Is a clinical application of hybrid liver support systems limited by an initial disorder in cellular amino acid and alpha-keto acid metabolism, rather than by later gradual loss of primary hepatocyte function?

Experimental Evaluation of a Cell Module for Hybrid Liver Support

Aim of the study was to evaluate a hybrid liver support system in a porcine model of acute liver failure, after hepatectomy. Pigs with a body weight of 70±18 kg underwent total hepatectomy and porto - cavo - caval shunting as well as ligation of the bile duct and the hepatic artery. Control animals were connected to the system (including capillary membrane plasma separation) containing a four compartment bioreactor with integral oxygenation and decentralized mass exchange but without liver cells. The treatment group received hybrid liver support with the same system including 370±42 g primary isolated porcine parenchymal liver cells in co-culture with hepatocyte nursing cells, tissue engineered to liver- like structures at high density. Treatment started after complete recovery from anesthesia and was performed continuously. A positive influence on peripheral vascular resistance and a reduced need of catecholamine dosage was observed in the treatment group. Hybrid liver support with a cell module upscaled for clinical application significantly prolonged survival time in animals after hepatectomy with the longest survival being 26 hours in the control group an 57 hours in the treatment group.

Development of a Hybrid Liver Support System: A Review

Hybrid liver support systems (LSS) for the use of the detoxifying, metabolic synthetic and regulatory capabilities of liver cells are under development for extracorporeal therapy of acute liver failure and for bridging to liver transplantation. A summary of our development is discussed. A five-step technique for primary liver cell isolation has been introduced in order to address larger scale procurement of hepatocytes. Immobilisation of the cells after isolation appears to be one of the main factors in maintaining hepatocyte function in vitro. Different techniques have been investigated. Using the cell-cell adhesion technique, a culture model was developed for the immobilisation of hepatocytes between capillary membranes. Four separate capillary membrane systems, each forming independent compartments are woven in order to create a three dimensional network. A bioreactor design has been developed. The construction provides different functions, including decentralised cell perfusion. The bioreactor enables 3 dimensional reorganisation of cells, integral oxygenation and decentralised metabolite exchange. The bioreactor has been scaled-up to allow hepatocytes and sinusoidal endothelial cells to be cultured in quantities sufficient for therapeutic application. In a healthy pig model, possible limiting side effects of therapy with this device were excluded. The efficacy of the system has been demonstrated in a hepatectomised pig model. Subsequently, a complete hybrid liver support system for human studies was introduced and applied clinically.

Comparison of Bioenergetic Activity of Primary Porcine Hepatocytes Cultured in Four Different Media

Primary hepatocytes have extensively been used in biochemical, pharmacological, and physiological research. Recently, primary porcine hepatocytes have been regarded as the cells of choice for bioartificial liver support systems. The optimum culture medium for hepatocytes to be used in such devices has yet to be defined. In this study we investigated the effectiveness of four culture media in driving energy metabolism of primary porcine hepatocytes. The media selected were William's E medium, medium 1640, medium 199, and hepatocyte medium. Cells (3 × 1010; viability 87 ± 6%) were isolated from weanling piglets and seeded on 90-mm plates in the above media supplemented with antibiotics and hormones at a density of 8 × 106 viable cells per plate. Using 1H NMR spectroscopy we looked at indices of glycolysis, gluconeogenesis, ketogenesis, and ureagenesis on days 2, 4, and 6 of the experiments (n = 9). We also studied urea and albumin synthesis and total P450 content. The examined metabolic pathways of the hepatocytes were maintained by all media, although there were statistically significant differences between them. All media performed well in glycolysis, ureagenesis, and albumin synthesis. William's E medium and medium 199 outperformed the rest in gluconeogenesis. Medium 199 was best in ketogenesis. Overall, medium 199 was the best at driving energy metabolism from its constituent substrates and we think that it preferentially should be used in the culture of primary porcine hepatocytes.

Bioreactors for extracorporeal liver support

Hybrid extracorporeal liver support is an option to assist liver transplantation therapy. An overview on liver cell bioreactors is given and our own development is described. Furthermore, the prospects of the utilization of human liver cells from discarded transplantation organs due to steatosis, cirrhosis, or traumatic injury, and liver progenitor cells are discussed. Our Modular Extracorporeal Liver Support (MELS) concept proposes an integrative approach for the treatment of hepatic failure with appropriate extracorporeal therapy units, tailored to suit the actual clinical needs of each patient. The CellModule is a specific bioreactor (charged actually with primary human liver cells, harvested from human donor livers found to be unsuitable for transplantation). The DetoxModule enables albumin dialysis for the removal of albumin-bound toxins, reducing the biochemical burden of the liver cells and replacing the bile excretion of hepatocytes in the bioreactor. A Dialysis Module for continuous veno-venous hemofiltration can be added to the system if required in hepato-renal syndrome.

Dynamics of amino acid metabolism of primary human liver cells in 3D bioreactors

The kinetics of 18 amino acids, ammonia (NH3) and urea (UREA) in 18 liver cell bioreactor runs were analyzed and simulated by a two-compartment model consisting of a system of 42 differential equations. The model parameters, most of them representing enzymatic activities, were identified and their values discussed with respect to the different liver cell bioreactor performance levels. The nitrogen balance based model was used as a tool to quantify the variability of runs and to describe different kinetic patterns of the amino acid metabolism, in particular with respect to glutamate (GLU) and aspartate (ASP).

A biochemical prognostic model of outcome in paracetamol-induced acute liver injury

BACKGROUND

The aim of this study was to develop a prognostic model of outcome for patients with paracetamol induced acute liver injury based on admission parameters

METHODS

We used a cohort of 97 patients admitted to the Scottish Liver Transplant Unit between 1997 and 1998 to identify biochemical prognostic markers of outcome and thus create a prognostic model. Blood samples were taken on admission for analysis. The model was subsequently validated by testing it on a second cohort of 86 patients admitted between 1999 and 2000.

RESULTS

The following were identified as independent variables of poor prognosis (death/ transplant); phenylalanine, pyruvate, alanine, acetate, calcium, haemoglobin and lactate. A prognostic model was then constructed by stepwise forward logistic regression analysis: (400xPyruvate mmols/L)+(50xPhenylalanine (mmols/L)-(4 x Hemoglobin (g/dL). A value of <16 had an accuracy of 93% in predicting death correctly. When applied to the validation cohort this model had a positive predictive value of 91%, a negative predictive value of 94%, a sensitivity of 91%, and a specificity of 94%. On the same population overall, the positive and negative predictive value of the King's criteria were 94% and 93% respectively, whereas their sensitivity and specificity were 88% and 96% respectively.

CONCLUSIONS

Using admission characteristics our model is able to identify patients who die from paracetamol overdose fulminant hepatic failure as accurately as King's College criteria, but at a much earlier stage in their condition.

Biochemical prognostic markers of outcome in non-paracetamol-induced fulminant hepatic failure

BACKGROUND

Fulminant hepatic failure (FHF) is associated with major metabolic disturbances, the onset and severity of which can predict clinical outcome. This study uses admission blood samples to identify early biochemical markers of clinical outcome in patients with non-paracetamol-induced FHF.

PATIENTS AND METHODS

Fifty-nine patients admitted to the Scottish Liver Transplant Unit with non-paracetamol-induced FHF were studied. Plasma samples were collected at a median of 5.4 hr after admission to our unit and analyzed using conventional laboratory tests and nuclear magnetic resonance spectroscopy.

RESULTS

A total of 19 patients underwent transplantation, 15 patients died without undergoing transplantation, and 25 patients survived with medical management alone. There were significantly lower levels of lactate, alanine, valine, and bilirubin and significantly higher levels of pyruvate and albumin in patients who survived spontaneously compared with the other two groups. By use of multiple logistic regression analysis, an equation was devised that best predicted clinical outcome: 0.5x(albumin [g/L])-2x(lactate [mmol/L])-36x(valine [mmol/L])-38x(pyruvate [mmol/L]). Values of less than 2 were associated with poor clinical outcome and had a positive predictive value of 91%, a negative predictive value of 86%, a sensitivity of 94%, and a specificity of 86% for death or transplantation. This algorithm can be applied on admission, thus expediting decision-making.

CONCLUSION

We identified biochemical markers that may be useful in predicting outcome in patients with non-paracetamol-induced FHF and should be evaluated further in a different patient population.

Quantitative determination of free intracellular alpha-keto acids in neutrophils

For the first time, a procedure is described for the quantitative analysis of free alpha-keto acid content in human neutrophils (PMNs) relative to single cell number by reversed-phase fluorescence high-performance liquid chromatography. The procedure is minimally invasive and is unsurpassed in the quality of PMN separation, ease of sample preparation as well as sample stability. This method can satisfy the rigorous demands for an ultra-sensitive, comprehensive and rapid intracellular alpha-keto acid analysis in particularly for the surveillance of severe diseases as well as cellular or organ dysfunction.

The effect of hypothermia on primary porcine hepatocyte metabolism monitored by (1H) nuclear magnetic resonance spectroscopy

OBJECTIVE

The aim of our study was to use (1H) nuclear magnetic resonance (NMR) spectroscopy as a tool to assess metabolic functions of hepatocytes and to monitor major metabolic pathways of these cells during culture following hypothermic preservation.

METHODS

After isolation, 2 x 10(7) primary porcine hepatocytes were preserved at 4 degrees C in supplemented Leibovitz L-15 medium for 48 h. Viability was assessed at isolation, 24 and 48 h. At isolation and at 48 h cells were plated and cultured with serum free supplemented Williams E medium. 1H NMR spectroscopy was used to assess indices of glucose metabolism, ammonia clearance indices and ketone bodies precursors at 48 h post-plating. Peak integration was applied with sodium 3-(trimethylsilyl-2,2,3,3-2H4)-1-propionate as an internal standard to obtain quantitative results.

RESULTS

Results were obtained from six isolations. Viability was 78.1 +/- 1.2% at isolation, 69 +/- 3.4% at 24 h and 58.9 +/- 3.8% at 48 h of hypothermia. Plating efficiency was 87 +/- 4% for freshly isolated cells and 33.6 +/- 7.6% for hypothermically preserved cells. Glucose consumption was comparable in both groups. Hypothermically preserved cells consumed more threonine, produced more pyruvate and alanine but less lactate. They also produced less acetate and consumed less tyrosine. Glutamate and glutamine concentrations were similar under both conditions.

CONCLUSION

1H NMR spectroscopy is a valid method for assessing metabolic pathways of cultured primary porcine hepatocytes. Although hypothermically preserved cells had a reduced plating efficiency, they were still metabolically active. Thus, hypothermia can be used as a temporary preservation technique for primary porcine hepatocytes.

1H NMR spectroscopy as a tool to evaluate key metabolic functions of primary porcine hepatocytes after cryopreservation

Proton NMR spectroscopy of biological fluids has produced interesting results lately. We used the technique to investigate the effects of cryopreservation on primary porcine hepatocytes as successful cryopreservation of primary porcine hepatocytes is of importance to the development of bioartificial liver support systems. After isolation 10(8) hepatocytes were cryopreserved for 1 week in Williams E/10% DMSO, either by quick freezing (-5 to -30 degrees C/min), slow freezing (-0.3 to -3 degrees C/min) or stepwise freezing protocols on cell suspensions and confluent cell plates. Plating efficiency was assessed by percentage LDH release. Metabolic functions of cryopreserved hepatocytes at 24 h post-thawing were compared with those of fresh hepatocyte cultures at 48 h. 1H nuclear magnetic resonance spectroscopy of the culture medium post-incubation, using the presaturation technique, assessed the following: glucose metabolism, transamination and glutamine synthesis and succinate synthesis. Freshly isolated cells had a viability of 82 +/- 4.3% and a plating efficiency of 87 +/- 3.8%. All cryopreservation protocols resulted in significantly reduced viability and plating efficiency. No significant differences were observed between different cryopreservation media or protocols. When comparing cryopreserved with freshly isolated cells, we observed that metabolism of acetyl-CoA precursors was significantly impaired in cryopreserved cells. Lactate and pyruvate production was also significantly less, although glucose consumption was similar. No differences were observed in gluconeogenic amino acid metabolism, transamination and urea synthesis. 1H NMR spectroscopy can be used to provide information about metabolic activity and functions of cultured primary cells.

The role of surface wettability on hepatocyte adhesive interactions and function

In this paper the effect of surface wettability on hepatocyte morphology and function was studied, using clean and octadecylsylane (ODS)-coated glass as a model for hydrophilic and hydrophobic surfaces, respectively. C3A cells--a hepatoblastoma cell line, and freshly obtained porcine hepatocytes were cultured for a short-time period of up to 4 days on the above substrata. Hepatocyte adhesive interactions were characterized monitoring the initial cell attachment, the overall cell morphology, the formation of focal adhesions, and actin filaments. Since hepatocytes showed a clear tendency for homotypic adhesion on ODS, specific E-cadherin staining was used to visualize the intercellular contacts by immunofluorescence microscopy. Additionally, functional assays were carried out to monitor proliferation, metabolic activity, and albumin synthesis of C3A cells. It could be shown that both C3A cells and normal porcine hepatocytes spread better on hydrophilic glass; spreading being accompanied by the development of pronounced actin stress fibers and focal adhesion contacts. In contrast, on hydrophobic substrata predominant cell-cell interactions took place which led to intense E-cadherin staining in the intercellular contacts of porcine hepatocytes but not in C3A cells. On the other hand, metabolic activity and growth of C3A cells were reduced on hydrophobic ODS, but albumin synthesis was similar on both surfaces. It was concluded that the wettability of materials has a strong influence on the attachment and morphology of hepatocytes while the influence of surface properties on the functional activity of hepatocytes still remains to be elucidated.

Development of a hybrid liver support system

Hybrid liver systems are being developed as temporary extracorporeal liver support therapy. The overview given here emphasizes the development of both hepatocyte culture models for bioreactors and of systems for clinical therapy. In vitro studies demonstrate long term external metabolic function in isolated primary hepatocytes within bioreactors. These systems are capable of supporting essential liver functions. Animal experiments verify the possibility of upscaling bioreactors for clinical treatment. However, since there is no reliable animal model for investigating the treatment of acute liver failure, the promising results obtained from these studies have limited relevance to human beings. The small number of clinical studies performed thus far are not sufficient to enable any conclusions concerning improvements in the therapy of acute liver failure. Although important progress has been made in the development of these systems, multiple hepatocyte culture models and bioreactor constructions are being discussed in the literature, indicating competition in this field of medical research. For the use of hepatocytes and sinusoidal endothelial cells in coculture, a bioreactor has been designed. The construction is based on capillaries for hepatocyte aggregate immobilization. Four separate capillary membrane systems, each permitting a different function, are woven in order to create a three-dimensional network. Cells are perfused via independent capillary membrane compartments. Decentralized oxygen supply and carbon dioxide removal with low gradients is possible. The parallel use of identical units enables easy upscaling. Initial studies on the use of discarded organs that are unsuitable for transplantation as a source for primary human liver cells seem to be promising.

The simulated microgravity environment maintains key metabolic functions and promotes aggregation of primary porcine hepatocytes

The high aspect ratio vessel allows the culture of primary porcine hepatocytes in an environment of low shear stress and simulated microgravity. Primary porcine hepatocytes have been difficult to maintain in culture long term while preserving their metabolic functions. This study was carried out in order to characterise key metabolic functions of cell aggregates formed by primary porcine hepatocytes cultured in a high aspect ratio vessel for a predetermined period of 21 days. 10(8) porcine hepatocytes were loaded into the high aspect ratio vessel and continuously rotated during the experiments. 0.7 ml of the culture medium was sampled on days 1, 2, 4, 7, 10, 14 and 21. 1H nuclear magnetic resonance spectroscopy of the culture medium, using the presaturation technique, assessed the following: glucose metabolism, glutamine synthesis and ketogenesis. There was glucose breakdown anaerobically during the first 10 days as manifested by lactate production and pyruvate and threonine consumption. After day 10 there was significantly smaller lactate production (day 1 vs day 10 P < 0.01), and significantly smaller pyruvate (day 1 vs day 14 P < 0.03) and threonine consumption (day 1 vs day 10 P < 0.002), indicative of an aerobic metabolic pattern. Significantly more glutamate was produced after day 10 (day 1 vs day 10 P < 0.031), and more glutamine was consumed after day 14. There was a steadily diminishing production of acetate which reached a minimum on day 14 (day 2 vs day 14 P < 0.00014). After an initial 10 day period of acclimatisation cell aggregates formed in the high aspect ratio vessel switched from the anaerobic pattern of metabolism to the more efficient aerobic pattern, which was exhibited until the experiments were terminated. The high aspect ratio vessel is suitable for long-term culture of porcine hepatocytes and it is worthwhile carrying out scale-up feasibility studies.

Physiological and cell biological aspects of perfusion culture technique employed to generate differentiated tissues for long term biomaterial testing and tissue engineering

Optimal results in biomaterial testing and tissue engineering under in vitro conditions can only be expected when the tissue generated resembles the original tissue as closely as possible. However, most of the presently used stagnant cell culture models do not produce the necessary degree of cellular differentiation, since important morphological, physiological, and biochemical characteristics disappear, while atypical features arise. To reach a high degree of cellular differentiation and to optimize the cellular environment, an advanced culture technology allowing the regulation of differentiation on different cellular levels was developed. By the use of tissue carriers, a variety of biomaterials or individually selected scaffolds could be tested for optimal tissue development. The tissue carriers are to be placed in perfusion culture containers, which are constantly supplied with fresh medium to avoid an accumulation of harmful metabolic products. The perfusion of medium creates a constant microenvironment with serum-containing or serum-free media. By this technique, tissues could be used for biomaterial or scaffold testing either in a proliferative or in a postmitotic phase, as is observed during natural development. The present paper summarizes technical developments, physiological parameters, cell biological reactions, and theoretical considerations for an optimal tissue development in the field of perfusion culture.

Bioreactors for hybrid liver support: historical aspects and novel designs

A novel bioreactor construction has been designed for the utilization of hepatocytes and sinusoidal endothelial cells. The reactor is based on capillaries for hepatocyte aggregate immobilization. Three separate capillary membrane systems, each permitting a different function are woven in order to create a three dimensional network. Cells are perfused via independent capillary membrane compartments. Decentralized oxygen supply and carbon dioxide removal with low gradients are possible. The use of identical parallel units to supply hepatocytes facilitates scale up. In vitro studies demonstrate long-term external metabolic function in primary isolated hepatocytes within bioreactors. These systems are capable of supporting essential liver functions. Animal experiments have verified the possibility of scaling-up the bioreactors for clinical treatment. However, since there is no reliable animal model for investigation of the treatment of acute liver failure, the promising results obtained from these studies have limited relevance. The small number of clinical studies performed so far is not sufficient to reach conclusions about improvements in the therapy of acute liver failure. Although important progress has been made in the development of these systems, various hepatocyte culture models and bioreactor constructions are being discussed in the literature, which indicates competition in this field of medical research. An overview, which emphasizes the development of hepatocyte culture models for bioreactors, subsequent in vitro studies, animal studies, and clinical application, is also provided.

Hepatocyte liver-assist systems--a clinical update

Liver failure is a serious problem that affects thousands of people in the United States each year. Other than liver transplantation, a supportive therapy has been unavailable for patients with liver failure that is refractory to medical treatment. An apparent solution to this problem is a hepatocyte liver-assist system. Such a system is composed of mammalian hepatocytes loaded in a mechanical apparatus, such as a hollow fiber cartridge. During extracorporeal perfusion of the system, the hepatocytes provide metabolic function to the patient with liver failure. At least two extracorporeal hepatocyte systems have shown promise in human clinical trials of acute liver failure. In fact, one system has gained approval from the Food and Drug Administration for testing in a randomized multicenter clinical trial. In this article, key issues of clinical testing are reviewed, and major contributions and questions that remain unresolved are emphasized.