- Email: [email protected]
172Safety of continuous human hepatocyte liver assist device
Program Abstracts
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ALOANTIBODIES A N T I R E D C E L L IN P A T I E N T S ~ I T H SERIUS IIEPATIC ILLNESS J L U n r e i n . V R a m u n d o . A Gonzalez. M Arias. A G u e v a r a Lrnidad H e m o t e r a p i a H g a "'Cosine Argerieh'" B u e n o s Aires, Argentina P u r p o s e - T o delermine the prevalence and clinical i m p l i c a n c e o f the aloinmunization anti red cell ( A A B ) in this population M a t e r i a l A n d M e t h o d s ; 504 patients clinical evaluated, b e t ~ e e n august 94 and s e p t e m b e r 09 The s a m p l e s w e r e procesated In A B O . Rh fenotipic and others red cell antigen, direct C o o m b s test ( D C T ) and indirel C o o m b s lest ( I C T ) and determination o f irregular a n l i b o d y e s ( I A D ) T u b e and gel test techniques were used in e v e r y c a s e The palients after a years o r m o r e o f O L T with ICT. D C T . l A D W e study Ion inmunoglobulin type and title with comercial idemificated cell R e s u l t s : 307 (010o) are w o m e n and 197 (39°,o) men A v e r a g e a g e 34 years (15/68) W e are detected A A B in 7c~ c a s e s ( 1 5 . 6 % ) I n m u n o g l o b u l i n "'G'" detention 5 anti K e l l a v e r a g e title 1/32. 4 in w o m e n (postransfusional etiology) and I non determinated etiology for husband fenolipic, I anli "'C'" title 1/64. I anti "'E'" title 1/64. I anti Kidd "'A'" title 1/32 in all c a s e s for previus non isot~notipic Iransfusion in other c e n t e r s lnmunoglobulin "iVI'" delention 74 anti "T" (a~erage title 1/16) and lermic r a n g e b e t w e e n 4 and 15 ~C 25 anti "l'" x,,as relationated with cirrhosis "'C'" virus and 49 cases non determinated cause In 8 cases (he D C T w a s positives (3 for eefalosporine. 3 tbr a u t o i n m u n i t y illness and 2 obil with non determinated causes) r h e patients with I year or m o r e o f O L T w a s all D A I n e g a t i v e s ( " i n m u n o s u p p r e s s i o n positive protection") and in 9 cases they are D C T positives all tbr cefalosporines Pos transthsional a d v e r s e s reaction non registrated C o n c l u s i o n s : T h r o u u the p r e v i o u s O L T sistematitalons in i n n t u n o h e m a t o l o g y high quality transthsional m e d i c i n e for patients is posib[e, and Ihe rule
GRAFT VERSUS HOST DISEASE IN KIDNEY TRANSPLANTATION EP Molmenli, D Smith, E Agnra, M Levy, R Goldstein, C Fasola, J Baker, T Gonwa, J McConmack, M Stone,and G Klintmalm. Baylor University Medical Canter, Dallas, Texas. INTRODUCTION: Graft ~ersushost disease(GVHD) is a rare but devastating complication of kidney transplantation. It occurs when T-lymphecylas from the kidney donor engraft in the recipient and attack the host tissues (skin, bone marrow, liver. intestinal tract). The improved results of HLA matched allogmlL~has led In a policy of giving priority to recipients with all of the HLA A, B, and DR antigens of the potential donor. The recipient however, often has antigens not pr~ent in the donor. These antigens can be the target for GVHD. PURPOSE: To examine the incidence of GVHD in kidney recipients. M E T H O D : Prospectively collected data on a total of gig renal transplantsperformed in g51 recipients at our Institution betweenJune 19g$ and December 1999. Immunosuppressinnprotocols consistedof cyclosporine(CyA) or Tacrolimus (FK), and tawing dosesof corticosgeroids in all patients. Azathioprine, mycophanolatemofetil, and OKT3 were usedas routine third immunosuppressive agents, as induction therapy in casesof delayed graft function, or as treatmentfor episodes of acute cellular rejection. Corticosteroids were weanedand selectively discontinued. After discharge from the hospital, recipients were followed up closely fog a period of six weeks. After that time period, patientswere followed locally by their referring physicians. RESULTS: Them was one episode of GVHD in the 0 mismatched recipients group. The patient was a 20 year old Caucasianwoman who had renal failure due to systemic lupus erythematusns. The donor was an 18 year old Hispanic male. The recipient had been on hemodialysisfor four years. Postoperatively she was placed on an immannsuppreasiveregimen including CyA, Azathinprine and pradnisolone. The recipient presentedon post op day 61 with fever, lankopenia,and elevated liver enzymes. She had a long course complicated hy intermittent cytopenins and fevers. She experiencedCMV infection and a Staphylococcalinfection originating in an intravenousline. She eventually becameprofoundly leukopenicand died from overwhelming infection with Candidn, Aspergillus, and Adenovirns. The diagnosis of GVHD was confirmed by demonstrating engraft'recurwith male (XY) [yrophacytas. In addition it was shown that the only HLA A and B antigens.detectablehy serologic methods were thoseof the kidney donor. Testing of DNA for variable number of tandem repeatsOCNTR) and for HLA class il alleles indicated only recipient phenotypesin the buff-y coat sample- however, this was misleading becauseonly 4% of the burly coat cells were lymphocytas. CONCLUSION: GVHD was found to have an incidence of 0. I O/oamoug renal transplantrecipienu. [t wss ohserved in a caseof 0 mismatched HLA antigens. This lack of mismatches in the direction of graft rejection predisposes to GVHD. A high index of suspicinn is necessaryto diagnose casesof GVHD. When it occurs, it is associatedwith a high morbidity and mortality. When trying to make the labomtury diagnosis of GVHD it is important to select for tests that look specifically at the T lymphecytes rather than at the whole huffy coal
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SAFETY OF CONTINUOUS HUMAN HEPATOCYTE LIVER ASSIST DEVICE J. M. Millist,D.C. Cronin t. R. Johnson: H. Conjeevaraml, L. Brady ~ R. O'Laughiin t, C, Conlin:,J. Brotherton 2, D. Trag_lia2. P. Maguirc z. ITransplant Surgery, University of Chicago, Chicago, IL, "VilaGen, Inn, LaJolla, CA, Patients with fulroinant hepatic failure (FHF0 have an unacceptably high pre- and post- transplant mortality rate. This is due to the lack of timely transplantation and dcterioration caused by the rapidly failing liver. Porcine based liver assist devices have the disadvantages of intermittenl therapy, minimal hepatocyte mass, and the potenlia] to transmit retroviruses. We have developed a system that provides continuous hepatic support with 400 gins of immortalized human hepatocytes for up to I 0 days. We are reporting the use of this newly designed Extracorporeal Liver Assist Device (ELAD) to treat three patients with rapidly progressive FHF. The purpose of this phase of the study was to demonstrate safety of the system. Methods: The records of all three patients (2 adults, I child) who have been ~ea"~"e'~[-werereviewed. All three patients had non-acetaminophen induced liver failure. All three patients were in stage Ill coma and listed for transplantation. The ELAD was used for 18-80 hours depending on organ availability. The ELAD was discontinued immediately following transplantation when acceptable liver function was observed. Data was converted to a percent change from baseline (immediately prior In ELAD initiation) and analyzed utilizing ANOVA comparison. Results: During the initial 24 hours after placement on the ELAD, there was no significant change (p value >0.05) in the following parameters: Heart rate, C3a, CSa, 1L-6, TNF, prothrombin time, platelets, ammonia levels, lactate, creatinine, ALT, or bilirubin. Evaluating all three patients together there was a significant dncrease (p value <0.05) in the following parameters: mean arterial pressure, WBC, and fibrinogen. Excluding the one child, treated with significant co-morbidity, the only significant change was fibrinognn (Hour 0 value: 206, Hour 24 value: 176); there were no significant changes in any of Ihc values. One of the patients under, vent ICP monitoring and this measurement was stable a112+ 2 mm Hg during therapy (36 hours). Thero were no adverse events associated with therapy. Al[three patients were bridged to transplantation. Two of the three are alive, while one (the child) died in the posl-operative period. Oxygen consumption and glucose utilization of the cartridges indicated continuous metabolic function of the cells throughout all three applications of the ELAD system. There were no mechanical malfunctions during treatments. Conclusions: Hcmodynamic and biochemical stability was achieved throughout the treatment course. Although there was a decrement in some measured parameters, these did not impact clinical events. The cells demonstrated metabolic function throughout the treatment. The ELAD therapy bridged the patients to transplantation. The EL.M) system fulfilled the initial test of safety for the first three patients.
EXTRA.CORPOREAL LIVER SUPPORT IN A PATIENT WITH FULM[NANT LIVER FAILURE USING A NEW SYSTEM A Gadnno. S Hyon. S Macins. E Sorkin` A Gullesio. A Villamil. E de Santibo~es. C Bonofiglio. G Rosa Die.~., J Vazquc,.:. P Ar~bay. Liver Transplantation UniL Intensive Care Unit and Experimental Medicine Unit. Hospital Italiano de BuenosAires. Argnmina. ACute liver failuro is an important cause of morbidi~' and monality. Conventional therapies are not suffciemly effective. Liver transplantation may be life saving, but u bridge thera~' is ncoded until ltunsplanlatiou is performed. Xenohemodiafillrolinn IXHDF). a combinalinn of cxtrocoq0oreal liver perfusinn, hcmofillmtion and ~'alisis is aimed ,'is a tmnsito~ support The firsl clinical case of XHDF is preseatcd. A 33 •,.car old woman ~,as referred to our hospital with [ulrninant hepatic faihu-c. The poficnt presented with stage IV encephalopathy. A CAT scan of the brain showed diffuse edema. The patient v,as placed on mechanical ventilation and an immcraninl prossurc (ICP) sensor revealed an ICP wa]uc of 2-I. cm H20. A transjugnlar liver biopay showed mussivc necrosis. The ptaicot was included in the waiting list for liver transplantation. After failure of convcntion~ therapeutic steps, a XHDF procedure was pafformed through a double lumen catheter inserted in the right femoral vein. A tubing from the cathet~ was passed through a roller pump and connected to a hcmofiltar. The lataru] ports of the hemofilter were then connected to the liver circuit over another ~'nchronized miler pump. A pig liver was harvested. The portal vein was cannulated for perfusion and after priming the liver it ,.ms set into a pol.vcarbonate roservoir. Ixrmittthg the suprahepafic vein to drain fro= into the containe*. The livex wns perfu.~d with group O human RBCs. The reconstituted blood was poured into the ,L~r','oir from where il was circulated through an ox'ygnnafion membrane and warmed to 37X" A pediatric c~.,ntrifugnIpump propelled the blood in this circuit. The oml~ o! the circuit was adjusled .so as to mantain a portal pressure of al~proximataly 20 mmHg The Ix'¢ssures gnnemtod ~ ' the miler pumps were equalized to avoid the cxchangn of fluids between the hvo circuits, and the flow was set at 100 ml/min. The ~'stcm ~as in operation for 5 hours. The ICP decreasod immediataly from an initial value of 34 cm H20 before XHDF to 5 cm H20. The I~'¢ls of serum amonia (673 In 37n ug/dl),lactic acid ( I I to 5mmoIB), and bilirmbio (7.4 to 2.$ mg/cg) fell throughout the preceduro.Monoothylglycinex.'ylidide, a product of hepatic ]idecaine metabolism. was undetectable he(ore initiation of the ProCedure and inoxasod in the determinations at 15 min and 30 rain through XHDF (92.9 and 107.65 ngtml.resp¢ctively). Normal bile (bilirruhin 16.07 mE/all) ~-as produced by. the pig liver at a rate of 6 ml/h. Ammonia. which was progrossively cleared front the hepatic circuit, col'T~,'ponded with an therese of ur~ in the pust-hepadc citcoit. Normal macroscopic and histalogical features were observed in the pig liver throughout XHDF with no signs of hcpatoc.vte necrosis, immune deposits or cell infiltrates. The patient underwent an tmevenfful liver Wans/~am~ion` rap/dly rocovering lis~r function. In conclusion. XHDF is a new method that can constitute an altemafi'~: clinical Iheml~. tu support patieaats with fulminanl hc'patic failure until an organ is avaiinblc for trans#antation.
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ALOANTIBODIES A N T I R E D C E L L IN P A T I E N T S ~ I T H SERIUS IIEPATIC ILLNESS J L U n r e i n . V R a m u n d o . A Gonzalez. M Arias. A G u e v a r a Lrnidad H e m o t e r a p i a H g a "'Cosine Argerieh'" B u e n o s Aires, Argentina P u r p o s e - T o delermine the prevalence and clinical i m p l i c a n c e o f the aloinmunization anti red cell ( A A B ) in this population M a t e r i a l A n d M e t h o d s ; 504 patients clinical evaluated, b e t ~ e e n august 94 and s e p t e m b e r 09 The s a m p l e s w e r e procesated In A B O . Rh fenotipic and others red cell antigen, direct C o o m b s test ( D C T ) and indirel C o o m b s lest ( I C T ) and determination o f irregular a n l i b o d y e s ( I A D ) T u b e and gel test techniques were used in e v e r y c a s e The palients after a years o r m o r e o f O L T with ICT. D C T . l A D W e study Ion inmunoglobulin type and title with comercial idemificated cell R e s u l t s : 307 (010o) are w o m e n and 197 (39°,o) men A v e r a g e a g e 34 years (15/68) W e are detected A A B in 7c~ c a s e s ( 1 5 . 6 % ) I n m u n o g l o b u l i n "'G'" detention 5 anti K e l l a v e r a g e title 1/32. 4 in w o m e n (postransfusional etiology) and I non determinated etiology for husband fenolipic, I anli "'C'" title 1/64. I anti "'E'" title 1/64. I anti Kidd "'A'" title 1/32 in all c a s e s for previus non isot~notipic Iransfusion in other c e n t e r s lnmunoglobulin "iVI'" delention 74 anti "T" (a~erage title 1/16) and lermic r a n g e b e t w e e n 4 and 15 ~C 25 anti "l'" x,,as relationated with cirrhosis "'C'" virus and 49 cases non determinated cause In 8 cases (he D C T w a s positives (3 for eefalosporine. 3 tbr a u t o i n m u n i t y illness and 2 obil with non determinated causes) r h e patients with I year or m o r e o f O L T w a s all D A I n e g a t i v e s ( " i n m u n o s u p p r e s s i o n positive protection") and in 9 cases they are D C T positives all tbr cefalosporines Pos transthsional a d v e r s e s reaction non registrated C o n c l u s i o n s : T h r o u u the p r e v i o u s O L T sistematitalons in i n n t u n o h e m a t o l o g y high quality transthsional m e d i c i n e for patients is posib[e, and Ihe rule
GRAFT VERSUS HOST DISEASE IN KIDNEY TRANSPLANTATION EP Molmenli, D Smith, E Agnra, M Levy, R Goldstein, C Fasola, J Baker, T Gonwa, J McConmack, M Stone,and G Klintmalm. Baylor University Medical Canter, Dallas, Texas. INTRODUCTION: Graft ~ersushost disease(GVHD) is a rare but devastating complication of kidney transplantation. It occurs when T-lymphecylas from the kidney donor engraft in the recipient and attack the host tissues (skin, bone marrow, liver. intestinal tract). The improved results of HLA matched allogmlL~has led In a policy of giving priority to recipients with all of the HLA A, B, and DR antigens of the potential donor. The recipient however, often has antigens not pr~ent in the donor. These antigens can be the target for GVHD. PURPOSE: To examine the incidence of GVHD in kidney recipients. M E T H O D : Prospectively collected data on a total of gig renal transplantsperformed in g51 recipients at our Institution betweenJune 19g$ and December 1999. Immunosuppressinnprotocols consistedof cyclosporine(CyA) or Tacrolimus (FK), and tawing dosesof corticosgeroids in all patients. Azathioprine, mycophanolatemofetil, and OKT3 were usedas routine third immunosuppressive agents, as induction therapy in casesof delayed graft function, or as treatmentfor episodes of acute cellular rejection. Corticosteroids were weanedand selectively discontinued. After discharge from the hospital, recipients were followed up closely fog a period of six weeks. After that time period, patientswere followed locally by their referring physicians. RESULTS: Them was one episode of GVHD in the 0 mismatched recipients group. The patient was a 20 year old Caucasianwoman who had renal failure due to systemic lupus erythematusns. The donor was an 18 year old Hispanic male. The recipient had been on hemodialysisfor four years. Postoperatively she was placed on an immannsuppreasiveregimen including CyA, Azathinprine and pradnisolone. The recipient presentedon post op day 61 with fever, lankopenia,and elevated liver enzymes. She had a long course complicated hy intermittent cytopenins and fevers. She experiencedCMV infection and a Staphylococcalinfection originating in an intravenousline. She eventually becameprofoundly leukopenicand died from overwhelming infection with Candidn, Aspergillus, and Adenovirns. The diagnosis of GVHD was confirmed by demonstrating engraft'recurwith male (XY) [yrophacytas. In addition it was shown that the only HLA A and B antigens.detectablehy serologic methods were thoseof the kidney donor. Testing of DNA for variable number of tandem repeatsOCNTR) and for HLA class il alleles indicated only recipient phenotypesin the buff-y coat sample- however, this was misleading becauseonly 4% of the burly coat cells were lymphocytas. CONCLUSION: GVHD was found to have an incidence of 0. I O/oamoug renal transplantrecipienu. [t wss ohserved in a caseof 0 mismatched HLA antigens. This lack of mismatches in the direction of graft rejection predisposes to GVHD. A high index of suspicinn is necessaryto diagnose casesof GVHD. When it occurs, it is associatedwith a high morbidity and mortality. When trying to make the labomtury diagnosis of GVHD it is important to select for tests that look specifically at the T lymphecytes rather than at the whole huffy coal
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SAFETY OF CONTINUOUS HUMAN HEPATOCYTE LIVER ASSIST DEVICE J. M. Millist,D.C. Cronin t. R. Johnson: H. Conjeevaraml, L. Brady ~ R. O'Laughiin t, C, Conlin:,J. Brotherton 2, D. Trag_lia2. P. Maguirc z. ITransplant Surgery, University of Chicago, Chicago, IL, "VilaGen, Inn, LaJolla, CA, Patients with fulroinant hepatic failure (FHF0 have an unacceptably high pre- and post- transplant mortality rate. This is due to the lack of timely transplantation and dcterioration caused by the rapidly failing liver. Porcine based liver assist devices have the disadvantages of intermittenl therapy, minimal hepatocyte mass, and the potenlia] to transmit retroviruses. We have developed a system that provides continuous hepatic support with 400 gins of immortalized human hepatocytes for up to I 0 days. We are reporting the use of this newly designed Extracorporeal Liver Assist Device (ELAD) to treat three patients with rapidly progressive FHF. The purpose of this phase of the study was to demonstrate safety of the system. Methods: The records of all three patients (2 adults, I child) who have been ~ea"~"e'~[-werereviewed. All three patients had non-acetaminophen induced liver failure. All three patients were in stage Ill coma and listed for transplantation. The ELAD was used for 18-80 hours depending on organ availability. The ELAD was discontinued immediately following transplantation when acceptable liver function was observed. Data was converted to a percent change from baseline (immediately prior In ELAD initiation) and analyzed utilizing ANOVA comparison. Results: During the initial 24 hours after placement on the ELAD, there was no significant change (p value >0.05) in the following parameters: Heart rate, C3a, CSa, 1L-6, TNF, prothrombin time, platelets, ammonia levels, lactate, creatinine, ALT, or bilirubin. Evaluating all three patients together there was a significant dncrease (p value <0.05) in the following parameters: mean arterial pressure, WBC, and fibrinogen. Excluding the one child, treated with significant co-morbidity, the only significant change was fibrinognn (Hour 0 value: 206, Hour 24 value: 176); there were no significant changes in any of Ihc values. One of the patients under, vent ICP monitoring and this measurement was stable a112+ 2 mm Hg during therapy (36 hours). Thero were no adverse events associated with therapy. Al[three patients were bridged to transplantation. Two of the three are alive, while one (the child) died in the posl-operative period. Oxygen consumption and glucose utilization of the cartridges indicated continuous metabolic function of the cells throughout all three applications of the ELAD system. There were no mechanical malfunctions during treatments. Conclusions: Hcmodynamic and biochemical stability was achieved throughout the treatment course. Although there was a decrement in some measured parameters, these did not impact clinical events. The cells demonstrated metabolic function throughout the treatment. The ELAD therapy bridged the patients to transplantation. The EL.M) system fulfilled the initial test of safety for the first three patients.
EXTRA.CORPOREAL LIVER SUPPORT IN A PATIENT WITH FULM[NANT LIVER FAILURE USING A NEW SYSTEM A Gadnno. S Hyon. S Macins. E Sorkin` A Gullesio. A Villamil. E de Santibo~es. C Bonofiglio. G Rosa Die.~., J Vazquc,.:. P Ar~bay. Liver Transplantation UniL Intensive Care Unit and Experimental Medicine Unit. Hospital Italiano de BuenosAires. Argnmina. ACute liver failuro is an important cause of morbidi~' and monality. Conventional therapies are not suffciemly effective. Liver transplantation may be life saving, but u bridge thera~' is ncoded until ltunsplanlatiou is performed. Xenohemodiafillrolinn IXHDF). a combinalinn of cxtrocoq0oreal liver perfusinn, hcmofillmtion and ~'alisis is aimed ,'is a tmnsito~ support The firsl clinical case of XHDF is preseatcd. A 33 •,.car old woman ~,as referred to our hospital with [ulrninant hepatic faihu-c. The poficnt presented with stage IV encephalopathy. A CAT scan of the brain showed diffuse edema. The patient v,as placed on mechanical ventilation and an immcraninl prossurc (ICP) sensor revealed an ICP wa]uc of 2-I. cm H20. A transjugnlar liver biopay showed mussivc necrosis. The ptaicot was included in the waiting list for liver transplantation. After failure of convcntion~ therapeutic steps, a XHDF procedure was pafformed through a double lumen catheter inserted in the right femoral vein. A tubing from the cathet~ was passed through a roller pump and connected to a hcmofiltar. The lataru] ports of the hemofilter were then connected to the liver circuit over another ~'nchronized miler pump. A pig liver was harvested. The portal vein was cannulated for perfusion and after priming the liver it ,.ms set into a pol.vcarbonate roservoir. Ixrmittthg the suprahepafic vein to drain fro= into the containe*. The livex wns perfu.~d with group O human RBCs. The reconstituted blood was poured into the ,L~r','oir from where il was circulated through an ox'ygnnafion membrane and warmed to 37X" A pediatric c~.,ntrifugnIpump propelled the blood in this circuit. The oml~ o! the circuit was adjusled .so as to mantain a portal pressure of al~proximataly 20 mmHg The Ix'¢ssures gnnemtod ~ ' the miler pumps were equalized to avoid the cxchangn of fluids between the hvo circuits, and the flow was set at 100 ml/min. The ~'stcm ~as in operation for 5 hours. The ICP decreasod immediataly from an initial value of 34 cm H20 before XHDF to 5 cm H20. The I~'¢ls of serum amonia (673 In 37n ug/dl),lactic acid ( I I to 5mmoIB), and bilirmbio (7.4 to 2.$ mg/cg) fell throughout the preceduro.Monoothylglycinex.'ylidide, a product of hepatic ]idecaine metabolism. was undetectable he(ore initiation of the ProCedure and inoxasod in the determinations at 15 min and 30 rain through XHDF (92.9 and 107.65 ngtml.resp¢ctively). Normal bile (bilirruhin 16.07 mE/all) ~-as produced by. the pig liver at a rate of 6 ml/h. Ammonia. which was progrossively cleared front the hepatic circuit, col'T~,'ponded with an therese of ur~ in the pust-hepadc citcoit. Normal macroscopic and histalogical features were observed in the pig liver throughout XHDF with no signs of hcpatoc.vte necrosis, immune deposits or cell infiltrates. The patient underwent an tmevenfful liver Wans/~am~ion` rap/dly rocovering lis~r function. In conclusion. XHDF is a new method that can constitute an altemafi'~: clinical Iheml~. tu support patieaats with fulminanl hc'patic failure until an organ is avaiinblc for trans#antation.