- Email: [email protected]
754 POSITIONAL CLONING IN GLS GENE: A MICROSATELLITE IN THE PROMOTER REGION PREDICTS THE RISK OF HEPATIC ENCEPHALOPATHY
02a: CIRRHOSIS AND COMPLICATIONS − a) PATHOPHYSIOLOGY 754 POSITIONAL CLONING IN GLS GENE: A MICROSATELLITE IN THE PROMOTER REGION PREDICTS THE RISK OF HEPATIC ENCEPHALOPATHY M. Jover1 , J. Galan2 , E. Hoyas1 , J.A. del Campo1 , C. Montoliu3 , J. del Olmo3 , E. Baccaro4 , M. Guevara4 , J. Cordoba5 , J.M. Navarro6 , M.D.C. Martinez-Sierra7 , L. Grande1 , B. Pardo1 , I. Camacho1 , A. Ruiz2 , M. Romero-Gomez1 . 1 CIBERehd-UGCED, Hospital Universitario de Valme, 2 Genomica Estructural, Neocodex, Sevilla, 3 Digestivo, Hospital Cl´ınico Universitario, Valencia, 4 Digestivo, Hospital Clinic de Barcelona. IMDiM. IDIBAPS. Ciberehd. University of Barcelona., 5 CIBERehdDigestivo, Hospital Vall d’Hebron, Barcelona, 6 Digestivo, Hospital Costa del Sol, Malaga, 7 Digestivo, Hospital Puerta del Mar, Cadiz, Spain E-mail: [email protected] Aim: Searching for a possible germline mutation in the GLS gene associated with the risk of developing hepatic encephalopathy (HE). Methods: We carried out a positional cloning of the coding sequence (18 exons) and untranslated regions (5 UTR and 3 UTR) of the GLS gene, in 20 cirrhotic patients selected considering their background haplotype and risk of overt HE, using techniques of HRM and direct sequencing. We included: estimated cohort (n = 100) and validation cohort (n = 156) of consecutive cirrhotic patients followed up in 6 Spanish hospitals. Main end-point: development of overt HE during follow-up. Estimation and validation cohorts were similar in terms of the distribution by sex, age, liver function and rate of development of HE. MHE diagnose was done measuring the critical flicker frequency (CFF) (Hepatonorm™ Analyzer, R&R, Germany) (altered CFF <38 Hz). We also measured the area under the curve (AUC) of ammonium production after intake of 10 grams of L-glutamine. AUC > 104 mg/dl/h was alterated. Patients were followed up every 3 or 6 months until development of HE, liver transplant, died or be free of complications at the end of follow-up (32±15 months). Results: We have identified and characterized a microsatellite DNA located in the 5 UTR region of the GLS gene, with a variable length of 177 bp and 210 bp. Microsatellite was classified in short (177–195 bp) and long (198–210 bp). We did not detect variations in the coding sequence nor affecting the union intron–exon. In the 3 UTR sequence analyzed, previously described polymorphisms have been detected. We found no relationship between polymorphisms in the 3 UTR region and the risk of encephalopathy. In the estimation cohort (n = 100) an association between the presence of microsatellite long-long and the risk of developing HE in the follow-up has been found (log-rank: 7.74, P < 0.005); OR 3.9 (95% CI: 1.4−11.1). In the validation cohort the presence of this microsatellite in the promoter of the GLS gene increased the risk of developing HE during the follow-up by 3.2-fold (95% CI 1.25−8.3). Conclusion: Presence of a long-long microsatellite is associated with an increased risk of developing HE. 755 CARDIAC FUNCTION STUDIED BY DOBUTAMIN STRESS MRI IN PATIENTS WITH MILD CIRRHOSIS A. Krag1,2 , F. Bendtsen1 , A. Kjær3 , C. Leth-Petersen4 , S. Møller2 . 1 Dept. of Gastroenterology, 2 Clinical Physiology, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, 3 Dept. of Clinical Physiology Nuclear Medicine & PET, Rigshospitalet & Cluster for Molecular Imaging, Faculty of Health Sciences, University of Copenhagen, 4 Dept. of Clinical Physiology, Frederiksberg Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark E-mail: [email protected] Background: Presence of cardiac dysfunction in patients with cirrhosis is still debated. Therefore, we aimed to investigate left ventricular systolic performance at rest and during pharmacological dobutamine stress in patients with mild disease (Child A and B) by magnetic resonance imaging (MRI). Methods: Twenty patients with Child A and B cirrhosis, 10 of which had non-alcoholic cirrhosis, and 7 matched controls participated. By cardiac MRI, we assessed left ventricular volumes and cardiac output (CO) at rest
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and during maximal heart rate (mHR) induced by increasing dosages of dobutamine and atropine. Results: Pharmacological responsiveness was similar in cirrhosis and controls and the HR increased by 55±5 vs. 58±7 beats/min in controls in accordance with the expected age adjusted mHR. Mean arterial pressure was lower during mHR in the cirrhotic patients 94±3 vs. 107±6 mmHg, p < 0.05. Left ventricular end-diastolic volume (LVEDV), strokevolume (SV) and CO, were similar in Child A cirrhotics and controls during mHR. The time to resume a HR of 100 beat/min after discontinuation of dobutamine infusion was longer in patients with cirrhosis 8.0±0.6 vs. 5.4±0.5 min, p < 0.05. LVEDV was significantly higher in Child B patients, 109±6.9 than in Child A patients 85±10.4 mL (p < 0.05). SV 84±5.3 vs. 66±7.1 mL and systemic vascular resistance (SVR) 1131±60 vs. 1696±171 were significant different between Child A and B patients (p < 0.05). During mHR, Child B patients had higher CO 10.1±0.7 vs. 7.9±0.8 L/min, LVEDV 87±6 vs. 65±7 mL and SV 78±6 vs. 60±7 mL than Child A patients, and SVR was lower, all p < 0.05, but the ejection fraction was equal. Conclusion: Patients with mild cirrhosis exhibit an autonomic dysfunction, but the systolic function during pharmacological stress by dobutamine is normal and we did not find evidence of cirrhotic cardiomyopathy in these patients. Haemodynamic responses may be due to differences in systemic vasodilation and the degree of the hyperdynamic circulatory state.
756 INTERLEUKIN 6 AS A PROGNOSTIC FACTOR IN HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS C VIRUS CO-INFECTED PATIENTS WITH DESCOMPENSATED CIRRHOSIS M. Montes de Oca Arjona1 , F. Brun1 , M. Marquez1 , C. RodriguezRamos2 , A. Terr´on3 , A. Vergara4 , C. Fern´andez-Gutierrez5 , J.A. Gir´onGonz´alez1 . 1 Internal Medicine, 2 Gastroenterology, Puerta del Mar Universitary Hospital, C´adiz, 3 Internal Medicine, Jerez de la Frontera General Hospital, Jerez de la Frontera, 4 Infections Disease Unit, Puerto Real Hospital, Puerto Real, 5 Microbiology, Puerta del Mar Universitary Hospital, C´adiz, Spain E-mail: [email protected] Background and Aims: Serum concentrations of lipoprotein-binding protein as well as the consequent macrophage activation, the association of these markers with the consequences of peripheral vasodilation and their implication in prognosis were analyzed in patients with human immunodeficiency virus (HIV) infection and hepatitis C virus (HCV)related cirrhosis. Methods: Fifty-two patients with HIV-HVC coinfection and decompensated cirrhosis and 20 healthy controls were included. Cirrhotic patients were followed during a median of 15 months, with evaluation, every three months, of clinical and ultrasonographic characteristics, plasma permeability and bacterial translocation (lipopolysaccharide-binding protein [LBP]), macrophage activation (soluble CD14 and interleukin 6 [IL6] determined by ELISA), plasma renin activity (PRA) and aldosterone concentration (PAC) (RIA). Liver function was analyzed by Child–Pugh and MELDsodium scores. HIV infection was evaluated by CD4+T cell count, antiretroviral therapy and HIV load. Cox’s regression analysis was used to identify factors independently associated with liver-related mortality. Results: Serum concentrations of LBP, sCD14, IL-6, PRA and PAC were significantly elevated in cirrhotic patients when compared with 20 healthy controls. Significant correlations were observed between LBP concentration and that of sCD14 (r = 0.190, p = 0.022) and IL-6 (r = 0.483, p < 0.001). Thirty patients (57.7%) died during the follow up. In twenty-six (86.6%) individuals, the cause of death was liver-related. The factors that predicted liver-related mortality in the univariate analysis were parameters related with liver function (Child–Pugh stage, MELD-Na score), with HIV infection (detectable HIV load and CD4 T cell count <200/mm3), proinflammatory molecules (IL-6) and parameters indicative of vasoactive activation (PRA and PAC). After multivariate analysis, the factors that independently predicted liver-related mortality were high Child–Pugh (relative risk [RR] 1.712) and MELD-Na (RR 1.142) scores, the absence
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and during maximal heart rate (mHR) induced by increasing dosages of dobutamine and atropine. Results: Pharmacological responsiveness was similar in cirrhosis and controls and the HR increased by 55±5 vs. 58±7 beats/min in controls in accordance with the expected age adjusted mHR. Mean arterial pressure was lower during mHR in the cirrhotic patients 94±3 vs. 107±6 mmHg, p < 0.05. Left ventricular end-diastolic volume (LVEDV), strokevolume (SV) and CO, were similar in Child A cirrhotics and controls during mHR. The time to resume a HR of 100 beat/min after discontinuation of dobutamine infusion was longer in patients with cirrhosis 8.0±0.6 vs. 5.4±0.5 min, p < 0.05. LVEDV was significantly higher in Child B patients, 109±6.9 than in Child A patients 85±10.4 mL (p < 0.05). SV 84±5.3 vs. 66±7.1 mL and systemic vascular resistance (SVR) 1131±60 vs. 1696±171 were significant different between Child A and B patients (p < 0.05). During mHR, Child B patients had higher CO 10.1±0.7 vs. 7.9±0.8 L/min, LVEDV 87±6 vs. 65±7 mL and SV 78±6 vs. 60±7 mL than Child A patients, and SVR was lower, all p < 0.05, but the ejection fraction was equal. Conclusion: Patients with mild cirrhosis exhibit an autonomic dysfunction, but the systolic function during pharmacological stress by dobutamine is normal and we did not find evidence of cirrhotic cardiomyopathy in these patients. Haemodynamic responses may be due to differences in systemic vasodilation and the degree of the hyperdynamic circulatory state.
756 INTERLEUKIN 6 AS A PROGNOSTIC FACTOR IN HUMAN IMMUNODEFICIENCY VIRUS AND HEPATITIS C VIRUS CO-INFECTED PATIENTS WITH DESCOMPENSATED CIRRHOSIS M. Montes de Oca Arjona1 , F. Brun1 , M. Marquez1 , C. RodriguezRamos2 , A. Terr´on3 , A. Vergara4 , C. Fern´andez-Gutierrez5 , J.A. Gir´onGonz´alez1 . 1 Internal Medicine, 2 Gastroenterology, Puerta del Mar Universitary Hospital, C´adiz, 3 Internal Medicine, Jerez de la Frontera General Hospital, Jerez de la Frontera, 4 Infections Disease Unit, Puerto Real Hospital, Puerto Real, 5 Microbiology, Puerta del Mar Universitary Hospital, C´adiz, Spain E-mail: [email protected] Background and Aims: Serum concentrations of lipoprotein-binding protein as well as the consequent macrophage activation, the association of these markers with the consequences of peripheral vasodilation and their implication in prognosis were analyzed in patients with human immunodeficiency virus (HIV) infection and hepatitis C virus (HCV)related cirrhosis. Methods: Fifty-two patients with HIV-HVC coinfection and decompensated cirrhosis and 20 healthy controls were included. Cirrhotic patients were followed during a median of 15 months, with evaluation, every three months, of clinical and ultrasonographic characteristics, plasma permeability and bacterial translocation (lipopolysaccharide-binding protein [LBP]), macrophage activation (soluble CD14 and interleukin 6 [IL6] determined by ELISA), plasma renin activity (PRA) and aldosterone concentration (PAC) (RIA). Liver function was analyzed by Child–Pugh and MELDsodium scores. HIV infection was evaluated by CD4+T cell count, antiretroviral therapy and HIV load. Cox’s regression analysis was used to identify factors independently associated with liver-related mortality. Results: Serum concentrations of LBP, sCD14, IL-6, PRA and PAC were significantly elevated in cirrhotic patients when compared with 20 healthy controls. Significant correlations were observed between LBP concentration and that of sCD14 (r = 0.190, p = 0.022) and IL-6 (r = 0.483, p < 0.001). Thirty patients (57.7%) died during the follow up. In twenty-six (86.6%) individuals, the cause of death was liver-related. The factors that predicted liver-related mortality in the univariate analysis were parameters related with liver function (Child–Pugh stage, MELD-Na score), with HIV infection (detectable HIV load and CD4 T cell count <200/mm3), proinflammatory molecules (IL-6) and parameters indicative of vasoactive activation (PRA and PAC). After multivariate analysis, the factors that independently predicted liver-related mortality were high Child–Pugh (relative risk [RR] 1.712) and MELD-Na (RR 1.142) scores, the absence