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Measurement of serum Gc protein levels by nephelometry: A rapid, accurate technique
HEPATOLOGY Vol. 22, No. 4, P t . 2, 1995
AASLD ABSTRACTS
409 M E A S U R E M E N T O F S E R U M Gc P R O T E I N L E V E L S BY N E P H E L O M E T R Y : A RAPID, A C C U R A T E TECHNIQUE. WM Lee, W Lin, L Brown, FH Wians Jr. Liver Unit, and Dept of Pathology. University of Texas Southwestern Med School, Dallas, TX Measurement of Gc protein concentration [Gc], an actin scavenger in plasma which is depleted in acute liver failure (ALF) patients, has been shown to predict survival (or need for transplant) in this condition. Quantitation of the free fraction of Gc in serum, i.e., that not bound to actin, is the most accurate predictive value. Current methods for quantifying serum [Go] (Western blot {WB }, or rocket or radial immunodiffusion) are technically demanding, cumbersome, and timeconsuming and thus, not suitable for clinical use. We developed a fast (
411 LIVERTRANSPLANTATIONFOR JEJUNOILEAL BYPASSASSOCIATED CIRRHOSIS: A L L O G R A F T H I S T O L O G Y IN T H E SETTING O F AN I N T A C T BYPASSED LIMB. SM D'SouzaGburek, KP Batts, GA Nikias, RH Wiesner, RAF Krom. Department of Laboratory Medicine and Pathology and Department of Gastroenterology, Mayo Clinic, Rochester, MN Jejuno-ileal bypass (JIB) is a well-known cause of steatohepatitis, which may, on occasion, require orthotopic liver transplantation (OLT). Little information is available on the risk of recurrent steatohepatitis after OLT. The aim of the study was to review our cases of OLT transplanted for JIB-induced steatohepatitic cirrhosis for histologic evidence of recurrent steatohepatitis and to further compare the histologic changes in this group to those of OLTs performed for other disease processes. Materials and Methods: We reviewed two cases of OLT transplanted for steatobepatitic cirrhosis secondary to JIB and thirtyone case controls (steatohepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis). In each case, hematoxylin-eosin and Masson's trichrome stained ailograft biopsy slides were examined for evidence of macrovesicular steatosis and fibrosis on a protocol basis at the following times: day 0, 1 month, 3 months, 6 months, 1 and 2 years. Results: Both our index cases demonstrated steadily increasing fatty infiltration over the two year intervai of follow-up. In case I, the steatosis is mild (30% steatosis) while in case 2, the changes are moderately severe (75% steatosis). However, both patients have essentially normal liver function tests and are clinically asymptomatic, and therefore, the JIB has been left intact. In contrast to our index cases, our case controls (with rare exceptions) exhibit minimal fatty changes. Conclusions: Reaceumulation of hepatic fat occurs post-OLT in patients with intact JIB. Although significant liver damage has not yet developed in our patients, allografts should be monitored closely for evidence of recurrent steatosis, with consideration of JIB takedown if allograft dysfunction due to recurrent fatty infiltration or significant fibrosis occurs in the post-transplant period.
410
209A
LIVER TRANSPLANTATION (OLTx) FOR FHF: A SCORE AIDED DECISION MAKING PROCESS U. Tedeschi, U. Cillo, G. De Silvestro, P. Marson. L. Urbani. P. Boccalmi. G. Ambrosino. A. Bmlese. G. Zanus. L. Borin. S. Fa~iuoli, P. Burra, D. D'Amico Univ. of Padua, Italy - Clin. Clair. I, Gastmenter., Servizio Immunoem. e Trasf. The decision to choose an orthotopic liver transplantation (OLTx) as reselutive therapeutic appmach for patients experiencing FHF and in particular the timing of the operation, represent two of the most difficult clinical decisions in the management of FHF which are crucial for the patient's prognosis. We studied retrospectively 40 patients with FHF due to various causes. In 25 cases (62.5%) FHF was related to virus B, in 5 (12.5%) to Amanita Phalloides toxicity, in 2 (5%) to Wilson disease, in 8 (20%) to NANB hepatitis. Nine patients (22.5%) underwent an emergency OLTx, whereas 31 (77.5%) were treated conservatively (in all cases plasmapheresis was adopted). Thirteen of these 31 patients (41.9%) survived whereas 18 (58.1%) died. Based on a substantial modification of the classic O'Grady's prognostic factors for FHF, we designed a score to distinguish favorable from unfavorable outcomes in the group of non-transplanted cases, as follows: 0
1
2
AGE
SCORE
< 10 or > 60
41-60
10-40
ETIOLOGy
Viral NANB
Viral B, Wilson
Aman. Phan.
IAUNDICE (days bef. onset of enceph.)
>7
<7
gNCEPHALOPATHY(on admission)
Grade IV
Grade < IV
EILIRUBIN(on admission)
> 300
PT (12 hours afler first plasmaph.)
< 20
MfaFP (48 hrs after AST peak)
< 30
4
< 300 20-40
> 40 > 30
This score (range 0-20) resulted ->13 (mean 14.5 SD&-I.3, range 13-17) in all survived patients. Oppositely, a score -<11 (mean 8.6 SD'L-_2.6range 1-11) was always associated with an unfavorable outcome. In the early detection of those patients responding to conservative treatment, this test showed sensitivity, specificity, accuracy and predictivity of 100%. A prospective study is needed to confirm the value of this score (Factor V included) in the decision making process to transplant patients with FHF.
412 Assessment of microchimerism following liver transplantation by microsateUite analysis. S. Norris, *M. Lawlor. *S. McElwaine. C. O'Farrellv. 1. Hegarty. Liver Unit & ERC, St. Vincent's Hospital, *Sir Patrick Dunn, Research Laboratory, St. James Hospital, Dublin, Ireland. Recent studies have hypothesised that a partial or mixed chimeric state may exist following solid organ transplantation and patients who exhibit stable mixed haemopoietic chimerism may not experience acute cellular rejection following orthotopic liver transplant [OLT]. The aim of this project was to examine the incidence of chimerism after OLT using a polymerase chain reaction [PCR] based method for microsatellite analysis of highly polymorphic simple tandem repeat [STR] sequences. The number of repeats varies between individuals and can be used to identify haemopoietic cells from different individuals. Three patients were studied prospectively from time of transplant, and six patients retrospectively 8 to 11 months after OLT. Methods: DNA was extracted from the donor organ and explanted organ at the time of transplantation. Thereafter, DNA was extracted from peripheral blood at serial time points following OLT. Donor and recipient cells were examined for chimerism by PCR-based amplification of STRs using a panel of microsatellites which included Cyp-19, Int-2 and vWF. A radioactive label, aP 32 was incorporated into the PCR reaction. Following amplification, gel electrophoresis was performed and subsequent autoradiography identified the amplified STRs. Results: Six patients studied at 8-12 months following OLT did not demonstrate peripheral blood chimerism. In the prospective group, one patient exhibited transient chimerism in peripheral blood 2 weeks following OLT and subsequent re-emergence of donor cells at 6-8 weeks. A further patient demonstrated microchimerism at 2,3, 4 and 6 months following OLT. However analysis of DNA from skin and duodenum at six months did not reveal evidence of donor cells at these sites. Conclusions: Preliminary results indicate that chimerism occurs following OLT, and that PCR based microsatellite analysis is a sensitive method of detecting chimerism. Donor derived lymphocytes may exert beneficial immunomodulatory effects in OLT recipients.
AASLD ABSTRACTS
409 M E A S U R E M E N T O F S E R U M Gc P R O T E I N L E V E L S BY N E P H E L O M E T R Y : A RAPID, A C C U R A T E TECHNIQUE. WM Lee, W Lin, L Brown, FH Wians Jr. Liver Unit, and Dept of Pathology. University of Texas Southwestern Med School, Dallas, TX Measurement of Gc protein concentration [Gc], an actin scavenger in plasma which is depleted in acute liver failure (ALF) patients, has been shown to predict survival (or need for transplant) in this condition. Quantitation of the free fraction of Gc in serum, i.e., that not bound to actin, is the most accurate predictive value. Current methods for quantifying serum [Go] (Western blot {WB }, or rocket or radial immunodiffusion) are technically demanding, cumbersome, and timeconsuming and thus, not suitable for clinical use. We developed a fast (
411 LIVERTRANSPLANTATIONFOR JEJUNOILEAL BYPASSASSOCIATED CIRRHOSIS: A L L O G R A F T H I S T O L O G Y IN T H E SETTING O F AN I N T A C T BYPASSED LIMB. SM D'SouzaGburek, KP Batts, GA Nikias, RH Wiesner, RAF Krom. Department of Laboratory Medicine and Pathology and Department of Gastroenterology, Mayo Clinic, Rochester, MN Jejuno-ileal bypass (JIB) is a well-known cause of steatohepatitis, which may, on occasion, require orthotopic liver transplantation (OLT). Little information is available on the risk of recurrent steatohepatitis after OLT. The aim of the study was to review our cases of OLT transplanted for JIB-induced steatohepatitic cirrhosis for histologic evidence of recurrent steatohepatitis and to further compare the histologic changes in this group to those of OLTs performed for other disease processes. Materials and Methods: We reviewed two cases of OLT transplanted for steatobepatitic cirrhosis secondary to JIB and thirtyone case controls (steatohepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis). In each case, hematoxylin-eosin and Masson's trichrome stained ailograft biopsy slides were examined for evidence of macrovesicular steatosis and fibrosis on a protocol basis at the following times: day 0, 1 month, 3 months, 6 months, 1 and 2 years. Results: Both our index cases demonstrated steadily increasing fatty infiltration over the two year intervai of follow-up. In case I, the steatosis is mild (30% steatosis) while in case 2, the changes are moderately severe (75% steatosis). However, both patients have essentially normal liver function tests and are clinically asymptomatic, and therefore, the JIB has been left intact. In contrast to our index cases, our case controls (with rare exceptions) exhibit minimal fatty changes. Conclusions: Reaceumulation of hepatic fat occurs post-OLT in patients with intact JIB. Although significant liver damage has not yet developed in our patients, allografts should be monitored closely for evidence of recurrent steatosis, with consideration of JIB takedown if allograft dysfunction due to recurrent fatty infiltration or significant fibrosis occurs in the post-transplant period.
410
209A
LIVER TRANSPLANTATION (OLTx) FOR FHF: A SCORE AIDED DECISION MAKING PROCESS U. Tedeschi, U. Cillo, G. De Silvestro, P. Marson. L. Urbani. P. Boccalmi. G. Ambrosino. A. Bmlese. G. Zanus. L. Borin. S. Fa~iuoli, P. Burra, D. D'Amico Univ. of Padua, Italy - Clin. Clair. I, Gastmenter., Servizio Immunoem. e Trasf. The decision to choose an orthotopic liver transplantation (OLTx) as reselutive therapeutic appmach for patients experiencing FHF and in particular the timing of the operation, represent two of the most difficult clinical decisions in the management of FHF which are crucial for the patient's prognosis. We studied retrospectively 40 patients with FHF due to various causes. In 25 cases (62.5%) FHF was related to virus B, in 5 (12.5%) to Amanita Phalloides toxicity, in 2 (5%) to Wilson disease, in 8 (20%) to NANB hepatitis. Nine patients (22.5%) underwent an emergency OLTx, whereas 31 (77.5%) were treated conservatively (in all cases plasmapheresis was adopted). Thirteen of these 31 patients (41.9%) survived whereas 18 (58.1%) died. Based on a substantial modification of the classic O'Grady's prognostic factors for FHF, we designed a score to distinguish favorable from unfavorable outcomes in the group of non-transplanted cases, as follows: 0
1
2
AGE
SCORE
< 10 or > 60
41-60
10-40
ETIOLOGy
Viral NANB
Viral B, Wilson
Aman. Phan.
IAUNDICE (days bef. onset of enceph.)
>7
<7
gNCEPHALOPATHY(on admission)
Grade IV
Grade < IV
EILIRUBIN(on admission)
> 300
PT (12 hours afler first plasmaph.)
< 20
MfaFP (48 hrs after AST peak)
< 30
4
< 300 20-40
> 40 > 30
This score (range 0-20) resulted ->13 (mean 14.5 SD&-I.3, range 13-17) in all survived patients. Oppositely, a score -<11 (mean 8.6 SD'L-_2.6range 1-11) was always associated with an unfavorable outcome. In the early detection of those patients responding to conservative treatment, this test showed sensitivity, specificity, accuracy and predictivity of 100%. A prospective study is needed to confirm the value of this score (Factor V included) in the decision making process to transplant patients with FHF.
412 Assessment of microchimerism following liver transplantation by microsateUite analysis. S. Norris, *M. Lawlor. *S. McElwaine. C. O'Farrellv. 1. Hegarty. Liver Unit & ERC, St. Vincent's Hospital, *Sir Patrick Dunn, Research Laboratory, St. James Hospital, Dublin, Ireland. Recent studies have hypothesised that a partial or mixed chimeric state may exist following solid organ transplantation and patients who exhibit stable mixed haemopoietic chimerism may not experience acute cellular rejection following orthotopic liver transplant [OLT]. The aim of this project was to examine the incidence of chimerism after OLT using a polymerase chain reaction [PCR] based method for microsatellite analysis of highly polymorphic simple tandem repeat [STR] sequences. The number of repeats varies between individuals and can be used to identify haemopoietic cells from different individuals. Three patients were studied prospectively from time of transplant, and six patients retrospectively 8 to 11 months after OLT. Methods: DNA was extracted from the donor organ and explanted organ at the time of transplantation. Thereafter, DNA was extracted from peripheral blood at serial time points following OLT. Donor and recipient cells were examined for chimerism by PCR-based amplification of STRs using a panel of microsatellites which included Cyp-19, Int-2 and vWF. A radioactive label, aP 32 was incorporated into the PCR reaction. Following amplification, gel electrophoresis was performed and subsequent autoradiography identified the amplified STRs. Results: Six patients studied at 8-12 months following OLT did not demonstrate peripheral blood chimerism. In the prospective group, one patient exhibited transient chimerism in peripheral blood 2 weeks following OLT and subsequent re-emergence of donor cells at 6-8 weeks. A further patient demonstrated microchimerism at 2,3, 4 and 6 months following OLT. However analysis of DNA from skin and duodenum at six months did not reveal evidence of donor cells at these sites. Conclusions: Preliminary results indicate that chimerism occurs following OLT, and that PCR based microsatellite analysis is a sensitive method of detecting chimerism. Donor derived lymphocytes may exert beneficial immunomodulatory effects in OLT recipients.