Cellular therapies for liver replacement

Technology insight: liver support systems

Emergency orthotopic liver transplantation (OLT) is currently the only standard treatment for fulminant hepatic failure (FHF). The waiting time for transplantation can exceed a week-using a liver assist device to bridge patients with FHF to OLT might therefore decrease the mortality rate. Several liver support systems have been described, but no system has gained FDA approval or widespread clinical acceptance. Although the results of many experimental and clinical trials are encouraging, the field is still in its initial stages. Using nonbiologic liver support is based on the assumption that several toxins that cause hepatic coma can be removed from the circulation by blood or plasma sorption methods. As these toxins could be involved in many FHF complications recovery without the need for transplantation is the ultimate aim. Biologic liver support uses xenogeneic livers or hepatocytes to support the failed human liver, exploiting biological cell functions, namely detoxification, metabolism, and biosynthesis. The classical nonbiologic dialysis methods could decrease mortality in patients with acute-on-chronic liver failure, but definitive conclusions are impossible to draw because of the small number of patients studied and inadequate follow-up. Larger studies performed in specialty centers should provide conclusive data about the role of the bioartificial liver support system as a possible universal bridge to OLT. This article presents an overview of published experience with liver support systems since the 1960s.

Stem cells for the treatment of liver disease

Stem cells tantalise. They alone have the capacity to divide exponentially, recreate the stem cell compartment as well as create differentiated cells to build tissues. They should be the natural candidates to provide a renewable source of cells for transplantation. Does the reality support the promise of this exciting alternative to conventional therapies for metabolic and degenerative liver disease? Can techniques be developed to provide the large number of cells that could be required? Must there be "space" in the liver to accept the cells? To what extent is the liver immunoprivileged, and is immunosuppression necessary for stem cell therapy? Is it better to use haematopoietic stem cells, fetal stem cells, mesenchymal cells, embryonic stem cells, hepatocytes or all of the above, but for different disease indications? This paper discusses why the exploration of stem cells for the treatment of liver disease is of great potential, and delineates some of the hurdles that need to be overcome before patients see benefits from laboratory-based research into stem cell transplantation and function.

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Establishment of Highly Differentiated Immortalized Human Hepatocyte Line With Simian Virus 40 Large Tumor Antigen for Liver Based Cell Therapy

Acute liver failure and metabolic liver disorder animal models have demonstrated that hepatocytes transplanted into the liver or spleen survive and participate in the liver repopulation process, and recent studies have documented the usefulness of hepatocyte transplantation in humans. However, despite the promising cell therapy, there are still many restrictions, such as the shortage of donor human livers and the limited lifespan and the functional insufficiency of primary cultured hepatocytes. The immortalized and highly differentiated human hepatocyte could provide an unlimited supply of transplantable cells. In this study, we established an efficient and highly differentiated immortalized human hepatocyte line for bioartificial liver and hepatocyte transplantation research. Hepatocytes isolated from the liver of a 25 year old, brain dead male were transfected with pcDNA3.1 (-) recombinant plasmid containing the genes encoding simian virus 40 (SV40) large tumor antigen. One of the hepatocyte clones, HepLL, displayed highly differentiated liver functions with immortalized characteristics and was selected with a 700-300 microg/ml of G418 technique in 42 days. To characterize this immortalized cell line for cell therapy in the near future, HepLL cells were studied with immunohistochemistry, reverse transcription-polymerase chain reactions, immunoblotting, and tumorigenicity tests. The results revealed that HepLL cells displayed morphologic characteristics of liver parenchymal cells, secreted albumin, synthesized urea and glycogen, and expressed liver enriched functional markers, but there were no tumorigenic qualities after transplantation into severe combined immunodeficiency mice. Thus this immortalized human hepatocyte line is expected to be a useful tool for studying the functions of differentiated human hepatocyte and a promising strategy to resolve the shortages of donor organs and the limits of primary human hepatocyte for transplantation and bioartificial liver support systems.

Liver failure

PURPOSE OF REVIEW

Liver failure is a rare but life-threatening condition affecting a multitude of other organ systems, most notably the brain and kidneys, following severe hepatocellular injury. Liver failure may develop in the absence ('acute') or presence ('acute-on-chronic') of liver disease with substantial differences in pathophysiology and therapeutic options. Within the last 12 months substantial progress has been made in identifying patients who will potentially benefit from extracorporeal support of their failing liver.

RECENT FINDINGS

In addition to traditional 'static' laboratory tests to assess liver function, the significance of 'dynamic' tests, such as indocyanine green clearance, has been better defined, and these tests are becoming more easily available. Transplantation remains the treatment of choice for fulminant, acute and subacute liver failure with predicted unfavorable outcome according to King's College or Clichy criteria, most notably in the absence of pre-existing liver disease, and should be performed before extrahepatic complications emerge. Encouraging results have been obtained with the use of support systems in patients with acute and acute-on-chronic liver failure in relatively small patient collectives, making well-conducted randomized trials a necessity to define their role in this high-risk population. Current (pre)clinical data suggest that programmed cell death is an important mechanism for the pathogenesis of acute and acute-on-chronic liver failure and, thus, antiapoptotic strategies are promising pharmacologically.

SUMMARY

Although mortality remains high, substantial progress has been made in 2004 regarding the understanding of pathophysiology, and the monitoring and support of the patient presenting with a failing liver.