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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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Zhou E, Xiang D, Yu B, Yao H, Sun C, Wang Y. Ovarian tissue transplantation ameliorates osteoporosis and dyslipidaemia in ovariectomised mice. J Ovarian Res 2022; 15:139. [PMID: 36578058 PMCID: PMC9798584 DOI: 10.1186/s13048-022-01083-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Ovarian insufficiency frequently renders postmenopausal women susceptible to osteoporosis and dyslipidaemia. Postmenopausal transplant women are at a higher risk developing osteoporosis and dyslipidaemia due to the concomitant application of glucocorticoids and immunosuppressants after solid organ transplantation. Thus, this study aimed to explore the feasibility of ovarian tissue transplantation (OTT) as an alternative to Hormone replacement therapy (HRT) for postmenopausal women with solid organ transplant needs. RESULTS Sixty mice were randomly divided into four groups: sham operation, ovariectomised (OVX group), ovariectomy plus oestrogen (E2 group), and ovariectomy plus OTT (OTT group). The inhibin levels in the OTT group were increased and the follicle stimulating hormone and luteinizing hormone were suppressed to normal levels, which could not be achieved in the E2 group. The femoral bone mineral density in the OTT group was significantly increased than the E2 group (P < 0.05), and the probability of fracture was reduced by 1.4-2.6 times. Additionally, the high-density lipoprotein cholesterol levels were higher in the OTT group than in the E2 group and the triglyceride levels were lower in the OTT group than in the E2 group (P < 0.05). CONCLUSION OTT not only achieves certain endocrine effects by participating in the regulation of the hypothalamic-pituitary-ovarian feedback control loop, but also ameliorates osteoporosis and dyslipidaemia, which may be an alternative to traditional HRT for postmenopausal women with solid organ transplant needs.
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Affiliation(s)
- Encheng Zhou
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
| | - Du Xiang
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
| | - Bin Yu
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
| | - Hanlin Yao
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
| | - Chao Sun
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
| | - Yanfeng Wang
- grid.413247.70000 0004 1808 0969Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, National Quality Control Center for Donated Organ Procurement, Hubei Key Laboratory of Medical Technology on Transplantation, Hubei Clinical Research Center for Natural Polymer Biological Liver, Hubei Engineering Center of Natural Polymer-based Medical Materials, 430071 Wuhan, China
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Prevalence and predictors of post-liver transplantation metabolic bone diseases. Clin Exp Hepatol 2021; 7:286-292. [PMID: 34712830 PMCID: PMC8527345 DOI: 10.5114/ceh.2021.109412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/11/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Post-liver transplantation (LTx) bone diseases have been poorly investigated. The frequency of bone diseases (osteopenia and osteoporosis) after LTx is unknown. Aim of the study To define prevalence and risk factors of bone disorders following LTx. Material and methods This prospective study was conducted on 100 consecutive adult patients who underwent living donor liver transplantation (LDLT) at the National Liver Institute (NLI) and survived longer than a year. Bone mineral density (BMD) was evaluated by dual-energy X-ray absorption (DEXA), as well as other pre- and postoperative risk factors. Results The frequencies of osteopenia and osteoporosis were found to be 14% and 8% among post-LTx patients. Seven recipients of the osteoporotic group were males, with mean age, and body mass index (BMI) before and after LTx 49.5 ±7.4 years, 24.1 ±4.7 kg/m2 and 22.8 ±1.5 kg/m2, respectively. A significant association between hepatitis C virus (HCV)-related cirrhosis, liver disease severity according to Child-Turcotte-Pugh (CTP) score, and alcoholism with decreased post-LTx BMD was substantiated (p < 0.05, 0.006). Post-LTx development of diabetes mellitus (DM), weight gain, use of corticosteroids and basiliximab all significantly affected decreased post-LTx BMD (p < 0.05). However, binary regression revealed that post-LTx occurrence of DM (p = 0.012, odds ratio [OR] = 0.099), the severity of liver disease (p = 0.023, OR = 0.217), and HCV (p = 0.011, OR = 0.173) are the main independent predictors of metabolic bone disease (MBD) occurrence one year after LTx. Conclusions Post-LTx bone disorders are not infrequent complications and should be more considered in those with HCV-related severe liver disease or developed DM after LTx.
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Risk Factors and Management of Osteoporosis Post-Transplant. ACTA ACUST UNITED AC 2020; 56:medicina56060302. [PMID: 32575603 PMCID: PMC7353876 DOI: 10.3390/medicina56060302] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023]
Abstract
Bone and mineral disorders are common after organ transplantation. Osteoporosis post transplantation is associated with increased morbidity and mortality. Pathogenesis of bone disorders in this particular sub set of the population is complicated by multiple co-existing factors like preexisting bone disease, Vitamin D deficiency and parathyroid dysfunction. Risk factors include post-transplant immobilization, steroid usage, diabetes mellitus, low body mass index, older age, female sex, smoking, alcohol consumption and a sedentary lifestyle. Immunosuppressive medications post-transplant have a negative impact on outcomes, and further aggravate osteoporotic risk. Management is complex and challenging due to the sub-optimal sensitivity and specificity of non-invasive diagnostic tests, and the underutilization of bone biopsy. In this review, we summarize the prevalence, pathophysiology, diagnostic tests and management of osteoporosis in solid organ and hematopoietic stem cell transplant recipients.
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EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70:172-193. [PMID: 30144956 PMCID: PMC6657019 DOI: 10.1016/j.jhep.2018.06.024] [Citation(s) in RCA: 513] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.
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Nel JD, Epstein S. Metabolic Bone Disease in the Post-transplant Population: Preventative and Therapeutic Measures. Med Clin North Am 2016; 100:569-86. [PMID: 27095646 DOI: 10.1016/j.mcna.2016.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Post-transplant bone disease contributes significantly to patients' morbidity and mortality after transplantation and has an impact on their quality of life. This article discusses the major contributors to mechanisms causing bone loss, highlighting the role of preexisting disease in both kidney and liver failure and contributions from glucocorticoids and calcineurin inhibitors. Suggested monitoring and investigations are reviewed as well as treatment as far as the current literature supports, emphasizing the difference between kidney and liver recipients.
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Affiliation(s)
- Johan Daniël Nel
- Division of Nephrology, Department of Medicine, Tygerberg Hospital and University of Stellenbosch, PO Box 241, Cape Town, Western Cape 8000, South Africa.
| | - Sol Epstein
- Mt Sinai School of Medicine, New York, NY, USA; University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Early C, Stuckey L, Tischer S. Osteoporosis in the adult solid organ transplant population: underlying mechanisms and available treatment options. Osteoporos Int 2016; 27:1425-1440. [PMID: 26475288 DOI: 10.1007/s00198-015-3367-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/06/2015] [Indexed: 12/21/2022]
Abstract
The prevention and treatment of osteoporosis is an increasingly important topic in the solid organ transplant (SOT) population. Compared to the general population, these patients are at an elevated risk of developing osteoporosis due to progressive disease, lifelong immunosuppressant therapy, and malnutrition. As patients live longer after transplant, chronic disease management is increasingly more important. Supplementation with calcium and vitamin D is often necessary in the SOT population due to a high incidence of vitamin D deficiency. Bisphosphonate therapy is most commonly used for prevention and treatment of osteoporosis, but therapy can be limited by renal dysfunction which is common in transplant recipients. Alternative agents such as teriparatide and calcitonin have not been shown to provide a significant impact on the rate of fractures in this population. Additionally, denosumab may be a promising treatment option due to its novel mechanism of action, and is currently being studied in renal transplant patients. Timely initiation of supplementation and treatment, and minimizing glucocorticoid exposure prior to and after transplantation will aid in the prevention and proper management of osteoporosis in these patients.
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Affiliation(s)
- C Early
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Victor Vaughan House, 1111 E. Catherine, Ann Arbor, MI, 48109, USA
| | - L Stuckey
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Victor Vaughan House, 1111 E. Catherine, Ann Arbor, MI, 48109, USA
| | - S Tischer
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Victor Vaughan House, 1111 E. Catherine, Ann Arbor, MI, 48109, USA.
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8
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Aron J, Agarwal B, Davenport A. Extracorporeal support for patients with acute and acute on chronic liver failure. Expert Rev Med Devices 2016; 13:367-80. [PMID: 26894968 DOI: 10.1586/17434440.2016.1154455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The number of patients developing liver failure; acute on chronic liver failure and acute liver failure continues to increase, along with the demand for donor livers for transplantation. As such there is a clinical need to develop effective extracorporeal devices to support patients with acute liver failure or acute-on-chronic liver failure to allow time for hepatocyte regeneration, and so avoiding the need for liver transplantation, or to bridge the patient to liver transplantation, and also potentially to provide symptomatic relief for patients with cirrhosis not suitable for transplantation. Currently devices can be divided into those designed to remove toxins, including plasma exchange, high permeability dialyzers and adsorption columns or membranes, coupled with replacement of plasma proteins; albumin dialysis systems; and bioartificial devices which may provide some of the biological functions of the liver. In the future we expect combinations of these devices in clinical practice, due to the developments in bioartificial scaffolds.
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Affiliation(s)
- Jonathan Aron
- a King's College Hospital , London , United Kingdom of Great Britain and Northern Ireland
| | - Banwari Agarwal
- b Intensive Care Unit , Royal Free Hospital , London , United Kingdom of Great Britain and Northern Ireland
| | - Andrew Davenport
- c UCL Centre for Nephrology , Royal free Hospital , London , United Kingdom of Great Britain and Northern Ireland
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9
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Current Status of Research on Osteoporosis after Solid Organ Transplantation: Pathogenesis and Management. BIOMED RESEARCH INTERNATIONAL 2015; 2015:413169. [PMID: 26649301 PMCID: PMC4662986 DOI: 10.1155/2015/413169] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/29/2015] [Accepted: 10/29/2015] [Indexed: 12/23/2022]
Abstract
Improved survival following organ transplantation has brought to the forefront some long-term complications, among which osteoporosis and associated fractures are the major ones that adversely affect the quality of life in recipients. The pathogenesis of osteoporosis in transplant recipients is complex and multifactorial which may be related to increased bone resorption, decreased bone formation, or both. Studies have shown that the preexisting underlying metabolic bone disorders and the use of immunosuppressive agents are the major risk factors for osteoporosis and fractures after organ transplantation. And rapid bone loss usually occurs in the first 6–12 months with a significant increase in fracture risk. This paper will provide an updated review on the possible pathogenesis of posttransplant osteoporosis and fractures, the natural history, and the current prevention and treatment strategies concerning different types of organ transplantation.
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Kulak CAM, Borba VZC, Kulak Júnior J, Custódio MR. Bone disease after transplantation: osteoporosis and fractures risk. ACTA ACUST UNITED AC 2014; 58:484-92. [DOI: 10.1590/0004-2730000003343] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 05/28/2014] [Indexed: 01/16/2023]
Abstract
Organ transplantation is the gold standard therapy for several end-stage diseases. Bone loss is a common complication that occurs in transplant recipients. Osteoporosis and fragility fractures are serious complication, mainly in the first year post transplantation. Many factors contribute to the pathogenesis of bone disease following organ transplantation. This review address the mechanisms of bone loss including the contribution of the immunosuppressive agents as well as the specific features to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and management of bone loss in the transplant recipient should be included in their post transplant follow-up in order to prevent fractures.
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11
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Alshayeb HM, Josephson MA, Sprague SM. CKD-mineral and bone disorder management in kidney transplant recipients. Am J Kidney Dis 2012; 61:310-25. [PMID: 23102732 DOI: 10.1053/j.ajkd.2012.07.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/09/2012] [Indexed: 12/11/2022]
Abstract
Kidney transplantation, the most effective treatment for the metabolic abnormalities of chronic kidney disease (CKD), only partially corrects CKD-mineral and bone disorders. Posttransplantation bone disease, one of the major complications of kidney transplantation, is characterized by accelerated loss of bone mineral density and increased risk of fractures and osteonecrosis. The pathogenesis of posttransplantation bone disease is multifactorial and includes the persistent manifestations of pretransplantation CKD-mineral and bone disorder, peritransplantation changes in the fibroblast growth factor 23-parathyroid hormone-vitamin D axis, metabolic perturbations such as persistent hypophosphatemia and hypercalcemia, and the effects of immunosuppressive therapies. Posttransplantation fractures occur more commonly at peripheral than central sites. Although there is significant loss of bone density after transplantation, the evidence linking posttransplantation bone loss and subsequent fracture risk is circumstantial. Presently, there are no prospective clinical trials that define the optimal therapy for posttransplantation bone disease. Combined pharmacologic therapy that targets multiple components of the disordered pathways has been used. Although bisphosphonate or calcitriol therapy can preserve bone mineral density after transplantation, there is no evidence that these agents decrease fracture risk. Moreover, bisphosphonates pose potential risks for adynamic bone disease.
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Affiliation(s)
- Hala M Alshayeb
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA
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12
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Chauhan V, Ranganna KM, Chauhan N, Vaid M, Kelepouris E. Bone disease in organ transplant patients: pathogenesis and management. Postgrad Med 2012; 124:80-90. [PMID: 22691902 DOI: 10.3810/pgm.2012.05.2551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Bone disease is common in recipients of kidney, heart, lung, liver, and bone marrow transplants, and causes debilitating complications, such as osteoporosis, osteonecrosis, bone pain, and fractures. The frequency of fractures ranges from 6% to 45% for kidney transplant recipients to 22% to 42% for heart, lung, and liver transplant recipients. Bone disease in transplant patients is the sum of complex mechanisms that involve both preexisting bone disease before transplant and post-transplant bone loss due to the effects of immunosuppressive medications. Evaluation of bone disease should preferably start before the transplant or in the early post-transplant period and include assessment of bone mineral density and other metabolic factors that influence bone health. This requires close coordination between the primary care physician and transplant team. Patients should be stratified based on their fracture risk. Prevention and treatment include risk factor reduction, antiresorptive medications, such as bisphosphonates and calcitonin, calcitriol, and/or gonadal hormone replacement. A steroid-avoidance protocol may be considered.
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Affiliation(s)
- Veeraish Chauhan
- Division of Nephrology, Department of Medicine, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, PA 19102, USA.
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13
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Maalouf NM, Sakhaee K. Treatment of osteoporosis in patients with chronic liver disease and in liver transplant recipients. ACTA ACUST UNITED AC 2012; 9:456-63. [PMID: 17081479 DOI: 10.1007/s11938-006-0002-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The pathogenesis of osteoporosis in chronic liver disease and post-liver transplantation is complex and heterogeneous. The development of hepatic osteodystrophy may be related to both increased bone resorption and decreased bone formation. Available medical treatments can be broadly classified into antiresorptive and bone-stimulating agents. Most published studies on the treatment of osteoporosis in patients with liver disease have used the commonly prescribed antiosteoporosis drugs approved for postmenopausal osteoporosis. These studies have included a small number of subjects and used bone mineral density (BMD) changes rather than fracture occurrence as an endpoint because of the short follow-up. Although the increases in BMD are promising, no intervention is proven to have antifracture efficacy in hepatic osteodystrophy. The natural history of bone disease following liver transplantation has not been fully investigated, although studies suggest that bone mineral loss is transient and generally reverses within a year following transplantation. The approach to treatment in liver transplant recipients should be targeted at preventing the early bone loss without interfering with the later recovery. Based on the available data, no single available agent can be considered as first-line therapy. In our opinion, the best treatment approach involves the elucidation of modifiable risk factors and the selection of agents targeted at the underlying derangements.
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Affiliation(s)
- Naim M Maalouf
- The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research and Department of Internal Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8885, USA.
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14
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Abstract
Transplantation is an established therapy for end-stage diseases of kidney, lung, liver, and heart among others. Osteoporosis and fragility fractures are serious complications of organ transplantation, particularly in the first post-transplant year. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. This review addresses the mechanisms of bone loss that occurs both in the early and late post-transplant periods, including the contribution of the immunosuppressive agents as well as the specific features to bone loss after kidney, lung, liver, cardiac, and bone marrow transplantation. Prevention and treatment for osteoporosis in the transplant recipient are also discussed.
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Affiliation(s)
- Carolina A Moreira Kulak
- Division of Endocrinology & Metabolism of Hospital de Clínicas-SEMPR, Federal University of Parana, Av. Agostinho Leão Júnior 285, Alto da Glória, Curitiba, Paraná, Cep: 80030-013, Brazil.
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15
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Affiliation(s)
- Yenna Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chan Soo Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Baccaro LF, Boin IFSF, Pedro AO, Costa-Paiva L, Leal ALG, Ramos CD, Pinto-Neto AM. Decrease in bone mass in women after liver transplantation: associated factors. Transplant Proc 2011; 43:1351-6. [PMID: 21620127 DOI: 10.1016/j.transproceed.2011.02.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the future, an increasing number of female liver transplant recipients will reach the climacteric with osteoporosis as a common complication. We evaluated the factors associated with decreased bone mass among women after liver transplantation. METHODS A prospective, cross-sectional study of 23 outpatient transplant recipients followed from February 2009 to March 2010 included women of age ≥35 years after liver transplantations ≥1 year prior. We recorded patient histories, liver enzyme levels, as well as bone mineral densities measured at the lumbar spine and femur. Statistical analysis used Fisher's exact test, simple odds ratio (OR), and Spearman's rank correlation coefficient. RESULTS The mean patient age was 52.5 ± 11 years with 30.4% premenopausal, and 69.6% perimenopausal or postmenopausal. Approximately 21% showed osteoporosis and 35%, a low bone mass. Postmenopausal women: OR 69.0 (95% CI 2.89-1647.18; P<.0001), aged ≥49 years: OR 13.33 (95% CI 1.78-100.15; P=.0123) and receiving a transplant after 44 years of age: OR 49.50 (95% CI 3.84-638.43; P<.0001) were associated with a lower bone mass. Having undergone transplantation for more than 5.8 years lowered the risk of bone mass change: OR 0.11 (95% CI 0.02-0.78; P=.0361). Clinical and laboratory variables, including corticosteroid use, were not associated with decreased bone mass. CONCLUSION Understanding the prevalence and factors associated with osteoporosis among female liver transplant recipients is important to enhance the strategies to diagnose and treat these women, seeking to improve their quality of life.
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Affiliation(s)
- L F Baccaro
- Department of Gynecology, State University of Campinas, Campinas, Brazil.
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17
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Post-transplantation osteoporosis. ACTA ACUST UNITED AC 2011; 54:143-9. [PMID: 20485902 DOI: 10.1590/s0004-27302010000200009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 02/09/2010] [Indexed: 11/22/2022]
Abstract
Transplantation is an established therapy for many hematologic disorders as well as for end-stage diseases of the kidney, lung, liver, heart among others. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods including the contribution of immunosuppressive agents as well as the specific features of bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis in the transplant recipient will also be addressed.
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Sakhaee K. Osteoporosis following organ transplantation: pathogenesis, diagnosis and management. Expert Rev Endocrinol Metab 2011; 6:157-176. [PMID: 30290452 DOI: 10.1586/eem.10.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Organ transplantation has become popular for the management of various chronic illnesses. With the advent of modern immunosuppressive treatments, the longevity of transplant recipients has increased. Consequently, morbid complications such as osteoporosis and bone fractures are seen at an increasing frequency in this population. In most transplant recipients, bone mineral density (BMD) falls shortly after transplantation. However, bone fracture rate plateaus in all except for post-renal transplant patients. Although the underlying pathophysiologic mechanism for this difference is not fully understood, potential mechanisms for sustained bone loss in renal transplant recipients may be persistent phosphorus wasting and defective bone mineralization. Current treatment regimens are based on studies in a small numbers of subjects with BMD as the primary outcome. Although BMD is recognized as a gold standard in the assessment of bone fracture risk, to date, its association with bone fracture risk in the general post-transplant population is not robust. Therefore, randomized controlled trials with bone fracture as the primary end point are crucial. The development of noninvasive bone markers in distinguishing bone turnover and bone mineralization status is also pivotal since skeletal lesions are heterogeneous in various organ transplantations. The elucidation of these underlying skeletal lesions is necessary for the consideration of selective treatment in this population.
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Affiliation(s)
- Khashayar Sakhaee
- a UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8885, USA.
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19
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Abstract
Osteoporosis is prevalent in transplant recipients and is related to pre- and post-transplantation factors. Low bone density and fractures may antedate transplantation, related to traditional risk factors for osteoporosis, effects of chronic illness, and end-stage organ failure and its therapy, on the skeleton. Bone loss after transplantation is related to adverse effects of immunosuppressive drugs (glucocorticoids and calcineurin inhibitors) on bone remodeling. Newer immunosuppressive medications may permit lower doses of glucocorticoids and may be associated with decreased bone loss and fractures. Bisphosphonates are currently the most effective agents for the prevention and treatment of post-transplantation osteoporosis.
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Affiliation(s)
- Emily Stein
- Division of Endocrinology, Department of Medicine, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH8-864, New York, NY 10032, USA
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Kulak CAM, Borba VZC, Kulak Júnior J, Shane E. Transplantation osteoporosis. ACTA ACUST UNITED AC 2007; 50:783-92. [PMID: 17117303 DOI: 10.1590/s0004-27302006000400023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 06/10/2006] [Indexed: 11/21/2022]
Abstract
In the past two decades, there has been a rapid increase in the number of organ transplanted worldwide, including Brazil, along with an improvement in survival and quality of life of the transplant recipients. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods, as well as the features specific to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis should be instituted prior and in the early and late phase after transplantation, and will also be addressed in this article.
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Affiliation(s)
- Carolina A M Kulak
- SEMPR, Department of Endocrinology and Metabology, Federal University of Parana, PR, Brazil
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Choi WC, Arnaout WC, Villamil FG, Demetriou AA, Vierling JM. Comparison of the applicability of two prognostic scoring systems in patients with fulminant hepatic failure. Korean J Intern Med 2007; 22:93-100. [PMID: 17616024 PMCID: PMC2687618 DOI: 10.3904/kjim.2007.22.2.93] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Distinguishing those patients with fulminant hepatic failure (FHF) and who require transplantation from those FHF patients who will survive with receiving only intensive medical care remains problematic, and this distinction is important because of the chronic shortage of donor livers. METHODS To assess the applicability of two prognostic scoring systems, referred to as the London and Clichy criteria, we compared using both systems, at the time of admission, for 43 FHF patients (15 M/28 F; age: 3716 yrs). Acetaminophen (ACM) was the etiology for 16 patients, while the remaining 27 had other etiologies. All the patients received intensive care, and 18 (8 ACM/10 non-ACM) had investigational BAL support. RESULTS For the ACM toxicity, neither the London nor the Clichy criteria exhibited acceptable sensitivity (71 vs 86%, respectively), specificity (78 vs 56%, respectively), a positive predictive value (71 vs 60%, respectively), a negative predictive value (78 vs 83%, respectively) or predictive accuracy (75 vs 69%, respectively) to predict patient survival without transplantation. In contrast, applying the London and Clichy criteria to the FHF patients with non-ACM etiologies showed a sensitivity of 96 vs 80%, respectively, a specificity of 100 vs 100%, respectively, a positive predictive value of 100 vs 100%, respectively a negative predictive value of 67 vs 29%, respectively and a predictive accuracy of 96% vs 82%, respectively. CONCLUSIONS Overall, the London criteria more accurately predicted the need for transplantation, and neither the London criteria nor the Clichy prognostic criteria accurately predicted the outcome of those patients who suffered with FHF due to ACM. BAL support may have contributed to the survival of the patients with ACM toxicity and who didn't undergo transplantation, and this survival exceeded the predictions of both prognostic systems. Additional multicenter studies should be conducted to refine these prognostic scoring systems, and this will help physicians rapidly identify those FHF patients who can survive without undergoing liver transplantation.
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Affiliation(s)
- Won-Choong Choi
- Department of Internal Medicine, Sanggye-Paik Hospital, Inje University, College of Medicine Seoul, Korea.
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22
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Sethi A, Stravitz RT. Review article: medical management of the liver transplant recipient - a primer for non-transplant doctors. Aliment Pharmacol Ther 2007; 25:229-45. [PMID: 17217455 DOI: 10.1111/j.1365-2036.2006.03166.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival 10 years after orthotopic liver transplantation now approaches 65%. Consequently, community doctors must manage the metabolic and neoplastic complications of orthotopic liver transplantation in an ageing population. AIMS To review common sources of morbidity and mortality in long-term orthotopic liver transplantation recipients, and to make evidence-based recommendations regarding their management. METHODS Pertinent studies and reviews were identified by literature search through PubMed. Where evidence-based recommendations could not be gleaned from the literature, expert opinion was obtained from syllabi of national meetings. RESULTS The two most common causes of morbidity and mortality in orthotopic liver transplantation recipients are atherosclerotic vascular disease and de novo malignancy. The pathogenesis of many complications begins before orthotopic liver transplantation, and many are potentially modifiable. Most complications, however, can be directly ascribed to immunosuppressive agents. Despite improvements in our understanding of the pathogenesis and epidemiology of the metabolic and neoplastic complications of orthotopic liver transplantation, remarkably few randomized-controlled studies exist to define their optimal management. CONCLUSIONS Orthotopic liver transplantation recipients experience and succumb to the same afflictions of old age as non-transplant patients, but with greater frequency and at an earlier age. Most recommendations regarding surveillance for, and treatment of, medical complications of orthotopic liver transplantation remain based upon expert opinion rather than evidence-based medicine.
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Affiliation(s)
- A Sethi
- Section of Hepatology and Liver Transplant Program, Virginia Commonwealth University, Richmond, VA 23298-0341, USA
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Affiliation(s)
- Albert Parés
- Liver Unit, Digestive Diseases Institute and Metabolic Bone Diseases Unit, Department of Rheumatology Hospital Clínic, IDIBAPS, Barcelona, Spain.
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24
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Millonig G, Graziadei IW, Eichler D, Pfeiffer KP, Finkenstedt G, Muehllechner P, Koenigsrainer A, Margreiter R, Vogel W. Alendronate in combination with calcium and vitamin D prevents bone loss after orthotopic liver transplantation: a prospective single-center study. Liver Transpl 2005; 11:960-6. [PMID: 16035083 DOI: 10.1002/lt.20466] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bone loss is a common complication in patients before and after liver transplantation (LT). The aim of this study was to investigate the efficacy of prophylactic treatment with bisphosphonates after LT in preventing progressive bone loss in LT patients. We included 136 patients with end-stage liver diseases awaiting LT. Bone mineral density (BMD) (by dual X-ray absorptiometry) and markers of bone metabolism were determined before, and 4, 12, 24, 36, and 48 months after LT. All patients received vitamin D and calcium supplementation before and after LT, those with osteopenia or osteoporosis prior to LT were additionally treated with alendronate following LT. Decreased BMD was seen in a high percentage of patients undergoing LT (osteopenia 48.5%, osteoporosis 23.5%). Reduced BMD before LT was not related to gender, underlying liver disease, or Child-Turcotte-Pugh classification. Body mass index (BMI) prior to LT, however, correlated significantly with the fracture risk. Alendronate prevented the ubiquitously observed bone loss after LT in patients with osteoporosis and osteopenia and, in addition, led to an increase in BMD in patients with osteoporosis within 24 months after LT. In conclusion, our study suggests that alendronate is efficacious in preventing the natural course of bone loss associated with LT.
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Affiliation(s)
- Gunda Millonig
- Department of Gastroenterology and Hepatology, Innsbruck Medical University, Innsbruck, Austria
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25
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Abstract
A osteoporose é uma complicação comum após os transplantes de rim, coração, fígado e pulmão. Os esquemas imunossupressores para evitar a rejeição do órgão enxertado após o transplante freqüentemente incluem glicocorticóides, ciclosporina A e tacrolimus, os quais possuem efeitos danosos sobre a homeostase mineral óssea, impostos a um esqueleto já comprometido. Outros fatores que provavelmente contribuem para a patogênese da osteoporose pós-transplante são deficiência de vitamina D, hiperparatireoidismo secundário e hipogonadismo. Medidas para avaliação da saúde óssea antes do transplante deveriam ser realizadas: densitometria mineral óssea, radiografia da coluna, avaliação do nível de vitamina D e dos hormônios gonadais. Todos os pacientes transplantados deveriam ser submetidos à profilaxia da perda óssea. Estudos clínicos sugerem que os bisfosfonatos são os agentes mais promissores para a prevenção e o tratamento da osteoporose pós-transplante.
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Affiliation(s)
- Rogério Cipriani
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ.
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26
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Cohen A, Sambrook P, Shane E. Management of bone loss after organ transplantation. J Bone Miner Res 2004; 19:1919-32. [PMID: 15537434 DOI: 10.1359/jbmr.040912] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Revised: 05/18/2004] [Accepted: 07/09/2004] [Indexed: 02/08/2023]
Abstract
Organ transplant recipients experience rapid bone loss and high fracture rates, particularly during the early post-transplant period. Early rapid bone loss occurs in the setting of uncoupled bone turnover with increased bone resorption and decreased bone formation. Because there are no clinical factors that reliably predict post-transplant bone loss and fractures in the individual patient, all transplant recipients should be considered candidates for early preventive therapy for osteoporosis. Long-term transplant recipients with densitometric osteoporosis and/or fractures should also receive treatment. Although active metabolites of vitamin D and bisphosphonates have both shown efficacy, data from clinical trials suggest that bisphosphonates are the safest and most consistently effective agents for the prevention and treatment of post-transplantation osteoporosis in adults. Kidney transplant recipients represent a special population, and more research is needed to delineate the risks and benefits of treating bone disease in these patients.
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Affiliation(s)
- Adi Cohen
- Department of Medicine, Duke University, Durham, North Carolina, USA
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27
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Ormarsdóttir S, Mallmin H, Naessén T, Petrén-Mallmin M, Broomé U, Hultcrantz R, Lööf L. An open, randomized, controlled study of transdermal hormone replacement therapy on the rate of bone loss in primary biliary cirrhosis. J Intern Med 2004; 256:63-9. [PMID: 15189367 DOI: 10.1111/j.1365-2796.2004.01342.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The prevalence of osteoporosis amongst patients with primary biliary cirrhosis (PBC) is high and may be a serious clinical problem. Hormone replacement therapy (HRT) is effective in preventing bone loss but has not been evaluated in randomized trials in PBC. The primary aim was to study the effect of transdermal HRT in combination with daily vitamin D and calcium supplementation on bone loss compared with vitamin D and calcium supplementation only in postmenopausal women with PBC. The secondary aim was to study the safety of transdermal HRT. SUBJECTS/INTERVENTIONS Eighteen females with PBC were randomized to receive 2 years therapy with either (i) transdermal oestradiol 50 microg 24 h(-1) two times per week + medroxyprogesterone 2.5 mg day(-1) + alfacalcidol 0.25 microg day(-1) and calcium 1 g day(-1) or (ii) alfacalcidol 0.25 microg day(-1) and calcium 1 g day(-1). Dual-energy X-ray absorptiometry for measurement of bone mineral density (BMD) and sampling of blood and serum for measurements of biochemical markers of liver function was performed before, during and at the end of treatment. RESULTS BMD increased significantly at the lumbar spine (P < 0.05) and the femoral neck (P < 0.05) in the HRT group whereas no significant change was found in the control group. One oestrogen-treated patient was excluded after 1 year because of deteriorating, but reversible, aminotransferases. Dropout frequency because of nonliver-related causes was higher in the HRT group. Otherwise, no difference with respect to adverse liver reactions was found between the groups. CONCLUSION Transdermal HRT increases BMD in PBC patients with few severe side effects related to the liver.
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Affiliation(s)
- S Ormarsdóttir
- Internal Medicine, Institution for Medical Sciences, University Hospital, Uppsala, Sweden.
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Karam V, Castaing D, Danet C, Delvart V, Gasquet I, Adam R, Azoulay D, Samuel D, Bismuth H. Longitudinal prospective evaluation of quality of life in adult patients before and one year after liver transplantation. Liver Transpl 2003; 9:703-11. [PMID: 12827557 DOI: 10.1053/jlts.2003.50148] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We assessed the impact of liver transplantation (LT) on the quality of life (QOL) of French recipients 1 year after surgery. A French version of the questionnaire used by the National Institute of Diabetes and Digestive and Kidney Disease-Pittsburg, USA (NIDDK), was validated by the back-translation method. Five QOL domains were evaluated: measures of disease, psychological distress, personal function, social function, and general health perception. Patients enrolled onto the waiting list completed the questionnaire before and 1 year after LT. Respondents were age- and gender-matched with healthy subjects recruited from the general population (GP). One year after LT, the analysis of data from 67 consecutive patients showed dramatic improvement in the five domains. Compared with baseline, patients noted fewer disease-related symptoms (P <.0001) and lower level of distress overall (P <.001). However, levels of distress caused by excess appetite (P <.01), trembling (P <.05), and headaches (P =.06) were more likely to increase than decrease. Twenty-five percent of patients prevented by their disease from going to work before LT were no longer so limited at 1-year follow-up. General health perception improved remarkably, with seven times as many recipients reporting improved health as reporting worse health. A correlation was found between the pretransplantation severity of cirrhosis and the social and role function after LT (P <.05). In summary, the French version of the NIDDK questionnaire seems to be reliable. The results of transplant recipients were generally close to those of the general population. Although it is not a true return to normal status, it approaches it.
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Affiliation(s)
- Vincent Karam
- Centre Hépatobiliaire, UPRES 1596, Assistance Publique-Hôpitaux de Paris, Université Paris Sud, Hôpital Paul Brousse, Villejuif, France.
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Affiliation(s)
- J Eileen Hay
- Mayo Clinic, 200 First street SW, Rochester, MN 55905, USA.
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Abstract
Fulminant hepatic failure (FHF) remains a rare but devastating disease. Viruses and drug-induced hepatotoxicity are the most common causes of the syndrome, but the relevance of each differs depending on the geographic area. In a large proportion of patients no cause for FHF can be identified. Good intensive care is critical for patient survival. Orthotopic liver transplantation (OLT) remains a definitive therapeutic option. Prognostic indices have helped to optimize patient selection and timing for performance of OLT. However, the accuracy of these prognostic indices decreases when they are applied to different populations, probably because of regional differences in etiology and peculiar native host factors. More accurate prognostic criteria and new therapeutic alternatives to OLT are required.
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Affiliation(s)
- Javier Vaquero
- Department of Medicine, Northwestern Feinberg Medical School, Searle 10-573, 303 East Chicago Avenue, Chicago, IL 60611, USA
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Mischiati C, Puviani AC, Brogli M, Guarniero S, Sereni A, Breda L, Ricci D, Galavotti D, Morsiani E, Gambari R. Modulation of pro-apoptotic (Bax) and anti-apoptotic (Bcl-2) gene expression in isolated porcine hepatocytes perfused within a radial-flow bioreactor after low-temperature storing. Int J Artif Organs 2003; 26:139-48. [PMID: 12653348 DOI: 10.1177/039139880302600208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Due to the scarcity of available human livers, porcine hepatocytes are currently being evaluated as a xenogeneic cell source for extracorporeal bioartificial liver (BAL). Hypothermic storage of isolated porcine hepatocytes could support stocking of cell-loaded bioreactors for BAL use and may provide bioreactors ready to be used at the patient's bedside. For the development of this technology, it is of utmost importance to ensure cell viability and differentiated functions after low-temperature storage and following warm reperfusion. We compared cell viability, functional activity and apoptosis in isolated porcine hepatocytes which were perfused within a radial-flow bioreactor (RFB), stored at 4 degrees C and then reperfused at 37 degrees C. RFBs were loaded with 8 x 10(9), > or = 90% viable hepatocytes at 37 degrees C for 3 h. RFBs were then flushed with 4 degrees C University of Wisconsin solution (UW) and subsequently stored for 24 h or 48 h. RFBs were then reperfused for 8 h with recirculating medium plus serum at 37 degrees C . Cytochrome P450 (CYP) activity was studied before and after cold storage by means of monoethylglycinexylide (MEGX) detection in the effluent medium, after repeated lidocaine injections. After reperfusion experiments, hepatocytes were harvested for total RNA isolation. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used in order to amplify specific mRNAs for Bcl-2 and Bax genes, by using appropriate primers; beta-actin primers were used as control. Total RNA was extracted by northern blotting analysis and for Bcl-2, Bax and beta-actin RNA messenger detection, RT-PCR amplification was used. Freshly isolated hepatocytes perfused into the RFB showed a progressive increase of MEGX while a loss in Bax expression was paralleled by an increase in Bcl-2 expression, in comparison to starting hepatocytes. After 4 degrees C storage and warm reperfusion, MEGX production was preserved in 24 h- and 48 h-stored bioreactors as well as a sharp increase of Bcl-2 and a decrease of Bax mRNAs. Our study suggests that refrigeration of hepatocyte-bioreactors is a suitable strategy to maintain both viability and function of isolated hepatocytes, for up to 48 h a time-length that is compatible with long-distance delivery of ready-to-use bioreactors.
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Affiliation(s)
- C Mischiati
- Department of Biochemistry and Molecular Biology, University of Ferrara, Ferrara, Italy
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Kjaergard LL, Liu J, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for acute and acute-on-chronic liver failure: a systematic review. JAMA 2003; 289:217-22. [PMID: 12517233 DOI: 10.1001/jama.289.2.217] [Citation(s) in RCA: 230] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CONTEXT Artificial and bioartificial support systems may provide a "bridge" for patients with severe liver disease to recovery or transplantation. OBJECTIVE To evaluate the effect of artificial and bioartificial support systems for acute and acute-on-chronic liver failure. DATA SOURCES Randomized trials on any support system vs standard medical therapy were included irrespective of publication status or language. Nonrandomized studies were included in explorative analyses. Trials were identified through electronic searches (Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Library, MEDLINE, EMBASE, and the Chinese Medical Database), bibliographies, and contact with experts. Searches were conducted of the entire databases through September 2002. STUDY SELECTION Of 528 references identified, 12 randomized trials with 483 patients were included. Eight nonrandomized studies were included in explorative analyses. DATA EXTRACTION Data were extracted and trial quality was assessed independently by 3 reviewers (L.L.K., J.L., B.A-N.). The primary outcome measure was all-cause mortality. Results were combined on the risk ratio (RR) scale. Random-effects models were used. Sources of heterogeneity were explored through meta-regression and stratified meta-analyses. DATA SYNTHESIS Of the 12 trials included, 10 assessed artificial systems for acute or acute-on-chronic liver failure and 2 assessed bioartificial systems for acute liver failure. Overall, support systems had no significant effect on mortality compared with standard medical therapy (RR, 0.86; 95% confidence interval [CI], 0.65-1.12). Meta-regression indicated that the effect of support systems depended on the type of liver failure (P =.03). In stratified meta-analyses, support systems appeared to reduce mortality by 33% in acute-on-chronic liver failure (RR, 0.67; 95% CI, 0.51-0.90), but not in acute liver failure (RR, 0.95; 95% CI, 0.71-1.29). Compared with randomized trials, nonrandomized studies produced significantly larger estimates of intervention effects (P =.01). CONCLUSION This review suggests that artificial support systems reduce mortality in acute-on-chronic liver failure compared with standard medical therapy. Artificial and bioartificial support systems did not appear to affect mortality in acute liver failure.
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Affiliation(s)
- Lise L Kjaergard
- The Cochrane Hepato-Biliary Group, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, H:S Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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Link TM. High-resolution magnetic resonance imaging to assess trabecular bone structure in patients after transplantation: a review. Top Magn Reson Imaging 2002; 13:365-75. [PMID: 12464748 DOI: 10.1097/00002142-200210000-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After organ transplantation patients have a higher incidence of osteoporotic fractures. Bone mineral density (BMD) measurements to assess fracture risk are of limited value in these patients. On the other hand, structure-based techniques have shown promise. In this review, the use of high-resolution magnetic resonance imaging in the analysis of the trabecular bone structure in patients before and after renal and cardiac transplantation cross-sectionally is presented. The analyses of calcaneal trabecular structure were compared with BMD with regard to the prediction of therapy-induced bone loss and osteoporotic fracture status. Sagittal and axial T1-weighted spin-echo sequences with a voxel size of 0.2 x 0.2 x 1 mm were performed at 1.5 T and structure measures analogous to bone histomorphometry were calculated. In addition, fracture status of the spine and of the peripheral skeleton was assessed. Structure measures showed significant differences between healthy controls and patients before and after renal and cardiac transplantation (p < 0.01). Osteoporotic fractures were found in approximately 35% of the transplant patients; the percentage was higher in the cardiac transplants. Structure measures and BMD were lower in patients with fractures; differences were more significant in the cardiac transplant patients. Using receiver operating characteristic analyses the diagnostic performance in differentiating patients with and without fractures was highest when BMD and structure measures were combined. Structure measures performed better than BMD in the cardiac transplant patients, whereas results were comparable in the renal transplant patients. In conclusion, structure measures determined in high-resolution magnetic resonance images may be useful in assessing changes of trabecular bone after organ transplantation and may improve the prediction of fracture risk.
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Affiliation(s)
- Thomas M Link
- Department of Radiology, Technische Universität München, Ismaninger Strasse 22, D-81675 Munich, Germany.
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Borra M, Galavotti D, Bellini C, Fumi L, Morsiani E, Bellini G. Advanced technology for extracorporeal liver support system devices. Int J Artif Organs 2002; 25:939-49. [PMID: 12456035 DOI: 10.1177/039139880202501008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute Liver Failure (ALF) still presents high mortality rates, and liver transplant is the only treatment with proven efficacy. However transplant is not always possible and systems for Extracorporeal Liver Support (ELS) are being developed which can treat patients with ALF, for whom a transplant is not available, or is delayed. They can also treat patients with chronic liver disease who develop ALF. There are two types of ELS: artificial systems (hemoperfusion, plasmaperfusion, therapeutic plasma exchange, continuous hemodialysis and high volume continuous hemofiltration) and bioartificial systems. These are based on a biological component (animal or human hepatocytes) inserted into a bioreactor, whose main function is to perform the metabolic activity and synthesis that the liver can no longer perform. The results obtained in clinical trials have so far shown that the best results in terms of compensating for lost metabolic function and detoxification are obtained inserting artificial components in the bioartificial circuit.
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Affiliation(s)
- M Borra
- RanD Biotech S.r.l., Medolla, Italy
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Abstract
Treatment of liver disease has been greatly improved by the advent and evolution of liver transplantation. However, as demand for donor organs continues to increase beyond their availability, the need for alternative liver therapies is clear. Several approaches including extracorporeal devices, cell transplantation, and tissue-engineered constructs have been proposed as potential adjuncts or even replacements for transplantation. Simultaneously, experience from the liver biology community have provided valuable insight into tissue morphogenesis and in vitro stabilization of the hepatocyte phenotype. The next generation of cellular therapies must therefore consider incorporating cell sources and cellular microenvironments that provide both a large population of cells and strategies to maintain liver-specific functions over extended time frames. As cell-based therapies evolve, their success will require contribution from many diverse disciplines including regenerative medicine, developmental biology, and transplant medicine.
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Affiliation(s)
- Jared W Allen
- Microscale Tissue Engineering Laboratory, Department of Bioengineering, University of California at San Diego, La Jolla, CA 92093-0412, USA
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Abstract
Further insights into the molecular regulation of bile acid transport and metabolism have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Novel insights into the mechanisms of action of ursodeoxycholic acid should advance our understanding of the treatment of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes in both infants and adults as well as cholesterol gallstone disease. Important studies have been published on the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, drug-induced cholestasis, and cholestasis of pregnancy.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Karl-Franzens University, School of Medicine, Graz, Austria
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Abstract
Successes in machine-based extracorporeal support for different organ functions stimulated research in the field of liver support approximately 50 years ago. Initial failure to improve outcome using detoxification methods like dialysis, blood and plasma exchange, or plasmapheresis over sorbents fueled interest in biologic liver support concepts using bioreactors or combined methods. New device configurations, technical improvement of existing detoxification methods, and the refinement in cell culture techniques led to a boost in research on biologic and nonbiologic approaches. Currently, many systems are in the preclinical phase or have entered clinical studies. A number of completed clinical trials have reported a favorable therapeutic impact of the most advanced solutions on the course and outcome of liver failure. Often, findings must be reconfirmed. However, current knowledge suggests that extracorporeal liver support can successfully stabilize liver function, improve the clinical condition of patients, and considerably improve survival in certain subgroups of patients with fulminant hepatic failure and acute decompensation of chronic hepatic failure. Although the initial focus of liver support methods was bridging to liver transplantation, bridging to recovery of organ function and treatment of intractable pruritus are now valuable indications.
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Affiliation(s)
- Steffen R Mitzner
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany.
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Morsiani E, Pazzi P, Puviani AC, Brogli M, Valieri L, Gorini P, Scoletta P, Marangoni E, Ragazzi R, Azzena G, Frazzoli E, Di Luca D, Cassai E, Lombardi G, Cavallari A, Faenza S, Pasetto A, Girardis M, Jovine E, Pinna AD. Early experiences with a porcine hepatocyte-based bioartificial liver in acute hepatic failure patients. Int J Artif Organs 2002; 25:192-202. [PMID: 11999191 DOI: 10.1177/039139880202500305] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Orthotopic liver transplantation (OLT) is the only effective therapeutic modality in severe acute hepatic failure (AHF). The scarcity of organs for transplantation leads to an urgent necessity for temporary liver support treatments in AHF patients. A hepatocyte-based bioartificial liver (BAL) is under investigation with the main purpose to serve as bridging treatment until a liver becomes available for OLT, or to promote spontaneous liver regeneration. We developed a novel radial-flow bioreactor (RFB) for three-dimensional, high-density hepatocyte culture and an integrated pumping apparatus in which, after plasmapheresis, the patient's plasma is recirculated through the hepatocyte-filled RFB. Two hundred thirty grams of freshly isolated porcine hepatocytes were loaded into the RFB for clinical liver support treatment. The BAL system was used 8 times in supporting 7 AHF patients in grade III-IV coma, all waiting for an urgent OLT Three patients with no history of previous liver diseases were affected by fulminant hepatic failure (FHF) due to hepatitis B virus, 3 by primary non-function (PNF) of the transplanted liver, and one by AHF due to previous abdominal trauma and liver surgery. Six out of 7 patients underwent OLT following BAL treatment(s), which lasted 6-24 hours. All patients tolerated the procedures well, as shown by an improvement in the level of encephalopathy, a decrease in serum ammonia, transaminases and an amelioration of the prothrombin time, with full neurological recovery after OLT Our initial clinical experience confirms the safety of this BAL configuration and suggests its clinical efficacy as a temporary liver support system in AHF patients.
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Affiliation(s)
- E Morsiani
- Department of Surgery, Sant'Anna University Hospital, University of Ferrara School of Medicine, Italy.
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Hoekstra R, Chamuleau RAFM. Recent developments on human cell lines for the bioartificial liver. Int J Artif Organs 2002; 25:182-91. [PMID: 11999190 DOI: 10.1177/039139880202500304] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Most bioartificial liver (BAL) devices contain porcine primary hepatocytes as their biological component. However, alternatives are needed due to xenotransplantation associated risks. Human liver cell lines have excellent growth characteristics and are therefore candidates for application in BAL devices. Tumour-derived cell lines HepG2 and C3A express a variety of liver functions, but some specific liver functions, like ammonia detoxification and ureagenesis are insufficient. Immortalised human hepatocytes might offer better prospects. The balance between immortalisation and transformation with dedifferentiation of cells seems controllable by conditional immortalisation and/or the use of telomerase as immortalising agent. Another promising approach will be the use of embryonic or adult human stem cells. Rodent stem cells have been directed to hepatic differentiation in vitro, which might be applicable to human stem cells. However, both functionality and safety of immortalised human liver cell lines and differentiated stem cells should be improved before successful use in BAL devices becomes reality.
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Affiliation(s)
- R Hoekstra
- Department of Experimental Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands.
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Abstract
End-stage liver disease is treated by liver transplantation, but donor organ shortages remain a serious problem. This has prompted the design of bioartificial liver devices to "bridge" patients until they either recover or receive a liver transplant. In these devices, patient plasma is circulated extracorporeally through a bioreactor that houses liver cells (hepatocytes) sandwiched between artificial plates or capillaries.
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Affiliation(s)
- Alastair J Strain
- Schools of Biosciences and Medicine, University of Birmingham, and Liver and Hepatobiliary Unit, University Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
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