Mo1916 Pre-Orthotopic Liver Transplant Transthoracic Echocardiogram Findings are Associated With Post-Transplant Cardiopulmonary Death

Mo1913

replication, increased ~30% in HSG but decreased ~80% in TSG at 48 h, indicating disruption of MB signaling. Daidzein largely prevented decreases in PGC1-α and TFAM in TSG and recovered OXPHOS enzymes in TSG to 80 - 90% of control levels. BrdU-positive cells were ~23% in HSG at 48 h but were only ~1% in TSG, consistent with suppressed liver regeneration. Serum total bilirubin increased 26-fold 48 h after transplantation of TSG, indicating poor liver function. Daidzein increased BrdU incorporation to ~26% and prevented hyperbilirubinemia in TSG recipients. While all mice survived after transplantation of HSG, survival decreased to ~10% in TSG. Daidzein increased survival in TSG to ~50%. Conclusion. Suppression of MB plays an important role in failure of small-for-size grafts. MB is a novel therapeutic target to improve the outcome of partial liver transplantation (NIDDK).

Hepatitis B Vaccine Repeat After Liver Transplantation Succeeds in Type-B Cirrhotics With Marital, High-Hbs-Antibody Donors Akinobu Takaki, Takahito Yagi, Hiroshi Sadamori, Susumu Shinoura, Yuzo Umeda, Ryuichi Yoshida, Daisuke Sato, Masashi Utsumi, Tetsuya Yasunaka, Kazuhide Yamamoto

AASLD Abstracts

Background and Aims: A combination of hepatitis B immunoglobulin and nucleos(t)ide analogues is the current standard of care for controlling hepatitis B recurrence after orthotopic liver transplantation. However, frequent immunoglobulin treatment is expensive and inconvenient. This study investigated the efficacy of hepatitis B virus vaccination in preventing recurrence of hepatitis B in carriers after orthotopic liver transplantation. Methods: Patients included 5 with acute liver failure and 21 with hepatitis B virus-induced liver cirrhosis; all had received orthotopic liver transplants. Starting at least one year after transplantation and continuing once monthly, recipients were immunized with hepatitis B surface antigencontaining vaccine. Patients who showed hepatitis B surface antibody titers above 30 mIU/ mL without hepatitis B immunoglobulin for a minimum 6 months were defined as good responders; the others were defined as poor responders. Interferon-gamma enzyme-linked immunospot assay against hepatitis B surface and core antigens were used to assay cellular anti-viral immune responses. Results: All five acutely infected patients displayed good responses after a mean of 3.8 vaccinations. Eleven of 21 chronic carriers displayed good responses after a mean of 18.1 vaccinations. Among chronic carriers, patients with livers donated by marital donors and high-titer surface antigen donors were good responders. The good-response chronic carriers showed higher interferon-gamma responses than the transplanted acute liver failure patients. Conclusions: Carrier recipients who received livers from marital, high-titer surface antigen donors were the best candidates for hepatitis B virus vaccine administration.

Mo1916 Pre-Orthotopic Liver Transplant Transthoracic Echocardiogram Findings are Associated With Post-Transplant Cardiopulmonary Death Monica Konerman, Jennifer Price, James P. Hamilton, Zhiping Li Background: The optimal evaluation of right heart function in liver transplant (LT) candidates has not been well established. Given that few patients (pts) are referred for right heart catheterization (RHC), transthoracic echocardiography (TTE) is commonly employed to evaluate right heart function. The aim of this study was to evaluate the association between pre-LT TTE findings and post-LT cardiopulmonary (CP) death. Methods: We conducted a retrospective analysis of adult pts who underwent LT from 2000-2011 and died within 6 months of LT. Pts without a pre-LT 2D/Doppler TTE or who underwent multiple LT's were excluded. Cause of death was categorized as either a primary CP process, such as cardiac arrest, cardiogenic shock, congestive heart failure, myocardial infarction, arrhythmia, respiratory failure, or massive pulmonary embolism, or non-CP process. Demographic, baseline clinical characteristics, pre-LT TTE, cardiac stress test, RHC, and left heart catheterization (LHC) data were collected. Pts with CP vs. non-CP death were compared using the chisquared statistic or Mann-Whitney U test. Results: Thirty-eight pts met the inclusion and exclusion criteria. Twenty pts died from a primary CP process and 18 from a non-CP process (13 sepsis, 5 hemorrhage). Pts with CP death trended towards longer intervals between the last pre-LT TTE and LT (median 122.5 vs. 29 days, p=0.0501) and were significantly more likely to lack a full assessment of right ventricular (RV) systolic function (60% vs. 17%, p= 0.006) as compared to pts with non-CP deaths. Age at LT (61 vs. 54.5 years, p=0.0495) and, among those with adequate RV assessment, reduced RV systolic function (25% vs. 0%, p=0.0427) were significantly associated with CP death (Table). None of the remaining TTE variables correlated with CP death. Only 1 pt in the cohort underwent RHC. Thirteen of the 20 pts in the CP group underwent stress tests; only 1 had evidence of ischemia prompting LHC. The remaining baseline clinical characteristics including Model of End-stage Liver Disease (MELD) score, donor type, body mass index, diabetes, hemodialysis, and tobacco use were not associated with CP death. Conclusions: In this retrospective analysis of LT pts, pts who died from CP processes were older, had depressed RV systolic function, and had more outdated and less detailed right heart evaluation on pre-LT TTE. Other TTE variables including right ventricular systolic pressure (RVSP) and valvular disease were not significantly associated with CP death. This study emphasizes the critical role of pre-LT TTE in evaluating post-operative CP risk and highlights the importance of adequately assessing right heart function prior to transplant. Table 1. Correlates of cardiopulmonary death among orthotopic liver transplant patients

Mo1914 JNK2, but Not JNK1, Contributes to Mitochondrial Depolarization and Graft Failure After Non-Heart-Beating Liver Transplantation in Mice Qinlong Liu, Hasibur Rehman, Yasodha Krishnasamy, John J. Lemasters, Zhi Zhong Background: Liver grafts from non-heart-beating (NHB) donors often fail after transplantation. Previous studies showed that c-Jun-N-terminal kinase (JNK) activation mediates ischemia/reperfusion injury. Aim: Because NHB livers are exposed to extended warm ischemia before harvest, this study tested the hypothesis that JNK is activated to a greater extent in NHB livers, thus leading to tissue injury and graft failure after transplantation. We also explored the relative importance of two subtypes of JNK (1 and 2) in NHB liver graft failure. Methods: Livers were explanted from wild-type (WT), JNK1 or JNK2-deficient mice immediately after 45 min of aorta clamping, stored in cold UW solution for 3 h, and implanted into WT recipients. In some studies with WT donors, SP600125, a JNK inhibitor, was injected into recipients (10 mg/kg, ip) immediately after implantation. Results: Hepatic JNK1/2 expression was not altered 3 h after transplantation but both phosphorylated JNK1 and 2 increased substantially. Serum ALT increased from ~40 U/L to ~500 U/L and 18,000 U/L after transplantation of grafts from heart-beating (HB) and NHB donors, respectively. Bilirubin did not increase after transplantation of HB donation but increased from 0.15 mg/ dL to ~3 mg/dL after transplantation of NHB livers. SP600125 decreased ALT release by 77% and hyperbilirubinemia by 75%, respectively, after NHB transplantation. All HB but only 20% of NHB liver grafts survived after transplantation. SP600125 increased survival to 83%. JNK1-deficiency did not affect liver injury of NHB grafts. In contrast, JNK2-deficiency decreased ALT by 74% and hyperbilirubinemia by 75%. Mitochondrial dysfunction plays essential role in liver ischemia/reperfusion injury. Mitochondrial potential-indicating rhodamine 123 (Rh123) fluorescence was punctuate in virtually all hepatocytes in sham-operated mice as visualized by intravital multiphoton microscopy, indicating mitochondrial polarization. Mitochondrial depolarization increased to ~70% in NHB liver grafts. SP600125 and JNK2-deficiency decreased mitochondrial depolarization to ~22% and 18%, respectively, whereas JNK1-deficiency did not prevent depolarization in NHB grafts. Conclusion: Activation of hepatic JNK2, but not JNK1, after non-heart-beating liver transplantation leads to mitochondrial dysfunction and eventually more severe graft injury. JNK inhibitors could be an effective therapy to improve the outcome of non-heart-beating liver transplantation (NIDDK). Mo1915 Daidzein Improves Mitochondrial Biogenesis in Small-for-Size Mouse Liver Grafts Qinlong Liu, Hasibur Rehman, Yasodha Krishnasamy, John J. Lemasters, Rick G. Schnellmann, Zhi Zhong Background: Mechanisms of small-for-size syndrome after partial liver transplantation remain unclear and therapies are only supportive, aiming at bridging the patients to re-transplantation. Mitochondrial function is essential for cell survival, liver regeneration and recovery of liver function after partial liver transplantation. The Aim of this study was to examine the effects of daidzein, a stimulator of mitochondrial biogenesis (MB), on the outcome of smallfor-size liver transplantation. Methods. Livers were reduced in size to 50% (HSG) and 30% (TSG), respectively, and then explanted. Full-size grafts, HSG and TSG were implanted after storage in UW solution for 2 h. Daidzein (50 mg/kg, ip) or diluent was injected immediately after transplantation. Livers and blood were collected 24 or 48 h later. Results. At 24 h after transplantation of HSG, ATP synthase-β (AS-β), a nuclear DNA (nDNA)-encoded mitochondrial oxidative phosphorylation (OXPHOS) enzyme, decreased to 75% of the control levels and then recovered to ~120% of control levels after 48 h, indicating MB. In contrast, AS-β decreased to ~40% at 24 h and remained low at 48 h in TSG. Mitochondrial DNA (mtDNA)-encoded OXPHOS enzyme NADH dehydrogenase-3 (ND3) increased to 135% in HSG but decreased to 27% in TSG at 48 h. These decreases in mitochondrial enzymes in TSG are consistent with MB suppression. PGC1-α, a master regulator of mitochondrial biogenesis, increased 37% in HSG at 24 h and remained elevated at 48 h. In contrast, PGC1α decreased ~35% at 24 h and ~60% at 48 h in TSG. Mitochondrial transcription factor A (TFAM), a key activator of mitochondrial DNA transcription and mitochondrial genome

AASLD Abstracts

S-998

IQR, interquartile range aIncludes four patients with hepatocellular carcinoma bPrimary biliary cirrhosis, primary sclerosing cholangitis, drug-induced hepatitis, hepatitis B virus, glycogen storage disease, sarcoidosis, Caroli disease, Budd Chiari, or autoimmune hepatitis. * Percentages calculated based on number of patients with information recorded for variable. Mo1917 Relationship of Serum Cytokine Concentrations to Outcome, Complications and N-Acetylcysteine Treatment in Patients With Non-Acetaminophen-Induced Acute Liver Failure R. Todd Stravitz, Arun J. Sanyal, Joan Reisch, William M. Lee N-Acetylcysteine (NAC) improves transplant-free survival (TFS) in patients with non-acetaminophen (APAP) acute liver failure (ALF) when administered in early stages of hepatic encephalopathy (HE). The mechanisms of this benefit are unknown. We hypothesized that NAC may improve TFS by ameliorating the surge of pro-inflammatory cytokines leading to the systemic inflammatory response syndrome (SIRS). Objectives. To determine the effects of NAC administration on serum cytokine concentrations, and to relate cytokine concentrations to outcome, progression of HE, and the SIRS in patients with non-APAP-induced ALF. Methods. Serum samples from 90 patients from the randomized, placebo-controlled ALF Study Group NAC Trial were analyzed. Samples from 45 patients in each group were assayed, and serum cytokine concentrations were determined in multiplex SearchLight® ELISA assays by ThermoFisher. Pro- and anti-inflammatory cytokines representing activation of Th1 (IL2, IFNγ, TNFα), Th2 (IL-4,6,10,13), and Treg (IL-17,23) classes of T-helper cells were chosen for assay. Results. The number of SIRS components on admission was a predictor of 21 day mortality (p=0.02 by ANOVA). Predictors of TFS in univariate analysis included NAC administration (p=0.005), admission bilirubin (p<0.001), INR (p=0.085), grade 1 vs. 2 HE (p<0.02) and higher admission IL-17 concentrations (p=0.02). However, there were no differences in any serum cytokine concentrations or in SIRS in patients treated with NAC vs. placebo. Stepwise multivariable logistic analysis identified each of these factors as independent predictors of TFS (p<0.0001). IL-17 levels were higher in patients with grade 2 vs. 1 HE (p<0.01) and in those who progressed to grade 3/4 HE (p<0.02). Patterns of elevated cytokines were observed, with levels of Th1 cytokines highly related (r=0.75, p<0.0001), and levels of pro- and anti-inflammatory cytokines also related (eg., IL-6 and IL-10; r=0.48, p<0.001). IL-6 and IL-10 concentrations were both related to number of SIRS on admission (p<0.01 and p<0.001) and inversely related to mean arterial pressure (r=-0.35 and -0.34, respectively; p<0.001 for both). Conclusions. NAC does not improve TFS by ameliorating the surge of pro-inflammatory cytokines in patients with non-APAPinduced ALF. However, specific pro- and anti-inflammatory cytokine concentrations are associated with outcome, HE grade, and the SIRS. IL-17 may have an important role in HE progression and outcome.

The proportion of our patients with F0-F2 fibrosis who meet published criteria for cirrhosis is depicted as a function of ALT level. Mo1920 Novel Nuclear Medicine Hepatocellular Function Test Shows Strong Correlation With MELD and Child Scores in Candidates for Liver Transplantation Mark Tulchinsky, Thomas Riley, Zakiyah Kadry

Mo1918

Introduction: Tc-99m-mebrofenin, the radiopharmaceutical used for hepatobiliary scintigraphy (HIDA), is cleared from circulation by hepatocytes via mechanism similar to indocyanine green (ICG) and bilirubin. Hence, it directly reflects hepatocyte function. A method for quantification of Tc-99m-mebrofenin hepatocellular clearance rate (MHCR), expressed as % of injected activity cleared per min (%/min), has been formulated by Ekman in 1992 and recently validated against ICG clearance rate. Methods: 59 patients (52±13 years old, 42% female) evaluated for liver transplantation between 12/1/2010 and 11/15/2011 at our institution were assessed with HIDA, as well as standard laboratory and clinical assessment of liver function. The MHCR was corrected for pts' body surface area, cMHCR (% per min per m squared), and correlated with MELD and Child scores, using Pearson's linear correlation (Figure). Univariate Chi-square analysis of variables in 2 by 2 tabulation was also performed to compare cMHCR with other variables (Table). Results: Pts characteristics (mean±s.d., range) included: cMHCR of 3.07±2.14, MELD of 13±5, 6-30; Child score of 7.7±2.2, 5-14; INR of 1.40±0.43, 0.96-3.49; total bilirubin of 1.90±1.86, 0.30-13.50 and albumin of 3.4±0.5, 2.2-4.5. The percent of pts with Child score ≥ 8 (class B), controlled ascites, uncontrolled ascites, encephalopathy, and varices were 51%, 66%, 22%, 56%, and 75%, respectively. There was strong negative relationship of cMHCR with both MELD (r=-0.489, p<0.0001) and Child (r=-0.635, p<0.0001) scores (Figure). Univariate analysis demonstrated statistically significant association between cMHCR and MELD score, Child Score, INR and albumin (Table). Conclusion: cMHCR had a strong inverse correlation with Child score, confirming its ability to reflect hepatocellular function. The strong inverse correlation with MELD score suggests that cMHCR is promising in prognostication of waitlist mortality. We intend to study its prognostic utility as sufficient follow up becomes available in this population. Future work will focus on incorporating cMHCR into stronger prognostic modeling. Univariate analysis of grouping by the threshold assignment, as listed for each variable.

Sirolimus use is Associated With Increased Risk for Cardiovascular Events Following Liver Transplantation Iliana Doycheva, Claudia A. Couto, Claudio L. Gelape, Jonathan Kish, David Levi, Paul Martin, Cynthia Levy Background and Aims: Survival of liver transplant (LT) recipients increased dramatically in recent years and cardiovascular disease (CVD) emerged as an important cause of morbidmortality. We sought to identify predictors of CVD in LT recipients. Methods: A random subset of adult patients undergoing first LT at the University of Miami between 01/2000 and 12/2010 and with follow-up > 6 months was evaluated. Statistical tests were used to examine predictors and odds of developing CVD; Kaplan-Meier curves and survival estimates were generated to examine overall survival by gender, ethnicity and CVD. Results: 304 patients were included, 69% male, mean age 54±10 years, 87% White, transplanted mostly due to HCV (52%) or alcohol-related liver disease (23%). Fifteen patients had NASH. Before LT, 21.8% had been diagnosed with diabetes, 11.5% were hypertensive, 24.7% had a BMI ≥30 (mean BMI = 26.9, SD 4.9), 13.4% had hypercholesterolemia (mean 146, SD 79 mg/ dL) and 4.6% of patients were on statins. Post-LT, 21.6% of patients had a BMI≥ 30 (mean BMI = 27, SD = 7.3, p<0.0001), 26.7% had diabetes (p<0.0001), 51.6% were hypertensive (p<0.0001), and 21% had hypercholesterolemia (mean 170, SD 71 mg/dL; p<0.0001). During a mean follow-up of 5.3 years, 31 patients (10%) had CVD and 41 (13.5%) developed posttransplant metabolic syndrome (PTMS). Patients who developed PTMS had higher prevalence of CVD (29% vs. 11.7%, OR 3.08, p<0.05). There was no association between pre-LT biomarkers (including total bilirubin, uric acid and MELD) and CVD, neither did they predict development of PTMS. On univariate analysis age (OR 1.05;CI 1-1.09), nonalcoholic steatohepatitis etiology (OR 3.53;CI 1.05-11.8), PTMS (OR 3.08;CI 1.31-7.27), pretransplant CVD (OR 5.06;CI 1.61-15.9) and treatment with sirolimus (OR 3.97;CI 1.59-9.91) were associated with post-LT CVD. Sirolimus treatment remained as the only significant predictor of CVD on multivariate analysis (OR 3.66, CI 1.44-9.31). There were 78 (22.7%) deaths during the follow-up period. Sirolimus treatment was related to lower survival (log rank p= 0.008) but CVD, NASH and PTMS did not predict increased mortality. Conclusion: Sirolimus use may be associated with increased risk for CVD and death in LT recipients and careful selection of immunossuppresion is needed until our results are validated in larger studies. Mo1919 Chronic Aminotransferase Elevation Confounds Transient Elastography in HCV Patients With Early Stage Fibrosis Elliot B. Tapper, Eric B. Cohen, Keyur Patel, Bruce R. Bacon, Stuart C. Gordon, Eric J. Lawitz, David R. Nelson, Imad Nasser, Tracy Challies, Nezam H. Afdhal

Statistical significance is indicated at the intersections of variables. Bilirubin unit - mg/dL cMHCR unit - % per min. per meter squired

Background: Hepatic elastography (HE) is a modified ultrasound technique used to noninvasively diagnose hepatic fibrosis by measuring liver stiffness. It can help avoid a staging liver biopsy in patients thought to have early stage disease, but only when confounding variables known to increase liver stiffness are excluded. Chronic inflammation from hepatitis C (HCV)

S-999

AASLD Abstracts

AASLD Abstracts

infection is not known to be one of these variables. Methods: We identified 684 patients with HCV and METAVIR fibrosis 0-2 from a prospective, multi-institutional study of liver stiffness of 2,880 patients with chronic liver disease. Results: Patients were 49.6 +/- 9.0 years old, 64.3% male and had an average body mass index of 26.7 +/-4.1. In a multivariate analysis, histological inflammation and alanine aminotransferase (ALT) levels were strongly associated with liver stiffness. The odds of a stiffness reading indicative of cirrhosis increased with grade of inflammation and ALT level. Using a conservative 14.5kPa cutoff for the diagnosis of cirrhosis, grade 3 inflammation had an odds ratio (OR) of 9.10 (95% CI: 2.4933.4). Likewise, ALT levels greater than 80 IU/L and 120 IU/L had an OR of 3.84 95% CI (2.10-7.00) and 4.0995% CI(2.18-7.69) respectively. The effect of ALT persisted when this analysis was restricted to F0-F1 fibrosis. The percentage of patients misclassified as cirrhotic by elastography using published cuttoffs increases in a step-wise fashion with rising ALT level (Fig 1). Conclusion: ALT elevation in chronic HCV is positively correlated with liver stiffness at the lowest strata of fibrosis (METAVIR 0-2). As a result, the predictive value of HE is compromised when intermediate/advanced scores are obtained, but strengthened when low scores are obtained. To our knowledge, this is the largest HCV cohort with early stage fibrosis showing a correlation between inflammation and liver stiffness.