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ANP preconditioning protects against hepatic ischemia-reperfusion injury by attenuating necrotic and apoptotic cell death
202A
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
113
114
LIVER TRANSPLANT RECIPIENTS OLDER THAN 60 YEARS HAVE A GOOD SURVIVAL, BUT A HIGH INCIDENCE OF POST-TRANSPLANT NEOPLASIA. J. Ignacio Herrero, Jorge Quiroga, Fernando Pardo, Bruno San-
ANP PRECONDITIONING PROTECTS AGAINST HEPATIC ISCHEMIAREPERFUSION INJURY BY ATTENUATING NECROTIC AND APOPTOTIC CELL DEATH. Tobias Gerwig, Department of Pharmacy, Munich Ger-
gro, Maite Herraiz, Javier Alvarez-Cienfuegos, Jesus Prieto, Clinica Universitaria, Pamplona Spain
many; Herbert Meissner, Institute of Pathology, Munich Germany; Hans Arnholdt, Zentralklinikum Augsburg, Augsburg Germany; Manfred Bilzer, Department of Medicine II, Munich Germany; Alexandra K Kiemer, Angefika M Vollmar, Department of Pharmacy, Munich Germany; Alexander L Gerbes, Department of Medicine II, Munich Germany
In recent years, the age of liver transplant recipients has increased. Short- and mid-term survival of older patients is comparable to that of younger patients, but the incidence of some age-related complications such as the development of 'de novo' neoplasia has not been studied. Patients and Methods: Between June 1994 and December 2000, 112 adult patients with liver cirrhosis received a first liver graft. They were divided in two groups: group I: patients younger than 60 years (N=54, median age: 52.65, range: 35.5-59.6) and group II: patients older than 60 years (N = 58, median age: 65.6 years, range: 60.7-73.7). They were followed up until June 2001. Baseline characteristics of the patients, their survivals and the incidence of 'de novo' neoplasia in both groups were compared. Resultsi Before liver transplantation, older patients had more frequently hepatitis C virus infection (gr6up I: 22%, group II: 41%; P=0.04) and hepatocellular carcinoma (group I: 28%, group II: 47%; P=0.05) and had better liver function at the time of liver transplantation, as staged by ChildPugh's status (P =0.03). Survival of both groups was comparable (1-, 2-, 3- and 4-year survival rates: group I: 94%, 94%, 92% and 88%; group II: 88%, 86%, 83% and 83%; P=NS). Older patients had a greater incidence of de novo neoplasia (1-, 2-, 3- and 4-year rates: group 1: 0%, 0%, 7% and 15%; group II: 7%, 14%, 23% and 27%; P=0.008) and non-skin neoplasia (1-, 2-, 3- and 4-year rates: group I: 0%, 0%, 0% and 4%; group II: 6%, 8%, 13% and 18%; P=0.009) than younger patients, whereas the incidence of skin cancer was similar in both groups. Conclusions: Liver transplant recipients older than 60 years have a survival comparable to that of younger patients, but their incidence of post-transplant malignancy is higher. A careful surveillance for early detection of neoplasia after liver transplantation might be indicated in patients older than 60 years undergoing this procedure.
Introduction: Ischemia reperfusion (I/R) injury is a main cause for severe complications after liver transplantation and liver surgery. In our previous work we could show that preconditioning with the Atrial Natriuretic Peptide (ANP) protects against hepatic I/R injury (Gerbes et al., Hepatology 1998, 28:1309-1317). Aim of this study was to determine apoptotic and necrotic cell death in I/R injury of the isolated perfnsed rat liver and to investigate a potential effect of ANP. Methods: Livers from male Sprague-Dawley rats were perfused with Krebs Henseleit buffer with or without ANP (200nM) or 8-Br-cGMP (50/zM), an analogue of the second messenger of ANP, for 20 rain, stored in UW solution (4°C, 24h) and reperfused for up to 120 rain (n=5, each). Apoptotic cell death was quantified by measuring caspase-3-1ike activity and by TUNEL assays. Necrotic cell death was determined by lactate dehydrogenase (LDH) effiux in the perfusate and trypane blue uptake of liver tissue. Histological analysis was quantitated by an independent investigator in 10 highpower fields per experimental condition. Results: Caspase-3-1ike activity and TUNEL-positive cells peaked after 24h of cold ischemia. Preconditioning with ANP and 8-Br-cGMP, significantly (p< 0.05) reduced caspase-3-fike activity by 54% and 49%, respectively. TUNEL-positive cells significantly (p<0.05) decreased by 37% and 28%, respectively. This was particularly evident for hepatocytes (p<0.05) rather than for endothelial cells. Necrotic cell damage indicated by LDH-efflux increased during reperfnsion (274-+96 mU/min*g liver) and was significantly (p<0.05) attenuated by ANP and 8-Br-cGMP (90-+60, 101 -+44 mU/min*g liver). Histological analysis of reperfused livers for trypane blue uptake showed significant reduction of hepatocyte damage by more than 70% (p<0.05) in the periportal but not in the pericentral areas. Furthermore endothelial cell damage was prevented (p<0.05) in portal veins, but not in central veins. Conclusion: ANP reduces necrotic as well as apoptotic cell death in I/R injury of the isolated perfused rat liver. The protection seems to be most prominent against necrosis in late reperfusion but also affects apoptosis after cold ischemia. (supported by DFG Ge 576/14-1 and 14-2)
115
116
ONE YEAR RESULTS OF LOW DOSE COMBINATION OF TACROLIMUS AND SIROLIMUS IN LIVER TRANSPLANT RECIPIENTS W I T H HIGH RISK FOR CALCINEURIN INHIBITOR RELATED TOXICITY. Olaf Pri-
ROLE OF SERUM AND URINARY MARKERS IN MONITORING BONE LOSS IN LIVER TRANSPLANT RECIPIENTS. Khondker K Islam, Loyola
dohl, University of Leipzig, Surgery II, Leipzig Germany; Kathrin Heinemann, Thomas Hartwig, Rene Schwarz, Helmut Witzigmann, Peter Lamesch, Josef Fangmann, Frieder Berr, Johann Hauss, Kay R Kohlhaw, University of Leipzig, Leipzig Germany Sirofimns (SRL) was found to provide effective immunosuppression in kidney transplantation in combination with reduced doses of calcineurin inhibitors (CI), resulting in less CI related toxicity. In this study 22 patients at individually high risk for CI toxicity after liver transplantation (LTx) were enrolled in a named patient program. Indications for a low dose SRL/TAC immunosuppressive therapy were acute hepatic failure or initial non-functioning graft (n = 5), patient age (n=4), pre-existing renal disease (n = 6) or diabetes (n = 3) and hepatitis (n= 4). Immunosuppressionconsisted of a low dose combination of Tacrolimus (TAC, trough levels 5-7ng/ml), SRL (trough levels 6-8ng/ml) and corticosteroids in order to reduce cumulative side effects of each single and both drugs together. Results: Patient survival was 91% (2 patients died of multi organ failure and sepsis) after a mean observation time of 10,5 months. Graft survival was 78%, 3 patients underwent 4 re-LTx (initial non-function n=2, hepatic artery thrombosis n= 2). Median SRL through levels were 2,5 - 3 ng/ml within the first month and 4 - 4,5 ng/ml thereafter. Median TAC trough levels were 6,5 - 9 ng/ml within the first month and 5,5 - 7,5 ng/ml thereafter. Acute rejection (RAI 3 (n=2)) was successfully treated with steroids in 3 patients (14%). Cholangitis was diagnosed histologically in case of moderately elevated serum transaminases and was treated successfully with antibiotics in another 5 patients. Severe opportunistic infections with the exception of one lethal candida pneumonia were not observed. Median s-creatinine was < 100umot/1 in all patients within the observation period and 125umolA in the 6 patients with the pre-operatively impaired renal function. Only 1 patient developed de novo diabetes. Median s-cholesterol and s-triglyceride levels did not exceed the upper normal range, 3 patients required atorvastatin to normalise blood lipids. Conclusion: The combination of low dose SRL with low dose TAC resulted in a safe immunosuppressionwith moderate toxicity in patients with high risk for CI toxicity within the first year after LTx. An enlarged observation period and/or a prospective study may be of help to confirm these encouraging results.
University Medical Center, Maywood, IL; Kyung SKim, Howard University Hospital, Washington, D.C., DC; Rana P Sokhi, Ravi Kondaveeti, Abdul Nadir, Nikunj Shah, James M Harig, David H Van Thiel, Loyola University Medical Center, Maywood, IL Aim:Although osteoporosis is highly prevalent in the general population, it is more pronounced in transplant recipients. Bone loss is accelerated by the use of corticosteroids and immunosnppressive drugs. This retrospective analysis was done to evaluate the role of serum and urinary markers of bone loss as documented by repeated bone mineral density (BMD) measurements in liver transplant recipients. Methods: Twenty four liver transplant recipients were selected for this study.All 24 recipients had a bone mineral density determination done pre-transplant,as well as 6 and 12 months post transplant. Osteocalcin, Pro-collagen 1, intact PTH, 25 hydroxy vitamin D and bone specific alkaline phosphatase were used as serum markers and pyridinoline crosslinks was used as an urinary marker of bone loss. Descriptive statistics were applied on each variable and Pearson's correlations were done. Results:In this group 20 were male and 2 were female.Their ages ranged from 28 to 69 years with mean age of 28. Bone specific Alkaline Phosphatase correlated well with post transplant bone mineral density (BMD)in femoral neck (p=0.04).Calcium level correlated with post BMD in the lumber vertebrae (p=0024).Pro collagen peptide -1 correlated well with the change in BMD in femoral neck (p= 0.044) and bone specific alkaline phosphatase (p<0.0001).Osteocalcin and urinary crosslinks did not show any statistical significant correlation with changes in pre or post transplant BMD either in the lumber vertebrae or femoral neck.Post transplant BMD loss was more marked in the femoral neck than lumber vertebrae. Conclusions:Based upon these data post transplant(1)the risk of fracture is greater in the femoral neck area than the lumber vertebrae and(2)Pro collagen pepfide can be used as a surrogate marker for BMD determination in transplant patients to monitor bone loss particularly those at higher risk for fracture.
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
113
114
LIVER TRANSPLANT RECIPIENTS OLDER THAN 60 YEARS HAVE A GOOD SURVIVAL, BUT A HIGH INCIDENCE OF POST-TRANSPLANT NEOPLASIA. J. Ignacio Herrero, Jorge Quiroga, Fernando Pardo, Bruno San-
ANP PRECONDITIONING PROTECTS AGAINST HEPATIC ISCHEMIAREPERFUSION INJURY BY ATTENUATING NECROTIC AND APOPTOTIC CELL DEATH. Tobias Gerwig, Department of Pharmacy, Munich Ger-
gro, Maite Herraiz, Javier Alvarez-Cienfuegos, Jesus Prieto, Clinica Universitaria, Pamplona Spain
many; Herbert Meissner, Institute of Pathology, Munich Germany; Hans Arnholdt, Zentralklinikum Augsburg, Augsburg Germany; Manfred Bilzer, Department of Medicine II, Munich Germany; Alexandra K Kiemer, Angefika M Vollmar, Department of Pharmacy, Munich Germany; Alexander L Gerbes, Department of Medicine II, Munich Germany
In recent years, the age of liver transplant recipients has increased. Short- and mid-term survival of older patients is comparable to that of younger patients, but the incidence of some age-related complications such as the development of 'de novo' neoplasia has not been studied. Patients and Methods: Between June 1994 and December 2000, 112 adult patients with liver cirrhosis received a first liver graft. They were divided in two groups: group I: patients younger than 60 years (N=54, median age: 52.65, range: 35.5-59.6) and group II: patients older than 60 years (N = 58, median age: 65.6 years, range: 60.7-73.7). They were followed up until June 2001. Baseline characteristics of the patients, their survivals and the incidence of 'de novo' neoplasia in both groups were compared. Resultsi Before liver transplantation, older patients had more frequently hepatitis C virus infection (gr6up I: 22%, group II: 41%; P=0.04) and hepatocellular carcinoma (group I: 28%, group II: 47%; P=0.05) and had better liver function at the time of liver transplantation, as staged by ChildPugh's status (P =0.03). Survival of both groups was comparable (1-, 2-, 3- and 4-year survival rates: group I: 94%, 94%, 92% and 88%; group II: 88%, 86%, 83% and 83%; P=NS). Older patients had a greater incidence of de novo neoplasia (1-, 2-, 3- and 4-year rates: group 1: 0%, 0%, 7% and 15%; group II: 7%, 14%, 23% and 27%; P=0.008) and non-skin neoplasia (1-, 2-, 3- and 4-year rates: group I: 0%, 0%, 0% and 4%; group II: 6%, 8%, 13% and 18%; P=0.009) than younger patients, whereas the incidence of skin cancer was similar in both groups. Conclusions: Liver transplant recipients older than 60 years have a survival comparable to that of younger patients, but their incidence of post-transplant malignancy is higher. A careful surveillance for early detection of neoplasia after liver transplantation might be indicated in patients older than 60 years undergoing this procedure.
Introduction: Ischemia reperfusion (I/R) injury is a main cause for severe complications after liver transplantation and liver surgery. In our previous work we could show that preconditioning with the Atrial Natriuretic Peptide (ANP) protects against hepatic I/R injury (Gerbes et al., Hepatology 1998, 28:1309-1317). Aim of this study was to determine apoptotic and necrotic cell death in I/R injury of the isolated perfnsed rat liver and to investigate a potential effect of ANP. Methods: Livers from male Sprague-Dawley rats were perfused with Krebs Henseleit buffer with or without ANP (200nM) or 8-Br-cGMP (50/zM), an analogue of the second messenger of ANP, for 20 rain, stored in UW solution (4°C, 24h) and reperfused for up to 120 rain (n=5, each). Apoptotic cell death was quantified by measuring caspase-3-1ike activity and by TUNEL assays. Necrotic cell death was determined by lactate dehydrogenase (LDH) effiux in the perfusate and trypane blue uptake of liver tissue. Histological analysis was quantitated by an independent investigator in 10 highpower fields per experimental condition. Results: Caspase-3-1ike activity and TUNEL-positive cells peaked after 24h of cold ischemia. Preconditioning with ANP and 8-Br-cGMP, significantly (p< 0.05) reduced caspase-3-fike activity by 54% and 49%, respectively. TUNEL-positive cells significantly (p<0.05) decreased by 37% and 28%, respectively. This was particularly evident for hepatocytes (p<0.05) rather than for endothelial cells. Necrotic cell damage indicated by LDH-efflux increased during reperfnsion (274-+96 mU/min*g liver) and was significantly (p<0.05) attenuated by ANP and 8-Br-cGMP (90-+60, 101 -+44 mU/min*g liver). Histological analysis of reperfused livers for trypane blue uptake showed significant reduction of hepatocyte damage by more than 70% (p<0.05) in the periportal but not in the pericentral areas. Furthermore endothelial cell damage was prevented (p<0.05) in portal veins, but not in central veins. Conclusion: ANP reduces necrotic as well as apoptotic cell death in I/R injury of the isolated perfused rat liver. The protection seems to be most prominent against necrosis in late reperfusion but also affects apoptosis after cold ischemia. (supported by DFG Ge 576/14-1 and 14-2)
115
116
ONE YEAR RESULTS OF LOW DOSE COMBINATION OF TACROLIMUS AND SIROLIMUS IN LIVER TRANSPLANT RECIPIENTS W I T H HIGH RISK FOR CALCINEURIN INHIBITOR RELATED TOXICITY. Olaf Pri-
ROLE OF SERUM AND URINARY MARKERS IN MONITORING BONE LOSS IN LIVER TRANSPLANT RECIPIENTS. Khondker K Islam, Loyola
dohl, University of Leipzig, Surgery II, Leipzig Germany; Kathrin Heinemann, Thomas Hartwig, Rene Schwarz, Helmut Witzigmann, Peter Lamesch, Josef Fangmann, Frieder Berr, Johann Hauss, Kay R Kohlhaw, University of Leipzig, Leipzig Germany Sirofimns (SRL) was found to provide effective immunosuppression in kidney transplantation in combination with reduced doses of calcineurin inhibitors (CI), resulting in less CI related toxicity. In this study 22 patients at individually high risk for CI toxicity after liver transplantation (LTx) were enrolled in a named patient program. Indications for a low dose SRL/TAC immunosuppressive therapy were acute hepatic failure or initial non-functioning graft (n = 5), patient age (n=4), pre-existing renal disease (n = 6) or diabetes (n = 3) and hepatitis (n= 4). Immunosuppressionconsisted of a low dose combination of Tacrolimus (TAC, trough levels 5-7ng/ml), SRL (trough levels 6-8ng/ml) and corticosteroids in order to reduce cumulative side effects of each single and both drugs together. Results: Patient survival was 91% (2 patients died of multi organ failure and sepsis) after a mean observation time of 10,5 months. Graft survival was 78%, 3 patients underwent 4 re-LTx (initial non-function n=2, hepatic artery thrombosis n= 2). Median SRL through levels were 2,5 - 3 ng/ml within the first month and 4 - 4,5 ng/ml thereafter. Median TAC trough levels were 6,5 - 9 ng/ml within the first month and 5,5 - 7,5 ng/ml thereafter. Acute rejection (RAI 3 (n=2)) was successfully treated with steroids in 3 patients (14%). Cholangitis was diagnosed histologically in case of moderately elevated serum transaminases and was treated successfully with antibiotics in another 5 patients. Severe opportunistic infections with the exception of one lethal candida pneumonia were not observed. Median s-creatinine was < 100umot/1 in all patients within the observation period and 125umolA in the 6 patients with the pre-operatively impaired renal function. Only 1 patient developed de novo diabetes. Median s-cholesterol and s-triglyceride levels did not exceed the upper normal range, 3 patients required atorvastatin to normalise blood lipids. Conclusion: The combination of low dose SRL with low dose TAC resulted in a safe immunosuppressionwith moderate toxicity in patients with high risk for CI toxicity within the first year after LTx. An enlarged observation period and/or a prospective study may be of help to confirm these encouraging results.
University Medical Center, Maywood, IL; Kyung SKim, Howard University Hospital, Washington, D.C., DC; Rana P Sokhi, Ravi Kondaveeti, Abdul Nadir, Nikunj Shah, James M Harig, David H Van Thiel, Loyola University Medical Center, Maywood, IL Aim:Although osteoporosis is highly prevalent in the general population, it is more pronounced in transplant recipients. Bone loss is accelerated by the use of corticosteroids and immunosnppressive drugs. This retrospective analysis was done to evaluate the role of serum and urinary markers of bone loss as documented by repeated bone mineral density (BMD) measurements in liver transplant recipients. Methods: Twenty four liver transplant recipients were selected for this study.All 24 recipients had a bone mineral density determination done pre-transplant,as well as 6 and 12 months post transplant. Osteocalcin, Pro-collagen 1, intact PTH, 25 hydroxy vitamin D and bone specific alkaline phosphatase were used as serum markers and pyridinoline crosslinks was used as an urinary marker of bone loss. Descriptive statistics were applied on each variable and Pearson's correlations were done. Results:In this group 20 were male and 2 were female.Their ages ranged from 28 to 69 years with mean age of 28. Bone specific Alkaline Phosphatase correlated well with post transplant bone mineral density (BMD)in femoral neck (p=0.04).Calcium level correlated with post BMD in the lumber vertebrae (p=0024).Pro collagen peptide -1 correlated well with the change in BMD in femoral neck (p= 0.044) and bone specific alkaline phosphatase (p<0.0001).Osteocalcin and urinary crosslinks did not show any statistical significant correlation with changes in pre or post transplant BMD either in the lumber vertebrae or femoral neck.Post transplant BMD loss was more marked in the femoral neck than lumber vertebrae. Conclusions:Based upon these data post transplant(1)the risk of fracture is greater in the femoral neck area than the lumber vertebrae and(2)Pro collagen pepfide can be used as a surrogate marker for BMD determination in transplant patients to monitor bone loss particularly those at higher risk for fracture.