Biliary malignancies in primary sclerosing cholangitis: timing for liver transplantation

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease associated in 10% to 36% of those with hepatobiliary malignancies, which are, in the majority of cases, not known prior to transplantation. Diagnosis of carcinomas in a PSC setting at an early stage has not yet been achieved, because there are no differences in the age of patients or clinical course, particularly with regard to the time between diagnosis of PSC and detection of carcinomas. To assess optimal timing for transplantation in patients with PSC, we applied the Mayo survival model to 48 patients receiving transplants for that disease in our center between 1972 and 1994. Of these patients, 10 had a biliary malignancy, which was incidental in 9. According to the Mayo model, low-, moderate-, and high-risk groups of patients could be formed. The actuarial patient survivals at 1 and 7 years were 100% and 100% (low risk), 68.6% and 68.6% (moderate risk), and 54.6% and 46.8% (high risk), respectively. Patients with a biliary malignancy had a 30% survival at 1 year; none survived 6 years. Local recurrence of the tumor was found in 3 patients, 2 of them with low tumor stages at the time of transplantation. Analysis of the Mayo Model risk scores demonstrated a marked increase in the incidence of biliary malignancies at a score above 4.4. All patients with tumors were found to have a score above 4. Moreover, the prevalence rate rose from 14.3% in the low-risk group to 33.3% in the moderate-risk group. There was no difference in the clinical courses at 6 to 12 months prior to transplantation; in particular, the bilirubin levels (PSC alone, 250 +/- 230 mumol/L; PSC with carcinoma, 288 +/- 182 mumol/L) did not differ significantly (P > .05) between both patient groups. Because the outcome after transplantation is poor even in patients with low-grade malignancies, early timing of transplantation in patients with PSC is suggested to prevent formation of biliary malignancies. Therefore, regular scoring of patients with the Mayo Model risk score is suggested, and transplantation should be taken into consideration at scores above 4.

Tissue oxygen saturation of human hepatic grafts after reperfusion: paradoxical elevation in poor graft function

The present study investigated the pathophysiology of primary nonfunction (PNF) of grafted livers with regard to hepatic tissue oxygenation. Hemoglobin oxygen saturation in hepatic tissue (H-So2) after reperfusion was determined using near-infrared spectroscopy. Graft tissue oxygen consumption was also estimated according to Fick's principle. Six grafts with PNF were compared with 40 functioning grafts. One PNF graft with extremely low and heterogeneous H-So2 after reperfusion was found to contain multiple intrahepatic portal thrombi. However, five other PNF grafts showed no lower and, on the contrary, more homogeneous H-So2 at the end of the operation. As a whole, mean H-So2 was negatively correlated and the coefficient of variation (CV) of H-So2 was positively correlated with graft tissue oxygen consumption at the end of the operation; grafts whose H-So2 showed a secondary decrease had better initial function. In later relaparotomy, the H-So2 of the five PNF grafts was significantly higher and more homogeneous than that of the functioning grafts. These results suggest that H-So2 level reflects tissue oxygen consumption as well as oxygenation, and that the dissociation of both factors can occur in hepatic graft reperfusion. Not only low and heterogeneous H-So2 but also high and homogeneous H-So2, suggesting some shunt mechanism, can be signs of poor graft function.

Immunoprophylaxis with a monoclonal anti-IL-2 receptor antibody in liver transplant patients

The immunosuppressive effect of a monoclonal antibody (moAb), BT563, directed to the alpha-chain of the IL-2R (CD25), was analyzed in a prospective nonrandomized trial and a prospective randomized trial. Primary objectives were evaluation of the incidence of acute rejections and infections; secondary objectives were safety and tolerability of the moAb. A total of 28 patients were enrolled (phase II) to receive 10 mg/day of BT563 (12 days) as immunoprophylaxis in combination with cyclosporine, azathioprine, and low-dose steroids. Subsequently 32 patients were randomly assigned (phase III) to receive BT563 (10 mg/day) for 12 days or ATG (5 mg/kg/day) for 7 days in addition to cyclosporine and low-dose steroids. No side effects of the BT563 treatment were noted. The actuarial survival was 82% at 12 months in the phase II trial and 92% at 12 months in both arms of the phase III trial. There was one acute rejection in the phase II trial. No acute rejections were noted in the BT arm of the phase III trial and 5 acute rejections were treated in the ATG arm. In the phase II trial 7 infectious episodes were observed, while one infection was seen in the BT arm and 7 in the ATG arm of the triple immunosuppression phase III trial. In all patients circulation of coated CD25+ lymphocytes was observed during BT563 treatment; there was no evidence of depletion or modulation of CD25+ cells. Mean serum levels of BT563 ranged from 1.6 to 7.6 microgram/ml throughout the therapy. An antimurine response was seen in 82% (phase II) and 100% (phase III) of the patients. Antirabbit antibodies were found in 56% of the patients treated with ATG. Analysis of the antimurine response specificity revealed in 56% blocking anti-isotypic antibodies and only in 3% of the patients an anti-idiotypic response. The data of the study presented suggest that therapy with an anti IL-2R moAb is at least equal to ATG application according to the incidence of acute rejections and infections.

[Acute esophagus variceal hemorrhage and portal vein thrombosis as a complication of TIPSS. An unusual emergency indication for liver transplantation]

Acute oesophageal variceal bleeding is a severe complication of portal hypertension caused by liver cirrhosis. The mortality of the first bleeding runs up to 50%. Recurrent bleeding deteriorates the long-term prognosis. The therapy of first choice for acute oesophageal haemorrhage is endoscopic sclerotherapy. A new option to decompress portal hypertension for patients who continue to bleed despite sclerotherapy is TIPSS-implantation. We report on a patient suffering from recurrent oesophageal haemorrhage caused by portal hypertension due to postalcoholic liver cirrhosis, who developed a portal vein thrombosis after TIPSS-implantation. TIPSS-procedure permitted a bridging period for five months, until eventually a severe uncontrollable oesophageal haemorrhage occurred and emergency liver transplantation was needed. The patient was discharged after 6 weeks from the hospital in excellent condition.

Squamous cell carcinoma of the liver originating from a solitary non-parasitic cyst case report and review of the literature

Squamous cell carcinoma of the liver arising from a non-parasitic cyst is a rare entity of a primary liver tumor with an unfavourable prognosis. We report a case of a patient with a cyst in the right lobe leading to upper abdominal symptoms and respiratory discomfort. Malignancy was not suspected from the clinical findings or repeated cytological examination of the cyst fluid. However, the blood stained brown color of the cyst fluid was unusual. Cyst recurrence after six attempts of conservative treatment with sonography guided drainage over a period for more than one year led to laparotomy with cyst unroofing. Because frozen section from the cyst wall revealed the unexpected finding of squamous cell carcinoma right hemihepatectomy was performed during the same operation. The patient is alive more than four years after surgery without cyst or tumor recurrence. The difficulties in establishing diagnosis are confirmed by the review of other reports. In the diagnosis and treatment of symptomatic non-parasitic liver cysts possible malignancy has to be considered. In case of proven carcinoma radical surgery with partial hepatectomy should be performed.

[Is liver transplantation as surgical therapy concept in metastases of neuroendocrine tumors justified?]

Between 1982 and February 1996 11 patients underwent liver transplantation for irresectable neuroendocrine hepatic metastases. The operative mortality was one of 11, while two patients died due to sepsis respectively tumor recurrence 7 and 68 months after transplantation. Eight patients are alive with a median survival of 55 months (range from 10 days to 8.5 years). In three patients there is no evidence of tumor and the longest disease-free survival is 102 months after LTx. These results suggest that liver transplantation represents a justified treatment for irresectable hepatic metastases arising from neuroendocrine tumors.

[Technical aspects of segment I resection of the liver]

Due to posterior location and the close relationship to vascular and biliary structures, resection of tumors within the caudate lobe of the liver may be a surgical challenge as well as an oncological hazard. Various approaches and techniques of isolated tumorectomy and combined liver resections are available and must be tailored to the individual situation. Prerequisite for a low operative risk is control of bleeding which can be achieved by sequential inflow and outflow occlusion of the liver.

Early intragraft inflammatory events of liver allografts leading to chronic rejection

In this retrospective study, we have investigated the early intragraft inflammatory events of 12 liver allografts leading to chronic rejection. The cytological findings and clinical follow-up were analyzed in detail. Nine patients underwent at least one typical lymphoid activation of acute rejection, and three of them were treated more than once. Diagnosis of rejection was based on biopsy histology, cytology and liver dysfunction. In addition to the acute rejections, cytological analysis demonstrated in 11 of 12 grafts an unidentified lymphoid episode that differed from that of rejection. These lymphoid responses were associated with viral infections; cytomegalovirus (CMV) infection in 10 of 12 patients, hepatitis C virus (HCV) infection in 2 of 12 patients, 1 combined with CMV, and hepatitis B virus (HBV) infection in 1 patient. Graft dysfunction was still seen at the end of the follow-up. Thus, intragraft inflammation caused either by acute rejection or by viral infections may be involved in the induction of chronic rejection.

Parallel blood concentrations of second-generation cyclosporine metabolites and bilirubin in liver graft recipients

Cyclosporine, a cyclic undecapeptide, is currently the major immunosuppressant used after liver transplantation. Since it is unclear whether or not cyclosporine metabolites play a part in toxicity, high concentrations of metabolites should be avoided. The quantification of cyclosporine metabolites requires immunoassays using nonspecific antibodies cross-reacting with metabolites or high-performance liquid chromatography (HPLC) analysis. Since no guidelines are available to date concerning when such additional analysis is required, it was the aim of this study to define biochemical parameters that parallel cyclosporine elimination and indicate whether or not cyclosporine elimination is impaired, requiring quantification of cyclosporine metabolites. One hundred and thirty adult liver graft recipients were included in a prospective study during their first hospital stay. Cyclosporine and 11 metabolites were quantified in blood every second day using radioimmunoassay and HPLC. When the cyclosporine metabolite patterns in trough blood samples of patients with impaired liver function were compared with those of patients with good liver function, concentrations of metabolites AM19 and AM1A were found to be elevated. Serum concentrations of conjugated and total bilirubin were significantly correlated with blood trough concentrations of AM19 and AM1A, while there was no correlation with cyclosporine or its first-generation metabolites. Distribution statistics showed that liver graft patients with impaired cyclosporine elimination had total bilirubin concentrations in serum > 60 mumol/l L. No correlation was found between bile acids and the concentrations of metabolites AM19 and AM1A, suggesting that the ion-coupled transport system is not quantitatively involved in cyclosporine excretion and that bilirubin and cyclosporine metabolites are eliminated by the same transport system through the biliary membrane. It is concluded that bilirubin and cyclosporine metabolite concentrations are strictly parallel and that the total bilirubin concentration in serum may be used as an indicator of impaired cyclosporine elimination.

Allogeneic liver transplantation for hepatic veno-occlusive disease after bone marrow transplantation--clinical and immunological considerations

Veno-occlusive disease (VOD) is a frequent complication early after bone marrow transplantation. In cases of severe liver failure treatment by allogeneic liver transplantation is possible. We report the clinical and immunological course of a patient after bone marrow transplantation for AML and subsequent allogeneic liver transplantation for severe hepatic VOD. After liver transplantation the patient recovered well clinically. Early after liver transplantation he had large numbers of liver donor T and NK lymphocytes in his circulation. He had no liver graft rejection, but he developed mild acute GVHD which was caused by liver graft-derived T lymphocytes. Two years after transplantation he had persistent microchimerism with donor liver cells detectable in his bone marrow. Now 36 months after transplantation, the patient has no evidence of recurrent leukemia, stable liver function, and no signs of graft-versus-host disease or bone marrow dysfunction.

Reconstruction of liver tissue in vitro: geometry of characteristic flat bed, hollow fiber, and spouted bed bioreactors with reference to the in vivo liver

Bioreactors currently being developed for hybrid artificial livers vary greatly with respect to their microenvironment. The specific architecture modifies the relationship parenchymal and nonparenchymal cells have with the exchange surfaces of the bioreactor. Most designs are either based on hollow fiber, spouted bed, or flat bed devices. This diversity is contrasted by the uniform and unique organization of the in vivo liver. The liver cells are arranged as plates and both sinusoidal surfaces of the hepatocytes are enclosed within the matrix of the space of Disse. In this study we intended to define the in vivo liver tissue characteristics in a manner useful for an organotypical approach to hepatic tissue engineering. Transmission electron microscopy of an in vivo liver was utilized to describe these ratios. The ratios defined in this study are based on the constant hepatocellular expression of two sinusoidal surfaces. A relationship is established between the expression of the sinusoidal surfaces and their use as attachment and exchange surfaces inside a bioreactor. The presence of biliary surfaces and nonparenchymal cell surfaces is compared. The functional relevance of an in vivo like extracellular matrix geometry for oxidative biotransformation of primary hepatocytes in vitro was studied using the two model drugs cyclosporin and rapamycin. The generation of the hydroxylated cyclosporin metabolites AM 9 and AM 1 and four rapamycin metabolites was analyzed by high performance liquid chromatography (HPLC). It is shown that the cell-specific biotransformation rates at 1 week in culture in matrix overlayed hepatocytes was 5-10 times that of hepatocytes without matrix overlay. Bilaminar membrane (BLM) bioreactors were used to reconstruct extracellular matrix geometry, three-dimensional cell plates, and sinusoidal analogs in between cell plates.

Backgrounds of early intragraft immune activation and rejection in liver transplant recipients. Impact of graft reperfusion quality

In solid organ transplantation, acute rejections are most frequent during the first weeks. The aim of this study was to investigate the relationship between graft reperfusion injury and later immune responses against the graft. Intragraft immune activation was routinely monitored by transplant aspiration cytology in 47 recipients of hepatic allografts. As a parameter of reperfusion quality, oxygen saturation of hemoglobin (SO2) in hepatic tissue was determined intraoperatively by a near-infrared spectroscopy. Grafts that presented aspiration cytology scores of 2 or more (i.e., more than 10% of lymphocytes activated) at 1 week after operation (group I, n = 14) were associated with a higher heterogeneity of hepatic tissue SO2 at the end of operation (coefficient of variation in 12 points 18.3 +/- 18.3%, mean +/- SD) than grafts with no or very mild intragraft immune activation (group II, n = 33, 9.2 +/- 4.2%; P < 0.01). Group I was also accompanied by higher postoperative peak glutamic oxalacetic transaminase level (corrected by graft size, P < 0.05) and higher donor age (43.9 +/- 12.9 vs. 32.6 +/- 13.9 years, P < 0.02). Heterogenous reperfusion (P < 0.01), higher peak glutamic oxalacetic transaminase level (P < 0.01), and higher donor age (P < 0.05) were also associated with clinical rejection at 1 week (n = 10), but not with later-onset rejection (n = 11). These data suggest that intragraft immune activation and clinical rejection in the early phase after hepatic engraftment are strongly influenced by graft injury, which can be recognized early after reperfusion.

Relationship of apolipoproteins AI, B and lipoprotein Lp(a) to hepatic function of liver recipients during the early post-transplant period

To evaluate serum apo AI, apo B, Lp(a) and the ratio of unesterified cholesterol to total cholesterol as markers of hepatic synthetic capacity after orthotopic liver transplantation, serial measurements of these variables were performed on post-transplant days 1, 3, 5, 7, 10 and 14 in 70 patients. Liver function was assessed by a quantitative dynamic test based on the hepatic conversion of lidocaine to monoethylglycinexylidide (MEGX). Patients were divided into two groups on the basis of clinical and laboratory findings, those with evidence (n = 46) and those without evidence (n = 24) of hepatic dysfunction. Apo AI levels fell in both groups to day 5, but then began to increase in the group with good hepatic function, a highly significant (P < 0.001) positive correlation being found with the results of the MEGX test on post-transplant days 7, 10 and 14. The ratio of unesterified cholesterol to total cholesterol rose in both groups from days 1 to 7 and then began to fall in the group without hepatic dysfunction; a highly significant (P < 0.001) negative correlation was observed with the results of the MEGX test on days 10 and 14, Apo B levels rose in both groups from days 1 to 10, with no significant differences between the two groups; no correlation was observed with the results of the MEGX test on any study day.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of bile on cyclosporin absorption from microemulsion formulation in primary liver transplant recipients

We analysed the absorption, after oral application, of a new galenic form of cyclosporin A (CyA-NOF) in liver-grafted patients (n = 12) during the 1st week (days 2-4) after transplantation. Pharmacokinetic profiling was performed with an open or clamped T tube in situ or with the T tube absent. The pharmacokinetic parameters of CyA-NOF were influenced by T tube clamping and bile diversion. The highest AUC, Cmax and earliest Tmax values were found in patients without a T tube in situ, indicating that absorption of CyA-NOF in patients during the early course after liver transplantation is not bile-independent. CyA-NOF, at a dose of 7.5 mg/kg, was enterally absorbed with appropriate AUC and Cmax levels. Patients receiving a starting dose of 7.5 mg/kg were successfully maintained on CyA-NOF during the subsequent clinical course.

Total hepatectomy and liver transplantation: a life-saving procedure in patients with severe hepatic trauma

Management of blunt hepatic trauma has been refined recently and now ranges from non-operative measures to the use of extensive surgical techniques. A consecutive series of eight patients was treated by total hepatectomy, either with a temporary portacaval shunt as a bridging procedure (since no donor liver was available immediately; six patients) or followed by standard liver transplantation (two). Previous operations included perihepatic packing, deep suturing, partial liver resection and hepatic artery ligation, and were attended by severe complications, namely uncontrollable bleeding (four patients) and massive liver necrosis (four). Six of the eight patients died from multiorgan failure or sepsis, and two recipients are alive 49 and 67 months after two-stage hepatectomy and transplantation. This experience demonstrates that total hepatectomy can be a life-saving procedure in exceptional emergencies in patients with potentially lethal hepatic trauma. The prognosis is dependent not only on the severity of liver injury but also on the complications of primary treatment.

Implications of host pancreatic hormones in the restart of grafted liver

Regulatory roles of insulin and glucagon in hepatic metabolism and function are well described. However, little is known about implications of host pancreatic hormones in primary function of grafted liver. This study aimed to investigate it in relation to hepatic mitochondrial function. Insulin, c-peptide, and glucagon in peripheral blood were monitored for 2 days in clinical liver transplantation by a continuous sampling technique to avoid influences of hormonal oscillation. In grafts with immediate function (n = 10), smooth increase of arterial ketone body ratio reflecting hepatic intramitochondrial redox state was accompanied by increased c-peptide and decreased glucagon, resulting in the increase of c-peptide/glucagon ratio. In other functioning grafts (n = 20), where ketone body ratio was rather lower, increased glucagon level, observed also during anhepatic phase, resulted in the slower increase of c-peptide/glucagon ratio. There were accompanied by increased free fatty acid and ketone body levels. In primary nonfunction (n = 4), rapid increase of c-peptide accompanied by hyperglycemia resulted in the accelerated increase of c-peptide/glucagon ratio, but ketone body ratio did not show any increase. Insulin/c-peptide ratio also showed a rapid increase. These findings suggest that the increase of insulin/glucagon ratio in portal blood, potentially influenced by recipient condition, is associated with the recovery of mitochondrial energy metabolism in survived hepatic grafts. However, this relationship does not work in failed grafts, where irreversible impairment of energy metabolism is attributed to graft itself.

Recurrence of hepatitis B virus cirrhosis and hepatocellular carcinoma: an indication for retransplantation?

Hepatitis B virus reinfection as well as recurrence of hepatocellular carcinoma are frequent complications in liver allograft recipients. This is the report of a patient who had two liver transplantations with a 6-year interval, both for the same indication-postnecrotic cirrhosis and liver cancer. Following first and second transplantation, hepatitis B reinfection occurred at 12 and 6 months, and allograft cirrhosis developed after 20 and 10 months, respectively. Intrahepatic recurrence of hepatocellular carcinoma was found after 69 months. Two years following retransplantation, the patient is tumor-free, and has normal graft function. In selected patients with hepatitis B-related liver disease, and hepatocellular carcinoma liver replacement is indicated when combined with effective immunoprophylaxis, and other adjuvant therapy. Late recurrence of both diseases is unusual, and retransplantation may come into question.

Postoperative liver allograft dysfunction: the use of quantitative duplex Doppler signal analysis in adult liver transplant patients

40 patients after orthotopic liver transplantation were prospectively analysed by serial quantitative duplex Doppler signal analysis (DDSA) to quantify the abnormalities of Doppler waveform of the hepatic artery (HA), the portal vein (PV) and the hepatic vein (HV) under various conditions of graft dysfunction. Quantitative analysis of the HA, PV and HV was obtained before, during and after allograft dysfunction by different Doppler angle independent parameters. The results obtained later on were correlated with clinical and laboratory data, cytological and histological findings of liver core biopsy and quantitative DDSA data of healthy transplanted volunteers. The increase of the resistive index of Pourcelot calculated for the hepatic artery (HA-RI) was found to be significant in early graft reperfusion reaction (p < 0.01). No correlation was found between the HA-RI and acute allograft rejection. Different patterns of damping quantified by the damping index (DI = minimum velocity shift/maximum velocity shift) for the portal vein (PV-DI) and the hepatic vein (HV-DI) Doppler signal were observed under various conditions of allograft dysfunction. Acute rejection was identified by premature decrease of PV-DI and increase of HV-DI (p < 0.01) with a sensitivity of 75%, a specificity of 91%, a positive predictive value (ppv) of 75% and a negative predictive value (npv) of 91%. Chronic allograft rejection was not associated with an increase of HV-DI but only with a significant decrease of PV-DI (p < 0.01), with a sensitivity of 80%, a specificity of 95%, ppv of 95%, npv of 98%.(ABSTRACT TRUNCATED AT 250 WORDS)

Which is the best surgery for Budd-Chiari syndrome: venous decompression or liver transplantation? A single-center experience with 50 patients

The optimal treatment of Budd-Chiari syndrome (BCS) remains an open question. It is still a matter of controversial discussion whether venous decompression or liver transplantation is superior. To elucidate the role and prognosis of both surgical options in our own experience, a consecutive series of 50 patients treated between 1981 and 1993 was retrospectively analyzed. Twelve patients had different types of portosystemic shunts or local decompressive procedures, and transplantation was performed in 43 cases, including five with previous conventional surgery. The overall mortality of 18 of 50 was conventional surgery. The overall mortality of 18 of 50 was concentrated within the early postoperative period, with no patient lost after 1 year. In the venous decompression group, the success rate was only 29%, and treatment failure was closely related to the finding of cirrhosis or technical problems like vascular thrombosis. After transplantation, early complications were rejection, primary nonfunction, or graft necrosis, and contributed significantly to the risk of sepsis. Thirty of 43 liver recipients are currently alive, including four rescued after failed decompressive surgery, with 1- and 10-year survival of 69%, and excellent recurrence-free rehabilitation. These results clearly indicate that patient selection plays a dominant prognostic role in the treatment of BCS. Venous decompression and liver transplantation should both be integrated in a common therapeutic concept, and the individual decision for the preferred approach must be based on the leading clinical symptom: portal hypertension or liver failure, together with the assessment of reversibility of hepatic damage, and the potential of cure of the underlying disease.

Extramedullary erythropoiesis in human liver grafts

Extramedullary erythropoiesis in the adult is very rare and is generally confined to situations of severe bone marrow irritation or replacement. In this study, we describe the occurrence of intrahepatic erythropoiesis in patients who have received a liver allograft and who have no evidence of bone marrow dysfunction. By routinely performed transplant aspiration cytology (TAC), marked intrahepatic erythropoiesis could be detected in 39 of 312 patients (12.5%) with liver allograft. In 19 patients, including 5 of 8 (63%) after combined liver and kidney transplantation, intrahepatic erythropoiesis occurred within the first 3 weeks after surgery. Twenty patients showed intrahepatic erythropoiesis between 3 weeks and 4 months after transplantation. Erythropoiesis was usually transient, lasting between 1 and 3 weeks. Cytologically, mature as well as immature erythroblasts of GlyA+ CD36+ CD45- phenotype could be detected in the grafts, whereas they were absent in blood; histologically, the cells could be localized to the sinusoids of the liver. There was no clear correlation of preoperative or postoperative hemoglobin levels, graft function, kidney function, and immunosuppressive medication with the presence or absence of erythropoiesis. Moreover, serum levels of erythropoietin (EPO) and stem cell factor (SCF) in patients with and without intrahepatic erythropoiesis in the early postoperative phase did not show significant differences. These findings show that intrahepatic erythropoiesis can occur transiently in human liver allografts and suggest that systemic stimuli as well as local factors may contribute to it.

Single-center experience of combined liver and kidney transplantation

Kidney or liver transplantation (KTx, LTx) today is a standard therapeutic procedure if one of these organs fails. However, the need for transplantation of both organs may arise with deterioration of organ function. To evaluate the success of combined LTx/KTx we analyzed 20 patients (aged 14-64) who received a total of 21 LTx and 31 KTx. Simultaneous LTx/KTx was performed in 14 patients, of whom 5 required further replacement of one or the other of the grafted organs. Six patients had sequential transplantation: 3 had LTx prior to the KTx, and 3 KTx prior to LTx. In 12 patients the indication for LTx was end-stage liver cirrhosis, and of these 8 died after LTx, mostly of infections. In a group of 8 transplant recipients without liver cirrhosis (e.g. polycystic liver), only 1 patient died. Eleven of the 20 grafted patients are still alive now (follow-up after LTx 14-120 months). Episodes of liver and kidney rejection occurred in only 30% and 15% of transplanted patients respectively. Only 1 patient is back on hemodialysis, the others have normal liver and kidney function. Combined LTx/KTx may be successful in appropriate circumstances. However, patients with liver cirrhosis have a very poor prognosis due to their poor overall clinical state at the time of terminal renal failure. In contrast, patients without liver cirrhosis are better candidates, even for simultaneous LTx/KTx. In general, the indication for simultaneous organ transplantation should be considered earlier than for transplantation involving only one organ.

Surgical treatment of cholangiocellular carcinoma

Intrahepatic cholangiocellular carcinoma (CCC) is known to be associated with severe symptoms and a particularly poor prognosis. Nonsurgical methods have failed to change this situation up to now. Surgical therapy, so far, is the only chance for effective treatment, but it has had limited success. The relative infrequency of this tumor does not allow extensive statistics and limits our present knowledge. In this contribution the outcome of 50 patients who underwent liver resection or liver transplantation in our institution is reported. Their courses have been reevaluated according to pathohistologic classification and TNM tumor staging. The median survival rates were 12.8 months in the group of patients after liver resection (n = 32) and 5.0 months after liver transplantation (n = 18). Liver transplantation, however, was performed only in patients with unresectable tumors. The longest survival after transplantation was 25 months; after resection four patients survived more than 5 years. In the resection group and the transplantation group survival rates correlated with tumor size and tumor stages according to TNM, although the differences were not statistically significant. Liver resection thus has its place in resectable situations. Liver transplantation for unresectable lesions of this tumor type--always deemed critically in the past--seems not to be indicated with our present stage of knowledge, unless adjuvant protocols appear promising and are tested.

Different cellular patterns associated with hepatitis C virus reactivation, cytomegalovirus infection, and acute rejection in liver transplant patients monitored with transplant aspiration cytology

Fine-needle aspiration biopsy (FNAB) is a routine diagnostic tool used for the monitoring of the graft during the first postoperative weeks after liver transplantation. The cellular pattern of acute liver rejection is typical in transplant aspiration cytology (TAC), documented and published by several authors. The lymphoid response associated with various viral infections may, however, provide differential diagnostic problems in the cytological monitoring. In this study, we have investigated in detail the cellular pattern of lymphoid response associated with hepatitis C virus (HCV) reactivation, and compared it with the pattern of cytomegalovirus (CMV) infection and with the typical diagnostic findings of acute cellular rejection. HCV reactivation was associated with rather mild total inflammation in the graft (4.5 +/- 1.5 CIU at the peak). The inflammatory infiltrate consisted mainly of small lymphocytes (3.1 +/- 0.2 CIU at the peak), with only occasional activated cells and without lymphoid blast response. No lymphoid activation was seen in the blood. CMV infection was associated with a mild immune response (3.9 +/- 0.4 CIU at the peak) recorded as a slight lymphoid activation and occasional blast cells both in blood and in the graft together with lymphocytosis in the graft (2.4 +/- 0.7 CIU at the peak). The typical findings of acute rejection were easily distinguished from the cellular pictures of both viral infections. The rejections were lymphoid blast (3.6 +/- 3.4 CIU at the peak) and activated lymphocyte (3.5 +/- 2.6 at the peak), dominated by a high peak of total inflammation (9.3 +/- 7.0 CIU). No blast cells and only a few activated cells were seen in the blood during rejection episodes. Thus, the cellular patterns of HCV reactivation and CMV infection differed slightly from each other, but significantly from that of acute liver allograft rejection monitored with the FNAB cytology.

Plasma vs whole blood for therapeutic drug monitoring of patients receiving FK 506 for immunosuppression

By retrospective analysis of 13,000 blood samples obtained from 248 patients receiving FK 506 therapy, we compared the suitability of plasma with that of whole blood as the matrix for therapeutic drug monitoring of FK 506. The plasma concentrations did not correlate with the concentrations in whole blood (r = 0.56). In contrast to plasma samples (analyzed by enzyme immunoassay), FK 506 was detectable in all whole-blood samples (analyzed by enzyme immunoassay/microparticle enzyme immunoassay). The inter- and intraindividual variations of FK 506 measurements were greater in plasma than in whole blood. Moreover, plasma concentrations correlated only poorly with clinical events. There was a tendency to greater plasma concentrations being measured during episodes of toxicity, but no clear difference was evident between stable course and rejection. In whole-blood specimens, a correlation between reduced or increased FK 506 concentrations and rejection or toxicity, respectively, was observed. The discriminatory power of whole-blood values was greater for the differentiation between toxicity and stable course than between rejection and stable course. We therefore recommend whole blood rather than plasma as the matrix for therapeutic monitoring of FK 506 concentrations.

Kidney transplantation in hepatitis B surface antigen carriers

Chronic hepatitis B surface antigen (HBsAg) carriers run a high risk of developing chronic liver disease after renal transplantation. To determine the impact of liver disease on long-term morbidity and mortality of HBsAg carriers following kidney transplantation we analyzed 1977 patients, including 76 HBsAg carriers, who underwent renal transplantation during the period 1968-1992. Although the HBsAg carriers had a better 5-year patient and graft survival rate (94% and 83%) than HBsAg-negative patients (87% and 61%), the prognosis was poor after the tenth year of transplantation. Transplant loss is more frequently caused by death of the HBsAg carriers, in contrast to the total population (34% vs 17% for HBsAg-negative patients). Death occurs in 73% of cases due to complications of hepatitis B. In the HBsAg-negative patients, the predominant cause of death is cardiovascular failure (51% vs 11% in HBsAg carriers), whereas only 2% died of liver disease. Kidney transplantation in HBsAg carriers with normal liver function appears to be justified because of rare graft loss due to acute rejection, low early morbidity and mortality, and late onset of fatal hepatic deterioration.

Plasma vs whole blood for therapeutic drug monitoring of patients receiving FK 506 for immunosuppression

By retrospective analysis of 13,000 blood samples obtained from 248 patients receiving FK 506 therapy, we compared the suitability of plasma with that of whole blood as the matrix for therapeutic drug monitoring of FK 506. The plasma concentrations did not correlate with the concentrations in whole blood (r = 0.56). In contrast to plasma samples (analyzed by enzyme immunoassay), FK 506 was detectable in all whole-blood samples (analyzed by enzyme immunoassay/microparticle enzyme immunoassay). The inter- and intraindividual variations of FK 506 measurements were greater in plasma than in whole blood. Moreover, plasma concentrations correlated only poorly with clinical events. There was a tendency to greater plasma concentrations being measured during episodes of toxicity, but no clear difference was evident between stable course and rejection. In whole-blood specimens, a correlation between reduced or increased FK 506 concentrations and rejection or toxicity, respectively, was observed. The discriminatory power of whole-blood values was greater for the differentiation between toxicity and stable course than between rejection and stable course. We therefore recommend whole blood rather than plasma as the matrix for therapeutic monitoring of FK 506 concentrations.

The Budd-Chiari syndrome: clinical presentation and diagnostic findings in 45 patients treated by surgery

We report on the clinical presentation and diagnostic findings in 45 patients with Budd-Chiari syndrome. The diagnosis was confirmed by histology at the time of liver transplantation (n = 37) or shunt surgery (n = 8). An underlying disorder could be established only in half of the patients, oral contraceptives as predisposing factor were known in 18 cases. Clinically, abdominal pain and distension as well as hepatomegaly and ascites were most frequent findings, whereas changes in laboratory data were more or less unspecific. By use of repeated ultrasound, a definite diagnosis of a Budd-Chiari syndrome could be confirmed in all cases by obligatory demonstration of obstruction or thrombosis of at least one major liver vein. Hepatic venography revealed only one false-negative result. Celio-mesenteric arteriography plus portography, cavography and preoperative liver biopsy did not present additional diagnostic information. These techniques may contribute to treatment planning of portosystemic shunt surgery or hepatic transplantation. In conclusion, the presence of hepatosplenomegaly, ascites, abdominal pain and distension, especially in combination with a known hypercoagulable state, should alert to the possibility of a Budd-Chiari syndrome. Ultrasound is the diagnostic tool of choice. Hepatic venography should only be performed if even repeated ultrasound is not conclusive.

Urodilatin: a new approach for the treatment of therapy-resistant acute renal failure after liver transplantation

A pilot study was performed in patients after liver transplantation (Ltx) to examine the effect of continuous intravenous urodilatin (URO, CDD/ANP-95-126)-infusion as an alternative therapy of acute renal failure (ARF) resistant to conventional therapy. Eight patients who developed ARF after liver transplantation and fulfilled requirements for haemodialysis/haemofiltration were treated. After URO infusion was started, renal function improved and all patients developed a strong diuresis and natriuresis within 2-4 h. The extracellular expansion due to sodium and water retention in anuric/oliguric ARF lead to an increased central venous pressure (CVP) and elevated blood pressure. During the URO infusion CVP declined and systolic, as well as diastolic, blood pressure were stable. In six patients where haemodialysis/haemofiltration could be avoided, serum creatinine (SC) and blood urea nitrogen (BUN) declined during URO treatment and creatinine clearance (CC) also improved significantly. Fluid and electrolyte disturbances changed promptly and normalized. This was in concordance with renal excretion of electrolytes. Two patients still required haemodialysis/haemofiltration. The six patients who did not require haemodialysis/haemofiltration after URO treatment normalized concerning their renal function and did well in a control period of 12 weeks. The study shows that continuous low dose URO infusion may present a new concept for treatment of postoperative acute renal failure resistant to conventional therapy.

Quadrennial review on liver transplantation

Within the last years, liver transplantation has definitely come of age, and evolved to the standard treatment of choice for patients with endstage liver disease, and after ineffective conventional therapy. This development became possible on the basis of intensive interdisciplinary scientific research and clinical experience, and is the result of a multiplicity of single factors related to patient selection, organ donation, the transplant operation, immunosuppressive therapy, and postoperative care of the recipient. Some of the most important aspects will be summarized in this article.

The use of plasma levels for FK 506 dosing in liver-grafted patients

FK 506 plasma levels were analyzed in 89 liver-grafted patients under FK 506-based immunosuppression. Plasma levels were found to be influenced by the patients' liver function: compared to patients without major liver dysfunction, those with cholestasis had higher plasma levels and these plasma levels were able to differentiate between rejection and toxicity. In patients with stable liver function, no clear difference was observed with regard to the plasma levels detectable during toxicity or rejection. We conclude that plasma levels can be used to determine the FK 506 dose but only in patients with cholestasis (i.e., during the early post-transplant course, or in patients with cholestatic rejection). In patients with stable liver function, plasma levels are only of limited clinical relevance.

Spontaneous proliferation of peripheral blood lymphocytes as an indicator of intragraft immune activation in liver transplant patients

The presence of activated lymphocytes in the blood of transplant recipients is considered to be a marker of an ongoing immune process. In this study, the clinical utility of spontaneous proliferation (SP) of peripheral blood mononuclear cells (PBMC) as a marker of in vivo activation was evaluated by in vitro [3H]thymidine incorporation in 22 patients in the 1st month after liver transplantation. Also immune activation in the graft was monitored by transplant aspiration cytology (TAC-A). In the study period, there were only 2 mild episodes of clinical acute rejection, where SP of PBMC was 1290 and 1541 cpm (vs. 99 cpm averaged in healthy controls). Though SP of PBMC was also increased in systemic infections, a significant positive correlation was observed between SP of PBMC and TAC-A score. In all episodes where TAC-A score was elevated to above 2, SP of PBMC was simultaneously increased to more than 1000 cpm. In 8 patients prophylactically treated with the anti-interleukin-2-receptor antibody, BT563, SP of PBMC was significantly lower compared to 7 patients treated with antithymocyte globulin. It is suggested that SP can be a reliable parameter of the in vivo activation of lymphocytes, which accompanies immune activation in liver graft, and is potentially useful as a sensitive, although rather non-specific, and non-invasive monitoring of intragraft alloresponse.

Indications for liver transplantation in hepatobiliary malignancy

Our personal experience with 172 patients, the results from the European Liver Transplant Registry and a review of the recent literature are summarized and discussed to define present indications for liver transplantation in hepatobiliary malignancy. The following conditions should be considered contraindications: advanced primary liver tumors with any extrahepatic spread, cholangiocellular carcinoma, hemangiosarcoma and liver metastases from nonendocrine primary tumor. Currently, "favorable" indications include uncommon tumors such as fibrolamellar carcinoma, epithelioid hemangioendothelioma, hepatoblastoma and metastases from endocrine tumors. Further indications may be nonresectable hepatocellular and proximal bile duct carcinoma in tumor stage II. Borderline indications are hepatocellular and proximal bile duct carcinoma in tumor stage III. In advanced tumors confined to the liver, transplantation should be restricted to multimodality treatment protocols. Although there are strong arguments for transplantation in early resectable hepatocellular carcinoma with underlying cirrhosis, it remains an open issue requiring further investigation in a controlled study using the same tumor classification. With regard to limited resources of donor organs, split-liver transplantation permits transplantation in tumor patients without neglecting those with benign diseases.

Use of organotypical cultures of primary hepatocytes to analyse drug biotransformation in man and animals

1. In conventional single-gel culture systems for primary hepatocytes, rapid loss of drug metabolizing capacities is a common feature and parallels general loss of function. An organotypical (double gel) culture technique for primary hepatocytes is established by enclosing the cells within two layers of extra cellular matrix. This serves to imitate the in vivo microenvironment within the space of Dissé. Using rat hepatocytes, this technique has been shown previously to maintain protein synthetic functions in vitro and to allow more efficient P450A-dependent biotransformation of drugs than a standard single-gel culture system. 2. The aim was to test the capacity of this organotypical culture model for primary rat and human hepatocytes to generate drug metabolites in a typical species-dependent pattern. 3. Urapidil, an antihypertensive drug, was used as a test compound, since it is metabolized in vivo in a species-dependent manner in rat and man. 4. Primary rat and human hepatocytes were cultured within two layers of collagen and exposed to 2.25 micrograms/ml urapidil for periods of 1-24 h at 3 days in culture. Urapidil metabolites were measured using hplc. 5. Metabolite M1 (hydroxylated product) was produced preferentially in human hepatocyte cultures, and metabolites M2/M3 (O-demethylated, N-demethylated product) were preferentially generated in rat cultures. This corresponded to the in vivo pattern found in man and rat, respectively. 6. Since in vitro urapidil metabolism by human and rat hepatocytes cultured in a double-gel system reflects that in vivo, it is suggested that information from such a system may be useful to predict the metabolic pathway of novel xenobiotics and to direct further toxicological evaluation.

Indications for liver transplantation in hepatobiliary malignancy

Our personal experience with 172 patients, the results from the European Liver Transplant Registry and a review of the recent literature are summarized and discussed to define present indications for liver transplantation in hepatobiliary malignancy. The following conditions should be considered contraindications: advanced primary liver tumors with any extrahepatic spread, cholangiocellular carcinoma, hemangiosarcoma and liver metastases from nonendocrine primary tumor. Currently, "favorable" indications include uncommon tumors such as fibrolamellar carcinoma, epithelioid hemangioendothelioma, hepatoblastoma and metastases from endocrine tumors. Further indications may be nonresectable hepatocellular and proximal bile duct carcinoma in tumor stage II. Borderline indications are hepatocellular and proximal bile duct carcinoma in tumor stage III. In advanced tumors confined to the liver, transplantation should be restricted to multimodality treatment protocols. Although there are strong arguments for transplantation in early resectable hepatocellular carcinoma with underlying cirrhosis, it remains an open issue requiring further investigation in a controlled study using the same tumor classification. With regard to limited resources of donor organs, split-liver transplantation permits transplantation in tumor patients without neglecting those with benign diseases.

Prostaglandin E plus famciclovir--a new concept for the treatment of severe hepatitis B after liver transplantation

New concepts for the treatment of hepatitis B in immunocompromised patients are urgently needed. We describe our first experience with the new antiviral agent famciclovir in combination with a short course of prostaglandin E in a patient with severe hepatitis B after liver transplantation. Initial treatment with prostaglandin E reduced the inflammatory activity, as measured by transaminase activities, but did not affect viral replication. Consecutive long-term treatment with famciclovir further normalized liver function and profoundly suppressed viral replication. HBeAg and HBV-DNA -PCR all became negative and only HBsAg persisted. Histology documented marked reduction of cellular infiltration. The patient completely recovered and is back to regular work as a teacher.

Influence of gender on the monoethylglycinexylidide test in normal subjects and liver donors

The objective of this study was to investigate the effect of gender on monoethylglycinexylidide (MEGX) formation in normal subjects and cadaveric liver donors. The study included 92 male and female healthy volunteers < 45 years of age and 98 age- and sex-matched liver donors from a previous study, whose livers were used for transplantation. Women < 45 years not taking contraceptives showed significantly lower MEGX concentrations 30 min after lidocaine administration than men [median (16-84th percentile)]: 59 micrograms/L (41-70 micrograms/L) versus 81 micrograms/L (58-98 micrograms/L)]. The lowest MEGX 30 min values were observed in women taking contraceptives: 39 micrograms/L (25-48 micrograms/L). Intraindividual variability of serial MEGX tests was moderate (median: 17.8%, n = 8) when measured in female subjects taking no contraceptives and males. Cadaveric liver donors showed significantly higher MEGX 15 and 30 min values compared with normal subjects (p < or = 0.0001). There was no statistically significant difference between MEGX values obtained in male and female cadaveric donors. The urinary excretion of MEGX was similar in male and female normal subjects. Our results suggest that sex-related differences in MEGX formation as well as the influence of contraceptives have to be taken into account when test results from living related liver donors and patients with less advanced chronic liver disease are evaluated. In cadaveric liver donors, however, sex-related differences do not affect MEGX formation.

Resting energy expenditure and nutritional state in patients with liver cirrhosis before and after liver transplantation

Resting energy expenditure (REE), body composition, and the biochemical parameters of liver function were measured in 26 patients before and 432 days (range: 103-1022 days) after liver transplantation (LTX). PreLTX REE was variable (mean: 1638 +/- 308 kcal/day, range: 1220-2190 kcal/day or +10 +/- 11% of Harris Benedict = HB prediction, range: -19 - +33%) and was closely related to body cell mass (r = 0.66, p < 0.0003). PostLTX REE was variable (mean: 1612 +/- 358 kcal/day, range: 1010-2490 kcal/day or +5 +/- 15% of HB prediction, range: -20 - +37%) and was closely related to body cell mass (r = 0.65, p < 0.0006). When compared with preLTX values only small changes in mean REE (-71 +/- 43 kcal/day) and a close correlation between pre and postLTX REE (r = 0.82, p < 0.001) were observed. In contrast to REE, changes in body weight were highly variable (-16.5 - +32.7 kg/year). This variance was not explained by the number of postoperative complications, pre and postLTX liver function, possible graft rejection and/or hepatitis reinfection. Pre-operative hypermetabolism (i.e. REE >+20% of HB prediction) was associated with postoperative hypermetabolism and a reduced liver function before and after LTX. Hypermetabolic patients had a poorer nutritional outcome after LTX (weight change: 0 +/- 8.4 kg/year) when compared with normometabolic controls (weight change: +5.7 +/- 7.4 kg/year; p < 0.05). There was no significant association between deviations in pre and postLTX REE and changes in body weight. When corrected for changes in the nutritional state our data provide evidence for the persistence of resting energy expenditure in liver transplant patients.

[Combined lung and liver transplantation. Anesthesiologic management]

A 53-year-old man with alpha-1-antitrypsin deficiency had an 8-year history of progressive dyspnoea and two episodes of bleeding oesophageal varices with liver decompensation. After the diagnosis of terminal pulmonary emphysema (Fig. 1) and liver cirrhosis with progressive liver failure was made, he was accepted for combined lung and liver transplantation. METHODS. Anaesthesia was induced with thiopentone and fentanyl and maintained with fentanyl, midazolam, and isoflurane. After relaxation with succinylcholine, the patient's trachea was intubated with a left endobronchial double-lumen tube. Haemodynamic monitoring included arterial, central-venous, pulmonary-artery, and capillary-wedge pressures and cardiac output measurement. Ventilatory monitoring consisted of pulse oximetry, side-stream spirometry, and continuous measurement of arterial and mixed-venous blood oxygen saturation with fibreoptic catheters. A left single-lung transplantation was performed under one-lung ventilation without cardiopulmonary bypass. Prostacyclin was infused to reduce pulmonary vascular resistance. The transplant was ventilated separately with 50% oxygen and positive end-expiratory pressure of 8-10 cm H2O, and then liver transplantation was carried out. The institution of veno-venous bypass during the anhepatic phase failed because of portal-vein and axillary-vein thrombi. RESULTS. Total operation time was 6 h 30 min. Clamping of the left pulmonary artery lasted 45 min and the duration of the anhepatic phase was 92 min. Ventilation and oxygenation during lung transplantation caused no problems (Table 1). Clamping of the left pulmonary artery caused a slight increase in pulmonary vascular resistance (104 to 124 dyn.s.cm-5) and mean pulmonary artery pressure (25 to 27 mm Hg) without a decrease in cardiac index (Table 2). During the anhepatic phase with exclusion of the portal vein and inferior vena cava, a marked decrease in cardiac index (-27.2%) was seen (Table 4). The operation required substitution with 10 units packed red blood cells, 12 units fresh frozen plasma, and 5 platelet concentrates. The post-operative course showed normal liver graft function (Table 5). Acute pulmonary rejection on the 7th day was treated successfully with methylprednisolone. The patient's trachea has extubated 10 days after transplantation and he was discharged from the intensive care unit 2 weeks later. CONCLUSION. The management of this combined lung and liver transplantation was performed according to the experience with isolated lung and liver transplants in our hospital. Aggressive haemodynamic and ventilatory monitoring, including systemic and pulmonary arterial fibreoptic catheters, seems of particular importance in such high-risk procedures.