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97 Evaluation of living donor liver transplantation: How much it cost in developing country?
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Posters
Category 1: Liver Transplantation/ Surgery/Acute Liver Failure
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EVALUATION O F LIVING D O N O R LIVER T R A N S P L A N T A T I O N : H O W MUCH IT C O S T IN D E V E L O P I N G COUNTRY.'?
R. Amil, L. Pacheco, M. Enne, A. Cerqueira, J. Alves, F. Madureira, E. Balbi, J.M. Martinho. Hepatobiliar Surgery Service, Rio de Janeiro,
Brazil The long waiting list time arid a few number of donations in die last years, made the living donor liver transplantation (LDLT) an acceptable alternative for adults and children that need an orthotopic liver transplantation. The aim of this study is to analyse the evaluation cost of a potential living donor (PLD) that fill all protocols guide in a public and private health unit at a developing country. Between December 2001 and October 2004, ninety PLD started the evaluation for fifty-four receptors (23 children and 31 adults). None evaluation was begun without a minimal morphological and ABO compatibility. Twenty-five PLD (23,1%) was approved and made the donation. The median evaluation time was tree months. The protocols was divided in three phases analysing laboratorial exams, serological status, tumoral markers, abdominal imaging exams (hepatic morphology) and a selective angiography of hepatic artery'. Liver biopsy was not made in all PLD, it was made only in patients with body index mass between 25 30 or patients with unexplained elevated liver enzymes. Interview with hepatologisty, liver transplant surgeon, infectologist, and psychologist was present in the protocol. The median cost of all evaluation process was US$665.75 in a public hospital, and US$3076.70 in a private unit. LDLT need a rigorous evaluation of the donor that means high cost for public and private hospitals, especially in a developing country. Less than a quarter of the PLD was able to donation. That made the evaluation more expensive than showed above. SELECTIVE M O N O C Y T E H L A C L A S S II A N D C O S T I M U L A T O R Y M O L E C U L E REDUCTION IN ACUTE LIVER FAILURE
C.G. Antoniades t E.T. Davies2, ~L Ma 1, J. Wendon ~, D. Vergani I .
1Institute of Liver Studies, King's College Hospital, London, UK," 2Department of Clinical Immunology, King's College Hospital, London, UK Introduction: We have previously demonstrated that expression of HLA
class II DR molecule (HLA-DR) is decreased on monocytes in patients with ALE Ex-vivo studies have shown that monocytes in septic shock patients show an attenuated response to lipopolysaccaride (LPS) stimulation and are described as "endotoxin tolerant''. We undertook an observational study to investigate whether ALF affected HLA-DQ (mHLA-DQ), and costimulatory molecule expression, CD86 (mCD86), and determined monocyte HLA-DR (mHLA-DR) expression following ex-vivo culture. Methods: We simultaneously measured mHLA-DR, -DQ and CD86 in 16 consecutive ALF patients within 48 hours of admission. 20 healthy volunteers served as controls. Monocyte HLA-DR, -DQ and CD86 expression was determined by double colour flow cytometry after staining
50 ptl fresh blood labelled with monoclonal antibodies for HLA-DR/DQ/ CD86 and CD14. Results are expressed as percentage of HLA-DR positive monocytes. Ex-vivo mill=k-DR expression was assessed in six ALF patients. PBMCs were cultured in the presence of 10% autologous (Aa), normal control (Ac) or foetal calf serum (At), at 0 and 72 hours and 7 days. In two patients ex-vivo cell cultures were undertaken with and without 2 ngjml LPS. Results are expressed as mean fluorescence intensity (MFI) of the HI=k-DR positive monocyte population. Results: Median mHLA-DR and mCD86 was significantly lower in ALF patients compared to controls (23.5% vs 77% [p < 0.0001], and 5.8% vs 19% [p=0.001] respectively). There was no significant difference in mHLA-DQ % expression between ALF patients and controls (98% vs 99%, p= 0.59). Culture experiments showed mHLA-DR MFI increased from 4.5 (time 0) to 217, 82.5 and 52 at 72 hours when cultured in the presence of Af, Ac and Aa respectively. Addition of LPS resulted in a significant reduction in mHLA-DR MFI, when cultured in the presence of Ac, compared to culture with Ac alone (7 vs 125, p = 0.05) at 72 hours. Conclusion: These data suggest a specific modulation of HLA-DR and CD86 surface expression in ALE whilst HLA-DQ expression remains relatively unaffected. Cell culture experiments show that ex-vivo ALF monocytes are able to re-express the immunologically pivotal HLA-DR molecule and the addition of LPS results in attenuation of HLA-DR expression.
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HEPATOCYTE-SPECIFIC DELETION OF IKKYtNEMO SENSITIZES MICE TO TNF A N D I S C H E M I N R E P E R F U S I O N INDUCED LIVER I N J U R Y
U.B. AssmusI , N. Beraza ~, T. Luedde ~, M.P. Manns I , M. Pasparalds 2, C. Trautwein ~ . 1Gastroenterology, Hepatology and Endocrinolog)~.
Medical School Hannove~ Hannover, Germany; 2EMBL, Monterotondo, Rome, Italy NF-kB is involved in mediating inflammatory and anti-apoptotic signals in the liver. NF-kB activation and nuclear translocation occurs after phosphorylation and degradation of I-kBoc. I-kB0~ phosporylation is tightly controlled through the IKK complex that consists o f at least three members IKK1, IKK2 and NEMO. IKK2 and NEMO knockout animals die during embryonal development because ofhepatocyte apoptosis. In order to study the relevance of NEMO for liver physiology we generated hepatocytespecific NEMO knockout animals through cross-breeding NEMO loxP with Alb-Cre animals (NEMO - / - ) . NEMO - / - mice were viable and born in a normal mendelian distribution. Deletion of NEMO was found in hepatocytes on the DNA, RNA and protein level. Quantification revealed that NEMO protein expression was almost completely abolished in NEMO ~ mice. After TNF stimulation, NF-kB activation was blocked in NEMO - / - mice in contrast to controls correlating with a lack of I-kB0~ phosphorylation and de~adation. Lack of NF-kB activation in NEMO - / - mice resulted in a massive increase in transaminases, apoptosis and caspase 3 activation, while Bcl-2 levels were significantly reduced in the NEMO - / - mice. Next, we induced ischernia/reperfusion (I/R) injury in NEMO - / - animals and controls. No significant difference in the increase in tr,msarninases was observed between NEMO - / - animals and controls after I/R. However in NEMO - / - mice by HE staining marked areas of necrosis/apoptosis were evident. TUNEL staining and caspase 3 assays revealed a more than 10-fold increase in apoptosis in the NEMO - / - animals compared to controls. Additionally, Western Blot analysis for Bcl-2 showed <5-fold
Posters
Category 1: Liver Transplantation/ Surgery/Acute Liver Failure
•;]
EVALUATION O F LIVING D O N O R LIVER T R A N S P L A N T A T I O N : H O W MUCH IT C O S T IN D E V E L O P I N G COUNTRY.'?
R. Amil, L. Pacheco, M. Enne, A. Cerqueira, J. Alves, F. Madureira, E. Balbi, J.M. Martinho. Hepatobiliar Surgery Service, Rio de Janeiro,
Brazil The long waiting list time arid a few number of donations in die last years, made the living donor liver transplantation (LDLT) an acceptable alternative for adults and children that need an orthotopic liver transplantation. The aim of this study is to analyse the evaluation cost of a potential living donor (PLD) that fill all protocols guide in a public and private health unit at a developing country. Between December 2001 and October 2004, ninety PLD started the evaluation for fifty-four receptors (23 children and 31 adults). None evaluation was begun without a minimal morphological and ABO compatibility. Twenty-five PLD (23,1%) was approved and made the donation. The median evaluation time was tree months. The protocols was divided in three phases analysing laboratorial exams, serological status, tumoral markers, abdominal imaging exams (hepatic morphology) and a selective angiography of hepatic artery'. Liver biopsy was not made in all PLD, it was made only in patients with body index mass between 25 30 or patients with unexplained elevated liver enzymes. Interview with hepatologisty, liver transplant surgeon, infectologist, and psychologist was present in the protocol. The median cost of all evaluation process was US$665.75 in a public hospital, and US$3076.70 in a private unit. LDLT need a rigorous evaluation of the donor that means high cost for public and private hospitals, especially in a developing country. Less than a quarter of the PLD was able to donation. That made the evaluation more expensive than showed above. SELECTIVE M O N O C Y T E H L A C L A S S II A N D C O S T I M U L A T O R Y M O L E C U L E REDUCTION IN ACUTE LIVER FAILURE
C.G. Antoniades t E.T. Davies2, ~L Ma 1, J. Wendon ~, D. Vergani I .
1Institute of Liver Studies, King's College Hospital, London, UK," 2Department of Clinical Immunology, King's College Hospital, London, UK Introduction: We have previously demonstrated that expression of HLA
class II DR molecule (HLA-DR) is decreased on monocytes in patients with ALE Ex-vivo studies have shown that monocytes in septic shock patients show an attenuated response to lipopolysaccaride (LPS) stimulation and are described as "endotoxin tolerant''. We undertook an observational study to investigate whether ALF affected HLA-DQ (mHLA-DQ), and costimulatory molecule expression, CD86 (mCD86), and determined monocyte HLA-DR (mHLA-DR) expression following ex-vivo culture. Methods: We simultaneously measured mHLA-DR, -DQ and CD86 in 16 consecutive ALF patients within 48 hours of admission. 20 healthy volunteers served as controls. Monocyte HLA-DR, -DQ and CD86 expression was determined by double colour flow cytometry after staining
50 ptl fresh blood labelled with monoclonal antibodies for HLA-DR/DQ/ CD86 and CD14. Results are expressed as percentage of HLA-DR positive monocytes. Ex-vivo mill=k-DR expression was assessed in six ALF patients. PBMCs were cultured in the presence of 10% autologous (Aa), normal control (Ac) or foetal calf serum (At), at 0 and 72 hours and 7 days. In two patients ex-vivo cell cultures were undertaken with and without 2 ngjml LPS. Results are expressed as mean fluorescence intensity (MFI) of the HI=k-DR positive monocyte population. Results: Median mHLA-DR and mCD86 was significantly lower in ALF patients compared to controls (23.5% vs 77% [p < 0.0001], and 5.8% vs 19% [p=0.001] respectively). There was no significant difference in mHLA-DQ % expression between ALF patients and controls (98% vs 99%, p= 0.59). Culture experiments showed mHLA-DR MFI increased from 4.5 (time 0) to 217, 82.5 and 52 at 72 hours when cultured in the presence of Af, Ac and Aa respectively. Addition of LPS resulted in a significant reduction in mHLA-DR MFI, when cultured in the presence of Ac, compared to culture with Ac alone (7 vs 125, p = 0.05) at 72 hours. Conclusion: These data suggest a specific modulation of HLA-DR and CD86 surface expression in ALE whilst HLA-DQ expression remains relatively unaffected. Cell culture experiments show that ex-vivo ALF monocytes are able to re-express the immunologically pivotal HLA-DR molecule and the addition of LPS results in attenuation of HLA-DR expression.
[•
HEPATOCYTE-SPECIFIC DELETION OF IKKYtNEMO SENSITIZES MICE TO TNF A N D I S C H E M I N R E P E R F U S I O N INDUCED LIVER I N J U R Y
U.B. AssmusI , N. Beraza ~, T. Luedde ~, M.P. Manns I , M. Pasparalds 2, C. Trautwein ~ . 1Gastroenterology, Hepatology and Endocrinolog)~.
Medical School Hannove~ Hannover, Germany; 2EMBL, Monterotondo, Rome, Italy NF-kB is involved in mediating inflammatory and anti-apoptotic signals in the liver. NF-kB activation and nuclear translocation occurs after phosphorylation and degradation of I-kBoc. I-kB0~ phosporylation is tightly controlled through the IKK complex that consists o f at least three members IKK1, IKK2 and NEMO. IKK2 and NEMO knockout animals die during embryonal development because ofhepatocyte apoptosis. In order to study the relevance of NEMO for liver physiology we generated hepatocytespecific NEMO knockout animals through cross-breeding NEMO loxP with Alb-Cre animals (NEMO - / - ) . NEMO - / - mice were viable and born in a normal mendelian distribution. Deletion of NEMO was found in hepatocytes on the DNA, RNA and protein level. Quantification revealed that NEMO protein expression was almost completely abolished in NEMO ~ mice. After TNF stimulation, NF-kB activation was blocked in NEMO - / - mice in contrast to controls correlating with a lack of I-kB0~ phosphorylation and de~adation. Lack of NF-kB activation in NEMO - / - mice resulted in a massive increase in transaminases, apoptosis and caspase 3 activation, while Bcl-2 levels were significantly reduced in the NEMO - / - mice. Next, we induced ischernia/reperfusion (I/R) injury in NEMO - / - animals and controls. No significant difference in the increase in tr,msarninases was observed between NEMO - / - animals and controls after I/R. However in NEMO - / - mice by HE staining marked areas of necrosis/apoptosis were evident. TUNEL staining and caspase 3 assays revealed a more than 10-fold increase in apoptosis in the NEMO - / - animals compared to controls. Additionally, Western Blot analysis for Bcl-2 showed <5-fold