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Rodriguez IE, Asher ZP, Klingenberg K, Wright FL, Nydam TL, Adams MA, Bababekov YJ, Peltz E, Smith JW, Saben JL, Kennealey P, Pomposelli JJ, Pomfret EA, Moore HB. Phase I clinical trial of the feasibility and safety of direct peritoneal resuscitation in liver transplantation. Am J Surg 2024:115815. [PMID: 39003094 DOI: 10.1016/j.amjsurg.2024.115815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Direct peritoneal resuscitation (DPR) is associated with improved outcomes in trauma. Animal models suggest DPR has favorable effects on the liver. We sought to evaluate its safety and assess for improved outcomes in liver transplantation (LT). METHODS LT patients with renal dysfunction and/or obesity were enrolled in a phase-I clinical trial. DPR lasted 8-24 h depending on postoperative disposition. Primary outcome was percent of patients completing DPR. Secondary outcomes evaluated complications. Controls with either obesity (control-1) or both risk factors (obesity + renal dysfunction, control-2) were analyzed. RESULTS Fifteen patients were enrolled (seven with both criteria and eight with obesity alone). DPR was completed in 87 % of patients, with one meeting stopping criteria. Controls included 45 (control-1) and 24 (control-2) patients. Return to operating room, graft loss, and late infections were lower with DPR. CONCLUSION DPR appears to be safe in closed abdomens following LT, warranting a follow-up phase-II trial to assess efficacy.
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Affiliation(s)
- Ivan E Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Zachary P Asher
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katherine Klingenberg
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Franklin L Wright
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Trevor L Nydam
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Megan A Adams
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Yanik J Bababekov
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Eric Peltz
- Department of Surgery, Logan Health Medical Center, Kalispell, MT, USA
| | - Jason W Smith
- Department of Surgery, University of Louisville Health, Louisville, KY, USA
| | - Jessica L Saben
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter Kennealey
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James J Pomposelli
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hunter B Moore
- AdventHealth Transplant Institute at Porter, Denver, CO, USA.
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Edwards JD, Quinn SA, Burchette M, Irish W, Poulin N, Toschlog EA. Direct Peritoneal Resuscitation in Trauma Patients Results in Similar Rates of Intra-Abdominal Complications. Surg Infect (Larchmt) 2021; 23:113-118. [PMID: 34813370 DOI: 10.1089/sur.2021.262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Trauma patients undergoing damage control surgery (DCS) have a propensity for complicated abdominal closures and intra-abdominal complications. Studies show that management of open abdomens with direct peritoneal resuscitation (DPR) reduces intra-abdominal complications and accelerates abdominal closure. This novel study compares intra-abdominal complication rates and the effect of DPR initiation in patients who received DPR and those who did not. Patients and Methods: A retrospective chart review was performed on 120 patients who underwent DCS. Fifty patients were identified as DCS with DPR, and matched to 70 controls by gender, race, age, body mass index (BMI), past medical history, mechanism of trauma, and injury severity score. Results: The two groups of patients, those without DPR (-DPR) and those with DPR (+DPR), were similar in their characteristics. The +DPR group was more likely to have a mesh closure than the -DPR (14% and 3%; p = 0.022). The +DPR group took longer to have a final closure (3.5 ± 2.6 days vs. 2.5 ± 1.8; p = 0.020). Infection complications and mechanical failure of the closure technique were similar among the two groups. Timing of DPR initiation had no effect on closure type but did statistically increase the number of days to closure (initiation at first operation 2.8 ± 1.8 days vs. initiation at subsequent operations 6.0 ± 3.3 days; p ≤ 0.001). Conclusions: The use of DPR did not result in different outcomes in trauma patients. Therefore, traditional resuscitative measures for DCS may not be inferior to DCS with DPR. When choosing to use DPR, initiating it at the first operation could reduce the number of days to closure.
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Affiliation(s)
- Jacob D Edwards
- Division of Trauma and Acute Care, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Seth A Quinn
- Division of Trauma and Acute Care, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Marissa Burchette
- Division of Trauma and Acute Care, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - William Irish
- Division of Surgical Research, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Nathaniel Poulin
- Division of Trauma and Acute Care, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Eric A Toschlog
- Division of Trauma and Acute Care, Department of Surgery, The Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
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Cayuela NC, Negreti GP, Rasslan R, Koike MK, Montero EFDS. Oxidative stress on ischemia/reperfusion injury in mice with non-alcoholic hepatic steatosis or steatohepatitis. Acta Cir Bras 2018; 33:753-761. [DOI: 10.1590/s0102-865020180090000003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/13/2018] [Indexed: 12/30/2022] Open
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4
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Kolachala VL, Palle S, Shen M, Feng A, Shayakhmetov D, Gupta NA. Loss of L-selectin-guided CD8 + , but not CD4 + , cells protects against ischemia reperfusion injury in a steatotic liver. Hepatology 2017; 66:1258-1274. [PMID: 28543181 PMCID: PMC5605411 DOI: 10.1002/hep.29276] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 04/30/2017] [Accepted: 05/08/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED Steatotic liver responds with increased hepatocellular injury when exposed to an ischemic-reperfusion insult. Increasing evidence supports the role of immune cells as key mediators of this injury in a normal (lean) state, but data about their role in a steatotic liver are practically nonexistent. The objective of the current study was to delineate the contribution of specific phenotypes of T cells and adhesion molecules in exacerbated cell death in steatotic liver injury. RNA sequencing was performed on isolated steatotic primary hepatocytes, and T-cell markers were assessed in hepatic lymphocytes after ischemia reperfusion injury (IRI) in high-fat diet (HFD)-fed mice. Cluster of differentiation 8 knockout (CD8-/- ) and CD4-/- mice along with CD8 and L-selectin antibody-treated mice were fed an HFD, and hepatocellular injury was assessed by histology, propidium iodide injection, and alanine aminotransferase after IRI. RNA sequencing demonstrated a strikingly differential gene profile in steatotic hepatocytes versus lean hepatocytes. After injury, the HFD liver showed increased necrosis, infiltrating CD8+ cells, alanine aminotransferase, and proinflammatory cytokines. Hepatic lymphocytes demonstrated increased CD8+ /CD62L+ (L-selectin) cells in HFD-fed mice after IRI. CD8-/- mice and CD8-depleted C57BL/6 mice demonstrated significant protection from injury, which was not seen in CD4-/- mice. L-selectin blockade also demonstrated significant hepatoprotection from IRI. L-selectin ligand MECA-79 was increased in HFD-fed mice undergoing IRI. CONCLUSION Blockade of CD8 and L-selectin, but not CD4, ameliorated hepatocellular injury, confirming that CD8+ cells are critical drivers of injury in a steatotic liver; this represents a therapeutic target in steatotic liver injury, underlining the importance of development of therapies specific to a steatotic liver. (Hepatology 2017;66:1258-1274).
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Affiliation(s)
| | - Sirish Palle
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ming Shen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Alayna Feng
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | | | - Nitika A. Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA,Transplant services, Children’s Healthcare of Atlanta. Atlanta, GA
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5
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Abstract
Critical illness is a major cause of morbidity and mortality around the world. While obesity is often detrimental in the context of trauma, it is paradoxically associated with improved outcomes in some septic patients. The reasons for these disparate outcomes are not well understood. A number of animal models have been used to study the obese response to various forms of critical illness. Just as there have been many animal models that have attempted to mimic clinical conditions, there are many clinical scenarios that can occur in the highly heterogeneous critically ill patient population that occupies hospitals and intensive care units. This poses a formidable challenge for clinicians and researchers attempting to understand the mechanisms of disease and develop appropriate therapies and treatment algorithms for specific subsets of patients, including the obese. The development of new, and the modification of existing animal models, is important in order to bring effective treatments to a wide range of patients. Not only do experimental variables need to be matched as closely as possible to clinical scenarios, but animal models with pre-existing comorbid conditions need to be studied. This review briefly summarizes animal models of hemorrhage, blunt trauma, traumatic brain injury, and sepsis. It also discusses what has been learned through the use of obese models to study the pathophysiology of critical illness in light of what has been demonstrated in the clinical literature.
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Samant S, Jiang XL, Peletier LA, Shuldiner AR, Horenstein RB, Lewis JP, Lesko LJ, Schmidt S. Identifying clinically relevant sources of variability: The clopidogrel challenge. Clin Pharmacol Ther 2016; 101:264-273. [DOI: 10.1002/cpt.459] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Affiliation(s)
- S Samant
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - XL Jiang
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - LA Peletier
- Mathematical Institute; Leiden University; PB 9512 2300 RA Leiden The Netherlands
| | - AR Shuldiner
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - RB Horenstein
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - JP Lewis
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - LJ Lesko
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - S Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
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7
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Laho T, Clarke JD, Dzierlenga AL, Li H, Klein DM, Goedken M, Micuda S, Cherrington NJ. Effect of nonalcoholic steatohepatitis on renal filtration and secretion of adefovir. Biochem Pharmacol 2016; 115:144-51. [PMID: 27381944 DOI: 10.1016/j.bcp.2016.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Adefovir, an acyclic nucleotide reverse transcriptase inhibitor used to treat hepatitis B viral infection, is primarily eliminated renally through cooperation of glomerular filtration with active tubular transport. Nonalcoholic steatohepatitis is a variable in drug disposition, yet the impact on renal transport processes has yet to be fully understood. The goal of this study was to determine the effect of nonalcoholic steatohepatitis on the pharmacokinetics of adefovir in rats given a control or methionine and choline deficient diet to induce nonalcoholic steatohepatitis. METHODS Animals received a bolus dose of 7mg/kg (35μCi/kg) [(3)H] adefovir with consequent measurement of plasma and urine concentrations. Inulin clearance was used to determine glomerular filtration rate. RESULTS Methionine and choline deficient diet-induced nonalcoholic steatohepatitis prolonged the elimination half-life of adefovir. This observation occurred in conjunction with reduced distribution volume and hepatic levels of adefovir. Notably, despite these changes, renal clearance and overall clearance were not changed, despite markedly reduced glomerular filtration rate in nonalcoholic steatohepatitis. Alteration of glomerular filtration rate was fully compensated for by a significant increase in tubular secretion of adefovir. Analysis of renal transporters confirmed transcriptional up-regulation of Mrp4, the major transporter for adefovir tubular secretion. CONCLUSIONS This study demonstrates changes to glomerular filtration and tubular secretion that alter pharmacokinetics of adefovir in nonalcoholic steatohepatitis. Nonalcoholic steatohepatitis-induced changes in renal drug elimination processes could have major implications in variable drug response and the potential for toxicity.
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Affiliation(s)
- Tomas Laho
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA; Charles University, Department of Pharmacology, Hradec Kralove, Czech Republic
| | - John D Clarke
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Anika L Dzierlenga
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Hui Li
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - David M Klein
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Michael Goedken
- Rutgers University, Department of Translational Sciences Research Pathology Services, New Brunswick, NJ, USA
| | - Stanislav Micuda
- Charles University, Department of Pharmacology, Hradec Kralove, Czech Republic
| | - Nathan J Cherrington
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA.
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8
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Greenblatt HK, Greenblatt DJ. Altered Drug Disposition Following Bariatric Surgery: A Research Challenge. Clin Pharmacokinet 2015; 54:573-9. [DOI: 10.1007/s40262-015-0259-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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9
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Gupta NA, Kolachala VL, Jiang R, Abramowsky C, Shenoi A, Kosters A, Pavuluri H, Anania F, Kirk AD. Mitigation of autophagy ameliorates hepatocellular damage following ischemia-reperfusion injury in murine steatotic liver. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1088-99. [PMID: 25258410 PMCID: PMC4254956 DOI: 10.1152/ajpgi.00210.2014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ischemia-reperfusion injury (IRI) is a common clinical consequence of hepatic surgery, cardiogenic shock, and liver transplantation. A steatotic liver is particularly vulnerable to IRI, responding with extensive hepatocellular injury. Autophagy, a lysosomal pathway balancing cell survival and cell death, is engaged in IRI, although its role in IRI of a steatotic liver is unclear. The role of autophagy was investigated in high-fat diet (HFD)-fed mice exposed to IRI in vivo and in steatotic hepatocytes exposed to hypoxic IRI (HIRI) in vitro. Two inhibitors of autophagy, 3-methyladenine and bafilomycin A1, protected the steatotic hepatocytes from HIRI. Exendin 4 (Ex4), a glucagon-like peptide 1 analog, also led to suppression of autophagy, as evidenced by decreased autophagy-associated proteins [microtubule-associated protein 1A/1B-light chain 3 (LC3) II, p62, high-mobility group protein B1, beclin-1, and autophagy-related protein 7], reduced hepatocellular damage, and improved mitochondrial structure and function in HFD-fed mice exposed to IRI. Decreased autophagy was further demonstrated by reversal of a punctate pattern of LC3 and decreased autophagic flux after IRI in HFD-fed mice. Under the same conditions, the effects of Ex4 were reversed by the competitive antagonist exendin 9-39. The present study suggests that, in IRI of hepatic steatosis, treatment of hepatocytes with Ex4 mitigates autophagy, ameliorates hepatocellular injury, and preserves mitochondrial integrity. These data suggest that therapies targeting autophagy, by Ex4 treatment in particular, may ameliorate the effects of IRI in highly prevalent steatotic liver.
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Affiliation(s)
- Nitika A. Gupta
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; ,2Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia;
| | | | - Rong Jiang
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;
| | - Carlos Abramowsky
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; ,3Department of Pathology, Emory University School of Medicine, Atlanta, Georgia;
| | - Asha Shenoi
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; ,2Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia;
| | - Astrid Kosters
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;
| | - Haritha Pavuluri
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;
| | - Frank Anania
- 4Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; and
| | - Allan D. Kirk
- 1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; ,2Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia; ,5Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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The critically injured obese patient: a review and a look ahead. J Am Coll Surg 2013; 216:1193-206. [PMID: 23522437 DOI: 10.1016/j.jamcollsurg.2013.01.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/31/2013] [Accepted: 01/31/2013] [Indexed: 02/06/2023]
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11
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Gupta NA, Kolachala VL, Jiang R, Abramowsky C, Romero R, Fifadara N, Anania F, Knechtle S, Kirk A. The glucagon-like peptide-1 receptor agonist Exendin 4 has a protective role in ischemic injury of lean and steatotic liver by inhibiting cell death and stimulating lipolysis. THE AMERICAN JOURNAL OF PATHOLOGY 2012; 181:1693-701. [PMID: 22960075 DOI: 10.1016/j.ajpath.2012.07.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 06/19/2012] [Accepted: 07/23/2012] [Indexed: 12/15/2022]
Abstract
Nonalcoholic fatty liver disease is an increasingly prevalent spectrum of conditions characterized by excess fat deposition within hepatocytes. Affected hepatocytes are known to be highly susceptible to ischemic insults, responding to injury with increased cell death, and commensurate liver dysfunction. Numerous clinical circumstances lead to hepatic ischemia. Mechanistically, specific means of reducing hepatic vulnerability to ischemia are of increasing clinical importance. In this study, we demonstrate that the glucagon-like peptide-1 receptor agonist Exendin 4 (Ex4) protects hepatocytes from ischemia reperfusion injury by mitigating necrosis and apoptosis. Importantly, this effect is more pronounced in steatotic livers, with significantly reducing cell death and facilitating the initiation of lipolysis. Ex4 treatment leads to increased lipid droplet fission, and phosphorylation of perilipin and hormone sensitive lipase - all hallmarks of lipolysis. Importantly, the protective effects of Ex4 are seen after a short course of perioperative treatment, potentially making this clinically relevant. Thus, we conclude that Ex4 has a role in protecting lean and fatty livers from ischemic injury. The rapidity of the effect and the clinical availability of Ex4 make this an attractive new therapeutic approach for treating fatty livers at the time of an ischemic insult.
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Affiliation(s)
- Nitika A Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.
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12
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Everson GT, Shiffman ML, Hoefs JC, Morgan TR, Sterling RK, Wagner DA, Lauriski S, Curto TM, Stoddard A, Wright EC. Quantitative liver function tests improve the prediction of clinical outcomes in chronic hepatitis C: results from the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis Trial. Hepatology 2012; 55:1019-29. [PMID: 22030902 PMCID: PMC3298578 DOI: 10.1002/hep.24752] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/03/2011] [Indexed: 12/13/2022]
Abstract
UNLABELLED Risk for future clinical outcomes is proportional to the severity of liver disease in patients with chronic hepatitis C virus (HCV). We measured disease severity by quantitative liver function tests (QLFTs) to determine cutoffs for QLFTs that identified patients who were at low and high risk for a clinical outcome. Two hundred and twenty-seven participants in the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis (HALT-C) Trial underwent baseline QLFTs and were followed for a median of 5.5 years for clinical outcomes. QLFTs were repeated in 196 patients at month 24 and in 165 patients at month 48. Caffeine elimination rate (k(elim)), antipyrine (AP) clearance (Cl), MEGX concentration, methionine breath test (MBT), galactose elimination capacity (GEC), dual cholate (CA) clearances and shunt, perfused hepatic mass (PHM), and liver and spleen volumes (by single-photon emission computed tomography) were measured. Baseline QLFTs were significantly worse (P = 0.0017 to P < 0.0001) and spleen volumes were larger (P < 0.0001) in the 54 patients who subsequently experienced clinical outcomes. QLFT cutoffs that characterized patients as "low" and "high risk" for clinical outcome yielded hazard ratios ranging from 2.21 (95% confidence interval [CI]: 1.29-3.78) for GEC to 6.52 (95% CI: 3.63-11.71) for CA clearance after oral administration (Cl(oral)). QLFTs independently predicted outcome in models with Ishak fibrosis score, platelet count, and standard laboratory tests. In serial studies, patients with high-risk results for CA Cl(oral) or PHM had a nearly 15-fold increase in risk for clinical outcome. Less than 5% of patients with "low risk" QLFTs experienced a clinical outcome. CONCLUSION QLFTs independently predict risk for future clinical outcomes. By improving risk assessment, QLFTs could enhance the noninvasive monitoring, counseling, and management of patients with chronic HCV.
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Affiliation(s)
- Gregory T. Everson
- Section of Hepatology, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, CO
| | | | - John C. Hoefs
- Division of Gastroenterology, University of California - Irvine, Irvine, CA and Gastroenterology Service, VA Long Beach Healthcare System, Long Beach, CA
| | - Timothy R. Morgan
- Division of Gastroenterology, University of California - Irvine, Irvine, CA and Gastroenterology Service, VA Long Beach Healthcare System, Long Beach, CA
| | - Richard K. Sterling
- Hepatology Section, Virginia Commonwealth University Medical Center, Richmond, VA
| | | | - Shannon Lauriski
- Section of Hepatology, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, CO
| | | | | | - Elizabeth C. Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
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Hurt RT, Frazier TH, McClave SA, Crittenden NE, Kulisek C, Saad M, Franklin GA. Stress Prophylaxis in Intensive Care Unit Patients and the Role of Enteral Nutrition. JPEN J Parenter Enteral Nutr 2012; 36:721-31. [DOI: 10.1177/0148607112436978] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ryan T. Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Thomas H. Frazier
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | | | | | | | - Mohamed Saad
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Glen A. Franklin
- Department of Surgery, University of Louisville, Louisville, Kentucky
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14
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Matheson PJ, Franklin GA, Hurt RT, Downard CD, Smith JW, Garrison RN. Direct peritoneal resuscitation improves obesity-induced hepatic dysfunction after trauma. J Am Coll Surg 2012; 214:517-28; discussion 528-30. [PMID: 22342791 DOI: 10.1016/j.jamcollsurg.2011.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 12/20/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR). STUDY DESIGN This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators. RESULTS In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p < 0.05), septic complications (p < 0.05), liver dysfunction (p < 0.001), and renal impairment (p < 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response. CONCLUSIONS Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient.
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Affiliation(s)
- Paul J Matheson
- Robley Rex Veteran's Affairs Medical Center, Louisville, KY, USA
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15
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Hurt RT, Frazier TH, McClave SA, Kaplan LM. Obesity epidemic: overview, pathophysiology, and the intensive care unit conundrum. JPEN J Parenter Enteral Nutr 2012; 35:4S-13S. [PMID: 21881014 DOI: 10.1177/0148607111415110] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Obesity is one of the leading causes of preventable death in the United States, second only to smoking. The annual number of deaths attributed to obesity is estimated to be as high as 400,000. Nearly 70% of the adult U.S. population is overweight or obese. The historical viewpoint toward obesity has deemed it to be a lifestyle choice or characterological flaw. However, given the emerging research into the development of obesity and its related complications, our perspective is changing. It is now clear that obesity is a heterogeneous disease with many different subtypes, which involves an interplay between genetic and environmental factors. The current epidemic of obesity is the result of an obesogenic environment (which includes energy-dense foods and a lack of physical activity) in individuals who have a genetic susceptibility for developing obesity. The pathophysiology associated with weight gain is much more complex than originally thought. The heterogeneous nature of the disease makes the development of treatment strategies for obesity difficult. Obesity in general is associated with increased all-cause mortality and cause-specific mortality (from cardiovascular, diabetic, hepatic, and neoplastic causes). Yet despite increased overall mortality rates, current evidence suggests that when these same patients are admitted to the intensive care unit (ICU), the obesity provides some protection against mortality. At present, there is no clear explanation for this obesity conundrum in critical illness.
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Affiliation(s)
- Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Hurt RT, Frazier TH, McClave SA, Cave MC. Pharmaconutrition for the Obese, Critically Ill Patient. JPEN J Parenter Enteral Nutr 2011; 35:60S-72S. [DOI: 10.1177/0148607111413775] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Ryan T. Hurt
- Department of Medicine
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas H. Frazier
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Stephen A. McClave
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Matt C. Cave
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
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