Experiences with liver transplantation in Hannover

Ninety orthotopic liver transplantations in 86 patients performed between 1972 and 1983 in the Medical University of Hannover are reviewed. Results in tumor patients (n = 46) are characterized by a high rate of early tumor recurrence. A few patients survived for prolonged periods, and some were cured. More experience is required to define more precisely suitable kinds and stages of malignancies so that liver grafting in tumor patients can be confined to situations with a favorable prognosis. The main problem of liver transplantation in cirrhotics (n = 40) is the appropriate time of indication. It is suggested that liver grafting be performed more often in an "elective" situation. This phase during the course of cirrhosis must be optimally defined by analysis of the underlying disease and by individual situation. Results of liver grafting in elective situations are better than those in emergency situations and may offer a tangible chance for cure. Liver grafting in pediatric patients gives the best results, although procurement of small donor organs is a major problem. More experience, better immunosuppression with cyclosporin A, and the search for the appropriate time of indication contribute to improvement in the results of liver grafting.

[Preprothrombin in acute viral hepatitis B]

In vitamin K deficiency or treatment with vitamin K antagonists, a precoagulant of prothrombin (Factor II) called preprothrombin has been established. We measured preprothrombin with Clarke-Freeman electrophoresis in 26 patients with acute viral hepatitis (21 HBS-AG positive) who did not suffer from vitamin K deficiency. Prothrombin and the vitamin-K dependent Factors VII, IX, and X were determined by standard coagulometric methods. Prothrombin was additionally estimated by immunoelectrophoresis according to Laurell. Three patients with acute HBS-AG positive hepatitis showed preprothrombin in their plasma. The activity of Factors II, VII, IX, and X was slightly below normal with normal concentration of Factor II in the immunoelectrophoresis. Liver parenchymal damage and cholestasis were slight; the pseudocholinesterase showed subnormal levels in all three patients. Possible causes for the appearance of preprothrombin in the peripheral blood in acute viral hepatitis and the possible connections with liver cell damage are discussed.

Intestinal lavage in the treatment of Crohn's disease: a pilot study

Taking into account that a damaged mucosal barrier may be responsible for the impairment and some systemic complications in Crohn's disease, we employed intestinal lavage as a therapeutic method in six patients suffering from active Crohn's disease. The results were compared with those obtained from a control group that received similar treatment with the exception of the lavage. Intestinal lavage was carried out with 18 1 of normal saline administered via a jejunal tube over a period of 2 h. The lavage procedure was tolerated well by all patients. A significant decrease of the Crohn's disease activity index and a significantly lower hospitalization time suggest a benefit in using the lavage method. Provided that these results can be confirmed in a larger series of patients, intestinal lavage may contribute to the strategy of conservative treatment of Crohn's disease.

Effect of pancreas transplantation on liver carbohydrate metabolism in streptozotocin diabetic rats

The failure of pancreas transplantation to normalize plasma glucagon concentration and insulin: glucagon balance in portal blood has recently been demonstrated on streptozotocin-diabetic rats. The same experimental model was used in the present study to examine the effect of pancreas transplantation on liver carbohydrate metabolism. Twenty weeks after pancreas transplantation, the left hepatic lobe was removed for studies of several glycolytic and gluconeogenic enzymes. Livers from nontransplanted diabetic rats showed decreased activities of glycolytic enzymes and enhanced activities of gluconeogenic enzymes. In recipients of pancreas transplants, however, the activities of glycolytic and gluconeogenic enzymes did not differ from those observed in normal control rats. It is concluded that the alterations of hepatic gluconeogenesis and glycolysis observed in streptozotocin-diabetic rats are restored to normal by the pancreas transplant despite its failure to obviate hyperglucagonaemia.

[Differential diagnosis of chronic hepatitis. Active chronic hepatitis--chronic destructive cholangitis?]

Analysis of the enzyme pattern in 34 patients with liver histology indicating porto-periportal inflammation showed two statistically well differentiated groups: 20 patients with clinical suspicion of early chronic active hepatitis and 14 patients with suspected chronic destructive cholangitis. The course of the disease and the response to immunosuppressive treatment were quite different in the two groups. For differentiation of the early stages of chronic active hepatitis and chronic destructive cholangitis correct interpretation of the enzyme pattern is of great importance. It is also relevant for the decision to use long term immunosuppressive treatment.

[Immunosuppressive treatment of the early stages of active or inactive chronic hepatitis: results of a pilot study (author's transl)]

Immunosuppressive treatment with prednisolone and azathioprine was administered to a small group of nine patients in the early stage of chronic active or inactive hepatitis about six months after onset of the disease. There occurred a relatively rapid improvement in the active liver process, including biochemical and histological findings, compared with ten patients in a control group who, with the same liver condition, were not given immunosuppressive treatment. There were no side-effects in the treated group.

"In vivo" distribution of liposomes between parenchymal and non parenchymal cells in rat liver

The in vivo uptake of 3H-methotrexate containing, 14C-cholesterol labelled liposomes was determined for the two major liver cell populations, parenchymal cells (PC) and non-parenchymal cells (NPC) after intravenous injection of the liposomes into normal rats and rats with a portocaval shunt, followed by isolation and purification of the two cell types. One hour after injection, the purified NPC had bound 2-3 times more of the liposome-attached radioactivity per cell than the purified PC, whereas 6 hours after injection the ratio was inverted. In animals with a portocaval shunt, the PC contained 3-4 times more liposomal radioactivity per cell than NPC already 1 hour after injection, although the total uptake by the whole liver was not diminished under these conditions. Recalculating the data obtained from the isolated cells for the whole liver, it is found that 1 hour after injection the liver NPC had bound the same amount of liposomal radioactivity as liver PC, although they account for only 7% of the liver volume. After 6 hours, the PC had bound 5 times more liposomal radioactivity than the NPC; this ratio is achieved in animals with a portocaval shunt already 1 hour after injection. This shift is simultaneously caused by a gain of PC-bound radioactivity and decrease of NPC-bound radioactivity.

[Immunosuppressive treatment of chronic active hepatitis (author's transl)]

Early-stage chronic active hepatitis treated with prednisolone and azathioprine has a good prognosis. In most of the 20 patients investigated improvement occurred already after 3 months of treatment, by 6 to 9 months the laboratory findings had become normal and after 12 months there was no definite evidence histologically for the initial aggressive form of liver disease. However, in the late stage of chronic active hepatitis the effect of immunosuppressive treatment seems questionable. The tendency for improvement of laboratory findings during immunosuppression was significantly worse than in early-stage disease. Histologically there was no real improvement in two thirds of the cases a year after onset of treatment.

The Szasz-ratio (CK/GOT) as example for the diagnostic significance of enzyme ratios in serum

The diagnostic significance of enzyme and isoenzyme ratios in serum relies on their different distribution at various levels: from organs to subcellular structures. Factors which modify the ratios are the molecular properties of enzymes and isoenzymes and their turnover in the cells and in the extracellular space. These pathophysiological principles are considered with respect to the Szasz ratio CK/GOT and its application for the differential diagnosis of acute myocardial infarction.

[Influence of (+)-cyanidanol-3 on the course of acute viral hepatitis (author's transl)]

A double-blind study was conducted in four hospitals to test the effect of (+)-cyanidanol-3 (Catergen) on the course of acute viral hepatitis. Activities of a number of enzymes, bilirubin levels and gamma-globulin concentrations, as well as elimination of HBs antigen in blood were measured serially in 73 patients with viral hepatitis, 37 being treated with the drug, 36 patients receiving a placebo. In addition, liver biopsies before and after treatment were compared (19 patients treated, 23 patients on placebo). There was no significant difference between the treatment and placebo groups with regards to morphological and biochemical changes.

Tests of bile-acid and vitamin B12 metabolism in ileal Crohn's disease

The bile-acid breath test, fecal analysis of labeled bile acids, and Schilling test were used to study bile-acid and vitamin B12 metabolism in 31 patients with ileal Crohn's disease. Results of the bile-acid breath test were positive for 42% of the patients; Schilling test, 42%; fecal analysis of bile-acid labels, 19%. Combination of the tests increased the percentage of positive cases to 65. About 50% of the patients who had positive breath tests had evidence of normal bile-acid absorption, indicating increased bile-acid deconjugation by small-intestinal bacteria. The other 50% had evidence of various degrees of bile-acid malabsorption. Disease activity did not correlate with results of any test. Extent of ileal involvement correlated with results of the bile-acid tests, but not with those of the Schilling test. The study demonstrates that there is a wide spectrum of disturbances of bile-acid and vitamin B12 metabolism in ileitis, and that the tests should be useful in the diagnostic evaluation of patients with proven or questionable Crohn's disease who have diarrhea and malabsorptive abnormalities that could be related to disturbances of bile-acid and vitamin B12 metabolism.

Creatine kinase (EC-No.2.7.3.2) and creatine kinase isoenzymes during pregnancy and labor and in the cord blood

Total CK and CK isoenzyme activity in serum was investigated during pregnancy, labor and after delivery as well as in cord blood. Total CK was decreased in the second trimester of pregnancy but increased in late pregnancy. Low CK-MB activity in serum was found in patients with early labor pains. CK-BB activity could never be detected during pregnancy. Total CK and isoenzyme activity increased after delivery. The rise of total CK and CK-MB in maternal serum is directly correlated with the following: type of delivery, duration of labor, parity of the mother, and birth weight. From this it can be deduced that postpartum CK levels depend on skeletal muscle activity as well as on the activity of uterine muscle. Prematures and infants "small for date" have significantly lower total CK and slightly more elevated CK-BB activity in cord blood than children of normal maturity. CK-BB activity is much more pronounced in high risk patients with low Apgar score.

Clinical aspects of gut enzymology

Enzymological alterations in functional disturbances and in diseases of the intestine are reviewed. Examples are given for diagnostic significance (e.g. in Hirschsprung's and Crohn's diseases), for pathogenetic considerations (e.g. in hypolactasia and in celiac disease), and for secondary involvement of the liver (e.g. in intestinal tumors and after bypass surgery) and are discussed in more detail.

Macro-creatine kinase-BB: observations on 6 patients

From 2000 sera with elevated total creatine kinase (EC 2.7.3.2) activity the sera of 6 patient showed a persistent high and anamnestically inexplicable creatine kinase activity level. The serum isoenzyme pattern was analyzed by four different methods. Electrophoresis revealed an atypical creatine activity band located between creatine kinase-MM and creatine kinase-MB. An adequate estimation of the persistent enzyme activity could only be achieved by immunotitration (immunoprecipitation), which identified the creatine kinase activity as due primarily to the isoenzyme creatine kinase-BB. Other methods (immunoinhibition and column chromatography) may lead to misinterpretations. The atypical serum creatine kinase-BB showed a higher molecular weight (Mr = 250,000) and altered substrate affinity as compared to native creatine kinase-BB. Both properties are attributable to the binding of creatine kinase-BB to immunoglobulins.

Total body water, extracellular water, plasma volume, and total body potassium in cirrhosis of the liver

Extracellular water (EWC; 82-bromide), total body water (TBW; 3-THO), intracellular water (ICW = TBW-ECW), plasma volume (PV; 51-Cr), and total body potassium (TBK; 40-K) were studied in patients with cirrhosis of the liver (n = 12) and in controls (n = 12). ECW (39%), TBW (28%), ICW (19%), and PV (24%) increased, TBK (28%) however, decreased in cirrhosis. The results indicate that it is less the lean body mass, but rather the intracellular potassium concentration that is lowered (cirrhosis: 84 +/- 21 mmol/l ICW; controls: 115 +/- 23 mmol/l ICW). Decreased potassium per cell (mmol) and increased intracellular water are discussed as possible reasons for this. The correlation between TBK (%) and serum potassium (mmol/l) was found to be r = 0.56 (p less than 0.002). Correlations between the biochemical parameters gamma-globulins, cholin esterase, serum sodium and serum albumin (g/l PV) and characteristic fluid disturbances in cirrhosis are highly significant whereas albumin (g/kg bodyweight) was the same in both groups. We can support the 'overflow theory' of ascites formation.

Evaluation of one dimensional profile scans with a whole body counter--82bromide space in liver cirrhosis: concise communication

One dimensional profile scans with a whole body counter are refocused with a linear space invariant filter in the frequency domain, 'Hanning' window and inverse system transfer function. Artifacts are eliminated in a way that a clinically applicable method is developed. Topographic information is achieved with the highly energetic nuclide 82bromide. The bromide space (extracellular volume) in patients with liver cirrhosis (n = 9) compared to normal subjects (n = 10) is increased most in the upper abdominal thoracic region.