Microcystin analysis in human sera and liver from human fatalities in Caruaru, Brazil 1996

In 1996, an extensive exposure of Brazilian hemodialysis patients at a dialysis center, using a municipal water supply water contaminated with cyanotoxins, provided the first evidence for acute lethal human poisoning from the cyclic peptide hepatotoxins called microcystins. During this outbreak, 100 of 131 patients developed acute liver failure and 52 of these victims were confirmed to have been exposed to lethal levels of microcystins. Detection and quantitation of microcystins in these biological samples posed some analytical challenges since there were no well-established and routine analytic methods to measure total microcystins in tissue or sera samples. At the time of the 1996 exposure we used analytic methods that combined the use of enzyme linked immunosorbant assay (ELISA), analytical high performance liquid chromatography (HPLC), electrospray ionization ion-trap mass spectroscopy (ES-ITMS) and matrix assisted laser desorption ionization-time of flight spectroscopy (MALDI-TOF). In the intervening years these methods have been improved and others developed that allow a more quantitative and critical analysis of microcystin contaminated tissue and sera. For these reasons, and to see how storage with time might effect the detection and stability of microcystins in these matrices, we reanalyzed selected liver tissues and sera from the Caruaru victims in Brazil. We developed and validated a procedure to measure total microcystins in Caruaru human sera and liver tissue using a combination of ELISA, liquid chromatography and liquid chromatography-mass spectrometry (LC/MS), GC/MS and MS/MS techniques. GC/MS and LC/MS were followed by MS/MS to obtain a fingerprint fragment spectra for the microcystins. The validity of the extraction procedure for free microcystins was confirmed by recovery experiments with blood sera spiked with microcystin-LR. We removed proteins with the Microcon Centrifugal Filter prior to LC/MS and ELISA analysis. A solid phase extraction (SPE) procedure was used for analysis of protein bound microcystins by conversion of ADDA to erythro-2-methyl-3-methoxy-4-phenylbutyric acid (MMPB) combined with GC/MS. We found that the GC/MS method yielded a higher concentration of microcystin than that obtained by ELISA and LC/MS. We hypothesize that this difference is due to better GC/MS detection of the covalently bound form of microcystins in human liver tissue. We also concluded that microcystins are very stable when stored under these conditions for periods of almost 10 years.

Acute hepatic failure and coagulopathy associated with xylitol ingestion in eight dogs

CASE DESCRIPTION

8 adult dogs were evaluated for treatment of lethargy and vomiting after ingestion of xylitol, a sugar alcohol used as a sweetener in various products.

CLINICAL FINDINGS

In addition to vomiting and lethargy, 5 of the dogs had widespread petechial, ecchymotic, or gastrointestinal tract hemorrhages. Common clinicopathologic findings included moderately to severely high serum activities of liver enzymes, hyperbilirubinemia, hypoglycemia, hyperphosphatemia, prolonged clotting times, and thrombocytopenia. Necropsies were performed on 3 dogs and severe hepatic necrosis was found in 2. In the third dog, histologic examination revealed severe hepatocyte loss or atrophy with lobular collapse.

TREATMENT AND OUTCOME

Treatments varied among dogs and included IV administration of fluids; plasma transfusions; and, if indicated, administration of dextrose. Three dogs were euthanatized, 2 dogs died, 2 dogs made a complete recovery, and 1 dog was recovering but was lost to follow-up.

CLINICAL RELEVANCE

Although xylitol causes hypoglycemia in dogs, hepatic failure after ingestion has not previously been reported. Because an increasing number of consumer products contain xylitol, clinicians should be aware that ingestion of xylitol can have serious, life-threatening effects.

[Survival analysis on liver failure patients treated with an artificial liver support system]

OBJECTIVE

To evaluate the efficacy of artificial liver support system (ALSS) in the treatment of liver failure patients.

METHODS

This is a prospective, multi-center, controlled, large sample clinic trial. 518 patients with liver failure from 5 hospitals were studied and followed. All the patients received similar pharmacological manipulation according to one and the same protocol but were divided into an ALSS treatment group and a control group without ALSS treatment. The ALSS treatment procedures included plasma exchange, molecular adsorbent recirculating system (MARS), plasma exchange plus hemofiltration and other combined nonbioartificial methods. The analysis of survival time was computed using the Kaplain-Maier method, and comparison among groups was done using Log-Rank, Breslow and/or the Tarone-Ware test.

RESULTS

Survival time of acute liver failure patients was prolonged from 4.0+/-0.2 days to 8.0+/-0.4 days (P=0.004). ALSS was shown to be two times more effective. ALSS increased the survival time of acute on chronic (A on C) liver failure patients from 27.0+/-1.6 days to 39.0+/-4.0 days (P less than 0.01). In addition, it increased the survival time of the patients in the middle and end stage of subacute liver failure and A on C liver failure, but had no significant effects on early stage patients. The survival time of middle stage patients was 38.0+/-17.5 days in the control group vs 66.0+/-18.6 days in the ALSS group (P less than 0.05). The survival time of end stage patients of the control group and the ALSS group was 18.0+/-4.0 days vs 26.0+/-2.5 days (P less than 0.01).

CONCLUSIONS

Multi ALSS treatment is more effective than the standard medicinal liver care treatment. Multi-ALSS treatment could increase survival time of patients suffering from acute liver failure or A on C liver failure, especially in their middle and end stages. It is important and necessary to treat these patients with ALSS.

Cryptogenic fulminant hepatic failure in infancy: report of 2 cases with unique vascular obstructive changes in native livers

Although the causes of fulminant hepatic failure (FHF) remain cryptogenic in many cases, a few reports have reviewed the pathological findings of native livers to evaluate the etiology. We report 2 cases of infantile cryptogenic FHF with unique vascular obstructive changes in the native livers. Clinically, it was notable that these 2 patients developed FHF very early in life, at 2 months and 5 months of age, respectively. One patient died from chronic rejection associated with hepatic veno-occlusive disease 4 months after transplantation. Histologically, hepatocytes in the native livers were completely destroyed in both patients, and vascular findings revealed obstruction of central veins in 1 patient and obstruction of portal veins in the other patient. Although the pathogenesis of vascular obstructions is not yet understood, this study suggests that an obstructive vascular event may be a contributing etiologic factor of FHF in infancy.

Intensive care unit management of fulminant hepatic failure

OBJECTIVE

The aim of this open/retrospective study was to evaluate the outcomes of intensive care unit patients treated for fulminant hepatic failure (FHF) for predictive indices.

METHODS

All patients were recovered in the intensive care units with a diagnosis of FHF. We considered three groups of patients: (1) survivors, deceased, and transplanted.

SUBJECTS

All patients were fully screened, including liver function indices such as AST, ALT, total and bound bilirubin, albumin and pre-albumin, factors 5 and 7, alpha fetal protein (alpha-PP), other coagulation tests (PT, aPTT, INR, ATIII), and renal function (BUN and creatinine) parameters. For each patient Apache II score was calculated upon admission to the intensive care unit.

RESULTS

Apache II score showed efficacy. alpha-PP increased in both surviving and deceased, but not in the transplanted group. After intensive care unit admission, AST and ALT peaks were higher in the deceased DP than in the transplanted group. The INR value at the third day after ICU admission improved in the survivors compared with the other two cohorts. Factor 5 levels were lower among patients undergoing transplantation, but increased in the other two groups. The prognosis was strictly dependent upon the development of renal failure.

CONCLUSION

The Apache II score was a sensitive predictive index for outcome. alpha-PP and factor 5 were not related to outcome, but useful for decision making when determining potential liver transplantation. INR can be used as a prognostic index. Intensive treatment beforehand is of primary importance to prevent multiple organ failure.

Utility of the MAYO End-Stage Liver Disease score, King's College Criteria, and a new in-hospital mortality score in the prognosis of in-hospital mortality in acute liver failure

INTRODUCTION

Several prognostic scores attempt to aid in the selection of patients with acute liver failure (ALF) to be treated either medically or by liver transplantation; however, their lack of fulfillment does not predict spontaneous survival in ALF and refined prognostic criteria are needed to improve such selection. Our aim was to evaluate and compare a new ALF in-hospital mortality prediction score versus King's College Criteria (KCC) and model for End-Stage Disease (MELD) score.

METHODS

First-time ALF-diagnosed individuals admitted to our institution (n = 58) were grouped according their final outcome as "alive" or "death," and those significantly different variables between groups entered into a logistic regression and lineal regression models. An ALF in-hospital mortality score (ALFIHMS) was produced and its sensitivity, specificity, and area under receiver operator characteristics were compared with those of KCC and MELD scores.

RESULTS

Since no significant differences (P = .81) in mortality rates between fulminant and subfulminant hepatic failure were found, no further analysis according to ALF's classification was performed. After obtaining and comparing ALFIHMS with KCC and MELD, we found that ALFIHMS prediction accuracy is higher than that of KCC and MELD score and that an ALFIHMS cutoff point >15 points is associated with an in-hospital mortality probability >50%.

CONCLUSIONS

ALFIHMS has higher prognostic accuracy than KCC and MELD scores in ALF.

Dengue virus infection: a major cause of acute hepatic failure in Thai children

BACKGROUND

Acute hepatic failure (AHF) can be caused by a variety of viruses, drugs, toxins and metabolic disorders.

AIMS

A prospective study was conducted to determine the aetiology and outcome of AHF in Thai children aged 1-15 years.

METHODS

All serum samples were tested for anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HCV, anti-HEV IgM and anti-dengue IgG and IgM. Further individual investigations were done according to the clinical impression.

RESULTS

Forty subjects were enrolled from 14 centres during February 2000 to December 2001. Five cases were excluded owing to a lack of evidence of encephalopathy. The causes of AHF were dengue infection in 12 (34.3%), Wilson disease in 2 (5.7%), T-cell lymphoma in 2 (5.7%), ischaemic hepatitis in two (5.7%), haemophagocytic syndrome in one (2.8%), CMV in 2 (5.7%), Reye syndrome in one (2.8%) and unknown in 13 (37.1%) patients. The fatality rate was 68.6%. Eight of 24 (33.3%) deaths were caused by dengue infection.

CONCLUSIONS

Improvements in sanitation and socio-economic status as well as the implementation of hepatitis B vaccine in the Extended Programme on Immunization (EPI) are likely to be the reasons for the observed absence of AHF caused by hepatitis A and B. The study showed that dengue infection, on the other hand, was a major cause of AHF in Thailand.

Predictors of fatal outcome in fulminant hepatic failure

OBJECTIVE

To determine prognostic indicators for morbidity and mortality in patients with fulminant hepatic failure.

DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from April 2003 to June 2005.

PATIENTS AND METHODS

Forty five patients with confirmed diagnosis of fulminant hepatic failure were included in this study. They were investigated for acute viral serology, complete blood count, liver function tests, renal function tests, serum electrolytes, arterial blood gases, initially daily and then on alternate days. Patients were followed in high dependency/ICU at the Shaikh Zayed Postgraduate Medical Institute. Data were analyzed by logistic regression analysis to identify predictors of mortality and morbidity.

RESULTS

Of the 45 subjects, 31 were males and 14 females. Twenty four patients were positive for acute hepatitis E. Twenty patients recovered fully, whereas 25 died with mortality rate of 55.6 %. Variables i.e. presence of non-A non-B viral hepatitis, serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis were found to have significant association with mortality on linear correlation. Only serum creatinine more than 2.0 mg/dl, serum phosphate > 3.5 mg/dl and development of sepsis were found to predict the outcome after multivariate analysis.

CONCLUSION

Patients with serum creatinine > 2.0 mg/dl, serum phosphate > 3.5 mg/dl and sepsis showed adverse prognosis for survival.

The effects of Gingko biloba, vitamin E and melatonin on bacterial translocation in thioacetamide-induced fulminant hepatic failure in rats

BACKGROUND AND STUDY AIMS

Bacterial translocation (BT) has been implicated in the development of infectious complications in many serious clinical conditions such as fulminant hepatic failure (FHF). We aimed to investigate the effects of Gingko biloba (GB), vitamin E (Vit E) and melatonin on intestinal oxidative damage and BT in thioacetamide (TAA)-induced FHF in rats.

MATERIALS AND METHODS

A total of 42 rats were divided into five groups. Group 1 (n = 8) was the control group. Group 2 (n = 10) was the TAA group, in which rats received 350 mg/kg TAA daily by the intraperitoneal (ip) route for 3 days. Oral 100 mg/kg GB per day was administered to group 3 (n = 8), oral 200 mg/kg Vit E per day to group 4 (n = 8) and ip 3 mg/kg melatonin per day to group 5 (n = 8) 48 h prior to the first TAA injection and was continued for 5 consecutive days.

RESULTS

When compared with the control group, serious hepatic and intestinal oxidative damage, increased Escherichia coli counts in ileal aspirates and high BT frequencies were observed in the TAA group (all p < 0.0001). Only GB treatment attenuated hepatic oxidative damage (p < 0.0001). There was no difference in intestinal oxidative damage, E. coli counts in ileal aspirates and BT frequency between TAA and the other antioxidant treatment groups (p > 0.05).

CONCLUSION

Our results suggest that intestinal oxidative damage plays a major role in the development of BT by disrupting the barrier function of intestinal mucosa.

Fulminant hepatic failure associated with the use of black cohosh: a case report

With data from the Women's Health Initiative indicating that estrogen plus progesterone are associated with an increased risk of cardiovascular events, many patients and practitioners are looking for alternative therapies to manage menopausal symptoms. One alternative is black cohosh, an herbal product used primarily to treat these symptoms. In recent years there have been several case reports associating this substance with hepatitis and fulminant hepatic failure. We present a case of a woman who developed hepatic failure requiring liver transplantation from the use of this herb.

The use Prometheus FPSA system in the treatment of acute liver failure: preliminary results

The preliminary outcomes of patients with acute liver failure treated with the Prometheus Fractionated Plasma Separation and Absorption (FPSA) system are presented herein.

PATIENTS AND METHODS

The procedures were performed in 13 patients (4, intoxication by Amanita phalloides; 4, unknown reason; 3, acetaminophen intoxication; 1, Wilson disease, and 1, liver insufficiency after hemihepatectomy owing to metastases of colon adenocarcinoma). The patients were qualified for the procedure according to the King's College Hospital criteria. The patients' general status was assessed on basic of GCS, UNOS, and the 4-grade encephalopathy classifications. The procedures were performed with the Prometheus 4008H Fresenius Medical Care unit.

RESULTS

The 29 procedures were of mean duration 6.5 hours. There were statistically significant reductions in total bilirubin, ammonia, and aminotransferase levels. In addition, the procedures corrected water, mineral, and carbohydrate disorders. One patient did not require liver transplantation. Seven patients received liver transplants: three patients with positive outcomes; two died due to septicemia within 30 days perioperatively, one died at 6 months after OLT owing to respiratory failure; and one, owing to hemorrhagic diathesis. Four patients did not receive a liver transplant because of lack of a organ, no consent for the surgery, or neoplastic disease with metastases.

CONCLUSIONS

The Prometheus FPSA-System was an effective detoxication method for patients with acute liver failure. The system was useful as a symptomatic treatment before liver transplantation allowing a longer wait for a graft.

[Surveillance of viral hepatitis: laboratory results. Cuba, 1992-2004]

The results of the surveillance of the viral hepatitis in the period 1992-2004 are presented. The HAV infection is the most frequent association that originates pictures of acute viral hepatitis among the patients under 24 years old with positive HBsAg, followed by the hepatitis B virus. The hepatitis A virus alone or co-infected with the hepatitis B virus accounts for 48.88% of the cases. Only 48.71% of the cases among whom acute hepatitis B is suspected, are confirmed from the virological point of view. These results allow to go deep into the knowledge of the behaviour of hepatitis viruses under the Cuban conditions, making possible to establish better strategies for the control or elimination of viral hepatitis, or both.

Treatment of surgically induced acute liver failure by transplantation of HNF4-overexpressing embryonic stem cells

OBJECTIVE

Tissue-specific stem cells from differentiating embryonic stem (ES) cells are both pluripotent and genetically flexible. Recent observations indicate that ES cells can differentiate into hepatocytes. Therefore, cell-based therapy can potentially be a therapeutic alternative to liver transplantation. In this study the treatment of acute liver failure in rats by transplantation of hepatocyte nuclear factor 4 (HNF4)-overexpressing ES cells was investigated.

METHODS

The HNF4 was transfected into ES cells and ES cell clones overexpressing HNF4 were selected. The levels of markers of hepatocyte differentiation, including albumin, transthyretin, glucose-6-phosphates (G-6-P) and SAPK/ERK kinase-1 (SEK1) mRNA, were tested in spontaneously differentiated HNF4-overexpressing ES cells by reverse transcription-polymerase chain reaction (RT-PCR). The ultrastructure of the spontaneously differentiated HNF4-overexpressing ES cells was examined by electron microscopy. To induce acute liver failure, Sprague-Dawley rats were subjected to 90% hepatectomy and given 5% oral dextrose. The rats were divided into three groups. The rats in the treatment group (n = 12) received intraliver injection of 2 x 10(7) undifferentiated HNF4-overexpressing ES cells from the same clone, the rats in control group 1 (n = 12) received 2 x 10(7) undifferentiated ES cells, and the rats in control group 2 (n = 12) received the same volume of media without any cells.

RESULTS

All rats in control group 1 and control group 2 died within 72 h, while 33% of rats that received undifferentiated HNF4-overexpressing ES cells transplantation survived more than 1 month. Spontaneously differentiated HNF4-overexpressing ES cells only expressed transthyretin mRNA. The cells were rich in mitochondrion and catalase-containing peroxisomes in ultrastructure.

CONCLUSIONS

Transplantation of ES cells could be a potential treatment in supporting life during acute liver insufficiency and could be a bridge to orthotopic liver transplantation.

[Specific therapy in acute liver failure]

Acute liver failure is defined as hepatic insufficiency (icterus and coagulopathy), hepatorenal syndrome and encephalopathy, associated with a high mortality. A number of conditions can cause this sudden severe liver failure, which finally triggers a multi-organ response. Its etiology shows considerable geographic variation, with viral hepatitis being the most common cause worldwide, whilst drugs, especially acetaminophen-induced hepatotoxicity, form the most common precipitant in many developed countries. The essential feature of a wide variety of agents is apoptosis and/or necrosis of liver cells which is associated with liver injury and insufficiency. Based on new experimental data, the identification of target molecules involved in apoptosis may offer new therapeutic options and improvement of prognosis scores in patients with acute liver failure.

Salvage effect of the vascular endothelial growth factor on chemically induced acute severe liver injury in rats

BACKGROUND/AIMS

The role of the vascular endothelial growth factor (VEGF), a potent angiogenic factor, in liver regeneration following acute severe liver injury (ALI) has not been elucidated. The aims of the current study were to investigate the role of VEGF, and to find out whether VEGF can improve the outcome of ALI in rats.

METHODS

ALI was induced in male rats by combination of D-galactosamine (Gal-N) and lipopolysaccharide (LPS). The survival rate and several indices were chronologically compared with or without VEGF treatment.

RESULTS

The overall survival rate of the VEGF-treated group significantly improved as compared with the untreated group (100 vs. 27%, respectively). The serum ALT elevation, with a peak at 24 h after Gal-N+LPS intoxication, was markedly attenuated with VEGF treatment. The proliferation of hepatocytes and sinusoidal endothelial cells (SEC) was stimulated by VEGF with a peak at 36 and 96 h, respectively. The immunohistochemical analysis revealed that VEGF drastically prevented destruction of the SEC architecture in ALI. Our in vitro study showed that VEGF significantly prevented the Gal-N+LPS-induced cytotoxicity and apoptosis of SEC.

CONCLUSIONS

VEGF treatment significantly reduced the mortality rate of ALI in the rat, and it may provide a new therapeutic strategy for ALI.

[Clinical features of fulminant hepatic failure in a tertiary hospital with a liver transplant center in Korea]

BACKGROUND/AIMS

Striking geographic differences have been noted in the etiology of fulminant hepatic failure (FHF). The prognosis of patients with FHF who do not receive liver transplantation in a timely manner is quite dismal. This study intended to identify the etiology and outcome of FHF in Korean adults and to examine the role of urgent living-donor liver transplantation (LDLT) for treating this unique situation.

METHODS

We identified all the adult FHF patients who were referred to our unit between 1999 and 2004. FHF was defined as severe acute hepatitis complicated by the rapid development of hepatic encephalopathy within 8 weeks of the initial symptoms in the patients without a previous history of liver disease.

RESULTS

One hundred fourteen patients (47 males and 67 females) were identified. The mean age was 39.5+/-15.3 years. Drugs were the most common cause (28.1%) of FHF (herbal medications, 9.6%), and acute viral infection accounted for 23.7% (HBV accounted for 15.8%). Indeterminate etiologies were noted in 34%. The 90-day survival rate of the nontransplant group was only 15%. Fourteen patients received liver transplants (13 right-lobe LDLT, 1 cadaveric whole liver), and 12 of these (85.7%) survived and showed good graft function during 22 months of median follow-up.

CONCLUSIONS

Although the causes of FHF in Korea were diverse, HBV infection and herbal medications were responsible for a significant proportion of the cases. Since urgent LDLT improved the overall survival rate of patients with FHF, this should be considered as an important treatment option for patients suffering with FHF.

Neonatal herpes simplex virus infection presenting as acute liver failure: prevalent role of herpes simplex virus type I

BACKGROUND

Acute liver failure (ALF) in neonates is rare but carries a high mortality without liver transplantation. Herpes simplex virus (HSV) is one of the microbes that more commonly causes ALF and is potentially treatable; hence, early diagnosis and treatment are important to avoid progression to liver failure.

PATIENTS AND RESULTS

We have analysed retrospectively the case notes of 11 patients with HSV-induced ALF. A history of possible herpes infection was elicited in 5 parents, but HSV had not been suspected clinically. All patients were asymptomatic when discharged from postnatal units and were presented with nonspecific symptoms of poor feeding and lethargy within 2 weeks from birth. Seven of the 11 patients had HSV-1 infection, 4 HSV-2. Only 2 patients who received early treatment with intravenous acyclovir survived.

CONCLUSIONS

HSV-related ALF in the neonatal period carries high morbidity and mortality and needs a high index of suspicion so that life-saving treatment can be started promptly. Both HSV-1 and HSV-2 can cause severe neonatal infection. It is important to recognise HSV infection in women of childbearing age and their sexual partners.

Risk stratification of adult patients undergoing orthotopic liver transplantation for fulminant hepatic failure

BACKGROUND

Orthotopic liver transplantation (OLT) is an effective treatment for fulminant hepatic failure (FHF), but postOLT mortality is higher for patients with FHF than for patients with other indications for OLT. In the current study, a large cohort of patients who underwent OLT for FHF was evaluated to develop and validate a system useful for estimating postOLT patient survival.

METHODS

The 1,457 patients who underwent OLT for FHF in the United States between 1988 and 2003 were enrolled through the UNOS database. This group was divided into a modeling group (n=972) and a crossvalidation group (n=486). With a multivariate regression analysis, the modeling group was used to identify clinical parameters that had a significant association with postOLT survival. This regression analysis was used to create a scoring system that was subsequently assessed in the crossvalidation group.

RESULTS

Four risk factors were identified with the multivariate analysis: 1) body mass index > or = 30 kg/m2; 2) serum creatinine > 2.0 mg/dL; 3) recipient age > 50 years old; and 4) history of life support. By assigning points based on the number of risk factors present, the scoring system was able to differentiate between low-risk patients (5-year survival, 81%) and high-risk patients (5-year survival, 42%). The relative risk of postOLT mortality increased by approximately 150% for each additional point.

CONCLUSION

The scoring system risk-stratified the crossvalidation group and accurately predicted postOLT survival. A scoring system utilizing clinical and demographic information readily available prior to OLT may help predict the probability of survival after OLT for FHF.

Catholic university experience with molecular adsorbent recycling system in patients with severe liver failure

BACKGROUND AND AIM

Molecular adsorbent recycling system (MARS) treatment is able to remove both hydrosoluble and small- and medium-sized lipophilic toxins. MARS plays an important role in modifying liver failure complications, such as hepatorenal syndrome and hepatic encephalopathy. We sought to evaluate the clinical efficacy and safety of a MARS device in a consecutive series of hepatic failure patients.

MATERIALS

Twenty patients with acute liver failure, transplantation failure, or acute on chronic liver failure fulfilled the inclusion criteria of total bilirubin > or =10 mg/dL and at least one of the following: hepatic encephalopathy (HE) > or =II grade, hepatorenal syndrome (HRS) for chronic patients or total bilirubin > or =5 mg/dL and HE > or =I grade for acute patients.

RESULTS

MARS was able to reduce cholestatic parameters and improve neurologic status and renal function parameters in all treated patients. We also observed an improvement in the 3-month survival rate compared to the expected outcome in patients with MELD scores between 20 and 29, as well as 30 and 39.

CONCLUSIONS

Based on these results, we confirm the safety and clinical efficacy of MARS treatment, with the best results in patients with MELD score of 20 to 29. Further studies are necessary to confirm whether this treatment is able to modify patient outcomes and prognosis.

Effect of albumin dialysis on intracranial pressure increase in pigs with acute liver failure: a randomized study

BACKGROUND

Increased intracranial pressure (ICP) worsens the outcome of acute liver failure (ALF). This study investigates the underlying pathophysiological mechanisms and evaluates the therapeutic effect of albumin dialysis in ALF with use of the Molecular Adsorbents Recirculating System without hemofiltration/dialysis (modified, M-MARS).

METHODS

Pigs were randomized into three groups: sham, ALF, and ALF + M-MARS. ALF was induced by hepatic devascularization (time = 0). M-MARS began at time = 2 and ended with the experiment at time = 6. ICP, arterial ammonia, brain water, cerebral blood flow (CBF), and plasma inflammatory markers were measured.

RESULTS

ICP and arterial ammonia increased significantly over 6 hrs in the ALF group, in comparison with the sham group. M-MARS attenuated (did not normalize) the increased ICP in the ALF group, whereas arterial ammonia was unaltered by M-MARS. Brain water in the frontal cortex (grey matter) and in the subcortical white matter at 6 hrs was significantly higher in the ALF group than in the sham group. M-MARS prevented a rise in water content, but only in white matter. CBF and inflammatory mediators remained unchanged in all groups.

CONCLUSION

The initial development of cerebral edema and increased ICP occurs independently of CBF changes in this noninflammatory model of ALF. Factor(s) other than or in addition to hyperammonemia are important, however, and may be more amenable to alteration by albumin dialysis.

Suramin prevents fulminant hepatic failure resulting in reduction of lethality through the suppression of NF-kappaB activity

AIM

Suramin is a symmetrical polysulfonated naphthylamine derivative of urea. There have been few studies on the effect of suramin on cytokines. We examined the effects of suramin on production of inflammatory cytokines.

METHODS

We made an acute liver injury model treated with d-galactosamine (GalN) and lipopolysaccharide (LPS). Plasma AST, ALT, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-6 levels were measured. We compared with survival rate, histological found and NF-kappaB activity between with and without treatment of suramin. In macrophage like cell line, TNF-alpha and IL-6 production, TNF-alpha and IL-6 mRNA expression, and NF-kappaB activity was measured.

RESULTS

The lethality of mice administered suramin with GalN/LPS was significantly decreased compared with that in mice without suramin. Changes of hepatic necrosis and apoptosis were slight in suramin-treated mice. Serum AST, ALT, TNF-alpha, IL-6 levels and NF-kappaB activity in the liver were significantly lower in mice administered suramin. In an in vitro model, suramin preincubation inhibited TNF-alpha and IL-6 production, TNF-alpha and IL-6 mRNA expression, and NF-kappaB activity.

CONCLUSIONS

Suramin inhibits TNF-alpha and IL-6 production through the suppression of NF-kappaB activity from macrophages and shows therapeutic effects on acute liver damage.