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The use of hepatitis B core antibody positive liver donors
HEPATOLOGY Vol. 22, N o . 4, P t . 2, 1995
1529
AASLD
ABSTRACTS
RRPATITIS B VIRUS MUTATIONS ASSOCIATEDWITH THE PHASES OF CHRONIC LIVER DISEASE. Yoichi Setoguchi, Susumu Kajihara, Toshihiko Mizuta, Toshiya Hare, Kyosuhe Yamamoto, Takahiro Sakai. Internal Medicine, Saga Medical School, Saga, Japan
1530
THE USE OF HEPATITIS B CORE A N T I B O D Y POSITIVE LIVER DONORS P Seu. A Murano. DK Ima=awa. P Kirk. P Martin. CR Shackleton, SM Rudich. M Kinkhabwala. K M Olthoff. and RW Busuttil. DumontUCLA Liver Transplant Center, Los Angeles, CA There have been several recent reports of Hepatitis B virus (HBV) transmission to recipients o f liver transplants from HB core antibody (HBcAb) positive donors. The reported seroconversion rates are 40%62%, with several cases o f allograft loss. Some centers have systematically rejected HBcAb(+) liver donors. We reviewed our experience with HBcAb(+) liver donors and report the largest published experience to date. Between 1-/91 and 2/95, among 1008 livers that were transplanted, 26 were from HBcAb(+) donors, and were transplanted in 26 recipients. Six recipients died within one month o f transplant and were excluded from further analysis. Three other recipients died at 3 months, 5 months and 2 years following transplantation. The causes of death were recurrent hepatitis C in the first 2, and sepsis in the third recipient. None of these had evidence of HBV disease. Seventeen patients are currently alive at a inean follow-up o f 18.8 + 12.4 months. O f these, 2 had been transplanted for HBV cirrhosis and both have normal allograft function. Among 14 patients in whom HBV serologies are available, 3 have positive HBsAg and HBV-DNA for a seroconversion rate of 21%. All three patients have normal liver function tests. Conclusions: 1) We have had no eases of hepatic allografl loss from the use of HBcAb(+) donors. 2) The HBV transmission rate is lower than previously reported. 3) The use of HBeAb(+) liver donors is not contraindicated. 4) More studies are needed in the role of anti-viral agents in these patients.
1532
APOPTOSIS AND PHAGOCYTOSIS OF CIRCULATING NEUTROPHILS IN RAT HEPATIC SINUSOIDS AFTER ADMINISTRATION OF LIPOPOLYSACCHARIDE(LPS). J Shi. H Fuiieda. Y Kokub0, and K Wake, Dept. of Anatomy, School of Medicine, Tokyo Medical & Dental University, Tokyo, Japan. A number of inflammatory mediators may modulate the rate of apoptosis in population of neutmphils aging in culture by inhibition of apoptosis and prolongation of neutrophil functional logevity have been reported. Whether the results obtained in vitro are coincided with ones in rive is uncertain. In previous study, however, administration of streptococcal preparation may induce apoptosis of cheulating neutrophfls in hepatic sinusoids (J Shi et al., 1994,1995). In order to confirm the results, in the present study, LPS, a wenknown inflammatory mediator, were intravenously injected. Livers of Wistar rats(BW.120-200gm) were examined by hgher and electron microscopy, TUNEL and immunohitochemical staining of Kupffer cells and macrophages with ED~and ED2 antibodies at different time points. Similar to streptococcal preparation treatment,the neutrophils were mainly trapped in periportal and midzonal regions and were often in contact with endothelial cells and Kupffer cells or encircled by Kupffer cells in peffused liver after LPS treatment. The number of trapped neutrophils was time-dependent and reached the maximum at 12 hours. Apoptotic neutrophils with or without budding were found as early as 3 hours in the lumen of hepatic sinusoids and strikinglyincreased in number and reached the maximum at 6 hours and decreased thereafter, being paralleled with the number of phagocytosed neutrophfls. Whereas the neutrophils in the portal vein, the Glissan's sheath and the wallofcentralveins were free of TUNEL staining. Double staining methods, the TUNEL and immunostaining with ED1 or ED2 antibodies, showed that neutmphils with DNA fragmentation were phagoeytosed or surrounded by Kupffer cells and macrophages. On the contrary, little apoptosis and phagocytosis were found in the spleen and lungs. The findings strongly suggest that occurrence of apoptotie circulating neutrophil and their quick clearance after the invasion c~ bacteria or inflammatorymediators into the blood stream may be important for the regulatinn of homeostasis and limitation of inflammation and tissue injury, and may represent a physiologicalremovalofsenescentcireulatingneutrophfls.
Recent studies have revealed that seroeonversion (SC) to anti-HNe in HBV carriers is related to mutations in the precore region that do not produce HSeAg. But it is s t i l l not knownwhy various phases of infection such as asymptomatio carrier (ASC), chronic hepatitis (CH) or acute exacerbation of CH may exist after SC to anti-HRs. We examined mutations in the precore, core and core promoter regions and attempted to elucidate the relevant mechanism. Methods: Serum samples were analyzed frem 2 patients with each of following phases of HBV infection: HBeAg positive ASC (group C), HgeAgpositive CH (group H), reciprocal seroeonversion and reversion of CH (group R), HNeAb-positive acute exacerbation of CH (group M) and HBeAb-positive ASC (group S). Nucleic acids were extracted from serum samples and entire precore, core and core promoter regions were amplified by nested polymerase chain reaction and directly sequenced by dideoxy methods. Some cases were also analyzed longltudinally. Results: Sequence analysis of 10 cases revealed mutations in the precore region with a stop eodon present in only group and 1 patient in group S. Mutations in the core region were not seen in group C, occurred at only one point in group H, increased longitudinally in groups R and M. and relatively commonmutations were Serine to Threonine in codon 26 and Isoleucine to Leucine in codon 97, and 5 to 6 mutations appeared in group S. Conclusions: ~ithout acquisition of a precore stop codon after accumulation of mutations in the core region, reversion of HBeAg may occur after sermconmersion to NSeAb. Mutations in the core region increased with the phase of infection, from group C ~ H * R ~ M - S, and also accumulated over time. Amino acids of codon 26 and 97 may be the focus mf the immune response of cytotoxie T lymphocytes. But the reason for the difference between groups M and S cannot be explained by mutations in the premore/core regioms. Someauthors have proposed mutations in the core promoter region that influence the transcription of pre-C mRRA. However, our results showed many mutations in the core promoter region regardless of the phase of liver disease, so this cannot be the mechanism underlying the different phases.
1531
EFFECTIVENESS OF TRANSJUGULAR INTRAIIEPATIC SHUNT (TIPS) FOR REFRACTORY ASCITES. S Sszai and K Kamisaka* and M Hirano**, Division of Gastroenterology, Kanto NTT Hospital* and Tokyo Metropolitan Police Hospital**, Tokyo Japan TIPS is an effective procedure primarily to relieve portal venous pressure. Since this has prospective improvements in tlie liver and other organs after the treatment, we have studied to clarify its effectiveness. Seven cases (4 men and 3 women} of refractory ascltes were studied. We made follow-up studies on their liver, esophagus, and kidney for one year after TIPS procedure. We studied portographic findings, portal circulation, liver function test, esophageal findings through endoscope, portal hypertensive gastropathy (PHG), gastrle mueosal blood flow (GMBF), sodium excretion into urine, serum creatinine, and the hormones related to renal function. Extrahepatic portosystemic shunts (EPS) were not revealed in 5 cases after 6 months. Portal venous pressure began to lower i~ediately and it was much lower 6 months later. The maximal velocity of portal venous flow (Ymax) was definitely higher than the rate noted among the other cirrhotic patients in our hospital. Serum level of hepatobiliary enzymes began to elevate at 2-3 weeks and reached the peak at i month. Esophageal varlces improved in all, and teleangiectasis at 2-4 weeks and malntalned the same level thereafter. Sodium excretion into urine returned to the normal level within one month. Serum creatltine level also returned to its normal range in 3. The hormone levels showed some changes, but without any specific patterns. We were able to confirm that TIPS brought up effectiveness to the other involved organs as well as the liver.
489A
1529
AASLD
ABSTRACTS
RRPATITIS B VIRUS MUTATIONS ASSOCIATEDWITH THE PHASES OF CHRONIC LIVER DISEASE. Yoichi Setoguchi, Susumu Kajihara, Toshihiko Mizuta, Toshiya Hare, Kyosuhe Yamamoto, Takahiro Sakai. Internal Medicine, Saga Medical School, Saga, Japan
1530
THE USE OF HEPATITIS B CORE A N T I B O D Y POSITIVE LIVER DONORS P Seu. A Murano. DK Ima=awa. P Kirk. P Martin. CR Shackleton, SM Rudich. M Kinkhabwala. K M Olthoff. and RW Busuttil. DumontUCLA Liver Transplant Center, Los Angeles, CA There have been several recent reports of Hepatitis B virus (HBV) transmission to recipients o f liver transplants from HB core antibody (HBcAb) positive donors. The reported seroconversion rates are 40%62%, with several cases o f allograft loss. Some centers have systematically rejected HBcAb(+) liver donors. We reviewed our experience with HBcAb(+) liver donors and report the largest published experience to date. Between 1-/91 and 2/95, among 1008 livers that were transplanted, 26 were from HBcAb(+) donors, and were transplanted in 26 recipients. Six recipients died within one month o f transplant and were excluded from further analysis. Three other recipients died at 3 months, 5 months and 2 years following transplantation. The causes of death were recurrent hepatitis C in the first 2, and sepsis in the third recipient. None of these had evidence of HBV disease. Seventeen patients are currently alive at a inean follow-up o f 18.8 + 12.4 months. O f these, 2 had been transplanted for HBV cirrhosis and both have normal allograft function. Among 14 patients in whom HBV serologies are available, 3 have positive HBsAg and HBV-DNA for a seroconversion rate of 21%. All three patients have normal liver function tests. Conclusions: 1) We have had no eases of hepatic allografl loss from the use of HBcAb(+) donors. 2) The HBV transmission rate is lower than previously reported. 3) The use of HBeAb(+) liver donors is not contraindicated. 4) More studies are needed in the role of anti-viral agents in these patients.
1532
APOPTOSIS AND PHAGOCYTOSIS OF CIRCULATING NEUTROPHILS IN RAT HEPATIC SINUSOIDS AFTER ADMINISTRATION OF LIPOPOLYSACCHARIDE(LPS). J Shi. H Fuiieda. Y Kokub0, and K Wake, Dept. of Anatomy, School of Medicine, Tokyo Medical & Dental University, Tokyo, Japan. A number of inflammatory mediators may modulate the rate of apoptosis in population of neutmphils aging in culture by inhibition of apoptosis and prolongation of neutrophil functional logevity have been reported. Whether the results obtained in vitro are coincided with ones in rive is uncertain. In previous study, however, administration of streptococcal preparation may induce apoptosis of cheulating neutrophfls in hepatic sinusoids (J Shi et al., 1994,1995). In order to confirm the results, in the present study, LPS, a wenknown inflammatory mediator, were intravenously injected. Livers of Wistar rats(BW.120-200gm) were examined by hgher and electron microscopy, TUNEL and immunohitochemical staining of Kupffer cells and macrophages with ED~and ED2 antibodies at different time points. Similar to streptococcal preparation treatment,the neutrophils were mainly trapped in periportal and midzonal regions and were often in contact with endothelial cells and Kupffer cells or encircled by Kupffer cells in peffused liver after LPS treatment. The number of trapped neutrophils was time-dependent and reached the maximum at 12 hours. Apoptotic neutrophils with or without budding were found as early as 3 hours in the lumen of hepatic sinusoids and strikinglyincreased in number and reached the maximum at 6 hours and decreased thereafter, being paralleled with the number of phagocytosed neutrophfls. Whereas the neutrophils in the portal vein, the Glissan's sheath and the wallofcentralveins were free of TUNEL staining. Double staining methods, the TUNEL and immunostaining with ED1 or ED2 antibodies, showed that neutmphils with DNA fragmentation were phagoeytosed or surrounded by Kupffer cells and macrophages. On the contrary, little apoptosis and phagocytosis were found in the spleen and lungs. The findings strongly suggest that occurrence of apoptotie circulating neutrophil and their quick clearance after the invasion c~ bacteria or inflammatorymediators into the blood stream may be important for the regulatinn of homeostasis and limitation of inflammation and tissue injury, and may represent a physiologicalremovalofsenescentcireulatingneutrophfls.
Recent studies have revealed that seroeonversion (SC) to anti-HNe in HBV carriers is related to mutations in the precore region that do not produce HSeAg. But it is s t i l l not knownwhy various phases of infection such as asymptomatio carrier (ASC), chronic hepatitis (CH) or acute exacerbation of CH may exist after SC to anti-HRs. We examined mutations in the precore, core and core promoter regions and attempted to elucidate the relevant mechanism. Methods: Serum samples were analyzed frem 2 patients with each of following phases of HBV infection: HBeAg positive ASC (group C), HgeAgpositive CH (group H), reciprocal seroeonversion and reversion of CH (group R), HNeAb-positive acute exacerbation of CH (group M) and HBeAb-positive ASC (group S). Nucleic acids were extracted from serum samples and entire precore, core and core promoter regions were amplified by nested polymerase chain reaction and directly sequenced by dideoxy methods. Some cases were also analyzed longltudinally. Results: Sequence analysis of 10 cases revealed mutations in the precore region with a stop eodon present in only group and 1 patient in group S. Mutations in the core region were not seen in group C, occurred at only one point in group H, increased longitudinally in groups R and M. and relatively commonmutations were Serine to Threonine in codon 26 and Isoleucine to Leucine in codon 97, and 5 to 6 mutations appeared in group S. Conclusions: ~ithout acquisition of a precore stop codon after accumulation of mutations in the core region, reversion of HBeAg may occur after sermconmersion to NSeAb. Mutations in the core region increased with the phase of infection, from group C ~ H * R ~ M - S, and also accumulated over time. Amino acids of codon 26 and 97 may be the focus mf the immune response of cytotoxie T lymphocytes. But the reason for the difference between groups M and S cannot be explained by mutations in the premore/core regioms. Someauthors have proposed mutations in the core promoter region that influence the transcription of pre-C mRRA. However, our results showed many mutations in the core promoter region regardless of the phase of liver disease, so this cannot be the mechanism underlying the different phases.
1531
EFFECTIVENESS OF TRANSJUGULAR INTRAIIEPATIC SHUNT (TIPS) FOR REFRACTORY ASCITES. S Sszai and K Kamisaka* and M Hirano**, Division of Gastroenterology, Kanto NTT Hospital* and Tokyo Metropolitan Police Hospital**, Tokyo Japan TIPS is an effective procedure primarily to relieve portal venous pressure. Since this has prospective improvements in tlie liver and other organs after the treatment, we have studied to clarify its effectiveness. Seven cases (4 men and 3 women} of refractory ascltes were studied. We made follow-up studies on their liver, esophagus, and kidney for one year after TIPS procedure. We studied portographic findings, portal circulation, liver function test, esophageal findings through endoscope, portal hypertensive gastropathy (PHG), gastrle mueosal blood flow (GMBF), sodium excretion into urine, serum creatinine, and the hormones related to renal function. Extrahepatic portosystemic shunts (EPS) were not revealed in 5 cases after 6 months. Portal venous pressure began to lower i~ediately and it was much lower 6 months later. The maximal velocity of portal venous flow (Ymax) was definitely higher than the rate noted among the other cirrhotic patients in our hospital. Serum level of hepatobiliary enzymes began to elevate at 2-3 weeks and reached the peak at i month. Esophageal varlces improved in all, and teleangiectasis at 2-4 weeks and malntalned the same level thereafter. Sodium excretion into urine returned to the normal level within one month. Serum creatltine level also returned to its normal range in 3. The hormone levels showed some changes, but without any specific patterns. We were able to confirm that TIPS brought up effectiveness to the other involved organs as well as the liver.
489A