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Acute gastrointestinal bleeding prolongs QT interval in cirrhosis
A32
Abstracts / Digestive and Liver Disease 40 (2008) A1–A40
A cannabinoid agonist (WIN5521-2) has been shown to increase the pruritus threshold in cholestatic rats. Moreover, in the course of chronic cholangiopaties hepatic progenitor cells are activated constituting a neuroendocrine compartment regulated by different agents including neuropeptides. Aims. (1) To evaluate whether the EC system is activated in PBC; (2) To evaluate if genetic variations in human cannabinoid-specific receptor genes (CB1 and CB2) might cause a different phenotypic expression of the disease in terms of association with pruritus. Methods. (1) Morphological study: CB1 and CB2 receptors were characterized in biopsy specimens of 4 normal human liver and 10 PBC by immunohistochemistry. CB1 and CB2 mRNA expression was also assayed through RT-PCR in liver samples. (2) Genetic study: the following groups of subjects have been enrolled: 55 consecutive PBC Italian pts, 56 PBC pts residents in USA; 55 controls, matched for sex, age, and geographical area with the Italian PBC pts. Genomic DNA was extracted from peripheral venous blood leucocytes with standard method. PCR was used to amplify the coding regions of the CB1 and CB2 genes with specific primers. Results. CB1 was markedly expressed in hepatocytes and biliary epithelial cells in PBC; conversely, in control livers was virtually absent. CB2 was markedly expressed in mesenchymal cells, particularly in Kupffer cells. Accordingly, mRNA of both CB1 and CB2 was expressed in PBC liver samples, as demonstrated by RT-PCR. CB1 polymorphism (1359 G/A) was present in 25.5% of Italian PBC pts, in 23.5% of healthy controls, and in 26.8% of an US PBC series (p = n.s.). CB2 polymorphism (188–189 AA/GG) was present in 22.5% vs. 30.4% of Italian and US PBC respectively, and in 27.5% of Italian controls (p = n.s.) Stratifying the PBC patients according to pruritus there was no difference in either Italian and US series in the distribution of CB1 and CB2 mutation in patients with or without pruritus. Conclusions. EC system is up-regulated in PBC; these preliminary results failed to show a relationship between EC system and pruritus, but this system probably exert a role regulating metabolic homeostasis in other compartments. doi:10.1016/j.dld.2007.12.082 HEPATOCELLULAR CARCINOMA INDUCES SPECIFIC IGM-BIOMARKERS IMMUNE COMPLEXES L. Beneduce a , G. Pesce a , A. Gallotta a , F. Zampieri a , A. Biasolo b , N. Tono b,c , P. Pontisso b , G. Fassina a a
XEPTAGEN SpA, Marghera Venezia, Italy of Clinical and Experimental Medicine, University of Padova, Italy c Istituto Oncologico Veneto (I.O.V.), IRCCS, Padova, Italy b Department
Background and aims. Recently it has been discovered that several cancer biomarkers circulate in serum of patients with hepatocellular carcinoma (HCC) associated to immunoglobulins M.
To support a tumour specific induction of immune complexes, we determined whether the presence of IgM complexes was correlated to an increase of total IgMs in the sera of patients with HCC and cirrhosis. Further, to extend our ongoing investigation on the relevance of IgM-biomarkers for HCC detection we compared the co-determination of des-gamma-carboxy prothrombin (DCP) and squamous cell carcinoma antigen (SCCA) as IgM immune complexes with AFP determination in patients with HCC and cirrhosis. Patients and methods. Serum samples from 31 patients with cirrhosis and from 33 untreated HCC patients were analyzed for the total IgM measurement. DCP-IgM, SCCA-IgM and AFP levels were determined in parallel using standard ELISA Kits. Results. The serum concentrations of IgM expressed in mg/ml were determined by interpolation of samples absorbance on the calibration curves plotted with IgM calibrators. The amount of IgM was not significantly different in the group of HCC patients (median level = 1.79 mg/ml) compared to those with cirrhosis (median level = 1.09 mg/ml, Mann–Whitney test p = 0.1376). The co-determination of SCCA-IgM and DPC-IgM was above the cut off in 19 of the 33 HCC patients (60% of diagnostic sensitivity; SE) and in 9 of the 31 patients with cirrhosis (70% of diagnostic specificity; SP). The serum levels of AFP were above the 20 ng/ml cut off in 48% (SE; 16/33) of HCC patients and in 4 out of 31 patients with cirrhosis (87% SP). The distribution of serum levels of immune complexes was significantly higher in HCC patients than in those with cirrhosis (DCP-IgM, Mann–Whitney test p = 0.0047), while the distribution of serum levels of free AFP was not statistically significant in the two groups. Conclusions. DCP-IgM and SCCA-IgM in HCC were not associated with an increase of total IgMs, supporting a tumour specific induction of immune complexes. The codetermination of SCCA-IgM and DCP-IgM provided a better diagnostic accuracy than the AFP assay, strengthening the diagnostic role of immune complexes for HCC detection. doi:10.1016/j.dld.2007.12.083 ACUTE GASTROINTESTINAL BLEEDING PROLONGS QT INTERVAL IN CIRRHOSIS A. Zambruni, A. Di Micoli, E. Bracci, K. Fontana, P. Caraceni, M. Domenicali, F. Mirici-Cappa, V. Santi, G. Magini, R. Casadio, M. Frigerio, M. Bernardi, F. Trevisani Dipartimento di Medicina Interna Cardioangiologia ed Epatologia, Universit`a di Bologna, Italy Background/aims. QT interval prolongation is the potential background for ventricular arrhythmias in cirrhosis. Interestingly, “Torsade de pointes” have been reported to occur during acute gastrointestinal (GI) bleeding in cirrhotic patients, Our working hypothesis was that GI bleeding in cirrhotic patients can favour arrhythmias through a prolongation of ventricular repolarization.
Abstracts / Digestive and Liver Disease 40 (2008) A1–A40
A33
Patients/methods. Sixty-one cirrhotic patients (age: 60.7 ± 13.0 years, Child-Pugh class: A/B/C: 19/23/19) with acute GI haemorrhage (45 from varices) and 15 non-cirrhotic control patients (age: 75.5 ± 3.0 years, bleeding causes: 3 gastric ulcers, 2 colonic lesions, 10 unknown) were enrolled. Patients were evaluated at the time of bleeding (T1) and, in survivors (42 cirrhotic patients and all controls), after recovery (2–15 days: T2). As baseline values (T0), we utilized the last data available before the admission to the emergency unit (time range: 20 days–16 months). Cirrhotic patients were treated with vasoconstrictors (16), endoscopic treatment (24), endoscopic treatment + vasoconstrictors (12) and laparotomic variceal ligation + vasoconstrictors (9). QT interval was corrected for heart rate according to the “cirrhosis specific” formula (QTc = QT/RR1/3.02 ) in cirrhotic patients, and the Fridericia formula (QTc = QT/RR1/3 ) in control patients. The upper normal value was 452 ms. Results. (Mean ± S.D.): in cirrhotic patients, bleeding lead to a drop of haemoglobin (T0: 11.7 ± 1.8, T1: 8.3 ± 1.7 g/dl; p < 0.0001) and mean arterial pressure (MAP) (T0: 88.0 ± 9.4, T1: 72.7 ± 12.5 mmHg; p < 0.0001), while heart rate increased (T0: 78.1 ± 14.7, T1: 94.1 ± 21.0 bpm; p < 0.0001). QTc interval prolonged in 51 (84%) cases (T0: 414.0 ± 36.8, T1: 453.8 ± 36.3 ms, p < 0.0001). In the 42 survivors, after the initial prolongation QTc interval shortened (T1: 445.7 ± 5.3, T2: 425.8 ± 36.3 ms; p < 0.0001). No correlation was found between QTc interval prolongation and haemoglobin or MAP drop. The Child-Pugh score significantly worsened at the time of bleeding (T0: 8.3 ± 2.5, T1: 10.0 ± 2.4; p < 0.0001), remaining unchanged thereafter (T2: 9.3 ± 2.2; p = 0.53). QTc interval at T1 was significantly longer in patients who died compared to survivors (471.8 ± 8.0 vs. 445.7 ± 5.3; p = 0.012). In control patients, bleeding caused a drop of haemoglobin (T0: 14.6 ± 1.7, T1: 8.9 ± 2.6 g/dl; p = 0.04) and MAP (T0: 106.7 ± 18.9, T1: 85.4 ± 21.5 mmHg; p = 0.021), and an increase of heart rate (T0: 75.3 ± 11.9, T1: 87.1 ± 22.3 bpm; p = 0.07) which were not statistically different from those observed in cirrhotic individuals. QTc interval tended to prolong during bleeding but the increase did not reach the statistical significance (T0: 407.4 ± 22.0, T1: 449.0 ± 18.9, T2 431.0 ± 25.7 ms, p = 0.083). Conclusions. In cirrhotic patients QT interval increases during acute bleeding. Moreover, a prolonged QT interval heralds a poor prognosis. A monitoring of QT interval in cirrhotic patients during acute bleeding is warranted.
Background and aims. AMPK is a fuel-sensing enzyme which regulates cellular metabolism in response to different stimuli, including stress conditions, antidiabetic drugs and adiponectin. We recently demonstrated that activation of AMPK inhibits PDGF-stimulated proliferation and migration, as well as collagen and chemokine secretion by human activated HSC. However, the potential role of this enzyme in the process leading to activation of HSC has not been fully established. Aim of this study was to investigate whether AMPK modulates the trans-differentiation (activation) process of HSC. Methods. HSC were isolated from normal rat liver and plated on plastic in complete medium, in the presence or absence of metformin (20 mM) or AICAR (5-aminoimidazole-4carboxamide-1-beta-4-Ribofuranoside) (0.5–1.0 mM), two activators of AMPK. Transition from the quiescent to the myofibroblastic phenotype was analysed in treated and untreated HSC 3, 7, and 15 days following cell isolation. Results. When HSC were isolated from rats treated with a single dose of CCl4 , a protocol which induces a transient HSC activation in vivo, the activation status of AMPK was reduced along the activation process. Exposure of freshly isolated HSC to AICAR or metformin prevented HSC to adhere to plastic, spread and proliferate. However, cell viability was not affected by AMPK activators, as demonstrated by trypan blue exclusion. Moreover, removal of AICAR or metformin from the culture medium after 15 days of culture, was associated with cell attachment and activation. In addition, when AICAR was added after 3 days of culture, the trans-differentiation process was blocked, and HSC detached from the culture dish. Western blot analyses showed that the expression of proteins associated with HSC activation, such as ␣-smooth muscle actin, was lower in cells treated with AMPK activators. Conclusions. The results of the study show that AMPK acts as a negative modulator of the activation process of HSC, suggesting a possible role of this molecule in limiting the development of liver fibrogenesis.
doi:10.1016/j.dld.2007.12.084
Liver Unit, Tor Vergata University, Rome, Italy of Internal Medicine, La Sapienza University, Rome, Italy
AMP-ACTIVATED PROTEIN KINASE (AMPK) REGULATES THE ACTIVATION PROCESS OF HEPATIC STELLATE CELLS C. Bertolani, A. Caligiuri, F. Vizzutti, C. Tosti Guerra, M. Pinzani, F. Marra Dipartimento di Medicina Interna, University of Florence, Italy
doi:10.1016/j.dld.2007.12.085 HIGH PREVALENCE OF METABOLIC SYNDROME AFTER LIVER TRANSPLANTATION DOES NOT INFLUENCE LONG-TERM SURVIVAL S. Francioso a , F. Angelico b , G. Tisone a , L. Baiocchi a , I. Lenci a , L. Tariciotti a , M. Angelico a a
b Department
Background and aim. Metabolic abnormalities such as hypertension, diabetes mellitus, obesity, and hyperlipidemia are common after liver transplant (LT), separately or grouped within the so-called metabolic syndrome (MS). Genetic, environmental and drug-induced factors may justify the high
Abstracts / Digestive and Liver Disease 40 (2008) A1–A40
A cannabinoid agonist (WIN5521-2) has been shown to increase the pruritus threshold in cholestatic rats. Moreover, in the course of chronic cholangiopaties hepatic progenitor cells are activated constituting a neuroendocrine compartment regulated by different agents including neuropeptides. Aims. (1) To evaluate whether the EC system is activated in PBC; (2) To evaluate if genetic variations in human cannabinoid-specific receptor genes (CB1 and CB2) might cause a different phenotypic expression of the disease in terms of association with pruritus. Methods. (1) Morphological study: CB1 and CB2 receptors were characterized in biopsy specimens of 4 normal human liver and 10 PBC by immunohistochemistry. CB1 and CB2 mRNA expression was also assayed through RT-PCR in liver samples. (2) Genetic study: the following groups of subjects have been enrolled: 55 consecutive PBC Italian pts, 56 PBC pts residents in USA; 55 controls, matched for sex, age, and geographical area with the Italian PBC pts. Genomic DNA was extracted from peripheral venous blood leucocytes with standard method. PCR was used to amplify the coding regions of the CB1 and CB2 genes with specific primers. Results. CB1 was markedly expressed in hepatocytes and biliary epithelial cells in PBC; conversely, in control livers was virtually absent. CB2 was markedly expressed in mesenchymal cells, particularly in Kupffer cells. Accordingly, mRNA of both CB1 and CB2 was expressed in PBC liver samples, as demonstrated by RT-PCR. CB1 polymorphism (1359 G/A) was present in 25.5% of Italian PBC pts, in 23.5% of healthy controls, and in 26.8% of an US PBC series (p = n.s.). CB2 polymorphism (188–189 AA/GG) was present in 22.5% vs. 30.4% of Italian and US PBC respectively, and in 27.5% of Italian controls (p = n.s.) Stratifying the PBC patients according to pruritus there was no difference in either Italian and US series in the distribution of CB1 and CB2 mutation in patients with or without pruritus. Conclusions. EC system is up-regulated in PBC; these preliminary results failed to show a relationship between EC system and pruritus, but this system probably exert a role regulating metabolic homeostasis in other compartments. doi:10.1016/j.dld.2007.12.082 HEPATOCELLULAR CARCINOMA INDUCES SPECIFIC IGM-BIOMARKERS IMMUNE COMPLEXES L. Beneduce a , G. Pesce a , A. Gallotta a , F. Zampieri a , A. Biasolo b , N. Tono b,c , P. Pontisso b , G. Fassina a a
XEPTAGEN SpA, Marghera Venezia, Italy of Clinical and Experimental Medicine, University of Padova, Italy c Istituto Oncologico Veneto (I.O.V.), IRCCS, Padova, Italy b Department
Background and aims. Recently it has been discovered that several cancer biomarkers circulate in serum of patients with hepatocellular carcinoma (HCC) associated to immunoglobulins M.
To support a tumour specific induction of immune complexes, we determined whether the presence of IgM complexes was correlated to an increase of total IgMs in the sera of patients with HCC and cirrhosis. Further, to extend our ongoing investigation on the relevance of IgM-biomarkers for HCC detection we compared the co-determination of des-gamma-carboxy prothrombin (DCP) and squamous cell carcinoma antigen (SCCA) as IgM immune complexes with AFP determination in patients with HCC and cirrhosis. Patients and methods. Serum samples from 31 patients with cirrhosis and from 33 untreated HCC patients were analyzed for the total IgM measurement. DCP-IgM, SCCA-IgM and AFP levels were determined in parallel using standard ELISA Kits. Results. The serum concentrations of IgM expressed in mg/ml were determined by interpolation of samples absorbance on the calibration curves plotted with IgM calibrators. The amount of IgM was not significantly different in the group of HCC patients (median level = 1.79 mg/ml) compared to those with cirrhosis (median level = 1.09 mg/ml, Mann–Whitney test p = 0.1376). The co-determination of SCCA-IgM and DPC-IgM was above the cut off in 19 of the 33 HCC patients (60% of diagnostic sensitivity; SE) and in 9 of the 31 patients with cirrhosis (70% of diagnostic specificity; SP). The serum levels of AFP were above the 20 ng/ml cut off in 48% (SE; 16/33) of HCC patients and in 4 out of 31 patients with cirrhosis (87% SP). The distribution of serum levels of immune complexes was significantly higher in HCC patients than in those with cirrhosis (DCP-IgM, Mann–Whitney test p = 0.0047), while the distribution of serum levels of free AFP was not statistically significant in the two groups. Conclusions. DCP-IgM and SCCA-IgM in HCC were not associated with an increase of total IgMs, supporting a tumour specific induction of immune complexes. The codetermination of SCCA-IgM and DCP-IgM provided a better diagnostic accuracy than the AFP assay, strengthening the diagnostic role of immune complexes for HCC detection. doi:10.1016/j.dld.2007.12.083 ACUTE GASTROINTESTINAL BLEEDING PROLONGS QT INTERVAL IN CIRRHOSIS A. Zambruni, A. Di Micoli, E. Bracci, K. Fontana, P. Caraceni, M. Domenicali, F. Mirici-Cappa, V. Santi, G. Magini, R. Casadio, M. Frigerio, M. Bernardi, F. Trevisani Dipartimento di Medicina Interna Cardioangiologia ed Epatologia, Universit`a di Bologna, Italy Background/aims. QT interval prolongation is the potential background for ventricular arrhythmias in cirrhosis. Interestingly, “Torsade de pointes” have been reported to occur during acute gastrointestinal (GI) bleeding in cirrhotic patients, Our working hypothesis was that GI bleeding in cirrhotic patients can favour arrhythmias through a prolongation of ventricular repolarization.
Abstracts / Digestive and Liver Disease 40 (2008) A1–A40
A33
Patients/methods. Sixty-one cirrhotic patients (age: 60.7 ± 13.0 years, Child-Pugh class: A/B/C: 19/23/19) with acute GI haemorrhage (45 from varices) and 15 non-cirrhotic control patients (age: 75.5 ± 3.0 years, bleeding causes: 3 gastric ulcers, 2 colonic lesions, 10 unknown) were enrolled. Patients were evaluated at the time of bleeding (T1) and, in survivors (42 cirrhotic patients and all controls), after recovery (2–15 days: T2). As baseline values (T0), we utilized the last data available before the admission to the emergency unit (time range: 20 days–16 months). Cirrhotic patients were treated with vasoconstrictors (16), endoscopic treatment (24), endoscopic treatment + vasoconstrictors (12) and laparotomic variceal ligation + vasoconstrictors (9). QT interval was corrected for heart rate according to the “cirrhosis specific” formula (QTc = QT/RR1/3.02 ) in cirrhotic patients, and the Fridericia formula (QTc = QT/RR1/3 ) in control patients. The upper normal value was 452 ms. Results. (Mean ± S.D.): in cirrhotic patients, bleeding lead to a drop of haemoglobin (T0: 11.7 ± 1.8, T1: 8.3 ± 1.7 g/dl; p < 0.0001) and mean arterial pressure (MAP) (T0: 88.0 ± 9.4, T1: 72.7 ± 12.5 mmHg; p < 0.0001), while heart rate increased (T0: 78.1 ± 14.7, T1: 94.1 ± 21.0 bpm; p < 0.0001). QTc interval prolonged in 51 (84%) cases (T0: 414.0 ± 36.8, T1: 453.8 ± 36.3 ms, p < 0.0001). In the 42 survivors, after the initial prolongation QTc interval shortened (T1: 445.7 ± 5.3, T2: 425.8 ± 36.3 ms; p < 0.0001). No correlation was found between QTc interval prolongation and haemoglobin or MAP drop. The Child-Pugh score significantly worsened at the time of bleeding (T0: 8.3 ± 2.5, T1: 10.0 ± 2.4; p < 0.0001), remaining unchanged thereafter (T2: 9.3 ± 2.2; p = 0.53). QTc interval at T1 was significantly longer in patients who died compared to survivors (471.8 ± 8.0 vs. 445.7 ± 5.3; p = 0.012). In control patients, bleeding caused a drop of haemoglobin (T0: 14.6 ± 1.7, T1: 8.9 ± 2.6 g/dl; p = 0.04) and MAP (T0: 106.7 ± 18.9, T1: 85.4 ± 21.5 mmHg; p = 0.021), and an increase of heart rate (T0: 75.3 ± 11.9, T1: 87.1 ± 22.3 bpm; p = 0.07) which were not statistically different from those observed in cirrhotic individuals. QTc interval tended to prolong during bleeding but the increase did not reach the statistical significance (T0: 407.4 ± 22.0, T1: 449.0 ± 18.9, T2 431.0 ± 25.7 ms, p = 0.083). Conclusions. In cirrhotic patients QT interval increases during acute bleeding. Moreover, a prolonged QT interval heralds a poor prognosis. A monitoring of QT interval in cirrhotic patients during acute bleeding is warranted.
Background and aims. AMPK is a fuel-sensing enzyme which regulates cellular metabolism in response to different stimuli, including stress conditions, antidiabetic drugs and adiponectin. We recently demonstrated that activation of AMPK inhibits PDGF-stimulated proliferation and migration, as well as collagen and chemokine secretion by human activated HSC. However, the potential role of this enzyme in the process leading to activation of HSC has not been fully established. Aim of this study was to investigate whether AMPK modulates the trans-differentiation (activation) process of HSC. Methods. HSC were isolated from normal rat liver and plated on plastic in complete medium, in the presence or absence of metformin (20 mM) or AICAR (5-aminoimidazole-4carboxamide-1-beta-4-Ribofuranoside) (0.5–1.0 mM), two activators of AMPK. Transition from the quiescent to the myofibroblastic phenotype was analysed in treated and untreated HSC 3, 7, and 15 days following cell isolation. Results. When HSC were isolated from rats treated with a single dose of CCl4 , a protocol which induces a transient HSC activation in vivo, the activation status of AMPK was reduced along the activation process. Exposure of freshly isolated HSC to AICAR or metformin prevented HSC to adhere to plastic, spread and proliferate. However, cell viability was not affected by AMPK activators, as demonstrated by trypan blue exclusion. Moreover, removal of AICAR or metformin from the culture medium after 15 days of culture, was associated with cell attachment and activation. In addition, when AICAR was added after 3 days of culture, the trans-differentiation process was blocked, and HSC detached from the culture dish. Western blot analyses showed that the expression of proteins associated with HSC activation, such as ␣-smooth muscle actin, was lower in cells treated with AMPK activators. Conclusions. The results of the study show that AMPK acts as a negative modulator of the activation process of HSC, suggesting a possible role of this molecule in limiting the development of liver fibrogenesis.
doi:10.1016/j.dld.2007.12.084
Liver Unit, Tor Vergata University, Rome, Italy of Internal Medicine, La Sapienza University, Rome, Italy
AMP-ACTIVATED PROTEIN KINASE (AMPK) REGULATES THE ACTIVATION PROCESS OF HEPATIC STELLATE CELLS C. Bertolani, A. Caligiuri, F. Vizzutti, C. Tosti Guerra, M. Pinzani, F. Marra Dipartimento di Medicina Interna, University of Florence, Italy
doi:10.1016/j.dld.2007.12.085 HIGH PREVALENCE OF METABOLIC SYNDROME AFTER LIVER TRANSPLANTATION DOES NOT INFLUENCE LONG-TERM SURVIVAL S. Francioso a , F. Angelico b , G. Tisone a , L. Baiocchi a , I. Lenci a , L. Tariciotti a , M. Angelico a a
b Department
Background and aim. Metabolic abnormalities such as hypertension, diabetes mellitus, obesity, and hyperlipidemia are common after liver transplant (LT), separately or grouped within the so-called metabolic syndrome (MS). Genetic, environmental and drug-induced factors may justify the high