Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients

BACKGROUND

Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients.

AIM

Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival.

METHODS

This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival.

RESULTS

The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival.

CONCLUSION

MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.

Does vancomycin resistance increase mortality in Enterococcus faecium bacteraemia after orthotopic liver transplantation? A retrospective study

BACKGROUND

The relevance of vancomycin resistance in enterococcal blood stream infections (BSI) is still controversial. Aim of this study was to outline the effect of vancomycin resistance of Enterococcus faecium on the outcome of patients with BSI after orthotopic liver transplantation (OLT).

METHODS

The outcome of OLT recipients developing BSI with vancomycin-resistant (VRE) versus vancomycin-susceptible Enterococcus faecium (VSE) was compared based on data extraction from medical records. Multivariate regression analyses identified risk factors for mortality and unfavourable outcomes (defined as death or prolonged intensive care stay) after 30 and 90 days.

RESULTS

Mortality was similar between VRE- (n = 39) and VSE- (n = 138) group after 30 (p = 0.44) or 90 days (p = 0.39). Comparable results occurred regarding unfavourable outcomes. Mean SOFA_Non-GCS score during the 7-day-period before BSI onset was the independent predictor for mortality at both timepoints (HR 1.32; CI 1.14-1.53; and HR 1.18; CI 1.08-1.28). Timely appropriate antibiotic therapy, recent ICU stay and vancomycin resistance did not affect outcome after adjusting for confounders.

CONCLUSION

Vancomycin resistance did not influence outcome among patients with Enterococcus faecium bacteraemia after OLT. Only underlying severity of disease predicted poor outcome among this homogenous patient population.

TRIAL REGISTRATION

This study was registered at the German clinical trials register (DRKS-ID: DRKS00013285).

Outcome after liver resection for primary and recurrent intrahepatic cholangiocarcinoma

BACKGROUND

Liver resection is the only curative therapeutic option for intrahepatic cholangiocarcinoma (ICC), but the approach to recurrent ICC is controversial. This study analysed the outcome of liver resection in patients with recurrent ICC.

METHODS

Demographic, radiological, clinical, operative, surgical pathological and follow-up data for all patients with a final surgical pathological diagnosis of ICC treated in a tertiary referral centre between 2001 and 2015 were collected retrospectively and analysed.

RESULTS

A total of 190 patients had liver resection for primary ICC. The 1-, 3- and 5-year overall survival (OS) rates were 74·8, 56·6 and 37·9 per cent respectively. Independent determinants of OS were age 65 years or above (hazard ratio (HR) 2·18, 95 per cent c.i. 1·18 to 4·0; P = 0·012), median tumour diameter 5 cm or greater (HR 2·87, 1·37 to 6·00; P = 0·005), preoperative biliary drainage (HR 2·65, 1·13 to 6·20; P = 0·025) and local R1-2 status (HR 1·90, 1·02 to 3·53; P = 0·043). Recurrence was documented in 87 patients (45·8 per cent). The mean(s.d.) survival time after recurrence was 16(17) months. Independent determinants of recurrence were median tumour diameter 5 cm or more (HR 1·71, 1·09 to 2·68; P = 0·020), high-grade (G3-4) tumour (HR 1·63, 1·04 to 2·55; P = 0·034) and local R1 status (HR 1·70, 1·09 to 2·65; P = 0·020). Repeat resection with curative intent was performed in 25 patients for recurrent ICC, achieving a mean survival of 25 (95 per cent c.i. 16 to 34) months after the diagnosis of recurrence. Patients deemed to have unresectable disease after recurrence received chemotherapy or chemoradiotherapy alone, and had significantly poorer survival.

CONCLUSION

Patients with recurrent ICC may benefit from repeat surgical resection.

P5267Cardiac tissue characterization in patients with wilsons disease using magnetic resonance imaging

Introduction

Wilson's disease (WD) is a rare autosomal recessive copper disorder with limited excretion of excess copper into the bile. Primary symptoms are hepatic or neurological. However, the clinical range of WD is wide and can result in cardiac symptoms as well. Previous studies revealed a higher incidence of heart failure in WD patients compared to the rest of the population.

Purpose

Cardiac magnetic resonance imaging (CMR) is used to identify the typical features of several systemic disorders with excessive myocardial deposition of substrates. The aim of this study was to perform a cardiac tissue characterization in WD patients by using CMR and to identify subgroups of WD patients with reduced ejection fraction (EF).

Methods

Patients with known WD using Ferenci-Score were included in this prospective study. WD patients were referred to 1.5 Tesla CMR. The following CMR protocol was performed; Cine-images, T1-, T2- and T2*-Mapping, fast-SENC strain and late gadolinium enhancement (LGE). Fast-SENC strain measurements were compared with values from healthy individuals scanned at the center.

Results

43 patients (age 38.7±12.8 years, 20 female, BMI 23.80 (17.4–33.1)) with WD could be identified and were evaluated with CMR. CMR revealed normal left ventricular (LV) EF (62.4±5.4%) and right ventricular (RV) EF (64.4±7.1%) overall. However, three patients (7%), who suffered primarily from neurological symptoms, were found to have mildly reduced LV-EF (46.5%, 51%, and 53.5%). Strain analysis revealed significantly reduced LV global circumferential strain (GCS) overall compared to healthy individuals (WD (%): −19.2 2.7; control (%): −20.71±1.5, p<0.05). Patients with primarily hepatic symptoms (WD-h) did not show reduced strain measurements compared to the control group. Patients suffering from primarily neurological symptoms (WD-n) showed significantly reduced LV GCS compared to healthy individuals (WD-n (%): −18.3±3.1; control (%): −20.7±1.5, p<0.05) and RV GCS (WD-n (%): −17.5±3.0; control (%): −19.2±1.8, p<0.05). Also, LV GCS in WD-n was significantly reduced compared to WD-h (WD-n (%): −18.3±3.1; WD-h (%): −20.0±2.0). Furthermore, there were no significant differences between the two subgroups, besides a significant thicker lateral wall in patients with WD-n (WD-n (mm): 7 (5–9); WD-h (mm): 6 (5–8), p<0.05). T1-, T2- and T2*-Mapping did not show any pathological pattern and were overall in the normal range (T1: 1020±30ms; T2: 52.9±3.0ms; T2*: 38.4±5.6ms). Epicardial LGE was present in 1 patient.

Conclusion

Cardiac tissue characterization was performed in WD patients using CMR. Reduced EF, LV and RV GCS have been detected in patients with primarily neurological symptoms. Cardiovascular autonomic dysfunction in this subgroup could be a reason for the reduced biventricular strain. It is unknown if reduced circumferential strain influences the prognosis of WD patients, which should be investigated in further studies.

Meta-analysis of the prognostic role of perioperative platelet count in posthepatectomy liver failure and mortality

BACKGROUND

Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta-analysis, the impact of perioperative PLT on PHLF and mortality was evaluated.

METHODS

MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non-randomized studies (MINORS) criteria. Meta-analyses were performed using Mantel-Haenszel tests with a random-effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals.

RESULTS

Thirteen studies containing 5260 patients were included in the meta-analysis. Two different cut-off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater.

CONCLUSION

A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.

[Durable remission under dual HER2 blockade with Trastuzumab and Pertuzumab in a patient with metastatic gallbladder cancer]

Gallbladder cancer represents a rare but dismal disease. The only curative option is complete surgical resection, though patients often develop recurrent disease. In patients with advanced biliary tract cancer, the combination of cisplatin and gemcitabine showed a benefit in overall survival compared to gemcitabine alone. However, there is no standardized second-line regimen after treatment failure. We report on a young patient with early recurrence of a gallbladder cancer with cutaneous and peritoneal metastases. Upon identification of an ERBB2 gene amplification within the NCT MASTER (Molecularly Aided Stratification for Tumor Eradication Research) exome sequencing program with resulting overexpression of HER2 in the tumors cells, the patient received a targeted therapy with the HER2 antibodies pertuzumab and trastuzumab in combination with nab-paclitaxel, which led to a durable remission for more than one year. This case report underlines the potential of molecularly aided personalized targeted therapy for patients with biliary tract cancer and the need for respective clinical trials.

Cardiac volume overload and pulmonary hypertension in long-term follow-up of patients with a transjugular intrahepatic portosystemic shunt

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPSS) cause haemodynamic changes in patients with cirrhosis, yet little is known about long-term cardiopulmonary outcomes.

AIM

To evaluate the long-term cardiopulmonary outcome after TIPSS.

METHODS

We evaluated cardiopulmonary parameters including echocardiography during long-term follow-up after TIPSS. Results at 1-5 years after TIPSS were compared to those of cirrhotic controls. Pulmonary hypertension (PH) diagnoses rates were included. Endothelin 1, thromboxane B2 and serotonin were measured.

RESULTS

We found significant differences 1-5 years after TIPSS compared to pre-implantation values: median left atrial diameter (LAD) increased from 37 mm [interquartile range (IQR): 33-43] to 40 mm (IQR: 37-47, P = 0.001), left ventricular end-diastolic diameter (LV-EDD) increased from 45 mm (range: 41-49) to 48 mm (IQR: 45-52, P < 0.001), pulmonary artery systolic pressure (PASP) increased from 25 mmHg (IQR: 22-33) to 30 mmHg (IQR: 25-36, P = 0.038). Comparing results 1-5 years post-implantation to the comparison cohort revealed significantly higher (P < 0.05) LAD, LV-EDD and PASP values in TIPSS patients. PH prevalence was higher in the shunt group (4.43%) compared to controls (0.91%, P = 0.150). Thromboxane B2 levels correlated with PASP in the TIPSS cohort (P = 0.033). There was no transhepatic gradient observed for the vasoactive substances analysed.

CONCLUSIONS

TIPSS placement is accompanied by long-term cardiovascular changes, including cardiac volume overload, and is associated with an increased rate of pulmonary hypertension. The need for regular cardiac follow-up after TIPSS requires further evaluation.

[Wilson disease--evaluation of disease-related topics through the eyes of patients by patient-generated paintings--a cooperative study with the German patient organisation Verein morbus Wilson e. V]

BACKGROUND

The importance of disease-related topics can vary widely between patients and doctors. Patient organisations such as the German Verein Morbus Wilson e. V. can overcome this discrepancy. The goal of the present cooperative study was the collection of topics important to Wilson patients by asking patients to generate paintings about their disease.

METHODS

Patients with Wilson disease were asked by mail to draw paintings about their disease and to donate them to the Verein Morbus Wilson e. V.

RESULTS

32 paintings from 27 patients were donated. The majority of the patients added written comments to their art work. Disease-related topics included in the paintings were as follows: psychological work-up of the disease 33 % (n = 11), presentation of affected organs (liver/brain) 22 % (n = 6), therapy 19 % (n = 5), diagnostic path 15 % (n = 4), inheritance 15 % (n = 4), copper-related diet 11 % (n = 3). 33 % (n = 11) of the paintings were composed of two parts reflecting before and after the disease or presenting the individual time course of the disease.

CONCLUSION

Psychological aspects of disease acceptance are the prominent topic in the paintings. The timepoint of diagnosis is experienced as major change in life. The paintings enable both the patient organisation and the caretakers to put more focus on the psychological aspects of the disease. Asking for paintings opens a new channel for patient-physician contacts and produces a feeling of interest and competence in patients.

NMR tomography for the visualization of the diffusion of Gd-DTPA in agar-gel and in brain tissue--in vitro studies

Serial magnetic resonance images of a diffusion model and of brain specimens have been performed to study the diffusion behavior of a paramagnetic complex (Gd-DTPA). The model consisted of solidified agar gel with layered Gd-DTPA solution on top of the gel. Corresponding studies have been performed with the brain specimen to visualize the penetration of the marker through the extracellular space into the brain tissue. Diffusion coefficients for the agar gel and the brain tissue model have been calculated. Magnetic resonance tomography proves to be a promising method for the study of complicated diffusion processes of paramagnetic complexes in biological tissue.

[Nisoldipine in the treatment of essential hypertension. Efficacy and tolerance]

The antihypertensive effect after a single dose of one tablet of Nisoldilpine (Bay k 5552) containing 5 mg, 10 mg or 20 mg respectively, was tested in a double-blind cross-over trial with intra-individual comparison on 60 patients with stable essential hypertension. Mean age was 51.6 +/- 7.1 years, mean body-weight 78.0 +/- 11.8 kg, mean height 169.8 +/- 8.2 cm and mean duration of illness 6.1 +/- 4.3 years. 34 patients were in WHO stage I, 24 in stage II. After 5 mg nisoldipine the blood pressure fell from 150/96 to 135/92 mm Hg, after 10 mg from 153/98 to 130/88 mm Hg and after 20 mg from 149/97 to 127/84 mm Hg. Compared with placebo pre-test levels there was also a significant reduction in blood-pressure at an exercise level of 100 W. Side effects were rare and dose-dependent.