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Predictors of pre-transplant death in cirrhotic veterans referred for orthotopic liver transplantation, 1997–2001
HEPATOLOGYVol. 34, No. 4, Pt. 2, 2001
AASLD ABSTRACTS
293A
483
484
PREDICTORS OF PRE-TRANSPLANT DEATH IN CIRRHOTIC VETERANS REFERRED FOR ORTHOTOPIC LIVER TRANSPLANTATION, 1 9 9 7 2 0 0 1 . Douglas M Heuman, Souheil G Abouassi, Leslie M Williams, Hochong S Gilles, Anastasios A Mihas, VCU Health System and McGuire DVAMC, Richmond, VA
CHOLANGIOCARCINOMA HAS HIGH TELOMERASE ENZYME EXPRESSION - A NOVEL F I N D I N G U S I N G TELOMERASE IMMUNOHISTOCHEMISTRY-A POTENTIAL EARLY BIOMARKER. Tarun Mullick, Jason E Tasch, Adrian H Ormsby, Cleveland Clinic Foundation, Cleveland, OH; Darwin L Conwell, Cleveland Clinic Founadtion, Cleveland, OH
Background: U.S. veterans with cirrhosis m a y receive OLT through the Departmerit of Veterans Affairs at 4 regional programs. The process of initial screening and evaluation takes place locally at over 170 medical centers throughout the U.S. Delay in referral is c o m m o n and may lead to high pretransplant mortality in potentially salvageable patients. Methods: We analyzed the records of 142 veterans referred to our program for consideration of OLT, of w h o m 45 subsequently died without transplantation. Survival was determined from the date of the most current clinical and laboratory data provided at initial referral. Results: 40 patients were denied OLT based on information in the referral package and 102 were assigned for further on-site evaluation. Of these, 14 died before evaluation could be completed. 15 were denied or deferred after evaluation; the remainder were listed for OLT. To date, 25 have undergone OLT, 3 have been withdrawn and 16 have died awaiting OLT. On ANOVA, six factors were found to be predictive of early pretransplant death ( n = 2 3 ) or early transplantation ( n = 1) within 180 days of referral. The strongest predictors were serum albumin and bilirubin (each p < 0.001). Unexpectedly, the AST/ ALT ratio at referral also was strongly predictive at p < .015. Significant at p < . 0 5 were s e r u m creatinine, severity of ascites, and presence of hepatocellular carcinoma. Factors lacking predictive value included INR, severity of encephalopathy, history of variceal bleeding, platelet count, absolute levels of liver enzymes, presence of gallstones, and other etiologies of liver disease (hepatitis C, ethanol). On further analysis, AST/ALT was found to correlate inversely with serum albumin. AST/ALT increased with severity of liver disease as judged by MELD or CTP scores. In three patients who died of hepatic failure without receiving OLT, AST/ALT was noted to rise acutely in the months prior to death. In patients undergoing successful OLT ( n = 2 2 ) , AST/ALT fell from 1.72+.16 (mean-+2SEM) immediately pre-OLT to 0.54-+.08 at the first outpatient visit after OLT (p < .001). Conclusions: 1) In cirrhotic U.S. veterans assigned to our program for OLT, nearly half of all pretransplant mortality in potentially transplantable patients occurs prior to listing. 2) Abnormalities of albumin, bilirubin, creatinine, AST/ALT and ascites severity identify a population at immediate risk requiring expedited evaluation. 3) The AST/ALT ratio deserves further study as a marker of disease severity and predictor of mortality in patients with chronic liver disease.
Purpose: It is imperative that better methods of diagnosis of and screening for cholangiocarcinoma are developed since current methods are inadequate. The role of telomerase, a reverse transcriptase enzyme whose upregulation in cancer confers immortality, as a biomarker of cholangiocarcinoma has yet to be determined. Our aim is to determine the role of tetomerase in pancreatobiliary malignancies using our novel telomerase enzyme immunohistochemical assay (Gastro 2001;120:A2114). Methods: From their surgical resection specimens, 10 patients with cholangiocarcinoma and 5 patients with normal bile ducts underwent telomerase enzyme immunohistochemical evaluation. Telomerase enzyme expression was graded as high (>- positive control [testis]) or low (
485
486
RAPAMYCIN MONOTHERAPY FOR LIVER TRANSPLANT RECIPIENTS W I T H RENAL INSUFFICIENCY DUE TO THE NEPHROTOXIC EFFECTS OF PROGRAF OR NEORAL- A PILOT STUDY. J. Leocadia Conlon, Joyce Maygers, Paul J Thuluvath, Johns Hopkins Hospital, Baltimore, MD
DEVELOPMENT OF A FULLY ANAESTHETISED PORCINE MODEL OF ACETAMINOPHEN-INDUCED ACUTE LIVER FAILURE. Philip N Newsome, Nell C Henderson, Steven Keatch, Leonard J Nelson, Celine Filippi, Chris Bellamy, Eddie Clutton, University of Edinburgh, Edinburgh United Kingdom; Tim King, Roslin Institute, Edinburgh United Kingdom; Alistair Lee, Royal Infirmary of Edinburgh, Edinburgh United Kingdom; Peter C Hayes, John N Plevris, University of Edinburgh, Edinburgh United Kingdom
Background:Tacrolimus (Prograf) or cyclosporine (Neoral) has been the standard treatment to prevent rejection of liver allograft in liver transplant recipients. Long-term use of these drugs is associated with nephrotoxicity. Sirolimus (Rapamune) is a non-nepbrotoxic immunosuppressant agent approved by the FDA in September 1999. However, its use as monotherapy in liver transplant recipients has not been well defined. Most studies investigating the use of sirolimus in liver transplant recipients have maintained patients on a combination of sirolimus and tacrolimus, cyclosporine or mycophenolate mofetil. ObJective:To assess the role of sirofimns monotherapy in liver transplant recipients with tacrolimus or cyclnsporlne induced nephrotoxicity. Methods: In this pilot study, liver transplant patients maintained on tacrolimus or cyclosporine, with a serum creatinine of > 1.5mg/dI, were considered for immunosuppressant monotherapy with sirolimns. The dose of tacrolimus or cyclosporine was gradually decreased as a small dose of sirolimus was introduced. Laboratory parameters including CBC, liver function panel, basic metabolic profile, and sirolimus leveIs were measured on a weekly basis until therapeutic levels of sirolimus were achieved at 10-15 ng/mI. The dose of sirolimus, and tacrolimus or cyclosporine, was adjusted according to the lab results. In addition, 24 hour urine creatinine clearance is being collected at baseline, and 3 months and 6 months after the induction of sirolimus. Results: Eleven patients (E:M, 6:5) with a mean age of 59 years (range 44-71 years)were gradually switched from tacrolimus or cyclosporine (5 tacrolimns, 6 cyclosportne)to sirolimus monotherapy. The mean time from transplant to the induction of sirolimus was 61 months (range 16-145 months). With a mean follow up of 4.3 months (range 1.5-10 months), six patients thus far, have reached therapeutic levels of sirolimus (10-15ng/ ml)with monotherapy. The mean maintenance in these patients (n=6) is 3.4 mg/day (range 2-7mg/day). In most of the patients (n-8) there was an improvement of serum creatinine levels from 2.3 mg/dl to 1.9 mg/dl (P=.009). Of the 3 remaining patients, two did not show improvement, and one did not have lab values available for comparison. Of the two that did not show improvement, the first patient required renal dialysis prior to the complete withdrawal of cyclosporine. The second patient has a secondary underlying kidney disease with proteinurea. Liver enzymes remained stable in all patients expect one patient with recurrent HCV proven by liver biopsy. There was no incidence of rejection or critical decline in cell counts in any of the patients. Data collection from 24 hour urine creatinine clearance is not yet complete at the time of reporting. Most patients tolerated sirolimus well with little to no symptoms. One patient reported oral apthous ulcers, and one mild general inflammation and erythema of the oral mucosa. Both continued therapy with improvement of symptoms. One patient, who was on renal dialysis, discontinued therapy because of diarrhea that began 3 months into therapy with sirolimus. Conclusion: Initial data has shovar evidence that: 1) in OLT recipients with tacrolimus or cyclosporine induced nephrotoxicty, conversion to sirolimus monotherapy improves renal function. 2) Sirolimus monotherapy is an effective immunosnppressant therapy in OLT recipients when a therapeutic range of 10-15 mg/ml is maintained.
Patient Group CholangioCA* Normal Bile Duct
N 10 5
TelorneraseHIGH t0 0
TelomeraseLOW 0
5
* P < 0.001 when compared to normal subjects
Introduction Acute liver failure (ALF)is a medicalemergencywith a high mortality.The devel~ opmentof effectivetherapiesis limitedby our knowledgeof the pathophysiologyof this condition. A large animalmodel of ALF would permit both researchinto the patbophysiologyof this syndrome and allow for rigorous testing of bio-artificial liver support systems. There is a lack of suitable large animalmodelsof acetaminophentoxicity,which is the commonestcauseof ALFin the West. The previousmodelshavebeenproblematicand not allowedintensivemonitoringof the animal. Aim To developa fully-anaesthetised,invasivdy-monitoredporcine model of acetaminophen-induced ALF. Method 35kg LargeWhite pigs were maintainedunder generalanaesthesia with isofluraneand nitrous oxygen.Haemodynamicparameterswererecordedby meansof arterial line, centralvenouspressure line and pulmonaryartery catheter. The latter allowedestimation of left atrial pressure and cardiacoutput (thermodilutioncatheter). Intracranialpressure (ICP) was monitoredwith a subdural pressure transducer.Urine output was monitored via a urethrostomy. Animalsreceivedphenobarbitone for the 5 daysprior to the experimentto niducep450 enzymes. Control pigs receivedno acetaminophenwhereas the acetaminophenpigs were divided into 2 groups: those that wereunfastedand those that werefastedfor 24 hours prior to the administration of acetaminophen.Acetaminophenwas administeredby intravenousinfusion for 12 hours keeping blood concentration between 200-300mg/1.Arterial blood gas and lactate levels were measured. Methaemoglobinwas measured concurrently spectrophotometrically.Total cytoehrome p450 levelswere measuredusing CO differencespectroscopyof Sodium bydrosulphitesamples. Experimentslasted up to 28 hours, and any animalssurvivingat this time-pointwere euthanased. Necropsy samples were then taken. Results p450 levels in phenobarbitone pre-treated animals weresignificantly'higherthan non pre-treatedanimals(300 vs 100 pmol/mgproteni). Controlpigs survivedthe 28 hour anaesthesiawithout incident. In the unfastedpigs who receivedacetaminophen 50% of animals died within 24 hours. These animalsdisplayedevidenceof haemodynamic compromise,as demonstratedby hypotension (47/22mmHg)and low pulmonaryarteryocclusion pressure (PAOP).Theydevelopedacidosis (pH<7.2), hypoglycaemiaand acute renal failure (Creatinnie >300/*mol/1), with evidence of severe liver injury manifested by increasing AST (>1200u/1) & LDH (>5900u/l)levels. Prothrombin times were prolonged and factorV and VII levels were reduced to < 10% of starting values. Liverhistology showed moderatecentrilobular damage.Of the fastedpigs administeredacetaminophen,67% died within 24 hours and displayed an acclerated pattern of liver injury. Parameterswere similar to the unfasted pigs except the changes occurred earlier. Histologicalanalysisrevealedevidenceof severecentrilobularnecrosis leading to coagulativenecrosis. Markedrenal tubular necrosis was also evident.Methaemoglobin levels did not rise above5%. Indocyanidegreen clearancewas significantlyreduced towards the end of each experiment.Despiteevidenceof severeliverinjury, no evidenceof intracranialhypertension was observedeither by ICP monitor (range 1-16mmHg)or histologically. Conclusion 1. Data thus far indicate this to be a reproduciblelargeanimalmodelof acetaminophen-inducedliver failure, which allows intensivemonitoring. The use of general anaesthesiaminimisesdistress to the animal during the procedure. 2. Pre-trealmentwith phenobarbitone and 24 hour fasting acceleratesliver injury and increasesreproducibility. 3. This model is suitable for further pathophysiological analysisand testingwith artificialliver support systems.
AASLD ABSTRACTS
293A
483
484
PREDICTORS OF PRE-TRANSPLANT DEATH IN CIRRHOTIC VETERANS REFERRED FOR ORTHOTOPIC LIVER TRANSPLANTATION, 1 9 9 7 2 0 0 1 . Douglas M Heuman, Souheil G Abouassi, Leslie M Williams, Hochong S Gilles, Anastasios A Mihas, VCU Health System and McGuire DVAMC, Richmond, VA
CHOLANGIOCARCINOMA HAS HIGH TELOMERASE ENZYME EXPRESSION - A NOVEL F I N D I N G U S I N G TELOMERASE IMMUNOHISTOCHEMISTRY-A POTENTIAL EARLY BIOMARKER. Tarun Mullick, Jason E Tasch, Adrian H Ormsby, Cleveland Clinic Foundation, Cleveland, OH; Darwin L Conwell, Cleveland Clinic Founadtion, Cleveland, OH
Background: U.S. veterans with cirrhosis m a y receive OLT through the Departmerit of Veterans Affairs at 4 regional programs. The process of initial screening and evaluation takes place locally at over 170 medical centers throughout the U.S. Delay in referral is c o m m o n and may lead to high pretransplant mortality in potentially salvageable patients. Methods: We analyzed the records of 142 veterans referred to our program for consideration of OLT, of w h o m 45 subsequently died without transplantation. Survival was determined from the date of the most current clinical and laboratory data provided at initial referral. Results: 40 patients were denied OLT based on information in the referral package and 102 were assigned for further on-site evaluation. Of these, 14 died before evaluation could be completed. 15 were denied or deferred after evaluation; the remainder were listed for OLT. To date, 25 have undergone OLT, 3 have been withdrawn and 16 have died awaiting OLT. On ANOVA, six factors were found to be predictive of early pretransplant death ( n = 2 3 ) or early transplantation ( n = 1) within 180 days of referral. The strongest predictors were serum albumin and bilirubin (each p < 0.001). Unexpectedly, the AST/ ALT ratio at referral also was strongly predictive at p < .015. Significant at p < . 0 5 were s e r u m creatinine, severity of ascites, and presence of hepatocellular carcinoma. Factors lacking predictive value included INR, severity of encephalopathy, history of variceal bleeding, platelet count, absolute levels of liver enzymes, presence of gallstones, and other etiologies of liver disease (hepatitis C, ethanol). On further analysis, AST/ALT was found to correlate inversely with serum albumin. AST/ALT increased with severity of liver disease as judged by MELD or CTP scores. In three patients who died of hepatic failure without receiving OLT, AST/ALT was noted to rise acutely in the months prior to death. In patients undergoing successful OLT ( n = 2 2 ) , AST/ALT fell from 1.72+.16 (mean-+2SEM) immediately pre-OLT to 0.54-+.08 at the first outpatient visit after OLT (p < .001). Conclusions: 1) In cirrhotic U.S. veterans assigned to our program for OLT, nearly half of all pretransplant mortality in potentially transplantable patients occurs prior to listing. 2) Abnormalities of albumin, bilirubin, creatinine, AST/ALT and ascites severity identify a population at immediate risk requiring expedited evaluation. 3) The AST/ALT ratio deserves further study as a marker of disease severity and predictor of mortality in patients with chronic liver disease.
Purpose: It is imperative that better methods of diagnosis of and screening for cholangiocarcinoma are developed since current methods are inadequate. The role of telomerase, a reverse transcriptase enzyme whose upregulation in cancer confers immortality, as a biomarker of cholangiocarcinoma has yet to be determined. Our aim is to determine the role of tetomerase in pancreatobiliary malignancies using our novel telomerase enzyme immunohistochemical assay (Gastro 2001;120:A2114). Methods: From their surgical resection specimens, 10 patients with cholangiocarcinoma and 5 patients with normal bile ducts underwent telomerase enzyme immunohistochemical evaluation. Telomerase enzyme expression was graded as high (>- positive control [testis]) or low (
485
486
RAPAMYCIN MONOTHERAPY FOR LIVER TRANSPLANT RECIPIENTS W I T H RENAL INSUFFICIENCY DUE TO THE NEPHROTOXIC EFFECTS OF PROGRAF OR NEORAL- A PILOT STUDY. J. Leocadia Conlon, Joyce Maygers, Paul J Thuluvath, Johns Hopkins Hospital, Baltimore, MD
DEVELOPMENT OF A FULLY ANAESTHETISED PORCINE MODEL OF ACETAMINOPHEN-INDUCED ACUTE LIVER FAILURE. Philip N Newsome, Nell C Henderson, Steven Keatch, Leonard J Nelson, Celine Filippi, Chris Bellamy, Eddie Clutton, University of Edinburgh, Edinburgh United Kingdom; Tim King, Roslin Institute, Edinburgh United Kingdom; Alistair Lee, Royal Infirmary of Edinburgh, Edinburgh United Kingdom; Peter C Hayes, John N Plevris, University of Edinburgh, Edinburgh United Kingdom
Background:Tacrolimus (Prograf) or cyclosporine (Neoral) has been the standard treatment to prevent rejection of liver allograft in liver transplant recipients. Long-term use of these drugs is associated with nephrotoxicity. Sirolimus (Rapamune) is a non-nepbrotoxic immunosuppressant agent approved by the FDA in September 1999. However, its use as monotherapy in liver transplant recipients has not been well defined. Most studies investigating the use of sirolimus in liver transplant recipients have maintained patients on a combination of sirolimus and tacrolimus, cyclosporine or mycophenolate mofetil. ObJective:To assess the role of sirofimns monotherapy in liver transplant recipients with tacrolimus or cyclnsporlne induced nephrotoxicity. Methods: In this pilot study, liver transplant patients maintained on tacrolimus or cyclosporine, with a serum creatinine of > 1.5mg/dI, were considered for immunosuppressant monotherapy with sirolimns. The dose of tacrolimus or cyclosporine was gradually decreased as a small dose of sirolimus was introduced. Laboratory parameters including CBC, liver function panel, basic metabolic profile, and sirolimus leveIs were measured on a weekly basis until therapeutic levels of sirolimus were achieved at 10-15 ng/mI. The dose of sirolimus, and tacrolimus or cyclosporine, was adjusted according to the lab results. In addition, 24 hour urine creatinine clearance is being collected at baseline, and 3 months and 6 months after the induction of sirolimus. Results: Eleven patients (E:M, 6:5) with a mean age of 59 years (range 44-71 years)were gradually switched from tacrolimus or cyclosporine (5 tacrolimns, 6 cyclosportne)to sirolimus monotherapy. The mean time from transplant to the induction of sirolimus was 61 months (range 16-145 months). With a mean follow up of 4.3 months (range 1.5-10 months), six patients thus far, have reached therapeutic levels of sirolimus (10-15ng/ ml)with monotherapy. The mean maintenance in these patients (n=6) is 3.4 mg/day (range 2-7mg/day). In most of the patients (n-8) there was an improvement of serum creatinine levels from 2.3 mg/dl to 1.9 mg/dl (P=.009). Of the 3 remaining patients, two did not show improvement, and one did not have lab values available for comparison. Of the two that did not show improvement, the first patient required renal dialysis prior to the complete withdrawal of cyclosporine. The second patient has a secondary underlying kidney disease with proteinurea. Liver enzymes remained stable in all patients expect one patient with recurrent HCV proven by liver biopsy. There was no incidence of rejection or critical decline in cell counts in any of the patients. Data collection from 24 hour urine creatinine clearance is not yet complete at the time of reporting. Most patients tolerated sirolimus well with little to no symptoms. One patient reported oral apthous ulcers, and one mild general inflammation and erythema of the oral mucosa. Both continued therapy with improvement of symptoms. One patient, who was on renal dialysis, discontinued therapy because of diarrhea that began 3 months into therapy with sirolimus. Conclusion: Initial data has shovar evidence that: 1) in OLT recipients with tacrolimus or cyclosporine induced nephrotoxicty, conversion to sirolimus monotherapy improves renal function. 2) Sirolimus monotherapy is an effective immunosnppressant therapy in OLT recipients when a therapeutic range of 10-15 mg/ml is maintained.
Patient Group CholangioCA* Normal Bile Duct
N 10 5
TelorneraseHIGH t0 0
TelomeraseLOW 0
5
* P < 0.001 when compared to normal subjects
Introduction Acute liver failure (ALF)is a medicalemergencywith a high mortality.The devel~ opmentof effectivetherapiesis limitedby our knowledgeof the pathophysiologyof this condition. A large animalmodel of ALF would permit both researchinto the patbophysiologyof this syndrome and allow for rigorous testing of bio-artificial liver support systems. There is a lack of suitable large animalmodelsof acetaminophentoxicity,which is the commonestcauseof ALFin the West. The previousmodelshavebeenproblematicand not allowedintensivemonitoringof the animal. Aim To developa fully-anaesthetised,invasivdy-monitoredporcine model of acetaminophen-induced ALF. Method 35kg LargeWhite pigs were maintainedunder generalanaesthesia with isofluraneand nitrous oxygen.Haemodynamicparameterswererecordedby meansof arterial line, centralvenouspressure line and pulmonaryartery catheter. The latter allowedestimation of left atrial pressure and cardiacoutput (thermodilutioncatheter). Intracranialpressure (ICP) was monitoredwith a subdural pressure transducer.Urine output was monitored via a urethrostomy. Animalsreceivedphenobarbitone for the 5 daysprior to the experimentto niducep450 enzymes. Control pigs receivedno acetaminophenwhereas the acetaminophenpigs were divided into 2 groups: those that wereunfastedand those that werefastedfor 24 hours prior to the administration of acetaminophen.Acetaminophenwas administeredby intravenousinfusion for 12 hours keeping blood concentration between 200-300mg/1.Arterial blood gas and lactate levels were measured. Methaemoglobinwas measured concurrently spectrophotometrically.Total cytoehrome p450 levelswere measuredusing CO differencespectroscopyof Sodium bydrosulphitesamples. Experimentslasted up to 28 hours, and any animalssurvivingat this time-pointwere euthanased. Necropsy samples were then taken. Results p450 levels in phenobarbitone pre-treated animals weresignificantly'higherthan non pre-treatedanimals(300 vs 100 pmol/mgproteni). Controlpigs survivedthe 28 hour anaesthesiawithout incident. In the unfastedpigs who receivedacetaminophen 50% of animals died within 24 hours. These animalsdisplayedevidenceof haemodynamic compromise,as demonstratedby hypotension (47/22mmHg)and low pulmonaryarteryocclusion pressure (PAOP).Theydevelopedacidosis (pH<7.2), hypoglycaemiaand acute renal failure (Creatinnie >300/*mol/1), with evidence of severe liver injury manifested by increasing AST (>1200u/1) & LDH (>5900u/l)levels. Prothrombin times were prolonged and factorV and VII levels were reduced to < 10% of starting values. Liverhistology showed moderatecentrilobular damage.Of the fastedpigs administeredacetaminophen,67% died within 24 hours and displayed an acclerated pattern of liver injury. Parameterswere similar to the unfasted pigs except the changes occurred earlier. Histologicalanalysisrevealedevidenceof severecentrilobularnecrosis leading to coagulativenecrosis. Markedrenal tubular necrosis was also evident.Methaemoglobin levels did not rise above5%. Indocyanidegreen clearancewas significantlyreduced towards the end of each experiment.Despiteevidenceof severeliverinjury, no evidenceof intracranialhypertension was observedeither by ICP monitor (range 1-16mmHg)or histologically. Conclusion 1. Data thus far indicate this to be a reproduciblelargeanimalmodelof acetaminophen-inducedliver failure, which allows intensivemonitoring. The use of general anaesthesiaminimisesdistress to the animal during the procedure. 2. Pre-trealmentwith phenobarbitone and 24 hour fasting acceleratesliver injury and increasesreproducibility. 3. This model is suitable for further pathophysiological analysisand testingwith artificialliver support systems.