Cholyl-lysyl-fluorescein (CLF) clearance provides a reproducible dynamic liver function test

prevalence of concurrent intection and/or prior exposure to the hepatitis viruses A and B as well as HIV in a U.S. veteran population chronically infected ruth hepatitis C. Patterns and Methods: The stud}, was contacted among 1463 veterans with chronic hepatitis C. HBV panel was obtained in all patients while HIV was a``'adable in 976 and HAV in 161 patients Serum aminotransflerases (ALT and As'r) and platelet counts were also obtained from all patients. Results : Of the 1463 HCV patients, the overwhelming nNority were men (1,398, 95.5%) and 65 (4.5%) were women, thus reflecting our predominantly male veteran populatinn The mean age was almost 50 years (range 27-82). Serum ALT and AST levels were 74.3 +- 66.2 and 63 9 _+53 1 (means _+SD) respectively. The mean platelet count was 211 D'mm3 /the derailed results are shown in the Table below'. The majority" of these HCV infected patients (62.4%) were seropositive tbr the hepatitis B core antibody (HBcAb), implying prior exposure to ttBV. Fifty t``vo percent (474 of 913) of these HBcAb-positive individuals ,,*,,ereseronegative for the HbsAb (anti-HBs). Only 17 (1.2%) of the 1463 patients were positive for the HbsAg. Apprommately 7% (68 of 976) of HCV-positive individuals tested positive for HIV by western blot. Lastly, a large number of patients (67 of 161, 40%) were negative tbr HAV antibody. Conclusions : 1. Only" a small percentage of veterans vAth HCV are ac6vdy cointected with HBV. 2. By contrast, almost two-thirds of the HCV patients have been exposed to the HBV and half of these lack neutralizing HBsAb. 3. Contrary to previons reports, the incidence of concurrent HIV infection in our HCV population is nelatis'ely low. 4 A large number of HCV patients have never been exposed to HAV, thus raising the isam of systematic detecBon and vaccination of these iodividuals

HCVP~ents Age Male Female HBV

follow-up time for the entire cohort was 630.0 days (1QR, 273.0 to 742.3 days). Patients were seen by their heahbeare providers a median of 10.0 times (IQR, 4.0 to 21.0 visits) during follow-up, and only 224 (35.1%) were reterred to the GI or liver clinic for evaluation. NAV antibody testing was performed in 305 of the 638 patients (47.8%); 150 (49.2%) were positive !immune) mad 155 (50.8%) were negative (susceptible). Among the 155 patients who were susceptible to superinfection with HAV, only 40 (258%) were vaccinated for HAV; the remaining 115 were not offered (n = 114) or refused vaccination (n = 1) Of the 40 susceptible patients who were vaccinated, 22 received I dose and 18 completed both doses of vaccine. Vaccination tor HAV was done in 3 of the 333 patients (0.9%) who did not have HAV antibody ordered; the remaining 330 were not offered (n = 329) or refused vaccination (n = 1). Conclusions: Despite published recommendations for vaccination against HAV in patients with HCV, healthcare providers often do not test or vaccinate susceptible individuals. Future studies to determine barriers to vaccination are warranted.

M1434 Morphologic Study of the Development of the Human Liver Eric Weiss, Robert Morreale, Charles Paidas, Grover Hutchins, Michael A. Choti Historically, descriptions of liver embyogenesis have been based on the microscopic study of two-dimensional histologic specimens. This approach has led to debate regarding the sequence of evems in early embyrugenesis and has made it difhcuk to study the surface features of the liver. The ability to visualize the developing liver in three dimensinns juxtaposed wuh surrounding organs could potentially provide new insights into its development. Therefore, to describe the early, development of the liver and stud), the origin of its unique three-dimensional structure, we used commercially" available software to three-dimensionally reconstruct eigl:t sectioned human embryos. The sections, ranging from 20-44 days post conception, were obtained from the Carnegie collection of staged human embryos. We further used a morphing technique to tbllow this development over time. These techniques have allowed us to dearly ~,asualize the early, development of the liver from a morphological perspective We demonstrate early' hepatic parenchymal invasion into the viteline veins showing that hepatic development begins syrametrically but later becomes asymmetric in correlation with the development of abdominal organs. This technique will turther allow us to measure volume of hepatic segments as they change over time as well as Mlow the relationship between prominent vascular and biliary structures within the developing hepatic parenchyma. This research has direct implications for understanding the formation of hepatic segments as well as structural mechanisms for hepatic defects.

1~3 49.8 ~7.2 1,398 (95.5%) 65 (45%)

HBsAg-positlve

17 (1,2%)

HBcAb~posil~e HBsAb+HBcAb HIV HAV

913 (62,4%) 474 (32,4%) 68/976 (7%)

671161(40%)

M1432 False-positive HCV-antibody by ELISA-2 : Evidence for the Involvement of Serum Rheumatoid Factor in RIBA-negative Cases Anastasios A Mihas, John A. Arledge, Christopher Lyons, Robert H. Lippman, Adil Habib, Souheil G. Abou Assi, Hochong S. Gilles, Douglas M. Heuman

M1435

Background : In recent years second and third generation immunoassays for the detection of HCV infection are' considered sensitive enough to be recommended for the iinttal screening ot patients at risk for chronic bepantis C.. However, the exact rate of false-positive results varies greatly. Moreover, there is no satisfactory explanation for the potential factors that might be responsible for tho~ sera that test positive for HCV antibody' but are not confirmed by RIBA (RIBAmegative) Aim: The aim of this study was the determination of the frequency of the talse-positive tests and its correlation with RE levels in our veteran population.Patients and Methods : All patients were initially screened for HCW infection with a second generation ELISA (ELISA-2, Abbort) and followed up with an HCV-RNA assay by PCR (Amplicor, Roche). To date, 31 sera with undetectable HCV-RNA levels were subjected to a RIBA 3.0 immunoblotting assay (Cbimn/and the quantitative determination of rheumatoid tactor(RF). Results :There were 51 men (93%) and 4 women (7%), thus reflecting our predominantly" male veteran population. The mean age was 51.6_+8.1 (mean_+ SD) years with a range of 29 to 73 years. The details of the resolts are summarized in the Table below. Conclusions : 1 Ten percent (10%) of veterans with positive HCV-Ab by EL1SAhad no detectable levels o{ NCV-RNA. 2 More than half (58%) of HCV-RNAmegative patients were also negative by the currently used confirmatory serological test (RIBA). 3. Patients with negative RIBA have statistically significantly higher RF levels than those with a positive RIBA These findings support previous data indicating that false-positive znti-HCV is as.~iated with autoimmumty.

HCV-posltlve (ELISA-2) HCV.RNA,negative RIBA.posittve RIBA-ne~aUve,

NUMBER(%) 535 55 (10.3%) 13/31 {42%} 18/31 (58%}

Clinical Superiority of Contrast Uhrasonography in Hepatocellular Carcinoma after Introduction of Muhidetector CT Shinjiro Yamaguchi, Kenji Fujimoto, Masahide Oshita, Junpei Kondo, Keisuke Kouga, Keisuke Hashimoto, Akiyoshi Okada, Shigeo Wada, Takashi Abe Haruya Meren, Manabu Masuzawa, Norio Hayashi [Obiectivel We previously reported that contrast uhrasonography' (contrast US) had a superior capability in evaluating the therapeutic efficacy against hepatoceUuiar carcinoma (HCC) as compared to dynamic CT, in particular (DDW2002). On the: other hand, muhidetector CT (MDCT) has come into use recently. This has led to improvements in the dynamic CT capability of tumor enhanced detection, and these improvements will expectedly lead to some changes in the clinical superiority of contrast US. In the present study, we compared the detection rates of tumor enhanced images betv,,een contrast US and CT in evaluation of the therapeutic efficacy against HCC before and after the introduction of MDCT (Methods] The study subjects were 204 nodes in 124 patients with HCC. These patients underwent therapy by percutaneous transcatheter arterial chemo-embolization, percutaneous ethanol irtjection therapy, and radiofrequency ablation therapy. (1) The operational conditions for dynamic CT before and after the introductinn of MDCT : The scan slice width of l0 ram was reduced to 7.5 mm. The scanning rate was increased three times~ The contrast medium infusion rate of 3 ml/sec was increased to 4 ml/sec. (2) The operatira'al conditions for contrast US: The imaging mode was uhraharmonic imaging (UHI). The contrast medium was used kevovist| was injected into the vein by 8-ml bolus (300 mg/ml). These conditions were not changed between betore and after the introduction of MDCT. Dynamic CT and contrast US ``vere done after 2weeks of the therapy. The sensitivity, the degree of specificity, and the ratio of matching were compared before and after the introduction of MDCT. [Results] Assessment of all the patients showed that the values of UHI tumor enhancement tot dynamic CT enhancement before and after the introduction of MDCT increased from 767% to 90.6% for the sensitivity, from 83.1% to 87.5% for the degree of specificity, and from 81.4% to 884% for the ratio of matching by impmvemems of operational conditions for CT. However, tumor enhancement was detected by UH1 but not detected by" MDCT in 6.296 to 10.7% of the patients in all groups after the introduction of MDCT, whereas the number of patients tor whom tumor enhancement was detected by MDCT but not detected by UHI was markedly small, 0% to 3.6% in all groups, lConclusionl It was demonstrated that contrast US capability of tumor enhancement detection was superior to dynamic CT in judgment of the tirerapeutic efficacy against t-ICC, even after the introduction of MDCT.

RF (iu/mL) 11 4.5 44 21

M1433 Susceptibility to Hepatitis A in Patients With Hepatitis C: Missed Opportunities for Vaccination Michael Shim, lnessa Khaykls, James Park, Fritz Francois, Edmund J. Bini Background: Vaccination against hepatitis A (bks is recommended for all patients with hepatitis C (HCV) because of the potential for severe acute HAV superimposed on chronic liver disease However, physician compliance with these recommendations has not been adequately" evaluated. The aims of this study were to determine the pmport/on of newly diagnosed HCV infected patients that are tested for immunity against HAV and vaccinated avcording to published guidelines. Mefbods: Consecutive patients with newly diagnosed hepatitis C between 1/1/00 and 6/30/00 were identified. Demographic data and the results of HAV antibody testing were collected by reviewing dectronic medical records, and patients were' excluded from this study if they were coinfected with HIV. Susceptibility to HAY was defined by tlte absence ot lgG antibody to HAV, Follow up was performed through 6/30/ 02 by revmwing electronic medical records and our pharmacy database, and the follow-up time was calculated from the time of diagnosis of HCV until the time of the last follow-up v:sit. Resuhs: 4,322 patients were tested tbr HC%~ and 743 were positive. After exclusion of 105 HIV + patients, there were 638 HCV+ patients remaining for analysis. The mean age ot the patterns was 55.9 -+ 10.4 years, 97 6% were male, and the racial distribution included 463% African Americans, 31 9% Caucasians, 21.2% Hispanics, and 0.6% others. The median

AASLD Abstracts

M1436 Cholyl-lysyl-fluorescein (CLF) clearance provides a reproducible dynamic liver function test El``vyn El/as, Charles Mills, Marc Halphen, Norman Barras, Hans-Juergen Gruas AIM: CLF is a fluorescein-labelled bile acid. We aimed to compare the CLF plasma and urine elimination in healthy volunteers (HVs) versus patients with liver cirrhosis (PLC) as a dynamic liver function test. PATIENTS and METHODS: Two separate studies were performed. One placebo-comrolled study was performed m 16 male HVs, who received up to four single Lv. doses of CLF (doses up to 30 rag) with at least 7 days between the dosing. Plasma samples were collected at time points between 0 and 480 minutes after dosing. In

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the second study (randotinsed, cross-over), 23 PLC (Child Pugh Score A or B) received 2 and 5 mg CLF Plasma samples were colketed at time points between 0 to 360 minutes after dosing Urine was collected pre- and post-dosing in both studies. Samples were analysed ,,wth a validated HP1C assay for C[.F. ENDPOINT8: The pharnaacokinetic (PK) parameters, including AUC, t~,~and clearance (CL) were assessed atier log-transformation. To develop a robust dynamic liver function test, several ratios of CLF plasma CL (e.g. T ~ ) were calculated In addition, a safety analysis was performed. RESULTS: In both studies AUC was proportional to the applied single iv. CLF dose, but the CL was independent of the dose administered, with a sigmficant diflerence (p<0,O01) between the mean CL of 14,8 L/h for the HVs and 8,1 L/h tot the PLC group. In addition, CL values were altered in relation to the increased Child Pugh scores and/or other markers assessing the extent of liver disease Tbe CLF T~O .~ plasma CI. ratios were in the 16 HVs with a mean of 0,32 (range: 0,21 to 0,46) significant difli:rent (p<0,O01) to the 23 PLC with a mean of 0,62 (range: 0,20 to 0,85). The reproducibility of multiple testing within individnals was high with au intra-class correlation coefficient of 0,82 tor the HVs and 0,97 for the PLC group. Furthermore, the T3c~'~ minnie CLF ratios correlated to CL and T~a, but also the severity of liver disease. The PK parameters derived from the urine showed only, minimal amorous ol CLF in the unne (up to 0,04 L&) and confirmed mainly non-renal eliminatkm mechanisms. The administration of CLF was ~t;e and well tolerated at all doses. CONCLUSION: Overall, the CLF CL showed a sigmficam and clear difference between HVs and PLC with an association to the severity of the liver disease. The CLF CL test (for example: T:~0/T~5CL ratio) is sate, reproducible and simple to pertdem in the assessment of the functional capacity of the liver. Additimta/studies are required to assess the clinical value of CLF in other liver disease conditions

(75%). Five patients with liver metastases could only be identified by CT/NMR (n=5f32; 15%). Four patients with liver metastases could only be identified by ultrasound imaging (n=4/32;12%). 2) Lesion to lesion analysis: In 18 % of the patients with liver metastases (n = 6/32) the ultrasound imaging techniques identified more metastastic lesions per individual patient than CT or NMR did In 31% of the patients with liver metastases (n = 10/32) CT or NMR identified more metastastic lesions per indi~sdual patient than the ultrasound imaging did. In 34 % of the patients with liver metastases (n = 11/32) echoenhanced ultrasound identified more metastastic lesions per individual patient than conventional b-scan sonography did. Conclusions: Echoenhanced phase inversion imaging is superior to conventional B-scan sonography in the detection of the amount of metastatic lesions per individual patient. Ultrasound imaging, even with the additional use of a echoer~hanced phase inversion imaging seems not to be able to substitute CT or NMK However, in case of a positive finding of liver metastases by" ultrasound and echoenhanced phase inversion imaging additional imaging techniques like CT and NMR could be spared.

M1439 Liver Cirrhosis Etiology by 31P MR Spectroscopy Pavel Taimr, Monika Dezortova, Milan Hajek, Julius Spicak Aims: Phosphorus magnetic resonance spectroscopy (~P MRS) enables the observation of liver metabolism in vivo through the signals of phosphomonoesters (PME), phosphodiesters (PDE), inorganic phosphate (f5) and ATP. This study deals with absolute quantificatinn of' liver metabolites obtained in 3p MR spectra of patients with fiver cirrhosis and the relationship bmween metabolite concentrations and the clinical status. Methods: 49 patients (51.4 • 10.9 yrs) with liver cirrhosis of diflerent etiology and severity described by Chlld-Pugh score (CPS) were examined afier overnight t~ting. Absolute concentrationa of PME, PDE, Pi and ATP were calculated. MR examination was pertbrmed on a whole-body MR imager Siemens Vision 1.5T using dual 3~P/~Hsurlace coil Results: Table summarizes absolute concentrations of selected metabolites together with Child-P@ score. According to ;~P MR spectra we ear* difti:rentiate vanous etiologies of cirrhosis. Alcohd liver disease (n = 19) differed in all studied metabolites (p<0.05 for Pi and ATP, p
M1437

Comparing Histological Findings with Contrast-EnhancedUhrasonography of Hepatocellular Carcinoma Nobnyuki Tatsumi, Yuji Nakayama, Gakahiro Yasuda, Tadashi Takeda, Daiki Habu, Hiroki 5akagochi, Shuhei Nishiga&i, Syuichi Seki Objectives: Contrast enhancement patterns of hepatocellular careinoina (HCC) by contrastenhanced uhramnography (CE-US) were analyeed in relation to histological differentiation of HCC. Furthermore the contrast enhancement effect was compared betveeen CE-US and dynamic CT in the early phase. Methods: The subjects of this study were 36 cases of histologically diagnosed with HCC (42 nodules m total). CE-US was performed after an intravenous bolus iqection of Levovist ~ (7 ml, 300 mg/ml). Using the FEI (flash echo imag"in-g'>colortechnique, eady phase images were taken for about 15-30 seconds, beginning 10 ~conds after the intravenous dose. A portal phase image was taken in a moment, 6090 seconds after the rejection (PowerVismn 8000, Toshiba). Dynamic CT was pertk)rmed oiler an intravmmus infusion of lopamiron ~ (100 ml, 300 mg/ml). Early phase images were taken 30 seconds alter the intusion (XVigor, Tosh:ba). The contrast enhancement pattern at each phase of CE-US was analyzed in relation to the histdogical degree of difli:rentiation of each nodular lesion of HCC The presence or absence of perfusiou (m early and portal phases was compared with that on early phase of dynamic CT Results: When examined by CE-.US, the tbllowing contrast entrancement patterns were noted. In many cases of well differenUated HCC, the tmnor was not wsible on early phase, but it svas visible on portal phase. In cases of moderately to poorly differentiated HCC, the tumor was visible on early, phase, and it remained wsible on portal phase. Thus, the contrast enhancement pattern diftered depending on the degree of tumor ditlerentiation. The perfusion positive rate on early phase was sigmficandy lower lnr nodules of well differentiated HCC (13%, 2/15) than fin" moderately difl~'rentiated HCC (75%, 12/16) and poorly differentiated HCC (75%, 6/8) (p < 0.001, X~) ~,u e~'amined by dynamic CT, the perfusion positive rate on early phase did not differ significantly between any three groups; it was 80% (12/15) for well differentiated HCC, 94% (15/16) for moderately differentiated HCC and 100% (8/8) for poorly" differentiated HCC (Table i ) Conclusion: CE-Ug can reflect the degree of tumor differentiation better than dynamic CT

Supported by" grants IGA MZ CR 6630-3 and CEZ:L17/98:00023001.

Absolute concentrations of 31P metabolttes [mM] in patients with liver ~ s | s N

r162

. . . . . w215p~O,~l

US ~ phase~ 13% (Z~15) 75% (12/16) 75~ (ee)

portal~ase 100% (15/15) 93% (14/15) ,___

Pi

POE

ATP Z70~0.94" 2.78,0,95' 2,61,0,94~ 3.60~0,94

M1440 Effects of BMP-7 on Liver Regenerationafter Partial Hepatectomy in Mice Changqing Yang, Hikam Sugimoto, Sudhakar Akulapalli, iVlauricio Giraldo, Nezam Afdhal, Michael Zeisberg, Raghu Kalluri Background: Acute liver failure is characterized by" loss of liver function and recovery., is only possible through adequate liver regeneration. TGF-hetal, a known inhibitor of prdit?ration for many kinds of cells, is also the most powerful inhibitor of hepatocyte proliferation in vitro and in vivo. Bone morphogenic protein-7 (BMP-'/), also referred to as Osteogenic protein-1 fOP-l), is a member of the TGF-betal superfamily. We have prevmusly demonstrated that BMP-7 functions as an antagonist of TGF-betal in murine models of chronic renal failure, inhibits TGF-betal induced pro-fibmtic responses. Therefore, in the present study we tested the capacity of BMP-7 to accelerate liver regeneration. Methods: 70% partial hepatectomy (PH) was performed by removal of the left and middle lobes of livers in 61 CD-1 mice. Three groups were studied; 300 mg/kg of' BMP-7 intraperitoneally (IP) ever}, other day; a placebo IP iNection and a sham surgery group. Mice were sacrificed after 2, 4, 7 and 10 days after surged~and regeneration potential was assessed by regeneration rate, tissue morphology, BrdU incorporation-proliferation index, and apoptosis using TUNEL assay. In addition TGF-hetal and hepatic growth factor (HGF) were also assessed in the tissue samples by Western blot and immunohistochemistry. Liver function was analyzed by serum ALT, AST and total bilirubin measurement. Results: Systemic admimstmnon of BMP~ 7 lead to a dramatic acceleration of liver regeneration at the groups of 2 days, 4 days and 7 days after PH, according to the BrdU index and liver regeneration rate, compared with control group and sham group Hepatocytes, which can express ALK-3 (type I receptor of BMP-7), become the tnain source of TGF-betal after PH. The expression HGF was not affected by the administration of BMP-7, however, the increase of TGF-betal expression afier PH was do,an-regulated. Apoptosis of hepatocytes also decreased at 7 day~ and 10days after PH in the BMP-7 treated groups. Liver tu.ncrion was improved at 4 days and 7 days after PH in the treated group. Conclusion: BMP-7 is an eftective nomtoxic protein capable of significant acceleration of liver regeneration BMP-7 appears to promote regeneration by down regulation of TGF-betal and by reducing hepatocyte apoptosis. Further studies are needed to evaluate a potential clinical role for BMP-7 m acute liver failure.

Perfuston positive rates for different imaging techniques hiMololgy well moderately

PME

All pat~erR~ 49 3.06~1.18 1.22~0.58" 5,32,2.64 s CPS: A+B 26 3,15 L06 1 23~0,59" 6.95 24Z -~ CPS:C 23 295~1,32 1.20~0,5T 5.67 2.75~,* Conbx/~ 9 2.78~1.27 1.690.70 9,88~2.69 *)p<005, s)p<0.01,~p<0.001from controls; *}p<0.05between CPS A+B to CPS: C

dynamic CT early phase 80% (12/~5) 94% (15116)

100~ ( ~ ) ............................

M1438 Detection of Liver Metastasis by Echo-EnhancedUltrasound - Interim Analysis of Prospective Multicenter Trial D Strobel, I". Bernatik, S. Heller, A. Bunk~ K Hi~chbuehl, G Adler, E G. Hahn, W. Kratzer Aim: To compare the diagnostic accuracy of echoenhanced ultrasound tor the detection of liver metastases in comparison to computed tomography, and nJagnetic resonance imagmg in a ongoing prospective multicenter trial Methods: Patients with known extrahepatic ~r~alignancy were screened tor lwer metastases using conventional B-scan sonography and echoenhanced ultrasouud (phase inversion imaging, Souovue 2.4 ml i.v. Bolus, Altana Pharma, Konstanz, Germany). The detectinn rate of liver metastases was compared to biphasic computed tomogaphy (CT) and maguetic resonance imaging (NMR). hi addition a lesion by lesion comparison was performed. Liver metastases was confirmed after a 3-6 months follow up. Resuhs: Up to nuw 46 patients with colorectal cancer (n = 20), pancreatic cancer (n = 13), gastric cancer (n = 4), breast cancer (n = 3), esophageal cancer (n = 1), lung cancer (n = I), cholangiocarcinoma (n = I), malignant melanoma (n= 1), adrenal cancer (n= 1), caminoid tumor (n = 1) were analyzed, in 32 patients liver metastases was identified: t) Detection late of hver metastases: CT/NMR detected liver metastases in 28/32 patients (87%) compared to B-scan-sonography/ecfio-enhanced pbase inversion imaging in 24/32 patients

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AASLD

Abstracts