Role of intracellular redox status in apoptosis induction of human T-cell leukemia virus type I-infected lymphocytes by 13-cis-retinoic acid

We have shown that cell cycle progression of human T-cell leukemia virus type I (HTLV-I)-transformed T-cell lines was inhibited by 13-cis-retinoic acid (13cRA). In the present study, we report that 13cRA inhibited proliferation and induced cell death of peripheral blood mononuclear cells obtained from four patients with acute adult T-cell leukemia but not of mitogen- or interleukin 2-activated peripheral blood mononuclear cells from HTLV-I-negative healthy donors. Because HTLV-I-infected lymphocytes are susceptible to oxidative stress, we examined the role of the intracellular redox state in 13cRA-induced cell death using a HTLV-I-positive T-cell line, ATL2, as a model. 13cRA induced apoptosis in ATL2 cells within 48 h in a dose-dependent manner. The ability of 13cRA to induce apoptosis was more potent than that of all-trans-retinoic acid. Apoptosis induction by 13cRA was significantly enhanced by buthionine sulfoximine (BSO), which decreased the levels of intracellular reduced glutathione, although 13cRA by itself did not alter them, suggesting that intracellular reduced glutathione may modulate 13cRA-induced apoptosis. In addition, flow cytometric analysis revealed that 13cRA increased intracellular peroxides in 24 h and that the addition of BSO further enhanced them. Although N-acetylcysteine had only a marginal effect, pretreatment with catalase markedly inhibited 13cRA-induced apoptosis. These results suggest that peroxide generation, ie., oxidative stress, may play a crucial role in the induction of apoptosis by 13cRA and further demonstrate that combined treatment with 13cRA and BSO induces apoptosis of HTLV-I-positive lymphocytes even more potently.

The protective effects of prostaglandin E1 on sinusoidal endothelial cells in xenogeneic pig liver perfusion

The effects of prostaglandin E1 (PGE1) on hepatic sinusoidal endothelial cells (SEC) in the xenogeneic immunoreaction were investigated. Porcine livers were perfused with fresh human blood via the portal vein (PV) and the hepatic artery (HA) either with the administration of PGE1 (Group PG) or without PGE1 (Group C). The creatine kinase-BB component (CK-BB) in the perfusate was measured to assess SEC damage. SEC activation and complement activation were evaluated immunohistochemically by the expression of von Willebrand factor (vWF) and by the deposition of membrane attack complex (MAC), respectively. Xenoperfusion in Group C was discontinued between 4 and 6 hr due to the rapid elevation of HA pressures and the massive loss of perfusate. In Group PG, both PV and HA pressures were kept stable for up to 9 hr. In Group C, severe interlobular bleeding and diffuse extrasinusoidal hemorrhage were observed at 4 hr histologically, while in Group PG, the hepatic architecture was maintained without hemorrhage at 6 hr. MAC was markedly deposited on SEC and parenchymal cells at 3 hr in both groups. The amount of vWF, however, was expressed on SEC in large amounts at 1 hr in Group C, while small amounts were expressed at 1 hr in Group PG. In Group PG, CK-BB release was significantly lower than in Group C (P < 0.01). These results suggest that PGE1 suppressed SEC activation and protected the impairment of hepatic SEC during xenoperfusion without suppressing complement activation, resulting in the prolongation of xenogeneic liver perfusion.

Humoral injury in porcine livers perfused with human whole blood

BACKGROUND

We investigated the influence of humoral injury during xenoperfusion of porcine livers by human blood.

METHODS

The porcine livers were perfused under physiological conditions for 9 hr. The perfusates consisted of porcine whole blood in group 1, human whole blood in group 2, and human whole blood with soluble complement receptor type 1 (300 microg/ml) in group 3.

RESULTS

Liver enzyme release and serum hemoglobin in group 2 increased significantly after 3 hr of xenoperfusion, compared with those in group 1 and group 3 (P<0.05). Severe histological damage with minimal cellular infiltration was observed in group 2 after 6 hr of xenoperfusion, but was present only at trace levels in group 1 and group 3. In group 2, von Willebrand factor, a possible target of natural antibodies, was induced on sinusoidal endothelial cells after 3 hr of xenoperfusion, correlating with diffuse deposition of human IgM and membrane attack complex. In group 3, von Willebrand factor, human IgM, and membrane attack complex staining in the intralobular region were present at trace levels. In group 3, the indocyanine green removal capacity, representing hepatocyte function, was significantly higher than in group 2 (P<0.05).

CONCLUSIONS

Based on these results, we suggest that humoral injury is a major cause of liver damage during liver xenoperfusion. The pattern of humoral injury in xenoperfused livers may be attributed to anatomical features of the liver and unique responses of sinusoidal endothelial cells to xenoperfusion.

Induction of various cytokines and development of severe mucosal inflammation by cagA gene positive Helicobacter pylori strains

BACKGROUND

Helicobacter pylori strains possessing the cagA gene are thought to induce interleukin 8 (IL-8) in gastric mucosa. However, it is still unclear whether a relation exists between the cagA gene and the expression patterns of cytokines other than IL-8.

AIMS

To investigate the relation between the cagA gene and the production of various cytokine proteins using an enzyme linked immunosorbent assay (ELISA).

PATIENTS AND METHODS

In 184 patients, the cagA gene was detected by polymerase chain reaction (PCR), and levels of production of IL-1 beta, IL-6, IL-7, IL-8, IL-10, and tumour necrosis factor alpha (TNF-alpha) in antral biopsy specimens were measured by ELISA.

RESULTS

Mucosal levels of IL-1 beta, IL-6, IL-8, and TNF-alpha were significantly higher in H pylori positive than in H pylori negative patients. Furthermore, the mucosal levels of IL-1 beta and IL-8 were significantly higher in specimens infected with cagA positive strains than in those infected with cagA negative strains. In H pylori positive patients, the mucosal level of IL-8 was closely correlated with that of IL-1 beta (p < 0.0001), and the mucosal level of IL-6 was closely correlated with that of TNF-alpha (p < 0.0001).

CONCLUSION

These findings suggest that the ability to induce cytokines differs among the strains; cagA+ strains induce various kinds of cytokines and may cause severe inflammation, whereas cagA- strains induce IL-8 and IL-1 beta only weakly and may cause only mild inflammation. However, as most patients infected with the cagA+ strains have gastritis, these strains may not be equivalent to ulcerogenic strains.

Hepatic arterial complications in pediatric segmental liver transplantations from living donors: assessment with color Doppler ultrasonography

To investigate the clinical utility of color Doppler ultrasonography in detecting hepatic arterial complications in pediatric living-related liver transplantation, we studied peak systolic velocity (Vp) and pulsatility index (PI) intrahepatic artery during and after surgery in 122 transplants. Six cases with hepatic artery thrombosis were detected by Doppler studies. In 2 cases with dampened waveforms at intraoperative flowmetry (Vp < or = 23 and PI < or = 0.6), thrombosis occurred soon after surgery. A further 2 cases had a rapid decrease in Vp and PI values postoperatively, leading to absence of arterial signals. Follow-up Doppler studies suspected collateral formation after thrombosis in 2 survivors. Normal Doppler waveforms were obtained in all of the 116 cases without arterial complications. Among them, 6 cases had absent signals or dampened waveforms at initial intraoperative flowmetry (Vp < or = 30 and PI < or = 0.9), and maneuvers such as re-reanastomosis of the artery improved flow signals with an increase in Vp and PI values. Serial intra- and post-operative Doppler examinations are useful for early detection of arterial complications.

Efficiency of pentoxifylline in donor pretreatment in rat liver transplantation

Donor pretreatment is a new concept in organ preservation. Pentoxifylline (PTX) has been reported to suppress the activation of Kupffer cells and to decrease injury to the hepatic graft after rat liver transplantation. We evaluated the efficiency of PTX pretreatment on the donor against hepatic injury following cold ischemia (CI) or warm ischemia (WI) using the rat liver transplantation model. Dose dependency: every rat was injected intraperitoneally with PTX (30, 50, or 80 mg/kg) or saline. One hour later, the portal vein (PV) and the hepatic artery (HA) were clamped for 30 min. Transplantation: the donor rat was injected intraperitoneally with 50 mg/kg PTX or saline, 1 hr before laparotomy. Animals were divided into two groups. In the CI group, grafts were preserved for 12 hr in University of Wisconsin solution at 4 degrees C and transplanted. In the WI group, the PV and the HA in the donor were clamped for 30 min before donor surgery, and the grafts were transplanted. Serum levels of tumor necrosis factor-alpha (TNF-alpha), glutathione S-transferase-alpha (GST-alpha), and aspartate transaminase (AST) were measured at 30 min, 3 hr, and 24 hr after reperfusion of the PV. Compared with those of a control group, the serum levels of TNF-alpha, GST-alpha, and AST in the PTX-pretreated groups were significantly lower after both CI and WI at 30 min and further suppressed in the WI group at 24 hr. These results indicate that PTX pretreatment on the donor is effective for suppression of hepatic injury after both CI and WI.

Regression of atypical lymphoid hyperplasia after eradication of Helicobacter pylori

A rare case of endoscopic and histological regression of a gastric lymphoid mucosal lesion after eradication of Helicobacter pylori is reported. A 72-year-old man was suspected of having a low-grade B-cell gastric mucosa-associated lymphoid tissue (MALT) lymphoma by endoscopic and histological findings. Histology of biopsy specimens showed massive infiltration of atypical lymphocytes and lymphoepithelial lesions. Immunohistochemical staining revealed kappa light chain expression in the infiltrated atypical lymphocytes to be twofold that of lambda light chain. The above diagnosis was thus highly suspected but not confirmed. Antibiotic therapy was given on the basis of evidence of H. pylori infection. Successful eradication of H. pylori resulted in remarkable improvement of endoscopic and histological findings. Follow-up studies were carried out 8 months after eradication, with no evidence of relapse. The eradication of H. pylori appears to be an effective alternative therapy for B-cell lymphoproliferative disease, although longer follow-up and further studies are needed before this treatment can be established.

[Surgical therapy for hepatocellular carcinoma with liver cirrhosis]

Approximately 80% of hepatocellular carcinoma (HCC) patients in Japan have associated liver cirrhosis, which increases the difficulty of surgical treatment. Liver dysfunction associated with liver cirrhosis is one of the most important predictive prognostic factors for HCC patients. Percutaneous ethanol injection therapy (PEIT) is useful for patients with small HCC or with poor hepatic functional reserve. Transcatheter arterial chemoembolization (TACE) is also useful both for patients with unresectable HCC and patients with multiple intrahepatic recurrence. Liver resection, however, lead to better outcome than other treatments when liver function is maintained after surgery. To determine operative procedures, it is important to evaluate the exact function of remnant liver, based on the preoperative liver function test and the evaluation of tumor character. For advanced HCC patients with vascular invasion, non-surgical treatments such as PEIT or TACE are not indicated, and surgical intervention can be an effective modality to improve their survival. Improvements of surgical technique and perioperative management have decreased fatal complications at a major liver resection and allowed us to carry out liver resection on patients with advanced HCC.

Hepatic preservation with histidine-tryptophan-ketoglutarate solution in living-related and cadaveric liver transplantation

1. Living-related liver transplantation has some advantages in the evaluation of novel clinical protocols, since many complicated factors affecting initial graft function are almost uniform in grafts obtained from healthy donors. 2. To compare histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) solution in terms of tissue oxygenation in living-related liver transplantation, oxygen saturation of haemoglobin (SO2) in hepatic tissue and its heterogeneity (CV, coefficient of variation) were measured by near-infrared spectroscopy. The HTK and UW groups consisted of 15 and 49 successful transplants respectively, in which no statistical differences in background were observed. 3. In the HTK group, hepatic SO2 after portal vein reflow was higher (P < 0.01) than that in the UW group, as was that after hepatic artery reflow (P < 0.05). In the UW group, hepatic SO2 remained at the lower level at the end of the operation. 4. Furthermore, the increase in CV after portal vein reflow was normalized after hepatic artery reflow in the HTK group. However, the CV remained at a high level at the end of the operation in the UW group. 5. Postoperative peak aspartate aminotransferase level in the HTK group was lower than that in the UW group (P < 0.05). 6. In cadaveric liver transplantation, higher hepatic SO2 and lower CV of hepatic SO2 in the early phase after reperfusion compared with the UW group (n = 18) were also observed in the HTK group (n = 30) (P < 0.05). 7. In conclusion, recovery of tissue oxygenation and its heterogeneity after reperfusion in HTK-preserved livers were more rapid and homogeneous than in UW-preserved livers in living-related liver transplantation. Accordingly, HTK solution may be a potential alternative to UW solution.

Cosinor analysis of feed intake cycle of rats fed a zinc-deficient diet and the effect of zinc supplementation

Rats fed a Zn-deficient diet develop a characteristic cyclic variation in feed intake (Mills et al., Am J Clin Nutr 22: 1240-1249 (1969). A preliminary analysis (Tamaki et al., Br J Nutr 73: 711-722 (1995)) of the cyclic variations was followed with a personal computer. Cosinor analysis revealed that the cyclic period of the feed intake of male rats was 3.5 +/- 0.05 d. The mesor, amplitude and acrophase value were 10.0 +/- 0.3 g/d, 4.4 +/- 0.2 g/d and 3.5 +/- 0.3 radian, respectively. The cycle of body-weight change of the Zn-deficient rats was well synchronized with that of feed intake. The parameters of the feed intake cycle had a high correlation to the corresponding parameters of body-weight change (mesor: r = 0.846; amplitude: r = 0.771; period: r = 0.925; acrophase: r = 0.452). With the supplementation of Zn (0.95-3.80 mg/kg of the Zn-deficient diet), cyclic variations in feed intake and body-weight change were also found. The mesor, amplitude and period of feed intake cycle were is good correlation with Zn intake (r = 0.856, p < 0.001, r = 0.804, p < 0.001 and r = 0.613, p < 0.01, respectively). The cycle of feed intake of the rats fed a Zn-free diet was simulated to be: mesor 9.7 +/- 0.1 g/d, amplitude 6.5 +/- 0.1 g/d and period 3.4 +/- 0.02 d. The concentration of Zn intake given the half-maximal value of the amplitude was assumed to be 56 +/- 1 microgram/d.

Development of microchimerism in pediatric patients after living-related liver transplantation

Microchimerism has been suggested to play an important role in the long-term acceptance of allogeneic organ grafts by transplant patients and for the maintenance of a state of donor-specific low responsiveness. In order to elucidate the kinetics of the development of chimerism we have performed a follow-up analysis in 10 pediatric patients with living-related liver transplantation (LRLTx). Blood samples obtained during the first 6 months and at 18 months post-transplant and skin biopsies taken at one month were analysed for the presence of donor cells by PCR using donor-specific HLA-DRB1 primer pairs or primers for a Y chromosome-specific sequence. Furthermore 13 long-term patients more than 2 yr after LRLTx were studied at two different time points. In the follow-up studies donor cells could be demonstrated in the blood of all patients immediately after transplantation. After a gradual decline all patients became chimerism-negative for several weeks or months. At 6 months, however, in five of eight patients tested and at 18 months in six of nine patients donor cells had reappeared. This biphasic pattern in the development of chimerism is proposed to reflect the occurrence of different donor-derived cell populations in the recipient. The population giving rise to the first wave of chimerism probably represents matured cells with a limited lifespan which are released from the graft into the circulation of the recipient during the first weeks after transplantation. The population of cells occurring with the second wave of chimerism is likely to have been generated by donor-derived cells with stem cell potential located either in the graft or in the hematopoetic organs of the recipient after emigration from the graft. This model may be able to explain fluctuations in the incidence and degree of microchimerism described in other patient populations during the first year post-transplant. Of the 13 long-term patients, chimerism could be demonstrated in 11. In seven patients it was detected in both blood and skin, in three patients the results obtained for blood and skin were discordant. In one patient only blood was analysed. It is not clear whether the negative results really reflected the absence of chimerism or whether the number of donor cells was below the level of detectability.

Coexistence of a graft with the preserved native liver in auxiliary partial orthotopic liver transplantation from a living donor for ornithine transcarbamylase deficiency

BACKGROUND

Auxiliary partial orthotopic liver transplantation (APOLT) has recently been performed in patients with noncirrhotic metabolic liver diseases. However, long-term outcomes for the preserved native liver and the transplanted liver graft have not been clearly established yet.

METHODS

The recipient was a 36-month-old girl with ornithine transcarbamylase deficiency. She underwent APOLT, using her father's left lateral segment.

RESULTS

Liver function was normalized soon after APOLT and the patient was able to ingest a normal diet without medication. Coexistence of the well-functioning native liver and graft was demonstrated in a computed tomography scan, Doppler ultrasonography, scintigraphy, and histological examination, during a relatively long-term follow-up period.

CONCLUSIONS

APOLT seems to be most useful for the treatment of noncirrhotic metabolic liver diseases.

A hepatic graft tuberculosis transmitted from a living-related donor

Exclusion of occult diseases in the donor organ and prevention of infectious disease transmission are minimal requirements in organ transplantation. We report here a case of hepatic graft tuberculosis, which was most likely transmitted by the graft from the living-related donor. The course of the recipient included tuberculosis, rejection, and other infections, which led to vanishing bile duct syndrome. Due to various infections and tuberculosis, as well as a strong interaction between rifampicin and tacrolimus, the patient died of pneumonia on day 273 after transplantation. This case emphasizes the importance of care in the selection of a living-related donor for liver transplantation.

Hepatic vein reconstruction in 152 living-related donor liver transplantation patients

BACKGROUND

Hepatic vein (HV) reconstruction is crucial in partial liver transplantation in which the inferior vena cava (IVC) is preserved.

METHODS

We reviewed the medical records of 152 living-related donor liver transplantations (LRDLTs) in 150 children (45 left lobe grafts, 106 lateral segment grafts, and 1 right lobe graft) monitored for 12 months or longer.

RESULTS

A standard technique was a wide end-to-side anastomosis between the donor HV and cuffs, consisting of the recipient middle and left HV and an incision to the IVC. In 15 of 22 partial grafts with two separated HVs the two vessels were reformed by back table surgery to have a common anastomotic orifice, and two separate anastomoses of the individual vessels were made for the remaining seven grafts. Four patients with an absence of infrahepatic IVCs and two with completely obstructed IVCs had end-to-end anastomoses with recipient IVCs. Four patients with stenotic IVCs had end-to-side anastomoses with new orifices on the IVCs. Two patients had acute HV obstruction caused by twisting of the HV that required laparotomy, and six had late-onset HV obstruction that required radiologic intervention. A tissue expander was placed prophylactically in the right subphrenic space in 10 patients to prevent the dislocation of the graft into the right subphrenic space.

CONCLUSIONS

It is important in HV reconstruction in partial liver transplantation to make wide orifices and to adapt each graft to its orthotopic place, taking into consideration graft shape, size of the abdominal cavity of the recipient, and anatomic variations in vessels.

Successful long-term xenoperfusion of the pig liver: continuous administration of prostaglandin E1 and insulin

For clinical utilization of extracorporeal liver perfusion as an artificial liver assist device, we examined the possibility of long-term xenoperfusion of the pig liver by the continuous administration of prostaglandin E1 (PGE1) and insulin. After a 3-hr perfusion period, pig livers that were xenoperfused with human blood exhibited a drastic decrease in the perfusate volume, a progressive elevation of the hepatic artery pressure, a gradual deterioration of bile production, and a marked increase in the release of creatine kinase-BB component. The continuous administration of PGE1 (25 microg/hr) and insulin (1 U/hr) significantly improved these derangements (P<0.05) and allowed stable perfusion for up to 9 hr. This manipulation also inhibited leukocyte aggregation in the graft, the characteristic perfusate hemolysis, and acceleration of ketogenesis. Histological examination revealed that the interlobular edema and hemorrhage, characteristics of tissue injuries in xenogeneic hyperacute rejection, were markedly alleviated in the PGE1 and insulin-treated group. This study clarifies the finding that the combined administration of PGE1 and insulin is effective for long-term xenogeneic extracorporeal liver perfusion, with the graft viability well maintained.

Prostaglandin E1 resuscitates hepatic organic anion transport independent of its hemodynamic effect after warm ischemia

Prostaglandin E1 (PGE1) is a promising agent against ischemic liver damage, but direct evidence of the benefit to intrinsic hepatocyte function has been lacking. We demonstrate here that organic anion transport can be supported by treatment with PGE1 even at a lower dose which does not affect hepatic microcirculation in rabbits with liver inflow occlusion. Near-infrared spectroscopy was applied to directly measure hepatic clearance of indocyanine green (ICG), an exogenous organic anion, and to estimate microcirculation as measured by oxygen saturation and the content of hemoglobin in the sinusoid. Also, morphological changes in microtubules, the cytoskeleton which is known to be associated with organic anion transport, and energy status, as measured by adenine nucleotide levels, were observed. ICG removal rate in hepatocytes decreased significantly from 0.100 +/- 0.018 to 0.027 +/- 0.019 min-1 (mean +/- SD, P < 0.01) by 60-min warm ischemia, whereas the value increased to 0.082 +/- 0.030 min-1 (P < 0.05) when PGE1 was given at a dose of 0.05 microgram/kg/min. The treated livers also showed early reorganization of microtubules, as well as amelioration of ATP resynthesis after reperfusion. However, there were no significant differences in intraoperative changes in oxygen saturation and the content of hemoglobin in the sinusoid between PGE1-treated and untreated groups, indicating that the influence of PGE1 at this dose on hemodynamic changes is not considerable. These results indicate that PGE1 resuscitates an inherent hepatocyte function of organic anion transport on reperfusion after warm ischemia and suggest that the benefit could be attributed solely to direct action on hepatocytes.

Reducing environment protects sinusoidal lymphocytes isolated from normal human liver from apoptosis

BACKGROUND/AIMS

We previously reported that the populations of lymphocytes and the expression of activated antigens in human sinusoidal mononuclear cells were different from those in peripheral blood mononuclear cells. Attempts to culture these cells for further study failed because they died rapidly under standard culture conditions in vitro after isolation from the liver. In this study, we evaluated the characteristics of cell death and the effects of various culture conditions on the viability of these cells.

METHODS

Sinusoidal mononuclear cells were isolated from University of Wisconsin solution that had been perfused through the portal veins of normal healthy human livers harvested for transplantation into living related recipients.

RESULTS

70% of sinusoidal mononuclear cells cultured in vitro were nonviable within 48 h after isolation, while only 10% of peripheral blood mononuclear cells died under the same conditions. Sinusoidal mononuclear cells showed DNA ladder formation of DNA on electrophoresis and characteristic morphological pattern on electron microscopic examination that suggested they had died in an apoptotic manner. The addition of human liver extracts or 2-mercaptoethanol and reduced glutathione to the cultures rescued the sinusoidal mononuclear cells from apoptosis. Furthermore, diamide, a sulfhydryl group specific oxidant, negated the effect of the liver extract.

CONCLUSION

In comparison with peripheral blood mononuclear cells, human sinusoidal mononuclear cells were more subject to death by apoptosis ex vivo, which was reversed by exogenous agents producing reducing conditions. These results suggested that hepatic sinusoidal mononuclear cells might express a different sensitivity to redox environment than peripheral blood mononuclear cells.

Postoperative monitoring of the oxygenation state of the graft liver in cases with hepatopulmonary syndrome

Postoperative changes in the oxygen saturation of hemoglobin in the graft liver (graft SO2) were monitored by near-infrared spectroscopy in four cases complicated by hepatopulmonary syndrome. A plastic cylinder was placed in the abdominal wall, and optical measurements of the graft liver were obtained through this window. Our findings were as follows; (1) graft SO2 decreased after abdominal wall closure, and decreased further 1 day after surgery. (2) Graft SO2 was maintained despite severe hypoxemia, with partial pressure of oxygen in arterial blood as low as 50 mmHg. High hematocrit was beneficial for oxygenating the graft. (3) Graft livers could tolerate hypoxia with a graft SO2 as low as 20%. (4) It may be useful to monitor graft SO2 during the critical period after transplantation for the assessment of graft function.

Factors associated with postoperative respiratory complications in pediatric liver transplantation from living-related donors

Factors associated with respiratory complications (RCs) after pediatric living-related liver transplantation were statistically analyzed in the first 100 cases where surgery was performed at Kyoto University. The overall incidence of postoperative RCs was 45%, including atelectasis (23%), pleural effusion (23%), and pneumonia (12%). Univariate and multivariate analyses were performed with regard to the association between postoperative RCs and 13 pre- and intraoperative variables that were considered to represent the preoperative medical status of the patients and the severity of operative insult. The following four independent variables were found to have prognostic significance with regard to the postoperative RCs: (1) history of preoperative RCs, (2) height < or = -2 SD from the mean for the age, (3) United Network for Organ Sharing score = 1, and (4) intraoperative blood loss > or = 20% of body weight. Postoperative death was highly affected by postoperative RCs: 8 of 11 deaths during the study period were directly or closely related to postoperative RCs. We conclude that postoperative RCs are major contributing factors to operative morbidity and mortality in pediatric living-related liver transplantation, which may possibly be reduced by intensive respiratory management of patients with the above risk factors for postoperative RCs.

Disorganization of microtubular network in postischemic liver dysfunction: its functional and morphological changes

Microtubules in the hepatocytes have been implicated to serve as lines of cytoplasmic transport of secretory materials, but are highly labile structures sensitive to pathological conditions in the cytosol. We examined the role of ischemia/reperfusion-induced cytoskeletal alterations in postischemic liver dysfunction. Rabbit livers were subjected to 60-min warm ischemia followed by 1 h or 24 h of reperfusion. Liver function was assessed by directly measuring hepatic clearance of indocyanine green (ICG), an organic anion whose cytoplasmic transport is assumed to depend on intact microtubules, using near-infrared spectroscopy. Structural alterations of microtubules were observed immunohistochemically using tissue sections stained with monoclonal anti-beta-tubulin antibody. ICG removal from hepatocytes into bile canaliculi deteriorated 1 h but reversed 24 h after reperfusion. Immunohistochemistry showed fragmentation of microtubules at the end of liver ischemia. This cytoskeletal alteration was evident 1 h but was not observed 24 h after reperfusion. Treatment with prostaglandin E1 exerted its beneficial effect by preserving ICG clearance and microtubular network. These results demonstrate that liver ischemia and subsequent reperfusion both affect the organization of microtubular network and suggest that structural disruption of microtubules may be a cause of postischemic liver dysfunction.

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1%) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant liver, which was the only post-operative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preoperative screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.

Extension of surgical indication for advanced hepatocellular carcinoma: is it possible to prolong life span or improve quality of life?

BACKGROUND/AIMS

We have tried to break through the limitations of treatment for advanced hepatocellular carcinoma (HCC), which has been regarded as a contraindication for surgical treatment.

MATERIALS AND METHODS

In 640 cases of hepatic resection for Liver cancer, we analyzed 55 cases of HCC with tumor thrombi in the trunk or first branch of the portal vein (PV) which required additional PV thrombectomy, 5 cases with direct invasion or compression to the inferior vena cava (IVC) which required replacement of IVC with a polytetrafluoroethylene (PTFE) tube, 9 cases with involvement of the extrahepatic bile duct (BD) which required additional extirpation of tumor fragments in the BD, 6 cases with tumor thrombi in the IVC which required IVC thrombectomy, and 4 cases of huge main tumor with intrahepatic metastasis in the entire liver which required intraoperative ethanol injection.

RESULTS

Mean survival times in these groups were 796, 717, 650, 220, and 147 days, respectively. All patients with IVC thrombi and large tumor with intrahepatic metastasis in the entire liver died of early recurrence in spite of surgical treatment. By contrast, half of the patients with PV thrombi, BD involvement and IVC invasion or compression survived approximately 500 days because of a combination of hepatic resection, additional intraoperative treatment and postoperative treatment, and some patients could enjoy a longer life.

CONCLUSIONS

Multimodality treatment including hepatic resection should be encouraged for advanced HCC patients with PV thrombi, BD involvement or compression or invasion of the IVC, as long as the remnant liver can overcome postoperative liver failure.

Ischemic preconditioning of the liver in rats: implications of heat shock protein induction to increase tolerance of ischemia-reperfusion injury

It has been reported that ischemic preconditioning of the heart or brain has a possible relevance to heat shock protein (HSP). It is still unknown, however, whether HSP induced by means of ischemic preconditioning of the liver is a direct factor in the acquisition of tolerance to succeeding ischemia-reperfusion injury. In the present study we used ischemic preconditioning of the liver to verify the effects of induced HSP72 in the liver on the subsequent longer warm ischemia and reperfusion. Rats preconditioned with short-term (15-minute) ischemia were compared with rats preconditioned by heat exposure or with control rats. After a 48-hour recovery from the sublethal stress for preconditioning, all rats were exposed to longer (30-minute) warm ischemia and reperfusion. Forty-eight hours after ischemic preconditioning, HSP72 was clearly induced in the liver, as well as in the liver preconditioned with heat shock, but not in the kidney or heart. This ischemic preconditioning also attenuated the liver damage in the subsequent ischemia-reperfusion injury, improving the restoration of hepatic function during reperfusion and resulting in higher postischemic rat survival. According to the proposed model of tolerance acquisition for ischemia-reperfusion injury by stress preconditioning, these observations support the speculation that the induced HSP72 plays some beneficial role in this protection mechanism.

Analysis of factors affecting the graft oxygenation state in living related liver transplantation

BACKGROUND/AIMS

In liver transplantation, graft dysoxia after reperfusion may lead to graft failure. The aim of this study is to investigate the relationship between the factors, which were supposed to affect the oxygen supply to the graft, and the oxygenation state of the graft in order to determine which factor is important to prevent the graft from dysoxia.

MATERIALS AND METHODS

The relationship between oxygen supply and oxygenation state of the graft was investigated in 56 successful cases of living related liver transplantation. Factors affecting the oxygen supply to the graft were considered as follows; portal venous flow (PVF), mean velocity of the hepatic artery (HA-Vm), hemoglobin concentration in the peripheral blood (Hb), size of the graft liver relative to the recipient body weight (G/R ratio), partial oxygen pressure in the arterial blood (PaO2), and rate-pressure product (BP*PR). Oxygenation state of the graft was estimated by oxygen saturation of hemoglobin in the graft tissue (graft SO2) as measured by tissue near infrared spectroscopy.

RESULTS

1) Graft SO2 was rather independent of PVF and HA-Vm probably due to compensatory interrelation between the portal venous flow and hepatic arterial flow. 2) Significant correlation between G/R ratio and graft SO2 was observed after portal reflow (p < 0.01), but the correlation diminished after hepatic arterial reflow. Positive correlation between G/R ratio and AKBR after portal reflow suggested that the graft with large G/R ratio is likely to suffer dysoxia early after reperfusion. 3) Graft SO2 was positively correlated with Hb (p < 0.05), while there was no significant correlation between graft SO2 and PaO2 or BP*PR.

CONCLUSION

This study clarified the contribution of the factors which were supposed to affect the oxygen supply to the graft and the oxygenation state of the graft, and which factor is important to prevent the graft from dysoxia.

Induction of endotoxin tolerance in transgenic mouse liver expressing creatine kinase

The liver plays an important role in maintaining homeostasis during endotoxin-triggered systemic inflammatory response. To study the effects of phosphocreatine on hepatic energy metabolism after endotoxin administration, we used transgenic mice whose livers express creatine kinase (CK). CK catalyzes a phosphocreatine/creatine reaction, that is, an adenosine triphosphate (ATP) reservoir system. Because dietary supplementation with creatine leads to an accumulation of creatine and phosphocreatine in transgenic livers, we compared the CK transgenic mice fed with creatine with the normally fed CK transgenic mice. In the creatine-fed mice, hepatic ATP, energy charge ([ATP + 0.5 adenosine diphosphate (ADP)]/[ATP + ADP + adenosine monophosphate (AMP)]), and mitochondrial oxidative phosphorylation activities remained at high levels after injection of 10 mg/kg of lipopolysaccharide (LPS) as compared with those in normally fed mice. Furthermore, there were beneficial effects on the functional reserve for ATP synthesis and work-cost performance, as calculated by free cytoplasmic ADP and the Michaelis constant (Km). Interestingly, a reduction of tissue necrosis factor alpha and interleukin-lalpha (IL-lalpha), and suppression of the decrease in glucose levels after LPS injection were observed in the creatine fed mice. Survival rates at 72 hours after injection of 10 mg/kg of LPS significantly increased in the creatine fed mice compared with the normally fed mice (80% vs. 24%, P < .001). Therefore, we concluded that the presence of phosphocreatine in the liver maintains energy metabolism and attenuates cytokine response, resulting in endotoxin tolerance.

Anatomical and physiological problems of Segment IV: liver transplants using left lobes from living related donors

We reviewed the problem of Segment IV in using left lobes from living related donors, in 18 left-lobe transplants performed on pediatric patients who ranged in age from 6.0 to 17.3 yr, and in body weight from 19.8 to 58.0 kg. The separate monitoring of oxygen saturation of hemoglobin in the liver sinusoid of segments, using a spectrophotometric technique, demonstrated a delay in re-oxygenation of Segment IV after the portal reflow, and revealed its return to comparable oxygenation with Segments II and III by the re-arterialization. Hemoglobin content, which was determined by the same technique, occasionally increased in Segment IV during the operation, implying sluggish microcirculation caused by inadequate hepatic venous drainage. These characteristic profiles on tissue oxygenation and hemodynamics in Segment IV should be considered when using left lobes as living related liver grafts.

Focal liver hyperplasia in Alagille syndrome: assessment with hepatoreceptor and hepatobiliary imaging

A child with Alagille syndrome, characterized by intrahepatic bile duct paucity, developed severe liver cirrhosis and was referred for liver transplantation. In the pre-transplantation evaluation, scintigraphic scans were performed using 99mTc-galactosyl serum albumin (99mTc-GSA) as a hepatoreceptor binding agent and 99mTc-pyridoxyl-5-methyl-tryptophan (99mTc-PMT) as a hepatobiliary agent. These studies demonstrated severe hepatobiliary dysfunction with an area of increased focal uptake in the liver. Histological examination at surgery confirmed that this focal lesion was an area of compensatory hyperplasia in advanced biliary cirrhosis. We present the usefulness of these tracers for detecting the focal hyperplasia of the liver.

A polysaccharide fraction of Zizyphi fructus in augmenting natural killer activity by oral administration

Shosaiko-to (Xiao-chai-hu-tang, SHO), a Kampo medicine, was prepared by decocting a prescription of 7 kinds of crude drugs, namely Bupleuri Radix, Pinelliae Tuber, Scutellariae Radix, Zizyphi Fructus, Ginseng Radix, Glycyrrhizae Radix and Zingiberis Rhizoma. Previously, we reported that the effect of the orally administered SHO in augmenting natural killer (NK) activity in the peripheral blood was attributed to the acidic polysaccharide fraction. To characterize the active components in the crude materials in SHO, the effects of extracts and various fractions were investigated by oral administration. The extracts of Zizyphi Fructus, Zingiberis Rhizoma, Scutellariae Radix, Glycyrrhizae Radix and Pinelliae Tuber augmented NK activity by oral administration. The high weight molecular fraction of Zizyphi Fructus was the most effective in augmenting NK activity. Thus, we obtained an active polysaccharide fraction from the high weight molecular fraction of Zizyphi Fructus. This polysaccharide fraction with a high molecular weight of approximately 43,000 contained 54.7% carbohydrate, 61.8% uronic acid and 20.9% protein. The sugar moiety was composed of rhamnose, arabinose, xylose, fucose, mannose, galactose, glucose and galacturonic acid in molar ratios of 28:59:11:9:7:32:20:100.

Living related liver transplantation for children younger than one year old

Living related liver transplantation (LRLT) is an effective modality to overcome the donor shortage in small children. We evaluated the safety of LRLT in case of recipients younger than 1 year of age.

PATIENTS AND METHODS

In 149 children who underwent LRLT, 44 were younger than 1 year. Original diagnosis were biliary atresia (42) and metabolic disorder (2). The body weight ranged from 3.1 to 9.3 kg. Preoperative risk factors, technical innovations, and survival rate were reviewed in comparison with those of older children.

RESULTS

Encephalopathy and respiratory disturbance due to massive ascites or bronchotracheal malacia were leading risk factors which demanded ICU care preoperatively. In reconstruction of the portal vein venous graft was necessary more often in infants than in the older children. Incidence of vascular complications was not higher in infants than in the older children. Biliary complications were more frequent in the infants. Survival rate was 81.9%, which was comparable to that of the older recipients. Incidence of rejection and infection was not different between the infants and the older children.

CONCLUSION

LRLT in recipients younger than 1 year can be safely done with some precautions.

Helicobacter pylori cagA gene and expression of cytokine messenger RNA in gastric mucosa

BACKGROUND & AIMS

Helicobacter pylori strains possessing the cagA gene are thought to be associated with gastroduodenal diseases. Furthermore, some cytokines are considered to play a role in gastric mucosal inflammation. The aim of this study was to investigate the relationship between cagA gene and cytokine messenger RNA (mRNA) expression in gastric mucosa.

METHODS

In 160 patients, the cagA gene was detected using polymerase chain reaction, and interleukin (IL) 1 beta, IL-6, IL-7, IL-8, IL-10, and tumor necrosis factor (TNF) alpha mRNA were detected using reverse-transcription polymerase chain reaction.

RESULTS

Specimens infected with cagA gene-positive strains (cagA-positive specimens) had significantly more severe infiltration of polymorphonuclear leukocytes and mononuclear cells than those infected with cagA gene-negative strains (cagA-negative specimens). Levels of expression of IL-6, IL-7, IL-8, IL-10, and TNF-alpha mRNA were significantly higher in H. pylori-positive than H. pylori-negative patients. Furthermore, the level of IL-8 mRNA expression was significantly higher in cagA-positive than cagA-negative specimens.

CONCLUSIONS

cagA-positive strains induce the expression of IL-8 mRNA, suggesting that IL-8 may play important roles in the pathogenesis of gastroduodenal diseases associated with H. pylori infection.

Evaluating the significance of HLA class II genotype matching in living-related liver transplantation

To evaluate the clinical significance of HLA class II matching in living-related liver transplantation, the genotypes of HLA class II including DPB1 were determined by the PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) method and their matching was compared to the postoperative course. Conventional serotypes included 15.6% and 13.6% errors in DR and DQ, respectively. Among 42 consecutive cases that were followed up over 1 year after transplant, rejection occurred in seven cases. There was no correlation between the matching for each locus and the frequency of rejection episodes. In this study, rejection-free cases were investigated in terms of the potency of immunosuppressive therapy and graft function during 1 year after operation. The doses of tacrolimus in unmatched cases tended to be larger than those in matched cases for every locus except for DQA1. Its trough levels in matched cases were lower than those in unmatched cases, especially at 9-12 months after operation for DRB1 (p < 0.05). The termination of steroid administration tended to be postponed in unmatched cases for every locus. Serum levels of asparatan transaminase, alanine transaminase gamma-glutamyltranspeptidase (gamma-GTP) and total bilirubin were generally lower in matched cases than in unmatched ones for DRB1, DQB1 and DPB1, while in DQA1 the tendency was the opposite, especially total bilirubin and gamma-GTP, which were p < 0.02 and p < 0.05, respectively, at 6 months after operation. Investigation of subclinical immune responses other than rejection episodes showed that DRB1, DQB1 and DPB1 matching had a beneficial effect on graft function, while DQA1 matching seemed to have a varied effect.

Significance of nucleosides and a nucleotide mixture infusion on hepatic energy metabolism of 70% hepatectomized rabbits in postoperative phase

BACKGROUND

The influence of administration of a nucleoside-nucleotide mixture on hepatic energy metabolism was investigated in 70% hepatectomized rabbits from 48 to 72 hours after hepatectomy.

METHODS

From 48 to 72 hours after hepatectomy, animals underwent continuous i.v. infusion of 2 mL/kg body weight/h of 9 g/L NaCl (group S), 5.99 mmol/L nucleoside-nucleotide mixture (group N1) or 11.98 mmol/L nucleoside-nucleotide mixture (group N2).

RESULTS

At 72 hours, there was no significant difference in the hepatic adenylate energy charge among groups (S, 0.84 +/- 0.01; N1, 0.82 +/- 0.02; N2, 0.85 +/- 0.01). The hepatic mitochondrial phosphorylation rate was 66.9 +/- 2.5, 76.3 +/- 11.1, and 108.4 +/- 14.1 nmol ATP/mg mitochondrial protein/min in groups S, N1, and N2, respectively. The value of group N2 was significantly higher than the value of group S (p < .01). In addition, DNA concentration of the remnant liver was 2.27 +/- 0.07, 2.56 +/- 0.17, and 3.19 +/- 0.42 mg/g wet liver in groups S, N1, and N2, respectively, showing a significant increase in group N2 compared with group S (p < .05).

CONCLUSION

A continuous i.v. infusion of a nucleoside-nucleotide mixture to 70% hepatectomized rabbits from 48 to 72 hours after hepatectomy prolonged an enhancement of the hepatic mitochondrial phosphorylation rate and elevated DNA content of the remnant liver.

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1%) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant liver, which was the only post-operative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preoperative screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.

Implications of surgical treatment for advanced hepatocellular carcinoma with tumor thrombi in the portal vein

BACKGROUND/AIMS

Highly extended liver surgery for advanced hepatocellular carcinoma with tumor thrombi in the portal vein was reconfirmed from the viewpoint of the risk of operation, actual effect on prolongation of the life time, and the beneficial effects.

MATERIAL AND METHODS

Sixty-two hepatocellular carcinoma (HCC) patients with tumor thrombi in the trunk or first branch of the portal vein (PV thrombi) were surgically treated by hepatic resection with removal of the PV thrombi and by postoperative transcatheter arterial embolization (TAE), while 38 HCC patients with PV thrombi were conservatively treated due to deleterious liver function and/or extensive spread of carcinoma.

RESULTS

The mean and median survival time of 44 patients who were surgically treated and survived more than 60 POD were 900.5 and 305 days, respectively. By contrast, these values in 38 conservatively treated patients were 199.6 and 90 days, respectively. The extended surgical operation had few serious adverse effects on biochemical functions of the liver and beneficial effects on portal hypertension and related hypersplenism.

CONCLUSIONS

Although the most critical problems were postoperative liver failure and early recurrence, extended surgical treatment should be encouraged for the prolongation of life span and quality of life, when HCC are relatively small and the remnant liver is normal or only fibrotic.