA-enriched elemental diet, in combination with a liver diet, characterized by restricted energy and protein, was administered in divided meals to 20 patients with liver failure associated with ascites or hepatic encephalopathy for 4 weeks.

RESULTS

The symptom of ascites abated as a result of increased total serum protein and albumin levels after the nutritional intervention in comparison with baseline levels. Ammonia levels were slightly increased without exacerbating hepatic encephalopathy, and the protein nutrition state consequently improved.

CONCLUSIONS

Divided meals of a BCAA-enriched elemental diet combined with a liver diet improved the nutritional state and clinical symptoms of patients with liver failure.

A Simple Index to Predict Liver Functional Reserve after Hepatectomy

BACKGROUND/AIMS

It is difficult to estimate the functional reserve of the liver required for safe hepatectomy in patients with severe chronic liver disease The aim of this study was to retrospectively construct simple model based on routine laboratory data to predict both early liver failure (ELF) and mortality from recurrence-free liver failure (MLF) as an index for late liver failure after hepatectomy.

METHODOLOGY

Between 2000 and 2004, 196 consecutive patients underwent curative hepatectomy, and data from 127 minor hepatectomies were included in this study.

RESULTS

Mean survival time was [mean (SD)] 1252 (670) days after hepatectomy. ELF and MLF were observed in 29 and 13 patients, respectively. PT%, TB, and direct bilirubin (DB) were the best predictors in patients with both ELF and MLF. PT% alone was the best predictor of ELF and MLF with area under ROC curves of 0.70 and 0.81, respectively. By using a preoperative PT% of ≤ 70, we could accurately predict ELF and MLF in 77% and 87% of patients, respectively. ICG-R15 could not accurately predict both ELF and MLF for any cut-off values.

CONCLUSIONS

Unlike ICG-R15, PT% is a simple noninvasive index for estimating liver functional reserve to predict both ELF and MLF.

[Comparative effectiveness of different treatment methods of liver failure]

It was analyzed the results of treatment of 217 patients (139 men, 78 women) with chronic liver failure in case of liver cirrhosis of various etiology for study of degree of hepatic encephalopathyregression. All patients were divided into 3 groups. In the first group the drug therapy was used. In the second group additionallyplasma exchange was performed, in the third group - alsomolecular absorbent recirculating system was used (effectiveness of MARS-therapy).The results showed that the use of extracorporeal treatment techniques can effectively reduce the severity of hepatic encephalopathy in patients with liver cirrhosis. MARS-therapy improved the neurological status of patientsmore significantly in this case. It is considered that the inclusion of MARS-therapy in the combined treatment of patients leads to a significant reduction of hepatic encephalopathyseverity (1-2 points), in comparison with other methods of treatment.

[ALPPS in case of massive liver metastases]

It was presented the first experience of ALPPS technique using in treatment of massive liver metastases in the Urals. The technique allows to carry out surgical treatment without danger of development of post-operative liver failure. Also it permits to complete treatment during one hospitalization without stretching the therapeutic process in time.

Portal hemodynamics before and after liver resection and its correlation with post-hepatectomy liver failure in patients with Child-Pugh class A: analysis of 151 consecutive cases

BACKGROUND/AIMS

Low portal velocity (PV) was found in cirrhotic patients, which was thought to be a risk factor for post-hepatectomy liver failure (PHLF). This study attempted to find out whether a correlation existed between portal hemodynamics and PHLF.

METHODOLOGY

From December 2010 to December 2012, all consecutive patients with Child-Pugh class A underwent liver resection were included. PV and PF were measured by using Doppler ultrasound preoperatively and on postoperative day 3. Portal hemodynamics change was explored. Univariable and multivariable analysis were used to identify risk factors for PHLF.

RESULTS

PHLF occurred in 25 of 151 patients, and persistent PHLF in 9 patients. Mean portal velocity change (PVmeanC) was significantly different between patients with PHLF and patients without PHLF, but it failed to be identified as independent predictor for PHLF in multivariate analysis, which found alanine aminotransferase (ALT) and Ishak score significantly associated with PHLF, and only ALT significantly associated with persistent PHLF. Subgroup analysis of the 73 cirrhotic patients also showed that none of the portal hemodynamic parameters were independent risk factors for PHLF or persistent PHLF.

CONCLUSIONS

None of the portal hemodynamic parameters could be used to predict PHLF or persistent PHLF.

Metal storage disorders: Wilson disease and hemochromatosis

Hereditary hemochromatosis and Wilson disease are autosomal recessive storage disorders of iron and copper overload, respectively. These metals are involved in multiple redox reactions, and their abnormal accumulation can cause significant injury in the liver and other organs. Over the last few decades clinicians have developed a much better understanding of these metals and their mechanism of action. Moreover, sophisticated molecular genetic testing techniques that make diagnostic testing less invasive are now available. This article updates and discusses the pathogenesis, diagnosis, and management of these metal storage disorders.

Liver function impairment in liver transplantation and after extended hepatectomy

Extended hepatectomy, or liver transplantation of reduced-size graft, can lead to a pattern of clinical manifestations, namely “post-hepatectomy liver failure” and “small-for-size syndrome” respectively, that can range from mild cholestasis to irreversible organ non-function and death of the patient. Many mechanisms are involved in their occurrence but in the recent past, high portal blood flow through a relatively small liver vascular bed has taken a central role. Therefore, several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation, such as portocaval shunt, mesocaval shunt, splenorenal shunt, splenectomy or ligation of the splenic artery. However, high portal flow is not the only factor responsible, and before major liver resections, preoperative assessment of the residual liver function is necessary. Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume, preventing post-hepatectomy liver failure. More recently, a new surgical procedure, that combines in situ splitting of the liver and portal vein ligation, has gradually come to light, inducing remarkable hypertrophy of the healthy liver in just a few days. Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.

Role of stem cells in repair of liver injury: Experimental and clinical benefit of transferred stem cells on liver failure

Although the liver has a high regenerative capacity, as a result of massive hepatocyte death, liver failure occurs. In addition to liver failure, for acute, chronic and hereditary diseases of the liver, cell transplantation therapies can stimulate regeneration or at least ensure sufficient function until liver transplantation can be performed. The lack of donor organs and the risks of rejection have prompted extensive experimental and clinical research in the field of cellular transplantation. Transplantation of cell lineages involved in liver regeneration, including mature hepatocytes, fetal hepatocytes, fetal liver progenitor cells, fetal stem cells, hepatic progenitor cells, hepatic stem cells, mesenchymal stem cells, hematopoietic stem cells, and peripheral blood and umbilical cord blood stem cells, have been found to be beneficial in the treatment of liver failure. In this article, the results of experimental and clinical cell transplantation trials for liver failure are reviewed, with an emphasis on regeneration.

[Interleukin-21 expression in serum of patients with acute-on-chronic liver failure and its significance]

OBJECTIVE

To investigate the level of the serum IL-21 and its correlation with serum biochemical indices of liver function test in patients with acute-on-chronic liver failure.

METHODS

Sixty patients with acute-on-chronic liver failure (severe hepatitis group) and 18 normal cases (control group) were enrolled in the study. Peripheral blood lymphocytes were isolated and total RNA of lymphocytes was extracted by using Trizol. Real-time PCR was used to assay IL-21 mRNA level. The serum IL-21 expression level was detected by ELISA method. The correlation between IL-21 and ALT, AST, TBiL, ALB was analyzed using Pearson's correlation analysis, respectively.

RESULTS

Serum IL-21 expression level in severe hepatitis group was higher than that of control group. Moreover, the difference between them was statistically significant (P < 0.05). Serum IL-21 level was positively correlated with serum ALT, AST, TBil, respectively (P < 0.05), but was negatively correlated with ALB, respectively (P < 0.05).

CONCLUSION

Serum IL-21 expression level was increased in patients with acute-on-chronic liver failure and was associated with the severe of inflammation. We, therefore, believe that IL-21 might be involved in the pathogenesis of acute-on-chronic liver failure and might be an index of the severity of liver inflammation.

Comparison of four prognostic models and a new Logistic regression model to predict short-term prognosis of acute-on-chronic hepatitis B liver failure

BACKGROUND

Acute-on-chronic hepatitis B liver failure (ACLF-HBV) is a clinically severe disease associated with major life-threatening complications including hepatic encephalopathy and hepatorenal syndrome. The aim of this study was to evaluate the short-term prognostic predictability of the model for end-stage liver disease (MELD), MELD-based indices, and their dynamic changes in patients with ACLF-HBV, and to establish a new model for predicting the prognosis of ACLF-HBV.

METHODS

A total of 172 patients with ACLF-HBV who stayed in the hospital for more than 2 weeks were retrospectively recruited. The predictive accuracy of MELD, MELD-based indices, and their dynamic change (D) were compared using the area under the receiver operating characteristic curve method. The associations between mortality and patient characteristics were studied by univariate and multivariate analyses.

RESULTS

The 3-month mortality was 43.6%. The largest concordance (c) statistic predicting 3-month mortality was the MELD score at the end of 2 weeks of admission (0.8), followed by the MELD: sodium ratio (MESO) (0.796) and integrated MELD (iMELD) (0.758) scores, DMELD (0.752), DMESO (0.729), and MELD plus sodium (MELD-Na) (0.728) scores. In multivariate Logistic regression analysis, the independent factors predicting prognosis were hepatic encephalopathy (OR = 3.466), serum creatinine, international normalized ratio (INR), and total bilirubin at the end of 2 weeks of admission (OR = 10.302, 6.063, 5.208, respectively), and cholinesterase on admission (OR = 0.255). This regression model had a greater prognostic value (c = 0.85, 95%CI 0.791 - 0.909) compared to the MELD score at the end of 2 weeks of admission (Z = 4.9851, P = 0.0256).

CONCLUSIONS

MELD score at the end of 2 weeks of admission is a useful predictor for 3-month mortality in ACLF-HBV patients. Hepatic encephalopathy, serum creatinine, international normalized ratio, and total bilirubin at the end of 2 weeks of admission and cholinesterase on admission are independent predictors of 3-month mortality.

Relationship between MELD severity score and the distance walked and respiratory muscle strength in candidates for liver transplantation

The model end-stage liver disease (MELD) severity scoring system is used in the allocation of organs for liver transplantation. However, there is no evidence of its relationship with the functionality and respiratory muscle strength in these patients. The aim of this study was to analyze the correlation of MELD with distance walked and respiratory muscle strength in patients awaiting liver transplantation. We performed a cross-sectional analysis of 24 individuals (16 male and 8 female) with mean age of 51.8 +/- 10.4 years. The MELD score inversely correlated with the 6-minute walking test (6MWT) (r = -0.85; P < .001) and with the maximal inspiratory pressure (MIP) (r = -0.69; P < .001). In addition, there was a correlation between 6MWT and MIP (r = 0.77; P < .001). Thus, MELD scores can be considered to be effective tools to predict the functional capacity and respiratory muscle strength in candidates for liver transplantation.

Effect of liver transplant on pulmonary functions in adult patients with alpha 1 antitrypsin deficiency: 7 cases

OBJECTIVES

Alpha 1 antitrypsin (A1A) is a 52 kD glycoprotein that is mainly synthesized in the liver. As a major protease inhibitor, it binds to and neutralizes neutrophil elastase, thereby limiting the damage to the normal tissues after an inflammatory response. A deficiency in A1A leads to end-stage liver disease, both in children and in adults. In addition, the deficiency also has a detrimental effect in the lungs of the adult population. Alpha 1 antitrypsin deficiency is corrected with hepatic replacement; however, the changes in pulmonary functions have not been studied before and after liver transplant. The purpose of this study was to observe the changes in the pulmonary functions of patients who underwent liver transplant for the treatment of A1A deficiency.

MATERIALS AND METHODS

Nine patients underwent liver transplant for A1A deficiency. Seven patients (5 men, 2 women; mean age, 49.95 -/+ 7.09 years) had their pulmonary function tests available before the liver transplant (mean, 5.6 -/+ 3.4; range, 0.9-10.1 months) and after the liver transplant (mean, 30.3 -/+ 18.4, range 7.8-48.1 months) for analysis.

RESULTS

The mean, preliver, transplant, FEV1 was 2.69 -/+ 0.9 L, which was nearly unchanged after the liver transplant to a mean of 2.7 -/+ 1.2 L. During the mean total interval of nearly 3 years, an estimated decline of 250 mL in FEV1 was expected.

CONCLUSIONS

It appears from the results of our study that liver transplant probably prevented the progression of pulmonary disease in A1A-deficient patients. Further study and close, postliver, transplant follow-up is warranted to support our initial findings.

Growth and bone health in chronic liver disease and following liver transplantation in children

Improved survival of orthotopic liver transplantation (OLT) has shifted the focus of patient care to quality of life, including prevention and treatment of pre- and post-transplant complications. End-stage liver failure affects bone length and strength, causing growth failure and hepatic osteodystrophy. Growth failure affects 60% of children assessed for OLT. Optimization of nutrition may prevent further stunting of growth before OLT but is rarely successful. Catch-up growth is observed following steroid withdrawal usually from 18 months post OLT. Whether growth hormone treatment would benefit the 20% of children who fail to regain normal height needs to be tested in randomized controlled trials. Hepatic osteodystrophy in children comprises vitamin D deficiency rickets, low bone mass and fractures caused by malnutrition and malabsorption. Vitamin D deficiency should be treated aggressively with cholecalciferol (D2) or ergocalciferol (D3). The active vitamin D metabolites alphacalcidol or calcitriol are used to increase calcium absorption from the gut but do nothing to replace vitamin D stores. Children before and after OLT have an increased prevalence of fractures of 10-13% and 12-38%, respectively. Most fractures are vertebral, and are related to low spine BMD. They often occur asymptomatically but may also cause chronic pain and later scoliosis. The main risk groups are infants with cholestatic liver disease, and adolescents with later OLT and greater BMI. Fracture prediction in these children is limited. OLT also bears the risk of avascular bone necrosis (4%), and development of scoliosis (13-38%). This paper reviews the literature and presents preventative and therapeutic strategies to improve bone length and strength.

Evidence for oxidative/nitrosative stress in the pathogenesis of hepatic encephalopathy

Hepatic encephalopathy (HE) is a serious complication of liver failure. HE manifests as a series of neuropsychiatric and neuromuscular symptoms including personality changes, sleep abnormalities, asterixis and muscle rigidity progressing through stupor to coma. The pathophysiologic basis of HE remains unclear. There is general agreement that ammonia plays a key role. In recent years, it has been suggested that oxidative/nitrosative stress constitutes part of the pathophysiologic cascade in HE. Direct evidence for oxidative/nitrosative stress in the pathogenesis of HE has been demonstrated in experimental animal models of acute or chronic liver failure. However, evidence from studies in HE patients is limited. This review summarizes this evidence for a role of oxidative/nitrosative stress in relation to ammonia toxicity and to the pathogenesis of HE.

The challenge of preserving renal function after liver transplantation

Thanks to new surgical techniques and the use of calcineurin inhibitors for the prevention of allograft rejection, the long-term outcome of liver transplantation has recently improved. In case of liver transplantation, the occurrence of renal failure can impair the outcome. Renal function preservation is, therefore, necessary to improve transplantation outcome.

Dietary and nutritional indications in hepatic encephalopathy

The restriction of dietary protein has long been considered a main stay in the therapy of hepatic encephalopathy. More recently it has been recognized that protein energy malnutrition is frequent in advanced liver disease and may adversely affect the patients'outcome. Moreover studies on inter-organ ammonia exchange in liver cirrhosis have shown that the muscle may have a crucial role in ammonia detoxification. In light of these evidences nutritional guidelines have proposed that protein restriction should be avoided in patients with hepatic encephalopathy as protein requirement is even increased in cirrhotic patients. Survey about the current clinical practice show that protein restriction is still considered advisable in patients with hepatic encephalopathy, however a recent trial evidenced that a low protein diet in patients hospitalized for acute hepatic encephalopathy exacerbates protein breakdown without inducing any specific clinical benefit when compared to a normal protein regimen. The relevance of an adequate protein intake and possible strategies to implement protein tolerance are also discussed.