Fulminant hepatic failure in children: Mortality and the role of orthotopic liver transplantation

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Abstracts / Digestive and Liver Disease 39 (2007) A29–A47

EFFICACY, SAFETY AND PHARMACOKINETIC PROFILE OF PASTEURIZED INTRAMUSCULAR ANTI-HEPATITIS B IMMUNOGLOBULIN FOR THE PROPHYLAXIS OF HEPATITIS B VIRUS RECURRENCE AFTER LIVER TRANSPLANTATION F. Filipponi a , P. Carrai a , P. De Simone a , A. Franchello b , R. Romagnoli b , M. Salizzoni b a

U.O. Trapiantologia Epatica Universitaria, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy b Centro Trapianti di Fegato, Azienda Ospedaliera S Giovanni Battista, Torino, Italy Background. Combined prophylaxis with hyperimmune human immunoglobulins (HBIG) and anti-nucleoside analogues has greatly improved the outcome of liver transplantation (LT) for hepatitis B virus (HBV)-related disease. This result is usually achieved by maintaining a stable anti-HBs titre ≥150 U/l indefinitely. However, the optimal way of administration and schedule in order to optimize costs and patients’ compliance needs further investigation. Methods. We assessed the efficacy in preventing HBV recurrence of a newly introduced pasteurized intramuscular HBIG (Igantibe® , Grifols Barcelona, Spain) administered at a standard dosage of 2000 IU every 14 days. Anti-HBs were measured before each administration, and a stable anti-HBs titre from month 4 to 6 was considered as endpoint. The drug pharmacokinetic profile was investigated, as well as its safety and tolerability. Results. Seventeen HBV transplant patients previously treated with intravenous HBIG and lamivudine were switched to prophylaxis with the study drug plus lamivudine for 6 months. No patient showed HBV recurrence or subclinical HBV infection by genomic analysis. Individual anti-HBs through titres were >150 IU/l at each time point (Table 1). The peak concentration was reached 4 ± 3 days from administration, and median half-life was 28 days (range 14–69). No changes in vital signs and laboratory tests, including viral markers, were found. Conclusions. At the proposed schedule, Igantibe® was effective in maintaining a protective anti-HBs titre and preventing graft re-infection post-transplantation. The drug was safe and well tolerated over a period of 6 months. Table 1 Mean anti-HBs titre (IU/l) over study period Months

4

5

6

Mean ± S.D. Range

452 ± 159 258–803

472 ± 145 262–709

508 ± 149 243–735

doi:10.1016/j.dld.2007.07.014 MYCOPHENOLATE MOFETIL PLUS LOW-DOSE CALCINEURIN INHIBITOR FOR RENAL DYSFUNCTION IN LIVER TRANSPLANT: A 24-MONTH CONTROLLED CLINICAL TRIAL M. Biselli a , G. Vitale a , A. Gramenzi a , A. Riili a , S. Berardi a , F. Dazzani a , C. Camm`a c , A. Scuteri a , M.C. Morelli a , C. Sama a , G.L. Grazi b , A.D. Pinna b , P. Andreone a , M. Bernardi a a

Dipartimento Malattie Apparato Digerente e Medicina Interna, Universit`a di Bologna, Italy b Unit` a Operativa di Chirurgia dei Trapianti di Fegato e Multiorgano, Ospedale S.Orsola-Malpighi, Bologna, Italy c Cattedra di Gastroenterologia, Universit` a di Palermo, Palermo; Italy

We tried to assess the long-term efficacy and outcome of low through level of calcineurin inhibitors (CNI) and introducing mycophenolate mofetil (MMF) in liver transplant (LT) patients with CNI-related renal dysfunction. Pts were matched for sex, age, months after LT, immunosuppressive treatment, creatinine level, presence of diabetes and calculated glomeru-

lar filtration rate (GFR) via Cockroft-Gault method, with a parallel control group who had received CNI only. We analysed: side effects, rate of rejection, serum creatinine reduction by at least 10% (10% creatinine) and/or a GFR increase of at least 10% (10% GFR) with respect to baseline values,
serum creatinine (serum creatinine level at baseline–serum creatinine level at 24 month),
GFR (GFR at 24 month–GFR at baseline). Thirty patients (25 M; mean age 61 ± 7 years; creatinine 1.77 ± 0.51 mg/dl; GFR 48.4 ± 14 ml/min) were converted to the combined therapy after a median of 63 months from LT and were compared with 30 patients (mean age 60 ± 7 years; creatinine 1.62 ± 0.25 mg/dl; GFR 48.9 ± 11.2 ml/min) used as contemporary control group. After 2 years, serum creatinine decreased in the MMF to 1.57 ± 0.71 mg/dl and GFR increased to 56.8 ± 17.2 ml/min (p < 0.001). The controls experienced a worsening of both serum creatinine (1.7 ± 0.35 mg/dl; p = 0.013) and GFR (47.3 ± 11.1 ml/min; p = 0.006). The logistic regression models employing 10% creatinine and 10% GFR as dependent variables, showed the use of MMF as the only statistically significant parameter associated with improvement of renal function (OR 5.7/95% CI 1.7–18.9, p = 0.004; OR 3.8/95% CI 1.2–11.4, p = 0.019, respectively). Multiple linear regression analysis identified only MMF as independent predictor of
creatinine and
GFR (regression coefficient B: −0.26/95% CI −0.1/−0.41; p = 0.002; −9.05/95% CI −4.9/−13.2; p < 0.001, respectively). No rejection episode was observed (3 in the controls). This study demonstrates the long-term efficacy and safety of MMF plus low dose CNI in reducing nephrotoxicity in LT recipients. doi:10.1016/j.dld.2007.07.015 FULMINANT HEPATIC FAILURE IN CHILDREN: MORTALITY AND THE ROLE OF ORTHOTOPIC LIVER TRANSPLANTATION F. Bruni, M. Bravi, M. Candusso, M. Bosisio, M.L. Melzi, P. Stroppa, D. Pinelli, M. Colledan, G. Torre Paediatric Liver Transplantation Centre, Ospedali Riuniti, Bergamo, Italy To evaluate the role of orthotopic liver transplantation (OLTx) in fulminant hepatic failure (FHF), defined by coagulopathy (INR > 2) with or without encephalopathy in a patient with no identified chronic liver disease. Retrospective analysis of all children with FHF referred to our centre from October 1997 to August 2006. FHF was diagnosed in 41 patients (23 male, 18 female; mean age 41 months; range 1 day–163 months): metabolic disorder in 10, toxic hepatitis in 7, autoimmune hepatitis in 6, multisystemic disease in 4 patients; in 14 patients there was a cryptogenic hepatic failure. In 56% of cases, waiting list for OLTx was activated; in the others, there was no indication for it because of underlying disease (multisystemic disorder) or improvement after appropriate medical therapy. The overall mortality rate was 20%. OLTx was performed in 19 out of 23 listed children; 4 were not transplanted for spontaneous recovery (2), for parents’ refusal (1), for death on waiting list (1). Indications for OLTx in the 19 patients were: cryptogenic hepatic failure (9), metabolic diseases (5 cases: 3 neonatal hemocromatosis, 2 Wilson’s disease), autoimmune hepatitis (4) and mushroom poisoning (1). Survival rate was 74% (14/19) in OLTx for FHF and 87% in OLTx with elective indication; the difference between FHF OLTx and elective OLTx cases is not significant (Fischer test). Primary non-function, re-transplantation for chronic reject, multiorgan failure and neurological complications were the causes of death. At a mean of 36.5 months follow-up time, in the transplanted children, we reported four biliary complications, two chronic rejections, one neurological delay as major long-term complications. According to intention-to-treat analysis, the survival rate was 74% (17/23) among listed children and 89% (16/18) among children not assessed for OLTx (two children died for the underlying disease (respiratory chain disorder)). The difference in mortality rate in the two groups was not statistically significant (Fischer test). Children with FHF should be referred to a specialized transplantation centre to receive all needed treatments. In our experience, mortality in FHF patients is low, as compared with other series, even in transplanted cases.

Abstracts / Digestive and Liver Disease 39 (2007) A29–A47 The lack of significant difference in survival rate with elective cases means that OLTx is a safe therapeutic option even in the most severe cases. doi:10.1016/j.dld.2007.07.016 LIVER ASSIST DEVICE AS BRIDGE FOR LIVER TRANSPLANT IN HEPATIC FAILURE: A FIRST IN VIVO STEP OF TISSUE ENGINEERING DEVELOPMENT

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Conclusions. Our study demonstrates that the liver device with pre-fabricated micro-vascular network supports hepatocyte viability and function in a short-term rat model. This device is promising for future development of a permanent ex vivo tissue-engineered liver-assist device. However, the problem of pressure build-up or fluid accumulation (lymph and bile) in the parenchymal chamber needs to be solved in the future designing of new devices.

A. Carraro a,b , W.-M. Hsu b,c , M.L. Miller b , K.M. Kulig b , C. Neville b , J. Borenstein d , K. Bonner c , B. Orrick b,c , E. Weinberg d,e , E. Swart d,e , K. Morgan b , M. Kaazempur-Mofrad f , Cillo Umberto a , Vacanti Joseph P. b a

Hepatobiliary and Liver Transplant Unit, University of Padua, Italy Department of Surgery and Center for Regenerative Medicine, Massachusetts General Hospital Harvard University, USA c Department of Surgery, National Taiwan University Hospital, Taiwan d Biomedical Engineering Center, Charles Stark Draper Lab, USA e Departments of Mechanical Engineering and Biological Engineering, MIT USA f Department of Bioengineering, University of California Berkeley, USA b

Introduction. A sufficient oxygen and nutrient delivery system is required to build a 3-D organ using tissue-engineering approach. The purpose of this study is to test the effectiveness of a liver device with a pre-fabricated vascular bed that supports hepatocytes in a rat model for developing a liver assist device as a bridge for liver transplant. Materials and methods. MEMS technology was used to design and fabricate a microfluidic network that approximates a native vascular bed. A 0.22 ␮m polyethersulfone (PES) membrane separates the vascular bed from the parenchymal compartment. The device was implanted in an athymic rat by connecting the inlet and outlet tubes to the femoral artery and vein. The pressure profile of femoral artery, vein and parenchymal chamber was measured before and after device connection. The blood flow pattern and perfusion status of the device were examined by laser Doppler scanning. A total of 28 devices were implanted with 16 devices seeded with 6 × 105 freshly harvested rat primary hepatocytes and 12 devices seeded with 6 × 105 HepG2/C3A cells in the parenchymal chamber. The parenchymal tubes of the 16 devices with primary hepatocytes were all freely drained. The 12 devices with HepG2/C3A cells were equally divided into four groups according to variant parenchymal tube settings: (1) free parenchymal tubes drainage; (2) closed parenchymal tubes; (3) parenchymal tubes drained to the device outlet tube; (4) parenchymal tubes drained to a separate femoral vein. Cell viability was assessed by calcein Am/ethidium homodimer-1 two colour fluorescent staining. The human alpha-FP levels in the blood samples were analysed by ELISA. Albumin immunofluorescent staining was a marker for secreted protein synthesis. Results and discussion. All the 28 implanted devices except 2 remained patent for the duration of the experiment (6–30 h, median = 12 h). Only 4 of 16 rats in the primary hepatocytes group and 1 of 3 rats in HepG2/C3A group 1 could survive up to 24 h; however, all the rats in other groups could survive up to 24 h. Rats that died experienced hypovolaemia due to excess parenchymal tube drainage. The pressure profile showed that the mean arterial pressure drop (from 119 to 93 mmHg) roughly equalled to the mean venous pressure rise (from 6.3 to 11.3 mmHg) plus mean parenchymal chamber pressure (20.3 mmHg). The laser Doppler scanning showed a homogenous blood perfusion through the device, as well as a flow pattern mimicking normal blood vessels (Fig. 2). The cell viability was more than 90% for all the primary hepatocytes and the group 1 HepG2/C3A cells. The cell viability for group 2 HepG2/C3A cells was less than 5%, group 3 was 60–70% and group 4 was 80–90% (Fig. 3). The primary hepatocytes maintained typical morphologic appearance and albumin expression (Figs. 4 and 5). Human alpha-fetoprotein levels were continuously detectable in the blood samples of groups 1, 3 and 4 rats with levels higher in groups 1 and 4 than group 3. However, no human alpha-fetoprotein was detectable in the blood samples of group 2 rats (Fig. 6).

doi:10.1016/j.dld.2007.07.017 FURTHER DATA SUPPORTING MACHINE PERFUSION ABILITY TO PRESERVE STEATOTIC RAT LIVERS: ROLE OF KUPFFER AND BILIARY EPITHELIAL CELLS A. Ferrigno a , V. Rizzo b , F. Carlucci c , A. Tabucchi c , E. Boncompagni d , G. Milanesi d , S. Barni d , U. Cillo e , I. Freitas d , M. Vairetti a a

Dept. Int. Med. and Therapeutics, Italy Dept. of Biochemistry, IRCCS San Matteo, Univ. of Pavia, Italy c Dept. Int. Med., Univ. of Siena, Italy d Dept. of Animal Biology and IGM-CNR, Univ. of Pavia, Italy e Dept. General Surgery, Univ. of Padua, Italy b

Cold storage is unsuitable to preserve steatotic livers, frequently resulting in primary graft nonfunction. An increased release of TNF-alfa and an impaired bile secretory function have been proposed as factors involved in cold preservation-induced damage. We tested whether rat liver preservation, performed by MP at 20 ◦ C, can enhance the functional integrity of steatotic livers versus simple cold storage. We also compared MP at 20 ◦ C with hypothermic MP at 8 ◦ C. Obese male Zucker rats were used as liver donors. MP: livers perfused for 6 h with oxygenated Krebs-Henseleit solution (KH) supplemented with glucose (5 mM) and n-acetylcysteine (5 mM) at 20 ◦ C or 8 ◦ C. Cold storage: livers perfused in situ and preserved with Celsior solution at 4 ◦ C for 6 h. Both MP and cold storage preserved livers were reperfused with KH (2 h–37 ◦ C). Fatty livers preserved by MP at 20 ◦ C show a significant lower hepatic damage at the end of reperfusion period as compared with MP at 8 ◦ C and cold storage. ATP levels, energy charge and ATP/ADP ratio were higher and a reduction of oxidative stress was observed in steatotic livers preserved by MP at 20 ◦ C compared with cold storage. Bile production was higher and biliary alkaline phosphatase release lower in fatty livers preserved by MP at 20 ◦ C. In livers preserved by cold storage or MP at 8 ◦ C an increase in TNF-alpha levels was observed as compared with organ preserved by MP at 20 ◦ C. In fatty livers caspase3 activity was largely increased in livers preserved by cold storage or MP at 8 ◦ C whereas during MP at 20 ◦ C the increase was markedly reduced, evidencing a decrease in terms of apoptosis activation, even if we did not observe DNA fragmentation in any sample. These data are substantiated by a better ultrastructure. MP at 20 ◦ C results in a better-quality hepatic preservation of steatotic livers compared with MP at 8 ◦ C and simple cold storage. Our results might provide a new method for a successful preservation of